NPD Silverstein, Cap, Disorders of the Self

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2NARCISSISTICPERSONALITYDISORDE R

The problemof understandingnarcissismholdsconsiderable interest,particularly in psycho analysis, although increasingly so in the field of per-sonality disorder theory and research. It is aconditionthat Sigmund Freudstruggled with and rethought at several stages of his career (Baudry,1983).Like other psyc hoanalytic exp lanations of personality disorders, a completeunderstanding of narcissistic personality disorder remains unsettled, despiteKohut's (1971, 1977) and Kernberg's (1975) systematic formulations of nar-cissism.It is also a condition plagued by imprecise terminology, perhaps m oresothanotherpersona lity disorders.

I have reserved narcissistic personality disorder for achapter by itself,not because it should be considered the p aradigm atic or signature disorder ofKohut 's self psychology, but rather because narcissistic personality disorderprovides theclearest illustration of the fundamen tal premisesof Kohut's ideasaboutthe self. Consequently, this chapter servesbothto introduce Kohut'sconcepts of the self and toap ply these concepts to an unders tandingofnar-cissistic personality disorder.

As Iwilldo foreachof the AxisIIdisordersinfo rthcoming chapters, Ibegin by examining the current status of this disorder with respect to its


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diagnostic validity, clinical phenomenology, and relationships with otherpersonality disorders. Isumm arize personality theory viewpoints about nar-cissismandthenpsychoanalyticperspectives emphasizing developm ental andobject relations views. Ne xt,Ipresent anoverviewofnarcissistic person alitydisorder and the main tenets ofKohut's self psychology.Iwillemphasize inthiscontextan important though sometimes overlookedpoint:Kohut'sview-point began as an attem pt to understand narcissistic personality disorder asan expansion ofdrive theory andpsychoanalytic egopsychological prem ises.An idea introduced inchapter 1 bears repeating: As Kohut extended histheory about narcissism to what was to become abroader psychologyof theself,his observations and theories were no longer confined to this particulardisorder. Indeed, it is the main purposeofthisbook todemonstratehow thebroad scope ofself psychological ideas may add to an understanding of thepersonality disordersofAxisII. Ialso include adiscussiono frelated selfpsy-chological viewpoints (primarily intersubjectivity theory) that were influ-encedbyKohut 's self psychology. Finally,I conclude (as Iwill in the chap-ters onother d isorders) with a comprehensive discussion of a clinical caseillustrating a self psychological approach to understanding narcissistic per-sonality disorder.

CLINICAL CHARACTERISTICSAND PHENOMENOLOGY:DESCRIPTIVE PSYCHOPATHOLOGYFrom ad escriptive viewpoint, narcissistic personality disorderhas arela-tivelylow prevalence rate (M attia & Zimmerm an, 2001); however, i ts diag-nostic overlap withother Axis II disorders is high, cutting across all three

clusters described in the fourthed ition of the DiagnosticandStatisticalManualofM ental Disorders(DSM-IV; American Psychiatric Association, 1994). Be-cause diagnostic overlap varies considerably across studies, Gunderson,Ronningstam,andSmith(1995)suggested thatidiosyncrasies of diagnosticcriteria and their assessment may partially explain why narcissistic personal-itydisorder isparticularlydifficult todefine, sam pling variations across stud-ies notwithstanding. For example, problems concerning definitions of em-pathicfailure and the nonspecificity of excessive envy arenotable.However,grandiosityhas been one of the bettercriteriafo risolating narcissistic per-sonality disorder. Paris (1995) observedthatpartof thedifficulty resultsfromhaving to rely on a substantial capacity for introspection on the part of pa-tients.Diagnostic inconsistency also arisesfrom variation in clinicians' judg-ments about th e boundaries between normal and pathological dimensions(e.g.,grand iosity, empathy,andhypersensitivity)on the onehandandbound-ariesbetween observable (behavioral) and nonobservable (inferred internaldynam ics) characteristicson theother.Gunderson, Ronningstam, an dSmith(199 5) also pointedoutthatvali-dation studiesarelacking or insufficient; thus, the value ofincludingthis28 DISORDERSOF THESELF


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diagnosis in DSMrests solely upon the attributions ofclinical utilityfrom awidelyrecognized, psychodyn amically informed clinical literaturea ndtradi-tion (p.209) .Thisstatement about narcissistic personality d isorder,adis-turbance prima rily of outpatients, raises a question about the validity of thiscondition,a question thatis raised lessoften aboutother personality disor-ders: It suggeststhatnarcissistic personality disorder is an im portant clinicalentityforpsychoanalytic clinicians butthatit is ofuncertain significancefornonpsychoanalytic clinicians, at leastas aconditionin its ownright.The conceptofnarcissismand its clinical variantshas also been con-sidered from nonpsychoanalytic frameworks. Bursten (1973) described fourtypesofnarcissistic disorders (craving, paranoid, m anipula tive,and phallic),which resemble a broad range of personality disorders similar to those de-scribed in the DSM-IVasdepend ent/histrionic, paranoid, antisocial, andnarcissistic. Previously, Leary (19 57) , anearlysocial-interpersonal theorist,described tw obroad forms ofnarcissismone characterizedby acold exte-rior,interpersonal aversiveness, and heightened independenceresultingfromfearfulness of dependency and a second type characterized by depression,hypersensitivity, and preoccupation with diminished self-esteem. Beck andFreeman's (1990) cognitive viewpoint emphasized schemas directed towardperpetuatinganaggrandizedself-imagecoupled w ith disregardfo rothers, lead -ingto insensitivitytonormal cooperativenessor reciprocityin social inter-actions.Thesecharacteristics describedbyBeckandFreeman predatedCostaand W idiger's (1994) suggestionthatnarcissistic personality disorder patie ntsarecharacterizedchieflyby lowagreeablenesson the five-factor model.Millon's (1969) biopsychosocial approach originally emphasized thegrandiose, overvalued aspect ofnarcissistic personality disorder, noting itsoriginsin an u nsustainable parental aggrandizem ent of a child's qualities orabilities.Hismorerecentemphasison an evolutionary perspective (Millon,1996) devoted attention to apassive pattern ofaccommodation in narcis-sism, where narcissistic individuals seek to have others acquiesce to theirwishes. M illon also stressed such patients' self-interest orientation, charac-terized b ydiminishedorindifferent interest inothers.Thesepatternsofindi-viduation in such patients' ada ptivestylescould account for their arrogant orhaughty demeanor, exploitative behavior,and expansive thinking patterns.Millon also observed that these patients' overconfidence can giveway todepressionan dfeelingso femptiness when defensesfail,causing them to turnto an inner life ofrationalizationsto satisfy needs external realityno longercan provide.

M illon (1996) described various prominent clinical manif estations, in-cludinganexaggerated exploitative nature centering exclusivelyon patients'needs.Thisformoverlaps with severalke yfeatures associated with antisocialpersonalitybehavior.Anothermanifestation is aseductiveDonJuanism domi-nated bypatients' grandiose fantasies about their abilities accompanied byindifference totheir targeted objects' needs.A lessovert aggrandized clinical

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presentation is characterized chiefly by attempts to compensate for deficien-cies by ever-constant aspirations for sup erior achievem ents; patie nts engagein anelitistway oflifecentered on marked ly overvaluedself-imagesan d self-promoting behavior.M illon (1996) attributed the dev elopme nt of narcissistic personalitydisorder to parental overindulgence, whereby parents imparted a sense ofspecialnessthatgave way to excessive expectations of praise or subservience

from others. People who are raised with such expectations typically do notlearn toconsiderth eneedso fother people; thus, they acquirealimited senseofinterpersonal responsibility and poorlydeveloped skills forreciprocalso-cial interaction. Such individualsfeel entitled to have theirown needs rec-ognized as the most important ones an d think that nothing iswrong withexploiting others to getwhat they want.Oncepatterns like these are set inmotion, a pathogenic ch aracter style is perpetuated , resulting in the rela-tively inflexible constellation of personality characteristics of most clinicaldefinitions ofnarcissistic personality disorder. Turning inward fo r gratifica-tion, narcissistic (as well as antisocial) personality disorder patients strivemore toenhance how they se e themselves than to influence what othersthinkofthem,inpartout of afearo flosingself-d etermination. Because theyoften devalueother people's points of view, narcissistic patients are morearrogantan dentitled thanantisocial patients,who aregenerally inclined tobe more distrustful.

