Which of the following best exemplifies the psychoanalytic idea of transference?

Defining Object Relations and Self Psychology

Object relations and self psychology delineate how human beings, from infancy onwards, develop a concrete inner concept of the fact that they are a separate self (with concrete boundaries and unique needs, feelings, perceptions, and cognitions) and that there are other separate selves in the world (with their own concrete boundaries and unique needs, feelings, perceptions, and cognitions). It also deals with how the human mind maintains theseintrapsychic constructs in such a way that an individual can interact effectively with his or her counterparts in the real world outside one's mind – the real people that the internal object relations represent.

Put succinctly, we are social animals. To function effectively, we must know who we are, who others are, and how we can effectively understand them and communicate with them. It is our internal object relations and our internal sense of self that allows us to do so.

Theoretically, all of this intrapsychic structure and processing is primarily unconscious. We are not aware of our object relations, nor do we consciously partake in shaping them. Moreover, in a classic reading of object relations/self psychology, the formation of our object relations happens during infancy and early childhood (although later events, such as severe abuse later in childhood, can certainly impact on both object relations and our sense of self and self-worth). The unconscious process that allows one to take an image of another person and bring it into one's own unconscious, where it becomes an object relation, is generally called introjection or internalization. Consequently, in the literature you will sometimes see a specific unconscious object relation called “an introject.”

At one level, our sense of self is so secure and natural that the above processes are hardly given a second thought by most of us, for they have been secured during infancy and toddlerhood (often secured at such an early age that we do not have many, if any, memories of the timeframe). Moreover, these unconscious introjects have been used daily since. They appear as “a given” aspect of our daily functioning.

At another level, this developmental process is, in reality, extraordinarily complex and delicate. A newborn probably has essentially no conceptual framework that it exists as a distinct entity from the rest of the world. A newborn will need to discover its own physical boundaries. As time goes on, this very basic sense of self will have to become vastly more sophisticated, to the point that the individual recognizes his or her own needs, feels capable and safe being alone, feels that he or she can safely approach other human beings (who for the infant and toddler are monstrously large and all powerful), generally feels that these other beings do not intend harm, can learn to recognize humans who do intend harm (such as an abusive parent or caretaker), develops a sense of self-worth, enjoys a sense of competency, and develops the ability to empathize and get along with others. This is the core evolution of a human's object relations and his or her self psychology in the opening 4 or 5 years of life.

I. Self Psychology Defined

Self psychology refers to the method, observations, and theory that grew from the novel clinical descriptions put forward by a pioneering psychoanalyst from Chicago, Heinz Kohut, primarily in the late 1960s and 1970s. However, the seeds for the development of self psychology were put in place by Kohut in a seminal 1959 paper titled “Introspection, Empathy, and Psychoanalysis.” In this early paper, Kohut set the groundwork for what was to come by defining the faculties of introspection and empathy as crucial tools and determinants of the clinician in the analytic encounter. Much as an internist uses a stethoscope, an analyst uses introspection and empathy. Introspection was defined as a person's ability to use self-reflection to know his or her own internal states, including emotions, thoughts, fantasies, and values. By contrast, empathy was defined as “vicarious introspection,” by which Kohut meant a person's ability to be cognizant of and accurately apprehend another's mental states, that necessarily involved accessing one's own internal cognitive skills, memories, and emotional states. In defining the arena of psychoanalysis as within the jurisdiction of that which is comprehended by empathy and introspection, Kohut moved psychoanalysis away from a preoccupation with forces, vectors, and structures, and toward subjective states and more explicitly phenomonological processes. It was the “self rather than a more abstract metapsychological concern that dominated Kohut's thinking, and which was made accessible by introspection and empathy.

How self psychology and classical analysis fit together is a fascinating study of politics in psychoanalysis. In some ways, over the years, self psychology has taken its own path and departed from the mainstream of classical analysis in the United States. However, in other ways, certain key aspects of self psychology have more recently been integrated into the mainstream of classical analysis and has fueled and enriched the entire corpus of contemporary psychoanalytic theory. Thus, although there are many clinicians who think of themselves as “self psychologists,” some of the principles of self psychology can now as well be found in the mainstream and are the source of many different and helpful ways of formulating clinical interaction.

Recognizing the Developmental Level of the Patient's Defense Mechanisms and Sense of Self

It is beyond the scope of this chapter to discuss the assessment techniques needed to determine the appropriateness of the patient for each form of therapy mentioned above. Instead, the focus will be on the delineation of the maturational level of the patient in the sense of the patient's ego development and sense of a stable self (seeChapter 15). The maturational level of the patient is of profound importance in determining suitability for psychodynamic therapies (those therapies derived from analytic theory dealing with the unconscious and transference) but is also of definite relevance in determining the potential for success in all of the therapeutic categories described above. The focus of this section is on a common denominator utilized in considering the use of any of the above therapies.

