An Interview with Otto Kernberg, MD on Transference Focused Therapy
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Otto Kernberg, MD on the topic of Transference Focused Therapy. Dr. Kernberg is one of the best known living psychodynamic (e.g., Freudian) theorists, famous for his work in object relations theory, and on the nature of personality disorders and their remediation.
According to Dr. Kernberg, personality disorders, broadly speaking, are characterized by a dysfunctional rigidity of personality (character) and behavior in place of the more normal flexibility. More normal people are able to choose the way they will respond to stressful circumstances (most of the time), but personality disordered individuals are forced by their problems to behave in particular ways that frequently lead them to have difficulty getting along with other person, and causing them to have social, relationship and occupational problems. Such people have a solid appreciation of reality - they are not in general psychotic, delusional or prone to experiencing hallucinations. They are often aware they have a problem but find themselves rather helpless to do anything about it.
Dr. Kernberg differentiates two varieties of personality disorder: the mild neurotic form, and the severe, more primative form. People with mild personality disorders function fairly well and have intact relationships but there are nevertheless rigid patterns of responding that cause problems in functioning. People with more severe personality disorders demonstrate very rigid functioning and typically have grave relationship and occupational problems. They may be functionally disabled by their personality disorder.
People with the more severe personality disorders share in common what Dr. Kernberg calls "Borderline Personality Organization", which is not the same thing as Borderline Personality Disorder. Borderline Personality Organization refers to the manner in which a person's self-concept and their concepts of other people are formed inside their minds. Mature normally functioning people are able to think of themselves and other people as possessing both good and bad aspects at the same time. They can still be friends with someone who has let them down in the past, for instance, because they can make an integrated assessment of that person taking into account their good and bad qualities at once, and decide that, on balance, there is more good than bad present. They may similarly view themselves as possessing a combination of good and bad qualities. In contrast, people with borderline personality organization have very polarized and non-integrated self- and other-concepts. They tend to either idealize people or themselves as all good, or demonize them as all bad. They may swing between positive and negative self and other views in rapid succession, or they may maintain a stable all positive or all negative self-concept or other-concept. What they cannot do is to integrate good and bad qualities into a single vision. Dr. Kernberg calls this very polarized self and other concept situation, "Identity Diffusion".
Biological, psychological and social factors all influence the development of the borderline personality organization. At the lowest level, there is an inherited genetic predisposition towards difficulties with negative emotions such as depression and anxiety. This manifests both as a lowered resistance to experiencing these emotions in the first place, and greater difficulty in keeping them from spiring out of control once they are being felt. There are brain and nervous system problems that seem to be responsible for this layer of the problem. Difficult early relationship experiences, in particular poor quality attachment relationships forming between infants and their caregivers worsen the problem. Such attachment difficulties may be caused by parental neglect or abuse, parental depression, or even simple parental disengagement and reluctance to offer physical comfort to the infant. They can also occur in the absence of bad parenting when the infant is himself sick or in chronic pain during the first year of life. Family trauma and/or parents who are chaotic or inconsistent in their parenting style can also impair early bonding.
As a result of these biological, psychological and social problems, affected children grow up with their minds dominated by the experience of chronic negative emotion, and the perception that other people are by default ready to harm or neglect the child. This leads to what Dr. Kernberg characterizes as a paranoid orientation (a feeling that others are out to get you), which is highly threatening. Identity diffusion, that tendency to create polarized all-good and all-bad perceptions of self and others which cannot be both present in consciousness at once, forms as a defense or coping strategy for dealing with the basic paranoid expectation.
In Dr. Kernberg's view, the various severe personality disorders, such as borderline personality disorder and narcissistic personality disorder, can be thought of as attempts at coping with an underlying borderline personality organization, and the paranoid expectation that this mindset leads to. The severe personality disorders are styles of handling the underlying difficulty of integrating emotional reactions and self and other concepts.
