Clinical Social Work Journal

Vol. 29, No. 2, Summer 2001

A SELF-PSYCHOLOGICAL PERSPECTIVE ON
CHRONIC ILLNESS
Carol Garrett, Ph.D., C.S.W., and
Michele Greene Weisman, L.C.S.W.

ABSTRACT: It is becoming increasingly common to encounter patients seeking psychotherapy for symptoms resulting from chronic illness. Regardless of the
specific diagnosis, chronic illness is a phenomenon with deep implications for
disruption of self-states and narcissistic injuries. Working with chronically ill
patients presents many challenges to the patient and the therapist, ranging from
acute grief and loss to a reworking of unresolved developmental issues. This paper
explores the use of a self-psychological perspective in the treatment of chronic
and terminal illness. Approaching treatment from a self-psychological perspective,
psychoanalytic psychotherapy can be successfully utilized in conjunction with
supportive therapy.
KEY WORDS: chronic illness; self psychology; narcissistic injury; selfobject
experience; countertransference.

It is becoming increasingly common to encounter patients seeking

psychotherapy for symptoms resulting from chronic illnesses, such as:
cancer, human immunodeficiency virus (HIV), multiple sclerosis (MS),
epilepsy, chronic fatigue syndrome, cardiopulmonary disease, and infertility. Regardless of the specific diagnosis, chronic illness may produce uncertainty and anxiety, threatening the sense of self. This heightens the potential for depression, emptiness, despair, isolation, and disillusionment.
Moreover, managed care has resulted in shorter hospital stays resulting
in more home care. These services are often provided in a fragmented,
uncoordinated manner, which parallels and thus magnifies the affective
disorganization of the patient (Hardiker & Tod, 1982). Thus, adjustment to
chronic illness requires the development of coping skills for the numerous
presenting problems. It is important that clinicians increase their knowl119

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edge base regarding the physical, biological, and psychological diagnostic

variables.
Patients with chronic illness often feel angry, frightened, inadequate,
confused, and alone. Therapy frequently includes a case management
component and direct services (such as contact with agencies involved in
the care plan) thus breaking with traditional psychoanalytic and psychodynamic approaches. Self-psychological concepts offer an important perspective and bridge to working with the narcissistic vulnerability and
disruption in self-object ties that chronic illness often stimulates. It provides an adaptive framework that addresses the fragmented self and
promotes a vitalizing self-object experience. Thus, the chronically ill patient can develop internal coping mechanisms and address both the fragmented self and the fragmented service delivery system. Moreover, the
capacity to maintain cohesion (of self and service delivery system) is
crucial in working with chronically ill patients.

CHRONIC ILLNESS
Chronic illnesses are diseases that are perpetual, permanently affecting, and disruptive. Patients are faced with incurable, sometimes debilitating illnesses with potential for physical disabilities, disfigurement, and
a shortened life (Blout, 1998). Irrevocable and pathological changes in
the body require continuing observations, diagnostic tests, medical interventions, and rehabilitated efforts. Syndromes may include the loss of
physical and/or mental capacity and create dramatic changes in the level
of functioning. Given the fact that each disorder produces a diverse and
unique symptomology, repercussions will vary with specific diagnoses
(Kerson & Kerson, 1985). Diagnostically, chronic illnesses can be difficult
to identify and their course hard to predict. Onset can be slow and insidious. A patients physical condition affects psychological functioning, implicating issues of self-concepts, mood, interpersonal relationships, and thus
impacting all aspects of diagnosis and treatment.
Most of the illnesses discussed in this paper tend to wax and wane
in an unpredictable non-linear pattern of remission and relapse. Since
denial and disbelief are almost inevitable elements in this unpredictable
scenario, physical symptomology must be addressed immediately in order
to avoid irreversible progression of the disease process. Unpredictability
and uncertainty are unifying themes leading to more complex intrapsychic
fears. Adjustment to diagnosis and treatment depends on previous levels
of psychological functioning, symbolism attached to the illness, object
relations, and the support available from significant others (Goin, 1990).
Pre-morbid history and level of psychological functioning will influence
the meaning attached to the illness and may stimulate a reverberation

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of disruptions experienced in earlier developmental stages. Fear of loss

of control, dependency, separation and loss, shame and guilt, anger, isolation, and sexual issues may be rekindled when confronting a chronic
illness. These earlier fears may cause current disillusionment and disruption in values, ideals, roles, ambitions, goals, and self-states.
Societys emphasis on personal responsibility extends to matters related to health. Although each illness presents with specific symptomology
and issues, all are permeated by societal concepts and themes that place
value judgments on sickness and health. Most individuals diagnosed with
a chronic illness contemplate some notion of blame for their sickness or
disability. Anticipating disapproval and even castigation, patients often
blame themselves, creating a false sense of mastery and control over their
illness. The clinicians role is to help patients and families realistically
assess and accept the illness and thus maintain a realistic and cohesive
sense of self that will facilitate re-adjustment and adaptation.

