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Mirroring and Idealiting in Psychotherapy
" with Schizophrenic Patients

presented by

Leslie Anne Wolowitz

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MIRRORING AND IDEALIZING IN PSYCHOTHERAPY
WITH SCHIZOPHRENIC PATIENTS

B.v

Leslie Anne Wolowitz

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Paychology

1988

ABSTRACT

MIRRORING AND IDEALIZING IN PSYCHOTHERAPY
WITH SCHIZOPHRENIC PATIENTS

By

Leslie Anne WOlowitz

Mirroring and idealizing are continuous developmental processes that
strengthen the self. In psychotherapy, the therapist is experienced as a
potentially mirroring selfobject, and the patient idealizes the therapist
(Kohut, 1971). Data from the Michigan State Project were used to assess
these processes in psychotherapy. The hypotheses were that patient change
was correlated with therapist mirroring, acceptance of the patient’s
idealizing statements, and insight into these needs.

Sixteen predominantly urban, Black, schizophrenic patients were given
psychotherapy with and without medication over 20 months. Six graduate
student therapists were supervised by 2 experienced therapists. For this
study, raters were trained to identify the Kohutian constructs and rated
each of the 16 patient’s therapy, using one full audio-taped therapy
session.

The results, from a multiple regression analysis, did not support the
hypothesis: confirming (part of mirroring) was found to be negatively,
significantly related to 20 month change (9 < .05). Therapist’s

acknowledgement of the need to idealize tended towards significance (p < .09).

ACKNOWLEDGMENTS

Gratitude is extended to Dr. Bertram Karon for his generosity,
insight, and support. I would like to thank Dr. John Hurley for his
availability and foresight, and Dr. Gil DeRath for his suggestions and
help. Thank you to my family for their encouragement. This is for

Bennet Wolper.

iii

TABLE OF CONTENTS

Page

LIST OF TABLESOIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO0.0.0000...

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Subjects.........................................................
Therapists.......................................................
Treatment........................................................
Outcome Measures of Treatment....................................
Operational Definition of Mirroring..............................
Operational Definition of Idealizing.............................
Raters...........................................................

mta AnalySiSOO0.00000.0000000000IOOOO0.0000000000000000000000000

RESUIJTSOOOO0..0.00.0.0....000.000.000.000...0.0.0000000000000000000000

DISC‘JSSIONOO0.0.0.0.0...0.0.00..0....00......0....OOOOOOOOOOOOOOOOOOOO

APPENDICES

“9999???

LIST’OF REFERENCES...

Instructional Tape for Raters................................
Training Workbook for Raters.................................
Rater’s Scoring Sheet........................................
Descriptive Statistics of Subscales..........................
Literature Review............................................
Subscale Correlations With 6 Month Change....................

iv

V

1

16

21
24
33
34
35
44

46

LIST OF TABLES

Table Page

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[‘3

Pearson Correlation of Therapist’s Behavior with
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3 Relationship of Mirroring and Idealizing to
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4 l‘iodel of Confirming and Insight-Ideal Contribution
topatiEI-lt Ollie-1.138000...ono00000000000000.00000.0000000000000000. 1|.)

6 Ebrltl] Cllarlge COI‘I‘EIBLECI witl-l SUk’ScaleSo o o o o o o o o o o o o o o o o o o o o o o o 44

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6 Multiple Regression Analysis: Subscales with
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INTRODUCTION

Kohut (1971, 1977) developed a theory of how the self experienced a

significant other as a selfdbject -- a part of the self. The selfdbject
is used as a mirroring, empathic source, as a figure to idealize, and as
a twin figure with which to form an identification. These three
psychological functions, when they occur in the psychotherapy situation,
are named the mirroring selfobject transference, the idealizing
selfobject transference, and the twinship selfobject transference. The
Kohutian model assumes that the therapist contains the patient’s
relational needs for mirroring, idealizing, and twinship.

The concept of mirroring began with Lacan (1936), who posited a
"mirror-stage" in the first year of life, where the child recognized
his/herself in the mirror. The mirror—looking was believed to supply a
pleasing sense of identity and integration of body parts with the whole
mirror image. Winnicott (1971) felt that the child’s first mirror was
the mother’s eyes. The baby, when held.and fed, saw his/her emotional
state reflected in the mother’s gaze (e.g., when a mother looks concerned
when she sees that the baby is distressed or smiles back at a happy
baby). A disturbed.mother would fail to mirror the child, leaving the
child feeling disapproved of or unrecognized. Roger’s (1957) notion of
accurate empathy is related to the mirroring concept in that both convey

a sense of being understood. Roger’s accurate empathy dimension accrued

2
considerable support in psychotherapy research (Bergin & Strupp, 1972;
Rogers et 31., 1967). Kohut expanded the concept of empathy to be
specifying the subject of what was being mirrored. A parent might mirror
only one aspect of a childfs personality, resulting in overstimulation of
one part of the child and understimulation of others (as exemplified by
the empty-headed beauty or the awkward intellectual). Furthermore, Kohut
believed that the empathy should extend to the child’s "healthy
narcissism." Kohut’s idealizing concept sprang from the Freudian concept
of the ego-ideal. The child needs a strong adult to identify with so
that he/she feels protected. Kohut believed that a healthy parent
idealizes the child which promotes a strong self; and the child,
optimally, idealizes the adult, which helps the child to feel secure and
whole.

Kohut’s concepts have been elaborated with theory and case
histories, but scientific investigations are needed to clarify their
psychotherapeutic efficacy (Schwaber, 1981). The exploration of specific
therapeutic interventions and their impact on psychological change seem
to yield the most fruitful results in therapy research (Bergin & Strupp,
1972). Freud’s notion of transference has a history of being considered
as intrapsychic and then as interpersonal, and, presently, as
intersubjective (Atwood & Stolorow, 1984). The intersubjective view of
transference recognized that both the therapist and the patient relate to
one another out of their own subjective experiences of the relationship
despite the therapist’s attempts at Objectivity. Kchut’s selfdbject
transference dimensions mapped the patient’s mirroring and idealizing

needs with the therapist’s acceptance, rejection, or unawareness of those

3
needs. This study aimed to measure mirroring and idealizing processes in
psychotherapy and to use them as predictors of patient change. Patient
change was operationalized by independently performed ratings of Clinical
Status Interviews (081) wherein a therapist, not connected with the
researchers, conducted an interview to assess the patient’s mental health
at intervals throughout the 20-month treatment.

The hypotheses were:

I. Therapist’s active mirroring (confirming, accepting, approving,
and admiring will positively correlate with patient change from
six and 20-mcnth ratings.

II. Therapist’s acknowledgement of the patient’s mirroring need
will positively correlate with patient change, from six and 20-
month ratings.

