The Emergence of Self Psychology: Opportunities and Dilemmas in the Treatment of Anorexia and Bulimia

The theoretical conceptualizations of self psychology and the ensuing implications for the therapeutic stance open up new opportunities for the treatment of anorexia and bulimia. This chapter presents these opportunities as well as the dilemmas stemming from implementing self psychology, illustrated through clinical vignettes (Bachar, 1998).

The fragility of the anorexic or bulimic patient and her tendency to dismiss her needs, feelings and interests mandate the application of a psychotherapeutic approach that would not impose an interpretation “from without,” but rather provide an experience-near “from within” attunement to the patient. Self psychologically informed therapists, more often traditional or classic psychoanalytically oriented therapists, deviate from the free-floating attention technique prescribed by psychoanalysis in favor of special attention and attunement for vicarious introspection into a patient’s sense of self. Special attention is given to the patient’s experience of the therapist’s impact on the patient’s sense of self.

According to Wolf (1988), the patient in self psychologically oriented psychotherapy feels the therapist maintains an attuned stance rather than an adversarial one. The patient thus experiences the therapist’s neutrality as benign; that is, the therapist is affectively on the side of the patient’s self, without necessarily adhering to all of the patient’s judgments and assessments. The therapist, according to Kohut (1984) experiences herself as simultaneously merged with, and separated from, the patient.

The self psychologically oriented therapeutic stance is sometimes mistakenly believed to be supportive or sympathetic, as if the therapist is expected to be kind and gratifying, and to substitute in the here-and-now for the deprivation that the patient had suffered in early development. However, it is important to stress that self psychology does not assert that by providing corrective emotional experience in the here-and-now, those past deficits can be repaired or filled in. The therapist’s transforming-repairing activity that enables such transformative process involves the therapist’s awareness of failures in being empathic to the patient’s needs. Provided that the therapist is successfill in creating an empathic milieu, these failures will not be harmful. On the contrary, these failures, and the therapist’s ability to analyze them in the transference within the basic empathic milieu, are what bring about the transmuting internalization: the process in which the patient (or the child, in normal development) undertakes the functions of the self thus far fulfilled by the therapist or the parent and independently executes them (Kohut, 1971). In other words, this is the process of growing up or being cured.

In infancy and childhood, the child needs to be sympathetically mirrored in the eyes of a parent who looks upon her with joy and delight and provides basic approval. The therapist’s task is to create the proper ambiance for mobilizing the patient’s demands for minoring and for the free expression of these demands in the session. Self psychologically informed therapists meet these needs by acknowledging and attempting to understand the patient’s feelings, wishes, thoughts and behaviors from the patient’s perspective. This is vicarious introspection/empathy. The therapists do not soothe the patient and are not actively enthusiastic about the patient. They understand, justify and interpret the patient’s yeaming for soothing and confinning responses and acknowledge it. They do not actively admire or approve of the patient’s grandiose experiences. Rather, by knowing the crucial role of such experiences in normal development, they can explain to the patient their role in the psychic equilibrium.

Kohut (1984) divides the therapy into two phases: understanding -the empathic minoring stage: and explaining - the interpretation phase. He suggested that there are patients with severe disturbances of the self with whom the entire therapeutic work can be done in the first phase. For eating-disordered patients, prolonged dwelling in this first stage of empathic minoring is crucial. These patients have rarely been understood and accepted for what they are and can therefore experience interpretation, particularly at the beginning of therapy, as an imposition of something from without (Bruch, 1985). The unique therapeutic stance of selfobject is especially significant for the therapeutic issue of interpretation experienced from within or from without (Schwaber, 1984).

To fully understand this stance, an explanation of self and selfobject is in order. Self is the center of the individual’s psychological universe. It is what we refer to when we say “I feel” such and such, “I do” such and such. The healthy human self is experienced as a sense of wholeness,

The Emergence of Self Psychology 21 aliveness and vigor, an independent center of initiative over time and through space. This is the essence of one’s psychological being (Tolpin, 1980).

When individual A approaches another individual B and needs and expects B to fulfill A’s internal needs that A cannot fulfill for himself or herself, then we can, in self psychology terms, say that A refers to B as a selfobject. A on that occasion expects B to behave as if B were not an independent center of initiative. In other words, the term “selfobject” refers to that dimension of our experience of another person that relates to that person’s function of shoring up our self (Kohut, 1984, p. 50).

The internal needs of the self that we have been referring to are needs of self-esteem, regulation of emotions, calming, soothing and a feeling of continuity over time and space. The healthy self can, to a great extent, meet these needs. It can largely regulate self-esteem and it can calm itself. It maintains a sense of continuity, coherence, consistency, cohesiveness and clarity of experience patterns even in the face of considerable stress. In the course of such healthy functioning of the self, others may serve as selfobjects, but the individual relies on them in a mature and limited maimer.

Self psychology (Kohut, 1971) asserts that even healthy and mature individuals need their internal needs to be fulfilled, at least partially, by selfobjects. However, their reliance upon such selfobjects is flexible and mature, i.e., they can endure and even outgrow failures of such selfobjects. The unhealthy self, on the other hand, is largely dependent - and sometimes totally and desperately - on selfobjects to do what the underdeveloped self cannot do.

