The Severe Reaches Of Psychological Disorder

There has always been considerable skepticism about the possibility of successful psychoanalytic treatment of borderline conditions or the major psychoses. Kohut conceptualized the therapeutic difficulty in these illnesses by positing a failure in the formation of a cohesive nuclear self in both—more pervasive and undefended in the psychoses

than in the borderline states. This failure seemed practically to be basically unrectifiable—though psychotherapeutic efforts were seen to be effective in strenghthening defensive structures of the personality. This strengthening might allow some patients to manage their profound vulnerabilities with greater success.

We do not know whether Kohut would have held as strictly to his early position on this issue today and there is some indirect evidence that he might have been less conservative about the possibility of greater success in the treatment of some of these patients.

Whatever the opinions or positions of others—Stolorow, Atwood, and Brandchaft as well as Galatzer-Levy—have boldly crossed the frontier into the new territories and have discovered exciting new formations to be considered and form judgments about. Let me begin by summarizing the closely argued, six-point section of Stolorow's and his colleagues' paper entitled “Schematic Conceptualization of Psychotic States and Their Treatment.” They say, and I am paraphrasing here: The essential structuralization of a sense of self, which depends on a firm belief in one's own subjective experience, fails if early childhood caretakers are not validatingly attuned to the child's perceptions and emotional reactions. Lacking that validation the child is left in doubt about his own subjective reality and it will be vulnerable to dissolution in later years. When attunement is “consistently absent or grossly unreliable” there may result a predisposition to delusional psychotic states. The treatment of such psychotic states in the adult requires the therapist's recognition of the c