By thematuration level of the patient, we are simply referring to a commonsense concept that patients will be functioning at widely varying degrees of psychological maturity at varying moments of their lives. As we saw inChapter 15, when we were exploring object relations and the psychology of the self, at one end of the continuum the patient may be functioning at a severely regressed and psychotic state, in which reality contact itself is compromised. In the middle of the continuum one finds the psychotic-prone personality disorders (people coping with personality dysfunction as seen with borderline and paranoid personality disorders) described inChapter 14. These people generally have better reality contact than grossly psychotic patients. On the other hand, such patients may be limited by rigid coping skills such as severe black/whiting and problems with object constancy that create great difficulties in establishing intimate relationships. At the opposite end of the maturation continuum we find the more stable personality disorders, the neurotic disorders, and those people with healthy functioning.

During periods of stress, individuals may move backwards along this continuum. Following an automobile accident resulting in the death of his spouse, a well-functioning individual may experience a brief reactive psychosis. On a more subtle level, a business executive who displays some passive-aggressive and narcissistic traits may, if hospitalized for a serious illness, begin to function as if truly representing an unstable narcissistic personality disorder.

This issue of stress represents a crucial consideration for the clinician as an attempt is made to identify the suitability of the patient for psychotherapeutic intervention. In general, the more immature the patient's level of psychological integration, the less likely he or she is to tolerate stress, especially on an interpersonal level. Specific therapies vary in the degree to which the patient is stressed by the clinician, either emotionally or cognitively. The goal of the interviewer is to determine which therapy will be of most value for this patient at this time.

1.01.2.1.3 Self-psychology Model

Self-psychology is a branch of object-relations theory and was introduced by Heinz Kohut (1913–1981), who initially started from constructing a theoretical model of narcissistic personality disorder. Departing from the Freudian theory of sexual drives, Kohut emphasized the critical role of empathy in human development and in the therapeutic relationship also. He stated that deficits in the self, and not internal conflicts, are the source of psychopathology (Gabbard and Rachal, 2012). According to Kohut, self-cohesion is the primary driving force of human development and is derived from the inevitable disappointments of innate grandiosity and exhibitionistic needs (Kohut, 1971). The child naturally expresses feelings of grandiosity, omnipotence, and perfection and needs a selfobject (e.g., the mother) to empathically mirror/allow the unfolding of these expressions. In this way, a healthy process of idealization occurs, where the child internalizes an idealized image of the parent with whom he wishes to merge (Fonagy, 1998). The internalization of the mirroring function and of the idealized selfobject (the mother) gradually lead to the consolidation of the self. When the child's narcissistic needs are not met, the primitive grandiose self and the image of the idealized parent remain unintegrated, and manifest in a crude form, such as the behaviors characteristic of pathological narcissism (e.g., rage in reaction to threats to self-esteem). When mirroring responses from the parents are appropriate, selfobject needs (i.e., to be mirrored) become less pressing and more diverse. Also, the internalization of selfobjects into the structure of the self will reduce the need for seeking external validation (Kealy and Ogrodniczuk, 2019).

Why Limbic Music?

Why introduce, let alone carry forward, “Limbic Music” in this text? One cannot justify attention to the limbic system with a trite, “because it's there,” since for more than four decades there has been debate over whether or not it is4—but more on that to come. Instead, the limbic system and the Limbic Music concept provide a site where philosophy, psychology, and biology can co-mingle in ways that are clinically practical. Make no mistake, though; while the limbic system is fertile scientific ground, its clinical usage in this chapter does not always reflect 100% established brain–behavior relationships.

Dr. Murray made no bones about his paper being “primarily heuristic.”5 Some aspects of Limbic Music stray into the realm of metapsychology. Describing an emotionally detached, hyper-rationalized person as an “overgrown neocort” or a mercurial, shallow thinker as a “thin-layer neocort”2 exemplifies the descriptive utility of indulging in neuroanatomic metaphor. However, couching meta-psychology in the jargon of neuroscience does not make itipso facto real. It is easy to find “skeptics and enthusiasts in neuropsychiatry.”6 Hyman notes the prematurity of claims sometimes staked by those willing to extrapolate from current neuroscience a complete lack of free will in those who suffer from addictions,7 and Uttal8 arguably puts the lie to a neuroscience of “love” being ready for pedagogic prime time in psychiatry training.9 On the other hand, skepticism is mobilized by some in the ironic service of defending their own non-biologically referent meta-psychologies (e.g., psychodynamics).10,11

