Approaches to The Treatment of Narcissistic Disorders: Kohut and Kernberg. Gary N. Goldsmith

Transcription

1 Page 1 Approaches to The Treatment of Narcissistic Disorders: Kohut and Kernberg Gary N. Goldsmith Accustom yourself to give careful attention to what others are saying, and try your best to ente into the mind of the speaker.---- Marcus Aurelius, Meditations The term narcissism is highly problematic in the psychoanalytic literature. This has caused controversy and misunderstanding among many practitioners, as the term refers variously to a diagnosis, a character trait, a specific dynamic, or a line of psychological development. Today I will confine my comments mostly to questions of the treatment of patients who suffer from narcissistic disorders, understanding that there is much disagreement in this area as well. Are the different approaches to treatment (and their corresponding theoretical models) compatible? How do we choose among them? I will try today to describe the two models that have achieved the most significant attention in the literature over the past 30 to 40 years. This will not cover all of the approaches, and will leave many questions unresolved. I will not take sides in the argument between the models of Heinz Kohut and Otto Kernberg, but if I can help to widen your scope of comprehension, and thus your options for applying analytic technique, I will have succeeded in my task. The term narcissistic pathology has been used to describe aspects of neuroses, psychoses, borderline conditions and personality disorders. Freud believed that the presence of excessive narcissistic pathology implied a poor prognosis, or even untreatability of these patients, as opposed to what he termed the transference neuroses, because he believed that in patients with narcissistic pathology the object-cathexes were turned inward onto the ego itself, and not onto the person of the analyst. Thus they did not avail themselves to interpretation. Since then, advances in our experience have enabled us to put these phenomena under the microscope, offering a better understanding of their role in development and psychopathology, and the possibilities for treatment. In general, when we speak of the treatment of the narcissistic personality disorders, we are referring to those patients with character traits marked by self-importance and grandiosity and a simultaneous exquisite sensitivity to slights and other narcissistic wounds. They have feelings of entitlement, and are prone to feelings of shame and envy. They have an exhibitionistic need for attention and admiration, yet lack empathy for others, whom they exploit for their own needs. They have difficulty maintaining a realistic and healthy sense of self-esteem, often complain of a feeling of emptiness, and have chronic difficulties in their social relationships. Kohut studied not only the pathology of narcissism, but also in the role of narcissistic phenomena in normal development. His chief contribution was to characterize the nature of the transferences that occur in the treatment of narcissistically-disordered patients. At first he called them narcissistic transferences but later chose the term self-object transferences as his theory developed. The change came about because he perceived that such patients related to objects not as separate persons, but as extended parts of the patients themselves, existing only in order to meet the needs and expectations projected into them. He described three of these, the mirror transference, in which the individual attempts to elicit the approving responses of the self-object for his ambitions ( the gleam in the mother s eye in response to the child s developmental efforts), the idealizing transference, in which the individual searches for a self-object that

2 Page 2 accepts the patients s idealized values and ideals (these two transferences reflect the two poles of the bipolar self ), and the twinship transference, which is a search for a self-object that will make itself available for the reassuring experience of essential alikeness to others. In his theory of the psychology of the self, Kohut considered the wholeness of the personality as an active agent, with the drives and the defenses playing only a subordinate role that represents merely the breakdown products of a self under pressure of regression, rather than as the primary constituents of a psychology of conflict. Kohut differentiated the pathology he observed from the classical description, by coining the concept of Tragic Man, who is troubled by developmental failures and deficits in the creation of a coherent, integrated self. This is in opposition to what he called Guilty Man, who is victimized by anxieties and dysphoric affect arising from conflicts among its different intrapsychic structures which relate to earlier developmental tasks. The key to resolution of narcissistic problems (unintegrated selves vulnerable to fragmenting pressures) is attention to the appearance of self-object transferences stemming from earlier and more archaic experiences of failures of parental empathy, that is, to experiences of emotional deficit. This is opposed to the treatment of neurotic problems stemming from the intrapsychic conflicts of developmentally more structured and integrated personalities, where attention is paid to the role of drive and defense (i.e., conflict) and its manifestation in the transference neurosis. (At least one underlying question will remain throughout our discussion: namely, is it necessary to have such an either/or picture of development, or is it better to speak of a both/and view, which assumes that there are two (or more) parallel lines of development?) What does this mean for Kohut s approach to treatment? On this subject there is some ambiguity in his writings and in those of his followers. On one hand he writes that cure does not come through interpretation or through the achievement of insight, but through the establishment of empathic in-tuneness between self and self-object on mature adult levels... [which replaces] the bondage that formerly tied the archaic self to the archaic self-object....the