Otto F. Kernberg

Otto F. Kernberg was born in Vienna in 1928 and in 1939 his family left Germany to escape the Nazi regime and emigrated to Chile where he later studied biology and medicine and afterwards psychiatry and psychoanalysis with the Chilean Psychoanalytic Society. He first went to the U.S. in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerome Frank M.D. at the Johns Hopkins Hospital. In 1961 he emigrated to the U.S. and joined, and later became director of, the C.F. Menninger Memorial Hospital. He was the Supervising and Training Analyst of the Topeca Institute for Psychoanalysis, and Director of the Psychotherapy Research Project of Menninger Foundation. In 1973 he moved to New York where he was Director of the General Clinical Service of the New York State Psychiatry Institute. In 1974 he was appointed Professor of Clinical Psychiatry at the College of Physicians and Surgeons of Columbia University. In 1976 he was appointed as Professor of Psychiatry at Cornell University and Director of the Institute for Personality Disorders Institute of the New York Hospital-Cornell Medical Center. He was President of the International Psychoanalytical Association from 1997 to 2001.

His principle contributions have been in the fields of narcissism, object relations theory and personality disorders.

He was awarded the 1972 Heinz Hartmann Award of the New York Psychoanalytic Institute and Society, the 1975 Edward A. Strecker Award from the Institute of Pennsylvania Hospital, the 1981 George E. Daniels Merit Award of the Association for Psychoanalytic Medicine.

Transference-Focused Psychotherapy
Otto Kernberg designed an intensive form of psychoanalytic psychotherapy known as Transference-Focused Psychotherapy (TFP), which is meant to be more suitable for Borderline Personality Organisation (BPO) patients. BPO patients are described as experiencing so-called 'splits' in their affect and thinking, and the intended aim of the treatment is focused on the integration of split off parts of self and object representations.

TFP is an intense form of psychodynamic psychotherapy designed particularly for patients with borderline personality organisation (BPO) which requires a minimum of two and a maximum of three 45 or 50-minute sessions per week. It views the individual as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations is called identity diffusion, and leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The consistent interpretation of these distorted perceptions is considered the mechanism of change.

Suitable Patients
Kernberg designed TFP especially for patients with BPO. According to him, these patients suffer from identity diffusion, primitive defence operations and instable reality testing.

Identity diffusion results from pathological object relations and involves contradictory character traits, discontinuity of self and either very idealized or devaluated object relations. Defence operations often applied by BPO patients are splitting, denial, projective identification, primitive devaluation / idealization and omnipotence. Reality testing is negatively influenced by the primitive defence mechanisms as they change a person's perception of self and others.

Goals of TFP
The major goals of TFP are better behavioral control, increased affect regulation, more intimate and gratifying relationships and the ability to pursue life goals. This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations and the resolution of identity diffusion that perpetuate the fragmentation of the patient’s internal representational world. To do this, the client’s affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference. Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.

Focus of treatment
A distinctive feature of TFP in contrast to many other treatments for BPO is the idea of a specific structure of the mind that underlies the symptoms of BPO. BPO patients suffer from a fundamental split of their mind. Aspects of self and other are defensively separated into “all good” and “all bad” representations. This internal split determines the patient's way of experiencing others and in general the environment. The aim of the treatment is the integration of split off parts of self and object representations.

This split is literally a defence against aggressive impulses, which may dominate, control and destroy the good parts of self and the object representations. The good parts of the self and object representations are tried to safeguard by splitting off.

The BPO might be caused by affectively charged interpersonal experiences that are cumulatively internalised over time in the individual's mind and become established in his/her psychological structure as “object relations dyads”.

In the course of psychological development, these separate dyads are unified into an integrated whole with a more mature and flexible sense of self and others.

Contract
The treatment begins with the development of the treatment contract, which consists of general guidelines that apply for all clients and of specific items developed from problem areas of the individual client that could interfere with the therapy progress. The contract also contains therapist responsibilities. The client and the therapist must agree to the content of the treatment contract before the therapy can proceed.

