From Narcissism to Self Pathology: New Pathology or New Perspective on Pathology?1

The path from narcissism to self pathology is described through five case vignettes. In Analysis Terminable and Interminable Freud presented a case illustration to argue that when a negative transference is not present, it can not be analyzed. After Freud, some analysts seem to have taken this argument a step further. They assumed that a patient's admiration of the analyst invariably conceals devaluation and therefore, beneath the positive transference there always lurks a negative transference. In this same paper Freud also described two “bedrocks”, which psychoanalysis can not penetrate. A man must accept his passive, feminine attitute toward another man. A woman must accept that she lacks a penis. Subsequently, these clinical and theoretical narcissistic issues have been reconceptualized within self pathology.

The diagnosis of narcissism was based on an inability to relate to other people due to a fixation to an early stage of development. Additionally, narcissism signified defenses against rage, envy and dependency. A vignette from a published case illustrates the analysts's use of interpretations and confrontations to point out a patient's denial of envy and hostility toward him. A contrasting, published, case vignette illustrates that resistances to analysis and concealed motives to devalue or depreciate the analyst, can be better understood as self protective and as deeply felt needs to be recognized. Significant differences between the theories of narcissism of the treating analysts are described. The two analyst-patient pairs created different pictures of narcissistic pathology, ushering in the shift from narcissism to self pathology. A fourth vignette illustrates the value of recognizing a normal Oedipal phase in the transference and a fifth vignette highlights the pitfalls when the analyst assumes that his or her reactions to the patient provide an insight into the patient's motivations. The question posed by the title of the paper is answered: self pathology is both a new perspective on pathology and a new pathology.