Can One Be A 'Master Therapist'?

It is from Adam Phillips and Todd Dufresne (in his very astute introduction to a new translation of Beyond the Pleasure Principle) that I have learned to regard the whole concept of being a 'master' of something with a good deal of skepticism. 

In several of his books (but perhaps especially Terrors and Experts from 1997, and more recently his The Cure for Psychoanalysis), Phillips notes that we should in fact be suspicious of the whole idea of mastery of the psyche (and much else). Any psychoanalysis or psychoanalyst that promises such a thing exceeds its brief, Phillips says, arguing that there is no such psychoanalytic equivalent as the King's English or an 'authorized translation' or editio typica of the mind. 

I must say that it has taken me rather a long time to make my peace with this, but I think Phillips is right: mastery is not ever completely possible, and it should in fact be interrogated when such a desire reveals itself. Though I have spent rather a lot of time on the analytic couch, and it has been invaluable in ways too numerous to mention, it was only my second analysis that led me to let go of my infantile wishes for omnipotence and omniscience and to abandon the hope that I ever could examine and thus come to control every part of my mind, draining it of all ambivalence and ambiguity and the anxiety both sometimes produce. (Put in a Winnicottian way, I would be tempted here to say I'm on better terms with my primary process!)

I have achieved a lot of insight, but it is not and never will be complete, nor anything approaching mastery, and I am now not only at peace with that but--thanks again to Phillips--rather amused (instead of alarmed and angered) at the surprises my unconscious will produce from time to time. As Phillips says "A good life entails the tolerance and enjoyment of inner complexity....There is no final resolution here" (On Flirtation: Psychoanalytic Essays on the Uncommitted Life).

None of this is to say, however, that 'mastery'--as in mastering a skill--is something I reject. Quite to the contrary, I do believe that when it comes to such practices as learning languages, playing piano, or comparable activities, mastery can and should be aimed at. 

That is especially the case with psychotherapy though--as we shall see--it seems paradoxically true that one crucial hallmark of being a 'master psychotherapist' is precisely an ongoing uncertainty about whether one is a master or not, and a recognition that one still has things to learn. The master therapist, it seems to me, is the one who never feels he has learned everything. 

With this as background, I picked up Jeffrey Kottler and Jon Carlson's On Being a Master Therapist: Practicing What You Preach (Wiley, 2014) and read it with interest. 

The authors begin on the right footing, by raising the right questions, asking whether 'mastery' of therapy is "based on the mastery of certain clinical skills, particular personal qualities, or professional characteristics" (p.11). They next note problematic ways of finding master therapists: do you self-nominate? are you nominated by colleagues? are patients who love you or got better with you able to nominate you as a master?

All of these selection methods have, of course, problems, so we are no closer to an answer of how and where one might find master therapists. Instead, the authors add additional questions: does mastery differ based on the type of therapist or therapy? They inch towards an answer by suggesting that "no two master therapists perform therapy in the same way" (p.16). 

From here we get some suggested characteristics that are likely to be encountered in those recognized as masters:

• they are more inventive
• they are more humble
• they are uncomfortable drawing attention to themselves
• they prefer difficult truths to comforting illusions
• they are emotionally honest with themselves and their patients
• they perceive things, and more quickly, that others usually miss

This takes us up to the end of ch.1 where the authors write: "the concept of a master therapist is neither easy to define nor easy to grasp, especially considering all the different ways such excellence might be manifested" (p.24). 

Ch.2 takes us into increasingly familiar territory: examining the person of the therapist and noting that good therapists are those who "think differently in a multitude of ways," enabling them to make connections others might miss, and to "apply a variety of complex theoretical constructs and then adapt them to any particular case" (29). 

Forming the Alliance:

From here they quote Barry Duncan to the effect that forming "solid therapeutic alliances" is the key to distinguishing great therapists from the mediocre. But this must extend not merely to the worried well, or the patients you like or find similar to yourself or can easily relate to: it must extend to those court-ordered into treatment, those extremely reluctant or resistant to engaging with you, those whose lives seem radically different from your own. If you can build a solid alliance with these sorts of people, then you may be on your way to mastery.

Additional signs that you are on your way include:

• flexibility
• creativity (reinventing therapy for each patient)
• originality: finding your own voice
• learning from mistakes
• evolving views responding to new evidence
• seeing the patient as the greatest teacher.

Learning How to Listen:

Ch. 3 focuses on deep compassion and caring, while ch.4 looks at the skills of a master listener. These latter are marked by an ability, of course, to listen with the third ear, which enables them to hear between the lines, to hear what is doubled, denied, denigrated, overlooked, and so on. 

Your listening is supplemented by sight: what is the patient doing when they tell you for the third time in ten minutes that life is great? What are they not doing that you might well expect them to do? 

Listening prompts speech, and here the authors say master therapists are not afraid to draw on a variety of approaches, including being quite directive when it is appropriate. But most of the time good listening requires that one be as centred in the session and focused on the patient as possible: "Many experts that being present is the most important element of helping others heal" (p.85). 

Speaking the Truth in Love:

When one does speak, the so-called master therapist will "practice transparent honesty with as much tact and diplomacy as appropriate," always guaranteeing to the patient that you will be truthful and will say the things nobody else will say (p.111).