gradual acquisition of empathic contact with mature selfobjects is the essence of the psychoanalytic cure. He adds, Increased ability to verbalize, broadened insight, greater autonomy of ego functions, and increased control over impulsiveness may accompany these gains, but they are not the essence of cure. A treatment will be successful because... an analysand was able to reactivate, in a self-object transference, the needs of a self that had been thwarted in childhood. In the analytic situation, these reactivated needs were kept alive and exposed.... to the vicissitudes of optimal frustrations [of the analyst s empathic responses]... until the patient ultimately acquired the reliable ability to sustain his self with the aid of self-object resources available in his adult surroundings. Thus the essence of the cure is the patient s new ability to seek out appropriate self-objects. Kohut states that this process of structure formation occurs through transmuting internalizations. (This is one of his terms that resists clear definition. Indeed, his use of the term structure also does not always seem to be the same as that used by Freud.) Kohut s theory is one of arrested development, rather than one of a dynamic, distorted ego structure with drives, defenses and psychological conflict. For Kohut, the self of the narcissistically-impaired patient is defective and must be repaired. This resonates somewhat with Franz Alexander s theory of corrective emotional experience. On the other hand, Kohut and his adherents were often heard to defend selfpsychology from its critics, stating that it is an interpretive treatment like any other, and that what is different is only the content of the interpretations, which are directed more at the self-object transferences and the patient s search for empathic responsiveness, than to conflict-oriented material. Failures of understanding, with consequent narcissistic regression or rage reactions, are to be empathically explored, in order to more closely attune the

3 Page 3 analyst s listening to the internal affective experience of the patient. Naturally, in the context of a long career, one can find many contradictions in the writings, which may only reflect the progressive enlargement of his ideas, rather than overt contradictions. Nonetheless, there is a distinct perception that interpretation was accorded a secondary role in his work, and that uncritical acceptance of the self-object transferences was seen as fundamental to his technique, since interpretation of those transferences could possibly be perceived as criticism, with the potential loss of the reparative function that the transference was serving. Kohut had a rather wide estimate of the kind of patient who was able to benefit from analysis. He felt that the basic criterion of analyzability is that the analysand must be able to engage the analyst as self-object and that the patient s self -- or, to be more exact, a remnant of whose self -- is still....in search of appropriately responsive self-objects... [the patient] must be able to mobilize in the psychoanalytic situation the maturation-directed needs for structure building via transmuting internalization of the revived self-objects of childhood. You will note self-psychology s persistent use of the term empathy in its description of analytic technique. Indeed, a major paper at the beginning of Kohut s opus was entitled Introspection, Empathy and Psychoanalysis. Kohut states that he built his psychology on the data gathered by empathic observation, which provides a more experience-near focus on the patient s sense of self and his inner life. He also feels that his method has broadened and deepened the field of empathic perception. He is critical of classical analysis a la Freud for being too confrontational and focused on a moralistically-based need to face the truth and make moralistic judgments of the differences between behaviors based on the pleasure principle and those based on the reality principle. For Kohut, insight occupies a less important place in the treatment than structure-building through empathic contact, and he claims this not only for the narcissistic disorders per se, but for all patients with narcissistic pathology, and perhaps for all patients, period. He minimizes the role of interpretation, defense, resistance, and conflict, and thus replaces the central role of the oedipus complex. The drives and the analysis of conflict become a secondary issue: Although self psychology does not disregard psychic conflict and analyses it when it presents itself in the transference, it does so only as a preliminary step on the way to... the essential task of analysis: the exploration...of the flaws in the structure of the self via the analysis of the self-object transferences. It is a psychology of deficit and its repair rather than of conflict and its resolution. Thus, pathogenic conflicts in the area of object ties, and the oedipus conflict itself, are not the primary cause of psychopathology but the result of disturbances of selfobject relationships in childhood. Kohut s view of the oedipal phase illustrates the altered model of development that he is offering. He differentiates between the oedipal stage and the oedipal complex, which he considers a pathological distortion of the normal stage. Thus, It is only when the self of the parent is not a normal, healthy self, cohesive and harmonious, that it will react with competitiveness..., rather than with pride and affection, when the child at the age of 5 makes a move toward a heretofore not achieved degree of assertiveness and affection. Thus, a child s oedipal complex is a response to the parents flawed selves, which fail to resonate with the child s growth experience. Only then does the self of the child disintegrate, and regressive symptoms emerge as by-products of this disintegration (hostility, repression, masochistic submissiveness, lust, etc.), constituting what has been called the classical oedipal complex. This is a direct challenge to Freud s view of the oedipus complex as the normal central source of conflict in development, and the core of all neurosis.

