A Self Psychological Perspective on Chronic Illness Carol Garet

Clinical Social Work JournalVol. 29, No. 2, Summer 2001

A SELF-PSYCHOLOGICAL PERSPECTIVE ONCHRONIC ILLNESS

Carol Garrett, Ph.D., C.S.W., andMichele Greene Weisman, L.C.S.W.

ABSTRACT: It is becoming increasingly common to encounter patients seek-ing psychotherapy for symptoms resulting from chronic illness. Regardless of thespecific diagnosis, chronic illness is a phenomenon with deep implications fordisruption of self-states and narcissistic injuries. Working with chronically illpatients presents many challenges to the patient and the therapist, ranging fromacute grief and loss to a reworking of unresolved developmental issues. This paperexplores the use of a self-psychological perspective in the treatment of chronicand terminal illness. Approaching treatment from a self-psychological perspective,psychoanalytic psychotherapy can be successfully utilized in conjunction withsupportive therapy.

KEY WORDS: chronic illness; self psychology; narcissistic injury; selfobjectexperience; countertransference.

It is becoming increasingly common to encounter patients seekingpsychotherapy for symptoms resulting from chronic illnesses, such as:cancer, human immunodeficiency virus (HIV), multiple sclerosis (MS),epilepsy, chronic fatigue syndrome, cardiopulmonary disease, and infertil-ity. Regardless of the specific diagnosis, chronic illness may produce uncer-tainty and anxiety, threatening the sense of self. This heightens the poten-tial for depression, emptiness, despair, isolation, and disillusionment.Moreover, managed care has resulted in shorter hospital stays resultingin more home care. These services are often provided in a fragmented,uncoordinated manner, which parallels and thus magnifies the affectivedisorganization of the patient (Hardiker & Tod, 1982). Thus, adjustment tochronic illness requires the development of coping skills for the numerouspresenting problems. It is important that clinicians increase their knowl-

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edge base regarding the physical, biological, and psychological diagnosticvariables.

Patients with chronic illness often feel angry, frightened, inadequate,confused, and alone. Therapy frequently includes a case managementcomponent and direct services (such as contact with agencies involved inthe care plan) thus breaking with traditional psychoanalytic and psycho-dynamic approaches. Self-psychological concepts offer an important per-spective and bridge to working with the narcissistic vulnerability anddisruption in self-object ties that chronic illness often stimulates. It pro-vides an adaptive framework that addresses the fragmented self andpromotes a vitalizing self-object experience. Thus, the chronically ill pa-tient can develop internal coping mechanisms and address both the frag-mented self and the fragmented service delivery system. Moreover, thecapacity to maintain cohesion (of self and service delivery system) iscrucial in working with chronically ill patients.

CHRONIC ILLNESS

Chronic illnesses are diseases that are perpetual, permanently affect-ing, and disruptive. Patients are faced with incurable, sometimes debili-tating illnesses with potential for physical disabilities, disfigurement, anda shortened life (Blout, 1998). Irrevocable and pathological changes inthe body require continuing observations, diagnostic tests, medical inter-ventions, and rehabilitated efforts. Syndromes may include the loss ofphysical and/or mental capacity and create dramatic changes in the levelof functioning. Given the fact that each disorder produces a diverse andunique symptomology, repercussions will vary with specific diagnoses(Kerson & Kerson, 1985). Diagnostically, chronic illnesses can be difficultto identify and their course hard to predict. Onset can be slow and insidi-ous. A patients physical condition affects psychological functioning, impli-cating issues of self-concepts, mood, interpersonal relationships, and thusimpacting all aspects of diagnosis and treatment.

Most of the illnesses discussed in this paper tend to wax and wanein an unpredictable non-linear pattern of remission and relapse. Sincedenial and disbelief are almost inevitable elements in this unpredictablescenario, physical symptomology must be addressed immediately in orderto avoid irreversible progression of the disease process. Unpredictabilityand uncertainty are unifying themes leading to more complex intrapsychicfears. Adjustment to diagnosis and treatment depends on previous levelsof psychological functioning, symbolism attached to the illness, objectrelations, and the support available from significant others (Goin, 1990).Pre-morbid history and level of psychological functioning will influencethe meaning attached to the illness and may stimulate a reverberation

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of disruptions experienced in earlier developmental stages. Fear of lossof control, dependency, separation and loss, shame and guilt, anger, isola-tion, and sexual issues may be rekindled when confronting a chronicillness. These earlier fears may cause current disillusionment and disrup-tion in values, ideals, roles, ambitions, goals, and self-states.

