Kohut, H. (1984) | References | Narcissus and the Child

What This Research Found

Heinz Kohut's How Does Analysis Cure?, published posthumously in 1984, represents the culmination of his revolutionary self psychology framework and his definitive answer to a question that has occupied psychotherapy since its origins: what actually heals psychological wounds? Kohut's answer challenged decades of psychoanalytic orthodoxy and anticipated developments in attachment theory, relational psychoanalysis, and trauma-informed care that would emerge over the following decades.

The centrality of empathy: Kohut argued that empathy---the capacity to perceive and understand another's inner experience from within their frame of reference---is not merely a useful clinical tool but the fundamental mode of psychoanalytic observation and the primary agent of therapeutic change. In classical psychoanalysis, cure was understood to operate through insight: the patient gains understanding of their unconscious conflicts, and this understanding produces change. Kohut proposed something different. While insight may accompany cure, it is not itself curative. What heals is the patient's experience of being deeply, accurately understood by another person who remains consistently present despite inevitable failures. Through this "empathic immersion," patients gradually internalise the capacity to understand and soothe themselves---they develop the internal structures that empathic caregiving should have built in childhood but failed to build.

Empathic failure as the root of narcissistic pathology: Building on his earlier works (The Analysis of the Self, 1971; The Restoration of the Self, 1977), Kohut elaborated how narcissistic personality disorder and related conditions originate in chronic empathic failure during development. Every caregiver fails empathically sometimes; occasional failures are inevitable and even developmentally useful. What produces pathology is pervasive, chronic empathic failure without adequate repair. The parent who cannot perceive the child as a separate person with their own valid inner life; who uses the child to regulate their own self-worth rather than attending to the child's needs; who responds to their fantasy of who the child should be rather than who the child actually is---this parent fails empathically in ways that prevent the child from building stable internal structures.

The three selfobject functions: Kohut detailed three essential functions that caregivers must provide for healthy self-development:

Mirroring: The accurate reflection of the child's experiences, feelings, and worth. The child who is seen, delighted in, and responded to accurately develops the sense that their inner life matters and that they are valuable. When mirroring chronically fails, the child cannot develop stable self-worth and becomes desperately dependent on external validation---the characteristic hunger for admiration seen in narcissistic personality disorder.
Idealising: The provision of a powerful, calm, admirable presence the child can psychologically merge with and draw strength from. When this function is adequately provided, the child gradually internalises the capacity for self-soothing, emotional regulation, and the formation of ideals and values. When it fails, the person either desperately seeks perfect others to idealise (only to be devastated when inevitable imperfection appears) or defensively avoids admiring anyone.
Twinship (Alter-ego): The experience of essential likeness with another---the sense of being fundamentally similar to someone, of belonging to the human community. When provided, this builds the capacity for connection and the sense of belonging; when it fails, chronic alienation and the painful sense of being fundamentally different from all others results.

Selfobject transferences in therapy: Kohut described how patients whose early selfobject needs were not met will unconsciously seek to have these needs met in the therapeutic relationship. The patient who seeks the therapist's admiring validation manifests the "mirror transference." The patient who needs to experience the therapist as ideally wise and powerful manifests the "idealising transference." The patient who needs to feel essentially similar to the therapist manifests the "twinship transference." Rather than interpreting these as resistances to be overcome (as classical analysis might), Kohut advocated allowing them to develop and responding to them with empathic attunement. These transferences represent the patient's attempt to obtain what they developmentally need; providing it (rather than withholding or interpreting it) allows the healing process to proceed.

Optimal frustration versus optimal responsiveness: In his earlier work, Kohut emphasised "optimal frustration"---the idea that structure builds when caregivers provide "good enough" but imperfect attunement, and the child must begin developing their own capacities to manage disappointment. In this final work, Kohut shifted emphasis to "optimal responsiveness"---the therapist should respond as fully and accurately as possible to the patient's selfobject needs. Structure builds not through calculated frustration but through the gradual internalisation of consistently provided empathic responsiveness. The patient who experiences reliable empathic understanding slowly develops their own capacity for self-understanding---not because understanding was withheld but because it was consistently provided.