Therapeutic Process
TFP consists of the following three-steps:
 * (a) the diagnostic description of a particular internalized object relation in the transference
 * (b) the diagnostic elaboration of the corresponding self and object representation in the transference, and of their enactment in the transference /countertransference and
 * (c) the integration of the split-off self representations, leading to an integrated sense of self and others which resolves identity diffusion.

During the first year of treatment, TFP focuses on a hierarchy of issues:
 * the containment of suicidal and self-destructive behaviors
 * the various ways of destroying the treatments
 * the identification and recapitulation of dominant object relational patterns (from unintegrated and undifferentiated affects and representations of self and others to a more coherent whole)..

Diagnostic Elaboration
In the psychotherapeutic relationship, self and object representations are activated in the transference. In the course of the therapy, projection and identification are operating, i.e. devalued self-representations are projected onto the therapist whilst the client identifies with a critical object representation. These processes are usually connected to affective experiences such as anger or fear. Examples of self-object representations that might be activated in the transference are mentioned in the following:


 * Self Object
 * Controlled, enraged child Controlling parent
 * Unwanted child Uncaring, self involved parent
 * Defective child Contemptuous parent
 * Abused victim Sadistic attacker
 * Deprived child Selfish parent
 * Sexually exciting child Castrating parent
 * Dependent, gratified child Doting admiring parent

The information that emerges within the transference provides direct access to the individual's internal world for two reasons. First, it is observable by both therapist and patient simultaneously so that inconsistent perceptions of the shared reality can be discussed immediately. Second, the perceptions of shared reality are accompanied by affect whereas the discussion of historical material can have an intellectualised quality and be thus less informative.

Interpretive integration of the split-off self representations

TFP emphasizes the role of interpretation within psychotherapy sessions. As the split-off representations of self and other get played out in the course of the treatment, the therapist helps the patient to understand the reasons (the fears or the anxieties) that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experience of strong affects within the therapeutic relationship. The combination of understanding and affective experience can lead to the integration of the split-off representations and the creation of an integrated sense of the patient's identity and experience of others. Therefore, the integration of the psychological structure can lead to a decrease in the BPO symptoms.

Mechanisms of change
In TFP, hypothesized mechanisms of change derive from Kernberg’s developmentally based theory of Borderline Personality Organisation, conceptualized in terms of unintegrated and undifferentiated affects and representations of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relation dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a ‘split’ psychological structure in which totally negative representations are split off/segregated from idealized positive representations of self and other (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is the integration of these polarized affect states and representations of self and other into a more coherent whole.

Theory on Narcissism and the Controversy with H. Kohut
Otto Kernberg states that there are three types of narcissism: normal adult narcissism, normal infantile narcissism, and pathological narcissism. Pathological narcissism, defined as the libidinal investment in a pathological structure of the self, is further divided into three types (regression to the regulation of the infantile self-esteem, narcissistic choice of object, narcissistic personality disorder) with narcissistic personality disorder being the most severe of all. Still, narcissism has been a great source of disagreement between Otto Kernberg and Heinz Kohut. Although both focused on narcissistic, borderline, and psychotic patients, the focus and content of their theory and treatment has been considerably differentiated. Their major diversities emerged in response to their conceptualizations regarding the relationship between Narcissistic and Borderline personalities, normal vs. pathological narcissism, their ideas about narcissistic idealization and the grandiose self, as well as the psychoanalytic technique and the narcissistic transference.

Kernberg's Developmental Model
Another major contribution of Kernberg is his developmental model. In this model he describes 3 developmental tasks an individual has to accomplish, when one fails to accomplish a certain developmental task this responds to the increased risk to develop certain psychopathologies. Whereby failing the first developmental task namely, psychic clarification of self and other, results in an increased risk to develop varieties of psychosis. Not accomplishing the second task, overcoming splitting, results in an increased risk to develop a borderline personality.