III. Therapist’s presentation of an idealized figure (power,
calmness, and confidence) will positively correlate with
patient change, from six and 20-month ratings.

IV. Therapist’s acceptance of the patient’s idealizing need will
positively correlate with patient change, from six and 20-month
ratings.

This investigation of mirroring and idealizing used psychotherapy
sessions between psychoanalytically trained therapists and schizophrenic
patients. Although Kohut intended his theory for narcissistic and other
neurotically disordered patients, Stolorow and Lachman (1985) stated that
Kohut’s theory should apply to psychotic individuals. Raters were
trained to understand and identify the constructs of mirroring and

idealizing. After the training period (described in detail in the method

4
section), raters were given audio-taped psychotherapy sessions (one for
each patient) in random groups of four until each of the three raters had

scored all 16 tapes.

METHOD

The data of study were Obtained courtesy of Professor Bertram Karon
and the Michigan State Project (Karon & vandenbos, 1981), which was
conducted at the Detroit Psychiatric Institute during 1967 and 1968. The
Michigan State Project’s (MSP’s) purpose was to assess the efficacy of
psychotherapy without medication and with medication for schizophrenic
patients, as compared to a hospital control group of routine care with
medication. This study used 17 audio-taped psychotherapy sessions which
were all of the psychotherapy data that remained intact from the
project’s total data that had originally included 24 psychotherapy
patients. The sessions were first selected.with the criteria that they
not be the first or last two sessions, and that there were at least ten
minutes of patient’s speech; from this group, one tape was randomly
selected to represent that patient’s therapy. Of the ten participating
therapists, two were experienced psychotherapists (over ten years of
clinical experience with schizophrenics), and the eight others were
either graduate students in clinical psychology graduate school or
physicians doing their psychiatric residencies. Of the 16 patients,
eight received psychotherapy with adjunctive psychotropic medication

(Thorazine) and eight received psychotherapy with no medication.

Subjects

All MSP subjects were selected to fit the following criteria upon
admission to the hospital: (a) diagnosis of schizophrenia; (b) onset of
psychotic symptoms within 3 months prior to admission; (0) first
admission to a mental hospital; (d) no history of electric shock therapy
or insulin shock treatment, (e) no diagnosed organic brain damage, and
(f) no history of substance abuse. A team, independent of the project,
evaluated and randomly assigned patients to the three groups:
psychoanalytic psychotherapy supervised by Dr. Karon, psychoanalytic
psychotherapy with adjunctive medication supervised by Dr. Tierney (a
Board certified psychiatrist with over ten years of treatment with
schizophrenics) and a hospital comparison group of routine care with
medication. The original MSP sample of 36 patients was reduced to 33
because of one patient’s death, an additional patient diagnosed as brain
damaged, and the last because of staff interference with treatment. Of
the 17 patients in the two psychotherapy groups, one patient was excluded
from this study because of staff interference towards the end of the 20
month treatment program. The 16 remaining patients were primarily poor,

urban Blacks as illustrated in Table 1.

Table 1

Patients’ Characteristics

 

 

SEX Males = 7 Females = 9

RACE Blacks = 11 Whites = 5

RELIGION Catholics - 3 Protestants = 9 Agnostics = 4

EDUCATION Grade K-6 = 1 Grade 7-9 = 2 Grade 10-11 = 8
Grade 12 = 4 College = I

MEAN IQ = 80

Therapists

The 10 therapists consisted of 7 males and 3 females. All were
White; eight of the therapists were from the United States, one was from
the Phillipines, and one was from Iran. Half of the therapists used an
active psychoanalytic approach without medication, and half used a

supportive, ego-analytic psychotherapy with medication.

Treatment

The patients averaged 70 psychotherapy sessions during their 20
month treatment program. Most of these therapy sessions took place
within the first six months. The patients initially received therapy
either three or five times a week; when they became outpatients the
therapy sessions were reduced to approximately once per week. The sample
of sessions used in this study consisted of one full audio-taped
psychotherapy session selected randomly from the group of available

sessions (as described above). The use of one taped session to represent

8
each patient’s therapy is problematic because the session selected could
misrepresent the total therapy experience. The author thought that the
raters would make a more meaningful decision about the therapy dynamics
based on one full session rather than fragments of many sessions, despite
the representation prOblem. It seemed that a therapy session can be read
as a meaningful story and that it would have been misleading to fragment

the session at random points.

Outcome Measures of Treatment

MSP utilized several outcome measures to identify patient change.
All patients were assessed on four occasions: at the onset of treatment,
at 6 months, at 12 months, and at 20 months. The assessments consisted
of the Thorndike-Galllup Vocabulary test, the Porteus Mazes, the Wéchsler
Adult Intelligence Scale, the Feldman-Drasgow Visual-verbal Test, the
Rorschach projective test, the Thematic Apperceptive Test, and Clinical
Status Interviews. The CSI was chosen as the measure for patient change
for several reasons. Most importantly, the CSI was selected because of
its construct validity. A clinician’s interview of a patient intended to
assess their mental health seemed.more related to meaningful change than
did the intelligence tests or the projective tests which were designed to
bring forth aspects of intellectual functioning and personality. The CSI
also yielded the highest validity coefficients with regard.to patients
staying out of the hospital. The patient’s ability to stay out of the
mental hospital represented a practical index of mental health.
Patient’s ability to stay out of the hospital after psychotherapy
treatment was also used as the criterion for health by Rogers in his

psychotherapy study of 1957. The average correlation of the CSI to the

9
other assessments was .50. The CSI was a clinical interview given by an
experienced psychiatrist who was not a member of the ward staff. The
dimensions were: ability to take care of self, work performance, sexual
adjustment, and social relationships; absence of delusions,
hallucinations; gross distortion of reality; degree of freedom from
anxiety and depression; amount and range of affect, life satisfaction,
achievement of capabilities, and benign rather than destructive effect on
others. The inter-judge reliability for the final quantification of the
CSI was .79. Patient change, for this study, was measured by the six
month ratings of the CSI and the 20 month ratings of the CSI, so that

each patient had two outcome scores.

Operational Definition of Mirroring

The mirroring construct was approached in two ways: an active
therapist attribute (confirming, accepting, approving, and admiring); and
as a need (the need to be mirrored) of the patient for the therapist to
acknowledge. There is some conflict in Kuhut’s work as to how to employ
the mirroring function; as an active technique or as an area of need to
be interpreted (Kohut, 1984). The study attempted to resolve this
problem by including an active and an insight version of the constructs.
The mirroring function was, in the active version, operationalized by
four Subscales: (1) confirming vs. non-confirming; (2) accepting vs.
not-accepting; (3) admiring vs. shaming; and (4) approving vs. not-
approving. The mirroring characteristics were constructed to fOrm a
hierarchy, with confirming meaning a basic sense of validating the
patient’s self; accepting meaning receptivity to the patient’s

communications; approving being a positive expression from the therapist;

10
and admiring meaning active support of the patient’s grandiose and
exhibitionistic strivings.
The insight version of mirroring construct was measured by subscale
(8) and rated the acceptance vs. rejection by the therapist of the

patient’s need to be mirrored.