SELF-PSYCHOLOGY
As theorized by Heinz Kohut (1984), self-psychology is based on selfobject theory. The self is conceptualized as an intrapsychic organization
that has stability over time and provides one with a sense of self-esteem
and well being. The creation of the self is built on the internalization of
the empathic responsiveness of selfobjects. The term selfobject is often
misunderstood, 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 experiences are brought about by the primary caregivers and help to develop
cohesion, vigor, and harmony (Kohut & Wolf, 1978, Wolf, 1988). Kohut
emphasized how vital it is to provide continually positive selfobject experiences to help maintain the sense of self. Kohuts (1971) major premise is
that selfobject experience is the mortar that holds the parts of the self
together. The emergence of the sense of self and its cohesion is affected
by three main selfobject experiences: idealizing, mirroring, and twinship/
alterego. Paradis (1993) eloquently describes how faulty selfobject experiences contribute to fragmentation and emptiness whereby self sustaining
selfobject experiences emanate from people, symbols, achievements, goals,
and aspirations, and contributes to the emergence, maintenance, and
completion of self identity (p. 405).
Empathy in the broadest sense refers to the identificatory reactions
of one individual to the observed experiences of another. The empathizer
is both in tune with and concerned about the internal world of the patient
in an affective experience-near state. It is variously referred to as empathic
concern or empathic emotion and is characterized by feelings of warmth,

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compassion, and concern (Davis, 1983b, Garrett, 1999). It is distinguishable

from both sympathy and unpleasant feelings of distress or unease, which
are not necessarily feelings in tune with the other, but more personal
feelings about the others experience. Social workers have long appreciated
the importance of empathy as critical to a supportive therapeutic relationship (Shulman, 1984). Kohut broadened the scope of empathy by bringing
it to the analytic relationship, making his contribution in this area unique.
Kohut (Elson, 1986) further described the nuclear self as a central
sector of the personality that was cohesive and enduring. He believed
that this structure was the basis for the sense of self, as an independent
center of initiative and perception, that it was integrated with central
ambitions and ideals, and with the experience of body and mind as a unit
in space and a continuum in time (p. 20). The nuclear self is what is
affected in chronically and terminally ill people, and their significant
others, as they experience loss of control precipitated by the knowledge
of the presence of disease. From the point of diagnosis, pervasive feelings
of powerlessness and fragmentation result in the inability to trust ones
body. Further, orientation is severely compromised as the knowledge and
presence of disease leads to feelings of disillusionment, unpredictability,
and the loss of a sense of self. Kerson and Kerson (1985) state, the patient
can never again be completely free of the knowledge that ones body has
betrayed her, and may again (p. 279). Thus, treatment of chronic illnesses
must contain a psychological component in which the clinician provides
a continuing positive selfobject experience that the patient can utilize to
sustain the sense of self with a vitalizing selfobject experience. Establishment of a self sustaining environment will protect current attachments
and promote an orientation to the future. Facilitating maintenance of
selfobject ties and sense of self may enhance the patients ability to follow
difficult 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 central
organizing force in personality development (Goldmeire & Fandetti, 1992;
Kohut, 1971, 1977; Wolf, 1988). Self-esteem is enhanced throughout life
by developing ideals, striving for competence, and pursuing goals. Kohut
posits 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 compromised
when physical problems deleteriously affect functioning. The disruption
of illness, especially serious and chronic conditions, may negatively impact
self-esteem and result in narcissistic injuries (Kohut, 1971, 1977, 1978,
1984, 1990). These narcissistic injuries, in essence wounds to the sense
of self, must be empathically understood in order for clinicians to assist
their chronically ill patients.
The self-psychologist understands, relates, and collects data through

