Finding self, forming virtue: the treatment of narcissistic defenses in marriage therapy.

Bland, Earl D.

Philip Ringstrom (2008) described psychoanalytically oriented couples treatment as something like an extreme sport. The complex interactions that emerge when couples open their lives to a therapist is enough to test the most intuitive and insightful minds in our field. Consciously stated conflict is maintained within a mosaic of unconscious organizing principles regarding affect, self-assemblage, and relational engagement. Communication is often multilayered and if one could speak through a prism, the colorations of meaning would spread out a host of implicit and repetitive relational patterns and ongoing selfobject needs. For distressed couples the orchestration of this relational complexity is beautifully symphonic and tragically discordant at the same time.

Given the complexity of many marital cases, it is essential that we understand not only the relational dysfunction, but how each partner's self-functioning contributes to the chaos and stuckness couples often feel when they present for treatment. Each couple presents with unique relational problems that emerge from the confluence of two interacting and connected selves. Consequently, it is likely that some self states are more problematic than others for the development and maintenance of healthy connection. This article discusses the treatment of narcissism which many argue is very disruptive to the ongoing success of marriage and couples' relationships (Garza-Guerrero, 2000; Lachkar, 1992; Levene, 1997; Links & Stockwell, 2002; Maltas, 1991; Solomon, 1988, 1989). After a brief theoretical overview of narcissism primarily within the domain of psychoanalytic self psychology, I pursue a clinical discussion of narcissistic traits in couples and how treatment dynamics are influenced. I start with transference concerns, and then examine treatment processes that are helpful in healing narcissistic wounding. Finally, I talk about treatment as a pathway for understanding the formation of virtue in relationship restoration. On the heels of Browning (1987), Roberts (1993, 2007), and Tjeltveit (1992, 2004), I argue that psychotherapy, especially from the view of self psychology, tangibly reflects a Christian ethical priority in virtue development. For expediency and clarity I have chosen to emphasize couples where the husband presents with self-states that are primarily narcissistic. While narcissism is no respecter of gender, there is some clinical evidence to suggest that males are more prone to using narcissistic defenses that are damaging to relational intimacy (Wright, O'Leary, & Balkin, 1989).

Narcissism: Theoretical Description

Due largely to the influence of self psychology (Kohut, 1971, 1977, 1984) modern psychoanalytic theory has accepted narcissism as a normal psychological position which, if developed in a responsive, empathic, realistic environment, will transform into healthy self-esteem and a capacity for mutuality in relationships. Conversely, narcissistic defensiveness and personality structure result from chronic affective misattunement and selfobject failure. This compromised self organization is vulnerable to fragmentation and responds to threats and stress through dysfunctional patterns of attachment including implicit relational procedures that prioritize self needs over the needs of others. Key to this perspective is how the unmet narcissistic needs for affirmation and recognition are maintained in a very immature form. Adult entitlement, grandiosity, and idealization are all desperate attempts to compensate for early deprivation of selfobject needs and to shore up a fragile self structure. Rage and compulsive acting out are responses to perceived threat to the self's integrity, the sign of impending fragmentation.

Further, self psychology and intersubjective theory view marriage as a joining of two people who serve sustaining selfobject functions for each other. A selfobject function can be thought of as the "self-affirming way ..." (Lachman, 2008, p. 8) the other is experienced. The degree of strength and/or deficits in the development of the self will significantly impact how these selfobject needs (needs for self-affirmation) will present themselves. For those with significant self-deficits there will be less flexibility in the way these needs are met by the other person. In other words, narcissistic personality traits express reasonable developmental needs that have been distorted and veiled by relationship interaction patterns meant to compensate for self-deficits and to protect against further damage. Therapy is a process of coaxing the vulnerable and underdeveloped self to establish new relationship patterns wherein legitimate self needs are validated and allowed expression while simultaneously developing empathy for the needs of the spouse.

