From the self psychological analysis of D.B., it seems like the underlying cause for the killings were related to the narcissistic aspects in his personality. Kohut’s theory is aimed at understanding and treating narcissistic disorders, or self-disorders, which they are often referred to (Ornstein, 1997): “Self-psychology is especially important and relevant, when we are investigating psychological states where the experience of a disturbed self accept and/or fragmentations of the self takes up the psychological developmental centre.” (Kohut, 1990, pp. 75-76. My translation). This statement of Kohut is illustrating why this theory seems to suit well to the analysis of D.B.
Kohut was optimistic in relation to treatment of these disorders. This way, the following are considerations and suggestions to a self psychological therapy for serial killers. This suggestion is applicable because of the assumed narcissistic aspects that can be seen attached to the case of D.B. And the aim in this is that the suggested therapeutic strategy will also be applicable for other patients, which have some degree of narcissistic personality. The following will still be based on the understanding of D.B., in which he will frequently be used as an example to illustrate the therapy in concrete terms.
3.3.1. What would be the aims with self psychological therapy with a serial killer
The following will imply three main aims in self psychological therapy with a narcissistic personality.
Understanding of self and the development of a coherent sense of self
Essential for patients in therapy, is to develop and mature the suffering narcissistic content of personality. This can be done by enhancing the understanding of the structure of ones self. If this understanding is emphasized in empathic harmony with the therapist, nurture to the surviving rest of the self will be given. In relation to D.B., this could for example mean to let him understand that his destructive childhood activities (fires and violent behavior), were not evil or disgusting, but that they were made out of a wish to get attention and experience the feeling of being alive (Kohut, 1998, p. 97; Kartrud, 2000, p. 25). The result of this will lead to increased self-acceptance and self-esteem (Kohut, 1990, p. 47). Karterud & Limes (2000) also states, in the spirit of Kohut, that patients who feels understood, will develop a more coherent, vital and authentic self (p. 149). With unconditional empathy, the patient will feel understood and will develop an ability to feel safe and to have trust in the therapist, which will also cause self cohesion to enhance. The changes in the coherent self will first appear in the therapeutic setting, and then the patient will find supportive selfobject milieu in his or her post-analytic life (Ornstein, 1997, p. 4).
Developing empathy and the ability to make confident relations
Improving empathy is an important aspect within self psychology, and this dimension is what seems to be absent in a serial killer. Enhancing empathy in the patient will mean that he will be able to understand more of his own self and other humans and of what is going on in the complex interpersonal relations (Kohut, 2000, p. 25). Developing empathy is important, as it is well-known that; “…empathy is an important motivator of prosocial, or altruistic behavior” (Berk, 2000, p. 411). Prosocial behavior is known as being the opposite of antisocial, in that prosocial actions are beneficial for other persons and not for the acting person (p. 411). This way, if empathy is developed, one can possibly presume that antisociality and acts of killing will disappear, or at least decrease.
Karterud (2000) claims in accordance to Kohut, that a crucial aspect with psychological good health, is the ability to continually be surrounded by close selfobjects, and not drive them away, which is a typical trait with severe personality disorders. Thus, by developing empathy, the patient will again be able to, in a balanced way, both give and take in relations with other people (pp. 25-26).
The uncovering of primary defects
Kohut states that therapy is completed when the primary defect has been uncovered. This is done when the therapy has identified and worked with the defensive structures that are covering the primarily defect. When this is done, the patient can internalize new experiences, and this way make the defect structures in the self function in a healthy manner (Kohut, 1990, pp. 17, 55). In relation to D.B., the primary defects seem to be his feelings of inferiority, neglects, depression and emptiness, in which he tries to defend him self against these feelings with mainly grandiose fantasies and ideas.
3.3.2. How can the aims be reached?
The two stages of self psychological therapy
As illustrated in the diagram that has earlier been presented in this work (part 2.5.3.), Kohut sees the personalities of narcissistic patients as often involving both a horizontal and a vertical split. He also sees these splits, as being the basis for the therapeutic work (illustrated in the figure on next page). The first stage in therapy is related to the line that is indicated with the number 1. Here is the therapeutic aim to remove the vertical barrier, which is maintained with denials. The other stage is related to the line that is indicated with the number 2. Here is the therapeutic goal to remove as much as possible in the horizontal split, which is maintained with suppressions (Kohut, 1998, p. 116; Kohut, 2000, p. 164).
