Otto F. Kernberg, Borderline personality disorder

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Transference-Focused Psychotherapy

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

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

Suitable Patients

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

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

Goals of TFP

The major goals of TFP are better behavioral control, increased affect regulation, more intimate and gratifying relationships and the ability to pursue life goals.^[1] This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations and the resolution of identity diffusion that perpetuate the fragmentation of the patient’s internal representational world.^[1] To do this, the client’s affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference.^[2] Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.^[1]

Focus of treatment

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

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

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

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

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Kernberg vs. Kohut

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

Relationship between Narcissistic personality & Borderline personality

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

Normal vs. pathological narcissism

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

Relationship Between Narcissistic Idealization and Grandiose Self

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