Wolf (1988) illustrates how a toddler may evoke selfobject response from his mother, whereas the same response cannot be expected in the case of an older child. An 18-month toddler throws a ball, hits a vase and smashes it. As long as the mother can be impressed with the athletic achievement, her response is a selfobject response for the child - she is able to share the child’s viewpoint and be happy with him. When the mother is angry at the child for smashing the vase, she acts as having independent interests of her own. This example demonstrates that the mother cannot always serve, and should not always serve, as a selfobject for the child. If she provided the child with enough selfobject experiences, an occasional failure and acting as an independent object would lead to the child growing up through the process of transmuting internalization.

In childhood, the healthy emergence of the self depends upon appropriate selfobject experiences. When treating patients with disorders of the self, the therapist renews the growth of the patient ’s self by servingas a selfobject for the patient. The therapist does that mainly through meeting the patient’s need of understanding, acknowledgment and approval of his or her unique perspective. As noted earlier, compared to the traditional therapist, the self psychologically oriented therapist emphasizes more and stays longer in the first stage of therapy - the phase of emphatic understanding - before proceeding onto the explaining stage - the phase of interpretation (Kohut, 1984). The therapist acknowledges the patient’s unique perspective, and by interpreting '‘from within” rather than “from without” (Schwaber, 1984), evokes selfobject experiences in the patient and thus renews the growth of the self. An essential element in this process is the therapist’s awareness of potential re-traumatization in the transference caused by inevitable empathy failures. The therapist conveys to the patients his or her special awareness of such recunent failures by interpreting them to the patient. The therapist’s awareness of this rupture and repair allows the therapeutic process to proceed and for internal mechanisms of regulation to be built within the self.

Barth (1991) describes how eating-disordered patients lack the sense of being understood. She describes how much they enjoyed the experience of someone making an active effort to understand then perspective. She vividly describes sessions with such patients, in which whenever the patient felt the therapist’s perspective to be discrepant from her own, the patient felt criticized and diminished. As therapy progresses, patient and therapist learn to identify when the therapist is less attuned to the patient’s perspective. Patients in advanced stages of therapy can talk about their hurt feelings rather than attempt to restore a sense of self cohesion through bingeing and vomiting (Barth, 1991).

Self psychology views eating disorders as disorders of the self. The core conceptualization of the disorder and its cure is that anorexic and bulimic patients cannot rely on other human beings to fulfill their selfobject needs. Instead of relying on people, they resort to food to fillfill these needs (Barth, 1991; Geist, 1989; Goodsitt, 1985; Sands, 1991). Kohut (1971) essentially described two main selfobject needs: mirroring selfobject needs and idealizing selfobject needs.

The anorexic patient derives her selfobject needs from food mainly through mirroring selfobject experiences. Her need of grandiosity is met not by admiration or approval from other human beings but rather from her own conviction that she possesses supernatural powers that enable her to avoid food. Anyone meeting anorexic patients knows how proud and triumphant they feel whenever they lose another pound. This sense of victory and supernatural or even immortal powers is also apparent in many memoirs written by anorexic patients (Verbin, 2016). Their- perceived

The Emergence of Self Psychology 23 ability to ignore this substance, food, fillfills mirroring selfobject needs and evokes a great sense of reward, described by one of our patients as being “wondei-fiil, strong, supernatural, above natural powers.” This sense of victory is accompanied by satisfaction and self-contentment. It validates the patient’s sense of grandiosity (Kohut, 1971).

The bulimic patient satisfies her selfobject needs through food mainly through idealizing selfobject experiences (Barth, 1991; Sands, 1991). She experiences food as an omnipotent power. It provides comfort, soothing and security. It regulates painful emotions like insult, anger, shame, guilt, depression or anxiety (Barth, 1991). Since the eating-dis-ordered patient experiences food and its associated rituals as the main source for fulfilling selfobject needs, she defends it with the same intensity that other people would adhere to a human selfobject.

Goodsitt (1985) identifies in the anorexic patient an extreme manifestation of her inability to refer to human beings in order to fillfill her selfobject needs. She aspires to live as if she is a selfless human being. To ensure such selfless position, she fulfills selfobject needs for others, mainly her parents. Clinging to the position of being a selfobject for others is an effective barrier preventing others from serving as a selfobject for her. Her selflessness is demonstrated through her alienation from her very basic needs, such as nutrition and occupying space in the world. Avoiding occupying space to the extent of almost diminishing one’s body is the most extreme expression of selflessness.

A typical saying of many parents of anorexic patients, confinning this observation, is that “she was our best child.” “She was obedient and never thought of herself and was always conscientious and aware of the needs of other family members.” These observations ensue from the basic position of the anorexic patient as a selfless human being who devotes herself to the fulfillment of others’ selfobject needs. The anorexic patient’s great feeling of triumph upon losing more and more weight actually signifies that she is looking for ways to gratify her grandiose needs; but the content that stands behind the triumphant feeling is again toward selflessness. This is because she is saying in effect, “I can be admired by my success in relinquishing myself.”

