239: Transference Focused Psychotherapy & Personality Disorders with Dr. Otto Kernberg
Podcast Host: David Puder, MD
Transcription Editing: Al-Baab Khan
Footnotes and editing: Andrea Witham, FNP-C, PMHNP-BC
Reviewer: Joanie Burns, PMHNP-BC
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00:47 Fleeing Nazi Austria
05:49 Early Influences
22:55 Borderline Level of Functioning and Primitive Defenses
30:24 Sexual Life in Borderline and Narcissistic Personality
45:08 Transference-Focused Psychotherapy and Reflective Function
1:03:52 Histrionic Personality
1:09:35 Paranoid Personality
1:11:19 Schizoid Personality
1:18:37 Why Therapists Want to Help
Fleeing Nazi Austria (00:47)
Puder:
I'm here with Dr. Otto Kernberg. He is a psychiatrist, born in Vienna, Austria. Immigrated to Chile. Subsequently came to America and is the founder of transference focused Psychotherapy and was instrumental in our understanding of things like borderline level of organization [he clearly defined its core components—including identity diffusion, primitive defense mechanisms, and intact reality testing]. We're gonna have a discussion today about his life, about the things that he wrote and ideas that he came up with and the evolution of it. So, welcome to the podcast. Can we start by, I know, you were born in Austria, Vienna in 1928. And you fled Nazi occupied Austria with your family to Chile. Tell me a little bit about that.
Kernberg:
Well, I was nine years and a half. Hitler invaded March, 1938, and I left with my parents on July 16th, 1939. My father didn't want to leave. He happened to be an Austrian monarchist and he believed all of this was going- just passing by. Hitler was a transitory phenomenon. He had a strong belief in Austrian survival. My mother had paranoid features. She was frightened to death with the invasion. And then after Kristallnacht, which in Vienna occurred on December 10th, 1938, she convinced my father that we had to leave. And so we got the Visa to Chile. And of course, I didn't know anything-I'm an only child, I was nine years and a half about.
Kernberg:
And on July 16th, 1939, she told me to pack everything- all toys that you have into this suitcase. We are leaving this afternoon, [sadness] and you are not supposed to tell a word to anybody. And by then, I was already acutely aware of the danger. And so that's how we left. I spent one year and a half under the Nazis, and it was a bad [anger], a bad experience. Violent [anger] antisemitism naturally. And all Jewish kids were expelled from schools, put into Jewish schools. Forbidden [anger] to go to movies, parks- everywhere Jews [sadness] and dogs are forbidden.
So although I was a child, I got the feeling for it. One day I was working with my mother on the street and this army man, who was in Hitler’s lower military guards, the SA [Sturmabteilung also known as the “Brownshirts”] in contrast to the SS, forced my mother to wash the street, the pavement. And my mother was washing the pavement and the crowd gathered, making fun of us. And I was standing there, I mean, this kind of bad experiences. And that was before the war started. It was started I think in October 1st, 1939. So we just managed to escape in time because after that, the border was closed and the rest of my family all ended up in the concentration camps. And they had except one cousin who managed to escape to England with the children's transport and then to the United States. That's- and we spent then six months in Italy before finally the visa came and we immigrated to Chile where I lived for more than 20 years before coming to the United States.
Puder:
I imagine in part, witnessing violent antisemitism- seeing signs reading “Jews and dogs are forbidden” or watching your mother forced to wash the pavement, even at that age, was both awful and degrading, a horrible feeling.
Your mom’s heightened sensitivity and adaptive paranoia, as you described, was a gift in this situation, yet I imagine to leave so quickly and without telling anyone, brought its own sense of loss.
With these early experiences in mind, could you tell me about the formative influences you encountered during your early years in Chile?
Dr. Otto Kernberg’s Early Influences with Psychoanalysis and Development of Transference Focused Psychotherapy (00:05:49)
Kernberg:
Well I studied medicine in Chile and was fascinated by the psychiatry professor, Ignacio Matte Blanco, who was trained in England. He was originally a neurologist trained in psychoanalysis by the client school in London, and he started the Psycholytic Society and Training Institute in Chile. He was a very outstanding man and became a personal idea.
I was interested, actually, in psychoanalysis since adolescence. I had read Freud and in immigration to Chile I came under the influence of a Jungian analyst. And by the time I entered medical school, I was already interested in psychoanalysis and within psychiatry, then that culminated. And I decided to study psychoanalysis in Chile under the leadership of Ignacio Matte Blanco, and graduated there. And before I came to the United States with the Rockefeller Foundation Fellowship to study research in psychotherapy, I was interested in psychotherapy: was it effective or not?
And did my first research efforts in Chile and then came to the United States, spent a year at Johns Hopkins with Sir Jerome Frank and his research group on psychotherapy. And then at the Menninger Foundation in Topeka, Kansas. Well, I mean, in between I went to Chile, did all the teaching that I had committed myself to the Rockefeller Foundation, who gave me the fellowship. So I fulfilled my obligation with the Rockefeller Foundation and then returned to the United States to participate in the psychotherapy research of the Menninger Foundation.