According to Dr. Kernberg, Narcissism is a "particular complication of borderline personality organization" in which the narcissistic person sets up an "all-good" idealized self-concept (which Dr. Kernberg calls the "pathological grandiose self") as a defense against the paranoid world view that arises from the borderline personality organization. The grandiose self provides a way to handle underlying feelings of envy and anger. It provides a sense of security and confidence that would not otherwise be present, but the cost of this confidence is the inability of narcissists to ever be emotionally intimate and trusting with other people. Narcissists are quite capable at work, but fail again and again when it comes to sustaining mutually nurturing intimate relationships. The problem in treating narcissists is the problem of how you best undo the grandiose self so as to best allow the narcissist to begin to participate in real and loving intimate relationships.
It is very stressful to have a borderline personality organization as this polarized manner of relating to the world is associated with severe anxiety, depression and mood swings, self-injury, suicidal thoughts, excesses of emotion, and impulsiveness. Such people aren't able to maintain relationships, rendering them frequently lonely, angry, ragefull and unemployable. They often make poor partner choices. When they do form long term relationships, these relationships are typically conflict-filled. Chronic depression, anxiety, eating disorders, addictions and antisocial acting out (e.g., anger-motivated destruction) are frequent consequences.
Dr. Kernberg discusses several approaches to treating severe personality disorders including cognitive behavioral approaches to the problem such as Dialectical Behavioral Therapy. He thinks cognitive behavioral therapies have their place as a way of helping affected patients to better manage their symptoms such as self-injury, suicidality, depression and anxiety, but he is concerned that such therapy approaches do not do anything to remediate the underlying borderline personality organization, and, as such, are not useful for really repairing the underlying problems that cause these symptoms to occur. He has developed Transference Focused Therapy (TFT), as an alternative or complementary therapy for working with severe personality disordered patients which promises to get to the root of the severe personality disorder problem, the identity diffusion, and repair it.
The term Transference refers to the tendency for people to interpret present-day relationships in the light of their understanding of past relationships, and more specifically, for people to reenact unresolved problems and issues from past relationships in present relationships. Dr. Van Nuys asks why Transference Focused Therapy has the name that it has given that all psychodynamic forms of therapy including traditional psychoanalysis are heavily focused on transference. Dr. Kernberg's response is that while it is true that all psychodynamic therapy involves a focus on transference, his Transference Focused Therapy does so in a more intensive manner. TFT takes place over a shorter time span than traditional psychodynamic psychotherapy, and involves a smaller time commitment each week (2 sessions per week instead of the 3 to 5 sessions associated with psychoanalysis). TFT immediately gets down to the business of identifying transferences that occur between the patient and therapist and makes the dominant element of the therapy the constant striving to clarify the relationship between therapist and patient. It also puts in place several methods for containing patients' tendency to act out angrily against the therapist that are not present in other forms of psychodynamic therapy. In sort, TFT is a more intense form of psychoanalysis played out over a shorter span and much more aggressively focused on the transference than other psychodynamic psychotherapies are. Also unlike traditional psychodynamic psychotherapy, TFT is the focus of an active research program designed to test which methods are most useful for inclusion in the therapy, and how to best deliver the therapy in a manner so as to provide the best outcome of repairing identity diffusion and borderline personality organization.
In concluding the interview, Dr. Van Nuys remarks on his admiration for Dr. Kernberg's work, but also his willingness to incorporate cognitive behavioral formulations, and Neuroscience research into his thinking about personality disorders. At one point in the interview, he asked Dr. Kernberg about this, and Dr. Kernberg's response was to note that Freud came to psychoanalysis as a neurologist, and only diverged from thinking about his patients in neurological terms when it became clear to him that the neurology of his day was hopelessly inadequate. It was his intention and hope that as neurology matured, that it would one day be possible to reintegrate his field of psychoanalysis and psychodynamic psychotherapy with neurology. In Dr. Kernberg's opinion, that day has come.
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About Otto Kernberg, MD
Otto F. Kernberg (born 1928) is professor of psychiatry at Weill Medical College of Cornell University. He is most widely known for his psychoanalytic theories on borderline personality organization and narcissistic pathology. In addition, his work has been central in integrating postwar ego psychology (which was primarily developed in the United States and England) with Kleinian object relations (which was developed primarily in continental Europe and South America). His integrative writings were central to the development of modern object relations, a theory of mind that is perhaps the theory most widely accepted among modern psychoanalysts.