Self psychology allows for a therapeutic approach that addresses the anorexic patient’s pathological position toward herself. The self psychologically oriented therapist would look for the patient’s unique subjective perspective even if this perspective is peculiar or weird. By the veiy attempt to look for her perspective, the therapist conveys to the patient the sense that someone values her self highly enough to acknowledge and seek. The therapist’s behavior provides the patient with an empathic milieu. Namely, according to self psychology, it is notnecessarily a warm milieu that is required, but a milieu seeking to understand the individual’s subjective perspective. Note that understanding does not necessarily mean agreeing. The individual needs someone who would make an effort to understand his or her perspective, even if that someone disagrees with it. Kohut (1984) asserts that the therapist’s understanding and acknowledgment of the patient's possibly pathological perspective is not to be feared as causing the patient to cling and adhere to this perspective. On the contrary, when the patient feels that the therapist understands her perspective, she can harness her powers to examine her own ambivalence toward the pathological perspective and rely on the therapist to gr ow.

After the anorexic patient feels that her self is bolstered by the therapist’s search for it and ability to acknowledge it, she can also accept interpretations as to her selflessness and selfless behavior. It is interesting to note, in this regard, a side note of Kohut (1971) saying that the anorexic patient must nourish her self to live, but her life is in danger for her inability to do so because she cannot think of herself as someone worth nourishing.

Self psychology (Geist, 1989; Goodsitt, 1985; Sands, 1991) suggests that eating disorders originate, like other disorders of the self, from chronic disturbances in empathy of the caretakers in early childhood. Eating disorders are unique in that at some crucial point of development, the disordered girl invents an entire alternative system to fulfill selfobject needs. In this system, distorted eating patterns - either avoiding food or bingeing - are used instead of human beings, and the child relies on them because her previous attempts to gain selfobject responses from her parents were frustrating and disappointing.

Geist (1989) maintains that the underdevelopment of the self is expressed as a severe, malignant sense of emptiness. To defend herself against this sense of emptiness, the eating-disordered patient attempts to monitor and control it through her symptoms. She attempts to gain control over the sense of emptiness through voracious and compulsive eating, or through creating “controlled emptiness” by purging (in bulimia) or by avoiding food (in anorexia). Geist suggests that eating is the activity most closely related to filling up or emptying. Therefore, food can become a reliable selfobject for the eating-disordered patient when she symbolically struggles with a sense of emptiness. Sands (1991) adds another element to explain why food and eating behavior can serve as such an attractive substitute for a human selfobject. Food is the first medium through which experiences of soothing and comfort were provided to the child by parental figures. Ulman and Paul (1989) further suggest that since the bulimic patient does not believe that she

The Emergence of Self Psychology 25 deserves to be indulged, her purging activity is her attempt to undo the overindulgence of the binge.

Disordered eating behavior affords the anorexic or bulimic patient a gr eat deal of autonomy over reliance on human selfobject. It provides a certain defense against total fragmentation. However, as Levin (1991) simply puts it, in the context of self psychologically oriented treatment of alcoholics, substance can never adequately fillfill the missing functions of the self. Substance taken in must, obviously, go out. Stable regulators can be built up only through transmuting internalization of self-selfobject relationships with human figures. It is noteworthy in this regard that Kohut (1977a) mentions that in treating a prolonged addiction to dings or alcohol, it is almost impossible to turn to a human selfobject.

The aim of therapy of eating disorders is to reestablish the confidence in the ability of close inter-personal relationships to mitigate dysphoric states. For the therapist, such an endeavor requires much effort and patience, which in turn requires plenty of time. The basic assumption of self psychology, as accurately put by Sands (1991), is that if therapists provide an empathic milieu and analyses the patient’s fear of another re-traumatization in her relationship with the therapist, the archaic narcissistic needs would be harnessed and mobilized toward the therapist in the transference.

In this context, Geist’s (1989) distinction between the object relations of borderline personality disorder and eating disorders is highly relevant. Borderline personality disorder patients swing between fury and fantasies of destroying the object, on the one hand, to immense attraction and desire to unite with the object, on the other. Unlike them, eating-disordered patients entirely give up the possibility of relating to human objects as a source of comfort, soothing and security. It appears that Kohut’s (1987a) distinction between symbiosis and selfobject relations is usefill in distinguishing borderline personality from eating disorders. In symbiosis, the two parties reinforce one another, whereas in self-selfobject relations only one party satisfies the selfobject needs of the other. According to self psychology, the eating-disordered girl’s parents have failed to fulfill their daughter’s selfobject needs and moreover, used their child to satisfy their own selfobject needs. Therefore, the eating-disordered patient does not expect human beings to fillfill her selfobject needs. Conversely, the future borderline personality patient is involved in childhood in symbiotic and intense relationship with the mother (Mahler, 1975; Masterson, 1976). As a result, as an adult the borderline patient is deeply involved in human (albeit unhealthy) relationships, with great fluctuations between approaching and distancing.

The following clinical vignettes illustrate some of the issues evoked by self psychology in the treatment of anorexia and bulimia.

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