The Two Analyses of Mr. Z, Plus Two

Kohut’s The Two Analyses of Mr. Z is an extraordinary document, one that has not gotten the attention it deserves. It is a scathing critique of classical id analysis, so cleverly couched that it can hardly be rebutted. Kohut hit on the device of exposing the way that classical id analysis is unempathic by showing how unempathic he himself was when working from that model, following that by showing how he corrected for this problem in a second analysis with the same patient, Mr. Z.

Strozier, in his biography of Kohut, says that although “there is no smoking gun,” the case was an elaborate hoax—although an inspired one. The first analysis of “Mr. Z.” was based on Kohut’s own analysis with Ruth Eissler 20 years earlier, which Strozier describes as “stupefying” (2001, p. 421n3). Strozier speculates that the second analysis was entirely fictional (being an account of how Kohut thought he should have been treated). No one has yet speculated further about Kohut’s motive, but Eissler’s interpretations enraged him and he must have craved this final refutation, especially as he now saw that her painfully unempathic interpretations were entirely representative of classical psychoanalysis. This meant portraying himself as the “stupefying” analyst, a fascinating move which put his reputation at some risk, but allowed him to savage the classical model by using himself as a human shield. To simplify the exposition I here play it straight.

The classical analyst almost literally laid siege to patients, using the rule of frustration and abstinence to starve them out—to intensify their repressed wishes (see A Key to Where the Bodies are Buried). Kohut argued, in essence, that this only threatened an already vulnerable ego, and that empathy was a necessary condition for insight and change. His central point in The Two Analyses is that the classical model makes the analyst unempathic. He or she may be sympathetic and may want to be empathic (able to identify with, experience being in the place of, the patient), but the id analytic model makes you automatically unempathic.

The first analysis was five-times-a-week for four years. Then about five and a half years later, Mr. Z returned for another four year five-times-weekly analysis.

At the center of both analyses was Z’s narcissism. He “became self-centered, demanding, insisting on perfect empathy, and inclined to react with rage at the slightest out-of-tuneness with his psychological states, with the slightest misunderstanding of his communication.” In the first analysis Kohut says that he had “at first tolerated it [Z’s narcissism] as unavoidable [but had] later increasingly taken a stand against it. ” Which meant confronting him with “interpretations concerning his narcissistic demands and his arrogant feelings of ‘entitlement’.”

In this first analysis, Kohut’s interpretation was that these reactions came from an attachment to his mother that “he was unwilling to break.” Note “unwilling.” He was “opposing maturation because he did not want to relinquish childish gratifications.” Note “did not want.”

“The patient opposed these interpretations with intense resistances. He blew up in rages against me, time after time.” But Z eventually accepted Kohut’s views and the analysis came to a mutually agreed-upon, reasonably successful termination.

This is the classical view of resistance: that it is a reluctance to give up gratifications. An “unwillingness.” This is why classical psychoanalysis is identified as a drive psychology. This means that people act, and do what they do, because they want to. So Mr. Z was seen as narcissistically fixated on an “overgratifying” mother.

Kohut says that, in the first analysis, he thought of Mr. Z as responsible for his reactions. “I had therefore expected that analytic insights would enable him to see his path clearly, to relinquish his narcissistic demands and grow up.” [emphasis added]

By the time of the second analysis, Kohut realized that Mr. Z was distressed because he hated Kohut’s interpretations, not because they were right and not because he could not tolerate insight, but because it hurt his feelings to be called immature—a momma’s boy. Of course, Kohut was well aware of that in the first analysis, but he just thought he was a momma’s boy.

By the time of the second analysis, Kohut knew that his interpretations hurt because they were attacks on Mr. Z’s self-esteem that were dictated by the drive theory. His Self Psychology is intended to correct for the drive fallacy.

What this actually meant was that the patient’s behavior was not always the expression of wishes. It was almost like a Papal dispensation. Patients did not always have to be held responsible for their behavior.

Kohut’s correction was to argue that what looks like drive-induced behavior is often the expression of developmental arrests. What this means is that Mr. Z couldn’t help it.

Kohut’s idea was that if you think of us as fundamentally driven by wishes, then it is hard to avoid thinking that how we act betrays our real aims—and it is hard to avoid thinking of defenses as a cover up, an evasion of responsibility for these aims.