Theory on Narcissism
According to Kernberg, the self is an intrapsychic structure consisting of multiple self representations. It is a realistic self which integrates both good and bad self-images. That is, the self constitutes a structure that combines libidinally and aggressively invested components. Kernberg defines normal narcissism as the libidinal investment of the self. However, it needs to be emphasized that this libidinal investment of the self is not merely derived from an instinctual source of libidinal energy. On the contrary, it stems from the several relationships between the self and other intrapsychic structures, such as the ego the superego and the id.

Normal Adult Narcissism
This is a normal self-esteem based on normal structures of the self. The individual has introjected whole representations of objects, has stable objects relationships and a solid moral system. The superego is fully developed and individualized.

Normal Infantile Narcissism
Regulation of self esteem occurs through gratifications related to the age, which include or imply a normal infantile system of values, demands or prohibitions.

Pathological Narcissism
Three Subtypes


 * Regression to the regulation of infantile self-esteem. The ideal ego is dominated by infantile pursuits, values and prohibitions. The regulation of self-esteem is overly dependent on expressions or defences against infantile pleasures, which are discarded in adult life. This is the mildest type of narcissistic pathology.


 * Narcissistic choice of object. This type is more severe than the first one but more rare. The representation of the infantile self is projected on an object and then identified through that same object. Thus, a libidinal association is generated, where the functions of the self and the object have been exchanged.


 * Narcissistic personality disorder. This type is different from both normal adult narcissism and from regression to normal infantile narcissism. It is the most severe type and is suitable for psychoanalysis.

In Kernberg's view, narcissistic personalities are differentiated from both normal adult narcissism and from fixation at or regression to normal infantile narcissism. Fixation at a primitive stage of development or lack of development of specific intrapsychic structures is not adequate to explain the characteristics of narcissistic personalities. Those characteristics (through a process of pathological differentiation and integration of ego and superego structures) are the consequence of pathological object relationships. Pathological narcissism is not merely the libidinal investment in the self but in a pathological, underdeveloped structure of the self. This pathological structure presents defences against early self and object images, which are either libidinally or aggressively invested. The psychoanalytic process brings to the surface primitive object relations, conflicts and defences, which are typical of the developmental stages that precede the stability of the object.

Kernberg vs. Kohut
Otto Kernberg and Heinz Kohut can be considered to be the two theorists that have markedly influenced past and current psychoanalytic thinking. Both focused on the observation and treatment of patients that were otherwise thought to be unsuitable for analytic therapy. Their main work has been mostly related to individuals with narcissistic, borderline, and psychotic psychopathology. Still, their perspectives concerning the causes, psychic organization, and treatment of these disorders have been considerably different. Taken as a whole, Kohut is regarded as a theorist that radically departed from Sigmund's Freud conjectural conceptualizations, focusing mostly on people's need for self-organization and self-expression. Kernberg in contrast, remained faithful to the Freudian metapsychology, concentrating more on people's struggle between love and hate. Their main differences are summarized below.

Relationship between Narcissistic personality & Borderline personality
On of the main disagreements between the two theorists revolves around their conceptualization among narcissistic and borderline disorders. According to Kernberg, the defensive structure of the narcissistic individual is quite similar to that of the borderline person since the former has a fairly underlying borderline personality organization which becomes obvious when one looks at the defenses of splitting and projective identification. He identifies constitutional along with environmental factors as the source of disturbance for these individuals by stressing the important role of the mother surrogate who treats the child on the surface (callously) with little regard for his/her feelings and needs. Kohut on the other hand, sees borderline personality as totally distinct from the narcissistic one and less able to benefit from the analytic treatment. Equally, a narcissistic personality is more apt for analysis since it is characterized by a more resilient self. According to Kohut, the environment alone is the major cause of troubles for these persons. Moreover, although both focus on the concept of the “grandiose self” in their narcissistic personality theorizing, they provide different explanations for it. For Kohut, “grandiose self” reflects the “fixation of an archaic 'normal' primitive self” while for Kernberg it is a pathological development, different from normal narcissism. For Kohut treatment should be primarily centered on encouraging the patient's narcissistic desires, wishes, and needs to open up during the process of transference. For Kernberg, the goal of treatment should be to use confrontation strategies so as to help the patient integrate his/hers internal fragmented world.