PSYCHOANALYTIC VIEWPOINTSFreud (1910/1957e) considered narcissism to be a stage of developm ent

thatledeventually to libidinal involvement (cathexis) ofothersand objectlove. He considered psychoanalysisto be unsuitableas atreatment methodfor narcissismfor the same reason it wasunsuitablefor the psychosestherewasafailure in both kinds of patients to develop an object (libidinal) trans-ference. Regard ing narcissism at tim es as a perversion and at other times as aform of severe psychopathology, Freu d returned at various times to the prob-lem withou t reaching a satisfactory resolution. His writ ings on the subjectaddressed the matter of narcissism as a developmen tal process (primarynarcissism) progressing to object love (Freud, 1910/1957e) and at othertimes as a w ithdraw al of narcissistic libido from object cathexes backintothe ego(secondary narcissism; Freud , 1914/1957B). This conceptua lizationofnarcissism became the basis for the ego ideal, which Freudrecognized asthe repository of remn ants of infantile narcissism . Freud 's (1931/1961c)evolving ideas about narcissism continued with his later description of anarcissistic libidinal type characterized by self-confidence and, at an ex-treme, grandiosity. Narcissistic libido thu s became the fo und ation of self-esteem. Freud's (1914/1957b) recognition of this connection influenced30 DISORDERSOF THESELF


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Kohut's (1966, 1968, 1971)early formulation of narcissism and later viewsabout the selfaswell.Freud'scontributions tounderstand ing narcissism thus werean impor-tantstarting point fo r Koh ut's viewpoint. It was through Freud's recognitionofthe relationshipbetweenthe ego and externalobjectsthatheintroducedthe concept of the ego ideal and its self-observing capacity (Freud ,1914/1957b).Inthis respect,the egoideal becamethe forerunnerof thesuperego.W.Reich (1933/1949), in hisexpansionofpsychoanalysis beyondsymp-tomneurosestocharacterology,continuedFreud's (1914/1957b)andAnd reas-Salome's (1921) attemptstounderstandthe balance between narcissismas anormal d evelopme ntal pattern and as a pathological d isorder. Reich likenedthe developmental levelofsuch patients to character formations basedonerogenous zones.Thus, Reich's description of the narcissistic character wasreferred to asphallic narcissism; for the same reason, he characte rizedoral-dependenta ndanal-compulsivecharacter types. Fenichel (1945) w as one ofth e earliest analytic writerstoemphasize prominent feelingsofemptinesso rdiminishment inpatients with narcissistic disorders,incontrastto theover-valuing of the self and disdain for others Reich and Freud had previouslyemphasized.Other psychoanalytic thinkers called attention to various associatedqualities such as exhibitionism as a defense against inferiority (A . Reich,1960) and se lf- ideal iza t ionand omnipotent denia l (Rosenfe ld, 1964) .Hartmann (1964) proposed aform ula t ionofnarcissismas ahypercathexisofself ratherthanas ego representations. Jacobson (1964) added an emphasison superego functions in narcissism to explanations of identity developm entan d self-esteem regulation.Shealso viewed psychosis largelyas aproductofnarcissistic identifications, representing the breakdow n or ded iffere ntiationof internalizationsof ego and superego identifications.The sectionsthatfollowp rovid e an ove rview of subsequent psychoana-lytic viewpoints about narcissism, some of which were formulated specifi-callya stheoriesofnarcissistic pathologyan d someo fwhich representedde-velopments in ego psychologyor object relations theory. M ydiscussionofthese viewswillcenter on their similaritiesto and differences from Kohut 'sselfpsychology.Developmental Viewpoints

Spitz (1965) an dMahler, Pine, an d Bergman (1975) contributed a de-velopm ental perspective on narcissism, emphasizing good and bad represen-tations of the self and objects.Theyconsidered magical omnipotence,mas-tery,and self-love to represent steps toward the developm ent of the self an dthe attainm ent of self-esteem. Interruptions or arrests of normal narcissismin the developm ental progression to object love set the stage for variousformsofnarcissistic pathology. Rem aining w ithinan egopsychological framew ork

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in which the object world was made up of good and bad part objects, Mahler'sbaby (M . Tolpin, 1980) w as continually trapped in intrapsychic conflictwhere individuation requires renunciation ofobjects.Psychoanalytic viewsofearly infant development began to shift, how-ever,froman em phasis on conflict toward an emphasis on deficiency (Koh ut,1971;M.Tolpin& Kohut, 1980) as a more important influenceon narcis-sism.Taking a different view from Mahler et al. (1975),M .Tolpin (1980)referred to Kohut's baby as a baby which 'every mother knows' althoughheretofore this babyhas not been integrated intoa tenable clinical theory(p. 54). M.Tolpin emphasizedhow youngchildren'searly development ischaracterized lessbysplitting defensesand curbing aggressive driveswhichare among the fundamental dynamics of classical drive theory in psycho-analysisthan by vigorous, developmentally in-phase needsthatlead to com -petenceandpridein their attainments. Normal development, therefore,in-volves aprogressive unfold ingofinfants' prideandvitality toannouncehi slegitimate developmental needs (p. 55).Forthisand other reasons,D. N.Stern's (1985) detailed videotaped recordings of mothers interacting withtheir infants, and more recently Beebe and Lachmann's (2002) extension ofinfant-mother observation to adult treatment, may also be thoughtof asimportant self psychologically informed reform ulationsof the conflict modelofpsychoanalytic eg o psychology. Further, Teicholz's (1999, p. 172) recon-ciliationofK ohut 's views withegopsychologicalan d postmodern viewpointsconsidered D. N. Stern's observations of infants as a meeting place for thesean d similar views.In considering thematterofd evelopment of the selfa sterminating in astate of individuation, as Mahler et al. (1975) maintained, Kohut (1977,1984) instead considered needs fo rself-cohesion ascontinuing throughoutlife.Thus,forexample,theneedforcohesivenessof the self doesnot disap-pear; ongoing sourcesofresponsiveness orvitalizationarerequiredfo rshor-in gup the self.Althoughhenoteddifferences betweenhisideasandMahleret al.'s, Kohut (1980) alsosawsimilarities, commenting in alettertoMahlerthathebelieved they were digging tunnels fromd ifferent directionsintothesameareaof the mountain (p .4 7 7 ) .Kernberg's Viewpoint

Kemberg (1975) proposed aviewofnarcissisticpsychopathologythatrepresented aspects of both ego psychology and object relations theory. Hisclearlyspecified d escriptionso fnarcissistic personalities w ere impo rtant fo restablishing the clinical criteria ofrecent editions of the DiagnosticandStatistical Manual ofM ental Disorders (Am erican Psych iatric Association,1980, 1987, 1994). Kern berg high lighte d the clinical importanceofnarcis-sistic patients ' unusual degree ofself-reference, noting also the contradic-tion between th eir inflated self-image and their heightened needs for love32 DISORDERSOF THESELF