In the second analysis of Mr. Z Kohut took the position that the patient’s grandiose self was not a defense and, also, did not represent the gratification of a wish or need. Rather, it represented a developmental arrest, at a normal developmental phase—an arrest resulting from a maturational failure, not from Z’s unwillingness to take responsibility for his reactions.

This was vastly different from seeing Z’s reactions as representing a fixation caused by maternal overgratification.

Kohut now saw him as ungratified—and, listen to this—he now described Z as “desperately—and often hopelessly—struggling to disentangle himself from the noxious selfobject [his term for an internalized object—using this term to make clearer how what we call the self is you as you experience yourself reflected by an internal other], to delimit himself, to grow, to become independent.” Kohut went from seeing Z as unwilling to give up his dependency and to grow up—to struggling to be independent and to grow!

So this is a story about resistance, about how what Kohut had seen as Z’s resistance was his own resistance to Z’s struggles, a resistance created by the drive/defense theory, that is, the id analytic model. In all the subsequent arguments about the Z case, this key reversal is hardly mentioned. Kohut was actually working through the concept of resistance itself. He came to see it, in our terms as loss of voice, and in gaining his own, he helped Mr. Z gain his.

There were a lot of criticisms of The Two Analyses. He didn’t quite get away with blaming himself for the faults of classical analysis. Kohut was faulted for simply doing a poor job of his first analysis of Z, for being technically inadequate and also unempathic! He was accused of having some personal difficulty coping with Z’s narcissism. His critique of drive theory was dismissed as his discomfort with the drives. Another criticism accepted the idea that he was the one who was resisting, but in contrast to his idea that the drive/defense model created his resistance to Z, the criticism was that he was resistant to the “austere and demanding discipline of psychoanalytic practice.” Analysts have always distinguished themelves by reaching for the ad hominem argument, the irony being that this only makes Kohut’s point for him; just as classical (id) analysts pathologize patients’ complaints, so they pathologize their critics.

More friendly analysts suggested that maybe Kohut made himself look bad in the first analysis as a foil for presenting his new approach. They believe that he could not have been as moralistic as he sounded.

To Kohut’s credit, he answered all his critics, including me, in his second and third books. When I was asked by Contemporary Psychology to review Kohut’s first book, I said I didn’t think I could do an unbiased review since I knew Kohut as one of the more rigid and orthodox classical analystic thinkers. I was told to go ahead anyway, and so there I was with an advance copy of The Analysis of the Self. I’d like to be able to say that I predicted that it was the opening contribution to a whole new approach to psychoanalysis, but far from it; I predicted the book would be largely ignored, as too abstract and unreadable, as well as by the fact that he overlooks crucial superego effects. What I had not anticipated was how much Kohut’s focus on empathy would appeal to the whole community of therapists, whether or not they understood his message or even read his book. Self Psychology has become the rubric under which a sizeable number of therapists practice.

In answering his critics, he stayed on their level—sort of the “No, I didn’t,” “Yes, I did,” kind of answers. In his rebuttals to criticisms of the Z paper, he did not acknowledge that it launched the most thoroughgoing attack on basic psychoanalytic assumptions that has ever been made by an experienced and sophisticated analyst. (He only acknowledged this much later, in his last writings. At the time he still preferred the veiled approach.) Some analysts even insist that Kohut said nothing new, that analysts have always known how to deal with narcissistic resistances and have always known of the necessity to be empathic.

But what Kohut means by empathy is that the classical stance is adversarial. To appreciate that you have to translate his theoretical revisions into plain language. His most well-known revision is that narcissism has its own separate line of development from object love. He was arguing against Freud’s idea that narcissism is a stage in the development of object love, as I mentioned above. Kohut saw that according to Freud’s conception, narcissism is developmentally inferior to object love. Therefore analysts working from Freud’s conception are likely to feel all the more left out by a patient’s narcissism, seeing it as a defense against the therapeutic relationship and as an obstacle to growth—a refusal to grow up, as Kohut had seen it. Seeing it as a refusal makes it inevitable that the therapy relationship will be adversarial, no matter how benign the therapist.

It is hard not to be adversarial in our instinctive ways of thinking about patients. We feel responsible for everything. That’s what AA is about in requiring people to recognize that they are not responsible for their problem. We have learned not to blame rape or abuse victims, but this is recent. A common example nowadays is the kid who won’t leave home after high school or college and who is seen as “refusing to grow up.” Even some therapists will take that view. Like people really don’t want to work; they’d rather lie around and watch TV and play video games. It isn’t just Republicans who look at things that way.