4 Page 4 In the well-known paper, The Two Analyses of Mr. Z (1979), Kohut demonstrates his change of technique from the classical model to his new self-psychological model. It is worth looking closely at his report of that treatment. Mr. Z first consulted Kohut as a graduate student in his mid-twenties. Kohut describes him as handsome and muscular with a pale, sensitive face, the face of a dreamer and thinker. He was an only child and lived with his mother, a widow. Mr. Z s father had died four years earlier. His initial complaint was vague. He had mild somatic symptoms such as excessive sweating, extrasystoles, stomach fullness, gastrointestinal complaints. He felt socially isolated and could not form relationships with women; he had good marks in his classes but he felt that he was functioning below his true capacity. He was lonely and had only one friend. A few months before the first consultation, his friend had met a woman to whom he became close, and no longer was interested in seeing Mr. Z. He had masochistic masturbatory fantasies, in which he performed menial tasks for a domineering woman. Yet he said his relationship with his mother was good. At the age of 3 ½, Mr. Z s father became ill and was hospitalized for several months. His father fell in love with the nurse who took care of him, and went to live with her instead of returning home. He rarely visited his son. However, he left the nurse and returned home after 1 ½ years, when the patient was 5. In the initial transference, he attempted to control the psychoanalytic situation, and demanded that he be admired and catered to. Kohut viewed this as a wish for an oedipal victory. These interpretations were responded to with explosive rage. At one point in Mr. Z s first analysis Kohut said, before offering an interpretation, that of course it hurts when one is not given what one assume to be one s due. At that time, Kohut didn t appreciate the significance of this comment for the patient. He assumed the case was moving toward the central conflict of his oedipal conflict and castration anxiety. Kohut interpreted the patient s narcissism as a protection against the painful recognition of the father s return, the father being a powerful rival who possessed the mother. He also saw the narcissism as a defense against experiencing the castration anxiety that he would feel if he were to become aware of his competitive and hostile impulses toward his father. The masochism was explained as a sexualization of his guilt about the preoedipal possession of his mother and about his unconscious oedipal rivalry. Kohut feels that his technique was based on standard and traditional psychodynamic interpretations. The patient revealed that at age 11 he was involved in a homosexual relationship with a 30 year old teacher, who worked at his summer camp. The relationship was characterized by mutual caressing and lasted about two years. It was described as a happy relationship for Mr. Z, who idealized his friend. That quality changed after the appearance of pubertal changes in Mr. Z s body, at which time the relationship became one of frank sexuality. Puberty increased his sense of social isolation and tied him more to his mother. He had no heterosexual experiences. The first analysis had some good results in that the masochistic fantasies gradually disappeared and the patient left his mother s house to live on his own. He began to date women, and had sexually active relationships with them. During the last year of the analysis he began a serious relationship with a woman and was thinking of marriage. These events occurred while Kohut rejected Mr. Z s narcissistic expectations, interpreting them as resistances against deeper fears connected with masculine assertiveness and competition with men. Before the termination the patient had the following dream: He was in a house, at the inner side of a door which was slightly open. The father was outside, loaded with gift-

5 Page 5 wrapped packages, wanting to enter. The patient was intensely frightened and attempted to close the door in order to keep the father out. Kohut felt that this dream confirmed the ambivalent attitude toward the father and the interpretation of the patient s psychopathology involving his hostility toward the returning father, the castration fear of the strong adult man, and the tendency to retreat from competitiveness and male assertiveness either to the old preoedipal attachment to his mother or to a defensively taken submissive and passive homosexual attitude toward the father. But in retrospect, Kohut felt uneasy about the termination phase, since it seemed to him emotionally shallow compared to the earlier part of the analysis when the patient talked in glowing terms about the idealization of the preoedipal mother and his admiration for the camp counselor. Four years later the patient contacted Kohut, saying he was having problems again. In the first visit of the second analysis Mr. Z said that although he was living alone and doing reasonably well in his profession, he did not enjoy his work. Kohut notes that Mr. Z added somewhat quickly and defensively that his masochistic traits had not returned. But Kohut felt that his masochistic tendencies had simply shifted to his work and to his life in general, as opposed to being confined to the sexual sphere and to fantasy. And in fact the patient had to call upon his masochistic fantasies during sexual intercourse as an antidote to premature ejaculation. After the break-up with his most recent girlfriend, he became alarmed about his increasing sense of social isolation and the internal pressure to masturbate with masochistic fantasies. The second analysis began while Kohut was already writing about his new understanding of self-psychology. Therefore when Mr. Z soon felt better after beginning the second analysis, Kohut understood this to represent the beginning of an idealizing transference similar to the time when he had turned from his mother to the camp counselor. This idealizing transference