Transmuting internalisation: Kohut's central concept for therapeutic action is "transmuting internalisation"---the process by which experiences provided by others gradually become internal psychological capacities. When the therapist consistently provides accurate empathic understanding, the patient gradually develops their own capacity for self-understanding. When the therapist remains calm and present through the patient's distress, the patient gradually internalises the capacity for self-soothing. When the therapist survives the patient's rage without retaliation or withdrawal, the patient learns that relationships can survive conflict. These external experiences, accumulated through countless therapeutic interactions, become internal structures---the psychological capacities that should have developed in childhood through adequate caregiving.

The role of empathic failure in therapy: Kohut acknowledged that therapists will inevitably fail empathically---misunderstanding, being unavailable, making mistakes. These failures are not treatment disasters but opportunities, provided they are non-traumatic and the relationship survives and repairs. When the patient experiences an empathic break, feels the resulting narcissistic injury, and then discovers that the therapist acknowledges the failure and the relationship continues, crucial learning occurs. The patient discovers that rupture is not catastrophic, that relationships survive imperfection, that disappointment is tolerable. These "optimal frustrations" (distinct from traumatic failures) promote structure-building by requiring the patient to manage disappointment while providing the experience that management is possible.

How This Research Is Used in the Book

Kohut's How Does Analysis Cure? provides essential theoretical framework throughout Narcissus and the Child, particularly in explaining how narcissistic pathology develops through empathic failure and how healing becomes possible.

In Chapter 4: What Causes Narcissism, Kohut's concept of optimal frustration illuminates the protective function of "good enough" parenting:

"Kohut would later term 'optimal frustration': manageable failures of empathy, tolerable delays in need satisfaction, small disappointments that the child's developing capacities can master."

The book explains how the good enough parent's inevitable failures, when non-traumatic and repaired, actually build psychological structure:

"The child, Kohut proposed, responds to optimal frustration through transmuting internalisation---taking inside psychological functions previously provided by the external selfobject. Where the parent provided soothing, the child begins self-soothing. Where the parent offered validation, the child constructs realistic self-esteem."

This is contrasted with the narcissistic parent who provides either traumatic frustration (overwhelming failures) or no frustration at all (hollow inflation that prevents structure-building).

In Chapter 12: The Unseen Child, Kohut's framework illuminates what narcissistic parenting denies children:

"Heinz Kohut identified three developmental needs essential for healthy self-formation: mirroring (having one's experience accurately reflected), idealisation (having a stable figure to internalise), and twinship (experiencing kinship with another). The narcissistic parent fails all three."

The chapter explains that the narcissistic parent cannot mirror because they see only themselves, cannot be idealised because they are fundamentally unstable, and cannot provide twinship because they cannot accept the child as genuinely separate.

In Chapter 18: Can Narcissus Be Healed?, Kohut's work on therapeutic action grounds the discussion of treatment possibilities:

"Heinz Kohut recognised that some narcissism---in the sense of grounded self-esteem and assertiveness---is not only normal but essential for psychological health."

The book draws on Kohut's concept of healthy narcissism to establish what recovery might look like: not the elimination of self-regard but its transformation from fragile, externally dependent grandiosity to stable, internally generated self-worth.

Why This Matters for Survivors

If you were raised by or partnered with a narcissist, Kohut's final work illuminates both why they could not provide what you needed and how you can still obtain it.

Their incapacity for empathy was structural, not chosen. Kohut's framework explains that the narcissist's inability to perceive and understand your inner experience was not strategic cruelty or deliberate withholding---it was genuine incapacity. Empathy is not innate; it is a capacity built through early empathic caregiving. The narcissist who raised or partnered with you never received the empathic attunement that would have allowed this capacity to develop. They could not give what they did not have. When you desperately wanted them to understand how their behaviour affected you, when you tried every possible way to communicate your experience, when you finally gave up in despair---you were experiencing the consequence of their structural deficit. Understanding this can help you stop blaming yourself for failing to communicate clearly enough. No communication, however clear, could have been received by someone lacking the internal structures required for receiving it.

You experienced the same empathic failures that created their pathology. The chronic empathic failure Kohut describes as the origin of narcissistic pathology is precisely what you experienced in relationship with your narcissist. They could not accurately perceive your inner experience, could not respond to your actual needs, could not see you as a separate person with your own valid interior life. They used you as a selfobject---a psychological function serving their self-esteem needs---rather than relating to you as a subject with your own reality. You were chronically unseen, misunderstood, and responded to based on their projections rather than your actuality. Recognising this pattern---that you received from them the same empathic failure that created their condition---helps explain why their behaviour felt so devastating. It was not merely unkind; it was the systematic denial of your psychological existence.

