Collapse of the Self and Its Therapeutic Restoration

This book is intended to integrate contemporary relational conceptions of psychoanalytic psychotherapy with the historically earlier drive-theoretic conceptions of Freud and Melanie Klein. The theoretical synthesis is illustrated with examples from literature and the arts, everyday life, and the author's clinical experience. The book's title phrase “collapse of the self” refers to self states in which an individual's sense of self is reduced, at least temporarily, to the confines of a particular set of largely implicit and automatic beliefs about self and others and the behaviors that ordinarily express them. Common examples are the angry “self-as-victim” or the remorseful, redemption-seeking “self-as-offender.” During such states, the perception of self and others collapses into the minimal dimensions essential to the self state. The full richness and complexity of self in everyday life are lost during the collapse. A consequence is that other persons in the individual's immediate relational world are, in reaction, themselves susceptible to complementary forms of collapse. For example, a therapist's own sense of self may (no matter how transiently) collapse into the “offender” who feels guilty and ineffectual in reaction to a “victimized” patient's plight.

The author differentiates her concept of “imaginative empathy” from Kohut's¹ “vicarious introspection.” She points out that for Kohut, therapists are “objective observers” at the same time that they consult their own inner reactivity to their patients. Kainer asserts that this is impossible because therapists are bound to experience a temporary loss of objectivity when reacting sensitively to patients' projections. Her view seems valid to this reader. If so, the difference from Kohut may be that the two attitudes (objective and subjective) occur in alternation rather than simultaneously. The therapist, as the target of a patient's projection, is influenced by his or her own needs in relation to the patient. Yet the therapist can recover, discern what is happening, consider what his or her own role in the process has been, and then respond in a therapeutically useful manner. This is not easy to do. As Kainer's case materials indicate, it requires the courage to “surrender” to the patient's unconscious demands on one's identity (that is, to “hear” the demands, not to carry them out); the confidence that one can survive the storm (not sacrifice one's own identity to the patient's demands); and the ability (of therapist and patient) to harness the energy of the storm's currents in the interest of the self-transformative process.

Kainer's effort to synthesize past and present is as worthwhile as it is problematic. The problems are twofold. The first is how to retain some of the older classical and object-relational facets of psychoanalytic theory without reifying or pathologizing patients and processes. The second is how to incorporate relational and intersubjective approaches into one's practice without losing sight of certain technical limits² on therapistexpressions of self in the patient– therapist relationship. These constraints once were surely overdone; yet in their current empathically attuned forms, they remain (just as surely) essential.

As to the first problem, retaining aspects of classical theory: when used too freely, terms like “psychotic” tend to pathologize patients in a manner that may sacrifice attunement. That is, terms like “psychotic” or even “sadomasochistic” are essentially metaphors when applied to patients who are not clinically psychotic or do not engage in overt acts of sadomasochism. Such metaphors may signify phenomena that overlap with the meanings that comprise their source concepts but are not identical with them. They may contribute affective color to one's clinical or scholarly rhetoric. But, in applying them too liberally, therapists implicitly collapse patients into stereotypical categories, thus tending to distance themselves from their patients' (to say nothing of their own) subjective worlds.

As to the second problem, expression of self: the author's concern for patients' selfobject needs is a highly useful aspect of contemporary psychotherapy. Yet therapists also need to modulate their efforts to sustain attunement to patient needs with a considered awareness of the psychoanalytic meaning of “therapist abstinence.”³ While this feature of the classical approach may once have been seriously overemphasized, it can also be underemphasized. Thus, in one vignette (“Ms. B”), a patient's sensed vulnerability had the therapist walking on eggshells through much of their work together, only to see the patient leave therapy abruptly and prematurely when the therapist suddenly expressed her exasperation with the patient's especially stubborn resistance at that moment in time. The “technical error” here may not have been in the therapist's immediate reaction, as Kainer suggests. Rather, it may have been that she had previously been too careful to support the patient's (and therapist's?) wish to be shielded from openly considering the nature of the patient's persistent implicit demand that the therapist not breach her patient's “prickly” sense of self.

This book is worth reading. The author is sensitive and candid, willing both to accept and to challenge, to learn and to teach, drawing on both her clinical work and her lively involvement with the world in which she lives.