Operational Definition of Idealizigg

 

The active idealizing construct was operationalized by three
subscales representing therapist attributes of: (5) calm vs. anxious;
(6) powerful vs. weak; and (7) confident vs. doubtful. The positive
attributes on these three subscales (calm, powerful, and confident)
theoretically formed an idealized therapist figure.

The insight version of the idealizing construct was measured by
subscale (9) which measured the therapist’s degree of acknowledgment and
acceptance of the patient’s idealizing statements and need.

All of the nine subscales were marked by 5 points with 3 standing

for "neither" (see Appendix C for a copy of the subscales).

Eat—ere

The three raters consisted of two White male college seniors with
psychology majors, and one Black female college graduate with counseling
experience in a community clinic. The raters were trained by the author
in three, 2 1/2-hour meetings during one month. The author told the
raters that they were working on a project looking at how therapists with
different training used various techniques that had unknown effects. The
constructs were communicated by a training workbook (see Appendix B), and

an audio-tape of the author and another student role playing the nine

11
concepts corresponding to the nine subscales (i.e., confirming,
accepting, admiring, approving, insight into mirroring needs, calmness,
powerfulness, confidence, insight into idealizing needs and their

opposites). At the meetings, the raters discussed the subscales and

practiced rating with clinical material. At the end of the third
meeting, all raters were given four audio-tapes, selected randomly.

After rating the first group of four tapes, the raters received the next
group of four tapes until each rater had rated the same total sample of
16 tapes. It took the raters two months to complete the ratings. All
three raters gave the exact same score for a patient on a subscale 68% of
the time. the average inter-rater reliability coefficient was .62. All
of the original subscale ratings were converted from the original sheets
so that the "5" endpoint of each subscale represented the positive aspect
of that subscale (i.e., in subscale 1, 5 = "confirming"). The
reliability coefficients (alphas) for the nine subscales were: subscale
1 = .28, subscale 2 = .87, subscale 3 = .50, subscale 4 = .50, subscale 5

: .75, subscale 6 = .32, subscale 7 = .35, and subscale 9 = .45.

Data Analysis

High scores on the subscales were used, hypothetically, as
predictors of patient change, using a multiple regression analysis. A
Pearson product moment coefficient was also performed on each of the nine

subscales independently, to assess their first-order correlations with

patient change.

RESULTS

The data analysis employed the six and 20 month ratings of the CSI
as the measure of patient change. The six month measure was selected
because most of the intensive psychotherapy took place during the first
six months of treatment, and the 20 month measure was selected.because it
was the last assessment time and would capturethe full effects of the
therapy. The six month evaluation outcome measure yielded no significant
results (see Appendix F). The 20 month evaluation provided some useful
information. The following table presents the nine subscales first-order
correlations with change at 20 months.’ From these first-order
correlations, it seemed that only the first mirroring subscale,
confirming, tended towards significance (p < .06), then in a negative
direction.

Table 3 illustrates the multiple regression analysis, using all nine
subscales. From these results it seemed that the confirming subscale
tended towards significance (p < .09) in the negative direction as
predicted, and that the insight into idealizing subscale tended toward

significance (p < .08), as hypothesized.

12

13
Table 2

Pearson Correlation of Therapist’s Behavior with Patient Change (N = 16)

 

 

Scale Pearson Coefficient Significance
(1) Confirming -.47 .06
(2) Accepting -.21 .44
(3) Admiring .18 .50
(4) Approving .26 .33
(5) Calm .13 .63
(6) Powerful -.26 .33
(7) Confident -.31 .24
(8) Insight-mirror .15 .58

(9) Insight-ideal .13 .62

 

Table 3

14

Relationship of Mirroringgand Idealizing to Patient Change (N = 16)

 

 

Scale Coefficient S.E. T Significance
(l) Confirming -1.36 .52 -2.06 .09
(2) Accepting .88 .35 .98 .37
(3) Admiring .32 .20 .90 .41
(4) Approving .02 .26 .04 .97
(5) Calm. - .84 .18 -1.15 .29
(6) Powerful - .50 .20 - .95 .38
(7) Confident - .22 .12 - .66 .54
(8) Insight-mirror - .09 .21 - .28 .79
(9) Insight-ideal .98 .19 2.11 .08+
Multiple R .85 Adj. R Square .33 : .24

 

15
The confirmdng (subscale 1) and insight into idealizing (subscale 9)
scores were then entered as the two variables contrasted with patient

change to form a final model, as illustrated by Table 4.

Table 4

Model of Confirming_and Insight-Ideal Contribution to Patient Change

 

 

 

Scale Beta Weight S.E. T. Significance

(9) Insight-ideal .44 .10 1.81 .09

Multiple R .62 SS(Reg) .46 SS(Res) .75

R Square .38 MS(Reg) .23 MS(Res) .06
Adj. R Square .28 DF 2.13 Significance F = .045‘
‘ p = .05

From the multiple regression analysis model, above, the confirming
subscale is significant in a negative direction. The insight into
idealizing subscale tends towards being positively related to change.
Together. these two variables significantly correlate with change
(significant F = .05). Both of the two subscales together account for

20% of the variation in change scores.

DISCUSSION

The hypotheses of this study were not fully supported by the
results. However, there are two aspects of the mirroring and idealizing
processes that seemed to contribute to patient change in the sample. The
confirming subscale (part of the mirroring measure) was found to be
negatively related to change. The therapist’s acceptance of patient’s
idealizing tended towards positive correlation with patient change.
Approximately one third of the fluctuations in patient change at 20
months was accounted for by the two findings: the negative confirming
finding and the acceptance of idealizing trend.

The six month therapy change measure did not correspond with any of
the mirroring and idealizing subscales, but the 20 month therapy change
measure yielded some relationships to the processes under study. This
differential yield suggested that the effects of the therapist’s
management of mirroring and idealizing increase over time. unlike a
chemical reaction, the intersubjective relationship between patient and
therapist may be thought of as an evolutionary process. Perhaps the 20
month results can be explained by the theory of introjection and
identification. The patient may, gradually, feel connected to the
therapist and may incorporate his/her therapeutic attitudes, as opposed
to the patient immediately receiving help from the therapist. An
unequivocal empirical answer does not exist for the question of when

16

17
patients change (from psychotherapy), and so this study’s results are
neither supported or contradicted by previous psychotherapy research.
Because this study used archival data, the effects of the therapist’s use
of mirroring and idealizing dimensions of transference may have been less
potent. Future research could employ therapists who were actually
training in Kohutian technique to better measure the effect of the
handling of mirroring and idealizing.