Transference Enactments and Transference Needs

Problems in marriage are generated by unwieldy transference enactments defined as the activation and mobilization of counterproductive and repetitive modes of affect regulation and relational engagement. Spouses, under stress and in times of frustration and deprivation, unconsciously rely on implicit relational scripts that evoke particular need states, feelings, and perceptions of self and other. When the couple enters treatment these same transference dynamics are now expanded to include the therapist and the unique perturbation a third person brings to the couple's relationship. Levene (1997) argues that transference is primarily between the couple and secondarily with the therapist. However, it is important to recognize that the presence of the therapist changes the nature of couple conflict and complaint. For example, highly conflictual and destructive couples can initially present as normal reasonable people. Conversely, conflict avoidant couples may unhinge their anger in the presence of a real and validating person who is finally able to hear complaints without judgment. Narcissistic needs for idealization, mirroring, or twinship are activated by the therapist as patients, especially narcissistic patients, expend effort to please or impress the therapist. For the narcissistic spouse this may be an ongoing process where significant energy is placed on maintaining a positive image with the therapist. To prevent shame reactions, the narcissistic patient tries to control the disclosures about his needs and behavior outside of the therapy office. Excessive complaints on the part of the wife can bring retribution between sessions or a refusal to return to therapy. Further, in what Levene refers to as a "contextual transference" (p. 128), the couple may have fantasies about the therapist and what he or she thinks of them as a couple. Couples project onto the therapist expectations of the holding environment wherein selfobject needs can be met (Solomon, 1989). Can the therapist be trusted to hold the marriage together cohesively? Does the therapist value the relationship?

Levene (1997) suggests that two other important dimensions of couple transference are the repetitive nature of dysfunctional interactions and the persistent presence of selfobject needs. This distinction can be significant as we look to interpret and explain transference interactions to the couple. First, it is useful for partners to see what part of their engagement with each other is the result of deficient interactional patterns that are repeated in response to perceived rejection, frustration, or disappointment that echo past traumas and losses. Secondly, couples need to understand what conflicts emanate from the activation and frustration of underlying selfobject need states. Leone (2008) states that the selfobject dimension of one's marital relationship is always present. Because our sense of self is sustained within a relational context, we cannot escape from our need for selfobject responsiveness. In treatment, which we will discuss in the next section, the therapist helps the couple to see how differing organizing principles create conflicting states of meaning and expectation. The underlying selfobject need and the self-protective defensive organization against expressing the need are brought to light, hopefully in a compassionate way that allows for understanding and validation.

Marriage Therapy Goals

Given that the intricacy of marital interactions and conflict expand when the therapist enters the transference system, what are realistic goals for a psychoanalytically oriented marital and couples therapy? Solomon (1989) calls for increasing awareness of unconscious emotions and encouraging partners to reshape the inner representations of their spouse. When exploring each other's needs each partner must learn to tolerate uncomfortable emotions as the other partner learns to integrate their own disparate emotions. Levene (1997) echoes the call for greater understanding of repetitive interaction patterns that replay old narcissistic injuries and failures. Later she points to the necessity for narcissistic individuals to develop a capacity to recognize the spouse, to see her as a separate person (Levene & Babiak, 1998). Kirshner (2001) describes this as a recognition and acceptance of the otherness of the other or developing the ability to engage in differentiating as well as mirroring dialogue. David Shaddock (2000) believes that psychoanalytic marital therapy identifies therapist activities that "facilitate an enhanced sense of relationship satisfaction" (p.109). The goal of these more active interventions would be to discover new principles for organizing experience (Trop, 1994). From the perspective of Links and Stockwell (2002), occasionally this will require the therapist to help curtail the narcissistic partner's acting out. Ringstrom (1994) states spouses must "... reckon with and tolerate inevitable disappointments; and utilize their own strong feelings as signals that indicate something to explore within themselves, instead of becoming fixated in blaming their spouse for their disappointment" (p. 163). Overall, Leone (2008) writes that most spouses want someone who will be understanding, affirming, and caring. Partners desire to live with someone who will enjoy who they are, help them when they feel badly, and celebrate when they have successes. Similarity in values is important as each partner wants a spouse they can respect and turn to in times of trouble. To the degree psychoanalytic therapy helps couples attain these characteristics, Leone believes success can be claimed.

Although the previously mentioned treatment goals may not be amenable to specific protocols, there is some basic convergence regarding the therapeutic process of marital therapy from a psychoanalytic perspective. Using self psychology and intersubjective theory Ringstrom (1994) outlines a sequential process of marital therapy. He indicates that establishing empathic attunement to each spouse's subjective experience and communicating that neither version of reality is preferable or more correct than the other is critical early in the treatment. Next, each person's complaint in the marriage is linked to a developmental history of unmet selfobject needs, trauma, and misattunements. After showing how complaints are linked to the past, the therapist talks about how problems are continually reenacted in the current relationship. When couples understand the repetitive nature of their problems, they are encouraged to identify any self-sabotaging behavior each person is doing to instigate the reenactment of past in the present. In a final step, Ringstrom supports the transfer of the empathic and supportive function of the therapist to each of the couples.