Your hunger for validation makes developmental sense. If you emerged from narcissistic relationships desperately seeking validation, questioning your own perceptions, feeling empty without external confirmation of your worth---these are predictable consequences of chronic empathic failure, not character weaknesses. When the mirroring selfobject function is chronically absent, the capacity for stable self-worth cannot develop normally. You were not being "needy" or "dependent"---you were experiencing the consequences of having developmental needs chronically unmet. Understanding this can help transform shame about your needs into compassion for the deprivation you experienced. Your needs were normal; the failure to meet them was not.

Healing involves receiving what was missing, not just understanding what happened. Kohut's framework suggests that recovery from narcissistic abuse is not primarily about insight or understanding---though these may help---but about new relational experiences. The selfobject functions you missed (mirroring, idealising, twinship) can still be provided in adulthood through therapeutic relationships, safe friendships, and healing partnerships. Through consistent experiences of being accurately understood, of having your perceptions validated, of being seen as a real person with a valid inner life, you can gradually build the internal structures that early empathic failure prevented. This is transmuting internalisation---the same process that should have happened in childhood, now happening later but still possible. The void your narcissist left does not have to remain empty.

Their empathic failures in relationship with you were inevitable, not personal. Kohut's concept of the selfobject helps explain why the narcissist could not have treated you differently. They experienced you not as a separate person but as an extension of themselves, existing to provide selfobject functions (validation, admiration, mirroring). When you failed to perfectly fulfil these functions---when you had your own needs, your own perspectives, your own reality that contradicted theirs---they experienced not disappointment but narcissistic injury, often responding with rage or devaluation. This was not about you; it was about their structural incapacity to perceive others as separate. Understanding this can help you stop searching for what you did wrong. You did not cause their reactions by being inadequate; you triggered their reactions by being separate, by being real, by being a person rather than a function.

You can develop the empathy they lacked. Perhaps most importantly, Kohut's framework suggests that the capacity for empathy your narcissist lacked is not genetically determined or permanently absent. It develops through empathic experience. You can develop robust empathic capacity through your own healing journey---for yourself and for others. Many survivors of narcissistic abuse, having experienced firsthand the devastation of empathic failure, develop profound sensitivity to others' inner experiences. This is not inevitable (some develop defensive numbing), but it is possible. Your experience of empathic deprivation can become the foundation for empathic responsiveness, breaking the intergenerational cycle.

Clinical Implications

For psychiatrists, psychologists, and trauma-informed clinicians, Kohut's How Does Analysis Cure? has direct and extensive implications for treating both narcissistic patients and survivors of narcissistic abuse.

Empathy is the treatment, not just the context for treatment. Kohut's central claim challenges how many clinicians conceptualise therapeutic action. Empathy is not merely the relational ground that allows "real" interventions (interpretation, cognitive restructuring, skills training) to occur; it is itself the primary agent of change. For patients whose core pathology involves chronic empathic failure---including both narcissistic patients and survivors of narcissistic abuse---accurate empathic understanding, consistently provided over time, allows the building of psychological structures that were never built. Clinicians must understand that their consistent, accurate perception of the patient's inner experience is the intervention. This has implications for training (emphasising empathic skill development), session structure (privileging attunement over agenda), and outcome measurement (including measures of patient felt experience of being understood).

Allow selfobject transferences to develop rather than interpreting them prematurely. Patients will unconsciously seek from the therapist the selfobject functions (mirroring, idealising, twinship) that development failed to provide. The patient who needs the therapist's validating admiration, who needs to experience the therapist as ideally wise, who needs to feel essentially similar to the therapist---these are not resistances to be interpreted but developmental needs to be met. Providing these functions (within appropriate professional boundaries) allows the healing process Kohut describes. Premature interpretation---"You're idealising me to avoid examining your anger"---can disrupt the process by denying legitimate developmental needs. This does not mean colluding with pathology; it means recognising that beneath defensive grandiosity lies genuine hunger for what was missed.