The confirming/disconfirming axis of mirroring brought the one
significant finding. Confirming was negatively related to change which
was in the Opposite direction, as hypothesized. This indicates that a
questioning, challenging approach is helpful, in psychotherapy, for the
patient. One possible explanation for the strength of the negative
finding (9 = .016) is that schizophrenic subjects were used. Confirming
the unhealthy, distorted persons of the psychotic individual may have
failed to motivate the patient to reorganize their way of relating to
self and others. If the therapist tells the patient that everything
about him/her and their world is fine, why would the patient undergo the
(often painful) experience of change? The author believes that the
negative confirming finding suggested a need for a modification of
KOhut’s mirroring theory, but the use of schizophrenic patients might
have enlarged the negative effect of confirming. If schizophrenia is the
result of a pathogenic parent (Karon & vandenbos, 1981), then the
confirming therapist may be felt as repeating the trauma of encouraging
the patient’s insanity. The schizophrenia may serve as a defense that
must be confronted in a climate of acceptance of the patient’s healthy

self. It is interesting that, in the overall multiple regression

18
analysis, all the mirroring subscales had positive valences (accepting,
admiring, approving) with the exception of confirming. Few conclusions
can be drawn about the other mirroring components because of their
failure to reach statistical significance, but this indicated that the
therapist’s mirroring must be directed towards the patient’s inner-
experience and, conversely, that the unhealthy, distorted expressions
should be challenged and questioned. This study found that high
confirming communications from the therapist hurt the patient’s growth
process. Confirming may have resulted in a kind of collusion with the
patient’s psychosis, which may serve as a screen to protect the patient
from getting close to others. The therapist may have to confront the

patient’s bizarre gestures and thinking to reach the deep core of the

self that may be available for alliance with the therapist. The need for

adequate mirroring (documented by Kohut) may be accompanied by a need for

confrontation of destructive personality organization. Psychotics have
more pathology than neurotic personalities, and this may account for

Kohut’s lack of incorporating confrontation into his theory of how

psychoanalysis can benefit the patient. The most controversial aspect of

Kohut’s mirroring theory, that people need praise and admiration requires

further empirical investigation. The aforementioned change in Kchut’s
model of therapeutic mirroring would specify that the mirroring be
directed at the healthy representations generated by the patient and
towards their need for appreciation and admiration. Some challenging by
the therapist may be needed to oppose the patient’s resistance and

continuation of old object-relational patterns.

19

The results of the study revealed a trend commensurate with the
hypothesis that the therapist who acknowledged the patient’s idealizing
benefited the therapy. Emery (1987) stressed that the therapist’s
understanding of the patient’s mirroring and idealizing selfobject
transference needs was more important than actually mirroring the patient
or providing them with a strong, idealizable role model. According to
Kohut, idealizing stemmed from the self’s hunger for an omnipotent figure
to identify with and, hence, strengthen the self (WOlf, 1984). Klein
(1956) stressed that the idealizing process was an important precursor to
the search for a good object, and that it protected the child from the
bad object which stimulated persecutory anxiety. Obviously many
schizophrenic individuals have fragmented selves which may be related to
a breakdown in the idealizing process. The delusional system, in
psychosis, might provide evidence for the existence of a different
idealizing process than occurs in more healthy persons. Delusions of
grandeur (as in feeling oneself to be God or in communication with God)
manifest idealizing but on to a non-human being; the delusional person
idealizes mythic or historical heroes, but not living people in their
world. A healthy relationship with a person who can contain the
idealizing activity (and the person’s ideals) protects the person from
dissolution. The delusional form of idealization fails to provide the
interpersonal security and growth that the healthy idealization achieves.
Another problem with the schizophrenic’s idealizing comes out in paranoid
imagery where the persecutor is endowed with grandiose, powerful traits
but is malevolent. The relational need for idealizing a strong, good

person may be awakened when the therapist acknowledged the need and

20

restores it to an interpersonal configuration rather than a fantasied
relationship. In terms of Kohut’s original model, the therapist’s
insight into the need to idealize may play a role in therapeutic growth.

This study has demonstrated that Kohut’s principles can be
communicated and measured in the context of psychotherapy research.
Future research might isolate each of the different aspects of idealizing
and mirroring as they work for psychotherapy with relatively healthy,
neurotic, and psychotic patients. The study also brought out the
possibility of changes in the Kchutian model where mirroring would be
supplemented with some limited challenging attitudes on the part of the
therapist. Kohut (1971) thought that the mirroring and idealizing
transferences should operate only in normal and neurotic patients. This
study’s findings indicated that the construct’s generalization to and
efficacy with schizophrenic patients remains a productive area for
further investigation. More clinical and research studies are needed to
explore the relationship of mirroring and idealizing processes in

psychotherapy. Additional research may help to reformulate Kohut’s theory.

APPENDIX A

INSTRUCTIONAL TAPE FOR RATERS

APPENDIX A

INSTRUCTIONAL TAPE FOR RATERS

This tape will present dialogues between a therapist and a patient.
After the patient’s statement, two alternative responses illustrating the

mirroring and idealizing concepts, will be given from the therapist.

Patient: "Over the weekend, I thought, I miss you like crazy, then I’d
think I miss you like poison."

ACCEPTING RESPONSE - Therapist: "Sometimes you miss me but other times,
you feel angry...must be a relief not to be here all the time."

NOT ACCEPTING RESPONSE - Therapist: "Is that your bad voice speaking?"

Patient: "That reminds me. I was in school and my teacher, Mr. Finney,
taught me to play piano, he was really nice. After my father dies, I
wanted to kill myself...I called him up, asking him to meet me and talk.
He couldn’t, said he was busy. So I turned on the stove, and tried to
burn my hand. I wanted to watch it burn. I had to go to the hospital."
CONFIRMING RESPONSE - Therapist: "When your teacher was too busy for
you, it must have made you very angry. You burned yourself when maybe
you wanted to hurt him."

DISOONFIRMING RESPONSE - Therapist: "Sounds like you become self-

destructive when your needs don’t get met immediately."

21

22
Patient: "This psychic told me that in a past life I was a man; a farmer
and very strong. I feel like that sometimes, people have mistaken me for
a man."
APPROVING RESPONSE - Therapist: "You enjoy your strength."
DISAPPROVING RESPONSE - Therapist: "What makes you want to be a man? Do

you feel confused?"