Therapist Neutrality

Although the previous processes may sound formulaic, Ringstrom (1994) and others (Levene, 1997; Leone, 2008; Gerson, 1998) would argue that the vagaries of transference enactments, the unique self-capacities of each partner, and the relationship history make marital therapy anything but predictable. The initial trust building phase, accomplished by sustained empathic listening and resistance to taking sides, is complicated and precarious with narcissistically vulnerable couples. As one listens to each partner, it is quite probable that the other partner will feel slighted and competitive, both wondering whose version of the relationship will trump. For the narcissistic spouse, specific articulation by his wife about destructive behavior or past hurts can cause intense narcissistic wounding. The therapist must walk the fine line of validating the wife and her complaint without allowing her opinion to diminish the fact that her husband may interpret the event very differently. Ringstrom's (1994) emphasis on empathic egalitarianism or equally validating the version of both spouses is supported by other writers (Leone, 2008; Solomon, 1989) and Gerson (1998) points out that countertransference concerns are often the impetus for therapists to preference one partner's story over the other. The only way to maintain credibility and the trust of both partners is to set an atmosphere where both partners believe they are going to get a fair hearing. In addition, therapists do not hold an a priori version of reality; we have to examine our own expectations of marriage, gender, and the role of each person in a marriage.

One clarification of this general principle of equally valid perceptions of reality concerns the implied moral dimension such a nonaligned therapeutic stance suggests. In all couples, especially those with a narcissistically oriented partner, there exists a distinct possibility for reprehensible behavior. Narcissistic styles of relating can be very destructive to intimate partners as rage begets actions of personal diminishment and violation. One husband, Bill, of a couple I was treating, so enraged at his wife Brenda's persistence during an argument, proceeded to corner her in a section of the kitchen and expose his genitals in a taunting manner. This humiliated and horrified Brenda to the degree that she was almost unable to talk about how degraded and scared she felt. Bill on the other hand, maintained a cool and removed demeanor effectively masking his shame and embarrassment. Therapists should not lose sight of being empathic with both partners' experience in such instances and the underlying emotional needs that propel such an interaction should be explored. However, it is also essential to label the behavior for what it is, destructive and blameworthy. I want to emphasize, in line with Goldner (2004), that therapists are in a position to impact real moral concerns when it comes to relational interactions. I do not believe shirking from the stark reality of who did what to who in such destructive encounters is beneficial; and probably reinforces an established pattern of minimizing such incidents so common to narcissistic relationships. In many conflicts both partners succumb to ignoble language or behavior. The fragility of narcissistic structures, however, and the culturally sanctioned entitlement of male rage, often causes the husband to trump his wife's anger and distress with the real or implied danger of physical force.

Again, therapist positioning and the establishment of trust with each partner through a stance of sustained empathy is critical. I find that the majority of narcissistic husbands who engage in these kinds of destructive behaviors know that they have behaved badly. compassionate exploration of the split off emotions and underlying need state can be effective in reducing avoidance and shame. At the same time therapists must be careful that the exploration of deprived need states behind the reprehensible action does not come across as explaining away, or absolving the husband from taking full responsibility for his actions. Further, in the context of couples work, the exploration of the husband's need states can sometimes trigger angry or accusatory remarks from his wife. Active therapeutic monitoring is critical so as to make the session a safe place for the husband to recognize and accept responsibility for negative behavior as well as mobilize the necessary empathic attunement to his wife's experience of his behavior so that an apology is possible.