A huge project that I participated in several ways until I became the director of it after Robert Wallerstein, who was the leader, left this professor of psychiatry in San Francisco. So during my work at the Menninger Foundation, I was there about 12 years, I became interested and learned all I could about the diagnosis and treatment of severe personality disorders and within the Menninger project, then I developed my own interest in studying outcome, comparing patients who were treated in supportive psychotherapy, in expressive or analytic psychotherapy and psychoanalysis.
And came to the conclusion that patients with severe personality disorder, the so-called borderline patients who fell in between neurosis and psychosis, really responded best to a treatment that was a well-structured psychotherapy, not standard psychoanalysis, nor the usual supportive psychotherapy that was the fashion at that point.
And so I developed a project about an ideal treatment for severe personality disorders, and at the same time had to differentiate severe personality disorders from non-severe and had to deal with the entire diagnostic differentiation within psychiatry in which Ignacio Matte Blanco helped me enormously. When he learned in Chile, that I spoke German, he said I had to read German, classical German psychiatry Bumke. I went to the library to get Bumke and I found out it was 12 volumes. I didn't dare to ask him which volume he wanted me to read. And I studied all 12 volumes of Bumke. It gave me knowledge in classical German psychiatry that helped me enormously. Then of course, in the United States, I got the American approach to diagnosis, but I became, I made myself an expert in differential diagnosis and concluded that the common features of severe personality disorders was a lack of integration of their concept of self and the lack of integration of their concept of significant others.
Kernberg:
What Erik Erickson had described is identity diffusion. I picked up Erickson's concept of identity diffusion, applied it to the differential diagnosis of severe personality disorders, and developed simultaneously a view of psychological development, depending not on the internalization of representation of significant others, is kind of mental representation of others from reality. But under the influence of a lecture I heard from Talcott Parsons, a leading sociologist in the United States, I learned that what is internalized are not representation of others, but representation of the relationship between self and others.
So we interact with others, we internalize our representation of the other and the self interacting. This explains, for example, why children who have been physically abused, severely abused over years become abusers in turn. We say that they identify with the abuser, yes. But in a deep sense, they have internalized the whole experience and simultaneously internalizing in their mind the representation of abuser and abused. And are able then to, in order to avoid- so they, their world becomes a relationship of abusers and abuse, all relationships are between abusers and abused. And it's better to be the abuser rather than the abused. So they learn role reversals and take on the role of the abuser, while the role of the abused is projected onto somebody else. So the internalized relationship with others becomes the guiding principle that organizes habitual behavior, what we call character.
So the character, what we now call personality- actually personality is a broader concept that includes cognitive functions and everything else. Character, habitual behavior patterns they are essential part of personality and so I defined borderline personality organization as those alteration, habitual alterations of the personality that had in common identity diffusion.
And developed a clinical instrument, a clinical interview, the so-called structural interview to diagnose identity diffusion and differentiate severe personality disorders from non-severe personality disorders. And of course, the entire field of personality disorder from ordinary forms of psychosis, madness in the usual sense and organic brain syndrome, such as mental retardation and dementias.
So I linked the specific instruments for diagnosing personality disorders with the general psychiatric diagnostic approach, and placed personality disorder within the general area of psychiatric diagnosis. And regarding the treatment, as I mentioned to you, proposed the combination of a psychotherapy under strictly controlled circumstances inspired by psychoanalysis, but different from psychoanalysis by modification of psychoanalytic instruments or methods, and different from supportive forms of psychotherapy.
More generally speaking, I would say that transference focused psychotherapy is a psychoanalytic psychotherapy, not psychoanalysis proper. Psychoanalysis is reserved by patients with less severe neurotic illness. But the severe personality disorders that we now call borderline personality organization can be treated with transference focused psychotherapy [TFP]. And that's preferable to treat them than to treat them with a supportive approach, which may be carried out within a psychoanalytic perspective or a cognitive behavioral approach. In general, you can divide treatments into cognitive behavioral ones that are very effective for some patients in some circumstances. In psychoanalytic psychotherapies that are effective with other patients in other circumstances. So I defined this specific psychotherapy for borderline patients. And this is how- what my career changed. In the middle of this, I became the head of the psychotherapy research project of the Menninger Foundation, but then was appointed director of the Menninger Hospital.
So I, some years, I was simultaneously medical director of the hospital and director of the research project. And then I felt I had nothing more to learn but I felt I needed a learning atmosphere to find different approaches, different ways of dealing with psychiatry and psychotherapy. Menninger Foundation seemed to me a more limited place. And I accepted an invitation to become a professor at the Columbia University of New York. Went to Columbia where I really began to start out the treatment that I devised. I was in charge of their inpatient service for severe personality disorder. And I gathered a group of people, who after a few years, we accepted moving to Cornell. And I became director of Westchester Division Hospital of the Department of Psychiatry at Cornell. And together with the group, we formed the Personality Disorders Institute.
And 20 years later after I completed my directorship of the hospital, I dedicated myself exclusively to being the director of the Personality Disorders Institute at Cornell with the help of some distinguished scientist, John Clarkin, and the director of our empirical research, Frank Yeomans, whom you have interviewed, who is the director of overall training. He's a fantastic psychotherapist. And there were two or three more people, a group of six or seven, who we first developed the diagnosis more clearly, more sharply, and described different types of personalities functioning at that borderline level. The narcissistic personality, the most important one which we have been studying in great depths, but we also studied the paranoid personality, the schizoid personality, the infantile or histrionic personality. So we did a journal study of personality disorders, their description and differentiation into those with normal identity or neurotic personality organization with identity diffusion or borderline personality organization.
