VS. ; by Susan Quinn
Published: June 30, 1981
Illustrations: photo of Heinz
Susan Quinn, is a freelance writer who reports frequently about the social sciences. By Susan Quinn he first parting of the ways took place more than four decades ago. Heinz Kohut, a 25-year-old medical student, stood on the platform of the railroad station in Vienna in 1938 and watched Sigmund leave on the first leg of his flight from the Nazis. Though Kohut was an admirer, he had not met the master, but when the student tipped his hat in farewell as the train moved out, Freud tipped his own hat in return. ''I had the feeling,'' Kohut remembers, ''of a crumbling universe.''
The second parting has occurred more gradually, over the last 15 years, yet it has not lacked for drama. The student has, in significant ways, strayed from the teachings of the master. And the impact of Kohut's dissent, coming at a time when psychoanalysis itself is vulnerable, may have reverberations far beyond the boundaries of the discipline.
Today, Heinz Kohut, 67 years of age, is a respected analyst, a veteran teacher of Freudian theory at the Institute for Psychoanalysis in Chicago and a past president of the pre-eminent American Psychoanalytic Association (A.P.A.). He is also the creator and chief expounder of a new body of analytic theory, which he calls ''self ,'' and of a new approach to the analytic process that challenge basic Freudian concepts.
Specifically, Kohut has chosen to concentrate, not on the neurotic, the usual subject of modern psychoanalysis, but on the narcissist, the person whose self-love has gone awry. Kohut's explanations and treatment of the narcissist's problems essentially bypass the Oedipus complex, which is central to Freudian analysis. And he has gone on to suggest that changes in family relationships and in the society as a whole may be producing a patient population in which narcissistic disorders predominate.
By and large, the analytic establishment has been inhospitable to Kohut's views. Before he went his own way, Kohut recalls, ''I was Mr. Psychoanalysis. In every room I entered there were smiles. Now, everybody looks away. I've rocked the boat.'' But in fact, there have been indications during the past few years that the psychoanalytic community is, however begrudgingly, taking his ideas seriously. Many agree that narcissism is at the current frontier of psychiatry. Other leading analysts have been focusing on the narcissist, though usually within the Freudian framework. Kohut himself has been invited to participate in panels at psychoanalytic meetings. And last week, for the first time, one of the nation's prestigious psychoanalytic institutes - the Boston Psychoanalytic Society and Institute -sponsored a conference devoted entirely to self psychology.
Psychoanalysis has been buffeted in recent years by the growing popularity of shorter, less arduous and less expensive treatments for emotional disorders - therapies such as biofeedback techniques and est. Most authorities agree that the number of patients who seek traditional psychoanalysis has been thereby diminished. Yet the profession remains the theoretical wellspring and training resource for American mental-health professionals. Thus the debate over the theory of Heinz Kohut will inevitably have an effect on the treatment of the millions of Americans who never lie on an an analyst's couch but who still invest their hopes and their dollars in some form of the talking cure. The idea that talking could be therapeutic was first suggested to Freud by a colleague's treatment of Anna O., who suffered from disturbances of her vision and paralysis of her limbs, complaints for which doctors could find no physical explanation. Using free association, a process she described as a sort of chimney sweeping of the mind, she was able to stir up the dust of memory and bring to consciousness the origins of her distress. Her symptoms were greatly relieved. Freud learned to achieve similarly dramatic cures with other patients suffering ''hysterical'' symptoms. And out of those labors evolved the theories and practices of the discipline he called ''psychoanalysis.''
Freud's followers revised and augmented his original formulations and techniques. His analyses, for example, used to last about six months; a modern analysis is likely to last from three to six years. Nonetheless, the basic approach remains intact: The analyst plays the role of a relatively neutral listener onto whom feelings toward important persons in the patient's past are displaced (a phenomenon called transference). Eventually, the analyst begins to see emotional patterns, which he discusses with the patient. And the patient uses these interpretations to better understand his past as a means to improving his present.