was soon replaced by a merger type of transference similar to that which had appeared at the beginning of the first analysis. However this time Kohut did not interpret it as having defensive origins, but rather as a re-opening of a childhood situation. Kohut didn t take a stand against it, and thus could rid the analysis of a burdensome iatrogenic artifact his unproductive rage reactions against me and the ensuing clashes with me. Kohut describes how he gave up his therapeutic ambition to get the patient to grow up, and instead attempted to study the patient s early experiences involving his enmeshment with the pathological personality of the mother. (His mother had fallen apart psychologically when Mr. Z left her during the first analysis, to the point that she had paranoid delusions.) In the second analysis many examples of the mother s bizarre use of Mr. Z as a selfobject were presented; a clearer image of her psychopathology emerged. She was not interested in her son but only in certain aspects of his body such as his feces and bowel function and later his skin, subjecting him to sadistic intrusions to which he had to submit. It became clear that she had been able to temporarily cover her psychosis by maintaining rigid control over her son, and when he left home she fell apart. The father s leaving was now more understandable too. Kohut believes that this material did not appear in the first analysis because his attention was directed to interpreting the regression from the oedipus complex rather than on the personality of the mother. So the improvement from the first analysis was a transference cure in which the patient complied with Kohut s convictions about traditional oedipal issues as the core of the analysis of the transference. Thus, outside the analytic office, Mr. Z met the analyst s expectations of him. He suppressed his symptoms and changed his behavior to fit the appearance of normality as defined by his analyst s

6 Page 6 understanding, at that time, of the need to move from narcissism to object love. In the second analysis however, the awareness of the mother s pathology and its pathogenic influence on Mr. Z was extremely emotional and dramatic. This was in sharp contrast to the emotionally shallow termination phase of the first analysis. As the patient gradually worked through the depressed aspects of his self (which was deeply involved in an archaic enmeshment with the psychic organization of the mother), a new independent and assertive set of interests arose, quite different from the previous submissiveness in Mr. Z s relationship to authority figures such as his mother and his analyst. Kohut then offered a different interpretation of the homosexual involvement: it did not involve a regression to the phallic mother, but rather a yearning for the figure of a strong fatherly man, perhaps the admired older brother Mr. Z never had. At the crucial moment in the treatment, it became clear that a powerful, positive, unrecognized relationship had formed to his self-object father. This was frightening, because it required the separation from the archaic self connected with the self-object mother, a self that Mr. Z had always considered his only one. Thus it was possible in the analysis to reactivate a formerly unknown independent nuclear self (crystallized around an up-to-now unrecognized relationship to his self-object father. ) The exchange between them was like this: While Mr. Z complained about his father s weakness and about the friend who had abandoned him, he also began to express curiosity about Kohut himself. What was your childhood like, he asked. What are your interests? Where were you educated? Do you love your wife? How s your sex life? Do you have children? Kohut interpreted: Your curiosity about me is a replication of your curiosity about your parents during the primal scene. You misunderstand me, Mr. Z retorted. Eventually Kohut agreed that indeed he was misinterpreting Mr. Z s motivations. The patient was not expressing a revival of sexual voyeurism, but was attempting to find out if Kohut was a strong man who had a healthy relationship with his wife, and who could serve as a strong father figure for his children. Mr. Z responded to this new interpretation with relief, and dropped his demands for information. Thus the analysis took a different turn from the first one, moving away from hopeless rivalry with the father to a feeling of pride in him. Oedipal material and conflicts did not lie hiding underneath, declares Kohut. The analyst-father was experienced as an image of masculine strength with which to merge temporarily as a means of firming the structure of the self. This termination was marked by a spontaneous return to the dream from the termination phase of the first analysis, which was now interpreted differently. Instead of being an expression of the child s ambivalence toward the oedipal rival, the dream was now explained as being a response to the father s sudden return, exposing the patient to the potential satisfaction of a central psychological need. This endangered the patient with a traumatic state, as he was suddenly offered all the psychological gifts (the packages) for which he had secretly wished. Kohut writes, This dream deals in its essence with the psycho-economic imbalance of major proportions to which the boy s psyche was exposed by the deeply wished-for return of his father, not with homosexuality, especially not with an oedipally-based reactive passive homosexuality. For Kohut, the major achievement of the analysis was the breaking of the deep merger ties with the mother. The patient went on to marry, have a family, and lead a satisfying and meaningful life. There has been much commentary on this case. I can only give a flavor of it here, and hope that you will read further. The most common criticism regards Kohut s technique in the first analysis. Did he miss the contradiction between the patient s idealizing statements about his mother, and the degree of hostility that he exhibited in the transference and in his masturbatory fantasies? By appearing rigid and inflexible in his