Patient: "I’m thinking about my buildings. During the sixties I was an
architect in New York City. I designed the Guggenheim museum, got paid a
lot for it."

ADMIRING RESPONSE - Therapist: "That’s a lovely building, I’m
impressed."

ASHAMED RESPONSE - Therapist: "That’s quite impossible, I’m afraid
because even if you had been an architect, you were hospitalized for much

of that time that you say you built that."

Patient: "Over the weekend, I spent some time with my ex and my kids.
They really don’t care about me, they spent all their time with their
friends. I watched the basketball game on TV, and I kept thinking that
you reminded me of Larry Bird. YOu always make the baskets, and seem to
make sense out of things for me."

POWERFUL RESPONSE - therapist: "SO you think in contrast to your family,
I’m able to care for you."

WEAK RESPONSE - Therapist: "Well I do my best, but, you know, I’m not

perfect...nobody is."

23
Patient: "I’m in so much pain and I feel crazy, do you think I’ll ever
get better?"
OONFIDENT RESPONSE - Therapist: "You’re wondering if I believe in your
ability to get well."

DOUBTFUL RESPONSE - Therapist: "I don’t know if you will or you won’t."

Patient: "Dr., I need to use your phone, I’m worried that my cab won’t
come, can I use your office phone?"

CALM RESPONSE - Therapist: "Well there’s a telephone in the lObby that
should work, our time is up for today."

ANXIOUS RESPONSE - Therapist: "Well my next appointment will be here any

time now. I guess if it will only take a moment you can use the phone."

APPENDIX B

TRAINING WORKBGX FOR RATERS

APPENDIX B

TRAINING WORKBOOK FOR RATERS

Purpose
The purpose of this study is to see how therapists employ certain

techniques. The techniques will be examined for how they relate with
different approaches to doing therapy. You will be listening to audio-
taped psychotherapy sessions. The patients are adult schizophrenic
individuals who have been temporarily hospitalized and were receiving
treatment. This workbook should help to teach you the techniques that
need to be identified in the tapes. Please read the workbook carefully.
When you begin to rate the tapes, you will want to know and be
comfortable with identification of the techniques.
Mirroring

Mirroring is the act of reflecting back to the person what he/she
really meant to convey. This can be a complex process because:

(a) The person may intend to say something but have trouble
expressing the idea clearly.

(b) The person may be ashamed to tell the message and will,
consequently, disguise the message.

(0) The person may not be clear about what they feel or think.

(d) The person may reveal a message that they are unaware of.

24

25

Sometimes the listener must probe for more information before
reflecting back, to the speaker, what they meant. PrObing for
information is not mirroring. Probing may be a good lead-in to a
mirroring statement. For example:

Speaker: "I don’t know what it is, but I don’t feel well today."
Listener: (PROBE) "YOu mean you don’t feel well physically?"

Speaker: "Yes, that too, but I feel kind of bad, My friend from out of
town left today."

Listener: (MIRROR) "So, you’re feeling a little down and blue."
Speaker: "'eah, that’s it."

The listener has accurately mirrored the speaker’s state of being,
but not without some sorting through of the situation. A lot of the
trick of mirroring is not the kind of response made (people mirror one
another often), but the extent to which they are able to do it with all
aspects of the speaker’s presentation. Good mirrorers can figure out
(with the help of questions) the message in almost any statement.
Sometimes the speaker may say something that makes no sense or is
distasteful to the listener. The listener who mirrors tries to extract
the underlying purpose of the expression. The only way to check with the
speaker to see if he/she was understood is to ask or wait for a
validation from the speaker. Listeners who insist that their
interpretation is correct are often not mirroring. Occasionally a person
may resist hearing back what they said, but usually the speaker will
respond positively to an adequate mirroring statement. The speaker is
always the authority on their subjective experience. Being mirrored is a

pleasant experience.

26

Part of mirroring in the therapeutic setting, is allowing the
speaker (or patient) to direct the topics brought up in the session. If
the listener (or therapist) changes the subject from what the speaker has
brought up, then he/she is probably not mirroring. The following is an
example of a speaker failing to mirror the listener’s topic of
conversation:

Speaker: "My brother asked me to go to the bar with him over the
weekend, and I told him I wouldn’t go. USually we have a few drinks and
somehow end up in an argument that ruins the rest of the weekend for me."
Listener: (NOT MIRRORING) "Let’s get back to the issue of you, what’s
going on with you and your feelings towards me." Here is an alternative
mirroring response to the speaker:

Listener: (MHRRORING) "Sounds like you’ve wised up to your brother and
you are protecting yourself."

Again there are some exceptions to this rule that mirroring means
staying with the issues that the speaker puts forward. For instance a
patient may avoid exploring some information because it might cause
anxiety, fear, or sadness, and the therapist may direct the patient to
that topic; not really mirroring the patient but not failing to mirror
either. If the therapist confronts the patient with new material before
the patient has signaled some readiness, then the therapist is attempting
to mirror (perhaps) but is not doing it as well as if the patient had
introduced the topic him/herself.

Another facet of mirroring is that the mirroring statement tends to
reflect the whole message rather than only a part of the message. If the

listener focuses on an unimportant detail of the speaker’s communication,

27
the listener may feel misunderstood. An example of successful mirroring
the whole over the part follows:
Speaker: "I finally enrolled in school. I’m starting next week at
Howell Conrnunity College."
Listener: (MIRRORING) "Really, that’s great. What classes are you
taking?"

Here is another response to the speaker’s statement that illustrates
not mirroring by focusing on the part instead of the whole:

Listener: (NOT MIRRORING) "Howell? Why did you choose a school so far
away from the city, where you might have problems commuting?"

It is important when evaluating the mirroring skills of the listener
to check if they responded to the speaker’s attempts to appear in a good
light. positively value their self, and to see if they respond to the
speaker’s attempts at accomplishing personal goals. With schizophrenic
individuals this task is complicated by the schizophrenic’s use of
magical thinking and delusion. Consider the content of schizophrenic
fantasy/delusion to see if it contains an attempt to brag or appear
important as its underlying intent. Many therapists concentrate on
deflating the delusion and pointing out reality. This is fine therapy
but it is not a mirroring tactic. The therapist may understand the
meaning of the delusion and mirror that back to the patient (which is a
mirroring tactic). An example of mirroring a delusion:

Patient: "The President of the United States has a job for me. I’ve
worked for the Secret Service before."
Therapist: (MIRRORING) "YOu seem to want a good job that’s worthy of

your talents."

28

A therapist may respond in a variety of ways to a patient’s
delusions and hallucinations. YOur job is to figure out how able he/she
is in mirroring the patient overall.