And those atypical psychotic cases that presented as if they were personality disorders, but with a more severe illness, a psychosis is a potential that might blow up or not in different cases. So we did- we spent the time first on differential diagnostic studies and publications, and then set up an empirical study comparing transference focused psychotherapy with supportive psychotherapy and with cognitive behavioral therapy. And confirmed the effectiveness of transference focused psychotherapy [TFP], both in research carried out in the United States, in New York, and then replicated in Europe under the direction of Stefan Doering, professor of psychoanalysis in psychiatry at the University of Vienna, who gathered internally group that carried out parallel empirical research in the in the German speaking countries. And of course, now we have groups in many different countries and are continuing both research training and treating patients. That's in a nutshell.
Borderline Personality Disorder and Primitive Defenses (00:22:55)
Puder:
Nice. Can you, can you…
Kernberg:
I hope I didn't put this into the technical terms.
Puder:
No, no, it's, it's good. Can you specifically talk about how in the borderline level of functioning, you have identity diffusion and primitive defenses. And can you talk about the primitive defenses that you see? How do you identify them?
Kernberg:
Yes. Freud had defined the ego defenses against awareness of unconscious conflicts, particularly repression and related defenses of suppression, rationalization, intellectualization, reaction formation. Those were unconscious defenses to be discovered in the course of the treatment of psychoanalytic treatment- searching for the unconscious conflicts of these patients. Melanie Klein, who influenced me very importantly in my psychoanalytic development, discovered a group of primitive defenses centering around splitting or primitive dissociation, in which the way to deal with conflicts between love and aggression, by sharp splitting of the emotional experience. So it is not, erotic patient may act lovingly and repress his aggression. Or he may act aggressively and repress his loving potential. Borderline patients express simultaneously love and aggression, but under different emotional conditions. And they have memory of when they felt opposite to the way they feel now, but they can't help it and have to feel now, the way they feel now.
So when they feel enraged, they are all rage- then there's no love. And when they feel love, all love and no rage, and they may shift from one to the other rather easily. So that's the mechanism of splitting, and it creates chaos in their relationship because they are violent and brusk changes of mood and attitude that creates difficulty with other people who in turn respond to that chaotic behavior with their own difficulties. And so, personality disorders tend to create abnormal interactions with other people and distort all relationships.
Another primitive mechanism is projective identification. Projective identification is a tendency to attribute to the other person what one cannot tolerate at the moment in oneself. So that while you are in a state of idealization, you project your own aggression onto somebody else, attribute somebody else as having aggressive motivation, aggressive behavior, and you induce it in him without being aware of it, and then try to control it.
So project identification is perception combined with induction- effort and control. And it is the primitive form of what advanced mechanisms show in projection, which is attributing something internal to somebody else, but without any internal contact anymore, with what you are projecting. In projection, you just declare the other one is what you are not, and you don't feel like that. In projective identification, you attribute it to the other one, but you know how it feels to feel like the other one, and you produce it in the other one, and you have to control it. So projective identification is primitive form of projection. Another mechanism is that of a very primitive idealization that doesn't tolerate in opposite of modifying it with the realization of your own aggression toward the ideal object. The idealization, or the higher level idealization, recognizes one's own limitations. The primitive one- there's somebody ideal, and you identified with that implicitly become ideal as well.
And the wish to omnipotent control the other person. The effort to deny that you've had a feeling or an action that you've had, but it no longer exists because of splitting operation. This is the primitive mechanism. So splitting, projective identification, omnipotent control, denial. These are typical primitive defensive operations. And they show the behavior of people, the advanced mechanism only showing the treatment. Primitive defenses show in the behavior, in the habitual behavior of people who use projective identification and splitting and omnipotent control, and deny aspects of themselves that have been evidence at other times.
And so we can diagnose through these behaviors the personality disorder. How do we diagnose a personality disorder? We try to find out how the person is functioning in work and profession, love and sex, social life, family relation, self-affirmation, and free time interests- hobbies. And what we, in the structural interview, what we ask people mostly, how are you doing in your work? Are you happy or not? Are you effective or not? Are you- do you get along with other people or not?
Sexual life in Borderline and Narcissistic Personalities (00:30:24)
And we ask the same about their sexual life. Are you happy? Do you have a relationship?
When sex becomes complicated, not only because it's a fundamental aspect of life that is in conventional reality, is usually suppressed and highly privileged, but because it involves implicitly the integration of the erotic dimension, sexual excitement, orgasm and sexual behavior with the emotional feelings of love and tenderness.
And when we study sexuality, we study the extent to which the erotic and the emotional have been integrated, which is what happens materially normally. In contrast to conflictual lack of integration by which the erotic and the emotional remains separate and create serious problems in intimate relations. So we try to find out about that. And regarding social life, we find out to what extent the person, his friend, his social environment that enriches life or feels isolated for whatever reason, incapable of establishing such a social life. And to what extent is he able to establish relationship in depth, in friendship, not only in sexual love or to what extent is this not possible? And with patients having borderline personality organization, usually there are serious problems in work and profession, in love and sex, and in their social life, family life such as between parents and children. And so the present, the careful study of functioning in present life leads to the diagnosis of the personality disorder.