Societys emphasis on personal responsibility extends to matters re-lated to health. Although each illness presents with specific symptomologyand issues, all are permeated by societal concepts and themes that placevalue judgments on sickness and health. Most individuals diagnosed witha chronic illness contemplate some notion of blame for their sickness ordisability. Anticipating disapproval and even castigation, patients oftenblame themselves, creating a false sense of mastery and control over theirillness. The clinicians role is to help patients and families realisticallyassess and accept the illness and thus maintain a realistic and cohesivesense of self that will facilitate re-adjustment and adaptation.

SELF-PSYCHOLOGY

As theorized by Heinz Kohut (1984), self-psychology is based on selfob-ject theory. The self is conceptualized as an intrapsychic organizationthat has stability over time and provides one with a sense of self-esteemand well being. The creation of the self is built on the internalization ofthe empathic responsiveness of selfobjects. The term selfobject is oftenmisunderstood, most frequently in thinking of the selfobject as a person.To be sure, a person frequently performs the selfobject function. However,the selfobject is the function not the person. The earliest selfobject experi-ences are brought about by the primary caregivers and help to developcohesion, vigor, and harmony (Kohut & Wolf, 1978, Wolf, 1988). Kohutemphasized how vital it is to provide continually positive selfobject experi-ences to help maintain the sense of self. Kohuts (1971) major premise isthat selfobject experience is the mortar that holds the parts of the selftogether. The emergence of the sense of self and its cohesion is affectedby three main selfobject experiences: idealizing, mirroring, and twinship/alterego. Paradis (1993) eloquently describes how faulty selfobject experi-ences contribute to fragmentation and emptiness whereby self sustainingselfobject experiences emanate from people, symbols, achievements, goals,and aspirations, and contributes to the emergence, maintenance, andcompletion of self identity (p. 405).

Empathy in the broadest sense refers to the identificatory reactionsof one individual to the observed experiences of another. The empathizeris both in tune with and concerned about the internal world of the patientin an affective experience-near state. It is variously referred to as empathicconcern or empathic emotion and is characterized by feelings of warmth,

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compassion, and concern (Davis, 1983b, Garrett, 1999). It is distinguishablefrom both sympathy and unpleasant feelings of distress or unease, whichare not necessarily feelings in tune with the other, but more personalfeelings about the others experience. Social workers have long appreciatedthe importance of empathy as critical to a supportive therapeutic relation-ship (Shulman, 1984). Kohut broadened the scope of empathy by bringingit to the analytic relationship, making his contribution in this area unique.

Kohut (Elson, 1986) further described the nuclear self as a centralsector of the personality that was cohesive and enduring. He believedthat this structure was the basis for the sense of self, as an independentcenter of initiative and perception, that it was integrated with centralambitions and ideals, and with the experience of body and mind as a unitin space and a continuum in time (p. 20). The nuclear self is what isaffected in chronically and terminally ill people, and their significantothers, as they experience loss of control precipitated by the knowledgeof the presence of disease. From the point of diagnosis, pervasive feelingsof powerlessness and fragmentation result in the inability to trust onesbody. Further, orientation is severely compromised as the knowledge andpresence of disease leads to feelings of disillusionment, unpredictability,and the loss of a sense of self. Kerson and Kerson (1985) state, the patientcan never again be completely free of the knowledge that ones body hasbetrayed her, and may again (p. 279). Thus, treatment of chronic illnessesmust contain a psychological component in which the clinician providesa continuing positive selfobject experience that the patient can utilize tosustain the sense of self with a vitalizing selfobject experience. Establish-ment of a self sustaining environment will protect current attachmentsand promote an orientation to the future. Facilitating maintenance ofselfobject ties and sense of self may enhance the patients ability to followdifficult and prolonged medical treatment.