Limbic Music favors neuroanatomically referenced explanations, does not shy away from potential accusations of “dualism,” but also recognizes that brain-based explanations are meaningless unless attached to the outside world as understood through psychology and philosophy. Stretching the music metaphor, Limbic Music treats these sometimes adversarial ways-of-understanding like the treble and bass clefs. A holist might see them (correctly) as artificially dividing up the unity of musical notes. But it does not take a dualist to see that some instruments, not to mention our bodies, are constructed such that composition, performance, and appreciation demand that the clefs sometimes be cleft. The same goes for mind–body, bio-psycho-social, and other ways of thinking about, interacting with, and treating our patients.12

So why privilege the brain, let alone the limbic system? Because it is the target organ of our specialty, because the explanation of disease through biological theory is the distinguishing trait of the Western medical tradition of which psychiatry is part,13 and because cognitive neuroscience is marching inexorably toward validating a materialist, brain-based understanding of psychological phenomena.14 Some would argue that, for clinicians, this understanding can be achieved without using the brain as an intermediary. Those arguing otherwise need to be wary of pushing their luck further than contemporary neuroscience can support.15 However, even (misguidedly) putting aside the neglected need for greater neuropsychiatric competency among psychiatrists, an everyday, pragmatic biological model of unconscious processes, which is the essence of Limbic Music, does not get much air time.

Self-Psychology

The theoretical model known as self-psychology was developed by Heinz Kohut and was derived from his observations during the psychoanalytic treatment of patients with narcissistic personality disorder. Unlike object relations theory, which focuses on the internalization of relationships, self-psychology emphasizes external relationships and their impact on the development of self-esteem and self-cohesion. Moreover, Kohut sharply departed from the works of Freud and subsequent ego psychologists by stressing that psychopathology arose from deficits in the self rather than from internal conflict. Hence borderline personality disorder arises from the inability to hold on to others as internal structures who are capable of soothing the self, drug addiction results from a need to fill missing parts of the self, and narcissistic personality disorder arises from being developmentally arrested at an early stage in the evolution of the structure of the self. This developmental stunting is regarded as secondary to empathic failures in the mother or other caretaker. Subsequently, the personality is forged by attempts at restoring wholeness and balance to a fragmented experience of self.

12.3.2 Relational and self psychologies

Social connections were of paramount importance for psychologists, such as George Herbert Mead and Charles H. Cooley, who argued that a child’s sense of self and indeed all thought and emotion emerge through relationships with others, called “objects” by object psychologists, like Margaret Mahler and Heinz Kohut. Cooley coined the term “looking glass self” to capture how the self is built from the qualities seen reflected in the eyes of others. Among the interpersonal experiences that these relational and self psychologists contended were building blocks for a cohesive and balanced sense of self were the following: mirroring (feeling recognized and affirmed), merging (feeling one with another), adversary (being able to assert oneself against an available and responsive other), efficacy (feeling able to elicit a response from the other), and vitalizing (feeling the other is attuned to one’s shifting moods) (Wolf, 1994). It was assumed that only other humans were eligible to provide such relationship benefits. However, human/animal interaction (HAI) research finds that many children report these building blocks in their relationships with their pets (Melson, 2001). Thus, the range of “self object” experiences now includes other species, not just human/human bonds.

An important relationship is that of caregiver/cared for, or nurturer/nurtured. Wild bird feeding (Beck et al., 2001) and even exposure to wild animals (Myers and Saunders, 2002) has been shown to prompt children to think about themselves as caregivers and conservers. There is evidence that children engage in caregiving, nurturing relationships with pets, along with play and companionship (Melson and Fogel, 1996). Given the high incidence of pet ownership and relatively lower incidence of younger siblings and dependent elderly living in households with children, pets may well be the most frequent opportunity to observe, learn and practice nurturing others. This opportunity, unlike the nurture of young children, is not perceived as gendered; that is, children do not identify pet care with the feminine role, but consider it gender neutral, equally appropriate for males and females (Melson and Fogel, 1989). By contrast, children as young as three years of age view the care of infants and young children as “female” (Melson and Fogel, 1988), and gender differences in observed nurturing behaviors toward babies appear by age five (Melson et al., 1986; Melson and Fogel, 1982).

Attachment theory singles out one type of relationship as particularly significant. In the secure attachment relationship, another individual provides the child with a sense of security and safety, particularly under conditions of perceived threat. The founding father, John Bowlby (1969), and mother, Mary Ainsworth (1979), of attachment theory began with the assumption that mothers were the primary attachment figures, but since then, attachment theory and research gradually have expanded the list of potential “attachment objects” to fathers, older siblings, grandparents and child care providers, among others. Human/animal interaction researchers have suggested that pets often function as attachment “objects” for children (Melson, 2001), by giving them a sense of reassurance, calm, and security.