7 Page 7 interpretations, did Kohut unwittingly reinforce the patient s compliant and masochistic attitude towards authority, as had been the case in the patient s relationship with his mother? This would also have blocked the expression of positive feelings towards the father, as well as abetting the formation of a false self, lacking the initiative to risk being genuine and independent. Other commentators claim that Kohut s empathy was lacking in the first analysis, and that he didn t avail himself of the opportunity to listen from the patient s point of view from the start, as any experienced analyst would have done. So the problem of the first analysis wasn t the inadequacy of the classical approach. Rather, it was the inadequacy of Kohut application of it. ( It wasn t classical analysis; it was bad analysis. ) Further, other interpretations of the patient s dream were possible, yet Kohut implies that only a selfpsychological interpretation was valid. Kohut, in his defense, claims that the empathic listening stance led to important changes in the analytic atmosphere, permitting more material to emerge, of a sort that traced the emergence of transferences unknown to traditional analysis. Here is another vignette portraying Kohut s approach. It occurred when a Kleinian colleague told him how she had responded to a patient s silent withdrawal in the hour following one in which the patient was told of a future cancellation of a session. The interpretation that the analyst gave was that the patient s perception of the analyst had been unexpectedly changed by the announcement of the cancellation, and that the analyst had shifted from being a good, warm, feeding breast to becoming a bad, cold withholding one, and that the patient had responded with sadistic rage against the analyst as a bad breast, a rage that was defended against through a general inhibition, particularly of oral activity, biting words. Kohut expressed surprise that this farfetched interpretation, even though it was given in a warm and understanding tone of voice, caused a very favorable response from the patient. He said that the analyst could equally have given an interpretation within classical ego psychological conflict-drive-defense terms (the cancellation experienced as an abandonment by the oedipal mother locking the child-patient out of the parental bedroom), or even within self psychological terms (the loss of a soothing self-object leaving the patient to feel empty and not fully alive). He considered all three of these to be examples of wild analysis. He said that even though he felt the Kleinian content of the interpretation may have been wrong, it (or any one of the three interpretations) was nonetheless therapeutically effective since the analyst was conveying her understanding that the patient was troubled over the cancellation and was understandably reacting unhappily to it. However, he emphasizes in his book that self-psychology provides the best framework (for this encounter as well as for all of clinical work) for understanding the nature of such clinical moments, even when such secondary phenomena of anxiety or apparent conflict or regressive drive derivatives seem to be at the forefront of the clinical material. Nonetheless there is a clear feeling in this vignette that theory itself plays a secondary role to the empathic ambience created in the analytic encounter. There has been much criticism of Kohut s characterization of classical analysis, and of the assumptions made by self-psychology. I will review them briefly, and let the rest remain for discussion: 1) Self-psychology overlooks or even suppresses the perception of conflict, by encouraging ego-supportive techniques. In this it is closer to supportive psychotherapy than to psychoanalysis. 2) It supports a false confirmation of the patient s fantasies of defect or weakness by accepting at face value (accepting as fact) their feelings of deficit and fears of loss of control, rather than seeing the feeling of defect as a subjective description of inhibited drives. Thus it minimizes the effort to find the disguised meanings of manifest statements and affects of

8 Page 8 the patient, and substitutes a focus on distortions of unconscious material in favor of an unexplored acceptance of conscious and preconscious material, on what is felt by the patient. 3) It gratifies, rather than analyzes the mirroring and idealizing transferences. 4) It overlooks the importance of aggressive impulses, assuming that they are just reactive breakdown products of regression, rather than primary contributions to behavior, affect and psychopathology. 5) Self-psychology assumes that clarification of self-experience is the same as interpretation of that experience. It uses the concept of self as a vague supraordinate unit, missing the contribution of the different parts of the psychic apparatus to the understanding of conflict and the unconscious origin of symptoms. 7) It minimizes the role of free association by the patient (and the complementary freely-hovering attention of athe analyst), which Freud had described as a way around the limitations of introspective self-observation (by the patient) and empathy (by the analyst). In other words, because the classical analyst cannot rely on surface content for all the needed clues (since surface phenomena are disguised representations of unconscious meanings), empathy with the stated feelings of the patient is insufficient as a method. 