An Analytic Life with Otto: Commentary on Kernberg

So ingrained is Otto Kernberg’s theory within my own work that when I searched my bookshelves to find his book Psychodynamic Psychotherapy of Borderline Patients (Kernberg et al. 1989), after much looking I found it filed with reference books, that shelf we all have reserved for oversized tomes that are seldom consulted. But my dog-eared and annotated copy attests to my repeated use of this book and to my assimilation of Otto’s perspective on object relations and severe character pathology into my own. It is so fully mine, in fact, that I might explain how I’m seeing a patient to a resident psychiatrist while forgetting to tell them that it’s Otto’s lens I’m looking through.

The year was 1991 when, as a PGY-2 psychiatry resident at Columbia, I stepped onto the so-called General Clinical Services (GCS) unit, informally known as the “Borderline Unit.” I’d had some psychotherapy myself but never before conducted any. I was up against the most storied of the difficult patients with borderline and narcissistic personality disorders, at least that’s how it felt to me at the time. The patients I would treat for the next six months at a frequency of three times weekly could be living on the GCS unit for years at a time. I’d made a special trip downtown to the Barnes and Noble medical bookstore and now found myself nervously opening to the table of contents and then the first chapter of Kernberg’s classic text. As I began to read, borderline personality disorder (BPD), according to DSM-III-R, displayed a tumult of confusing and scary-sounding symptoms: unstable and intense interpersonal relationships with alternations between devaluation and idealization; impulsivity; affective instability; inappropriate and intense anger; recurrent suicide threats, gestures, and attempts at self-mutilation; marked and persistent identity disturbance; chronic emptiness; and frantic attempts to avoid real or imagined abandonment. What an introduction to all I was about to encounter! I remember swallowing hard as I wondered how I would survive. But I was drawn to challenges and to learning, and soon opted to spend additional time on the unit beyond what was required. You might say I had a certain concupiscence—a lust for an intellectual and emotional challenge about the whole idea of learning to manage and treat patients with borderline personality disorder. I’d been taught that schizophrenia was the most serious and severe form of mental illness; but my reaction to reading these descriptions of severe personality disorders hinted at my future perspective that they, not schizophrenia, can actually be more severe because of their lack of response to most medications. Because there was no overall magic pharmacological bullet for severe personality disorders, to me they seemed the purview of master therapists. As I began to experience life on the unit I wondered, “How could anyone live like this?”

Thankfully, these scary symptoms were quickly organized into Kernberg’s concept of Borderline Personality Organization, with identity diffusion, primitive defensive operations like splitting, projection, and projective identification, and a poor capacity for reality testing its central features. The book promised to teach me what I needed to know to work with such patients, including transference phenomena, defense mechanisms, resistance, and interpretive techniques, plus modifications of the frame and of technical neutrality. The goal of treatment was also mercifully clear: the gradual integration of split-off and dissociated components of the patient’s internal object world that would facilitate a more differentiated and accurate view of his or her self in relation to others. This goal was to be my bulwark against the affective storms and intensity of transference and countertransference phenomena, and I clung to it like a sailor at sea steering by Polaris. From the beginning, in all things borderline, Kernberg was my North Star. Technical neutrality, boundary setting, and the nature of the task itself unfolded, and through it all I learned to establish the treatment contract. I still think about the nature of the treatment contract every time I start working with a new patient, because the explicit nature of Kernberg’s instructions apply to every treatment. For certain types of patients, modifications and the need for additional structure are added, but the emphasis on the frame is relevant to all treatments. Page 27 of my Psychodynamic Psychotherapy of Borderline Patients is especially dog-eared; there Kernberg conveys the fundamental rule of free association, something I likewise refer back to upon beginning any analysis. The concept of hierarchies of thematic priority—from suicidal and homicidal behavior, to lying, to in- and between-session acting out—was also ideal for a beginner adrift in the firehose-like font of information produced in a single psychotherapy session, especially one with a borderline patient. Similarly, a detailed guide of what to interpret, when to interpret it, and how to establish a common view of reality taught me exactly what I wanted to know: What the heck do I actually say to the patient? All of this I read assiduously, feeling that my life depended on it. Kernberg’s matter-of-fact attitude toward the intensity of feelings borderline patients generate in their therapists also helped greatly to assuage my beginner’s guilt at experiencing a variety of intensely negative affects. Blazing narcissistic rage—whether my own or that directed at me by a patient—was largely outside the realm of my daily life experience. The fact that I traffic in repression and other higher-order defenses made me cling to an intellectual framework for understanding my patients that did indeed help bind these intense feelings. Of course, later in my own psychoanalysis I learned that, indeed, I had all the same feelings as my patients had, just usually more deeply buried, which is not always healthier!