A different approach to mirroring is to respond to the listener’s
need to be mirrored. This approach to empathy is aimed at giving the
patient insight into his/her interpersonal motives. There will be a
separate scale for active mirroring and for pointing out the need to be
mirrored (called the insight mirror scale). It is important to identify
whether the therapist helps the patient gain insight into need states.
The therapist may supply the insight comment after the patient asks for
approval in some way. An example of recognizing the speaker’s need to be
mirrored:

Patient: "Last night I spoke to my wife and told her that we should go
out more. You know I don’t usually take her out to dinner or a show. Do
you take your wife out a lot?"

Speaker: (INSIGHT INTO NEED) "Seems like you want me to know that you
are trying to improve your relationship with your wife. It’s hard to
know, for you, if you’re doing the right thing."

In the active version of mirroring, the mirroring response will be
rated on 4 axes. This breakdown of the components of mirroring should
help you to focus. When rating the therapist’s mirroring ability with

each patient, these four dimensions will be assessed:

 

 

1. CONFIRMHNG DISOONFIRMING
2. ACCEPTING NOT ACCEPTING
3. APPROVING NOT APPROVING

 

 

4. ADMIRING NOT ADMIRING

29
These four components of mirroring can be thought of as a hierarchy
beginning with a rather mild, global confirming attitude and ending with
the strong, specific approving attitude. It is assumed that each
therapist may evidence any combination of these mirroring behaviors. The
confirming/disconfirming axis means that the therapist may confirm
(validate) the patient’s self as-is, or they may take a more
confrontative, questioning (disconfirming) stance. The accepting/not
accepting axis relates to the therapist’s benign evaluation of the
patient’s statements, needs, and goals or (at the other end of this
scale) the rejection of those statements, needs, and goals. The axis of
approving/not approving should measure the therapist’s favorable comments
about the patient’s statements or actions. This axis is meant to
identify positive approaches from the therapist rather than the milder,
more neutral axes of confirming and accepting. Finally the
admiring/ashamed axis should be used to measure the therapist’s pleasure
in the patient’s skills, and in the patient’s self-love - their
grandiosity.

In addition to scoring the four qualitative aspects of mirroring,
you will need to mark an intensity number for each axis with the
endpoints representing the words described (points 1 and 5). Points 2
and 4 will represent "somewhat" the quality on the half of the subscale
and "3" will represent "neither" which means that the therapist’s
behavior did not fall on either end of the axes.

Idealizing
The therapist may want to create, in the patient, a feeling that the

therapist is strong and can take good care of the patient. There are

30
different ways to help a person to feel safe. The qualities that I am
mean by this are the presentation of confidence, power, and calmness.
Confidence, here, means that the therapist feels confident in his/her
abilities and in the therapeutic process - that the patient will probably
get better. By power, I mean that the therapist communicates that he/she
is strong and can hold up in the face of the patient’s anger, anxiety,
and neediness. Calmness means being able to soothe the patient and
provide a general sense of even temperedness. The concepts are fairly
self-explanatory. If the therapist seems comfortable with their role,
then that is a sign that the therapist is fulfilling this "ideal" image.

Here is an example of a powerful therapist:

Therapist: "YOu seem angry with me."

Patient: "I don’t see how I’m getting better, I feel terrible, and maybe
you’re hurting me...I don’t know about whether I’ll be here next time."
Therapist: "If you leave, I’ll still be here next week."

Here is an example of the weak therapist’s response:

Therapist: "Do you really think I’m hurting you? That’s different from
the way I see it."

The powerful therapist handles the patient’s anger with an
overriding sense of certainty in him/herself and seems unafraid of the
patient’s threat to leave therapy. The weak therapist may be doing ok,
but it is through a weaker approach.

The confident versus doubtful therapist axis is based on the
therapist’s confidence in him/herself as a therapist and about the

patient’s capacity to change. An example of the confident therapist is:

31
Patient: "I feel very depressed lately. Thought I was getting better
but the last few nights I can’t sleep and I cry a lot."
Therapist: (OONFIDENT) "Well, I think it’s important that you can let
yourself feel your sadness."

An example of an alternative response that is doubtful is:
Therapist: (DOUBTFUL) "Really, maybe there is something that you’re not
telling me that I could help you with. It sounds bad for you."

The calm therapist is soothing and does not withdraw from material
that is shocking or disturbing. The following is an example of the calm
therapist:

Patient: "When I was in Vietnam, some of my buddies and I would smoke
dope and take pills. I blacked out a lot; maybe I have brain damage.
Therapist: (CALMING) "Uh-huh, I understand that a lot of people in your
position took drugs. Unless you notice some drop in your abilities and
memory, you’re probably ok, but it should like it was frightening."

The response of an anxious therapist to this might be:

Therapist: (ANXIOUS) "That sounds very serious; it might explain your
mood swings; why don’t we get a brain scan assessment."

The calm therapist is not placid or, necessarily, understated but is
reassuring, and not ruffled by topics that arouse anxiety in the patient.
In other words, the calm therapist purposely does not mirror the
patient’s frightened affect.

In the insight-idealizing subscale, you will be looking for the
therapist’s attention to the patient’s need to idealize the therapist.
This means that the therapist can point out that the patient wants to see

the therapist as perfect. If the therapist seems uncomfortable with the

32

patient’s idealization, then he/she will score low on this subscale. The
patient may praise the therapist in an unrealistic way. If the therapist
rejects the patient’s praise, the therapist should receive a low score on
acceptance of idealizing. If the therapist interprets the patient’s
disappointments with authority figures (i.e., parents, bosses, other
staff members in the hospital), then he/she is probably going to score
high on acceptance of idealizing; since the therapist recognized the need

for the patient to find people to direct his idealizing towards.

APPENDIX C

RATER ’ S S(X)RING SHEET

Circle the nunber that

RATER’S SCORING SHEET

APPENDIX C

best describes this tape on each scale.