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andad mirat ion. He calledattentionto frequently associated features, suchas their shallow em otional lives, diminished em pathy, and lim ited enjoy-ment oflife beyond narcissistic gratifications.H ed escribed ho w narcissisticpatients

feelrestlessandbored w hen external g litter wearsoffand no newsourcesfeed their self-regard. They envy others, tend to idealize some peoplefromw hom they expect narcissistic supplies and to depreciate and treatwith contempt those from whom they do not expect anything (oftentheir former idols),(p .2 2 8 )Kernberg(19 75) wenton todescribe narcissistic patients' und iffe renti-

ated affect states an d their freq uent emotionalflare-ups.Such patients lackgenuine feelingsof sadness, despite the ir propensity for depressive reactions,which he explained as the resentful sadness of feeling abandoned or disap-pointed rather than th e sorrow of mournful longing. Kernberg consideredthe essential psych ological structure of narcissism to closely parallelthatofborderline personality organization. Thus, he regarded narcissistic patients'smooth social capacities coexisting with om nipotence and grand iosity as sur-face man ifestations of pronoun ced ego and superego defects. Consequ ently,Kernbergconsidered narcissism to be characterized bydefenseso fsplitting,projective identificat ion, and primit ive idealizat ion in a personality struc-ture otherwise prone to intense oralaggressive conflicts, no t unlike thoseseen in borderline personality organization.Kernberg (197 5) observedthatnarcissistic patients oftenfail to developacapacitytodepend on andtrust others, despite overt ind ications ofdepen-dency. If rejected, these patients feel hate as they drop and devalue theirformer idols.They m ayalso lose interest inpeople who looked up to them,even becoming offended ifpeoplewho no longer interest them move on todevelop other interestso rsourcesofadmirat ion.Thus,th eessential natureoftheir object relationships isnarcissistic explo itation basedon the need to beadmired. They arealso prone toexperience em ptinessas adefensive minimi-zation of the anger or envythat Kernberg regarded as regularly associatedwith object relationships.

Narcissistic patients may have better impulse control and social func-tioning (which Kernberg [1975] termed pseudosublimatory potential)thanp a-tients w ith bord erline persona lity organization. Narcissistic personalities ma ytherefore be seen as leaders in their work and professional activities or increative fields, althoughcareful observation . . . of their produ ctivity over a long period of timewillgive evidence ofsuperficiality an d flightinessintheir work,of alackofdepth w hich eventually reveals the em ptiness behind the glitter.Quitefrequently, these are the promising geniuses w hothen surpriseotherpeople by the ban ality of their developm ent. (K ernberg, 1975, pp. 229-230)

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Kernberg (1975) observedthat such patients often had mothers w hoexploited special qualities in them while simultaneously showing callous in-difference an d spiteful aggression.Thispattern exposed such children to re-vengeful envyo rhatred byothers. Acold ratherthanacomfort ing maternalrelat ionship would l ikely set in mo tion a search for compensatory adm ira-tion, although such children simultaneously developed a characterologicaldevaluat ion ofothers.K ernberg considered hi snarcissistic patients to havemore stablee goboundariesthand id Jacobson (1964)and A.Reich (1960),who described their patients as being more vulnerable to egoregressions.Kernberg called attention to the pathological fusion among ideal self an dobject representations andactual self-images.Hethought this interfered withnormal differentiat ion of the superego, leading to p rimit ive and aggressivesuperego pathology. As Kernberg (19 75) wrote, I t is the image of a hung ry,enraged, empty self, full of impotent anger at beingfrustrated, an d fearfulof a world which seems as hateful and revengeful as the patient himself(p. 233). Narcissistic patients' defe nsive organization , likethatof borderlinepatients , isdom inated by splitting or prim it ive dissociation of split-off eg ostates.Thispersonality organizationc anaccountfor thecoexistence ofgran-diositya nd inferiority,no tunliket he vert ical spli t Kohu t (1 971) proposedtodescribe how contradictory self states m ight appear simultaneou sly as con-sciousphenomena.

Kernberg(1975) considered hisviewof the pathological structuraldeficitin narcissistic personality disord erto befundam ental lyd ifferentthanKohut 's(1971),whichIwill describe morefully in aseparate section. Ke rnberg placedparticular emphasis on rage and the relat ionship between libidinal and ag-gressive drives. He regarded this dynamicfeature to be a fundamen tal one,whereas Kohut viewed narcissist ic pathology as an interruption of the d evel-opm ent of a norma l albeit archaicself.Kernberg's position did not em phasizea continuity between normal and pathological narcissism.

Theirtheoretical differences mayreflect differences in the types of pa-t ients Kernberg and K ohut saw in treatment while formu lat ing their views.Forexample, Kernberg (197 5) recognizedthatnarcissistic patients ofte n func-tioned inlife at ahigher levelo fcompetence thand idborderline pat ients , atleast when judgedbyovert indications. But asKernberg came tound ers tandnarcissistic patients in greater depth, their s tructurald eficits and degree ofpathology became more apparent ,andthey begantoresemble pat ients w ithborderline personality disorder.Ko hu t (1966, 1968, 1971), howev er, formu lated his ideas by stud yingpatients inpsychoanalytic t reatm ent who did not necessarily showthe pro-pensityf or regression, splitting, an d archaic pathology resultingfrom poorlyintegrated rage of the type Kernberg treated an d thus emphasized. Kohutconsidered the patients he treated to have achieved a more stable, intactdegree of self-cohesion than those with borderline disorders, despite theirpropensity for self-esteem dy sregulat ion produc ing excessive g randiosity or34 DISORDERSOF THESELF


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inferiorityandvulnerabili tyto disappointment. Kohut also called attentionto such patients' dep letion depression oranxiety, diminished zesto r enthusi-asm, and in some cases hypochond riacal preoccupations.Whereas Kernberg (1975) conceptualized narcissism from th e frame-work of pathological internalized object relations, Kohut's (1966, 1971) ap-proach was derived from his discovery of specific transferences. Kohut didnot, however, delineate clinical characteristics of narcissism as clearly asKernberg did. Kohut also regarded narcissism as a line of normal develop-ment much like bu t different from object love. He thus considered patho-logical narcissism to be aderailment ofnormal narcissism, whereas Kernbergemphasized its inherently pathological structureandregardedit asbeing clearlydifferent from normal narcissism.Thus, Kernberg saw a closer relationshipbetween narcissisticand borderline personality disordersthan Kohut did.

OtherObjectRelations ViewpointsKernberg's (1975) integration of ego psychology and object relationstheory wasinfluenced inpartby M. Klein's (1930, 1935) viewofnarcissism

as a defense against envy. The so-called middle or independ ent school ofobject relations also proposed viewsabout narcissismand the selfthatwereinfluenced by Klein, though these views departed from some of Klein's moreextrem e views. Whereas Ke rnberg proposed a view of narcissism, object rela-tions theories such asWinnicott's(1965) an d Fairbairn's (1954) were aboutthe self and its development.

Winnicott (1965) in particular considered early development largelyasan existence inwhich a good enough mo ther providesa holding envi-ronment that facilitates infants' an d young children's growth an d develop-ment. Hisconceptof a maternal subjective object comprises the nearly indi-visible unit formed bymother an d infant that gave rise to his well-knowncomment , Thereis nosuch thing as ababy (p .39),bywhichhemeantthatinfants could not beund erstood in the absence ofmothers' m aternal care.This concept has aclosebut notidentical correspondence with Kohut's (197 7,1984)concept ofselfobject func tions and the self-selfobject unit describedlaterinthis section. How ever, Bacal (1989) regarded Winnico tt 's conceptofa su bject ive object as being nearly synonymous w ith K ohut 's original idea ofthe selfobject operating as an extension of the selfthat is, the psychologi-cal or internal experience of an object that provides functions that sustainan dstrengthen th e self.Notwithstanding this similarity,Winnicott's(1971)reference to the mirroring function of a mother's face, for example, does notindicatethatKohut borrowed Winnicott 's ideaofm irroringtoexpress Kohu t'sownconceptof mirroring; Kohut'sconceptof the mirroring selfobject func-tion ismore nuanced thanWinnicott's use of the idea of a mirror, whichWinnicott intended mostlyas an analogy.