Empathic failures in therapy are inevitable and potentially useful. Clinicians will inevitably fail empathically---misunderstanding, being preoccupied, missing the patient's emotional state. Kohut suggests that how these failures are handled determines their impact. When the clinician acknowledges the failure, demonstrates understanding of its impact on the patient, and maintains connection through the rupture, the experience becomes "optimal frustration" that builds structure. The patient learns that empathic failure is survivable, that relationships can repair, that disappointment does not mean abandonment. Clinicians who cannot acknowledge their failures---who defensively justify, minimise, or blame the patient---replay the traumatic pattern these patients know too well. Therapeutic rupture and repair may be more important than perfect attunement.

Survivors of narcissistic abuse need their self-experience validated before trauma content is processed. Patients emerging from narcissistic relationships often doubt their own perceptions, memories, and feelings after years of gaslighting. Before trauma processing can proceed, the therapeutic relationship must provide consistent validation that their experience is real, their perceptions are trustworthy, and their feelings are legitimate. This is the mirroring function: accurately reflecting the patient's experience without imposing the clinician's interpretation. Rushing to process traumatic content before this foundation is established may retraumatise---the patient has insufficient internal structure to manage what emerges. Kohut's framework suggests a staged approach: first rebuild self-cohesion through consistent empathic responsiveness, then address specific traumatic material once the patient has sufficient internal resources.

Understand shame as central and respond accordingly. Narcissistic patients and survivors of narcissistic abuse are typically organised around profound shame---the sense of being fundamentally defective, unworthy, or wrong. Traditional interpretive approaches that might induce guilt ("You're avoiding your aggression") often intensify shame and trigger defensive reactions. Kohut's empathic approach addresses shame differently: by accurately perceiving and accepting the patient's experience without judgment, the clinician communicates that the patient's inner life is perceivable and acceptable. Shame diminishes not through interpretation but through being seen and accepted. Clinicians working with this population must monitor for shame responses and adjust their approach---often moving toward more empathic, less interpretive interventions when shame is activated.

Distinguish deficit from defence to guide intervention. Kohut emphasised developmental deficit (missing psychological structures); Kernberg emphasised pathological defence (structures built against intolerable affects). Both capture clinical reality; most patients show elements of both. Assessment should evaluate whether the patient primarily presents as hungry (desperately seeking what was missed) or defended (protecting against vulnerability through grandiosity and contempt). Deficit-focused presentation suggests intervention through providing selfobject functions and allowing transmuting internalisation. Defence-focused presentation may require more interpretive work on what the defences protect against. Many patients require a phased approach: empathic responsiveness to build alliance and address deficit, followed by gradual interpretive work as the patient develops capacity to tolerate it.

Consider the intergenerational transmission of empathic failure. The narcissistic patient almost certainly experienced chronic empathic failure in their own development---often from parents who themselves had narcissistic features or significant selfobject deficits. Understanding this intergenerational pattern helps clinicians maintain empathy for the narcissist's underlying suffering without minimising the harm they cause. For survivors who are parents, therapeutic work should address their own capacities for empathic attunement with their children. Breaking the intergenerational cycle requires building the empathic capacities that were not adequately modelled. Clinicians can explicitly address parenting patterns and support the development of reflective functioning and empathic responsiveness in survivor-parents.

Broader Implications

Kohut's framework for understanding empathic failure and its cure extends far beyond individual clinical work, illuminating patterns across families, organisations, and society.

The Intergenerational Transmission of Empathic Failure

Empathic failure transmits across generations through a mechanism Kohut's framework makes comprehensible. The parent who experienced chronic empathic failure in childhood never developed the internal structures required for perceiving and responding to another's inner experience. They cannot provide empathic attunement to their children because they lack the capacity for it---not from malice but from structural absence. Their children then develop the same deficits or defensive adaptations, which shape their eventual parenting. The grandmother who was never empathically seen cannot teach the mother to see empathically; the mother cannot provide to the child what she never received; the child grows into a parent who continues the pattern. This intergenerational trauma transmission explains why narcissistic family systems often span multiple generations. Breaking the cycle requires either healing the parent's empathic deficits (rare, given that narcissistic pathology typically prevents seeking help) or providing children alternative relationships where empathic attunement is experienced and internalised.