Normal vs. pathological narcissism
One of the main arguments between Kohut and Kernberg is about normal and pathological narcissism. As mentioned earlier, Kohut assumes that a narcissistic personality suffers from developmental arrest. Specifically, he assumes that this type of personality mirrors adaptive narcissistic wishes, needs, and objectives that, nevertheless, have not been satisfied during childhood development by the parental environment. Here, the grandiose self is nothing more than an archaic form that prospectively ought to become the normal self. When this does not occur then pathological narcissism emerges. In his explanation of pathological narcissism, he pays attention on the libidinal forces or charges in order to provide an etiology of how this disorder develops. For him the aggression drive is of secondary importance in respect to the libidinal drive and that is why one should differentiate between ordinary aggression and narcissistic rage. The first, according to him, is adaptive for eradicating obstructions when heading toward a realistic goal whereas the second is the forceful response to narcissistic injury. Kernberg however, sees Kohut's ideas as de-emphasizing the power of aggression. He allies more to the Freudian conceptualization, by proposing that narcissistic behavior results from pathological development in which aggressive drives play a central role. He argues that narcissism on the whole involves a strong aggressive drive that cannot possibly be analyzed separately from the libidinal one. As he says, “one cannot study the vicissitudes of normal and pathological narcissism without relating the development of the respective internalized object relations to both libidinal and aggressive drive alternatives”

Relationship Between Narcissistic Idealization and Grandiose Self
Kohut departed from the classical Freudian view, which suggested that some patients could not be analyzed given that they lacked the ability to develop transferences. He postulated that narcissistic patients are able of presenting transferences but these are somewhat different from those of other patients, such as the neurotics. He distinguished three types, namely the idealizing, the mirror, or the twinship transference. His debate with Kernberg concerns mostly the idealizing transference, which, according to Kohut, relates to a fixation at an archaic level of normal development. Still Kernberg believed that the idealizing transference is nothing more than a pathological type of idealization that is produced as a response to the substantial instigation of the grandiose self in the transference.

Psychoanalytic Technique and Narcissistic Transference
Kernberg and Kohut regard the analytic process as well as the role of the analyst quite in different terms.

Specifically, Kohut advocates that the analyst's position within treatment should be one where a full narcissistic transference should be encouraged. In the same line of thinking, the analyst should be further able to present an empathetic style that would reflect the narcissist's self experience so that a new united and healthy self would eventually emerge. Empathy, according to him, is the most important therapeutic instrument that an analyst can employ for helping the patient. Still Kernberg, although he also supports the development of full transference, he deems that the analyst's main function should be to foster a more integrated object relation by examining and elucidating the narcissist's basic aggression. The role of the analyst should be neutral rather than supportive, especially during the confrontation process, in order to modify the narcissist's pathological structure.

Kernberg's Developmental Model
One of Kernberg's major contributions is his developmental model. This model is built major on the developmental tasks one has to complete in order to develop healthy. Completing each developmental task represents a level of psychopathology, as is described under the heading developmental stages. Furthermore his developmental model includes Kernberg's view about drives, in which he differs from Freud. Kernberg was obviously inspired by Melanie Klein, whose model draws mainly on the paranoid-schizoid position and on the depressive position. More elaborate information on Kernberg's ideas can be found in a recent publication by Cohen M. (2000).

First Months
Kernberg saw the infant in the first months of his life as struggling to sort out his experience on the basis of the affective valence of this experience. The infant moves back and forth between two different affective states. One state is characterized as pleasurable and gratified; the other state is unpleasurable, painful and frustrating. Regardless of what one is in, no distinction is made between self and other.

First developmental task: psychic clarification of self and other
The first developmental task embodies being able to make a distinction between what is self and what is other. When this task would not be accomplished, one cannot develop a dependable sense of the self as separate and distinct because one cannot make a distinction between one's own experience and the experience of others. This failure is hypothesized to be the major precursor for all psychotic states. In the symptoms of schizophrenic symptoms (hallucinations, delusions, psychic fragmentation) we can see a lack of being able to separate between internal and external world, own experience and experience of others, own mind and the mind of another.

