Chapter 6 On Some Challenges to Clinical Theory in the Treatment of Character Pathology

In her contribution to this volume, Anna Ornstein has raised some challenges to the clinical theory of psychoanalytic self psychology. It was in the treatment of narcissistic character pathology that Kohut's (1968) clinical formulations were first presented. Since that time, and more recently in the preceding volumes of the Progress in Self Psychology series, the gradual establishment of selfobject transferences, the structure-building effect of attunements to ruptures in the selfobject transferences, and the requisite self-reflective stance of the analyst have been documented. Thus, we are now in a position to turn increasing attention to the more problematic issues that challenge clinical practice. These issues, addressed by Ornstein, include the self-psychological understanding and treatment of character defenses and character pathology, structure formation through sustained attunement and its disruption, transferences by the patients toward important figures in their lives outside of the analytic relationship, and shifts in the analyst's perspective to address the outside-of-analysis life of the patient. The discussion to follow will focus on the questions and challenges raised by Ornstein and the implications for the evolution of self psychology's clinical theory.

Ornstein has presented segments of an analysis of a patient whose character defenses are frequently encountered in clinical practice. Her patient, Mr. S, appeared to be a rigid and humorless man. He controlled himself so that he would not betray feelings or any spontaneous affective responses. He was hypercritical and rationalized