To embark on a psychoanalysis, a patient must have time, money (from $40 to $125 per 50-minute hour) and, paradoxically, a personality that is sufficiently intact to bear up during the often stormy journey backward into memory. During the last decade, many have found less arduous treatments for their emotional ills. In psychotherapy, for example, patients sit up and meet with their doctor once or twice a week, as opposed to the four-or-five-times-aweek analytic schedule. The therapist may proceed along neutral, Freudian lines or may be openly supportive, advising the patients on their current problems. Behavior modification or group therapy, as analysts themselves acknowledge, may also be useful for many patients. ''If you can overcome a potency problem in six easy lessons,'' notes the psychoanalyst Philip S. Holzman, a professor in the department of psychiatry at Harvard University Medical School, ''why spend years in analysis?''
The vulnerability of the profession to new, competing modes of treatment has not thus far made a perceivable dent in the roster of psychoanalysts. The membership of the A.P.A., for instance, is now 2,632, a rise of 30 percent in the last five years. But the number of psychoanalytic patients, as measured by applications for low-fee analysis, has been steadily falling. Over the last decade, there has been a 40-percent decrease at the institute in Boston and a 40-percent drop at the New York Psychoanalytic Institute. Individual analysts confirm the trend. Meanwhile, there has been a growing impression within the profession that, among those who do enter psychoanalysis, a new kind of complaint is prevalent.
During the early years of psychoanalysis, many patients suffered from hysterical symptoms, but today such patients are extremely rare. One reason, analysts suggest, is that sexual repression has lessened. The more usual patient in recent decades has been what the profession calls the ''classic neurotic.'' He has a specific symptom - premature ejaculation, for instance, or fear of job failure. But today, the classic neurotic may be yielding his place on the couch to the narcissist. Narcissism, or self-love, is a vital dimension of mental health. It begins in the infant as a feeling that the world revolves around him. Then, under normal circumstances, the love bestowed by parents on the child is internalized and becomes the basis for the child's sense of self-worth. A ''narcissistic character disorder,'' as described by analysts, occurs when the child fails to develop this independent sense of self-love. He will then spend the rest of his life seeking a sense of self through the affirmation of other people.
Unlike the traditional neurotic, who comes into analysis with one symptom, the narcissistic patient is likely to experience a generalized feeling of discontent. He has great difficulty in forming lasting, deep relationships with others - and may not even acknowledge the need for such relationships. A charming and engaging surface may conceal an underlying indifference or ruthlessness. Often the narcissistic patient feels an insatiable hunger for admiration, coupled with an excessive readiness to feel ashamed. Neither the accomplishments of yesterday nor the possibilities of tomorrow gratify him for long. Without a loved one to grow old with and lacking the ability to identify with others, including his children, the narcissist's problems are likely to become increasingly acute with age.
The increased incidence of narcissistic problems - what Heinz Kohut calls ''disorders of the self'' - is attested to by such observers as Arnold H. Modell, who trains analysts at the Boston Psychoanalytic Institute. He reviews the applications of would-be psychoanalysts and also of applicants for low-fee analyses done by analytic trainees. In both groups, he says, narcissism is increasingly a core problem. He calls it today's ''paradigmatic'' complaint. Many individual psychoanalysts say their practices have witnessed a similar change, though there are those who have their doubts. ''Any epidemiologist will tell you,'' says Harvard's Philip Holzman, ''that waiting to see who comes into your office is a very bad way to do case finding.''
Heinz Kohut suspects that any increase in narcissistic disorders may have been caused by a change in the quality of family life during the last century. The middle-class Victorian household was bustling with servants and extended family members, all of them involved with the children; that, says Kohut, provided a child with an excess of stimulation, including sexual stimulation. The modern household, he says, with only one or two parental figures, tends to provide a child with too little stimulation, and that can lead to feelings of isolation and disconnectedness.