Disruption and Repair

The process of repairing the emotional damage of a destabilizing conflict can tax the emotional resources of both partners. To begin, when the wife has been offended it is critical that the relationship learn to tolerate her expression of anger, hurt, and disappointment. While this will likely be experienced as narcissistically injurious by the husband, he must begin to absorb the criticism or the affective intensity of his wife without shifting blame or leaving the room emotionally. A key therapeutic task is to bolster the husband's ability to take the criticism without making excuses. consequently one must be wary of early precursors to self-esteem crashes in which the narcissistic spouse becomes overcome with debilitating self-feelings. Subtle shifts in facial expression or body posture can be clues to how the husband is receiving his wife's statements. checking in with the husband's affective arousal state and helping the wife to use non-inflammatory language can allow the thorough discussion of an event. It is my experience that narcissistic husbands often have an arousal set point of no return. Gottman (1999), talks about "diffuse physiological arousal" (p. 74) wherein the autonomic nervous system and cortical processes create a paradoxical emotional experience of feeling hostile and helpless simultaneously. Helping otherwise oblivious husbands understand the slow escalation of their physiology and the corresponding self-other meanings such states imply is a critical process. The therapist can encourage a tempered disclosure of the wife's internal distress while assisting the husband in modulating affective arousal. Further, the therapist can challenge the validity of destructive relational interpretations and meanings for both partners, allowing them to be exposed to the underlying dynamics of their conflict.

Procedurally an important step is to give voice to the unspoken fears of abandonment, rejection, and humiliation in each partner. In tandem, underlying selfobject needs for nurturance, acceptance, respect, mirroring, and affirmation are given legitimate review. As the therapist encourages each spouse to sit still and feel the pain and longing such states evoke a space opens up for mutual recognition. It is here where the otherness of the other and validation of mutual need states can lead to empathy and compassion as well as to exploring pathways to sustaining interactions that meet these needs. Further, in this therapeutically empathic place of sustained exposure, one can feel shame due to having failed or acted poorly with the concomitant experience of another's anger and disappointment. The narcissistic spouse can accept responsibility for his actions and not be faced with the withering criticism or interpersonal abandonment he has experienced in the past. He is able to tolerate his wife's anger without fearing attack or desertion when he admits fault or shows remorse.

Narcissistic Injury

A related variation of the disruption/repair sequences that command much of marital counseling is when the narcissistic husband has been hurt or angered. There are several factors that can complicate understanding and resolution of his emotional distress, including a general impairment in the ability to effectively communicate internal affective states. Ranging from exquisite sensitivity to disruptions in one's emotional equilibrium to relative denseness of even expected variations in emotional displays, the narcissistic husband's emotional state can dominate relational interactions. Sourced out of narcissistic injury, the anger or hurt does not have to begin with the spouse although she often ends up bearing the brunt of the emotional fallout due to defensive projection and displacement. The therapist's empathic response to the patient's attempts to prevent fragmentation and reassert some level of self-esteem serves two purposes. First, it demonstrates to the husband that therapy is a safe environment in which to experience vulnerability. Second, therapist empathy acts as an exemplar for his wife regarding compassionate responses to emotional disruption. Further, the therapist demonstrates that behavior, emotion, and meaning are linked. The therapist's exploration of the meaning behind hostile anger or passive withdrawal invites curiosity and demonstrates courage in the face of what have been frightening emotional states for both partners. The therapist's ability to carve out an insular pocket of self and relational reflectivity provides a new perspective on the patient's pain out of which new meaning and behavior can emerge.

Specific actions on the part of the therapist are determined by particular patient characteristics, but usually narcissistic men need to gain an appreciation of the intensity and pervasive interpersonal impact of their mood. Because of the generally entitled nature of narcissistic emotional displays many husbands are not aware of how frightening or intimidating they can be when aroused by anger or frustration. Moreover, what feels to them like a need to be alone is experienced by others as indurate withdrawal. The intensity of the emotion can leave wives scrambling to escape, pacify, or cajole their husband's into a less ominous disposition. At times wives may experience reactive anger or avoidance as a self-protective mode. I have often found it helpful to encourage wives to calmly and specifically identify the fear they experience in the face of their husband's emotional escalation or abandonment. Having the husband use this response by his wife as a cue to reflect on his behavior and feelings often helps him to pay more attention to how his negative self-state is capitalizing and intruding on his ability to get his needs met. It also helps to encourage early identification of narcissistic injury and the implementation of self-soothing processes. Although many narcissistic men can use compensatory behavior or isolation to soothe, they also need to experience what it is like to talk about their negative self-state and take in the empathic resonance of the therapist and partner. At times, as Lichtenberg (2008) points out, a person may have experienced such aggressive early trauma that the ability to be soothed through attachment behaviors is missing. In these cases the need for attachment is not diminished as much as the capability of finding such attachments soothing and rewarding. couples with this organization can come to a compromise that allows the husband to give his wife notice of how he feels and have her help him create enough space for behaviors or activities that do help him moderate his distress.