So Kohut came to see the conception of narcissism as itself an obstacle to therapeutic empathy. He proposed that narcissism has its own line of development, separate from object love. So that even a mature adult was entitled to it. That was a really clever move, so clever that the point can be overlooked if you just take it as an abstract theoretical innovation.

With this formulation, when you look at grandiose or self-absorbed patients, you think they need to be this way. You don’t think you’re being a bad or weak therapist if you let them get away with it. In a word, you can be forgiving. But Kohut never actually said this. He just said that narcissism has its own line of development. This automatically made you forgiving, just as the old view automatically made you disapproving. Kohut made being forgiving just seem like being objective.

What I’m saying is that Kohut couched his innovations in such abstract language that he could almost get away with being “revisionistic” without seeming to be (a goal of most major analytic theorists, cf. Greenberg and Mitchell).

Another seemingly purely abstract idea of Kohut’s was that drives are part of the self rather than outside the self, that the self is superordinate to drive. What this meant was that the drives, aggression and sex, are normally in the service of self-consolidation. He then went on to propose that what we see as libidinal and aggressive drives, separate from and in conflict with the self, are actually “the breakdown products of self-fragmentation.” In other words, he saw the drives as reinforcing an intact self, and as ego-alien only to a disorganized self.

This is a remarkably sterile and opaque way to put a pretty simple idea that would even be obvious to begin with if it had not been for Freud’s special take on it. Applying this idea to Mr. Z, it is only saying that he has to defend against the analyst or to attack him, not because he needs to compete with him or to humiliate him or to triumph over him, but because he is vulnerable to feeling erased by him. (One patient who had come to be more self-empathic about his narcissism, said, “It feels erasive around here.”)

So it was Kohut’s genius to tinker with the classical model in such a way as to make the analyst more empathic and less likely to see the therapy as a power struggle —less liable to feel the need to be tough. To put it another way, Kohut exposed, as no one else had, the way that the classical model (and in many ways the standard dynamic model most therapists have been taught, that derives from the analytic model) makes the therapist prone to feel manipulated and tricked, with patients out to defeat the therapist and sabotage the therapy. So what Kohut meant by empathy is not necessarily perfect attunement, but just undoing the unempathic effect of the classical model.

Kohut is saying that patients need to have their narcissistic states. Like Z, they need to be “self-centered” and “demanding,” to insist on “perfect empathy,” and to become enraged at slights, without having this interpreted as resistance. When Kohut argues that their behavior is not the expression of drives or defenses, what he actually means is that, despite how it might seem, they are not being fundamentally competitive, depreciating, envious, or hostile. You might say that they are just doing what they are supposed to do—trying to put together (“consolidate”) a self.

Kohut argues that much of the intensity of the narcissistic patient’s rage at slights is iatrogenic. It expresses the patient’s frustration at the therapist’s resistance to being a selfobject. This is to say that patients need the therapist to tolerate being shoved into the background and allowed only limited participation, maybe having to simply be a yes-person.

Equipped with this new model in the second analysis of Z, Kohut was able to experience Z’s grandiosity, with none of his previous need to counter it, to interpret it away, or to get Z to renounce it.

Instead of getting Z to give up his narcissism, Kohut says, “I relinquished the health-and-maturity morality that had formerly motivated me.” He says, “I had acquired a more dispassionate attitude.” And “I now focused on [Mr. Z’s grandiosity] with the analyst’s respectful seriousness.” (That memorable sentence captures the spirit of Kohut’s contribution.)

THE THIRD ANALYSIS: INTERSUBJECTIVITY

Now, I want to add a third and a fourth analysis to the first two. The first is not of Mr. Z, although it could be, since it takes a further step in the direction Kohut pointed. The fourth is a hypothetical ego analytic version.

The third version is the intersubjective model, with its best known contributor being Robert Stolorow, a Harvard PhD who was Contemporary Psychology‘s choice to review Kohut’s second book, The Restoration of the Self, which he not only reviewed enthusiastically, but took as the inspiration for his own work. His approach is also called “relational,” or “perspectivist,” and he sees himself as part of this self-conceived new wave of social constructivists.