This working model is different from the psychoanalytic position of Freud. Freud would claim that one has arrived at the deepest level, when one has reached the patient’s experience of his impulses, wishes and drives. This means that a Freudian psychoanalysis would be regarded as successful when the patient has become aware of his unconscious processes (Freud, 1999, p. 228). Freud will this way, only work with the barrier for suppression (horizontal split). But self psychology does not believe that the curative process is ultimate when the unconscious has become conscious (Kohut, 1984, p. 64). How the work in the therapeutic self psychological lessons will be, either one is at the first or second stage in the work, will be described in the following.
Selfobject transferences in therapy
As has earlier been outlined, Kohut suggests that an individual that have been exposed to enduring lack of empathic selfobject in childhood, has not developed a healthy and consolidated self. As a result of this, Kohut claims that all existing defects in the self become spontaneously mobilized as “selfobject (narcissistic) transferences”. Further, Kohut states, that it happens in everyday settings, and also in a therapeutic situation, that the narcissistic patient has a self that is likely to be in search for appropriately responsive selfobjects (Kohut, 1984, pp. 4, 70-71). These transferences, Kohut claims, are unique for narcissistic disorders, and differ from transferences that other patients develop. The narcissistic transferences develops in connection to the three different parts of the self; the pole of ambitions, the pole of ideals and the pole of talents and skills which is manifested in the twinship-seeking pole. This way, Kohut identified the possible transferences (selfobjectobject transferences) as; 1) the transferences that are based on the damaged pole of ambitions and grandiosity, which is attempting to elicit the confirming-approving responses of the selfobject (mirror transference); 2) The transference based on the damaged pole of ideals, that searches for a selfobject that will accept its idealization (idealizing transference); 3) The last possible transference is based on the damaged intermediate area of talents and skills, that seeks a selfobject that will make itself available for the reassuring experience of essential alikeness. This is called the twinship- or alter ego transference (pp. 192-193). Whether it is a mirroring, idealizing or twinship transference that develops, it is the task of the therapist to use the particular transference, and understand the vital selfobject function the patient has (unconsciously) given the therapist. This is because this transference is equal to the function that was not provided by the original selfobjects (Consolini, 1999, p. 74). In relation to serial killers, it seems likely that it is a mirroring selfobject transference that will develop. This assumption is based on the fact that the killing actions are possibly aimed at getting attention or approve (even though they are negatively laden). This interpretation seems especially to concern D.B., as has earlier been illuminated.
Kohut sees defects in the self as causing maintenance of a patient’s selfobject (narcissistic) transference. Because of this, hi sees the working through of this transference as significant when attempting to fill the defects in the self (Kohut, 1984, p. 4). This way, he states that in order to be capable to treat a patient, the patient must be able to let the therapist function as a selfobject. This is done, when the patient is using his inner experiences and reactivates, re-experience and work through the depressions and rages of early life in the transference with the therapist (p. 5). If the selfobject transference is well established and the patient does not experience disappointments in relation to the expected selfobject function of the therapist, he will gradually
internalize (“internalized transformation”) the new experiences and make them his own. This is named “optimal frustration” (Karterud, 2000, p. 19; Kohut, 2000, p. 51). In relation to D.B., and the assumed lack of mirroring selfobjects throughout his life, it is likely that if the therapist will be able to represent D.B.’s archaic mirroring selfobjects and give him the attention he needs, the fragments in the self will develop into a more coherent structure. It is however important to do this in a balanced way, as overindulgence and extraordinary attention might give nurture to the grandiose fantasies that already exists. If however, healthy attention and gratifications are given to the patient, it is likely that he will internalize this experience and therefore make the grandiose self satisfied, this time in a healthy manner and not due to “macabre” actions like killing.
The vital empathy
Empathy has earlier been described as the essential quality that individuals’ selfobjects ideally should have, for the individuals’ ability to develop a healthy self. As an extension of this, it is also essential that the therapist is experienced as empathic, since he optimally, will get the role as a selfobject for the patient.