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Winnicott(1965) also distinguished between truean dfalseselves;th efalse self is adefensive presentation patients use toprotect themselves froman authentic but fragile true self. Consequently, th e authentic or true selfbecomes underminedby theabsenceof asufficientlycaring holding environ-ment, resultingin the prominent appearance of afalse self.Winnicott'strueself an dKohut s (1971) cohesive selfar esimilar inthattheybothrepresentfavorable outcomes of maternal responsiveness in normal development.Winnicott'sfalseselfparallels Kohut s (1971) vertical split (describedinchap.11), in which pseudo-omnipotent grandiosity conceals asimultaneouslyex-perienced bu t split-off enfeebled self.

Although Bacal (1989) understood Kohut (1971)to intend mirroringto refer toarchaic grandiosity, Kohut, likeWinnicott (1965, 1971),had inmind the ideathat mirroring represented confirmation ofone s uniqueorcreative capacities. Bacal also pointed outthat bothWinnicott andKohutcommentedon the capacityto bealone.ForWinnicott, this representedaninternalized psychological experienceof an adequate holding environment;for Kohut, itrepresented the psychological experience of acohesive selfde-rivedfrom theexperienced senseofthere being availableasustainingselfobjectsurround.

Bacal and Newman (1990) and Summers (1994) considered thatFairbairn (1954),Winnicott(1965), Balint (1968), andGuntrip (1969,1971)developed object relations formulationsofseveral phenomena Kohut (1971)would later emphasize, anticipating positionsthatKohut brought togetherina more crystallizedform. For this reason, Bacal an d Newman (1990) an dSummers (1994) regarded Kohut s self psychologyas a further step withinobject relations theory ratherthanas theparadigmatic advance thatKohutan d severalof hisfollowersconsidered it to be. In anycase, Kohut,aswellasall of these object relations theorists, had in mind aconcept of infantsasengaging in object seeking from birth or shortly thereafter. Selfobject wasKohut 'sparticular termfordenoting the ideaof the selfs object.

Although Fairbairn (1954)andGuntrip (1969,1971) usedthetermegomuch asKohut usedth e termself, their conceptsof the objectdiffered fromthe drive theoryand egopsychologicalviewsof anobjectas an embodimentof libidinaloraggressive drives.All three theorists considered libidinalan daggressive experiences asbeingsatisfyingwhen early relationships weread -equate. They spoke oflibidinal and aggressive experiences as representingdrive dischargeso rpathological breakdowns when earlyrelationships werefrustrating.Moreover, Fairbairn s viewof the outcomeo fsuccessfuldevelop-ment was amature dependence onobjects basedond ifferentiation betweenself an d object. Fairbairn san d Guntrip s views were considerably differentfrom Kohut s emphasison the predominant roleo fempathic failures in self-selfobject relationships. FairbairnandGuntrip emphasized instead th eever-constantstruggles betweenthe longingto be inrelationshipsand the fearfuldistrustthatintimacy leadsto feelingdevoured.3 6 DISORDERSOF THESELF


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A SELF PSYCHOLO GICAL VIEWPO INTThe Selfand Its BasicConstituents

Koh ut's (1966, 1968, 1 971) seminal workson narcissistic personalitydisorder opened up a newperiod of psychoanalytic theory formation.Theyrepresented ad ifferent way for clinicians to understand an d treat a typeofpatient that stymiedthembydefying treatment attempts basedon classicaldrive theoryand egopsychology.As Inotedearlierin this chapter, narcis-sismh ad presented anexplanatory problemfo rFreudand forpsychoanalysissince itsbeginnings.AlthoughKohut hasbeen criticizedforseemingto ig-nore important views in psychoanalysisthat could legitimately be seen asforerunnersof his own viewpoint (Bacal & New man , 1990; Su mm ers, 1994),th e innovations he introduced nevertheless formed th e basisfor a newpsy-choanalyticviewofpsychopathology,onethat despite criticism calledfor asubstantial revision of psychoanalytic theory and treatment.Although Kohut distinguished between narcissistic personality disor-ders and narcissistic behavior d isorders, he sometimes used these terms inter-changeably because their main dyn amics were similar. Narcissisticpersonalitydisorderencompassed d isturbances where the prim ary symptomatic presenta-tion included depression, purposelessness,chronic boredom or disappoint-ment , or related aspects ofdepletion an d generalized experiences ofdimin-ished self-esteem.The narcissisticbehaviordisorderswere disturbancesinwhichmosto fthesesame phenomena were manifestedasbehavior disorders ratherthan as psychological experiences . Such behavior disorders inc ludedsexualizations(e.g., perversions), add ictions, or d elinqu ent (antisocial) acts.

Kohu t (1959, 1966, 1971) identified emp athy as aprimary method ofclinical investigation. Empathic listening was a way of understanding pa -tients'verbalizedandnonverbalized experiencesand their clinical histories.Understanding such experiences and what gave riseto them thus enablesclinicians to reconstruct patients' lives as their struggles to sustain self-esteem and cohesiveness of the self. Considered in this way , empathy haslittle (ifanything) to do with sympathetic expressionsofunderstanding ortenderheartedness. It isinstead the way a clinician gathers information an dthenattemptsto comprehend clinical data.

Kohut (1971, 1977) also introduced the term selfobject to refer to theinternalpsychologicalexperienceof anobjectthatprovides fu nctionsneces-saryfo r self-regulation.In self psychology,as in psychoanalysis more gener-ally, th e term object often refers to an actual person (such as a mother orother person soughtfor his or herm aternal functions).It saccurate d efinitionisthe psychological fun ction such a person has come to provide or represent(men tal represen tation). Thus, a m other or a maternal object in the sense ofan object relation isreallythat person's maternal capacity. From th e selfpsychological viewpoint, therefore,a selfobjectis an object needed by the

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hold one'sown, sometimes masqueradingasexcessive shynessorunassertive-ness. Paradoxical reactions such asthese may comprise the main clinicalpresentation fo rsome patients, orthesereactions m ay firstemerge after aninitial burstofsuperficial,grandiose bravado givesway and afundamentallyinjuredself appears. The most crucial considerations in Kohut's understand-ingof narcissistic personality disorders were the characteristic deficiencies incohesion,vitality, or harmony of the self.Selfobject Functions

Kohut's (1966, 1971) early descriptions ofnarcissistic personality dis-order emphasized how the three attributes of the selfcohesion, vigor, andharmonyoperate to produce the clinicalformsof the disorder. He explainedthatthe selfrequires attuned responsiveness from theexternal worldtosus-tain its cohesiveness. Byattuned responsiveness Kohut meant empathicselfobject experience. (As Inotedearlier in thischapter,clinicians appre-hend the psychological significance ofattuned or failed selfobject experi-encethrough empathyas amodeofinvestigation.) Kohutat firstidentifiedtw oprimary kindso fselfobjectexperiencemirroring an didealization, rep-resenting sectorso rpolesof abipolarself(Kohut, 1971,1977).H elater addedathird, twinship, which previouslywasincluded inmirroringand wassubse-quentlydifferentiated as aselfobjectfunctionin its ownright (Kohut,1984).Mirroring

Mirroringis the echoingpresence Kohut regardedas the meansbywhichothers'affirmingresponsiveness strengthensth e self.It is oneroutefo rfirming up asenseofbeing valued. Mirroringisbuiltu pfromexperiences innormal development inwhich young children expectthattheir accomplish-ments willberecognized and metwith pr ideful satisfaction. Kohut (1971)conceptualizedmirroring needs as arising from what he termed the grandi'oseexhibitionistic self,comprisingthree forms. The most psychologicallya r-chaic form is afusion ofself an d other (the self and itsselfobjects),which isdetected intreatmentby amerger transference.Asecond, healthier manifes-tation is, asKohut phrasedit, amirror transferencein thenarrow sense, whichisthe familiarseekingof an affirming oradmiring presence without compro-misingtheboundary betweenselfandmirroring selfobject.The thirdformofmirroringis the twinshiporalteregotransference, representinganeed for an-other to be afaithfulreplica of the patient. Kohut (1984) subsequentlyrefor-mulated the twinship transference as a distinct selfobjectfunction, onethatwasseparate frommirroring, which Idiscussin aseparate section.