8) It blurs the distinction between idealization and realistic respectful attitudes, and between the mirroring of grandiosity and the realistic recognition of caring. Still, many commentators, including those from outside the self-psychology movement, have had much to praise about its contributions to clinical work. Especially important is the recognition of previously unknown transferences that can lead to a new understanding of developmental stresses, whichever technique one then applies to work with these transferences. Analysts of any school can appreciate the value of the insights about the development of the self. In addition, perhaps Kohut has enabled some analysts to be more tolerant of the patient s need to love the analyst, or to regress and to act out, than was current in clinical practice when he was first writing. He permitted a more affirmative attitude to the patient, instead of an implicitly critical or subtly authoritarian stance. Thus he enhanced our capacities for neutrality in respect of the patient s behavior, and showed the advantages of listening from an empathic point of view. I should add here that Kohut has himself been accused of being overly narcissistic, with self-psychology as an outgrowth of his own narcissism, a creation of his grandiose self. It has been said that Mr. Z was Kohut himself, and that he was writing first about his own analysis with August Aichhorn, and then his later self-analysis. The facts of Kohut s background are similar to Mr. Z s. They were both only children, both of their fathers died when they were in their early twenties; both lived with their mothers; both were physically large but had timid personalities when young, as boys they both had friendships with older men; they married late, and had just one child. Then there is the project that Mr. Z begins at the end of his second analysis, which establishes him in his field just as happened to Kohut with his first book. Kohut was vague about details of the case, and never gave the dates of the treatment. He also never responded to questions about these noteworthy similarities. We find an entirely different approach to patients with narcissistic problems when we turn to the work of Otto Kernberg. Kernberg has dedicated himself to the elucidation of borderline personality disorders, paying particular attention to what he defines as pathological narcissism. He has tried to build on Freud s tripartite model of the mind by incorporating into it the findings of object relations theory and ego psychology, feeling that this could better address the pathology observed with borderline patients. Looking at

9 Page 9 internalized object relations, he felt that units of self- and object-representations (and the affective coloring and role relationships that bind them together), could be seen as the building blocks of the structures of mind. He then tried to show what the consequences of this would be for clinical work with borderline and narcissistic patients. His modification of classical theory borrowed heavily from Kleinian influences, especially Klein s emphasis on innate aggression, oral greed, and envy. Unlike Kohut, Kernberg believes that his theoretical advances remain fully within the bounds of traditional psychoanalysis, as opposed to a new theoretical structure that challenges that theory. Thus his work was seen as less controversial by the analytic community. Kernberg believed that the essential defensive operation of these patients was the mechanism of splitting, the process of keeping apart introjects and identifications of opposite affective quality (all-good or all-bad). An important consequence of this internal psychological activity is the observable splitting of attitudes toward external objects into allgood (idealized) or all-bad (denigrated), as well as an abrupt shifting of attitude toward the external objects, from positive to negative (and vice versa), which is similar to the description of sudden rage reactions in the patient with narcissistic personality disorder, when the self-object disappoints. Kernberg believed that the borderline, while often presenting a chaotic, wildly fluctuating, impulse-ridden picture, nonetheless represented on closer scrutiny a specific, stable, pathological personality organization, unique and welldifferentiated from both neurosis and psychosis. Whereas Kohut claimed that the non-responsiveness of early self-objects was the fundamental developmental problem, Kernberg felt that in these patients there was an excessive amount of aggressive drive owing to a combination of constitutional instinctual forces, a weak ego unable to tolerate anxiety, and serious external trauma from childhood caretakers. As a consequence, they could not integrate the self and object representations held together by positive emotional attitudes, with the emotions that were linked to negative representations. The excessive aggression led to the persistence of all-good or all-bad self- and object- representations. (If integration were to occur, it would move the patient into the sphere of neurotic disorders.) The effect of splitting is that it protects the good objects from being destroyed by the powerful oral aggression (greed and envy) of the all-bad self and objects. Other common defenses that intensify this problem are projection, projective identification, omnipotence and grandiosity, primitive idealization, denial and devaluation. These low level defenses are distinct from the higher level ones of neurotic patients, such as suppression, isolation, reaction formation, sublimation, etc. The inability to integrate the aggressive with the libidinal object ties interferes with ego and superego development, with the resulting persistence of primitive superego introjects having sadistic and over-idealized qualities. In treatment, particularly in the countertransference, the analyst may experience himself in the role of the patient s object (perhaps a sadistic parent-figure), or in the role of the patient as the small and helpless child. (Racker s complementary and concordant identifications). If he feels himself to be the fantasied object, he may feel anger, disdain, and a wish to impose his will on the patient; but when he feels like the patient he may feel small, scared, impotent and worthless. The important difference between Kernberg and Kohut here is that Kernberg believes that these projections represent distorted parts of the self and parts of the object, as well as early fantasy distortions of traits that were not actually true of the object, but distorted by the child s fantasy life owing to his developmentally primitive perception of reality at early libidinal stages. He does not assume, as Kohut does, that the sadistic part-object projections represent actual unempathic childhood objects or experiences. The core of Kernberg s