With the establishment of the self at the core of the personality,Kohut sees the striving to gain and maintain self-esteem as the centralorganizing force in personality development (Goldmeire & Fandetti, 1992;Kohut, 1971, 1977; Wolf, 1988). Self-esteem is enhanced throughout lifeby developing ideals, striving for competence, and pursuing goals. Kohutposits that the need to be continually fueled by empathic attunement(idealizing, mirroring, twinship, and adversarial selfobject experiences)is necessary throughout the life-cycle. Self-esteem is often compromisedwhen physical problems deleteriously affect functioning. The disruptionof illness, especially serious and chronic conditions, may negatively impactself-esteem and result in narcissistic injuries (Kohut, 1971, 1977, 1978,1984, 1990). These narcissistic injuries, in essence wounds to the senseof self, must be empathically understood in order for clinicians to assisttheir chronically ill patients.

The self-psychologist understands, relates, and collects data through

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empathic attunement and vicarious introspection. This enables the clini-cian to provide the soothing and confirming functions necessary to addressdisruptions within the nuclear self. Since the nuclear self is a product ofearly selfobject experiences, the less secure the internal nuclear self,the more there is a need for externally reflected reparative selfobjectexperiences. The nature of the selfobject experience, the subsequent statusof the nuclear self, and the appropriate corrective response of the clinicianwill all vary and must be assessed on a case-by-case basis. As Wolf (1977,personal communication) stated, one mans wobble is another mansearthquake.

Experience-near empathy informs the therapist how to assess andrespond to the unique dilemmas of the chronically ill patient. Workingwith chronic illness highlights what Goldstein (1995) believes about im-mersion of the therapist into the clients experience: the therapist relin-quishes the role of expert judge of reality and what the patient thinksand feels. Moreover, he or she gives up a one-sided view of what transpiresin treatment, recognizing that both therapist and client exist in an inter-subjective context in which they exert a mutual impact on one another(p. 409). In a similar vein, Pine (as cited in Buckley, 1994) suggests thatthe therapist support the object relation ties and maintenance of defensivestructure, thus creating a balance in the therapeutic relationship thatsupports the clients subjective experience of the unpredictable issuesarising from chronic illness.

The analysis of the self and defensive pattern it maintains whenfacing the disruption of chronic illness can provide a window to previouslyexisting self-states and the nature of the narcissistic injuries by whichthey have been compromised. The crisis of diagnosis and subsequentmedical treatment confronts mortality, self-sufficiency, and self-identity.The awareness that life is finite and the body imperfect disturbs themirroring, alterego, and idealizing selfobject experiences that providesstability to the self. The patient may experience despair, isolation, anddepression. Rather than feeling positively mirrored and supported, thepatient can feel rejected and worthless. Twinship and alterego selfobjectexperience is disrupted by the loss of likeness, partnership, and identifica-tion with others who remain healthy. The idealizing selfobject experiencebecomes critical in facilitating the merger with the selfobject other toprovide, calmness, power and goodness for the restoration of the self (Wolf,1988).

PHASES OF ILLNESS

Developmental phases of the illness are distinguished in three sepa-rate and distinct phases: crisis, chronic, and terminal (McDaniel et al.,

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1992). Predictable and universal psychological factors color patients expe-rience during every phase of illness. These issues may be present indifferent stages, although more dominant in one phase than another.Conversely, adaptive coping patterns and selfobject experiences activatedfor one stage may not be functional at another point in the illness.

The crisis phase often begins prior to and during diagnosis and maybe reactivated during acute episodes (McDaniels et al., 1992). Defensesmay become rigidified or completely shattered, as the patient experiencesthe uncertainty and even terror about facing abandonment, dependency,and the unknown. In the crisis phase, the illness plays a dominant rolein the patients identity. Some patients live their lives around the illnessand may even become the illness (Kerson & Kerson, 1985). Others maypretend they are not ill, adding stress to an already stressed existence.The selfobject needs at this time are mirroring and idealization that willprovide acceptance, affirmation, and validation. It is important for thepatient to idealize the treating medical team as a means of fosteringtherapeutic hope.