 

 

 

 

 

 

 

 

 

 

 

 

 

l. 1 2 3 4 5
(confirming) (neither) (disconfirming)
2. 1 2 3 4 5
(not accepting) (neither) (accepting)
3. 1 2 3 A 4 5
(admiring) (neither) (ashamed)
(approving) (neither) (not approving)
5. 1 2 3 4 5
(anxious) (neither) (calm)
6. 1 ---2 —-- 3 4 5
(powerful) (neither) (weak)
7. 1 ----2 3 4 5
(doubtful) (neither) (confident)
8. 1- 2 3 4 5
(points out (neither) (ignores mirroring
needs)
9. 1 2 3 4 5
(ignores or rejects (neither) (accepts
idealization) idealization)

33

APPENDIX D

DESCRIPTIVE STATISTICS OF SUBSCALES

Scale
OONFIRMING
ACCEPTING
ADMIRING
APPROVING
CAUfl

POWERFUL
OONFIDENT
INSIGHT/MIRROR

INSIGHT/DEAL

APPENDIX D

DESCRIPTIVE STATISTICS OF SUBSCALES

4.78

4.51

3.33

4.14

3.98

3.73

4.17

4.02

3.54

34

Standard Deviation

0.53

0.80

0.73

1.02

1.41

1.15

1.11

0.82

1.03

APPENDIX E

LITERATURE REVIEW

APPENDIX E

LITERATURE REVIEW

Rank (1923) was one of the first psychoanalysts to stress the
management of the relationship to the patient, as opposed to
interpretation of unconscious material. Rank felt that the therapeutic
cure was buried in the actual relationship between therapist and patient.
The American interest in Rank resulted in "relationship therapy" (Taft,
1933). The goal of relationship therapy was to help the person to
experience their inner self. Although this school of therapy (originated
at the Pennsylvania School of Social Work) was not far from Freud’s
notion of transference, the phenomenology of the relationship began to
take precedence over the "blank screen" management of the patient.
Comments from the analysand about the analyst were here understood as not
just projections; the analyst took some responsibility for his/her
effects. The experiential dimension of therapy was evolved by Rogers
with client-centered therapy during the 1950’s. Much of Roger’s
elaboration upon the empathic process in therapy parallels Object-
relations theory, especially that of Kohut. Kahn (1985) has also
compared Rogers and Kchut. According to Kahn, Rogers and Kohut both
focus on empathy as the key condition for psychological growth. Rogers
and Kohut realized that people depend on others to function empathically

so that they are, at times, experienced as one. Kahn noted that the two

35

36
theorists held divergent conceptions of the personality. Kohut’s self is
based on the traditional conflict model whereas Rogers conceptualized the
self as congruent and whole when given unconditional acceptance.
Ultimately, Rogers and Kohut described similar processes, but Kohut
looked at where the empathy was directed. Too much empathy for one area
of personality could overstimulate the self in one aspect and
understimulate the rest of the self.

Rogers’ (1957) therapeutic triad of accurate empathy, unconditional
positive regard, and congruence formed the "necessary and sufficient"
conditions for change. The therapist entered the client’s subjective
world and became "another self" for the client (Rogers, 1951). The
therapist’s ability to understand the client in a warm, accepting
atmosphere was the curative action. Rogers tested his therapeutic
conditions with schizophrenic, neurotic, and healthy individuals (Rogers
et al., 1967). The Wisconsin Project found that therapists high on the
three conditions (empathy, warmth, and congruence) helped schizophrenic
patients stay out of the hospital. Accurate empathy of the therapists
also correlated with reduction in the schizophrenia subscale on the MMPI.
Later empirical research on Rogerian conditions for therapy met with
mixed results (Meltzoff & Kornreich, 1970). Yet Bergin and StruPP (1972)
concluded that even with difficult patients, empathy, warmth and respect
facilitated change. In tracing the movement of therapy process from
interpersonal to intersubjective, Rogers’ concepts are still therapist
traits, independent of the patient (Garfield, 1980).

The interpersonal theory of therapy began in the United States with

Sullivan (1953) and in Europe with Klein. Fairbairn, Guntrip, and

37
Winnicott. While Rogers felt transference to be a somewhat annoying
artifact of therapy (Rogers, 1951), the object-relations theorists saw
that in the transference were the hopes and fears of a new healing
relationship. The transference was a "creative illusion" (Cannon, 1968)
that motivates the patient and must be used along with the real reactions
of the patient to the therapist’s persona.

KOhut defined three essential types of transferences. The
mirroring, idealizing, and twinship transferences were the basis of
Kohut’s relational needs for a strong self. The self’s need for a
mirroring other and an idealized figure can be seen as Kohut’s version of
Freud’s sexual and aggressive drives. Kohut’s sense of the person’s
fundamental needs emphasize subjective rather than biological
expressions. V

Interest in the mirror as an actual and metaphorical experience
started with Lacan in the thirties (Lacan, 1977). Lacan noted that
somewhere between six and 18 months, the infant first recognized his/her
self in the mirror. The child during this "mirror-stage" played in front
of the mirror and exerted control over its body. The mirror afforded the
child a sense of identification with the whole self and with mastery over
the body.

Winnicott expanded on Lacan’s mirror stage by placing the origin of
the mirror to the mother’s face (Winnicott, 1971). Ideally, the mother
performs a mirroring function by giving back to the infant what he/she
(communicated; a preverbal sense of being understood. The mother must
adapt herself as an Object to be used.by her child. the mother is a

"holding environment." Winnicott stressed that the baby’s feeling of

 

38
omnipotence must not be interfered with by the mother in her handling of
the child. Kohut’s proposal of the selfobject is anticipated in
Winnicott’s description of the good (enough) mother. The caretaker must
give priority to the baby’s needs over their own. The mirror role of the
mother provides the child with approval and recognition. The child’s
identity is grounded in communications with the parent. Later experience
with the actual mirror image is colored by historical experience with
looking into the mother’s eyes. Winnicott added dimensions of early

object relationships to Lacan’s theory of identity formation in the

 

mirror-stage.

Winnicott (1971) found that the unresponsive or overly moody parent
failed to mirror the child. The failure to mirror produced a defensive
or withdrawn child. Winnicott observed that the child who had not been
adequately mirrored treated actual mirrors with fear or with
preoccupation with physical beauty. Miller (1981) indicated that an
unmirrored child embarks on a life-long search for a mirroring other.

With reference to the process of psychotherapy, Winnicott touched on
the mirror role of the therapist. The therapist must give to the patient
what he/she puts forth to the therapist. The mirroring therapist helps
the patient feel real and accepted. Patients feel angry when their
therapist has failed to empathize (Winnicott, 1955). Again Winnicott,
like Rank and Rogers, felt that the therapist’s cannunications helped or
hurt the patient.

The end of Lacan’s mirror-stage, age 18 months, became the focus of
attention for the American Object-relations theorists, Kohut and

Kernberg. The developmental stage of narcissism was conceptualized as

39
taking place between 18 months and 8 years (Wolf, 1984). Kernberg and
Kohut worked to classify and explain the narcissistic self-disorders they
encountered in clinical practice. Kernberg (1975), guided by his
integration of Fairbairn’s relational model and Freud’s drive model,
found that intersubjective experience influenced internal psychic
structure. Kernberg approached character development from the mechanisms
of introjection, projection, and splitting. Kohut (1984) rejected the
concept of drive and build his theories around the idea of the self and
its relational needs.