What this all means is more modest than it sounds. It just means that when the patient experiences a failure of empathy, it can really be a failure of empathy on the therapist’s part. It seems as if Kohut was saying the same thing, but his stress was on how a therapist’s theory predisposes him or her to be unempathic. The intersubjectivists stress how the therapist’s personal vulnerabilities, as well as the classical model, make him or her vulnerable to being unempathic or, in more usual language, defensive.

This is why it is called “intersubjective. ” These writers make a point of how therapy is a two-person situation, not one person and an infallible therapist. What this all amounts to is hard to pin down without a case, so here is one from the book The Intersubjective Perspective; Stolorow is the senior author.

This is the case of Henry (pp. 128-130). This was from the fourth year of therapy with Peter Thomson. “One morning, after a long silence, Henry said: ‘It is upsetting to have to say this. Rob died over the weekend’.” (Rob had leukemia.) The therapist responded: “You must have a lot of feelings about that, and I guess it is difficult to talk about them.” The therapist then says to the reader,

I believed myself to have been compassionate, but as this conversation transpired, his view was vastly different. He remained silent for several days [the frequency of sessions is not given, but this makes it sound like three or four times-a-week], and all efforts to encourage him to speak were of no avail [Thomson does not say what else he may have done, or why he tried to encourage him to speak].

Finally, four days [sessions?] after the aforementioned exchange, I said, “I think you are angry with me.” Henry responded, “Yes, I needed a more intuitive response to my experience. My reaction has been to withdraw and to do things on my own.”

I noted myself feeling defensive and I wished to protest that I had done my best to empathize with him. Henry went on: “You did not seem to understand how upset I was. I felt you were very distant and harsh. You sounded technical, not genuine or sympathetic. I would have appreciated a more simple and personal comment.” For some time he continued to chide me.

I had to work quite hard to decenter [this an intersubjective term describing their key move] from my pressing need to believe that I had only been kind. I then made a number of remarks that I considered to be understanding of his feelings, but they were not accepted as such. For example, I said: “I truly appreciate your feeling so mistrustful and that you need the right kind of response.” When Henry said that I was of no use to him, I responded, “Perhaps you could help me to become more usable.”

(Thomson says that he realizes that such remarks were generated by his feeling of failure, and) …a concretization of my sense of responsibility for his disappointment in me. I was thereby prevented from pursuing a genuine empathic inquiry into the source of his experience with me.

Henry’s feeling that it was futile to talk to me, along with his anger and negativism, continued for two or three more weeks. Henry said, “If the quality, the tone and language, of your response isn’t exactly right, it leaves me enraged. My sense is that you are far away from what I am experiencing. You suggested at one point that I fear to let you come closer to me. That infuriates me, it is so far removed from where I am.”

Gradually Henry’s rage dissipated. My concretized sense of guilt and responsibility failed to take into account of how Rob’s death had triggered in Henry a heightened sensitivity to a traumatic response.

Upon self-reflection, I recognized the influence of my classical training, which induced in me a prereflective [another intersubjectivist’s term] need to regard Henry’s silence as resistance. This aversive attitude caused me at times to match his silence with my own, and at other times to make excessive efforts to push Henry to speak.

My response to his news of Rob’s death must be understood in the light of my prereflective attitude. Although I thought I had been compassionate, the intersubjective field had already been colored by my response to his continued silence. [This is how the intersubjectivists’ talk.]

Henry continued for another two or three weeks to feel that it was futile to talk to me, that I was far away from his experience. Why did his rage finally dissipate? I have no definitive answer, but I think as Henry sensed I was more in touch with his experience, this began to change the intersubjective “weather.” I also have the strong impression that Henry’s negative feelings gave expression to healthy adversarial strivings. A little later on, he commented on how he was pleased to, as he put it, have attained the freedom to “rant and rave.”

I believe that the material I described illustrates the complex mutual regulation and dysregulation of intersubjective interplay to be an organizing theme of analysis.

In my opinion, what Peter Thomson’s case presentation shows is that intersubjectivity theory does not adequately protect the therapist against the countertransference. The case also shows how decentering doesn’t work. It only resulted in the therapists having symptoms, that is, expressing his defensiveness indirectly.

When Henry accused Thomson of being cold and unfeeling, Thomson had to take too much responsibility for it, as he himself points out. Also, Henry’s silence clearly did worry and distress Thomson, as if the patient just should be talking.