To understand and treat a patient with a disorder of the self, the most important aspect, is the therapist’s ability to put oneself into the patient’s situation and show genuine empathy. Empathy is seen as the entry point, firstly to understand the patient’s subjective experiences, and also to be able to treat. This way, empathy is both “…a methodological principal and the therapeutic position” (Karterud & Urnes, 2001, p. 146. My translation). Being able to be unconditional empathic will gain insight to the strengths and vulnerabilities of the patient and this way understand the patient. But empathy is also important, because, with the therapist’s experience of the inner world of the patient, he is able to predict and avoid vulnerable interpretations and thereby avoid “resistance” in the patient that might be elicited by a fear of retraumatization (Ornstein, 1997, p. 3). Kohut (1990) states that it is necessary to support the crumbled self by explaining what it is that makes the self feel threatened by disintegration, and not to come with rationalizations, like for example with confrontations (p. 85).
If then, the therapist is able to give a consistent and sustained empathic submersion in the patient’s inner life, it is what can create a constructive atmosphere for the necessary tool; selfobject transference. Ornstein claims that the empathic observational position, a non judgmental, a non- confrontational and a truly accepting attitude towards the patient and his problems, will contribute to the vital development of trust and safety. Trust and safety are provisions for the emergences of selfobject transference, where earlier unanswered archaic wishes and needs can be manifested and worked with (Ornstein, 1997, p. 3).
Countertransference as a challenge to empathy in the therapist
Two of the elementary aspects in self psychological therapy (selfobject transferences and empathy) have been described. One might wonder, if it is possible for a therapist to be unconditional empathic towards a multiple, well planned murderer, and whether a therapist can allow himself to take the role of an archaic genuine mirroring selfobject in the transference. These two affairs seem to be very challenging aspects in therapy with criminal psychopaths, and I believe that these, at least, the tendency to lack empathy as a therapist, is the core explanation to why psychopathic criminals, in general are found to have such pessimistic prognosis for treatment.
Freud introduced the term “countertransference” in 1910, and he was arguing that this was something that the therapist had to overcome (Sandler et al., 1994, p. 101). More recent views, sees countertransferences differently. These newer and more positive attitudes look at countertransferences as something that should be recognized and used as a source of information. An argument for this is that the other part that is involved with the patient is often experiencing the affect that the patient is avoiding (Strasburger, 2001, pp. 301-302). But there are indeed potential problems with countertransferences. This can be due to repressions of them, or at the opposite, from becoming overwhelmed by them (p. 302). This last consequence is what seems to be relevant in the treatment of criminal psychopaths and indeed for serial killers. If the therapist’s genuine feeling is disgust, hate or indifference towards these patients, then it does not strike as a surprise that the prognosis are pessimistic.
To overcome the potentially devastating absence of empathy as a potential result of countertransferences, it is a necessity that therapists realize that behind the narcissistic or antisocial facade is the patient’s feelings of inferiority and depression, neglect, worthlessness or rejection and in relation to that, possibly has a hunger for acknowledgement (Kohut, 1990, p. 18). This way, it could in relation to D.B. be essential to focus on the depression he felt after the losses he experienced, and the hopelessness that followed (Abrahamsen, 1985, p. 61; Kohut, 1998, p. 92), and to realize that the manifest actions are defensive structures, that are probably aimed at covering the defects in the grandiose self (Kohut, 1990, p. 45).
If an empathic failure do happen, which inevitable happens from time to time, it is possibly to use this episode to find out about the patient’s vulnerability and in that, what makes the patient experience being injured. The therapist can then use what he learns through further exploration to connect the current experience of narcissistic injury with the original injury inflicted by the selfobjects during childhood (Consolini, 1999, p. 76).
Using countertransferences in a constructive way might not be a simple matter. But it does seem as an essential issue to not be overwhelmed by the countertransferences and thus still be able to take an empathic stand. This is one suit that can be seen of great value with self psychology, and can seem as an aspect that other perspectives fail to pay extra attention to, when conducting and evaluating therapy with criminal psychopaths.
The importance of avoiding confrontations
Confrontations in therapy are about interpreting or asking the patient a question that he does not want to accept or identify with (Gabbard, 2000, p. 97). Kohut argues that one must not, like many therapists do, traumatize self disordered patients unnecessarily. Attacks on the narcissism, must be avoided, he claims (Kohut, 1978, p. 639). If the therapist, by any means, confronts the patient in therapy, the patient might react with agitation. This is because traumatic situations from earlier life have been re-experienced in the therapeutic setting. If now the therapist is being confrontational, it is likely that the patient will experience it the same way as when selfobjects were disappointing him earlier in life. The consequences of not giving an empathic response, in the re-traumatized situation, will thus potentially result in the occurrence of narcissistic rage (Kohut, 1990, p. 73). An argument for using empathy and avoid confrontations, is that confrontations and its potential consequence of making the patient feel criticized, will possible make him maintain the already internalized belief that he is rejected and abandoned.