Another key concept, and again something I constantly refer back to when I’m teaching, is Kernberg’s illustrative role pairs for patient and therapist (also parent and child): destructive bad infant with punitive sadistic parent; deprived child and selfish parent; unwanted child and uncaring self-involved and selfish parent; etc. The borderline inpatient unit of my residency made all this come alive for me with great immediacy; it made what Kernberg described real and recognizable. Seeing it first in patients with borderline character was to prove helpful to seeing more muted forms of these themes in both myself and my neurotic patients later on. Then as now, Kernberg was clear and concise, the only analyst whose works I read that I could easily understand and digest; his book was not only a manual for treating borderline patients but also a model of clarity for analytic thinking.

Psychodynamic Psychotherapy of Borderline Patients garnered some criticism at the time it was published. In one review, for example, the authors noted that the book’s “clarity, forcefulness and order” were its strengths, but that “these virtues have their price” (Kolb and Gunderson 1990, p. 513). One price often cited was “the high treatment dropout rate with borderline patients,” and the fact that a patient may “substitute the idealization [of a charismatic therapist] for the real relationship” (Adler 1993, p. 296). However, the psychotherapy researcher Lester Luborsky (1984) correctly stated that a

psychotherapy manual ideally has three aspects: it gives the essence of the principles of the techniques for the treatment; it pins down these principles by examples so that there is little ambiguity about how to apply the principles; it gives a set of scales for each principle so that any sample of the therapy can be judged for its adherence to the manual. The first two of these aspects are fully satisfied by Kernberg and associates. The third is only partially satisfied, but adherence scales can easily be constructed from the principles they provide [p. 285].

My first encounter with Kernberg—and with psychoanalysis—via his classic text, a summary of knowledge of borderline personality organization, highlights his overall trajectory in psychodynamic research. The first seeds that were planted in Kernberg’s work on the Menninger project have continued to sprout into a multi-decade psychodynamic psychotherapy research program involving specific techniques for specific patient groups. Serious and careful research involves putting your money where your theory is, including being willing to revise theories that don’t seem to work in the real world, something many analysts are loath to do or feel is of little importance. We often resist such clarity, claiming psychotherapy research is overly simplistic and cannot possibly capture the nuances of clinical work. Like Kernberg, I believe this view is largely poppycock, and likely defends against the possibility that dynamic psychotherapy is somehow diffuse or ineffective. Psychoanalysis would benefit from paying more attention to the need for demonstrating therapeutic efficacy and testing models of the mind more generally. In my own Columbia Analytic Process Scale (Vaughan and Roose 1995), the mega-interpretation, in which the analyst speaks to affect, behavior, motivation, genetic history, and transference all at once, was affectionately known to our research team as “the Kernberg.” Kernberg’s group

(co-led by John Clarkin and including many of my Columbia Psychoanalytic colleagues such as Eve Caligor, Frank Yeomans, Eric Fertuck, and Barry Stern) has spent the past twenty-five years creating research methods and measures. Together with Kernberg, they have demonstrated the efficacy of transference-focused psychotherapy (TFP) in randomized controlled trials (Clarkin et al. 2007; Doering et al. 2010). Over the years, Kernberg has created a new and more detailed theoretical understanding of the entire spectrum of personality disorders.

