By Philip Chanin, Ed.D., ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center

“Some theorists understand the matter in this way: The therapist becomes an inner function of the patient, the conscience, say, or the heart. The usual analogy is with a child who can skate only when a parent is on the ice right beside; the parent is the child’s nerve or guts, or even the stiffness in the child’s ankles. You may need what the child skater needs, additional self. We can all use additional self. (Outside therapy, people often enter relationships in order to get self and then complain that they have not gotten something else, say, romance; and to point out the distinction may help them to evaluate the relationship.). We borrow parts of people constantly. If self is what you require of me, the advising aspect of my job will be easy. You will tell me what you already know, and I will confirm your conclusions.” (Should You Leave by Peter D. Kramer, M.D.; New York: Scribner, 1997, p. 43)

In the course of a recent treatment hour, a patient who experienced a very abusive childhood said to me, “I don’t have a self.” Though it is early in her therapy, already she understands and can articulate why she has come to see me. This is something she has never experienced—having a sturdy, separate, independent-yet-connected self. She understands that this will be a process that likely will take years, and is not amenable to time-limited psychotherapy.

Characterological deficits—which we are so often dealing with in our offices—cannot be ameliorated with brief psychotherapy. One book which richly conveys the magnitude of the task of treating character disorders is David Celani’s The Illusion of Love: Why the Battered Woman Returns to Her Abuser. Like Murray Bowen, Celani uses the concept of lack of differentiation to describe what it means to lack a self. He writes: “Lack of differentiation is a key to understanding both males and females who desperately return to destructive relationships…The normal healthy sense of self has a firm boundary around it that cannot be breached. The empty, emotionally abandoned individual invites others ‘on the outside’ to come ‘inside’ in order to make them feel whole.” (pp. 41-42)

In psychotherapy with individuals with such deficits, part of our task is to help them to acknowledge and affirm subtle aspects of the self, especially aspects that were disapproved of by their parents. Celani uses the analogy of the sophisticated wine taster, who is “able to distinguish one year’s growth from lesser or better vintages of the same vineyard. The same holds true for the human ability to gradually differentiate among subtle differences in the feeling states within one’s interior world.” (p. 35)

Without a consistent, coherent sense of self, it is almost impossible for the individual to make good choices. In Celani’s words,

“A poorly integrated ego leaves the unfortunate person on the brink of chaos. This is yet another ‘key’ reason (there seem to be about a dozen ‘key’ reasons that contribute to adult personality disorders) that the poorly reared child develops into an adult who is confused, chaotic, and easily taken over by others. The poorly integrated individual has so many contradictory views of himself, and of others, that he loses confidence in his perceptions, feelings, and opinions. He is easy prey for people who (to him forcefully) present another version of reality, for he is so unsure of his own shifting and chaotic view.” (pp. 60-61)

It is my firm belief, and Celani’s as well, that the therapeutic work involved in helping a patient to build a consistent self upon which s/he can rely is a task best measured in years, and not amenable to brief psychotherapy. Celani asks, “How does this process happen?” “In truth,” he answers, “it happens slowly over time, like grains of sand falling in an hourglass. Each small positive introject (of the therapist) weighs little individually…Because of the gradual nature of the introjection process, very little appears to happen at the outset of therapy, as there are too few positive introjects to alter the patient’s normal coping strategies.” (pp. 182-183)

While advocating for the importance of the therapeutic task of working with individual with characterological impairments, it is also essential to be aware of the extraordinary impediments that we face in doing psychotherapy with them. In Celani’s words, “The struggle between the newly internalized memories and the enormous pressures from inner emptiness turns out to be a David and Goliath battle, as it seems impossible for the fifty-minute hour to compensate for a lifetime of neglect.” (p. 191)

While doing long-term psychotherapy with these patients can be deeply rewarding, it is also fraught with peril. The opportunities for therapeutic missteps are legion. In my judgment, it would be unwise to take on this type of patient without extensive personal psychotherapy and good weekly consultation or supervision.

Celani is writing about his experience doing psychotherapy with individuals who have been involved in battering relationships. However, his view of the psychotherapeutic task certainly applies, in my experience, to the problems encountered with most character disorders, which represent a significant percentage of the individuals who come to us for help. To reiterate what I have suggested above, brief treatment strategies are sorely inadequate for doing this work. As Celani concludes,

“When the therapeutic process does go well, it is possible to restructure the ego of many battered women in three to five years of individual psychotherapy. This assumes that the therapist has a good working model that helps him withstand the pressure from the frequent reversals and from patient aggression that is directed toward the therapist during the treatment process. It also assumes that the patient has the insurance or financial resources to pay for the long course of treatment…It is a venture that has many obstacles in its way because of the sheer amount of time it takes to repair characterological disorders. Long-term treatment of the abused woman demands that the patient think of the future rather than the present and lead a stable life that allows her to stay in one geographical area for many years. (pp. 205-206)