Avoiding confrontation and almost exclusively focus on being empathic, is what Kohut would see as essential in developing a more cohesive self in the patients. According to Kohut, a therapist with a confrontational style, will, in the same way as the original archaic selfobjects, not be able to function as a vital selfobject. Kohut has stated quite clearly that challenging the patient’s grandiosity is not only useless, but that it also is likely to make the patient suppress powerful wishes, and thus make them inaccessible to modification (Consolini, 1999, pp. 77-81).
But what if it appears in a therapeutic setting, that the patient is lying? As lying is a characteristic trait with psychopaths this is a likely scenario in therapy with a serial killer. An example is how, as has been described earlier, D.B. tried to pretend that he was delusional as he claimed that it was demons that had told him to kill (Abrahamsen, 1985, p. 109). This attempt to pretend being psychotic, has also been used of other “sane” serial killers, as an attempt to prevent being judged as responsible (Palermo & Knudten, 1994). Should one not, as a therapist, confront the patient with this, if it happens in the therapeutic setting? Kohut has inferred that for the best outcome in a situation with a patient who is lying, one should use the lye as a source of information to find out about the vulnerable areas of the patient (what is he lying about and why?) and to “accept it with equanimity” (Kohut, 1984, p. 72). Kohut’s attitude concerning this matter seems to differ from the majority of views, where it is emphasized to confront lies and untruthfulness (Gabbard, 2000, p. 511; Kernberg; 2003; Coid, 2003). For Kohut however, it is essential to avoid indignation and rejection, at any price (Kohut, 1984, p. 72).
When the patient is successfully treated
Therapy of a narcissistic personality is seen to have been successful, when the patient’s previous needs for responses from archaic selfobjects are replaced with an experience of having sufficient empathic feedbacks available, and when a sense of genuine security is obtained. In the analytic situation, these reactivated needs are kept alive and exposed, repeatedly and enduring, until the “internalized transformation” occurs, and until the patient has a reliable ability to sustain his self with the aid of the selfobject resources available in his present environment. An increased ability to gain insight, verbalize and have control over impulsiveness may accompany these gains (Kohut, 1984, p. 77).
3.3.3. Implications for using self psychology as an attempt to treat a serial killer
Kohut has named one of his books: “How does analysis cure” (1984). What he means by cure, however, is not necessarily a state with absolute absence of symptoms. He states that cure is about a continuum. When the center of the personality (self) has been reestablished and a productive life is possible, one can talk about having been cured (p. 7). The question is so, whether a serial killer, in self psychological terms can be said to be cured- realistically speaking. The following will take a critical view concerning some of the aspects with treatment of serial killers.
Can a serial killer learn to develop adaptive representations of others and empathy?
Most of the characteristics shown in a psychopath, and a serial killer, seem to be closely linked with a general lack of empathy. This is, to refer to PCL-R, the symptoms; irresponsibility, lack of realistic goals, pathological lying, manipulativeness, lack of remorse or guilt, egocentricity, shallow emotions, deceitfulness, short- term marital relationships, callousness and grandiose self-worth (Hare, 1999, p. 44). This way, improving the ability to be empathic seems to be of great importance when committing treatment with a serial killer, as it might have impact on the traits just mentioned. But is this possible?
There are disagreements among theorists concerning whether personality emerges early and persist due to heredity and early experience, or whether changes are possible and likely to occur, if new experiences support it (Berk, 2000, p. 9). Most developmental theories like, for example, those of Piaget, Kohlberg Freud and Kohut, see empathy and also moral as something that is exclusively or mainly developed in early stages of life. But even though they see moral and empathy as being developed in childhood, they do not reject that they can be changed later in life (Berk, pp. 481-494).