10 Page 10 analytic technique with borderline patients is in fact the clarification of these primitive transferences, with constant attention to, and interpretation of them. This requires a hereand-now focus on the transference, while genetic reconstructions are left for a later phase when the patient has attained a more neurotic level of functioning, particularly in regard to relating to objects as more whole. This occurs when the aggression has abated enough to permit more integration of the good and bad object representations, with a consequent diminished reliance on splitting as a defense. Kernberg recommended a modified analytic technique for these patients, neither a supportive-expressive therapy, nor a standard analytic approach, as was being used by the British object-relations theorists. He asserted that, because primitive transferences are immediately available and persistent, and that they in fact determine the severity of intrapsychic and interpersonal disturbances, they can and need to be focused on immediately, starting with their interpretation in the here and now and leading into genetic reconstruction only at the late stages of the treatment (when primitive part-object transferences have been transformed into advanced transferences toward total objects). He states that there can be no interpretation of primitive transference without a firm, consistent, stable maintenance of reality boundaries in the therapy. This requires a carefully maintained technical neutrality with the use of clarification and interpretation. Suggestive and manipulative techniques are to be strictly avoided. This is contrasted with psychoanalysis proper, in that, for Kernberg, the analysis of the transference is not systematic, but is modified by the need to focus on the severity of acting out and on the disturbances in the patient s external reality (which could threaten the treatment itself). Because the treatment elicits the acting out of primitive transferences, and the patient s reality testing may be weak, interpretation must focus on the predominant conflicts in immediate reality, the overall specific goals of treatment, and by what is directly available in the transference. The analyst must be sure that his confrontations of the patient are based on good technical reasons, not on a countertransference anger that is often produced by borderline and narcissistic patients who can be manipulative and denigrating of the analyst s motivation and skills. Critiques of Kernberg s work have centered on the following points: 1) He has an overly rigid theoretical scheme, with related precise recommendations for handling different situations. (Yet for some, his theoretical and clinical classifications are a welcome relief from the former lack of clarity in the treatment of patients with chaotic clinical pictures.) An example of this is Kernberg s view that the response to a trial interpretation of primitive defensive operations can clearly differentiate between borderline and psychotic functioning. With the borderline, such an interpretation is said to have a positive and integrative effect, helping to strengthen the patient s ego functioning and reality testing; with the psychotic the same approach is said to have a negative and regressive impact, worsening the manifest clinical picture. To some degree this may be accurate, but it can t be pinned down as a sure-fire diagnostic measure. Patients are more unpredictable and complicated than that. 2) Although he says that supportive techniques are to be avoided, he seems to make generous use of them in the treatment. Indeed, his understanding of the possibility of brief regressions into psychosis under transference pressures requires the aid of reality testing maneuvers and attention to the potential for self-harm. 3) Kernberg presents an overly optimistic picture of the treatability of primitive borderline and narcissistic patients. This contradicts his description of patients with highly resistant negative therapeutic reactions that stem from an envious need to destroy, in patients whose unconscious identifications with primitive sadistic objects require such

11 Page 11 destructive behavior as the price for maintaining any kind of object attachment at all, in patients with deeply anti-social characters, and those for whom suicide is a way of life. These aggressive, destructive and manipulative patients illustrate Kernberg s warning not to underestimate the many forms human aggression and aggression against the self can take. Yet he often fails to qualify which of these patients can be helped by his modified analytic approach. 4) His technique is not empathic. In fact, his readiness to employ a confrontational style may induce an iatrogenic negative transference and acting out, and may by experienced by the patient as a repetition of the original traumatic situation with his primary figures, with the expected negative consequences for the treatment. 5) He departs from basic analytic principles such as free association and freely hovering attention. Instead, he has a system of pre-conceived ideas based on diagnostic labels, which causes him to miss the individuality of his patients, and to treat them with a one size fits all approach that is too mechanistic. He may focus on a single defense mechanism, that of splitting, to describe too many characteristics of borderline patients, who use other defenses as well, to varying degrees. That is, he seems to be treating the dynamic, rather than the patient. 