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empathic attunement and vicarious introspection. This enables the clinician to provide the soothing and confirming functions necessary to address
disruptions within the nuclear self. Since the nuclear self is a product of
early selfobject experiences, the less secure the internal nuclear self,
the more there is a need for externally reflected reparative selfobject
experiences. The nature of the selfobject experience, the subsequent status
of the nuclear self, and the appropriate corrective response of the clinician
will all vary and must be assessed on a case-by-case basis. As Wolf (1977,
personal communication) stated, one mans wobble is another mans
earthquake.
Experience-near empathy informs the therapist how to assess and
respond to the unique dilemmas of the chronically ill patient. Working
with chronic illness highlights what Goldstein (1995) believes about immersion of the therapist into the clients experience: the therapist relinquishes the role of expert judge of reality and what the patient thinks
and feels. Moreover, he or she gives up a one-sided view of what transpires
in treatment, recognizing that both therapist and client exist in an intersubjective context in which they exert a mutual impact on one another
(p. 409). In a similar vein, Pine (as cited in Buckley, 1994) suggests that
the therapist support the object relation ties and maintenance of defensive
structure, thus creating a balance in the therapeutic relationship that
supports the clients subjective experience of the unpredictable issues
arising from chronic illness.
The analysis of the self and defensive pattern it maintains when
facing the disruption of chronic illness can provide a window to previously
existing self-states and the nature of the narcissistic injuries by which
they have been compromised. The crisis of diagnosis and subsequent
medical treatment confronts mortality, self-sufficiency, and self-identity.
The awareness that life is finite and the body imperfect disturbs the
mirroring, alterego, and idealizing selfobject experiences that provides
stability to the self. The patient may experience despair, isolation, and
depression. Rather than feeling positively mirrored and supported, the
patient can feel rejected and worthless. Twinship and alterego selfobject
experience is disrupted by the loss of likeness, partnership, and identification with others who remain healthy. The idealizing selfobject experience
becomes critical in facilitating the merger with the selfobject other to
provide, calmness, power and goodness for the restoration of the self (Wolf,
1988).

PHASES OF ILLNESS
Developmental phases of the illness are distinguished in three separate and distinct phases: crisis, chronic, and terminal (McDaniel et al.,

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1992). Predictable and universal psychological factors color patients experience during every phase of illness. These issues may be present in
different stages, although more dominant in one phase than another.
Conversely, adaptive coping patterns and selfobject experiences activated
for one stage may not be functional at another point in the illness.
The crisis phase often begins prior to and during diagnosis and may
be reactivated during acute episodes (McDaniels et al., 1992). Defenses
may become rigidified or completely shattered, as the patient experiences
the uncertainty and even terror about facing abandonment, dependency,
and the unknown. In the crisis phase, the illness plays a dominant role
in the patients identity. Some patients live their lives around the illness
and may even become the illness (Kerson & Kerson, 1985). Others may
pretend they are not ill, adding stress to an already stressed existence.
The selfobject needs at this time are mirroring and idealization that will
provide acceptance, affirmation, and validation. It is important for the
patient to idealize the treating medical team as a means of fostering
therapeutic hope.
Shame based concepts of illness can be problematic for both patients
and significant others. The patient may feel inferior for having an illness
and guilty for exposing significant others to grief and pain. The desire to
protect self and others can result in withdrawal and isolation, further
compromising an already fragmented self. Significant others may not be
cognizant of either the patients emotional state or how best to relate to
this fragile individual. Communication breakdowns can further exacerbate disruptions in object relations and the accompanying feelings of
isolation and abandonment. Treatment in this phase is directed toward
empathic attunement, so that the clinician can receive and help the patient become aware of the range of feelings about the illness, many of
which are being defended against. It is crucial for the clinician to avoid
moving faster or slower than the patient. The clinician may feel the patient
should not be in denial when in fact the denial is a necessary and healthy
defense and coping mechanism. Empathic attunement and mirroring are
crucial skills during the crisis phase and provide the patient with an
available empathic selfobject experience. By facilitating the development
of a regressive relationship with the therapist, the patient can begin to
work through the crisis in a safe and supportive environment (Cohler &
Galatzer, 1990). The case of Ms. K illustrates how denial is used both
defensively to ward off fears of dependence and as a coping mechanism
to 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 episode
of 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-reliant
woman. Her fears that her diagnosis would result in dependency on others and
an inability to work was a situation perceived to be a narcissistic injury and
intolerable. Thus, Ms. K articulately verbalized how the impaired vision stimulated her fear of loss of future plans and goals, of becoming disabled, and the
uncertainty of the course of the disease. Without effective sight, she could not see
a future for herself. After remittance of the first MS episode, and a return of her
vision, Ms. K resumed her regular routine with a vengeance, increasing her
responsibilities with an obsessive quality to restore her sense of vitality, self
worth, and deny her narcissistic vulnerability.
She presented in sessions with anger and self-pity juxtaposed with self-determination. She admonished herself for any complaining while wishing she could
be taken care of. Her bipolar self was attempting to stabilize the narcissistic
injury. At first the client told the therapist that she felt the therapist had seen
her as too strong as had others in her life, and therefore expected her to be
superwoman. I just want to rest and be taken care of, Ive had enough. When
the therapist was able to explore her countertransferential fears associated with
illness and disability, she was able to become a mirroring selfobject by reflecting
the acute feeling of loss and fear. Hence, the patient was empowered to express
her grief about her perceived loss of potency and efficacy.
Ms. K experienced a disrupted sense of self and an inability to regulate selfesteem. Her ambivalence surrounding her need to merge and fear of merging
presented in her intensity in her work and periods of procrastinating in response
to deadlines from her office. These symptoms centered on merger, self-esteem and
separation in Ms.Ks early development.

