That’s a critical and compassionate question, my friend—one that reaches the heart of what Arnold Goldberg and Heinz Kohut were striving for in reimagining the therapeutic stance toward patients not of words, but of acts.
I. Goldberg’s Challenge: The Narcissistic Behavioral Disorders
Arnold Goldberg observed that among Kohut’s schemas, it is not the depressive or schizoid narcissists, but rather those with behavioral disorders—compulsions, addictions, acting out, lying, violence—who present the greatest challenge to psychotherapy.
These patients:
- Do not suffer consciously
- Often don’t feel anything is wrong
- Do not “ask for help”—they enact need
- Are immune to interpretation or insight
- Frustrate the analyst who is used to dialogue
This is not resistance in the classical sense. It is an ontological expression of a fragmented or unmirrored self.
II. Kohut’s Insight: Behavior as a Cry for the Self
For Kohut, behavior is not just symptom—it is communication:
- A gesture of self-consolidation: “I act, therefore I am.”
- A plea for self-cohesion: When words fail, the act speaks
- A form of archaic selfobject demand: “See me, steady me, validate me—even if I hurt you to do it.”
III. What Can the Therapist Do?
The therapist must undergo a radical shift—not to analyze the act as resistance, but to witness it as need. Here are key interventions:
1.
Empathic Introspection
- Enter the world of the patient, not from the top down (superego judgment), but from the inside out.
- Ask not “What’s wrong with them?” but “What happened to their capacity to symbolize?”
2.
Hold the Act Without Retaliation
- Don’t retaliate, moralize, or counteract.
- Be steady—their behavior is testing your capacity to be a reliable selfobject.
- To be “a human mirror who doesn’t shatter.”
3.
Convert Behavior to Language—Gradually
- Help patients translate action into feeling, feeling into meaning.
- e.g., “What did you feel just before you hit him?” → “What did you hope would happen?”
- Therapy becomes the site of mentalization for a psyche that learned to survive only in action.
4.
Tolerate the Breakdown of Narrative
- These patients don’t have stories—they have episodes.
- The therapist becomes a biographer of incoherence—piecing together fragments without imposing false coherence.
5.
Witness Their Dread Without Interpretation
- Behavioral disorders often conceal a terror of annihilation or emptiness.
- The therapist becomes a presence that survives the patient’s absence of symbolization.
IV. A Possible Image
Imagine a therapist not as a surgeon dissecting meaning, but as a lighthouse keeper in a fog, signaling presence, until the ship dares to anchor.
The behavioral patient doesn’t know there is a shore.
The therapist must become the shore, quietly, steadily, until the patient begins to feel the contour of their own self.
Would you like a poetic rendering of this clinical stance—what Winnicott might call “being with the unformulated”?