AsKohut (1977,1984)fur therdevelopedthepsychologyof the self,hede-emphasizedthe idea of a grandiose-exhibitionistic sector of the selfas apathological formation.H eshiftedh isemphasis, therefore,from atheoryo fpsychopathology to a view of infants' and young children's exhibitionistic

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displaysof their abilitiesexaggeratedan d overestimated though theym aybeas normal developmental strivings. Consequently, the appropriatepa-rental responsetomirroring needs (and th eir grandiose-exhibitionistic man i-festations) issimply an adm iring recognition of this aspect ofchildren's ex -p e r i e n c e in a t i m e l y , d e v e l o p m e n t a l l y i n - p h a s e w a y .This t y p e ofacknowledgement servestoinstill normal prideandfeelingsofwell-being.Itbecomesthe echoing presenceofempathic attunem ent to young children'snative talents and skills that emerge normally during development. Thus,Kohut no longer regarded thisprideful boasting aspathologically grandioseorexhibitionistic strivings. Rather, he understood it as aproduct ofvitalityresultingfromc aregivers' em pathic responsiveness to their accom plishmentsin the form of proud encouragement.Idealization

Before K ohut (1984) d ifferentiated twinship from mirroringas adis-tinctselfobjectfu nction, he describedanothersector (pole) of theself(Kohut ,1966, 1971)the idealized parental imago. Idealizationas a selfobject func-tionis mob ilized when a sustained impetu s emerges in young children to tu rnto others asall-powerful inorder to feel calmedbytheir strongorsteadyingpresence; inthis way,th e others become idealizedselfobjects. Like mirroringan d twinship, idealizationis aproduct of a normal developmental thrust. Itbecomes appa rent when children experience their caregive rs as provid ing asoothing function when their own capacity to calm themselves is incom-pletely strengthened from within, thus compromising self-cohesion.Chil-dren idealize selfobjects whom they ca n look up to in thisway fortheir all-knowing or all-powerful vigor.Children's longings to merge with idealizedselfobjects' strength foster the restoration ofequ il ibriumwhen the selfis ex-perienced as weakened. Bacal and Newman (1990) aptly expressed this ideaintheir descriptionof the selfa s walking proudlyin the shadow (p .2 3 2 )ofit sadmired ob ject; they thus captured the essential quality of the idealizationselfobject experience asconsolidating self-cohesion.

Selfobject failures m ay occur when idealizedselfobjects no longer canprovide this function. Idealizedselfobjects m ay lose interest orprematurelywithdrawtheir availability and in so doing interrupt a normal, developmen-tally in-phase process. A child or a patient with a prominent idealizationselfobject need mayexperience such disruptionsa sabandonment ifthey oc -cu r before the person has internalized enough of what he or she needs tosustain self-cohesion.Idealizationselfobject disturbances may compel the p atient to perpetu-allyseek perfectioninselfobjects whooffer the promiseoffulfilling his or herthwarted idealization longings. Patients with such id ealization needs maythus attempt to merge with omnipotent selfobjects, sometimes successfullyrevitalizing self-esteem.How ever, such mergersareoften sho rt-livedandthusfutile, because they typ ically do not lead to a depend able structu rethat40 DISORDERSOF THESELF


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strengthens self-cohesion. Many patients with such thwarted idealizationlongings are frequ entlyleftfe eling disappointed in once-idealized selfobjects.Attempts to secure self-cohesion through repeated idealizations often fail torestarta developmental processofinternalizing self-cohesion thathadbeeninterrupted. Kohut (1971) referred to this developmental process as trans-muting intemalization. In its absence, chronically disappointing or unavail-able idealized selfobjects reexpose such p atients to injuriesthat ca n over-whelm an infirmself (M .Tolpin, 1971).Relat ively healthy sublimationsm ayalso occ ur, such as the acquisitionof deeply feltconvictions or principles. In general, though, many patientswith idealizat ion deficits remain vulnerable to feeling disappointed in ideal-ized selfobjects.Theyare frequ ently unable to g radu ally let go of their needfor om nipotence in idealized selfobjects.Otherscling to idealizedselfobjectslong past the point when holdingonto this possibilityisviable. F urther,it isno t uncommon to reconstruct historiesofparents' failures torecognize theirchildren's idealization needs or of aparent , u ncomfortable being idealized,who unwit t inglyfails towelcomeorprem aturely dismissesthe child's normalidealized selfobje ct longings. Such parents may seem surprisedto find thattheir children feel rejected bythem, having m isinterpreted their children'sneed fo ridealizing selfobject function sa sclinging depend ency. Deficits aris-in gfrom rebuffed idealization needs m ay also result in the child's inab ility tocalmor soothe him-orherself.Idealization m ayrepresent another oppo rtunity in early developmentto repair the injuries to the self if mirroring needs were thwarted. A suffi-ciently robu st idea lization selfobject relationship thatsolidifies self-cohesionin the face of mirroring deficiencies can provide a compensatory structure(Kohu t, 1977; M.Tolpin, 1997). In this wa y, if mirroring has been irrepara-bly damaged as an avenue for strengthening the self, it may be possible toachieve a reasonably robust and enduring degree of self-cohesion ifanotherroute (such as idealization or twinsh ip) is available to sustain a damaged self.A compensatory structure established in this manner m aypermit develop-menttoproceedoncourse insteadofleadingto an inevitable stateofchronicdevitalizat ionfrom which recoverycannotbe expected.Twinship

The third primary selfobject function Kohut identifiedwas the twin-ship or alter ego transference. He originally identified this selfobject func-tionas am anifestat ionofmirroring (Ko hut, 1971),but he later became con-vinced of itssignificanceas anindependent selfobject function (Kohut, 1984).Like mirroring and idealization serfobject needs, twinship also represents anormal developmental striving. Kohut (1984) characterized it as a longingfor an intima te experience in which a selfobject is perceived as a faithfulreplicaofoneself, capableofmatching one'spsychological statesas ifself andselfobject wereone and the same.It is not amerger,inwhich the senseof an

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autonomous self is submerged, although in archaic forms it may m anifest inthis way . More typically, twinshipselfobject needs spur people to turn to theirselfobjects and ex perience them as a part of the self.The twinship or alter egoselfobject function, like those ofm irroringan d idealization, exists toprovidecalming of a vulnerableself. It operates as a silent presence to keep one com-pany when self-cohesion requires bolstering. Corresponding in some ways tothe colloquial term soulmate,the twinshipselfobject functionrefers to the ex-perience of acompanionate presencethatfeelsandthinksjustlike oneself.It isakin to the feelingof a specialconnectionwith someone whouncannily fin-ishesone's sentences, although this sense ofconnectiongoes far deeper to sus-tain self-cohesion when the self is experienced as being dev italized.Disordersof the Self:Narcissistic Personality and BehaviorDisorders