6) The patient may masochistically submit to Kernberg s forceful confrontation, losing the chance to strengthen his weak positive self-representation. Chances for development of a therapeutic alliance may be lost, as is the patient s need for an external holding object. Rather than confrontation, it might be better to focus on the ways in which the patient feels that the therapist is hateful (i.e., on the projection), and stay with an inquiring approach. Others have defended Kernberg s approach here by pointing out that for many patients a confrontational approach may be more supportive and empathic than so-called empathic listening. They point out that an alliance can t develop until confrontation has succeeded. It is the aggression itself which stands in the way of an alliance, so it must be addressed before anything else can happen. In other words, the confrontation shows that the analyst understands the patient s angry, orally hungry self. If used correctly, this technique will help him to feel understood and held, that his rage and badness are accepted by the analyst and cannot destroy him, and therefore they can be accepted by the patient himself. The therapeutic alliance will be strengthened by a forceful analyst who cannot be tricked, manipulated or destroyed by the patient. Kernberg and Kohut differ not only in their theoretical and clinical views, they also come from different philosophical positions. Kernberg s approach is closer to the philosophical assumptions that governed much of Freud s work, an empirical scientific orientation founded on positivist philosophy. Human mentation and behavior are seen as the outcome of conflicting vectors as in classical physics, and are open to empirical observation by the analyst-observer who takes a neutral stance. Kohut s technique employs a more experience-near focus on the patient s sense of self, and utilizes holistic concepts closer to the philosophical movements of phenomenology and hermeneutics than to Freud s hydrodynamic model. Data is gathered by what he calls the method of empathy or vicarious introspection. These fundamental differences highlight how different the clinical approaches are. You would be right to question to what degree they are talking about the same patients. The difficulty of integration of the two models is complicated by the varied use of analytic terminology, the amount of overlap between the diagnostic entities, the degree of severity of the narcissistic and borderline pathology in any given patient (e.g., narcissistic disorder as opposed to narcissistic traits ), and the changes that patients undergo as the treatment

12 Page 12 progresses. Do the narcissistic and borderline features present as aspects of a broader and less precise personality picture that also determines what approach should be taken? Are these problems to be found in every patient, if not at the beginning of treatment, then during the regression in the transference? How do the personal traits and skills of the treating analyst affect the choice of the technical stance? As analysts, do we see in the patient that which we are comfortable with, and exclude data that would challenge our assumptions about pathology and treatment? Is it correct to apply the label psychotherapeutic or supportive in a disparaging way to the work of treatment, if those techniques seem to help the patient? Are there not psychotherapeutic elements in every analysis? And finally, which of these approaches is truly the more empathic one? I thought that at the end of my paper I would begin to answer some of the questions I raised earlier, but it seems as if I am just asking more of them! What I can say definitively, and what you already surely know, is that we don t treat diagnoses; we treat patients. One cannot always gear the treatment to the presence of a single conflict or single defense mechanism. Character structure is complex and individualized. All sorts of defenses are combined in the personality, as are different transference reactions, superego conflicts, genetic material, etc. I say this not to avoid the recommendations of either Kohut or Kernberg. I do it rather to remind you that close, extensive and open-minded listening to the patient is a primary task of the analyst. In this way, we remain open to the possibility of surprise, and the work will be forever interesting. Heinz Kohut did not discover empathy. For that matter, I doubt that Marcus Aurelius did either. But of course, empathy is a sine qua non of the analyst s attributes. That is not in question. Rather, the question is, how is that empathy to be employed? Both authors offer insights and technical recommendations for the treatment of these very difficult patients. This has expanded our ability to listen and to work with patients thought to be unreachable by analytic means in the early history of our field. We will understand and learn more if we don t politicize the differences in their theories, but instead look to them for what they have to teach us about complex issues of treatment. Neither of them has the last word on this subject. But that is my last word. Bibliography Calef, Victor and Weinshel, Edward, The new psychoanalysis and psychoanalytic revisionism, Psa Q., 48: Chessick, Richard, Psychology of the Self and the Treatment of Narcissism (Aronson; New Jersey and London), 1985 Kernberg, Otto, Borderline personality organization, (J. Amer Psa Assn), 15: , Borderline Conditions and Pathological Narcissism, (New York; Aronson), 1975 Kohut, Heinz, The psychoanalytic treatment of narcissistic personality disorders. (Psychoanalytic St. of the Child), 23:86-113, The two analyses of Mr. Z. (Intl J Psa), 60:3-27, The Analysis of the Self, (New York; IUP), 1971

13 Page The Restoration of the Self, (New York; IUP), 1977 Levine, F.J., On the clinical application of Kohut s psychology of the self, (J. Phila Assn Psa), 6:1-19 Schoenewolf, Gerald, Turning Points in Analytic Therapy, (Aronson; New Jersey and London), 1990 Wallerstein, Robert, How does self-psychology differ in practice? (Intl Jl Psa), 66: , The narcissistic personality disorders and the borderline personality organizations, in The Talking Cures, (New Haven; Yale), pp , 1995