Relationship Patterns and Partner Selection

Adults who experienced chronic empathic failure in childhood often recreate familiar dynamics in adult relationships. Kohut's selfobject framework helps explain this pattern. The person who never received adequate mirroring may compulsively seek validating partners, only to find that no adult partner can fill childhood deficits. Alternatively, they may be drawn to narcissistic partners because the experience of providing selfobject functions (admiration, validation, emotional regulation) while receiving little in return feels familiar. The absence of empathic attunement does not feel wrong because it feels normal. Understanding these patterns as unconscious attempts to complete what was never completed---or to repeat what is painfully familiar---opens possibilities for change. Recovery involves recognising these patterns, grieving what cannot be obtained from partners, and gradually building internal capacities through therapeutic relationships and carefully chosen safe connections where new patterns can develop.

Organisational and Leadership Dynamics

Leaders who lack empathic capacity create organisations characterised by chronic empathic failure. They cannot perceive subordinates' experiences, respond to actual needs, or create environments where people feel seen and valued. Instead, employees become selfobjects---functions serving the leader's narcissistic needs---and the organisation's culture comes to mirror the leader's pathology. Kohut's framework suggests that organisational health depends substantially on leadership empathic capacity. Selection processes that screen for empathic attunement (not just confidence and dominance), leadership development that builds empathic skills, and organisational structures that provide feedback to leaders about their impact on others may help protect against narcissistic leadership dynamics.

Cultural and Social Patterns

At a societal level, Kohut's framework raises questions about cultural conditions that either support or undermine empathic development. Societies that provide conditions for adequate caregiving---parental leave, economic security, mental health support for parents, strong communities---create environments where empathic development can proceed. Societies that isolate caregivers, impose economic stress, undermine community bonds, and fail to support parental mental health create conditions where empathic failure becomes more likely. The consequences cascade across generations and affect not only individual mental health but social cohesion, political susceptibility to narcissistic leadership, and collective capacity for democratic deliberation (which requires capacity to understand perspectives different from one's own). Kohut's clinical framework thus has public health and political implications.

Prevention Approaches

Viewing empathic failure through a prevention lens suggests intervention possibilities. Early childhood programmes that provide empathic experiences for children whose parents cannot adequately provide them; parenting interventions that teach attunement and help parents recognise and respond to children's inner experiences; support for parents struggling with their own selfobject deficits; and early identification of empathic failure patterns (through assessment of parent-child interaction) all represent potential prevention strategies. The goal is not to produce perfect parents but to ensure that children receive "good enough" empathic responsiveness from someone---if not parents, then grandparents, teachers, mentors, or other caring adults. The return on investment---measured in reduced personality pathology, improved relationships, healthier workplaces, and more empathic social and political discourse---could be substantial.

Limitations and Considerations

Kohut's influential final work has important limitations that warrant acknowledgment alongside its insights.

Empirical operationalisation remains challenging. Kohut's core concepts---empathy, selfobject function, transmuting internalisation---emerged from clinical observation and resist precise operationalisation for quantitative research. While clinically generative and widely influential, they are difficult to measure directly. Research has explored related constructs (attachment security, reflective functioning, therapeutic alliance) that may overlap with Kohut's concepts, but the specific mechanisms he proposed remain incompletely validated empirically. Clinicians should hold these concepts as useful frameworks rather than empirically proven facts, while recognising their substantial clinical utility.

Treatment intensity requirements limit accessibility. Kohut's recommended approach---intensive, long-term therapy focused on the therapeutic relationship---requires resources (time, money, availability of trained therapists) beyond the reach of most people who need it. While his framework has influenced briefer and more accessible treatments, questions remain about whether the deep structural changes Kohut described require the intensive approach he advocated or can be achieved through modified applications. The gap between evidence-based treatment and real-world access is substantial and ethically concerning.

Cultural assumptions require examination. Kohut developed self psychology primarily through work with mid-twentieth-century American patients from particular cultural and socioeconomic backgrounds. His emphasis on the individual self and its development reflects Western, individualistic assumptions. In collectivist cultures where the self is more relationally defined from the start, the developmental trajectory Kohut describes may differ. The concept of appropriate empathic attunement also varies across cultures. Clinicians working cross-culturally must adapt Kohut's principles thoughtfully rather than applying them universally.

