Abstract
In The Inseparable Nature of Love and Aggression: Clinical and Theoretical Perspectives, Otto Kernberg demonstrates his breadth of knowledge and command of psychoanalytic theory while highlighting its connection to neuroscience and empirical systematic research. In contrast to volumes such as those by Charles Brenner (2006) and Leo Rangell (2007), two giants of so-called American ego psychology from the latter part of the twentieth century, this work by Otto Kernberg (written from the perspective of object relations theory) distinguishes itself by its attempt to engage psychoanalytic ideas with the rest of the scientific and academic universe. He ends his introduction as follows: “At . . . bottom, this volume is based on the conviction that neurobiology and psychoanalysis are two basic sciences that, in their collaboration, have the potential to significantly advance our understanding of the human mind in health and illness” (p. xvii). To my mind this is a challenge to psychoanalysts, regardless of theoretical persuasion. For psychoanalytic ideas to continue to influence the mental health field, we must engage with allied fields and embrace methods, already in place, to systematically evaluate both core concepts and the mutative value of various techniques. Kernberg’s volume is an important step in that direction.
The book, a collection of recent papers, is organized in several sections: Part I, Severe Personality Disorders; Part II, Reflections on Psychoanalytic Theory and Its Applications; Part III, The Psychology of Sexual Love; Part IV, Contemporary Challenges for Psychoanalysis; and Part V, The Psychology of Religious Experience.
The first part, together with the chapter on affects (the first chapter of Part II), is the most important part of the volume and comprises half the book, dealing with topics for which Kernberg is renowned: borderline personality disorders, narcissistic disorders, transference-focused psychotherapy, and the relationship between affect theory and neurobiological findings.
The first chapter deals with identity and identity diffusion, beginning with Erik Erikson’s seminal contribution and ending with a transcript of the Diagnostic Structural Interview to illustrate identity diffusion. The chapter highlights the clinical importance of differentiating identity diffusion from the normative identity crisis of adolescence, with “a normal set of internalized ethical values, interests, and ideals” (p. 20) absent when identity diffusion is present. In chapter 2, transference-focused psychotherapy (TFP) is discussed. The work in TFP “is facilitated by the fact that unconscious conflicts are activated in the transference mostly in the patient’s behavior . . . [as a result of an] intolerance of overwhelming emotional experiences expressed by acting out, in the case of most borderline patients, and somatization, in some other personality disorders” (p. 36). There are three steps in the process of TFP: formulation of the transference-countertransference being activated in the interaction; observation of the corresponding roles between patient and therapist; and interpretive linking of “mutually dissociated positive and negative transferences” (p. 35).
For me, chapters 3, “Mentalization, Mindfulness, Insight, Empathy, and Interpretation,” and 4, “Countertransference,” are notable for their discussion of the mechanism of change and the technique that it entails, as well as of the role of the therapist in the treatment. For example, are early transference interpretations, as used in TFP, valuable in work with severe borderline patients? Or are these interpretations risky, and to be avoided, as in mentalization-based therapy (MBT) with its focus on helping the patient develop an increased awareness of mental processes? (p. 59). The transcript of a session with a patient and the discussion of countertransference in chapter 4 would serve well as a teaching tool showing how one determines the degree to which countertransference reactions in the therapist derive from within, or are elicited by the patient, and how much they are intertwined. Caper (2012) has most astutely addressed this dilemma. Whenever a therapist experiences an unconscious countertransference reaction (considered to be a projective identification), one must assume that the patient has touched on something from the therapist’s past that was experienced as conflictual, and that it has provoked the therapist to unconsciously react to the patient and play a role important for the patient’s historically derived, internally provoked drama. Clearly, with patients who have greater identity diffusion, transference-countertransference interplays will be more intense. TFP, with its careful attention to these interactions, intensifies both transference reactions in the patient and potential countertransference responses in the therapist.
It is beyond my scope here to discuss the case illustration extensively (pp. 69–73), but it would be valuable to review and discuss this material in depth to see if we can generalize from it regarding how a therapist chooses what to say, when to say it, and how to say it. In addition, this case transcript illustrates the problem of an author, on the one hand, trying to convey a clinical interchange and its meaning, and a reader, on the other hand, trying to make an independent judgment of the material’s significance. The use of a transcript from audiotape allows for a more independent judgment by the reader, yet even with an accurate rendition of the dyad’s utterances, does the reader’s personal theory affect how he or she will understand or misunderstand the data?
For example, toward the end of the segment the patient says, “I have intense reactions about not being understood” (p. 72). This comment struck me, because throughout the report it seemed to me that the therapist was not on the same wavelength as the patient. This seemed to be confirmed as the session drew to a close. At one point, the therapist interprets, “You can’t win because if I’m right, you feel humiliated. And, if I’m wrong, you feel disappointed. Do you follow me?” (This question struck me as reflecting the therapist’s concern that he was not connecting with the patient.) The patient responds: “If you are wrong, I feel disappointed because you are my therapist, and you’re no good.” The therapist responds: “Right. And if I am right, you feel humiliated because I know better than you, and you feel put down.” The patient says, “Yeah, that one’s very vague. The other one is the one that is more active.” To my reading, this last brief segment illustrates the disconnection between patient and therapist. How much comes from the patient, trying to provoke the therapist not to understand, and how much comes as a result of the therapist’s difficulties? Thus, I do not feel satisfied with Kernberg’s explanation that there is an “activation of a dominant persecutory object relation between a superior controlling, sadistic object (an image of the father) and a humiliated, controlled, subjugated self (of the patient) and the rapid interchange of these two roles between patient and therapist in the context of this session” (p. 73). This case does not convincingly illustrate whether the therapist is trying to impose his ideas on the patient (ideas with which the patient overtly disagrees) and how much the therapist’s activity results from the patient’s imposition of the superior sadistic object.