Shame based concepts of illness can be problematic for both patientsand significant others. The patient may feel inferior for having an illnessand guilty for exposing significant others to grief and pain. The desire toprotect self and others can result in withdrawal and isolation, furthercompromising an already fragmented self. Significant others may not becognizant of either the patients emotional state or how best to relate tothis fragile individual. Communication breakdowns can further exacer-bate disruptions in object relations and the accompanying feelings ofisolation and abandonment. Treatment in this phase is directed towardempathic attunement, so that the clinician can receive and help the pa-tient become aware of the range of feelings about the illness, many ofwhich are being defended against. It is crucial for the clinician to avoidmoving faster or slower than the patient. The clinician may feel the patientshould not be in denial when in fact the denial is a necessary and healthydefense and coping mechanism. Empathic attunement and mirroring arecrucial skills during the crisis phase and provide the patient with anavailable empathic selfobject experience. By facilitating the developmentof a regressive relationship with the therapist, the patient can begin towork through the crisis in a safe and supportive environment (Cohler &Galatzer, 1990). The case of Ms. K illustrates how denial is used bothdefensively to ward off fears of dependence and as a coping mechanismto allow her to continue to maintain her sense of self-esteem.

Ms.K, a 45-year-old woman, was diagnosed with MS after an acute episodeof optic neuritis resulting in double vision, vertigo, and loss of peripheral vision.Upon diagnosis Ms. K became frightened and depressed, presenting with phobic

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symptoms and anxiety. She verbalized feelings of anger and fear of loss of control.Prior to diagnosis, she had been a highly successful, professional, self-reliantwoman. Her fears that her diagnosis would result in dependency on others andan inability to work was a situation perceived to be a narcissistic injury andintolerable. Thus, Ms. K articulately verbalized how the impaired vision stimu-lated her fear of loss of future plans and goals, of becoming disabled, and theuncertainty of the course of the disease. Without effective sight, she could not seea future for herself. After remittance of the first MS episode, and a return of hervision, Ms. K resumed her regular routine with a vengeance, increasing herresponsibilities with an obsessive quality to restore her sense of vitality, selfworth, and deny her narcissistic vulnerability.

She presented in sessions with anger and self-pity juxtaposed with self-deter-mination. She admonished herself for any complaining while wishing she couldbe taken care of. Her bipolar self was attempting to stabilize the narcissisticinjury. At first the client told the therapist that she felt the therapist had seenher as too strong as had others in her life, and therefore expected her to besuperwoman. I just want to rest and be taken care of, Ive had enough. Whenthe therapist was able to explore her countertransferential fears associated withillness and disability, she was able to become a mirroring selfobject by reflectingthe acute feeling of loss and fear. Hence, the patient was empowered to expressher grief about her perceived loss of potency and efficacy.

Ms. K experienced a disrupted sense of self and an inability to regulate self-esteem. Her ambivalence surrounding her need to merge and fear of mergingpresented in her intensity in her work and periods of procrastinating in responseto deadlines from her office. These symptoms centered on merger, self-esteem andseparation in Ms.Ks early development.

The chronic phase varies with each illness but is informed by pre-morbid functioning and early developmental events. When stabilizationoccurs, patients seek education about their illness and become activeparticipants in the medical treatment. This is a time of reorganization oflearning how to live a normal life amidst abnormal conditions (McDanielet al., 1992). The course of chronic disease can be progressive, constant,or relapsing-remitting. Twinship selfobject needs are strong at this time.Homogeneous groups provide this twinship, alterego experience. Adver-sarial selfobject experiences allow for the aggressive drives that paralleladolescent strivings for mastery. A de-idealization of the medical teammay occur in an attempt to restabilize and restore self-functioning. Thisde-idealization may coincide with a common countertransference reactionof the therapist wanting to withdraw from the repetitious focus on bodilycomplaints. During a remissive phase, there is often the collusion of unre-alistic hope and a denial of the chronicity of the illness. This transference/countertransference reaction is reflective of the selfobject needs: mirroringand twinship.