Asnotedearlierin thischapter,thesymptom atic m anifestations ofselfdisorders centering on mirroring, idealization, or twinship selfobject failuresare often indist inguishable on clinical presentation. Therefore, on e mus tdetermine the predominant selfobject disruptionthat is comprom ising self-cohesion. M oreover, admix tures of selfobject d eficits are not uncomm on.Selfobject needs may also shift in prominence as a resultof time, stressors,and progress of treatm ent and over the course oflife. Although the narcissis-ticpersonality an d behavior disorders need no t reflecto ne selfobject deficitalone (indeed, m anifestat ions of morethan on e selfobject failure may verylikely appear), on e sector of the self is usually more prominently injured.Compensatory structures (Kohut, 1977; M. Tolpin, 1997) may sometimesbecome established and relatively firmed up as reparat ivealthough st i l limperfectattempts tosubst i tuteoneselfobject function (typically idealiza-t ion) foranother (usuallym irroring) .Finally,the selfobject func tions of mirroring, idealizat ion, and twinshipmay n ot represent acomplete com plement ofsuch fu nctions; these are onlyth e ones Kohu t himself addressed. Kohutan d Wolf (1978)an d Wolf (1988)outlined other possibilities, such asadversarialan d efficacy selfobject func-tions; however, theseandother potential selfobject functions havenot beensufficiently studied.Experiences o fem pty depressionand lackofpurposeorenthusiasmm ayensue when normal m irroring, idealizat ion,o r twinship selfobject needs be -come m obilized andthenare thwarted. E mpathicfailuresof normal selfobjectresponsiveness typically implythata caregiver provid ingselfobject functionsfailedtorecognizeandapp reciatethatanormal needhademerged,onethatcouldnot beoverlooked orignoredbutthat instead neededto be acceptedenthusiastically (M.Tolpin, 1978;M.Tolpin& Kohut, 1980). Frequently,narcissistic manifestations (as well as self disorders in general) become ex-pressed as deplet ion or fragmentat ion phenomena accompanied by tensionstatesthatare incompletely relieved andchronicaffect experiences of being42 DISORDERSOF THESELF


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adrift in lifeorlacking purposeorgoals. Some peoplefeel chronically under-powered or devi ta l ized.Others perpetu ally seek out intense id ealizationselfobject relationships and often feel let down or dropped when their needtope rceive greatnessorvigorinsuchselfobjects is met withth e disappoint-mentsthatinevitably ensue.Suchpatients struggle hardtofeel enthusiasticabout them selves,thepeople they love, their work,and the peopleorvaluesthatw ould normallyenhanceself-esteem and make them feel their lives areworthwhile.Regardlessof how prominently the surfacem anifestationsofgrandios-ity orentit lement m ay initially appear in narcissistic personality disorders,eventually weaknesses or deficits such as those jus t described will becomeevident, especially in treatment. Just as therapists need to recognize suchpatients' defensive bravadoan d loud, angry clamoringsastheirway ofpro-tecting themselves, they must understand thedepression, ennui,anddimin-ished zestthatem erge alongside such defenses as the outcome of devitalizedstrivings to sustain arobu st, assuredself.

Selfobject deficitsmay benoted clinicallya schronic emp ty depressionor as a cold or arrogant dem eanor. M anifestations such as these ind icatethatthe patient isd efensively sequesteringfeelings ofshame and self-depreciationthatare notfarfrom thesurfacepresentation. Heightened sensitivity to slightsan d criticisms also iscommon. Rageful reactions (narcissistic rage)areoftenapparent that represent th e anger resulting from rebuffed expectations ofaffirming selfobject responsiveness from others. N arcissis tic rage, ifpro-nounced andwidespread,maysignal frag me nting self-cohesion, here u nde r-stood a s the breakdown (d isintegration products)of adevitalized , underpow-ered self. Disintegration products may also take the form of addictions orperversions, whichfunction tom omentarily shoreup the self.

When insufficient mirroringi s prolonged during early d evelopment,th e ensuing injuries toyoun g children's normalprideful strivings dera il theirhopesforthemselves,frequently leadingtod evitalization.Inadult treatment,establishing empathic therap eutic und erstand ing requires the therapist toreconstruct how his or her own misunderstandingsfrom time to time repeatcaregivers'chronic empathic failures. The diminished self-esteem that en-suesintreatment isthusarepetitiono fchildhood reactionstothwarted needsfor selfobject responsiveness. Byunderstanding ho w therapy reexposesp a-tients to caregivers' em pathic breaches, the psychotherapist is able to seehow d eficient m irroring responsiveness created th e condition for acore ex-perience to take root in which the patient came to perceive him- or herself asinadequateord evalued,concealed thoughit may bebehindaveneerof de-fensivebravado.Thisveneerofgrandiosityorexhibitionismmayrecede w henpatients come up against uncertain ty about their abilities.Theycome to feelthat their accomplishmentsdo not matter, predisposing them to feelingsofemptydepression, disappointm entinthemselvesaswellasothers,and agen-eralized senseofennui a bout their lives.



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Thus,narcissisticpersonality disorder typically results from failuresofthe echoing, affirming responsiveness of mirroring selfobjects or from fail-uresofpotentially idealizable selfobjectsto provide adependably sustainingpresence. Sometimesboth mirroring and idealizationselfobject failuresmaybe detected, particularly when a stable compensatory structure could not beestablished. So inju red as young children, patients with a disorder of the selfmoveintoad olescence an dthen adulthood, repeatedlyfailingtorealize theirgoals.Theyfrequently achieve far less inlifethanthe promise theyoncemayhave shown. Ambition isoften stifled; initiative ismanifested clinically aslethargic indifferenceassociatedwithdepression, affectiveconstriction,orblunting. Hypochondriacal concerns m ayoccur,inwhich som atization over-lies an ever-present sense of a weakened, devitalized self. A propensity toshame is also common, coexisting wit h rage reactions wh en shortcomingsare exposed.Such disturbances do not preclude other forms of psychopathology, in-cluding comorbid Axis I syndromes and Axis II personality disorders.Comorbid disorders may represent d epressiv e, anxious, imp ulsive, aggres-sive,or other symptom atic perturbations of an underlyingself disorder. Thenarcissistic behavior disorders in particular may resemble Axis I and AxisII disorders characterized by perversions (sexualizations)of painful affectstates, addictions, delinquency, or propensity for intense outbursts of help-lessanger (narcissistic rage).Thesebehavioral dysf unctions typically achieveonly momentary soothing; they replace the internalizations of selfobjectfunctions that failed to develop, thus impedingacapacity to calmor soothethe self.MaturationofNarcissisminNormal DevelopmentWith Treatment

Kohu t (196 6,197 7, 1984) frequently observedthatthere is noselfwith-out a selfobject, which was how he expressed the ideathat throughout lifethe selfrequires persons, ideals, or sustaining goalsfrom which it can derivevitalityan d cohesion. Self objects never become c omp letely unnecessary; in -stead, they always remain important to fuel or sustain self-cohesion, whichKohut likened to akind ofpsychological oxygen.A selfobject surroundm ayconsist of parents orother caregivers (including grandparents,other closerelatives,or sometimes beloved na nnies); love objects; intima te friends;teach-ers,mentors,o rsimilar admiredorbeloved figures;oreven profoundly mean-ingful values, principles, or institutions. The selfobject environment func-tions to affirm one's attributes or qualities to ensure a sense of initiative,efficacy, and w ell-being. Selfobject needs in normal development, therefore,are not thought of asinherently pathological; rather, they representabaselineoflegitimate expectations. One turnsto the people orother selfobjects whoare important inone's life, it is hoped with confidence, expecting to be re-sponded to in a waythat invigorates the self.44 DISORDERSOF THESELF


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edge (M iller, 1985) of conflicts, defe nses, and sym ptoms. M.Tolpin( 2 0 0 2 )recently revived thisconcept,which Kohu t spoke about inform ally (Miller ,1985)but d id notw rite about .Tolpindescribed forward edge transference sthatcoexist withaself disorder; these transferen cesfrequently aresilent an ddifficult to recognize because they may be deeply submerged. Nonetheless,searchingfor and integrating forward edge transferences can represent animportant mu tat ive factor, because such transferences reach th e potentiallyrevivable tendrilso fselfobject longingsthat have been driven underground.The remob ilizat ion of such buried (bu t not entirely abandoned) efforts m ayallow previously interrupted developmen t to continue, thus restartingapro-cessof securing more advan tageous emp athic selfobject responsiveness.Thesetransferences represent patients' hopeful anticipation that something thatha dgone awryin their development w illberecognizedandresponded to as areasonable, normal need ratherthanas apathological need state.