More to the point, you can see from Thomson’s rather painful efforts to get on Henry’s side, that his framework gave him no way to accomplish this. He can only do his best to convey solicitude, managing only, in each instance, to dig himself in deeper, with Henry feeling all the more caught in the clutches of Thomson’s performance anxiety. The ego analytic framework is all about how to get on Henry’s side, and how to get him on his own side, without having to role-play being empathic, and with the issue of the therapist’s fallibility being either irrelevant or taken for granted.

If Mr. Z had come in for a third analysis with an intersubjective analyst, what happened would have been even more of a contrast from the first analysis. Kohut did still feel that at some point he had to confront the patient’s narcissism. This is illustrated in his equally famous case of Miss F (see Ego vs. Self Psychology). Kohut never actually gave up the drive theory, and he thought of narcissism as unneutralized narcissistic libido. Eventually it had to be painfully confronted, Kohut thought, although with her he did this as gently and as gradually as he could.

There is no such idea in the intersubjective approach. No drive theory and no idea that there is any necessity for painful confrontations. So Mr. Z would have gotten even more of a break from a relational analyst than he got from Kohut the second time around.

THE FOURTH ANALYSIS: EGO ANALYSIS

Which bring me to the fourth analysis of Mr. Z. Both Kohut’s work and Stolorow’s revisions are thought of as re-evaluations of the idea of resistance. But, more than that, they represent a recognition that therapy can be damaging, not primarily because of therapist’s vulnerabilities, but because of how those vulnerabilities get intensified by standard dynamic assumptions.

Evidence of this appears right away, in Peter Thomson’s opening comment to Henry: “I think you are angry with me.” That’s a good example of an unempathic interpretation. It has a shaming effect, inevitably conveying disapproval. A more empathic interpretation would have taken account of what eventually gets recognized: Henry’s inability to “rant and rave,” that is, his silence. When he is angry he has to withdraw—the response of the shamed.

“I think you are angry with me” is an example of a “naming” interpretation. In Fred Pine’s sense it is too “open ended.” As Pine would put it, the patient does not know what the interpretation means. Henry would not know “what it means in terms of his own badness, dangerousness, babyishness; what he is supposed to do with it, whether he should act on it or not, and what attitude the therapist has toward it.” To put it more simply, it can sound like a reproach, maybe even is a reproach. It does not sound encouraging. The patient is not going to think he is being encouraged to be more at home with his anger. If it does not sound like a reproach, it at least sounds regretful, even a bit mournful. “I’m sorry to see that you are angry with me” can be even harder to hear than anything else.

More intact patients can take such interpretations with a grain of salt. You can say practically anything to them and they will take it in the way you want them to. But more vulnerable patients are not such good sports. It seems to me that a more empathic interpretation would have been, not “I think you are angry with me,” but “I think you are struggling with some angry feelings toward me.” Or, “I think you are feeling angry at me, but you are afraid that if you express it it will upset me, and only get us into a wrangle, like I’ll have to prove how empathic I really am.” (For another discussion of this kind of intervention, see The Shame-Blame Reflex).

Paradoxically, this new responsibility for the intersubjective field made Thomson feel he just had to empathize with Henry, which made it hard to let himself react to the ways Henry made him feel unempathic, and then to use these as a clue to Henry’s internal dialogue.

What both Kohut and the intersubjectivists are concerned about is therapist vulnerability and defensiveness. Kohut’s remedy is to recognize that the patient is suffering and can’t help acting provocative. Stolorow adds that it is helpful to decenter and reflect. We add that these are only partial solutions although they point the way. Our view is that both Kohut and Stolorow are right, that therapist vulnerability and defensiveness have more to do with what we have been trained to think than who we are. Our theory should protect us from who we are, rather than intensify our anxieties.

Therapists want to be empathic. It feels much better; it feels more powerful. But the classical analyst is afraid to be; it can just mean being weak. The relational analyst feels bad and incompetent about not being able to be fully empathic. But what we think makes it possible to be empathic is to recognize that you want to be and that something is stopping you. In Henry’s case what stops you is Henry.

Our way of putting it is to say that Henry can’t “speak from his position.” He can’t say. “I’m having trouble expressing myself, or knowing what to say.” Or,”I don’t feel like talking.” Or, “I feel like you want me to talk, and that if I don’t you’ll feel like a failure.” So you then need to help him to be able to articulate his position in this way. The mark of success is that once he is able to do that, you automatically feel empathic.