The crisis of diagnosis and each subsequent episode must be under-stood from two perspectives: introspective and extrospective. Not onlydoes it impact on the patients sense of core self but on the reality of object

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relationships. A patient will often present with despair in response toperceived losses relating to body integrity. Body integrity is the sense ofphysical well being where one can depend on ones own body to functionin predictable ways. The illness may be perceived as an external assaultand an internal betrayal. The significance of the body in regard to emo-tional integrity is not so remarkable if one thinks of it in a developmentalperspective. The first information that infants obtain is through bodilyfunctions.

Goin (1990) posits that the body is critically connected with the evolve-ment of basic trust, separation-individuation, and an integrated senseof self. This concept of the physiological individual combining with psy-chological growth plays a central role in development throughout life.Damage to the integrity of the body has a natural symbolic link to damageto the integrity of the ego (p. 521). Dealing with a range of symptomsthat encompass many losses, the chronically ill patient often suffers afeeling of fragmentation, depression, and withdrawal in attempting tocope with his or her illness. There is a sense of fear, shame, apprehension,and helplessness. The patient may feel rejection from those who are closeto him/her and a withdrawal of affection. The realities of the illness andtreatment may lead to physical disfigurement, disability, and dependence,which further serve as a reminder of lack of control over their own bodiesand vulnerability as human beings. As with Mrs. L, many patients whoare faced with chronic illness pose the question Why Me.

Mrs. L, a 33-year-old married social worker, originally sought psychotherapyfor issues related to anxiety and depression. She had a strong need to controleverything around her and had begun to explore her perceptions of herself asfraud, not good enough, and fearful of others discovering her liabilities. She haddecided that she wanted to have a child when she was 30. Six months after her30th birthday, when she had not conceived she began to seek medical advice.After many procedures and failed attempts she became isolated, removed, andangry. She grieved with each menstrual cycle, saw herself as a failure and inade-quate as a woman. My body has betrayed me, every one around me is havingbabies but I cant do it, its my fault.

The countertransference reactions to this client were intense. At first thetherapist was able to be a mirroring object, to reflect and empathize with thepain, loss of control, and severe disappointment the patient felt. The selfobjectexperience allowed the patients selfobject needs to unfold in the transference.She became less anxious and was able to relinquish control over her work andin her relationship with her husband. However, in a session when she spoke aboutthe insensitivity of friends who brought their babies to gatherings and of notbeing able to go the mall because there were babies all around, the therapist feltreality-testing was in order to help the client understand her subjective distress. Itseems like youre having difficulty conceiving and sensitivity to fertility issues isslowly narrowing your ability to interact with others. This statement was takenas an affront. Youre like everyone else, you dont understand what it feels like

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to be the one who is left out, every one is moving ahead and Im stuck with abody that rejects me and wont work for me, no matter how hard I try. Thereality-testing caused a rupture in the empathic bond, which manifested in anexacerbation of the self-pitying response. Self pitying is a response to an injuryto the self, its purpose is to be self-soothing, reengaging of another, and it is asubtle but potent expression of hostility. The latter is directed both toward theself and others (Wilson, cited in Goldberg, 1985).

It was at this point that the therapist realized she had taken an experiencedistant position in response to her discomfort (helplessness and powerlessness)causing an empathic failure. Ms. L felt that the therapist had become critical ofher, reviving the harsh punishing selfobject experience she had had with hermother. The clinicians urge to help Ms. L manage her adversity increased herdistress. It was only when the therapist became a recipient for the patientsanguish, anger, and loss, and discussed the therapeutic failure, a positive self-object experience could occur. Thus, the patient was able to experience her feelingsof inadequacy without the shame of failure. Because of the mirroring and twin-ship selfobject experience she became less isolated, restoring and strengtheningthe selfobject tie. Emergence of an alter-ego/twinship transference enabled Ms.L to move forward and become more related and connected to others. She joinedan infertility group and later joined a group for adoptive parents. This alter-ego selfobject experience provided a sense of sameness, competence, and be-longing.

The curative therapeutic relationship results in a selfobject experi-ence that allows the patient to feel understood through the mirroring of thevitality affects. Stern (1985) describes vitality affects as an immeasurablewave of feelings: for example, a rush of anger or joy, an explosivesmile, surprise, or fright, or a burst of determination. There are countlessvariations of these affects, however, each one presents a different vitalityaffect. The therapist taking an experience-near stance mirrors the inten-sity, and validates the affective state.