Thus,Kohutand hiscolleagues considered the emergencein treatmentof patients' mirroring, idealizat ion, and twinship selfobject needs asbothreactivations ofearlierinjuriesand asat tempts toconveytoothers what theyrequire to promote repair of the self.This understanding ofselfobject trans-ferenceswas not technicallyd ifferent from the w ay other t ransferences wereapproached in treatment. Thus, selfobject transferences were amenable tointerpretation using essentiallyt he same technical approach asthatof otherwell-understood transference configurat ions. Further, Kohu tdid not discarddrives as impo rtant psycho logical mec hanisms, but he increasingly regardedthemas requiring a differentway ofbeing understoodwithout delegatingthemto aposition of secondary importance (Kohut, 1977, 1984). He under-stood sexual and aggressive drive s as vitalizing fun ctions toenhance well-beingan dself-cohesion (M .Tolpin, 1986).Thisunderstandingofdrivesbe-came a part of howselfpsychologically informed treatm ent facilitated revivingpatients' initiativetopursue goals with enthusiasmand totake pridei n theirabilities an d accomplishments.Kohut (1971, 19 77) also was not convinced of the primacy of an ag-gressived rive, certainlynot in the wayKernberg (197 5)a ndotherfollowersof Melanie Klein's (1935) work had emphasized. Kohut considered Klein's essential attitudethat the bab y is evil and a pow der keg of envy , rage, anddestructiveness (Ko hu t, 1996, p. 104) to be misguided . Kohut (1972 ) in -stead considered narcissistic rage reactions to arise from selfobject failureswhen caregiversdid not respond tophase-appropriate need sthe relat ivelynormal, expectable developmental needsofchildhood . He explained narcis-sistic rage as excessive or severe frustration and not as primary or archaicresidualsof an aggressive drive.Though Kohut considered frustrat ion to beoptimal when it promoted firmed -up self-cohesion through internalizat ion,he regarded excessive frustrat ionasproducingabreakuporfragmentat ionofself experience. Kohut called fragmentat ions of the self disintegrationprod-ucts,and na rcissistic rage is one exam ple. Kohu t (199 6) also observed in this46 DISORDERSOF THESELF


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contextthat the baby cries,andthenthe baby criesangrily when whateverneedsto bedone is not done immediately.Butthere is no original need todestroy;the origina l need is to establish an equ ilibrium (p. 199).Other Self Psychological Viewpoints

Although Ihave em phasized Kohut's psychologyof the self, other selfpsychological perspectives also exist that were influenced by and extendKohut's views.These view points were not concerned specifically with nar-cissism,a nd even K ohut 's later formulations emphasizedselfdisorders ratherthannarcissistic disorders. Nonetheless, th e other selfpsychological viewsIoutline in this section al l have implications fo r understanding narcissisticpersonality d isorder.Stolorow and his colleagues' intersub jectivity theory was one of theearliesttohave evolved (Stolorow& Atwood, 1992; Stolorow, Brandchaft,& Atwood, 1987). Lichtenberg's (1989) concept of motivational systemsandShane,Shane,andGales's (1998) integrative viewpoint basedonThelenand Smith's (1994) no nlinear dy nam ic systems theory are also closely alliedwith psychoanalytic approaches to disorders of the self. Lichtenberg's andShane et al.'s emphases on develop ment and the self incorporated aspects ofattachment theory aswell.Intersubjectivity Theory

Stolorow and Atwood (1992 ) considered their intersubjective view-point to beclosely allied with Kohut'sself psychology insofarasboth view-points regarded selfobject experiencea s aprimary aspectofmental life.LikeKohut, intersubjectivity theorists emphasized empathic understanding as amethod for therapists to use in obtaining the su bjective data needed to ap-prehend patients' experienceof the selfand itsconstituents. Stolorow andcolleagues'(Stolorow&Atwood , 1992; Stolorowet al, 1987) intersu bjectiveviewpointisperhaps m ore closely relatedto(butnotn ecessarily deriv edfrom)Kohut's concept of the self an d selfobject functionsthan are other view-points based on intersub jectivity, such as Ogd en's (1994 ). Stolorow an dAtwood commented that they arrived at their point ofview independentlyof Kohu t an d that their view emergedfrom a different frame of reference,on e that was influenced appreciablyby Tomkins's (1963) theory of affectregulat ion. Further, intersubjectivity theory expanded selfpsychology'su n-derstanding of borderline and psychotic disorders (Brandchaft & Stolorow,1984; Stolorow et al., 1987).

Stolorow and hiscolleagues (Stolorow& Atwood, 1992; Stolorow etal., 1987) stressed the primary importance of intersubjective contexts, whichthey definedas an intersectionof twosubjective ly true realities, suchasthatbetweenachild and its caregiversorthat between apatientand his or hertherapist.Thisintersection isthought to construct (their termfor this, like

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that of many relational theorists, is coconstruct) a new or different realitythan that of either party alone. By contrast, Kohut and his colleagues re -garded others as independent persons w ho provideselfobject functions toshore up theself. Intersubjectivity theoryadvocatesthatpsychological expe-rience cannotbeunderstood without considering the intersubjectivefield.Thus, other persons motivations and perceptions (i.e., subjectivities)arebelieved to equally influence the perception ofone s ownsense ofpsycho-logical reality.The perceptions an d beliefs resultingfrom suchanewly cre-ated intersubjectivity, whether accurate or faulty, represent what Stolorowand his colleagues termed invariantorganizing principles.Theirviewh asbeencriticized,however,fo rconflating experience with social determinism (Sum-mers,1994), perhaps even withanextremeformof it.

Acrucial concept inintersubjectivitytheory concernsthecentral roleofaffectsratherthandrivesasprimaryorganizerso fexperience.Affect statesthatare inevitably embedded inintersubjectivefields arethemselves regulatedbythe reciprocal influencethatoccursindyads. Psychopathology, therefore, rep-resentsfailurestointegrateaffectiveexperience (Socarides&Stolorow, 1984-1985) becausethe earlychild-caregiver systemo freciprocal mutual influencethatnormally promotesaffective integration ha s broken down. Under moreoptimal conditions, the childcaregivermutual influence system ensuresthataffect states become integrated with ongoing experience.Affects ca n thusbetolerated an d differentiated to signal what people experience at anygivenmoment. Disturbedaffect articulation results therefore from intersubjectivecontexts inearlydevelopment whereaffectswere walledoffor inhibited, usu-ally because caregivers remainedunattunedtotheir children'saffect states.The intersubjectivityperspectiveisintegrally anchored in the selfpsy-chological pointofviewinwhich the selfis the centerofpsychological expe-rience. Stolorowandcolleagues (Stolorow&Atwood, 1992; Stolorowetal.,1987) have consistently stressed the importance of affects asorganizersofthe experienceof the self.Theyalso emphasizedthemutual (bidirectional)influence ofdyadsas the basisfo r self regulationand selfobject experience.Thisemphasisiscongruent with studiesofobservationso finfantsand moth-ersin interaction (Beebe&Lachmann, 2002;D. N.Stern, 1985); these stud-iesalso highlight th e importance of the mother-infant dyad as amutuallyinfluencing systemthat is important for self regulation. In recent years,Stolorow andcolleagues have increasingly taken the position thatKohut sso-called traditionalselfpsychology remained to oweddedto the one-personpsychology of drive theoryand egopsychology. Consequently, intersubjectivitytheorists have criticized important selfpsychological concepts suchastrans-muting internalization, because they consider its view ofselfobject experi-ence to be too closelyanchored in a Cartesian isolated-mind tradition ofconceptualizing internal experience. These theorists have arguedthat selfpsychology doesnot sufficientlyemphasize what Stolorowan dAtwood (1992)consideredto be ofcrucial importancedyadicsystemsand theintersubjective48 DISORDERSOF THESELF


