Academic journal article American Journal of Psychotherapy

The Contributions of Self Psychology to the Treatment of Anorexia and Bulimia

Academic journal article American Journal of Psychotherapy

The Contributions of Self Psychology to the Treatment of Anorexia and Bulimia

Article excerpt


The major contributions of self psychology to the treatment of anorexia and bulimia include: (a) the unique therapeutic stance of the therapist as a selfobject who tries to empathize with the patient from an experience-near position; (b) the conceptualization of food as fulfilling selfobject needs; and (c) the respect that the theory attributes to the significance of the symptoms for the patient.


The theoretical conceptualizations of self psychology and the ensuing implications for the therapist's stance open up new opportunities for the treatment of anorexia and bulimia.

This article will outline opportunities and dilemmas that ensue from the application of this most modern development in psychoanalytic therapy Clinical vignettes will illustrate the approach.

The fragility of the anorexic or bulimic patient and her** tendency to ignore her needs, feelings, and interests, necessitate the application of a psychotherapeutic approach that will not impose an interpretation "from without," but rather experience-near "from within" attunement to the patient. Self-psychologically informed therapists, more often than traditional therapists, slip from free-floating attention to the patient into special attention for vicarious introspection into the 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.l

According to Wolf,2 the patient in therapy with a self-psychologically oriented therapist feels that the therapist maintains an attuned stance rather than an adversarial one. The patient experiences the therapist's neutrality as benign, that is, the therapist is affectively on the side of the patient's self without necessarily joining the patient in all of his/her judgments. The therapist, according to Kohut,3 sees him/herself as being simultaneously merged with, and separated from, the patient.

The stance of the self psychologist is sometimes mistakenly thought to be supportive or sympathetic, as if the therapist were supposed to be kind and gratifying, to substitute in the here-and-now for the deprivation that the patient had suffered in early development. Self psychology does not assert that by providing corrective emotional experience in the here-andnow, the deficits can be repaired or filled in. The activity of the therapist that enables the mutative process of the restoration of the self involves the awareness of the therapist of failures in being empathic to the patient's needs. Provided the therapist succeeds in establishing an empathic milieu, these failures will not be harmful. The therapist's ability to analyze them in the transference is what brings about the transmuting internalization: the taking over by the patient of functions of the self that the therapist fulfilled for the patient.

In infancy and childhood, children do need to be mirrored, to be looked upon with joy and basic approval by delighted parental selfobjects. The role of the therapist is to create the proper ambiance for mobilization of the patient's demands for mirroring and the free expression of these demands in the session. The self-psychologically informed therapist meets these needs by acknowledging and attempting to understand the patient's feelings, wishes, thoughts, and behavior from the patient's perspective (vicarious introspection-empathy) before proceeding into the interpretive work. The therapist does not actively soothe or mirror. He understands, acknowledges, justifies, and interprets the patient's yearning for soothing and confirming responses. The therapist does not actively admire or approve of the patient's grandiose experiences, but, knowing their crucial role in normal development, explains to the patient their role in the psychic equilibrium.

Kohut4 divides the psychotherapeutic work into two phases: the empathic mirroring phase (understanding), and the interpretation phase (explaining). …

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