Chapter 6 A Self Less Divided: A Discussion of Hazel Ipp's Clinical Case

Gayle, a woman in her forties, who suffers from recurrent bouts of depression, along with a major disturbance in her capacity to form interpersonal relationships, once again seeks help from analysis after disappointment in previous attempts. Although “The Great Depression” (a wonderful blending of hopeless despair with the attempt to be perceived in grand historical terms), which is the patient's term for her regressed states, is not described in detail, my conjecture is that this refers to the empty depression—the state of profound lethargy Kohut described as the typical regressed state in the narcissistic personality disorder. The most prominent pathogenic material is the history of having been raised as the oldest of eight children by a bitter, joyless, and depressed mother who married at 19 and was exhausted by her brood of children whom she blamed for the many deprivations in her life. All expressions of need, desire, and self-affirmation are dominated by deep-seated feelings of depression and anxiety. Success in treatment (a good session) inevitably leads to the compulsion to run away, and the patient's most persistent defense organization is a pattern of vertical splitting, where she literally lives in two worlds (as Goldberg would put it), one elegantly sophisticated and presentable and the other hidden, filthy, disorganized, known only to herself and her therapist.

The above description of symptomatology and pathogenesis could have been written by Kohut in 1971. The narcissistic disturbance from which this patient suffers (which today we refer to as a disorder of the self) represents a profound failure of the selfobject environment in its