Is my response to this case material based on my theoretical perspective, which stresses the centrality of addressing defenses against unpleasant affects (Hoffman 2007), and on my lack of familiarity with the subtle aspects of technique advised by object relations theory? Unfortunately, psychoanalysis does not yet possess an accepted method of judging the nature of an interpretation and of determining its accuracy or inaccuracy.
Chapters 5 and 6, “The Almost Untreatable Narcissistic Patient” and “The Destruction of Time in Pathological Narcissism,” discuss very difficult cases. The major negative prognostic factors in these patients include “secondary gain of the illness, including social parasitism; severe antisocial behavior; severity of primitive self-directed aggression; drug and alcohol abuse as chronic treatment problems; pervasive arrogance; general intolerance of a dependent object relation; and the most severe type of negative therapeutic reaction” (p. 137). In addition, the “destruction of time in narcissistic pathology . . . condemns the patient to the experience of an empty life” (p. 158).
In chapter 7, “Supervision,” Kernberg contrasts his technique with that of authors who write about supervision from the perspective of the supervisee, and what he or she has to learn. In this chapter, following the therapeutic model that has led to TFP, Kernberg focuses on what supervisors must learn and the difficulties that occur for them.
In chapter 8, “Psychoanalytic Affect Theory in the Light of Contemporary Neurobiological Findings,” Kernberg reviews various psychoanalytic and neurobiological theories about affects. He summarizes his own theory as follows: from the beginning of life there are instinctive dispositions that organize behavior. Their integration depends on the environment and the experience of the individual. Freud distinguished between instincts and drives, the latter being individualized. Kernberg proposes that affects are hardwired and organize the two superordinate drives, libido and aggression, which determine the overall motivational system involved in unconscious intrapsychic conflict. An implication of Kernberg’s formulations is that the deepest layers of psychic experience that will organize the psychic apparatus are represented by peak affect states of a positive or negative quality, in the context of which the deepest aspects of the relationship between self and others are internalized, presumably initially into procedural memory, and only later as declarative or preconscious memory (p. 195).
What are the neurobiological correlates of the development of ever more complex intrapsychic structures? They must include processes such as procedural and declarative memory, linguistic memory, and the perception of self as a reflecting agency. It seems reasonable to suggest, on the basis of present empirical evidence, that intrapsychic changes mediated by symbolic processes such as psychoanalytic treatment may affect processes and organization at a neurobiological level. The dissociation of affects into their primitive, idealizing, and persecutory types under conditions of predominance of splitting and related defensive operations signals the activation of primary affect states directly related to their original neurobiological organization. In some cases of severe borderline pathology, these states cannot be tolerated intrapsychically. In short, affect theory provides a bridge between psychoanalysis and neurobiological studies.
In chapter 9, on the death drive, Kernberg concludes that it may not be an inborn disposition but that it is relevant to clinical practice. In chapter 10, “Some Observations on the Process of Mourning,” whose origin was a “personal, painful, extended experience of mourning” (p. 222), and based on clinical material as well as interviews, Kernberg concludes that “the most impressive aspect of the mourning process is the moral or ethical injunction to carry on the aspirations of the deceased person” (p. 242).
In Part III, The Psychology of Sexual Love, Kernberg discusses, in three chapters, variations in mature love, limitations to the capacity to love, and sexual pathology in borderline patients. In Part IV he bemoans the isolation of psychoanalytic institutes from the university, proposing some solutions and outlining various attempts to integrate psychoanalytic work in universities. He also discusses the problem with “dissidence” in psychoanalysis, dating back to Freud’s sharpening differences with dissenters beginning with Adler. In the book’s final section (Part V), Kernberg discusses psychoanalytic ideas about religious experience and the spiritual realm.
Certainly this collection of Kernberg’s work reflects the breadth of his knowledge and experience. There is, however, a limitation to this volume, inevitable as it may be, that points up the biggest obstacle to psychoanalysis being viewed as a basic science of the mind. Kernberg is obviously steeped in the theoretical world of object relations theory. Working clinically, one must have a theory that organizes how one listens to a patient. Yet why have psychoanalysts not been able to develop a consensually accepted theory of the mind?
I have noted (Hoffman 2008) that “one would have to say that the jury is still out with regard to a scientific demonstration that conflict / compromise formation theory is indeed the ‘best fit’ for ‘the available, relevant data’” (p. 1024). Unfortunately, we must conclude that this goes for object relations theory, as well as for other psychoanalytic theories. Rangell (2007) proposed that aspects of various theories that are acceptable should be incorporated into a total composite theory, while those deemed unacceptable should be discarded. He stressed the importance of “reasonable consensus” (p. 91).
Kernberg clearly supports the idea that psychoanalysis needs to proceed in a more systematic manner. One of the next steps must be to develop valid and reliable methods for determining the degree of accuracy or inaccuracy of interpretations. This will allow psychoanalysts to come to “reasonable consensus” regarding the nature of mutative interventions in all psychological treatments. Only in that way will its ideas be more acceptable to the academic and scientific community. Other theorists should proceed in the same manner as Otto Kernberg has.