The chronic phase varies with each illness but is informed by premorbid functioning and early developmental events. When stabilization
occurs, patients seek education about their illness and become active
participants in the medical treatment. This is a time of reorganization of
learning how to live a normal life amidst abnormal conditions (McDaniel
et 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. Adversarial selfobject experiences allow for the aggressive drives that parallel
adolescent strivings for mastery. A de-idealization of the medical team
may occur in an attempt to restabilize and restore self-functioning. This
de-idealization may coincide with a common countertransference reaction
of the therapist wanting to withdraw from the repetitious focus on bodily
complaints. During a remissive phase, there is often the collusion of unrealistic hope and a denial of the chronicity of the illness. This transference/
countertransference reaction is reflective of the selfobject needs: mirroring
and twinship.
The crisis of diagnosis and each subsequent episode must be understood from two perspectives: introspective and extrospective. Not only
does 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 to

perceived losses relating to body integrity. Body integrity is the sense of
physical well being where one can depend on ones own body to function
in predictable ways. The illness may be perceived as an external assault
and an internal betrayal. The significance of the body in regard to emotional integrity is not so remarkable if one thinks of it in a developmental
perspective. The first information that infants obtain is through bodily
functions.
Goin (1990) posits that the body is critically connected with the evolvement of basic trust, separation-individuation, and an integrated sense
of self. This concept of the physiological individual combining with psychological growth plays a central role in development throughout life.
Damage to the integrity of the body has a natural symbolic link to damage
to the integrity of the ego (p. 521). Dealing with a range of symptoms
that encompass many losses, the chronically ill patient often suffers a
feeling of fragmentation, depression, and withdrawal in attempting to
cope with his or her illness. There is a sense of fear, shame, apprehension,
and helplessness. The patient may feel rejection from those who are close
to him/her and a withdrawal of affection. The realities of the illness and
treatment may lead to physical disfigurement, disability, and dependence,
which further serve as a reminder of lack of control over their own bodies
and vulnerability as human beings. As with Mrs. L, many patients who
are faced with chronic illness pose the question Why Me.
Mrs. L, a 33-year-old married social worker, originally sought psychotherapy
for issues related to anxiety and depression. She had a strong need to control
everything around her and had begun to explore her perceptions of herself as
fraud, not good enough, and fearful of others discovering her liabilities. She had
decided that she wanted to have a child when she was 30. Six months after her
30th birthday, when she had not conceived she began to seek medical advice.
After many procedures and failed attempts she became isolated, removed, and
angry. She grieved with each menstrual cycle, saw herself as a failure and inadequate as a woman. My body has betrayed me, every one around me is having
babies but I cant do it, its my fault.
The countertransference reactions to this client were intense. At first the
therapist was able to be a mirroring object, to reflect and empathize with the
pain, loss of control, and severe disappointment the patient felt. The selfobject
experience allowed the patients selfobject needs to unfold in the transference.
She became less anxious and was able to relinquish control over her work and
in her relationship with her husband. However, in a session when she spoke about
the insensitivity of friends who brought their babies to gatherings and of not
being able to go the mall because there were babies all around, the therapist felt
reality-testing was in order to help the client understand her subjective distress. It
seems like youre having difficulty conceiving and sensitivity to fertility issues is
slowly narrowing your ability to interact with others. This statement was taken
as 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 a
body that rejects me and wont work for me, no matter how hard I try. The
reality-testing caused a rupture in the empathic bond, which manifested in an
exacerbation of the self-pitying response. Self pitying is a response to an injury
to the self, its purpose is to be self-soothing, reengaging of another, and it is a
subtle but potent expression of hostility. The latter is directed both toward the
self and others (Wilson, cited in Goldberg, 1985).
It was at this point that the therapist realized she had taken an experience
distant position in response to her discomfort (helplessness and powerlessness)
causing an empathic failure. Ms. L felt that the therapist had become critical of
her, reviving the harsh punishing selfobject experience she had had with her
mother. The clinicians urge to help Ms. L manage her adversity increased her
distress. It was only when the therapist became a recipient for the patients
anguish, anger, and loss, and discussed the therapeutic failure, a positive selfobject experience could occur. Thus, the patient was able to experience her feelings
of inadequacy without the shame of failure. Because of the mirroring and twinship selfobject experience she became less isolated, restoring and strengthening
the selfobject tie. Emergence of an alter-ego/twinship transference enabled Ms.
L to move forward and become more related and connected to others. She joined
an infertility group and later joined a group for adoptive parents. This alterego selfobject experience provided a sense of sameness, competence, and belonging.