Others trace the increase in narcissism to larger social trends. John E. Mack, for example, an analyst who is the assistant editor of The Journal of the A.P.A. and a Pulitzer Prize winner for his biography of T.E. Lawrence, points to ''a great sense of insecurity that grows out of the breakdown of local structures.'' He adds: ''Nobody is safe from terrorism, the bomb. There's a feeling of rootlessness.'' Two facts of Heinz Kohut's early life made him sensitive to the theme of self-fragmentation that has dominated his work in recent years. The first was the experience of being an often-lonely only child. The second was being forced to abandon his home and way of life in Vienna.
While attending medical school, Kohut began to read Freud's work and then underwent analysis with a Freudian disciple, August Aichhorn, who wrote a classic psychoanalytic treatment of delinquency, ''Wayward Youth.'' It was Aichhorn who, in 1938, suggested that Kohut go to the railroad station to see Freud's final departure from Vienna.
The moment was profoundly moving for Kohut. For one thing, the Nazis represented a personal threat. His mother was a practicing Roman Catholic, but his father, though an agnostic, was of Jewish descent. Under Nazi racial laws, Kohut was in danger. Moreover, the departure of Freud symbolized for him the loss of ''everything that I had lived for.''
Kohut explains: ''I was passionately involved with German and Austrian culture. This was the peak of humanity to me - Goethe and the great German philosophers and writers and musicians. I was sitting up in coffeehouses until 3 o'clock in the morning, discussing each night another sonnet of Rilke. You know, this was life for me. And then, all of a sudden, these bullies came along who claimed they were the real Germans and I was all of a sudden a foreigner and didn't belong. It was the end of a world, it was the end of an era. And I had the feeling that it was also the end of my life, in terms of the continuity of my cultural existence.''
The next year, Kohut, too, fled Vienna. He traveled first to Britain, then to the United States, where he entered upon a residency in neurology at the University of Chicago and went on to become a leading practitioner and teacher of Freudian theory. ''I've led two totally different, perhaps unbridgeable lives,'' he says. It was that monumental disruption, Kohut believes, that made him ''alert to the problems of the fragmented self and how it tries to cure itself.''
Kohut has remained in Chicago ever since, but even after four decades, his manner remains European. On a weekend morning, he bows his greeting to a visitor to the apartment he shares with his wife, Betty, 12 floors above the uneasy streets of South Chicago. He is a diminutive, energetic figure in running shoes, gray flannel slacks slightly frayed at the hem and a gray cardigan with silver buttons. His hair, thick at the sides, is pure white.
It is just 9 o'clock. Kohut is at the small desk in his study, writing in a German shorthand. During the summer after he retired from the presidency of the A.P.A., he began to bring together his unorthodox ideas about a new method of treating the fragmented, narcissistic personality. They emerged in his first book, ''The Analysis of the Self,'' published in 1971.
Kohut has frequently looked to the arts for illustrations of the society's preoccupation with themes of confused identity. He talks of Gregor Samsa, the man-cockroach of Kafka's ''Metamorphosis''; of the fragmented portraits of Picasso; of the confusion of O'Neill characters in ''The Great God Brown.'' Kohut says, ''Sometimes they have masks on, sometimes they have no masks on; they are not clear about whether they're the right people with or without the masks.'' It is just such a confused, shifting sense of self, Kohut believes, that is central to the difficulties of many of his narcissistic patients. At the time Heinz Kohut's first book came out, the narcissistic character disorder was thought to be resistant to psychoanalytic treatment. The underlying problem, the inability to form attachments to others, was believed to have its origins in the infant's relationship with his parents prior to his learning to talk. Since these interactions were preverbal, they were thought to be inaccessible to the talking cure.
Kohut was not alone in moving beyond that view. Otto F. Kernberg, for example, a training analyst at Columbia University Medical School and medical director of the Westchester division of New York Hospital-Cornell Medical Center, has also written extensively about narcissism, suggesting methods of treatment that go beyond the boundaries of strictly classical analysis. But Kohut and Kernberg differ strongly over approach and theory. Kernberg has remained very much within the Freudian mainstream; Kohut has departed increasingly from it.