My next memorable encounter with Kernberg was in 1996, my third year of psychoanalytic training, when I decided not to read an assigned chapter from his new book, Love Relations (1995), for a class he was teaching. In a classic example of contempt prior to investigation, I was grumpy about the fact that Kernberg had used the word “perversion” in an earlier book title (Kernberg 1992, p. 326). I felt that I would likely take umbrage with what I read in this new work. I was the first openly gay or lesbian person in training at Columbia, and there was plenty in the curriculum that I found problematic (while also feeling under great scrutiny at the institute). I sometimes decided to put things that upset me aside, planning to read them later, once I was not in training, and sometimes “not getting around to it.” Yet I also found the man himself quite intriguing as I watched a gay colleague in treatment with him change in quite positive ways. And as I got to know Kernberg the man, as a teacher in my classes, and heard about fellow candidates being in supervision with him as well, I saw how students revered him and appreciated how approachable we all found him to be.

The first time I finally opened Love Relations was in 2010, just after teaching, with Justin Richardson, the institute’s first class on sexuality and gender (now a key part of our curriculum). Justin and I realized that we’d somehow designed a course on sexuality without including Kernberg, clearly an enactment on our part and a huge oversight. My grudging attitude toward the book gave way to interest, admiration, and then delight. Kernberg opined that when both partners in a couple have libidinal instincts that prevail over their aggressive instincts, healthy love relationships are created (1995, p. 32). I’d never been certain what would prevail for Kernberg—love/libido or hate/aggressive instincts. As spelled out here, Kernberg believes the capacity for gratitude that is basic to reciprocity in human relationships is created by libido trumping aggression in each member of the pair. More surprising, to my reading, was the marginalization of perversity, which Kernberg defined as “the recruitment of love in the service of aggression” (p. 45). With few clinical vignettes about gay or lesbian or bisexual couples and little attention to so-called “deviant” sexual practices in couples of whatever stripe, I did not find myself or some of my patients in Love Relations. But I did find Kernberg’s honest acknowledgment that “we actually know little about what determines a child’s eventual sexual object choice and very little about the sexual experience of children that may underlie that choice” (p. 46).

What I did find in Love Relations proves remarkably useful on a daily basis, beginning with the sweep of embryology and hormones. Kernberg tracks a general developmental continuum from sexual excitement to erotic desire, and finally to mature sexual love. I appreciate how beautifully it interfaced with the work of Daniel Stern (1985) on how self and object differentiation unfolds in early life. Kernberg treats sexual excitement as a specific affect that evolves into a motivational system that channels libido into erotic desire colored by the object relations of a person. He defines mature love as a phenomenon that “expands erotic desire into a relationship with a specific person in which the activation of unconscious relationships from the past and conscious expectations of a future life as a couple combine with the activation of a joint ego ideal. Mature sexual love implies a commitment in the realms of sex, emotion, and values” (1995, p. 29). As always, rather than just pontificating on mature love, Kernberg carefully defines both the term and what a person might do to demonstrate it.

One aspect of this book I have always appreciated is Kernberg’s discussion of triangulation, both “direct” and “reversed,” and the potential placement of a partner in the role of the excluded third both in fantasy and in reality. In direct triangulation, an imagined other is the excluded third, while in reversed triangulation the self or partner is the excluded third. For Britton (1997), “in the early oedipal situation . . . the infant is the observing third to the witnessed or fantasied primal scene: in other words, the recognition that sex is initially the [sole] possession of the parental couple” (p. 1336). Kernberg’s views on triangulation help clarify this missing aspect of the oedipus conflict. Also, Kernberg’s praise of Robert Stoller led me to steep myself in the work of Stoller as well, adding bite to Kernberg’s concept of aggression in the service of love.

Additionally, Kernberg helped me realize what a tall order mature love really is: integration of sexual excitement, tenderness for the other person, identification with the other, mature idealization, and passionate investment in the sexual relationship, the object relationship, and superego investments. Further, each of these factors requires the integration of libidinally and aggressively invested identifications and object relations. Kernberg concludes that with all the oedipal and preoedipal identifications involved, “there are potentially, in fantasy, always six persons in bed together: the couple, their respective unconscious oedipal rivals, and their respective unconscious oedipal ideals” (p. 88).