BACK TO MR. Z

Kohut exposed the drive/defense fallacy, but risked committing what can be called the “developmental fallacy.” As we see it, the contemporary scene is characterized by the overuse of developmental explanations in reaction to the still prevalent overuse of drive/defense explanations.

As we also see it, what looks like drive-induced or developmental phenomena are actually attempts to cope. There is always a hidden rationality at work, and the therapeutic key is to show this to the patient.

Going back to Mr. Z, as we understand such patients, he would have no confidence about being able to control the give and take in the relationship. Once the therapist speaks, Z would feel the hour is lost to him, because then the therapist’s ego is on the line. So he would try to fill up the time and to avoid giving the therapist an opportunity to speak, in order to get his experience across. And that has to be done in considerable detail because the therapist’s attention is fickle, as he or she waits for the next opportunity to take over.

Our finding is that if you really get into narcissistic patients’ theory, they see the therapist as narcissistic, as always trying to take the stage, or having to suppress trying to take the stage. They are especially sensitive to therapists’ need to have their comments acknowledged and accepted, to be appreciated, to feel competent and caring. It feels risky to get the therapist’s ego going. Narcissistic patients are not confident of their ability to take care of the therapist’s narcissism.

Now the big accomplishment, from this ego-analytic point of view, is for therapist and patient to be able to talk on this level. Being able to talk on this level means that the patient would get to the point of being able to talk about worrying about the therapist’s narcissism. Like to say that “Once you begin talking, I feel like it isn’t safe to ignore you, like I have to show respect by following your lead. Also, I’m afraid to say that because it might make you mad, or make you have to prove it isn’t so.”

So that’s the funny part—or let’s call it the ego-analytic part—that the accomplishment for the narcissistic patient is to be free to ignore you. That’s funny because it supposedly is the problem: that the narcissistic patient tries to monopolize the hour—and even gets enraged if you try to say something.

Kohut said that Mr. Z “blew up in rages against me, time after time.” This was in the first analysis, and Kohut later decided that this anger was justified, that it expressed the patient’s frustration at the therapist’s not being a selfobject. But that is not all it expressed. It also expressed the patient’s difficulty being able to articulate a complaint.

Apparently, in the second analysis, Mr. Z did not have these tantrums. This had to be what conclusively convinced Kohut although, mysteriously, he makes no mention of what must have been a dramatic contrast.

What I mean is that undoubtedly there were times in the second analysis when Z felt slighted, even if in that analysis Kohut was able to respond in such a way as to defuse rather than exacerbate this reaction. But it clearly never became a goal for the patient to be able to say “I feel slighted.” Or to say that he felt ignored when Kohut talked. Maybe to say that “It feels like when you talk, you’re taking over, with your own impressions of what I was saying, and that what you say is more about you than about me.” There is no suggestion that even in the second analysis Z ever got to organize this complaint.

Our idea is that Z does not only need to have his narcissistic demands and rage tolerated or accepted, he needs help to better express his position. It’s almost like saying he needs help to be better at being narcissistic.

So let’s think for a minute about what it means to be narcissistic. And let’s take the simplest version, which Z represents. Kohut is famous for his formulation that the narcissistic patient experiences the therapist as if the two of them are “one body and mind,” and then when the therapist misses a cue, the patient can’t stand the separation and goes into a rage.

For the classical analyst this was a defense against genuine closeness. The idea was that the patient is afraid of closeness, and experiences it as a loss of self. Modern analysts would agree with Kohut that Z’s rage was a reaction to suddenly feeling separate, or as it is now more likely to be put, his feeling suddenly abandoned. But this does not go deep enough—or is not superficial enough.

The key deficiency that characterizes narcissism is the inability to regulate give and take in a relationship. Once the therapist speaks, Z could feel the hour is lost to him, because as I said earlier, such patients see the therapist (and everyone else, I should add) as the narcissistic one. So once the therapists speaks his ego is on the line. This would infuriate Z in just the same way that his own behavior could infuriate others. And narcissistic people tend to be among the most intolerant of narcissism. Indeed, that is their problem.

When we get further into the heads of patients like Mr. Z, we find some surprises. First, we are likely to find that Z is puritanically opposed to narcissism. In other words, once we stop being opposed to it and holding patients responsible for it, we find that they are opposed to it, and even that that is their problem.