While the husband explores more effective methods for affect regulation, it is also critical that his wife develop responses that allow her to maintain her sense of self in the relationship as well as be emotionally accessible to her husband. Some women are able to readily mobilize empathy and compassion when they experience their husband slacken and make room for her to join in his fear of fragmentation. Hopefully her husband responds with gratitude and accepts the soothing response as a balm. At other times, when the history of the relationship is peppered with narcissistic acting out, the wife is less willing to let her defenses down. Past experience has taught her that these emotionally accessible times are not points of conversion. Rather, consumed with his own fragmentary threat the husband's selfobject need is blinded to her otherness. He may express hurt, anguish, even remorse for past transgressions, but there is little differentiating dialogue. It is as if his need consumes her compassionate attempts to help regulate his emotions and his hunger is not assuaged. This mirror/affirmation hungry component of the narcissistic structure is linked to an internal emptiness that many men will readily admit exists on a pervasive basis. One of my patients acknowledged that he thought all people felt empty all of the time. He found his wife's soothing ministrations comforting for a time, but they were just distractions from the constant experience of a vacant inner self. When this came to light in the session his wife became very discouraged: "When," she asked, "is he going to stop needing me to help him survive?" Therapeutic interventions at this point are geared towards validating her fear while encouraging her to risk moving towards her husband. I have found stage setting is important at this juncture. If the wife experiences the therapist as trustworthy, based on past empathic validations and a willingness to confront her husband regarding his destructive behavior, she is more willing to let her own defensive anger abate and provide the needed selfobject function for her spouse. Another component of the wife's reluctance to demonstrate compassion and empathy for her husband's distress is a nagging feeling of unfairness: "Why should I show compassion to him when he never shows it to me?" Again, if the therapist is able to validate this fear of repetitive trauma and acknowledge the underlying selfobject need for safety, many patients will be willing to at least tentatively move to a more responsive position.

To this point I hope it has become evident that the multiple levels of monitoring required in couples session make active participation on the part of the therapist essential. Selecting which of the many interaction sequences to focus on requires dexterity and a persistent willingness to alter one's course if one partner begins to disengage or dominate the sessions. As I have tried to point out, this therapeutic acumen is tested the most in disruption/repair sequences that make up much of the conflict resolution work of marital treatment. However, I also believe that it is in the understanding of how to change unmodulated affect, disrupted self-states, and faulty relational organizing principles that couples learn virtues that many say are missing in distressed couples. To conclude this discussion I want to focus a few thoughts on the integration of Christian virtue development in the context of psychoanalytically informed marital treatment.

A Word about Virtue

In his seminal paper Forms and Transformations of Narcissism, Kohut (1966) begins a shift in our understanding of narcissistic personality characteristics and behaviors. Prior to Kohut, therapists tended to view treatment as involving the replacement of a patient's immature narcissistic position with object love. In contrast Kohut asserted that desirable human attributes and virtues such as creativity, empathy, humor, wisdom, and the acceptance of transience all emerged, not from the denial of self, but from the transformation of the self and its early narcissistic needs. In the thirty-plus years since Kohut wrote his paper we are certainly much more comfortable with the idea of narcissistic self-needs as a legitimate component of mental health. In fact, given our current cultural preoccupation with self-esteem and self-fulfillment, we have made the enhancement and exploration of the self a prime cultural value (Taylor, 1989). critical to understanding Kohut's (1966) vision, however, is the idea that narcissism should be transformed if one is to live with a sense of purpose and well-being. Essential to this transformation, maybe somewhat paradoxically, is that narcissistic needs must be "... passed through a cherished object." (p. 249) before they are reinternalized at a higher developmental level. Later identified as a selfobject function, Kohut emphasizes the path to overcoming rabid selfishness in early life is through attachments to cherished objects. Developmentally, recognition of the child's needs is critical as these cherished objects must respond with affirmation, mirroring, and reasonable expectations. In everyday emotional language the child must be loved if he or she is going to be capable of love. Self-needs are not something one needs to eradicate or replace with object love, it is the self that needs love if it is to be capable of love. In a phrase: love begets love.