An aspect that can be seen in relation to the potential for changes is the biological perspective and how it is linked to the development of personality. There have been done substantial research concerning the presence of neurobiological factors and changes in psychopaths,
criminals and antisocial PD, and there can be seen indications for a link between antisocial behavior and biological conditions. Among numerous theoretics and researchers considering this correlation, Larry J. Siever claims, based on his study of neurobiology in psychopaths, that genetic and/or early environment will potentially cause changes in the neurological development in cortical regions (Siever, 2003, p. 240). Damasio (2001) is also working with the link between biology and psychology and he points, that the development of antisocial behavior can be localized to frontal lobes (pp. 71-80). Another biological aspect is the assumption that the human brain is “plastic”, meaning that it has the ability to develop new structures and compensate for defects or lacks. But most often, this plasticity of the brain is considered to be present the first 6 or 10 years of life. Later, abnormalities in the brain are, according to Berk (2000), more difficult, if not impossible to be recovered from (p. 189). These views might look like contraindications for psychological treatment with individuals who potentially have biological impairments, in that an argument might be that one can not treat biological defects with psychological treatment. But, however, Damasio does see biological and psychological processes as inseparable and he does underline the fact that the brain and bodily reactions develop and change from second to second, because of what is experienced in the world (2001, pp. 236-237). Also Solms and Turnbull (2004) agree with Damasio’s assumption. They claim, just like him, that humans just have one psychic apparatus, meaning that there is no split between the body and the psyche, which means that it is natural that the brain and neurological matters will changes according to mental experiences (p. 293). According to Damasio and Solms and Turnbull, changes and abnormalities will, unavoidable, be manifested in the brain as long as there is mental life. Because of this, there should be no reason why psychological treatment can not promote changes in the brain. If one believes that one can not influence abnormalities in the brain,
one will probably be left with a minimum of patients. Biological defects and psychological treatment do instead seem to be consistent aspects. This way, the biological abnormalities that can be seen in psychopaths does not necessarily indicate that medical treatment is the only alternative or that they are untreatable.
Implications with the unconditional empathy and avoidances of confrontations
Kernberg is in a strong disagreement with the unconditional empathy and lack of confrontations in Kohut’s theory. Kernberg is known for his view that it is necessary to confront narcissistic patients when they are using their defensive maneuvers (Consolini, 1999; Kernberg, 2001, p. 326). Gabbard (2000) also disagrees with the use of continual empathy. He states that when an antisocial patient is revealing his antisocial activities, it is wrong to take the self psychological stand and be unconditional empathic. He states that this would be; “…both misguided and collusive.” (p. 512). Further, Gabbard claims that it is not realistic to think that a therapist can maintain a neutral and empathic stance when listening to, and seeing the patient’s antisocial behavior. This way, the unconditional empathy that Kohut pursues, can be argued to be both over-optimistic and for sending out the wrong signals, when “accepting” the antisocial activities, like for example lying in the therapeutic sessions.
Ogloff et al. (1990) have some reflections upon confrontations in (group) therapy with psychopaths. In their evaluation of their research with treatment of psychopaths, they have the hypothesis that confrontations in the therapy actually were helpful at some level, as it might have caused the psychopaths to become aware of the impact that their destructive and irresponsible behavior can Ile on their peers and the staff. However, Ogloff et al. also have the hypothesis, that the confrontations are what lead to the substantial drop-out rate of psychopaths, as the insight to their impact on others can cause so uncomfortable feelings that the patient is motivated to quit. If this is a right interpretation, Kohut’s view of the unconditional empathic position of the therapist might be of value to make the patient stay in therapy and thus increasing the chances for successful outcome.
However, one might suspect that unconditional empathy would give D.B., once and again an experience of having manipulated the therapist, just like he did with Dr. Schwartz (see quote in part 3.2.3.). According to Kohut (2000), however, patients with narcissistic problems, have (un)conscious wishes of being in empathic contact with others. Thus, he claims that, no matter what defenses the patient is using, it is a necessity to continuously expose the patient to empathy. This is necessary as it is the only way a narcissistic patient will have the possibility to successfully increase his own ability to be empathic (pp. 267-268). But Kohut also highlight that one should, at the same time as one is empathic and giving the patient attention and not rejection, appear with “equanimity” (Kohut, 1984, p. 72). This means that one must react to behavior or stories that could potentially have caused a re-traumatizing experience, with acceptance and in an unaffected manner, this way appearing in a respective manner.
Is the focus on empathy unique for self psychology?