Puder:
Can you say a little bit more about when someone has this borderline level of organization and their sexual intimacy is separated from more of the erotic side. Like how does that show up? What would a patient be saying to let you know that they've separated those two things?
Kernberg:
First of all, I need to modify what I said- that in that they are patients on a higher level of functioning, or the neurotic level of functioning, who also have such separation between love and sex, namely people with a masochistic personality, which is a non-borderline personality disorder. But the borderline personality organization, patients have the greatest difficulties. The most typical is presented by the narcissistic personality. The most typical cases, they have great difficulty for intimate relations. They can't maintain an intimate relation. The men have relation with women for a few months- it's all they tolerate before the relationship goes up in smoke. So they replace the lack of intimacy of love with freedom in sex. So you find men, and the same thing holds for women, and men get involved with many women, have great sexual relations and infatuation that lasts for weeks or a few months. Then they get bored, fed up, end of relationship, on with the next.
So that sex determines the capacity to maintain brief, repetitive relationships without a capacity for relation in depth. On the other hand, they may maintain a very dependent relationship with one woman who has a kind of a motherly function with whom they have no sexual interest, but are very dependent and exploitive. So they may be married men who act like children who are exploitative to women who tolerate it while they have sexual pleasure with a number of women. That would be one way. Another possibility is there is a full sexual relation, but in which there is an alternation between intense aggression and rejection. And then re-encounter sex permits them to re-encounter the relationship in which there is depth and dependency. In contrast to narcissistic personality, the ordinary, non-narcissistic borderline patient is capable of maintaining long-term relationships, but within each of them, chaos in which love and aggression shift rapidly and create chronic couple conflicts.
There are patients who- of course there are some patients with a total inhibition of their sexual impulses in which there has been too much aggression in very early development to permit eroticism to develop, or this strictly rigid, excessively rigid education has kind of severely inhibited their sexual behavior or forced it into remaining at the level of infantile sexuality. Sexual life begins with birth- what we now know is that children, if you leave, if you leave babies alone, in the sense you don't forbid sexual behavior, they start masturbating in the second half of the first year of life. And during the second year of life, boys and girls masturbate. Girls in general tend to end this first masturbation phase around age three, around age three, but reestablish it later at age five or six. Boys tend to, if not forbidden, tend to masterbate all through until adulthood.
Masturbation is a normal sexual activity when there is no other sexual outlet. And we have learned that it's a normal aspect of infantile psychology. It has taken us, Sigmund Freud, and a hundred years later to have this slowly sinking in. Even in the modern forms of the various Western religions, masturbation is no longer a major sin. And so science has been able to modify our attitude towards sexuality. But in general, in borderline personality organization, either sexuality is combined so much with aggression that chronic chaotic conflict prevents a good sexual relationship, a stable one with stable love, stable sexual erotic gratification- excitement is an alternative to not being able- a woman may be sexually excited and or orgastic with one man, totally non responsive to another one. So there may be a sharp way of splitting or division within erotic life. I don't know whether I've answered your question.
Puder:
Do you see with the narcissism, specifically, more of the sadism in the sexuality? Or is it specific to a certain personality type? How do you see that play out in the work that you've done?
Kernberg:
We all have a potential for love and for aggression. That's universal. Usually love wins over aggression. From babyhood on, we have more experience of good relations than bad ones. But of course, there are traumatized children whose life has mostly bad experiences. They are- everything goes wrong. Under ordinary circumstances, we use aggression constructively by self-affirmation, by endurance, by defending ourselves realistically. And aggression also enters— sexuality — in the sense that from the beginning of life, there is a pleasure in penetrating and being penetrated that already has an erotic quality. There is an erotic quality in biting, in being bitten, in fusing lovingly with the other by touching skin— as well as the feeling as one penetrates the body of the other, or as being penetrated. So the erotic impulses show from the beginning of life in the capacity to experience sexual excitement and to the erotic pleasure in watching once partner, the baby watching mother and mother watching the baby, which is the origin of voyeurism or sexual pleasure with seeing the sexually prohibited part of others.
And exhibitionism, which is the opposite, the erotic pleasure in showing one's forbidden parts to others, to excite them. In masochism, the slight pleasure in mild pain, that is part of sexual excitement. And sadistic pleasure in inducing pain in the other, which is part of sexual excitement when it is within a dominant loving atmosphere and signals the erotic pleasure of mutual fusing. When there's an excessive degree of aggression, then these tendencies become dominant and create problems.
And the most important problem is that excessive aggression makes ordinary sexual intercourse dangerous— dangerous to penetrate, dangerous to be penetrated. And so one remains with a childlike equivalence of masturbation, voyeurism, exhibitionism, fetishism. We call them perversions, or paraphilias, when they become indispensable preludes to sexual intercourse when the individual only acquires the security of sexual excitement and orgasm after having fulfilled these pregenital, early erotic desires. So, perversions are really sexual inhibitions of ordinary sexual behavior— retreat from it into the infantile equivalence.