Freud believed that two basic drives, sex and aggression, underly human behavior. They form the basis of the Oedipal conflict - the child's sexual desire for the parent of the opposite sex and his rage against the ''rival'' parent of the same sex. In Freud's view, this intergenerational conflict is inherent in the parent-child relationship. Thus, in Kernberg's view, the sexual and aggressive drives and the conflict they produce in the Oedipal period, between the ages of 4 and 6, are critical in treating narcissistic disorders. ''I have not found a single patient with a narcissistic personality,'' Kernberg insists, ''in whom I have not found Oedipal conflict to be very important.'' Kohut disagrees. ''Narcissistic personalities can be analyzed,'' he says, ''once you realize what they are all about. They cannot be, however, if you insist that they have Oedipal disturbances.'' Kohut maintains that, in a normal family environment, such conflict, while it may be extremely common, is not inevitable. ''We are born,'' he maintains, ''as an assertive whole, as an affectionate whole, not as a bundle of isolated biological drives - pure aggression or pure sexual lust - that have to be gradually tamed. Intergenerational attitudes are not primarily sexual and aggressive. They are primarily nurturing or caring or enjoying of the other's growth.''
Kohut's most controversial assertion grows out of this altered view of the parent-child relationship. ''I believe,'' he says, ''we have to very, very carefully re-evaluate what has been so famous now as the central conflict of human beings, the Oedipal conflict. Is the Oedipal conflict really the normal issue that causes all our ills later? Or is it a disintegration product, when the assertiveness of the young is not responded to with pride? Really parental parents, like really therapeutic therapists, do not respond to the exuberance of their children by becoming sexually excited or by becoming hostile. They respond by thinking themselves into what the next generation experiences.'' When this occurs, in Kohut's view, Oedipal conflict may not become a major issue.
It was a radical departure, based upon a view of man that is profoundly at odds with that of Freud. Says Philip Holzman of Kohut's position: ''Classical psychoanalysis is turned on its head.''
Kohut's theories have led him to approach the patient's past in a new way. Traditional psychoanalysts tend to search the past for old, unresolved and buried conflicts including repressed sexual and aggressive wishes. Kohut, however, searches the past to discover ''thwarted developmental needs,'' ways in which the self was not supported or confirmed by parents in childhood.
In a paper called ''The Two Analyses of Mr. Z.,'' Kohut illustrates the differences between these approaches. Mr. Z. was a young graduate student when he first presented himself to Heinz Kohut for an analysis about 20 years ago. An only child, Mr. Z. still lived with his mother, who was his main companion. By the end of the first four-year analysis, he had moved into his own apartment. He had also been able to supplant masturbation, which had been his only sexual release, with sexual relationships with women. At that point, Kohut writes, ''I had no doubt that Mr. Z.'s vast improvement was indeed based on the kind of structural change that comes about as a result of bringing unconscious conflicts into consciousness. To my analytic eye, trained to perceive the configurations described by Freud, everything seemed to have fallen into place.''
But five years later, Kohut heard from Mr. Z. again. He had had a succession of affairs with women, but he feared a return to his earlier sexual isolation. His work was going reasonably well, but he experienced it as a burden and a chore. Kohut concluded that a second analysis should be undertaken.
By that time, Kohut was in the process of developing what he calls his ''psychology of the self.'' He writes: ''The change in my theoretical outlook that had taken place during this time ... enabled me, to the great benefit of the patient, to give him access to certain sectors of his personality that had not been reached in the first part of his treatment.''
The change was illustrated by a particular dream that Mr. Z. had related in the first analysis and that came up again in the second. The dream concerned Mr. Z.'s father, who had left his mother for another woman when Mr. Z. was 3 years of age and had rejoined the family some two years later. In the dream, Mr. Z. was inside a house. His father was outside, ''loaded with gift-wrapped packages, wanting to enter.'' Mr. Z. was ''intensely frightened'' in the dream and ''tried to close the door to keep the father out.''