Born in Vienna, Kernberg and his family fled Nazi Germany in 1939, emigrating to Chile. He studied biology and medicine and afterwards psychiatry and psychoanalysis with the Chilean Psychoanalytic Society. He first came to the U.S. in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerome Frank at the Johns Hopkins Hospital. In 1961 he emigrated to the U.S. joining the C.F. Menninger Memorial Hospital, later became director of the 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 and Training and Supervising Analyst at the Columbia University Center for Psychoanalytic Training and Research. 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 developed a novel and useful framework for coordinating personality disorders along dimensions of structural organization and severity. 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.
The borderline - RC - Jan 9th 2012
I really enjoyed this interview. Dr. Kernberg's explanations were incredibly clear and understandable.
I did find a couple of things confusing. One is the diagnosis of so called "borderline personality" problems. Many of the symptoms that Dr. Kernberg ascribes to these disorders sound like half the people I know! Are things like "all good or all bad" thinking and struggles with intimacy really disorders? Certainly they are characteristics to be worked on in therapy, but how does pathologizing them help?
Another point of confusion for me is this whole idea of these things having a genetic component. I keep hearing conflicting statements about this. I've read that there are studies showing definitively that psychological symptoms do have a genetic component, and that often, these issues are caused by abnormalities in the brain. But then I'll read or hear someone say that there is absolutely no evidence that mental illness has any genetic or biological root; that obviously parts of the brain are involved, but that the brain itself is not the actual cause of such things as clinical depression, panic attacks, etc.
I would love to hear more discussion about these issues since they seem to really be a point of contention in the psych world, and as a lay person and a therapy client, it's hard to know what to believe.
Information about Kleinian Psychoanalysis in Dr. Kernberg's brief bio is incorrect - Joshua B. Lerner - May 16th 2010
Just a brief commebt Kleinian (object Relations Theory) Psychoanalysis did not develop in continental Europe but rather in E?ngland and then South America.
As a graduate of the British Psychoanalytic Society/Institute of Psychoanalysis and having studied with various leading Kleinians I can state with some authority that continental Europe was not it's origin.
transference - wendy r. - Feb 8th 2009
As a patient, I can say that transference is great but can also be terrifying. I think very highly of Dr. Kernberg. I do think that in dealing with transference that the therapist must be in control of his countertransference, especially his destructive impulsives. You may not talk about this much in the field, but I am very familiar with it. I always find your interviews with Dr. Kernberg fascinating. He is very gifted, and I met hin once.
Is TFT to aggressive - David Raath - Oct 28th 2008
Ever since reading Otto Kernbergs paper "Borderline Personality Organization" I was in total admiration with the way he formulated his theory on this type of personality organization. I think Prof Kernbergs insights are "Onn the button" however since we know and as he has quoted that the central element to BPD is identity diffusion we must realise that the patient with a severely impaired ego can not tolerate transference on this level.These patients rely heavily on the presence of others for self definition and identity. ie the patient's sense of self is over sensitive and any interpretation offered by the therapist will be assimilated as an attack.One should note that an Anorexic with (BPD/NPD) will react to the therapist's interpretations as the attacking invasive withholding mother. The BPD patient with a sexualy abusive background will react to the therapists interpretations as the sadistsic abuser. Both reactions as we can see will not contribute to a positive transference but rather a " Transference Psychosis" .
My own ideations surrounding Prof Kernbergs insights is that although highly accurate can be "Brutal" . If one views past authors such as Klein ,Freud etc who are psychoanalytic in foundation one will notice that their discipline although accurate comes from a place of power. A power/authority which these patients could assimilate as destructive and witholding.
I would like to conclude that patients with identity diffusion need to be handled gently and very slowly at first in order for them to attain "psychological breathing" and resonance with the therapist. I also would like to suggest that Therapists need to be trained more adequately on the issues on Counter Transference with these patients so that they can obviate therapeutic blind spots.Authors worth looking at this juncture would be Harold Searles and Katherine Zerbe.
Just a few thoughts.