Normal sexual relations, however, include all those infantile components. So a couple that has a good, mature sexual relationship may have games, plays, and fantasies, and activities of a masochistic, sadistic, exhibitionistic, voyeuristic, heterosexual and homosexual quality, and apropos homosexuality and heterosexuality unconsciousness— we have both tendencies, although usually one clearly predominates in most cases. But there are persons who, of course, who maintain both homosexual and heterosexual impulses of various degrees. So sexuality becomes complicated. This has been accentuated in recent fashions and political movements.
Transference Focused Psychotherapy and Reflective Function (00:45:08)
Puder:
One thing that I really loved about the- when I read the transference focused psychotherapy articles is when they looked at reflective function before and after transference focused psychotherapy therapy. And I think transference focused psychotherapy is one of the only therapies that has shown an improvement in reflective function. Reflective function being measured by the adult attachment interview. Fonagy was the main originator of that manual. Do you have any thoughts on why transference focused psychotherapy increases reflective function where things like dialectical behavioral therapy (DBT) did not show any change in reflective function?
Kernberg:
Because transference focused psychotherapy (TFP) permits the full expression of a conflict in its positive and negative aspects. Patients who develop a negative transference, we don't try to reduce it. To the contrary, we try for the patient to experience fully the negative transference in terms of identifying with the hostility of the object and the self as victim, and then with the hostility of the self and the object as victim. In other words, we try to familiarize the patient to make him accept the extreme of his reaction, to then confront him with the opposite extreme that we also tolerate of the intensity of loving and erotic impulses to the therapist, both is dual and recipient of love. So that by permitting the full expression of the extremes of love integration, we facilitate the interpretive integration of them and permit the patient to tolerate the simultaneous contradictory impulses that are part of normal human ambivalence.
And the patient then is able to see that yes, he has an ideal view of himself as a very nice person, but in part of him is also a nasty person. And introspection, insight consists in the capacity of an integrated view of all potential that one has. In contrast to remain splitting into a false idealized version completely separate from all aggression. So self reflection signifies a realistic way of assessing one in one's strength and weaknesses. Good and bad aspects are a mature distance from oneself acting in any concrete interaction.
Puder:
Okay. Okay. So a lot of people do not like the idea that we all have aggression. Right? And what I'm hearing from you is that you really allow the patient to feel the full weight of their aggressiveness. And that's very different than like trying to give them coping strategies or trying to tell them, no, you're not really aggressive, or you're not really angry. So like, give me some examples or help me understand how you might help someone tolerate their own aggression.
Kernberg:
Take a marital conflict. A woman hates her man because he has been treating her badly during breakfast, has not been coming home, has forgotten something important, gets enraged at him. He in turn gets enraged defending himself. They're in the middle of a big fight, but at the same time, they both have a consciousness that they love each other. And that fight is going to end in a good way into a good relationship. They have no doubts about that. They tolerate bad momentary interaction with a deep conviction of the consistency of a dominant love. In contrast to another couple who, when they are enraged, they feel this is the end. I'm walking out of this. I don't want to see that man ever again, or that woman, never again.
So the tolerance of one's fighting mood when one is angry with the consciousness of the permanent, of the deep relationship, that transcends the momentary one. That is what characterizes self reflectiveness: the capacity to see one's overall relationship rather than being victim of a certain mood and then having the sense that there is no other possibility is that particular mood. A man gets enraged at the way his wife is treating the children and gets so enraged to say, “You do this once again, I walk out.” And he's ready to walk out, and drop the relationship. So there is an intolerance of the bad, unavoidable, bad aspects of any relationship of daily life. Tolerance of ambivalence is really what marks self-reflectiveness. What Kleinian psychoanalysis calls the depressive position, which is the sense of the potential for sadness for treating badly people one really loves.
All of us have moments in which we don't treat those we love well. It takes a baby a year or two to realize that the mother that he hates, when he hates her, is the same mother that he loves when he loves her. And eventually is the capacity of feeling depressed when he's angry at the mother that he loves, and he sad over losing the mother that he loves because he's so angry. That is an indication of mature reflection. The capacity for reaction with sadness about one's own reaction and the awareness that one has different- general relationship with somebody with one is in a momentary mood, very different from the usual habitual one.
Kernberg:
A person who tends to be kind of rough and is acting superior with subordinates has a kind of inappropriate grandiosity, may recognize that he has that tendency and accept that he has a problem in the way he treats others that he has to correct. And that becomes part of his personality watching out what he knows of problems in his own tendencies. That indicates self-reflection. The general intention, how we should behave with others controls the immediate behavior, even if it's very different from what his general attitude is. This is what we mean by an integrated view of self and an integrated view of others. I mean, a man comes home with his serious mind and his wife thinks, oh, he doesn't love me anymore.
Then he comes home with a little friendly face, ah, he loves me. She doesn't have the capacity to know that he loves her, whether it's in a good mood or a bad mood. The integration of his present mood into his general relation with her indicates maturity, integration of the object representation. So integration of self-representation and integration of object representation. Mark normality, normal identity and capacity for reflectiveness. And we develop that throughout the treatment that tends to resolve primitive defensive operations, normalize identity, and therefore normalize the capacity of dealing with a major task of work and profession, love and sex, social life, and one's own creativity.
Envy, Promiscuity, and the Link with Personality Disorders (00:55:43)
Puder:
Tell me about your thoughts on envy and how someone with maybe more narcissistic borderline level functioning, how envy shows up for them versus maybe normal people.