Despite this somewhat idyllic formulation, I want to suggest that psychoanalytic treatment can assist in the pursuit of virtues essential to healthy relationships and that we might consider the function of marriage therapy as akin to a spiritual discipline. If we judge spiritual disciplines to be those activities which ". bring us into more effective cooperation with Christ and his Kingdom" (Willard, 1990, p. 156), is it possible that marital therapy can give us glimpse of how to live a faithful life? Parsons (2006) supports the notion that spiritual pursuits and psychoanalysis are alike in their concern ". with processes that work to bring people into deeper contact with the sources of meaning in their lives" (p. 126, emphasis in original). For Christians and many others the height of this meaning is a life of love. The ability to be in relationships and enjoy them as expressions of Christ's love is a fundamental Christian ethic.

Although psychoanalytic marriage therapy does not prescribe spiritual disciplines per se, it does make demands of its participants that sometimes end up being rigorous and very painful. For example, we have explored how marital therapy, like psychoanalytic therapy in general, prioritizes the total honesty of couples thoughts, feelings, and motivations regarding their relationship. Setting the tone for what hopefully is adapted by each partner, the marital therapist becomes a usable selfobject and encourages each partner to be truthful; to honestly examine how he or she participates in the creation and maintenance of the very problems from which they so desperately wish to be free. Of course this is hard and paradoxically many patients seek to protect themselves from the very thing they desire. While patients call for more love, patience, kindness, and humility in their partners, the fear of these is palpable in the frenetic way they protect vulnerable selves and defend against feelings of need and longing. As Livingston (2004) points out, marital therapy in general attempts a "transformation of the patients' narcissistic experience" (p. 443). Partners must face their own selfishness, their own longing, their own loss and disappointment in the presence of a longed for cherished object. As therapists we validate and affirm the needs and longings and create realistic expectations as old, repetitive and painful fears are played out in the gritty exchanges of disruption and repair. Not unnoticed, but often unspoken is how these interventions and therapeutic maneuvers are helping to operationalize experiences of virtue.

Therapists who encourage and listen to disappointment and rage experienced due to faulty selfobject functioning on the part of the spouse are in vivo examples of patience and kindness. When a narcissistic husband musters the courage to experience his shame and remorse in front of the therapist and his wife, virtue is afoot. When a wife is able to let down her emotional walls and give her husband another chance to meet her needs, forgiveness is finding space in the interactions. The list could continue and includes relational exchanges that promote hope, generosity, justice, love, and many other expressions of the Christian character. As therapists tenaciously promote and sustain an atmosphere of empathic validation, couples are allowed to slowly shed their defenses and consider a different way of being. New relational organizing principles emerge and toleration of distressing affect is increased. Illusions and dreams can be released for the more palatable and satisfying experience of real hope and authentic connection. This is not nirvana; tragic disappointments must be metabolized and not forced into cosmetic arrangements of resolution. The goal, however, of a relationship that is sturdy, able to accept the particular self weaknesses, celebrate and affirm each other's ambitions, soothe and affirm in times of fragmentation, and tolerate the inevitable disappointments life brings is possible. Therapists who are able hope in the leading edge possibility of this type of relationship, catalyze virtue and, I believe, expand the kingdom of God.

References

Browning, D. S. (1987). Religious thought and the modern psychologies: A critical conversation in the theology of culture. Philadelphia: Fortress Press.

Garza-Guerrero, c. (2000). Idealization and mourning in love relationships: Normal and pathological spectra. Psychoanalytic Quarterly, 69, 121-150.

Gerson, M. J. (1998). The significant other and the psychoanalytic relationship: Reflections on couples therapy. Psychoanalysis and Contemporary Thought, 21, 61-84.

Goldner, V. (2004). When love hurts: Treating abusive relationships. Psychoanalytic Inquiry, 24, 346372.

Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York: W.W. Norton.

Kirshner, L. A. (2001). Narcissistic couples. Psychoanalytic Quarterly, 70, 789-806.

Kohut, H. (1966). Forms and transformations of narcissism. Journal of the American Psychoanalytic Association, 14, 243-272.

Kohut, H. (1971). The analysis of the self. Madison, cT: International Universities Press.