Because secure attachments in childhood are predictive of concurrent and later adjustment, resilience and coping with stress, it is possible that children’s attachments to their pets may be linked to these positive outcomes as well. As we discuss later, there is growing evidence that pets do function as supports when children are feeling distressed or going through difficult transitions (Melson, 2001). The possible role of animals as coping “mechanisms” has implications for children in therapy.

Pets can also help children by acting as an emotional buffer for children coping with a stressful environment or emotional discord. According to Strand (2004), children who have pets in their home often turn to them for comfort during high stress situations such as parental disputes. She has found evidence that children who use their pet interaction as a “buffer” or as a self-calming technique may exhibit fewer behavioral problems because they have an outlet to help them regulate reactions to environmental stressors. The companion animal’s presence allows the child to have something to turn to for emotional support during times of high internal or external conflict. Additionally, the pet provides the constant nurturing and acceptance needed to facilitate healthy coping skills, even in difficult times (Strand, 2004).

Self Psychology

The theorist most identified with the self psychology movement is Heinz Kohut (1913–81), who viewed the development of a cohesive and positive sense of self as the motivation of all patients (Wolitzky, 2011). Unlike traditional Freudian theory, which considers narcissism as pathological and as something individuals typically move away from in the interest of pursuing love of others, Kohut saw narcissism as developing in either a healthy or unhealthy way. He viewed the development of love of self as being separate from love one develops for other objects and suggested that a love of others is not necessary to lead a fulfilling life (Eagle and Wolitzky, 1992). By making this claim, Kohut brought into question Freud's stance that individuals are driven by instinctual (or sexual) gratification (Kohut and Wolf, 1978). According to Kohut, healthy development is dependent on the ability of a child's parents to provide what Wolitzky (2011) terms ‘adequate empathic attunement’ (p. 90).

Failure of parents to provide appropriate empathy is seen as the source of most psychopathology. However, intensive therapy can reproduce the essential elements of the patient's early environment in order to make up the inadequate environment. The goal of therapy is not to interpret unconscious conflict but to help the patient to develop or strengthen one's sense of self. The experience of being fully understood by another person is seen as curative, in that it allows the patient to resume healthy growth.

III.B.2. Self Psychology

Originally formulated by Heinz Kohut, and elaborated on by others, the self psychology paradigm focuses on the role of external relationships in the shaping and maintenance of self-concept and self-esteem. Kohut developed this approach while treating severely narcissistically disturbed patients who appeared to require certain kinds of responses from others in order to be able to function. Although everyone has the need throughout life for a certain amount of affirmation from others, people with narcissistic problems require excessive ongoing validation and confirmation to maintain any equilibrium. Kohut suggested that there may not have been appropriate “mirroring” of self by caretakers who could not empathize with the child's experience when exhibitionistic behavior was a phase-appropriate part of development, consequently impeding the child's formation of a stable identity. As a result, an adult person with narcissistic difficulty cannot internally regulate his or her sense of self and so may feel required to be perfect, or to perform for others to gain adequate attention, constructing a grandiose self. Others do not exist as separate individuals, but merely as objects for gratifying needs.

This dynamic for need gratification might be manifest in treatment in the form of a “mirroring transference,” whereby the patient is compelled to act in various ways to try to gain the therapist's admiration and approval. At the same time, Kohut also described an “idealizing transference” in which the therapist is seen as the powerful and perfect figure who can protect and heal, and the patient's status is boosted merely by association. The self psychology approach has been influential in informing therapists about the nature of narcissistic issues, and the important role of empathy in helping patients with character pathology to develop more cohesive and stable self-identities.

Introduction

Broadly, the field of psychodynamic theory and practice can be divided into the classical drive model and its extension, ego psychology; the object relations models; and the self-psychology model. These approaches can be distinguished by their conceptualization of the libido, first described by Freud as the energizing force of human mental and physical life.

From a drive perspective, the libido is drive-seeking, which means that humans are primarily motivated to reduce the pressure exercised by drives such as the basic sexual and aggressive instincts. In this model, the connection to psychological objects (people cathected with libido) has the purpose of reducing drive-induced tension. For example, the connection with the romantic object serves the purpose of reducing, among others, the sexual drive.

With some variations, the object relations models posit that the libido primarily is object-seeking, meaning that what motivates humans is the connection with psychological objects rather than the reduction of drives. In this model, drive satisfaction is the expression of a successful interpersonal connection rather than its purpose.

Finally, the self-psychology model is a somewhat mixed model whereby the purpose of the connection with others remain the satisfaction of drives. However, what is most developmentally formative is how those drives are satisfied, incarnated in the quality of the connection with one’s psychological object.

In the following three sections, these models will be briefly reviewed with a focus on their elements most relevant to their contribution to the understanding of body image. For space considerations, the child is referred as ‘he’ throughout the text.