We find it common for the narcissistic patient to be an expert at picking up other people’s narcissism and feeling especially vulnerable to it, as well as very disapproving of it. As I noted earlier, the therapist is seen as always trying to take the stage, or having to suppress trying to take the stage. So Z would try to fill up the time in order to get himself heard. As I also noted earlier, that has to be done in considerable detail because the therapist’s attention is seen as fickle, waiting for the next opportunity to grab the stage.

But since being so self-centered is, for these patients, the worst thing to accuse anyone of and since everyone seems to be that way, they are not likely to ever reveal this view on their own.

This makes it a big accomplishment for a narcissistic patient to say, once the therapist has begun to speak, “Well, there goes my hour.” This is being free to be narcissistic. Maybe even to enjoy it. That’s what narcissistic gratification would really look like. If the narcissistic patient has this kind of freedom, then narcissistic rage at slights is much less likely.

This is what makes the CBT discoveries relevant. If we really take a close look at what is going on in patients’ minds, a lot of the guesses therapists make about what patients are doing don’t hold up. For example, the narcissistic patient who is enraged and denounces the therapist can sound like a little child. And that itself is important, because partly it is a repetition of childhood tantrums (any adult who has tantrums will have had tantrums as a child, or at least I have not found any exceptions to that rule). But, as I put it earlier, there always is an ego and superego at work, even though it can be hard to detect. Freud did not “discover” the superego until he had been doing psychoanalysis for 25 years, and even thought his life work was complete (see Analyzing, Not Psychoanalyzing).

So it is hard to see that when Z had his tantrums he was condemning himself for it, and also feeling that he was making Kohut hate him. If you keep the self-talk paradigm in mind then you do not need to “decenter,” because then you really don’t see the patient as doing anything that unified. Then you take the Kohut revolution one step further, seeing Z as highly divided, and as likely to be more condemning of himself than Kohut. Or seeing Henry as struggling with his anger at the therapist.

Remember how Henry’s therapist reported Henry as saying that “he was pleased to have attained the freedom to ‘rant and rave’.” “Ranting and raving” is a self-mocking expression. It is not like having the fun of getting to really put the therapist down, like for Henry to be able to stop being polite and to say to Thomson: “Thomson, I’m sick and tired of you moaning and groaning about how I’m making it so hard for you to be helpful.”

Henry really did not feel he had much of a right to be angry. And for the therapist to take Henry’s silence as simply anger is really leaping over the fact that Henry is sitting there, or lying there, immobilized. The literal fact is that Henry can’t be angry.

So the fourth analysis of Z would need to get into more of the details of what was going on inside him. To use a contemporary analytic buzz word, each of Z’s analyses was getting more “experience near. ” The first analysis was the one most distant from his experience.

Now, what is all this saying about insight and about interpretations? First, that we assume that interpretations really do promote insight. But do they? Here is what Kohut finally came out and said in one of his last papers (How Does Analysis Cure, p. 208):

I believe that drive theory and the theory of the movement from dependency to autonomy and from narcissism to object love are, or have gradually become, a moral system in scientific disguise; I therefore believe, verbal disclaimers to the contrary, that the actual practice of analysis is burdened by hidden moral and educational goals.

In other words, what we can call the standard dynamic model is prone to be moralistic, which in simple terms means condemnatory—that interpretations often are putdowns, sometimes subtle, sometimes not. So when we ask “Do we have time for insight?” the answer is “No, not for a lot of what we think of as insights.” They often are hidden putdowns, as Kohut is saying here.

Or, another lesson from all the analyses of Mr. Z, is that interpretations are often not experience near. They often do not strike an immediate chord, and often, as in Z’s first analysis, they even violate a patient’s experience.

It is hard to accept patients’ experience enough to really help them have it. Even Kohut never got that far. He could forgive Z for being touchy and difficult, but he never went so far as to help him to be better at convincingly expressing such feelings. Like for Miss F (see Ego Analysis Vs. Self Psychology) to put the shrillness into words, as to say:

When you speak I just suddenly get furious, and then you get careful with me and that makes me feel even more furious. I feel like I’m really getting something across (“controlling your mind”) and then I suddenly find you’re someplace else.

Maybe she would even get to the point of being able to enjoy complaining, really making Kohut sit up and take notice.

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