The curative therapeutic relationship results in a selfobject experience that allows the patient to feel understood through the mirroring of the
vitality affects. Stern (1985) describes vitality affects as an immeasurable
wave of feelings: for example, a rush of anger or joy, an explosive
smile, surprise, or fright, or a burst of determination. There are countless
variations of these affects, however, each one presents a different vitality
affect. The therapist taking an experience-near stance mirrors the intensity, and validates the affective state.
Ms.A is a 50-year-old Jewish woman from a middle class suburban background
with a two-generation family history of breast cancer. Ms. A was referred three
days after a diagnosis of unilateral breast cancer with significant node involvement. She was simultaneously scheduled for a radical mastectomy, breast reconstruction, and breast reduction, similar to her mothers surgery five years ago.
Ms. A presented as an anxious, agitated woman, obviously intelligent, with a
quick, sarcastic wit. Underneath her bravado, was a fragmented woman, angry
and terrified of what was in her immediate and distant future.
Ms. A described her mother as rigid, cold, and demanding. She was critical
and rejecting; not only of her obesity and smoking, but also of her professional
choices, parenting style, and a host of other core issues. It was diagnostically
clear that there was a primary disruption in the merger/mirroring process between
Mrs. A and her mother. Her grandiose self had not developed fully and would
dominate the ways in which she experiences herself and would inform the development of the transference. Ms. As understandable anxiety state showed a deficit
in her ability to soothe herself as her mother was not able to positively mirror
her. 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 as
mutilating surgery followed by a year or more of intravenous poisoning.
Ironically, Ms. As treatment coincided with the therapist experiencing a
surgical procedure. Goldstein (1997) believes that whether or not the therapist
self-discloses, patients are often aware unconsciously of subtle changes in the
therapist. Self psychology, based as it is on narcissism and taking the empathic
position toward clinical material, enhances the therapists experience-near position and not being seduced into self-disclosing or dealing directly with the content
of the presenting material. The genuine, empathic response of the therapist to
the intensity of the presenting material formed an immediate mirroring transference 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 lengthy
chemotherapy. Initially, she perceived treatment as a way to alleviate her anxiety.
Her defensive use of sarcasm was her resistance to developing a dependency on
the therapist, utilizing an adversarial transferencemirroring her conflicts over
dependency. When she was anxious and uncomfortable from the treatments, she
was desperate to attend sessions however nauseous. Empathic reflections of her
distress, both physically and emotionally, were the key to the development of
mirroring and twinship selfobject transference resulting in a vitalizing selfobject
experience. The feeling that the therapist understood activated a dimension of
self-representation that allowed for relief of somatic preoccupation, dysphoria,
and improved energy level. She slowly resumed activities from which she had
withdrawn.
Not only did the merger and mirroring in the therapy restore dimensions of
self 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 ensuing treatments, and the resulting rage, anxiety, and depression were the presenting problem. However, the cancer was not the causal factor, merely the trigger
that activated the early disruption-restoration process to create a selfobject experience that was healing.
It is important for the therapist to have knowledge of the procedures, side
effects, and prognosis of the specific diagnosis. Cancer particularly, is often met
with dread and myth. It is a selfobject failure for the therapist to perpetuate
myths and/or misinformation. Education becomes crucial in strengthening the
patients competency and locus of control. In Ms. As case, focusing on the disease
alone, without considering developmental issues, would have been a therapeutic
failure. Therapists often wish to dispense a cure and in so doing, minimize the
emotional effect of the circumstance from the patients perception. This disruption
in empathic attunement may create a derailment in therapy resulting in loss of
the therapist as a representation of past selfobject failures.