In the first analysis, Kohut interpreted the dream according to classic psychoanalytic theory. He concluded that it was the manifestation of an Oedipal conflict. The dominant feeling was Mr. Z.'s hostility toward his father, returning home laden with sexual gifts for his mother; Mr. Z. could not hope to compete. As a child, it was felt, Mr. Z. had retreated from that Oedipal competition. In his relationship with his mother and in much of his life since, he had clung to a pre-Oedipal attitude, the narcissistic position of a very young child who expects and demands that the world gratify his every wish. Kohut felt at the time that the analysis was drawing to a close. Mr. Z.'s ''unconscious ambivalence toward the Oedipal father had come to the fore.''
By the time of the second analysis, Kohut was convinced that patients like Mr. Z. had disorders of the self that derived from a failure in parental empathy. There is, Kohut contends, an ''appropriate responsiveness for the inner need or inner state of children that most parents can give quite normally. Continuity of the self is established by these parents from the beginning. Continuity is confirmed by the accepting presence of the parent, by the smile of recognition, by the pleasure, 'Ah, here you are.' '' What counts, Kohut says, is not the degree of closeness or distance a parent maintains: ''The point is an appropriate, empathically well-informed and understanding responsiveness which is different at day one, or age 1 or age 5, 10 or 15.''
Lacking such parental responses, children are likely, in adulthood, to be left with narcissistic disorders. They are likely to use other people, not in a mutual give and take, but as supports or means to an end. When the others are gone, the narcissist experiences a feeling of incompleteness arising out of his inadequate sense of self. There is a need to lose oneself, as an infant does, in the embrace of someone else who is not experienced as ''other'' but as a part of oneself - a ''self-object,'' in Kohut's terminology.
In the course of an analysis, the patient can be expected to behave and feel toward the analyst as he did toward parents. This is known as transference. In Kohut's approach, the transference is likely to take the form of these early and troubled parent-child interactions. When that happens, the analyst's job is to try to enter the patient's emotional world through empathy and to be appropriately responsive. Kohut emphasizes that this does not mean providing the patient with the understanding that was missing in childhood: ''There is still a gap between what one might want after all the deprivation of childhood and what one gets, which is words and understanding. But it is very satisfying to be understood, particularly when one has never been understood.'' At those moments when the patient is disappointed by the analyst, patient and analyst explore together the early childhood antecedents of such feelings. Eventually, the patient reaches a new understanding of the flawed early parental relationship. He becomes less reliant on the analyst as ''self-object'' and more able to take on the regulation of his own self-esteem.
In the second analysis of Mr. Z., it became clear that the patient's mother had not beenmerely indulgent toward her son. She had, in fact, kept him under surveillance in the manner of a very intrusive drill sergeant, routinely inspecting his bowel movements until the age of 6, at which point she began conducting, on a weekly basis, a lengthy inspection of his skin. Kohut concluded that Mr. Z.'s major difficulty was rooted not in an Oedipal conflict but in his mother's overpowering of his sense of himself.
When, toward the end of the second four-year analysis, the dream of the father, laden with gifts, came up again, the associations that accompanied it were quite different. Kohut no longer felt it was ''a portrayal of the child's aggressive impulse against the adult male, accompanied by castration fear.'' The return of the child's father, Kohut now believed, ''exposed him suddenly to the potential satisfaction of a central psychological need.'' The child was being offered, ''with overwhelming suddenness, all the psychological gifts for which he had secretly yearned.'' What Mr. Z. was fending off in the dream was a threat to his psychological equilibrium.
