Clinically, we observe that patients whose self-esteem is especially brittle require certain considerations in formulating a treatment plan (e.g., Gold & Stricker, 2011). We refer to such patients as narcissistically vulnerable, but we are not using the term narcissistic pejoratively or as an equivalent to the Diagnostic and Statistical Manual of Mental Disorders (DSM) category of Narcissistic Personality Disorder. In contemporary psychoanalysis, as informed by self psychology (Kohut, 1977, 1984) and relational theory (e.g., Mitchell, 1986), narcissism is appreciated as a normal part of being human, and healthy self-love has its own developmental course intertwined with that of developing love for others. Regulating self-love and self-worth-that is, self-esteem-through life's inevitable failures, successes, losses, accomplishments, disapproval, and praise is a universal challenge requiring multiple adjustments, calibrations, and stabilizations daily. Some people, however, because of developmental setbacks and insufficiencies, struggle significantly with restoring a realistic, positive, and integrated sense of themselves through the upturns and downturns of fortune and misfortune. 7 EXPERIENCE OF SELF AND OTHER: NARCISSISTIC VULNERABILITIES

The hypothesis that number of hours of personal therapy would be positively associated with therapists' ability to display empathy, warmth and genuineness in the treatment hour was tested. Seventeen therapists, male and female graduate students in a clinical psychology doctoral program, submitted sample tapes of their therapy sessions and completed questionnaires regarding their therapy experience as a client. The tapes were rated by mental health professionals trained in the use of the Truax and Carkhuffscales for Accurate Empathy, Nonpossessive Warmth and Genuineness. These scores were compared with number of hours of therapy experience as a client using a Spearman rank order correlation. Comparisons were significant for Empathy and Genuineness in the positive direction at the .05 level. Implications for training and suggestions for future research were discussed.

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A severe case of post-traumatic stress disorder stemming from consciousness (with auditory and pain perception) during surgery was treated with 8 sessions of hypnosis. Abreaction and revivification used alone initially retraumatized the patient, and her symptoms worsened. Ego-mastery techniques were then added; emphasis was placed on the role of the therapist as a new object presence to be internalized in restructuring the traumatic memory; memory consolidation and working-through techniques were instituted. The patient's symptoms abated and her condition remitted. The similarities between hypnotic and analytic work are highlighted. In addition, the case material provides a clinical example of the existence and potential traumatic effects of conscious awareness during surgery. It is like through glass, and you see movement and color and stuff--like you see thick glass--and now the glass is real thick and I can see a mass of colors that are not moving or nothing, like a wall. I can't remember anything past that [The Patient]. In the great majority of cases it is not possible to establish the point of origin by a simple interrogation of the patient, however thoroughly it may be carried out. This is in part because what is in question is often some experience which the patient dislikes discussing; but principally because he is genuinely unable to recollect it and often has no suspicion of the causal connection between the precipitating event and the pathological phenomenon. As a rule it is necessary to hypnotize the patient and to arouse his memories under hypnosis of the time at which the symptom made its first appearance; when this has been done, it becomes possible to demonstrate the connection in the clearest and most convincing fashion [Breuer & Freud, 1893/1955, p. 3].

Over 50 years of empirical data demonstrate unequivocally that psychotherapy can cause harm as well as good. Two therapist factors increasing harm risk are inadequate assessment of patients' vulnerabilities and certain attitudes/affects. Adding hypnosis as a technique within psychotherapy heightens risk for harm because: (a) trance can unexpectedly expose patient vulnerabilities (through loosening reality orientation, lessening structure, generating unfamiliar sensations and perceptions, and intensifying access to interior information such as emotions and imagery); and (b) trance can unexpectedly increase porousness to therapist's attitudes/affects (through heightening mental receptivity to the internal states of others). A century of clinical data from psychoanalysis offers guidance for protecting against such risks. Concepts of structure, interiority, and countertransference are explicated and translated into practical clinical suggestions for harm prevention.