Kernberg:
A very good question. Envy is a normal aggressive affect with very specific characteristics. It is anger at somebody who has something that we want and we don't have. So we want something that we don't have and are angry at whoever has it when we don't. It is a normal way in which a baby sees another baby has a toy that it- he wants to have that toy and gets angry if he doesn't get that toy or something exactly like it. So it is a human emotion. That is one of the negative aspects of our potential that normally we have. We tolerate it. It doesn't control our lives. With narcissistic personality, the problem is they present very intense aggression that takes the form of envy. Usually the cause of that is a lack of loving, sufficiently loving relationships in very, very early life in the first two or three years of life.
When one feels loved, one internalizes a good representation of others, and feels fulfilled by the people who have been good to one. If one doesn't have any of this, there's a sense of emptiness and one gets the painful observer that other people feel so good about their relation with others while we feel so bad. So envy becomes a very strong motivation because basically we don't feel the internalization of love that others have. And envy then grows to the extent that whatever we like and don't have enrages us. It destroys our relationship because whomever we could love, and be friendly with. Turns out to have things that we don't have to begin with, the very capacity to love. So the way that envy gives one a painful sense of lacking, of emptiness. And the way to fight it off is to devalue what one end is.
Normally, when we get a good response to our behavior from others, we feel very happy that others love us, and we see it as a gift. In other words, normally we have a feeling of gratitude for the love that we get. Envious people lack the capacity of gratitude, because what they get gives them a sense of what they didn't have. It reminds them of what they didn't have, which colors what they get. They're happy that they get it, but they don't have that feeling of happiness. With the happiness that the other feels in giving them something. So envy tends to spoil what one end is, which means that narcissistic personality fall in love with the woman, unconsciously hate what they admire in her from her physical appearance to her capacity, to her potential. And so unconsciously, they tend to devalue it and that makes this woman indifferent and boring, and they have to drop her.
So unconscious envy, the defense against it by devaluation is what motivates the sexual promiscuity of narcissistic personalities. The counterpart of envy is an unconscious destruction of the values that others have and that one doesn't. Students with a narcissistic personality can learn only what they feel they learn because they take over what others know. They incorporate the knowledge from others. That's kind of, it's like stealing from others makes them feel good. But when they have to acknowledge that they depend on the other, it spoils it. Because then envy is unavoidable. Narcissistic personalities can learn from what they learn, by what they feel they are learning by themselves without anybody giving them anything. They take it from others, but they can't read a book. They can't learn from a book because they have to- they have is independent knowledge from them, and they resent it. So you find very intelligent people who can't read a book or spoil their own capacity of interest in a certain field. So envy tends to ruin the capacity to absorb good things, establish good relationship. In the worst case, any area, one cannot enjoy anything except being admired, which is recognizing of one's greatness by the others. And if one of the predisposition to the narcissistic personality are parents who really don't love the children, but they are happy with admirable things that children have, that others admire the child. The parent, the narcissistic parent, uses the child as something great, “Look what beautiful children I have.” So they admire their child, but they don't love it.
So when the- when love is replaced by admiration is the only source of what loved one receives, it fosters narcissistic personality. One has no hope for love. Only when others admire one, one can feel good about oneself. So the psychopathology of envy is very damaging. And any major issue in the treatment that one solves by analyzing all its causes and consequences.
Histrionic vs. Hysterical Personality: Otto Kernberg Clarifies Neurotic and Borderline Levels of Functioning and Sexual Dynamics (01:03:52)
Puder:
I'm also curious about- you mentioned histrionic personality before. Do you see this on the borderline level of functioning or more the neurotic or both?
Kernberg:
Yeah. There is a confusion in the literature about this. There exists a high level personality disorder, the hysterical personality disorder. Which has normal identity and the main problem is sexual inhibition and efforts to overcome the sexual inhibition by various means. Sexuality is a great problem. They act quite maturely except when it comes to sex, when they become quite childish. Now, because politically hysterical personality usually went together with an attack of women because the impression was that only women had hysterical personality, which is false. Men also present hysterical personalities. The official classification of personality disorders called it histrionic personality disorder, so to take it away from its political implication. And the histrionic personality disorder, in the official classification, covers both the hysterical and the histrionic in a strict sense equivalent to the infantile personality, which are patients who have sexual difficulties, but part of a general severe personality disorder with identity diffusion. So that the histrionic personality, how it is used generally refers to a broad spectrum. Most of them are really their borderline personality organization, when in fact, a subgroup is part of a higher level neurotic organization.
How do we make that differentiation? The histrionic personality disorder is childlike or infantile in all aspects of life, work, professional, school, love, sex, social life. And is part of this childlike regression. Feelings are expressed through behavior more than verbally. And the exaggeration of behavior is what from the outside looks at theatricality, an exaggeration. Theatrical exaggerated behavior, which has an infantile quality to it, and is important aspects of those personality disorders. Histrionic means behavioral exaggeration of real feelings one has and conveys a sense of artificiality in contrast to the expression of real feelings in a profound sense. So these are patients who give the feeling that they exaggerate, that they do theater with what they feel to impress others, as if it were profound. It’s lack of sincerity, lack of honesty, when it is really part of a general childlike regression to childlike communication of affect.
