Book Review
Psychotherapy
Impact of Narcissism—The Errant Therapist on a Chaotic Quest. Peter Giovacchini. Northvale (NJ): Jason Aronson Inc; 2000. 324 p. US$40.00.
Reviewer
rating*: Very Good
Review by: Douglas H Frayn, MD, FRCPC
Toronto, Ontario
This book is written by a renowned psychoanalyst who is best known for his American object relations point of view and his work with patients with borderline and narcissistic personality disorders. He is now in the twilight of his career and looks back at the theoretical, technical, and political changes that he has seen over 45 years of practice as a psychotherapist. Giovacchini trained in Chicago and is familiar with Alexander’s brief therapies in the 1940s, which were based on “corrective emotional experiences.” As a close friend of Heinz Kohut, he saw the rise of the self psychology movement and its cultish followers in the 1970s. Thus, he is well aware of unorthodox revisions and of the weaknesses and strengths of the classic approach and the practice of psychoanalysis and its psychotherapies over the past half-century.
Giovacchini stresses that it is the integrity of the “intrapsychic” aspect of object relations that is the most important psychodynamic feature when assessing and treating patients, rather than the individual’s objective environmental and traumatic experiences. By intrapsychic, Giovacchini means the mental representations of the self and our objects, past and present, and how the ego manages contradictory images that we have internalized. He laments that, in contemporary society, “everything seems to be on the surface.” Further, he notes that many patients with narcissism lack repression or guilt and tend to be supported by a society that sees victimization by our environment as the problem, rather than the individual’s participation in making choices and possessing unwarranted feelings of entitlement. Unconscious motivation is ignored in some quarters; psychophysiological explanations are most popular, appearing initially to relieve the patient and the therapist of personal responsibility for character traits and symptomatic behaviours.
The role of narcissism and its new ascendancy in theories are foremost in his writings. He focuses on 3 contemporary approaches to narcissistic pathology: self psychology, intersubjectivity, and relational psychology. Generally, he finds that these theories, and even techniques, are at best “old wine in new bottles,” although he is more accepting of Stephen Mitchell’s intrapsychic relational model. He also writes of the pedantic “philosophers at the gate,” which represents the Lacanians and the postmodernists, neither of whom have clinically relevant formulations to offer therapists and whose esoteric linguistic and philosophical systems do not warrant their inclusion as psychodynamic schools of thought. The investigators of intrapsychic phenomena make 2 scientific assumptions: 1) there is an inner world (the world of the unconscious), and 2) this intrapsychic world functions according to certain laws and principles, based mainly on Freud’s early concepts of the mind. Giovacchini views this as the primary philosophy that is still necessary to understand present-day behaviour and mental functioning.
The chapter on self psychology is the author’s devastating personal recall of Kohut’s weaknesses, as well as some of his strengths. That Kohut’s own grandiosity should be coupled with his theory stressing grandiosity amuses the writer, but he makes a serious charge about Kohut’s articles concerning a patient (Mr Z) who had 2 analyses: the success of the latter one was a fraud. In the same way, writing about his own case history perpetuates serious scientific concerns about the basis of self psychology itself. More condemning, Giovacchini states that those close to Kohut knew of his confabulations and accepted them. Recalling the words of his friend and colleague, Arnold Goldberg, one must remember that Kohut was the only national monument that contemporary American psychoanalysis had. He credits Kohut with being a superb teacher, clinician, and scholar. He also credits Kohut with bringing the problems of narcissism to the forefront of psychotherapy, with expanding techniques for dealing with narcisistic transferences, and with recognizing the usefulness of empathy prior to making definitive interventions, such as clarification and interpretation. Self psychology focuses on the initial need for idealization and gratification of the developmentally injured self- representations, a preoedipal emphasis, and the avoidance of confrontations concerning infantile needs and expectations of the subject with narcissism. By encouraging positive (self–object) transferences, maturational growth occurs, so later “debunking” of the grandiosity and mutual idealizations can occur without catastrophic regression. Like many practising analysts, Giovacchini’s concern is that some therapists have interpreted mirroring and idealizing “self–object” transferences as a maneuver that the therapist does, rather than as the patient’s unfettered expression of narcissistic transference as a precursor to more sustained object transference and as a way to relate to people outside of himself or herself.
Large segments of modern psychiatry have given up on drive and conflict theory, even though they still tend to revert to the outmoded idea that prohibitions stultify creativity and cause anxiety. The intrapsychic focus has been obscured, and the idea of an individual’s internal problems has given way to focusing on external difficulties and solutions. Some of the recent schools reflect the attitudes that we are primarily a product of our environment and of our genetic makeup and that it is necessary for a change in society or in neurohumors to occur before we can liberate ourselves. This type of thinking is the product of the ascendancy and attempted marriage of social psychology and medical neuroscience, as taught by medical schools under the rubric of the supposed “psychosocial biological approach.” There is little mind or soul (psyche) in this mind-or-brain paradigm. It has limited usefulness in the practice of psychotherapy, and the individuals are internally aware that something is not right within, in their way of seeing themselves, and in functioning in their work and love life that is greater than unappreciative parents, spouses, and bosses.
Giovacchini also sees that the successful struggle of nonphysicians, particularly women, to gain entrance into training programs previously run primarily by male psychiatrists, has changed the face of psychotherapy. The “male medical model” has been attacked as tyrannical and authoritarian, and this has led to many positive changes in our thinking and approaches to patients, as well as to some changes in practice that may not benefit. Shorter hours, smaller case loads, and poorer pay accompany the contemporary therapist’s wishes to work part-time, to place family demands first, and to prolong therapies as long as insurance coverage continues. Conversely, many psychiatrists who have been trained in psychotherapies, including psychoanalysis, complain that they cannot earn a competitive medical wage and have turned to brief interventions and to forensic, insurance, and drug-related practices instead. New students in psychotherapy programs are predominantly women.
This book’s last chapter on narcissism and creativity is charming and fresh. It resembles a work of love. It concerns 3 of George Bernard Shaw’s famous plays (Pygmalion, Major Barbara, and Anthony and Cleopatra), which cleverly portray how narcissistic investment may misfire for all concerned. It alone is worth the price of the book and should be on all reading lists concerning drama, psychotherapy, and political science studies. This very good book could have been edited to make repetitious themes briefer. Being brief and succinct, however, is not a trait of the older scholar. Perhaps, one hopes to finally say what hasn’t been listened to earlier, with urgency, before the “higher power” says, “Our time is up!”
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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