The difference between Kernberg and Kohut is that Kernberg viewed
the self as besieged by libidinal forces and, consequently, potential
dangerous. Kohut saw the self as inherently self regulating. Aggression
and perversion are considered by Kohut to be a kind of last hope to
repair a damaged self and not as manifestations of libidinal drive.

Kohut tended to look for the whole self’s message in any symbolic act,
whereas Kernberg found the self as an orchestration of superego, ego, and
id.

Kohut elaborated on the journey of selfhood. Injury to the self
that occurred during the narcissistic stage resulted in a narcissistic
personality disorder. Kohut (1977) felt that a successful handling of
this developmental stage left the person with a residue of "healthy
narcissism." This fundamental narcissism accounted for the adult’s
capacity for initiative and zest. Yet the early appearance of narcissism
had to be nurtured by the social environment. The other is perceived as
a facilitator of self control or as an impediment to smooth functioning,

with all the shades of gray in between helping and hurting. Kohut used

40
the term selfobject to describe the child’s significant other(s). The
parents are narcissistically cathected by the child.

There are three selfobject roles in the Kohutian framework that
serve interrelated needs (Kohut, 1971, 1977; WOlf, 1984): (l) the
mirroring selfobject that confirms the child’s sense of greatness and
perfection; (2) the idealized selfObject that serves as a source of calm
and omnipotence with which the child can identify and feel safe; (3) the
twinship selfobject that provides a sense of sameness between child and
adult; often based on common gender identity.

The mirroring selfobject is needed to respond to the child’s self
exaggeration of perfection and grandiosity. Kohut (1971, 1977) sets the
mirror transference (in childhood) as the stage for mObilization of the
self. The larger than life sense of self helps to strengthen the child’s
self. The mirroring function of the parent is expressed by the saying
that the child is the "apple of the (parent’s) eye."

The idealized selfobject supplements the sense of security because
the idealized parent is large enough to contain the child with his/her
sense of grandiosity. The idealized selfobject is comparable to
Winnicott’s holding environment, and to Kernberg’s soothing, holding
introject. The idealized selfObject is also a reservoir for the self’s
goals and ideals.

The twinship selfObject addressed the need for connectedness between
child and parent. The parent who tells their child that the child is a
"chip off the old block" is expressing this twinship process (Kohut,
1984). The ego ideal is activated through the parent’s confirmation of

the child’s positive resemblance to the parent.

41

In the natural evolution of the healthy self, there was the presence
of an adequate selfobject environment that met the child’s needs. The
self, though, benefited from."optimal frustration" (Kohut, 1971, 1977)
from the parents. When the parent failed to empathize, the child begins
an internal process Of "transmuting internalizations" wherein the
psychological functions of the selfObject are taken over and cultivated
inside the self. Gradually the child acquires the acceptance,
confirmation, strength, and calm that was once gotten solely from the
parents. The transmuting internalization process is similar to when a
romantic liaison has ended. Each member of the couple may act in ways
that resemble their lost partner. This chameleon-like gesture is related
to Winnicott’s transitional Object theory where a toy may replace the
absent parent. Transmuting internalization may be characterized as a
transitional identity where the self recreates what was Obtained from the
other.

In pathological development, the self remained fragile and
uncohesive because the selfObject needs went unmet. the adult may hunger
for mirroring, idealized figures, and a twin figure. The parents can
fail the child by not giving enough empathy or by overstimulation of the
grandiose, exhibitionistic acts and goals of the child. If a specific
capacity was celebrated to the exclusion of others, the child experienced
the parents as not really being behind them but as selfishly interested
in that one talent. The adult who had been overwhelmed with attention in
one area may be conflicted.about that skill, or may be deficient in other

areas of life. When selfObject needs were not provided, the adult may be

42
frightened of their own neediness and avoid intimacy (Kohut & Wolf,
1978).

In psychotherapy it is assumed that the patient will experience all
of the selfobject transferences (e.g., mirroring, idealizing, and
twinship). Kohut (1979) in his case study "The Two Analyses of Mr. 2"
interpreted Mr. Z’s narcissistic demands (displayed through
hypochondriacal symptoms) as unhealthy defense mechanisms. A second
analysis with the patient, using the new theory, resulted in Kohut’s
mirroring of his need to show Off. Kohut’s acceptance of Mr. Z’s
narcissism helped Mr. 2 to directly express his demands rather than to
disguise them in body complaints. Kohut recognized unfulfilled yearning
for an idealized parent in the patient that had been developmental
frustrated by the father. Kohut’s second analysis led to profound change
in the patient.

Kohut believed that his conception of the analytic cure differed
from others in that it focused on the scope of empathy rather than on the
kind of empathy. For example acting-out behavior in therapy was
interpreted as an attempt to empower the self (Kohut, 1984). As Karon
(1981) stated about work with schizophrenic patients, the therapist must
be felt as nonpunitive. In the Kohutian model of therapy the analyst is
invested in finding the ways in which the self comes to feel strong.
Unlike Rogers, Kohut used the transference response as a guide to needed
empathic experience. Like Rogers, the therapist and patient function as
a unit (Schwaber, 1981) rather than in a confrontational posture with the
analyst reminding the patient of reality. The therapist provided some

facilitating conditions whereby the narrative of the patient unfolded

43

(Stolorow & Atwood, 1984) in the presence of a powerful and confirming

audience.

This literature review has attempted to show the development of

Kohut’s concepts of mirroring and idealization as they related to their

application in psychotherapy.

APPENDIX E

SUBSCALE CDRRELATIONS WITH 6 PDNTH CHANGE

APPENDIX F

SUBSCALE CDRRELATIONS WITH 6 I‘DNTH CHANGE

Table 5

6 Month Change Correlated With Subscales (14:16)

 

 

 

 

Scale Pearson Coefficient Significance
( 1 ) Confirming . 17 . 53
( 2) Accepting . 31 . 25
( 3) Admiring . 06 . 83
(4 ) Approving . 31 . 25
( 5 ) Calm . 34 . 20
(6 ) Powerful - . 26 . 32
( 7) Confident - . 32 . 23
(8) Insight-mirror . 21 . 44
( 9 ) Insight-ideal . 1 1 . 71

 

44

Table 6

Multiple Regression Analysis:

Subscales with 6 Month Change

 

 

Scale Beta weight S.E. T. Significance
(1) Confirming -.41 .71 -.56 .59
(2) Accepting .40 .48 .83 .44
(3) Admiring -.33 .27 -1.25 .26
(4) Approving -.06 .35 - .17 .87
(5) Calm .05 .24 .23 .83
(6) Powerful -.08 .27 -.31 .77
(7) Confident -.05 .16 -.31 .77
(8) Insight-mirror .14 .29 .48 .65
(9) Insight-ideal -.01 .25 -.04 .97

 

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