So the histrionic personality of personalities with childlike behavior in all their interactions may include sexual inhibition, but very often surprisingly doesn't. So often, the histrionic personality on a borderline level are freer sexually than the hysterical personality on a neurotic level, because the hysterical personality, using the mechanism of repression, inhibits totally the sexual response. While the borderline personality, by the splitting mechanism, is able to have great sex with one partner and zero with others. So in a strange way, borderline patients may be freer of sexually than higher level neurotic patients. The main problem is in the relationship with others, and of course, borderline patients who, on top of all their problems, have an extremely severe sexual inhibition with zero capacity for any sexual excitement or enjoyment constitute the most serious part of sexual inhibition that requires long term treatment.
Paranoid Personality (01:09:35)
Puder:
Hmm. Do you want to talk about borderline level of functioning with the paranoid personality type? Like what is kind of like the thing that is most common with that group?
Kernberg:
Paranoid personalities are using the mechanism of projective identification as a dominant mechanism. They are part of borderline personality organization with intense aggression that they attribute to others because of that mechanism, meaning that they are hypersensitive to anything that can be interpreted as a negative attitude toward them. They're suspicious that others' behavior indicates hostility toward the person- hostility or the effort to disguise or hide hostility. At the same time, they tend to be very aggressive because they have excessive aggression, and they tend to use omnipotent control efforts to control the other person whom they see is dominated by aggression toward them. So the combination of aggressive behavior, hyper-suspiciousness, and efforts of sadistic control of others are the main characteristics of the paranoid personality.
Schizoid Personality (1:11:19)
Puder:
And, and you touched on schizoid a little bit. Schizoid with borderline level of functioning.
Kernberg:
Yeah. The schizoid personality uses predominantly the mechanism of splitting in efforts to avoid conflicts by such generalized splitting of the expression of all affects, that it is as if they had no affects. There is a kind of a fragmentation of affect as if extreme forms of splitting. So they fragment both their aggressive affects and withdraw from contacts in order not to be tempted to become aggressive. And they fragment the view of themselves as aggressive to avoid it. And sometimes they show a very sharp perception of others because they're so suspicious and so observant. Nothing escapes them. They are very good in spite of the identity diffusion, to know exactly what to expect from others. But about self, they have a complete confusion because of the fragmentation of all affective experience. So the identity diffusion shows in sharp description of others while they look and integrated view of them. It's- they see the wood, they see the trees, but they don't see the wood. And they withdraw protectively from avoiding aggressive induction with others. They are in-they look as if they didn't need affective relation and love. That's a mistake. They do need love, but they are afraid that their own aggression will destroy the affective potential of a good relation with significant others.
So the withdrawal protects them from direct search for love. And to the contrary, they have to do a tremendous effort to be able to express any close relationship with others. So their relationships are distant. The affect is dispersed, so it's hard for them to know what they really want, and they are ignorant of their own deep needs for love, that they have to reject out of fear of being rejected. And so there is hyper-alertness to what's going on, but without the aggression of the paranoid personality.
Social withdrawal rather than omnipotent control. And the sense of uncomfort and loneliness and distance in group situations. So a sense of loneliness, confusion about the self, not clear awareness of their need of significant others, and they are capturing the great details of the personality of others without really putting it together in an integrated view. These are the main characteristics of the schizoid personality, and the so-called schizotypal is just the more severe form of that, except that in the schizotypal there is genetic stronger genetic, hereditary disposition than in the schizoid personality.
Puder:
What role does fantasy play for schizotypal and schizoid? What role did you understand my question?
Kernberg:
Where, where does that play…
Puder:
Fantasy?
Kernberg:
In withdrawing from immediate social reality for the reasons that I mentioned, they replace their interaction with others by an intense fantasy life. They find in their intense fantasy life, an expression of their needs relating to others. So they are particularly prone to create their own internal world, gratifying their needs, because they don't dare to express it in external reality, out of the fear of their own aggression.
Puder:
Hmm. How about someone who's classically borderline personality disorder? Do you- how do you make sense of their intense fear of disconnection, of the withdrawal of the other?
Kernberg:
Well because the splitting operation and the activation of intense aggression toward people whom they love they project the aggression and any real frustration creates an exaggerated reaction. They are afraid of being left, of being dropped, of being abandoned because they see others with the intense aggression that they can't tolerate in themselves.
So they take one way to solve the dilemma between love and aggression is to look for an ideal relation with the other as a protection against the field. Aggressive rejection by the other, they become very dependent and intolerable of being separate, that intolerance of separation has to do with the fact that any separation is immediately translated into a sense of an aggressive rejection of the patient.
Why Therapists Want to Help (01:18:37)
Puder:
Good. Good. I, what do you think of most therapists who come into practice? Do you find them more of the depressive personality type? Or what kind of range have you seen?
Kernberg:
Well, I've had a long professional life and I've seen, I think, a very broad spectrum of patients. Yes. I believe I've seen probably most patients described in the literature.