As a result of the insights of the second analysis, Kohut wrote, ''The zest with which he (Mr. Z.) ultimately turned towards life had a depth and genuineness that had been absent during the first treatment.'' Mr. Z. went on to marry a woman who seemed to be compatible, and he became an outstanding contributor in his field of research. The publication in 1977 of Heinz Kohut's second book, ''The Restoration of the Self,'' was a bolder challenge to Freud's ideas than Kohut's previous work. It led some analysts to charge the author with hubris. Said one such: ''Kohut's work is eminently usable. At the same time, there is this attitude on the part of him and his followers that they have brought religion to the world.'' In a cutting review in the premier journal of psychoanalysis in the country, The Journal of the American Psychoanalytic Association, the New York analyst Martin H. Stein concluded that Kohut's work ''is difficult to accept as a genuine addition to psychoanalytic theory and practice.'' Kohut and his followers claim that he has been ostracized by the psychoanalytic establishment. Indeed, the opposition to him has been both reasoned and highly emotional.
Kohut maintains that, in his new analytic technique, as exemplified by the second analysis of Mr. Z., there is less struggle with the patient than in traditional analysis. And many analysts note approvingly that his approach encourages the analyst to act warmly toward patients. Some critics, however, feel that Kohut avoids necessary struggles. They wonder if the process he describes actually leads to structural change, as he contends. Comments Philip Holzman: ''Kohut's technique is very beguiling. It probably represents a general corrective to what a lot of analysts have done. But then, if that's all you've done, you're a really good bartender. The question is, are you more than a good bartender or a good listener?'' Even Arnold Modell, who uses some of Kohut's techniques, says, ''After a while I begin to confront the patients much more than Kohut would.''
Otto Kernberg sounds a somewhat similar alarm. He feels that Kohut neglects the angry, aggressive dimension of narcissistic disorders. ''In Kohut's theory,'' he says, ''there are only idealized selfobjects. There are no devalued, hateful, aggressive or bad selfobjects. This runs counter to clinical experience with patients, particularly narcissistic patients, who tend to experience, in the transference (to the analyst), relations with very bad parental images.''
Kohut is most sharply criticized by other analysts for not giving credit where it may be due. ''Other writers on the subject of narcissism,'' notes Martin Stein in his review, ''are given short shrift.'' This has led some analysts to suggest that Kohut is, himself, a grandiose narcissist with designs on becoming ''the next Freud.'' Kohut insists he gives Freud all appropriate honor (''Whatever we contribute now, it's still the dwarf on the shoulders of the giant'') and suggests that others have made of Freud ''a central figure that has an emotional meaning that goes beyond his scientific contribution.''
Amid all the controversy, the interest in Kohut's work continues to grow. Last year, at the fall meeting of the A.P.A. in New York, the Starlight Roof of the Waldorf-Astoria was overflowing with hundreds of analysts craning to get a look at Kohut, who made a rare appearance. Conferences on self psychology in Los Angeles and Chicago have attracted large crowds. The Boston session last week had a registration of 1,000 persons, including analysts and other mental health professionals from all over the United States, from Europe, Asia and South America.
The uses to which Kohut's work - and psychoanalytic ideas, in general - is put are far reaching, as well. Most psychoanalysts do not spend all their time on analysis. Many do other kinds of therapy, including individual and family work. They are frequently teachers of psychiatry in medical schools and residency programs, and many are involved in clinical research into such mysteries as infant development, schizophrenia and dreams. Thus the kind of intellectual ferment touched off by Kohut's theories has an impact far beyond the analytic consulting room.
One of Kohut's followers has suggested that Kohut is to Freud what Einstein was to Newton, a disciple who will transform the field of psychoanalysis. More impartial observers are doubtful. ''I do pay greater attention to self-development as a result of reading Kohut,'' John Mack says. ''But if you find a way to extend theory and clinical experience to a group of people you haven't been able to work too well with in the past, then there's a tendency to universalize it and say, 'That's the way we should have treated hysterics in the first place,' or 'That's the way we should treat all our patients.' ''
Kohut, however, believes it was necessary for him to ''weave a consistent whole -not to flirt with it but to be married to it. The new ideas that I have expressed, I feel very strongly, are constructive further steps. You know, people get very angry and argumentative. But Freud began that way. He was very tolerant of diversity of opinions up to a point, but not beyond that point. And I suppose that was necessary. He had to first clearly go his own way. And in a way, I do that, too.''
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