Kohut, H. (1977). The restoration of the self. Madison, cN: International Universities Press.

Kohut, H. (1984). How does analysis cure? chicago: The University of chicago Press.

Lachkar, J. (1992). The narcissistic / borderline couple: A psychoanalytic perspective on marital treatment. New York: Brunner/Mazel.

Lachman, F. M. (2008). Transforming narcissism: Reflections on empathy, humor, and expectations. New York: the Analytic Press.

Leone, c. (2008). couple therapy from the perspective of self psychology and intersubjective theory. Psychoanalytic Psychology, 25, 79-98.

Levene, J. E. (1997). couples therapy with narcissistically vulnerable individuals: contributions from self psychology. Canadian Journal of Psychoanalysis, 5, 125-144.

Levene, J. E., & Babiak, T. (1998). Dyadic capacity: Progress in narcissistic development. Progress in Self Psychology, 14, 181-201.

Lichtenberg, J. D. (2008). Sensuality and sexuality across the divide of shame. New York: The Analytic Press.

Links, P. S., & Stockwell, M. (2002). The role of couple therapy in the treatment of narcissistic personality disorder. American Journal of Psychotherapy, 56, 522-538.

Livingston, M. S. (2004). Stay a little longer: Sustaining empathy, vulnerability, and intimacy in couple therapy. Psychoanalytic Inquiry, 24, 438-452.

Maltas, c. (1991). The dynamics of narcissism in marriage. Psychoanalytic Review, 78, 567-581.

Parsons, M. (2006). Ways of transformation. In D.M. Black (Ed.), Psychoanalysis and religion in the 21st century (pp. 117-131). London: Routledge.

Ringstrom, P. A. (1994). An intersubjective approach to conjoint therapy. In A. Goldberg (Ed.), A decade of progress: Progress in self psychology (Vol. 10, pp. 159182). Hillsdale, NJ: The Analytic Press.

Ringstrom, P. A. (2008). Improvisation and mutual inductive identification in couples therapy: commentary on paper by Susan M. Shimmerlik. Psychoanalytic dialogues, 18, 390-402.

Roberts, R. c. (1993). Taking the word to heart: Self and others in an age of therapies. Grand Rapids: MI: Eerdmans.

Roberts, R. c. (2007). Spiritual emotions: A psychology of Christian virtues. Grand Rapids: MI: Eerdmans.

Shaddock, D. (2000). Contexts and connections: An intersubjective approach to couples therapy. New York: Basic Books.

Solomon, M. F. (1988). Treatment of narcissistic vulnerability in marital therapy. Progress in Self Psychology, 4, 215-230.

Solomon, M. F. (1989). Narcissism and intimacy: Love and marriage in an age of confusion. New York: Norton.

Taylor, c. (1989). Sources of the self: the making of the modern identity. cambridge, MA: Harvard University Press.

Tjeltveit, A. c. (1992). The psychotherapist as Christian ethicist: Theology applied to practice. Journal of Psychology and Theology, 20, 89-98.

Tjeltveit, A. c. (2004). The good, the bad, the obligatory, and the virtuous: The ethical contexts of psychotherapy. Journal of Psychotherapy Integration, 14, 149-167.

Trop, J. L. (1994). conjoint therapy: An intersubjective approach. Progress in Self Psychology, 10, 147-158.

Willard, D. (1990). The spirit of the disciplines: Understanding how God changes lives. New York: HarperSanFrancisco.

Wright, F., O'Leary, J., & Balkin, J. (1989). Shame, guilt, narcissism, and depression: correlates and sex differences. Psychoanalytic Psychology, 6, 217-230.

Earl D. Bland

MidAmerica Nazarene University

Author

Earl D. Bland (Psy.D. in Clinical Psychology, Illinois School of Professional Psychology, 1996) is a Professor of Psychology, MidAmerica Nazarene University, Olathe, KS. His psychoanalytic psychotherapy training is from the Chicago Institute for Psychoanalysis and the Greater Kansas City/ Topeka Psychoanalytic Institute. His research interests include the integration of psychology and faith, psychoanalytic self psychology, narcissistic disorders, psychology-clergy collaboration and virtue development.

Please address correspondence regarding this article to Earl D. Bland, PsyD., MidAmerica Nazarene University, 2030 E.College Way, Olathe, KS, 66062; ebland@mnu.edu