Ms.A is a 50-year-old Jewish woman from a middle class suburban backgroundwith a two-generation family history of breast cancer. Ms. A was referred threedays after a diagnosis of unilateral breast cancer with significant node involve-ment. She was simultaneously scheduled for a radical mastectomy, breast recon-struction, and breast reduction, similar to her mothers surgery five years ago.Ms. A presented as an anxious, agitated woman, obviously intelligent, with aquick, sarcastic wit. Underneath her bravado, was a fragmented woman, angryand terrified of what was in her immediate and distant future.

Ms. A described her mother as rigid, cold, and demanding. She was criticaland rejecting; not only of her obesity and smoking, but also of her professionalchoices, parenting style, and a host of other core issues. It was diagnosticallyclear that there was a primary disruption in the merger/mirroring process betweenMrs. A and her mother. Her grandiose self had not developed fully and woulddominate the ways in which she experiences herself and would inform the develop-ment of the transference. Ms. As understandable anxiety state showed a deficitin her ability to soothe herself as her mother was not able to positively mirrorher. Ms. A needed an affirming, vitalizing selfobject experience in order to feel

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whole. This was complicated by her projection of facing what she described asmutilating surgery followed by a year or more of intravenous poisoning.

Ironically, Ms. As treatment coincided with the therapist experiencing asurgical procedure. Goldstein (1997) believes that whether or not the therapistself-discloses, patients are often aware unconsciously of subtle changes in thetherapist. Self psychology, based as it is on narcissism and taking the empathicposition toward clinical material, enhances the therapists experience-near posi-tion and not being seduced into self-disclosing or dealing directly with the contentof the presenting material. The genuine, empathic response of the therapist tothe intensity of the presenting material formed an immediate mirroring transfer-ence that enhanced Ms As ability to deal with the vicissitudes of her anxiety.

Ms. A remained in treatment throughout the course of her surgery and lengthychemotherapy. Initially, she perceived treatment as a way to alleviate her anxiety.Her defensive use of sarcasm was her resistance to developing a dependency onthe therapist, utilizing an adversarial transferencemirroring her conflicts overdependency. When she was anxious and uncomfortable from the treatments, shewas desperate to attend sessions however nauseous. Empathic reflections of herdistress, both physically and emotionally, were the key to the development ofmirroring and twinship selfobject transference resulting in a vitalizing selfobjectexperience. The feeling that the therapist understood activated a dimension ofself-representation that allowed for relief of somatic preoccupation, dysphoria,and improved energy level. She slowly resumed activities from which she hadwithdrawn.

Not only did the merger and mirroring in the therapy restore dimensions ofself and cohesion, but enabled Ms. A to begin to mourn the loss of her mother.The process of dealing with the diagnosis and chronicity of breast cancer, the en-suing treatments, and the resulting rage, anxiety, and depression were the pre-senting problem. However, the cancer was not the causal factor, merely the triggerthat activated the early disruption-restoration process to create a selfobject experi-ence that was healing.

It is important for the therapist to have knowledge of the procedures, sideeffects, and prognosis of the specific diagnosis. Cancer particularly, is often metwith dread and myth. It is a selfobject failure for the therapist to perpetuatemyths and/or misinformation. Education becomes crucial in strengthening thepatients competency and locus of control. In Ms. As case, focusing on the diseasealone, without considering developmental issues, would have been a therapeuticfailure. Therapists often wish to dispense a cure and in so doing, minimize theemotional effect of the circumstance from the patients perception. This disruptionin empathic attunement may create a derailment in therapy resulting in loss ofthe therapist as a representation of past selfobject failures.

A countertransferential risk in working with this client populationis the therapists own fears and vulnerabilities to illnesses. This mayarouse the need to distance from the clients affective state in order toease the therapists discomfort. The therapists recommendations of sug-gestions often stimulate a negative response as the patient may feel thetherapist is denying the illness and its impact. The client may experiencesuggestions as critical and assume the therapist has an agenda for well-ness rather than an empathic understanding of how best to live with thedisorder. Inappropriate self-disclosure is another risk. The therapist who

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has had a similar condition may assume his/her experience and the pa-tients are the same. Although, this may seem like a twinship experience,it can lead to a disruption because affective states are subjective.