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context.However,selfpsychologists consider Stolorow and colleagues' dis-tinction to be oflimited importance. They instead have emphasizedthatthecentral feature ofbothviewsonethatd ifferentiates them from early psy-choanalytic positionsisafundamentalconcernaboutthe interdependencybetween self an d others, regardlessof whether this isconceptualized asselfobjectexperience or as an intersubjectivefield.MotivationalSystemsa ndD evelopmentLichtenberg's (1989) view of the self isderived partly from Kohut'semphasis on the self-selfobject unit and partly from assumptions ofintersubjectivity theory and themother-infantobservation literature. His par-ticular emphasis rests on motivational systemsthatunderlie self-regulation,a concept Lichtenberg introduced to expand the scope of selfpsychologybeyond the empathically observed data ofclinical psychoanalysis.His is atheory of the self, because it considers experiences of optimally attunedselfobjectsto beaffectively invigorating when needsaremet, thus strength-ening the self. (Lichtenberg's term self-righting approximates Kohut's con-ceptofrepairorrestorationof theself.)Themotivational systems Lichtenbergoutlined included adescription of their precursorsin infancy based on at-tachment patterns. Thus, he linked motivation with development as crucialinfluences on self-integration. Lichtenberg also attempted to integrateintersubjectivity theory's emphasis on childcaregiver interactions asserv-ingmutuallyaffect-regulatingfunctionsforbothchildrenandtheir caregivers.Hisconceptof the selfemphasizes motivation more as asense ofinitiativethanas drive states. Motivations thus serve to organize and integrate experi-ence, specifically selfobject experiences, which Lichtenberg definedas themutualorreciprocalregulatoryrelationshipof theselfand itsobjects.

Like Lichtenberg,Shaneet al.(1998) also integrateda literaturebe-yondthe data of the consulting room, building on Kohut'sviewsby incorpo-rating recent knowledge from contemporary attachment theory, mother-infantobservation research, developmental psychology, neurobiology, andstudiesoftrauma.Theirintegrationofthese areas withselfpsychology formedth e basisf orwhat they termed nonlineardynamicsystems,basedon aperspec-t ivefirstproposed byThelenand Smith (1994). According toShaneet al.'sadaptationofthis model, development representsaconsolidationof the selfand of the selfwiththeworld outsideit.Theyviewedtraumaasinterferingwith consolidation of the self,broadly defining it asincluding neglect an dlossinadditiontoovert abuse. Such disruptionsofnormal development leadtoself-protectivecopingmechanisms thatdo not promoteconsolidationofthe self.Shaneet al. did notconsider these self-protective adaptationsto befundamental lypathological defenses,butrather survivalstrategiesofvulner-able children. They also considered this view from an attachment theoryperspective,observingthat such adaptations attempted to preserve an at-tachment to needed others.



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Like Kohut (1971, 1977),Shane et al. (1998) considered that treat-ment could possibly mobilize a reactivation of normal d evelopmental strivingsthath adbeen interrupted.Treatment should beconducted with th e goaloffostering consolidation of the self, which is the same process Kohut calledself'Cohesion. Shane et al. regarded the work of repair in treatment as self'with-otherconsolidation,in which patients turn toothers fo rsecurityan d self-regulation. They considered thisconceptto be onethatw asimpliedbut notspecifically articulated byKohut 'sconceptofselfobject functions.Shane etal . thus reformulated Kohut's viewofselfobjects asrelational configurationsfor promoting a new experience of the self-transformingother. Shaneet al.discussed severalspecific configurations representing trajectoriesofdevelop-mental progressions to achieve th e self an d self-with-other consolidationsthey emphasized.CurrentStatusofSelfPsychologicalViewpoints

As Inoted earlier in this chapter, these an d other theories recentlyallied with a selfpsychological viewpoint do not explicitly form ulate viewsabout narcissism or narcissistic personality disorder. They can, how ever, readilybe applied to an understanding of narcissism. My mainintent in includingotherselfpsychological theories in this discussion of Kohut's selfpsychologyis not to argue for their specific relevance to narcissism but rather to showhow they have provided a context f or und erstanding ongoing developmentsin the psychology of the selfsince Kohut formulated his ideas.

I will no t characterize most of these viewsor their differences fromKohut 'sselfpsychology beyondth egeneral descriptions presented in thepre-ceding sections, although readers should note thatgood comparative reviewsofthe various self psychologies areavailablebyGoldberg (1998),ShaneandShane (1993), an d Wallerstein (1983). In this an d succeeding chapters, Imakenote ofcom plementary or alternative viewpoints such as those out-lined above alongside K ohut's when such concepts offer related perspectivesfor understanding a self psychological point of view. In regard to whetherone or several self psychologies may be said to have existed since Kohut'sformulations, suffice it to saythat Goldberg regarded the primary conceptsthat Kohut first articulated as having led to separate tributaries, each ofwhich lays some claim to serve as the major voice in the field (p. 2 54).Shanea ndShane considered Kohuttohave clearly shaped th e advancesinselfpsychology du ringhislifetime;however,further developments, although dedicated to hisvision, also wer e not limitedby it (p.779) .

CLINICAL ILLUSTRATIONThe clinical historyan d courseof treatment presented in this sectionillustrate a self psychological approach to conceptualizing narcissistic per-

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sonality disorder. The patient, Mr. A., presented with a mixedanxiety-depressivesyndrome withfeaturesofhypomaniaan d somatic symptoms.M ydiscussion will demonstrate how these comorbid conditions may be concep-tualized within a self psychologicalframework. This case is of interest be -cause the characteristic Axis IInarcissistic personality disorder features ofgrandiosityand entit lement werenot in itially prom inent, although theybe-came more apparent in his treatment with me shortlyafter he was clinicallystabilized.M r. A. was a 2 7-year-old singleWhite man, a college graduate whoworked as an occupational therapist. He was admitted by his internist to ageneral hospital withaspecialized med ical servicefortreating illnesses withaprominent psychiatric overlay or medical managem ent problems. Mr. A.had developedchestpains anddizzinesscomplicated by an8-monthperiodof heavy drinking that he had terminated on his own before admission.M edical workups were negative. He presented w ith depression and ag ita-t ion,and heshowedahistrionic preoccupation w ith somatic functionsandwas fearfulthathe was dying. His history revealedthathe had had a similarbut less severe and pro tracted reaction at age 18, d uri ng his 1st year atcollege.M r. A.'s current som atic complaints had beg un about 1 yearbeforethe episode under discussion,and he had attempted to subduethem withalcohol use.His somat ic symptomshad intensified during the 3 monthspreceding admission, perhaps associated with his self-imposed terminationofalcohol abuse.Several events during the p revious year contribu ted appreciab ly to theonset of the present illness.First,M r.A.'s father, who had a2 0-year historyof heart disease, hadsufferedanotherheart attack 18 months previously, andhe had died9months before the patient's hospital admission.The patientfelt that hisfatherw asparticularly weakened several months beforehedied,but M r. A. had little overt emotional reaction to his father's decline andeventualdeath.However,oncehe hadbegun treatmentin thehospital,Mr.A. became more overtly depressed an d agitated, mainlyout ofconcern fo rhimselfand how he w ould manage without his father.

For 4 years, Mr. A. had been living in an apartment in the home ofmarried friends. H e felt needed there, because this married couple arguedf requently, and he had become a source of emotional support fo rboth ofthem , sometimes acting as a go-between. About 1 yearpreviously, he hadmoved out of this apartment, even though he d id not feel secure enough tolive alone. His decision to try living on his own coincided with his father'sweakeningcondition and M r. A.'s feelingthathis fathe r would soon d ie. Hischest pains began around that time.The patient endedupsharinganapart-ment with afriend he k new casually. Mr. A. was unhappy in this situation;he felt that hisroommatewasirresponsibleand worriedthathis newlivingarrangement wasunstable, a worry thatcoincided with his worsening so-matic sym ptoms and the onset of alcohol abuse.

NARCISSISTIC PERSON ALITY DISORDER 51

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NPD Silverstein, Cap, Disorders of the Self

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