As the years have ticked by and I have accrued clinical experience, my vision of psychoanalytic work has broadened to accommodate more aspects of self psychology, including deficit- rather than, or in addition to, conflict-based models of the mind. Relational models of co-created meanings and the analytic third enrich my work as well. But object relations as explicated by Kernberg remain core to my way of working as an analyst. I think this is because Kernberg uniquely combines a developmental perspective on how we internalize important others, highlights the tension between “real” reality vs. reality upon which fantasy operates, provides an inherently dyadic, two-person model to use in transference and countertransference understanding, and establishes clearly the model for and goals of treatment. Relational theory adds an important, expansive seasoning to my work, while object relations remains the meat and potatoes.

Kernberg’s article in this issue, “Therapeutic Implications of Transference Structures in Various Personality Pathologies,” in which he offers “definitions of specific organizations of transference developments . . . for neurotic, borderline, narcissistic, schizoid, symbiotic, and psychotic character structures” (p. 951), is a huge undertaking characterized by his signature clarity of thought. The different organizations of transference developments explored in this paper correspond to the underlying characteristics of internalized object relations stemming from the conflictual implications of split-off, idealized, and persecutory self- and object representations. Kernberg maps the extent to which internal object relations of self and other develop during peak affective states in childhood. He demonstrates how these object relations can reflect an integrated or fragmented self, and how particular object relations lead to specific transference-countertransference paradigms. He takes on difficult questions of clinical technique by providing useful case vignettes. To me this masterful summary brings things full circle. Before reading this paper I had not, for example, completely connected the idea that the resolution of conflicts regarding aggression allows for the recovery of eroticism.

This is an impressive overview that both reassesses and advances his ideas by collecting them in one giant paper, one suitable for a wide range of readers. It can be summarized in its broad strokes by my modification of Kernberg’s own diagram of personality along introversion/extroversion and level of personality organization (see Figure 1).

OPEN IN VIEWER

Figure 1.

Level of organization

Once I clung to Kernberg the author as a life preserver of sorts. Otto helped me at other times during my training as well, with brilliant teaching (but no clinical supervision from him). My fantasies about his views on homosexuality caused me to actively avoid reading some of his work; in truth, I admired him so much I didn’t want to have my admiration crushed. In my current role as director at the Columbia Center for Psychoanalytic Training and Research, I’ve increasingly come to know the man. Otto deplored the “bean counting” found in much of psychoanalytic education and predicted, as psychoanalysis enters its mature phase of development as a field, the fall of the training analyst system (Kernberg 2014). As he has explained, academic promotions to the position of training analyst are subject to bias and tribal favoritism, giving modern institutes the feel of clubs. At Columbia we have taken his critique to heart, and Otto has been generous with his praise of changes we have made to our training. Meanwhile, with the securing of his views as an alternative personality model in DSM-5, Otto has redefined the concept of personality disorders to contain both dimensional (introversion/extroversion) and categorical (levels of personality organization) features into a system that can plot character disorders on a 2-D grid. He has brought a psychoanalytic personality model back to DSM and psychiatry and in the process provided, in TFP, the first truly evidence-based psychoanalytic treatment.

At ninety, Otto has a brilliant and always active mind housed in a man who delights in his work and his family, and whose attitude is playful, creative, and forward-thinking. As I watched him in London at the IPA talk about shifts in the training model in psychoanalysis, I found myself thinking that he is matched in charisma, character, energy, and enthusiasm only by Eric Kandel. Two Viennese Jewish immigrants who were forced to flee Nazi Germany, Kernberg and Kandel have transformed psychoanalysis and neuroscience, and both have demonstrated an ongoing interest in putting the two together. Each thinks it is important to reintegrate psychoanalysis into mainstream psychiatry and neurobiological research, developmental psychobiology, and models of character that can be studied using the established methodologies of psychotherapy research and psychiatric work on personality disorders.

Otto deplores “hero worship,” but what makes him a hero to me is the fact that he is always working, always thinking, always experiencing and reflecting on life and his experiences. A giant in the field, he could simply collect accolades and prizes, but he appears far less interested in power and praise than in his continuing exploration of the fundamentals of our field, as evidenced by this paper. At ninety he understands that progress is impossible without change and that those who cannot change their minds cannot change anything. Continued concupiscence—lust in all its forms—seems essential to physical and mental health as we age, and if his is any measure, the spry and curious Otto will continue to thrill us with his brilliance for a long time to come.