Kohut was in fact the aim of substantial criticism when he introduced his prominent focus on empathy (Karterud, 2000, p. 12). But, however, empathy is not only essential within self psychology. The humanistic psychologist, Carl Rogers, is well- known for his focus on empathy (Rogers, 1992) and also Yalom is especially emphasizing the importance of the therapist’s ability to be empathic (2002, p. 17). This can seem like the self psychological theory claims to have a crucial aspect that other theories in fact contain too. It has, however been stated that Kohut’s self psychology “alone views empathy as a means of finding out about the subjective experience of the other” (Messer & Warren, 1990, p. 385) and not only as a therapeutic technique. This statement seems though, not to be totally correct. Rogers defined empathy in 1957, the following way: “To sense the client’s private world as if it were your own.” (1992, p. 829). Also Yalom, though later on, talks of how the relevance of “looking out the patients window” (2002, p. 17). This way, it can look like Kohut, Rogers and Yalom all are seeing empathy as important as both a way to grasp the subjective experience of the patient as both a method to understand and as a method to a treat the patients. Also other therapists like psychoanalysts Bateman and Fonagy (2004), underline that empathy is important in treatment with personality disorders (pp. 167-168). But it does, however, seem like Kohut is more consequent than others. For Kohut, empathy is not something one just needs to do, but it has to be learned, and it will take time, effort and also personal qualifications to be able to really deepen oneself into the subjective experience of the patient, and see the world through the patient’s eyes (Kartrud, 2000, pp. 12-13). Kohut has also thoroughly outlined how empathy is a “vicarious introspection”, which involves a substantial and vital capacity to enter and observe (introspect) the patient’s consciousness with the belonging thoughts, feelings and experiences (Kohut, 2000, p. 261; Thielst, 1998, p. 44). Kohut’s idea does this way seem to be incorporated with more substantial content, than many other theories that emphasizes empathy. As for Rogers and Yalom, it seems like they are also paying considerable attention to this aspect of therapy, and it is likely that they will such be able to contribute in treatment of serial killers.
Nevertheless, the considerable focus on empathy in self psychology, seem to suggest that it is a favorable theoretic stand in therapy with serial killers. This is as it seems likely that it will have fatal consequences if one is not able to fully understand the patient. Without a real understanding, which is likely to be found via empathic introspection, where one is able to realize the serial killer’s vulnerable aspects, one might be trapped in the external symptoms of the serial killer.
Is one theory enough in therapy?
What seems to be the trend in present therapeutic strategies is the “Dodo verdict”; “Everybody has won, and all must have prizes” (Rosenzweig, 1936, p. 412). This revolves the assumption that there are no significant differences in the effect of different psychological approaches (Hougaard, 1993). In relation to this, there has been a widely spread tendency for therapists to take an integrative approach to therapy. The use of pure theories and techniques are hence seen as insufficient to explain and treat psychological problems (Holmes & Bateman, 2002, p. 5). But even though integration is the most popular approach, some fundamental theoretical frame is necessary to avoid that the therapy gets as fragmented, conflicted and changing as the patients’ inner world (Karterud & Wilberg, 2002). When the therapist meets complex problems in therapy, he can be leaded to change strategy of intervention according to the patient’s wishes. This can cause a confusing and minimal organised therapy (Livesley, 2004). The solution to this problem is to have a fundamental theoretical frame that the therapist is completely familiar with, and in addition have some strategies from other theoretical frames, when working with specific problems, like, for example a cognitive strategy when working with a phobia. The integrative trend is such not a contra-indication to the use of a specific theory, like self psychology, in the understanding and treatment of psychological problems. It can instead be seen useful to apply the traditional self psychological theory as a basis, in opposition to start the analysis with the newer, already integrated self psychological theories. This is also as, like has been mentioned earlier (part 2.7.2.), newer self psychological perspectives, tend to regard empathy and selfobject transferences in therapy as the most central and creative features of the traditional self psychology (Mitchell & Black, 1995, p. 167). This way, the newer self psychological perspectives, do not differ in relation to the most essential Kohutian terms.
This way, to evaluate whether self psychology is sufficient in relation to treatment of a serial killer, it can be argued that the a self psychological foundation can be beneficial, as it seems to be consensus in the importance of having one basic theory. So, to add other theories to arrange an integrated treatment method might potentially increase efficacy in treatment. But, as it can be seen of substantial value to have complete insight and overview of one therapeutic theory/strategy (Karterud & Wilberg, 2002), a traditional self psychological based treatment strategy is most likely sufficient in treatment.