Potential for therapeutic collusion. Kohut's emphasis on empathic provision of selfobject functions can be misunderstood as endless validation without limit-setting or challenge. Clinicians may inadvertently collude with narcissistic defences by providing narcissistic supply that reinforces rather than modifies pathology. Kohut himself distinguished between genuine empathic understanding (which requires perceiving the patient's actual inner state, including defended vulnerability) and superficial validation (which accepts the patient's self-presentation at face value). But this distinction is subtle and easily lost. Integration with Kernberg's emphasis on confrontation of defences may be necessary for some patients.

The Kohut-Kernberg integration remains incomplete. Kohut and Kernberg offered competing theories of narcissism that have never been fully integrated despite decades of dialogue. Kohut emphasised empathic provision of missed developmental needs; Kernberg emphasised interpretation and confrontation of pathological defences. Both capture clinical truth; neither has been conclusively demonstrated as superior. Most contemporary clinicians draw on both, but the field lacks clear guidelines for when each approach is indicated. Individual patients may respond better to one approach or the other, or require phased combination.

Questions about mechanism specificity persist. Kohut proposed that empathic attunement specifically allows transmuting internalisation of selfobject functions. But other therapeutic factors may also contribute to change---the relationship per se, behavioural activation, cognitive change, medication, social support. Disentangling the specific contribution of empathic attunement from other factors remains methodologically challenging. The mechanism Kohut proposed is clinically compelling but not definitively established as the specific agent of change.

Historical Context

How Does Analysis Cure? was completed shortly before Heinz Kohut's death from cancer in October 1981 and published posthumously in 1984, edited by his colleagues Arnold Goldberg and Paul Stepansky. The book represents Kohut's most mature statement of self psychology and his definitive answer to questions about therapeutic action that had occupied psychoanalysis since Freud first wondered what actually healed his patients.

The intellectual context was significant. By the early 1980s, classical psychoanalysis was under sustained pressure. Biological psychiatry was ascendant, with the DSM-III (1980) establishing categorical diagnosis and pharmaceutical treatments offering simpler solutions for many conditions. Cognitive-behavioural therapy was demonstrating empirical effectiveness in randomised trials. Managed care was beginning to limit intensive psychotherapy. Psychoanalysis needed to articulate clearly what it offered that other approaches could not.

Kohut's answer was radical: what psychoanalysis uniquely provides is sustained empathic immersion in the patient's subjective world, allowing the development of psychological structures that only emerge through relational experience. This could not be achieved through medication (which might reduce symptoms but could not build self-structure), through brief therapy (which might provide relief but insufficient time for transmuting internalisation), or through behavioural techniques (which might change behaviour without addressing underlying self-deficits). The claim was ambitious: psychoanalytic treatment, properly understood, offered something irreplaceable.

The book also represented Kohut's final statement in his long dialogue (and disagreement) with Otto Kernberg. Where Kernberg emphasised confrontation of pathological defenses and interpretation of primitive aggression, Kohut insisted that empathic understanding was both necessary and, ultimately, sufficient. The debate reflected fundamental differences about human nature: Is pathology primarily about defense against intolerable affects (Kernberg) or about deficit in self-structure (Kohut)? Is the analyst's task to interpret or to understand? Is the narcissist's grandiosity a wall to be breached or a cry for help to be answered?

History has not definitively resolved this debate, but Kohut's influence has proven enormous. His emphasis on empathy as both observational method and therapeutic agent anticipated developments in attachment theory (where secure base experience builds internal working models), relational psychoanalysis (where the therapeutic relationship itself is transformative), interpersonal neurobiology (where attunement shapes brain development), and trauma-informed care (where safety and connection precede processing). Concepts he introduced---selfobject, mirroring, narcissistic injury, transmuting internalisation---have entered mainstream clinical vocabulary across theoretical orientations.

The posthumous publication added poignancy: Kohut's final testament on how healing occurs arrived only after his own death, leaving his followers to carry forward a message he could no longer elaborate or defend. Self psychology institutes worldwide continue his work, and contemporary clinicians treating personality disorders, trauma survivors, and attachment difficulties draw regularly on his framework---often without knowing its source.

How Does Analysis Cure?

APA Citation