A countertransferential risk in working with this client population

is the therapists own fears and vulnerabilities to illnesses. This may
arouse the need to distance from the clients affective state in order to
ease the therapists discomfort. The therapists recommendations of suggestions often stimulate a negative response as the patient may feel the
therapist is denying the illness and its impact. The client may experience
suggestions as critical and assume the therapist has an agenda for wellness rather than an empathic understanding of how best to live with the
disorder. 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 patients 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 of
any treatment. The feelings of hopelessness, helplessness, and loss that
reverberate for the therapist and client often interfere with the therapists
ability to maintain their experience-near stance. Simply put, the task
of the therapist is to listen, receive, and establish a mirror vitalizing
transference 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, anticipatory
grief, death, and mourning. Idealizing needs, spirituality, and/or a connection 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 to
retain a modicum of cohesion, firmness, and harmony of the self, his
surroundings must not withdraw their selfobject functions at the last
moment of his conscious participation in the world (Kohut, 1984, p.18).
Maintaining selfobject bonds in the terminal phase is a difficult clinical
task. Because of the realities of impending death and the potential for
the unbearable feelings that there is nothing we can do or say to reverse
the process, the therapist must face his or her own impotence. This highlights the treatment dilemma for both patient and therapist across developmental stages. Therapeutic activities must be directed toward strengthening the self and addressing the subjective feeling states stimulated by
illness.
The state of withdrawal becomes a crucial issue for the patient and
those connected in the intersubjective context. The issue of separation
and loss is primary. Family and friends may withdraw from the patient
as a defense against loss. This defense is indicated in the refusal to
listen to or focus on the patients need to talk about mortality, advanced
directives, or saying goodbye. Instead, the family offers platitudes and
denial of reality leaving the patient feeling isolated. Withdrawal may be
the preferred defense by rejecting visitors, creating an illusion of well
being, or utilizing reaction formation of their rage by reversing the roles
and caring for the caregiver. An empowering paradoxical effect of this
reaction results in the patient experiencing a sense of independence as
death approaches. In the therapeutic relationship the patient may withdraw by canceling or failing sessions, withholding payment, or other resistance. An effort to disengage from the therapy emphasizes the need for
an understanding selfobject; it does not eliminate that need.
Despair is a common theme at this time. The therapeutic goal is to
transform this profound despair into a healthier process of mourning.
The powerful affect of despair, combined with the reality of feeling hopeless 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 is

the essential treatment element. Facing the reality of death, the therapist
does not necessarily have to mirror the same emotions but needs to reverberate the same intensity of emotions.

IMPLICATIONS FOR PSYCHOTHERAPY

Kohut (1971) has suggested that by carefully attending to the demands of the transference, by providing optimal empathy to the selfobject
needs, the therapeutic process can proceed to build internalized selfstructures. The assault on the self, caused by the crisis of chronic illness,
requires an experience near empathic experience to restore and maintain
self-esteem and self-cohesion. Kohuts (1977) theory of self-psychology
is based on the concept that when the needs of the self are not met,
fragmentation occurs and defenses become more primitive. The case examples of Ms. K., Ms. A, and Ms. L illustrate the response to empathic
mirroring, support for healthy assertiveness, and the availability of a
hopeful idealized other.
Chronic illness is a phenomenon with deep implications for disruption
of self-states and narcissistic injuries, presenting many challenges ranging from acute grief and loss, to a reworking of unresolved developmental
issues. By approaching treatment from a self-psychological perspective,
psychoanalytic psychotherapy can be successfully utilized in conjunction
with supportive therapy to resolve developmental issues. The therapeutic
relationship becomes one of the crucial components toward attaining cohesion over fragmentation and vitality triumphing over despair.

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Carol Garrett, Ph.D., C.S.W.

999 Walt Whitman Road
Melville, NY 11747
631-385-0037
CarGarrett@aol.com

Michele Greene Weisman, L.C.S.W.

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mopgw@aol.com