Second developmental task: overcome splitting
The second developmental task is to overcome splitting. When the first developmental task is accomplished, one is able to differentiate between self-images and object images; however, these images remain segregated affectively. Loving self images and images of good objects are held together by positive affects, or libidinal affects. Hateful images of the self and bad, frustrating object images are held together by negative or aggressive affects. The good is separated from the bad. The developmental task is accomplished, as the child is able to see objects as “whole”, meaning that the child can see objects as being both good and bad. Next to seeing “whole” objects, the child is required to the self as being loving and hating, as being good and bad at the same time. When one fails to accomplish this second developmental task, this will result in a borderline pathology. Meaning that objects or the self cannot be seen as both good and bad, or something is good, or it is bad, both affects cannot be in the same object together.

Developmental stages:
As seen in the description of the developmental tasks, Kernberg has established developmental stages that, if not accomplished, result in psychopathology.

When one has failed to accomplish the first developmental goal, one has not been able to establish clear boundaries between self and other; this is seen as a precursor for psychosis.
 * First Stage: Varieties of Psychosis

When one has accomplished the first developmental task but has failed to accomplish the second developmental task, thus not being able to integrate loving and hating, good and bad, this results in a borderline psychopathology.
 * Second Stage: Varieties of Borderline Personalities

Varieties of higher-level personality development, corresponding to Freud's vision of neurosis, can develop when the first and second developmental tasks are accomplished, thus self-object boundaries are established and object images are integrated. Neurosis is a result of the conflict between libidinal and aggressive impulses.
 * Third Stage: Varieties of Higher-Level Personality Development

Kernberg's View About Drives
In contrast with Freud's perspective, drives are not inborn according to Kernberg. The libidinal and aggressive drives are shaped, developed over time by experiences of interactions with others. The child's good and bad affects become consolidated and shaped into libidinal and aggressive drives. Good, pleasurable interactions with others consolidate, over time, into a pleasure-seeking (libidinal) drive. In the same way bad, unsatisfying and frustrating interactions with others, become consolidated into a destructive (aggressive) drive over time.

General references

 * Clarkin, J.F., Yeomans, F.E., & Kernberg O.F. (1999). Psychotherapy for Borderline Personality. New York: J. Wiley and Sons.
 * Cohen, M. (2000). Love Relations: Normality and Pathology: Otto Kernberg, Yale University Press. Journal of American Academic Psychoanalysis, 28, 181-184.
 * Consolini, G. (1999). Kernberg Versus Kohut: A (Case) Study in Contrasts. Clinical Social Work Journal, 27, 71-86.
 * Foelsch, P. A. & Kernberg, O. F. (1998). Transference-Focused Psychotherapy for Borderline Personality Disorders. In Session: Psychotherapy in Practise. 4/2:67-90.
 * Kernberg, O.F., Selzer, M.A., Koenigsberg H.A., Carr, A.C. & Appelbaum, A.H. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.
 * Kernberg, O.F. (2001). The suicidal risk in severe personality disorders: Differential diagnosis and treatment. Journal of Personality Disorders. The Guilford Press
 * Kernberg, O. F. (1975). Borderline conditions and pathological narcissism.
 * Koenigsberg, H.W., Kernberg, O.F., Stone, M.H., Appelbaum, A.H., Yeomans, F.E., & Diamond, D.D. (2000). Borderline Patients: Extending the Limits of Treatability. New York: Basic Books.
 * Mitchell, S.A. and Black, M., (1995). Freud and beyond: A history of modern psychoanalytic thought. Basic Books: New York.
 * Yeomans, F.E., Clarkin, J.F., & Kernberg, O.F. (2002). A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Northvale, NJ: Jason Aronson.
 * Yeomans, F.E., Selzer, M.A., & Clarkin, J.F. (1992). Treating the Borderline Patient: A Contract-based Approach. New York: Basic Books.  Kernberg, O. (2001) The suicidal risk in severe personality disorders: differential diagnosis and treatment