It is expected that empathic failure will occur during the course ofany treatment. The feelings of hopelessness, helplessness, and loss thatreverberate for the therapist and client often interfere with the therapistsability to maintain their experience-near stance. Simply put, the taskof the therapist is to listen, receive, and establish a mirror vitalizingtransference bond, whereby the patient feels held and understood.

The terminal phase occurs when the inevitability of death is clear.This stage demands a focus on issues of dependency, loss, anticipatorygrief, death, and mourning. Idealizing needs, spirituality, and/or a connec-tion with a higher power can serve the function of an idealized selfobject.Kohut felt it was essential that in order to enable the dying person toretain a modicum of cohesion, firmness, and harmony of the self, hissurroundings must not withdraw their selfobject functions at the lastmoment of his conscious participation in the world (Kohut, 1984, p.18).Maintaining selfobject bonds in the terminal phase is a difficult clinicaltask. Because of the realities of impending death and the potential forthe unbearable feelings that there is nothing we can do or say to reversethe process, the therapist must face his or her own impotence. This high-lights the treatment dilemma for both patient and therapist across devel-opmental stages. Therapeutic activities must be directed toward strength-ening the self and addressing the subjective feeling states stimulated byillness.

The state of withdrawal becomes a crucial issue for the patient andthose connected in the intersubjective context. The issue of separationand loss is primary. Family and friends may withdraw from the patientas a defense against loss. This defense is indicated in the refusal tolisten to or focus on the patients need to talk about mortality, advanceddirectives, or saying goodbye. Instead, the family offers platitudes anddenial of reality leaving the patient feeling isolated. Withdrawal may bethe preferred defense by rejecting visitors, creating an illusion of wellbeing, or utilizing reaction formation of their rage by reversing the rolesand caring for the caregiver. An empowering paradoxical effect of thisreaction results in the patient experiencing a sense of independence asdeath approaches. In the therapeutic relationship the patient may with-draw by canceling or failing sessions, withholding payment, or other resis-tance. An effort to disengage from the therapy emphasizes the need foran understanding selfobject; it does not eliminate that need.

Despair is a common theme at this time. The therapeutic goal is totransform this profound despair into a healthier process of mourning.The powerful affect of despair, combined with the reality of feeling hope-less and helpless, requires a reframing to produce a vitalizing selfobject

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experience. The restoration of vitality to the patients sense of core self isthe essential treatment element. Facing the reality of death, the therapistdoes not necessarily have to mirror the same emotions but needs to rever-berate the same intensity of emotions.

IMPLICATIONS FOR PSYCHOTHERAPY

Kohut (1971) has suggested that by carefully attending to the de-mands of the transference, by providing optimal empathy to the selfobjectneeds, the therapeutic process can proceed to build internalized self-structures. The assault on the self, caused by the crisis of chronic illness,requires an experience near empathic experience to restore and maintainself-esteem and self-cohesion. Kohuts (1977) theory of self-psychologyis based on the concept that when the needs of the self are not met,fragmentation occurs and defenses become more primitive. The case exam-ples of Ms. K., Ms. A, and Ms. L illustrate the response to empathicmirroring, support for healthy assertiveness, and the availability of ahopeful idealized other.

Chronic illness is a phenomenon with deep implications for disruptionof self-states and narcissistic injuries, presenting many challenges rang-ing from acute grief and loss, to a reworking of unresolved developmentalissues. By approaching treatment from a self-psychological perspective,psychoanalytic psychotherapy can be successfully utilized in conjunctionwith supportive therapy to resolve developmental issues. The therapeuticrelationship becomes one of the crucial components toward attaining cohe-sion over fragmentation and vitality triumphing over despair.

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Carol Garrett, Ph.D., C.S.W. Michele Greene Weisman, L.C.S.W.999 Walt Whitman Road 58 Gentry DriveMelville, NY 11747 Englewood, NJ 07631631-385-0037 [email protected] [email protected]

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A Self Psychological Perspective on Chronic Illness Carol Garet