Puder:
Is there a commonality of the helper of the person that wants to help? Maybe of the person where there was a role reversal early on in their childhood where they were the ones who were like the family therapist, even at a very young age. Like, what is-like how- where do those people fit in your sort of…
Kernberg:
I think that therapists may have many reasons for becoming a therapist. Very often, persons who have had strong personal problems that they have overcome, they then want to become therapists out of an experience of gratitude and identification with the people who help them. Some people are looking for solutions to their own problems in helping others. For some people it is a source of great gratification to have a profession that helps others. And there go all the motivations for medical professions, nursing, psychology, including that of psychotherapist interested in the psychological functioning of self and others, and how to modify it. There are some people who become psychotherapists secondary to their interests in neurobiology with the functioning of the brain. Sometimes psychotherapists have the unconscious motivation of helping others out of the situation in which the therapist had been in the past broadening the effect of his treatment. And one thing that was important for me was that sense of being able to change one's way of behavior. I had ways of behaving I was not happy with, and I had difficulty changing, and I wanted to know how much change can one or turn in self and in others. That drew me to get into a personal psychoanalysis first, and then became interested in psychotherapy in general.
Puder:
And how much did you change?
Kernberg:
Well, I changed significantly. I changed significantly. I had two personal analysis, so I had people helping me, and I had the luck of great teachers, really an unusual luck that- and met a number of the leaders of the field and with some of them became real friends, and that was very important. I owe a great deal to people such as Jacob Arlow and Andre Green and Betty Joseph and many others.
Puder:
But it sounds like you were also a great student because when he gives- when he tells you to read the book, you read the 12 volumes. Sounds like you, which-
Kernberg:
Yeah.
Puder:
It's an unusual student to come back and said, “I read the 12 volumes!”
Kernberg:
I read the- I admired him greatly and it was worth it. I learned the descriptive psychiatry more than most psychiatrists of my generation. It helped me to become very observant about small issues of behavior. It really wasn't- I got a specialized training..
Puder:
What would you say is something that you feel a lot of therapists don't understand that you wish they would understand at this point?
Kernberg:
It's very difficult to- generalize. My experience is mainly with the psychodynamic psychotherapists. I have limited experience of working with the cognitive behavioral therapist. Although I do have some, and very impressed by what some cognitive behavior therapy can achieve. But for psychoanalytic psychotherapists, I think the most important issue is first of all, comfort with one’s own aggression.
Therapists have to be comfortable with their own aggression, not having to act it out nor being afraid of it. That's one important issue. One, of course, a crucial issue is having a real interest in people and getting to know about people. Being curious about how other people are functioning. There are many therapists who don't pay sufficient attention to that. Then I think psychotherapists need to have a great, a great common sense. Psychotherapy starts where common sense ends. And in order to deal with the subtlety of conflicts, one has to have first a good hold of solid reality. I think that therapists can come from many directions. They can come from a very intuitive emotional direction or very intellectual ones, and they have to learn to compliment what comes natural with what they have to learn. The very intellectual ones have to learn about expression of emotions, and the most emotionally intuitive ones have to learn how to formulate things cognitively. And it really is a strong wish to help other people. I think these are the most important ingredients.
Puder:
Yeah. Yeah. That's good. Well, as we kind of- I don't want to take too much of your time today, and I'm- I feel like almost a part two is necessary to hash out some more of these ideas, or part 10 or part 11. But I'm curious, as we've talked today, if any lingering ideas are going through your mind that you haven't had adequate time to express.
Kernberg:
I think the great goals of treatment are to help people to become more effectively self affirmative, and at the same time more capable to develop relationships in depth with others. These are two basic issues of normal functioning, to take care of one's relations with others and to take care of oneself in a reasonable way. Acquire full responsibility for one's behavior in one's life.
Puder:
Do you, okay, so one more- one more question.. What was- do you feel like there's any room to explore the thing that you were doing before you did the psychoanalysis two times that you wanted to change? And did you actually feel it changed?
Kernberg:
Are you asking me what I was considering some other profession?
Puder:
No, no, no, no. You said earlier there was something about yourself that you wanted to change through psychoanalysis. Is there anything else you would be willing to share about that publicly?
Kernberg:
Yeah. Well, I don't want to share too many personal issues, but I used to be quite obsessive, excessively intellectual, and I have become much freer with my emotions.
Puder:
Well, I thank you for that and thank you for coming on. I've really enjoyed my time talking to you, Dr. Kernberg. It's a pleasure. And I'm very grateful for your many articles and books. And there was just a recent biography that was written about you [Otto Kernberg: A Contemporary Introduction]. I think Yeomans wrote it in part that I've appreciated and I know the people that I've been listening to my podcast for a while have been grateful for his expertise, and I'm sure they'll be grateful for you coming on today. So thank you so much.
Kernberg:
You're most welcome. It has been a pleasure. I'm glad it worked out.
Puder:
Fantastic. Thank you so much. I will stop the recording now.
Kernberg:
Okay.
Additional Resources
Episode 029: What is psychodynamic theory?
Episode 087: Disorganized Attachment: Fear without Solution
Episode 130: Borderline Personality Disorder: Psychotherapy Schema Therapy
Episode 171: Nancy McWilliams on Mental Health, Transference, and Dissociation
Episode 213: Reflective Functioning: The Key to Attachment with Dr. Howard Steele
Episode 215: Understanding Complex PTSD and Borderline Personality Disorder
Episode 224: Understanding Borderline Personality Disorder (BPD) Medications & Treatment
Episode 231: Borderline Personality Disorder: Splitting & Identity Diffusion with Mark Ruffalo
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