Clinical application of the concept of a cohesive sense of self

Recent psychoanalytic studies have contributed significantly to our understanding of how the formation of self-image groupings (the body self, the self experienced as individuated, and the grandiose self) integrate to form a cohesive sense of self. In addition to our increased knowledge of the normal development, we have a richer understanding of vulnerability to fragmentation of the sense of self. Knowledge of the development of the sense of a cohesive self and its vulnerability to fragmentation are applied to illnesses familiar to psychoanalysts. During normal adjustment reactions different aspects of the self predominate. In most such instances, images of the self can be balanced so that self-cohesion is retained. In the conflicts of the psychoneurotic, aspects of the self may be defensively segregated. Psychoanalysis must enable these aspects of the self to come into awareness and be blended into the general experiencing of the self; rarely does the threat of loss of self-cohesion present a special problem in working on this with a psychoneurotic patient. In contrast, the narcissistic personality and borderline personality disorders present specific problems centering on the potential of the patients to experience fragmentation of their sense of self. Clinical vignettes and theoretical formulations contrast these with the familiar problems that arise in the treatment of the psychoneuroses. The therapist's full empathic contact and a correct strategy of interventions arise from the appreciation of the presence or absence in the patient of threatened fragmentation of the cohesive sense of self.