Be Not Afraid to Make Mistakes:

The authors quote several researchers, including Scott Miller and Bruce Wampold, to the effect that not only are great therapists going to make mistakes, but they may "make more mistakes than others, or at least are more inclined to admit them" (p.129). Such therapists are more self-critical, looking honestly at what they are doing and not doing, and what is working and not working. They fault themselves--and not the patient--if things are not working; but they are also gracious towards themselves in their criticism. Their self-critiques are not totalized or masochistic.

Obtaining Feedback:

The authors note the importance of obtaining accurate, useful feedback from patients on a regular basis. This can prevent ruptures from worsening and patients simply silently walking away. Duncan has written about this, as has Scott Miller, and before them Jerome Frank. 

Key Personality Traits:

At the end of ch. 10, the authors list what they regard as key personality traits in great therapists:

1. Trustworthiness
2. Dependability
3. Integrity
4. Flexibly tolerant
5. Modestly self-assured (believing in the patient, the process, and themselves)
6. Truthful
7. Spontaneous and Intuitive without being Impulsive
8. Kindness

But the most important trait is the outgrowth of kindness: love. As they begin to wrap the book up, Kottler and Carlson devote a chapter to the role of Love, putting me in mind of Freud's celebrated comment to Jung in a 1911 letter that "essentially, one might say, the cure is effected by love."

The Volkans on Schizophrenia

Nearly a decade ago, I began exploring the underlying psychodynamics of ISIS propaganda, and the wider historiography of the Crusades. In the course of that research, I think it was the historian and psychoanalyst Charles Strozier (in his book  The Fundamentalist Mindset: Psychological Perspectives on Religion, Violence, and History) who first introduced me to the works of Vamik Volkan and his pioneering and pivotal concepts of "chosen trauma" and "chosen glory." 

I went on to read several of Dr Volkan's books, including Bloodlines: From Ethnic Pride To Ethnic Terrorism. These and others of his corpus have been very helpful to me in several articles and lectures, and now in a book I have coming out later this year on the dynamics of Russian-Ukrainian historical and religious conflicts. 

More recently, as readers may recall, I interviewed him about his Large Group Psychology which was published by Phoenix in 2020. (By all means order the books through Phoenix directly where you will often get a discount.)

All this is to say that when I learned last year that Phoenix was publishing a new book he co-wrote with his son Dr Kevin Volkan, and that the book was on schizophrenia, about which I have been reading extensively since last fall, I was very excited and determined that I must read it, as I have now done, and also determined to interview the authors, as they have also now graciously consented to doing. 

Before turning to their thoughts, let me further entice you to order their new book Schizophrenia: Science, Psychoanalysis, and Culture by pointing out just two of its paramount virtues (and leaving you to discover the rest for yourselves): first, there is a consistent and wholly welcome modesty throughout the book. It is sometimes put about by lazy and uninteresting people (who are usually engaged in projective identification) that those of us who operate psychodynamically are hide-bound rigid ideologues rejecting all other forms of psychotherapy, from drugs to CBT to whatever this week's acronym du jour is. But, as you will presently read, while both Volkans (père et fils) are clearly steeped in psychoanalytic thought and approaches, they do not brandish any of that as a means of denigrating or dismissing pharmacotherapies and CBT. Time and again throughout the book one encounters--if you will--the "subjunctive mood" on many occasions. Their language is modest and quite sincerely so: regularly one reads that some people may be helped by some of the treatments examined here, but that no treatment is appropriate for everyone. There is no totalizing language here buttressing sweeping claims!

This is all embedded in a book whose first half looks at contemporary neurological and aetiological research into schizophrenia and acknowledges the use of psychotropics as being helpful, whether as stand-alones or as adjuncts to other therapies. It also examines CBT approaches and recommends some of those where appropriately indicated.

Second, and related to this first virtue, is the extensive attention paid--in the final quarter of the book--to cultural questions about the history, diagnosis, manifestation, and treatment of schizophrenia outside a middle-class American context in the early 21st-century. This too marks the book out as distinct in my (so far limited) experience in the field. 

With that in mind, let us turn to our two very distinguished authors and hear from them. 

AD: Tell us about your backgrounds

Kevin Volkan, EdD, PhD, MPH (KV) is a founding faculty member and Professor of Psychology at California State University Channel Islands. He also currently serves on the Graduate Medical Education faculty for the Community Memorial Hospital System in Ventura, CA, and as an adjunct faculty member for California Lutheran University’s clinical psychology doctorate program. 

Vamık D. Volkan, MD (VDV) is the author, co-author, editor, or co-editor of over fifty psychoanalytic and psychopolitical books. He is an Emeritus Professor of Psychiatry at the University of Virginia, Charlottesville and an Emeritus Training and Supervising Analyst at the Washington Psychoanalytic Institute, Washington, DC. In 1987, Dr Volkan established the Center for the Study of Mind and Human Interaction (CSMHI) at the School of Medicine, University of Virginia. He is the President Emeritus of the International Dialogue Initiative (IDI), which he established in 2007. 

As we say in the foreword of the book, we come from different but overlapping backgrounds. We give a more comprehensive overview of our backgrounds there.

AD: What led you to write this book on schizophrenia now?

VDV: Many individuals with this condition do not get enough or necessary treatment. Many are out there wandering around. It is important to bring attention to this mental/societal condition.

KV: Where I live in Southern California, we have an enormous homelessness problem. This is also true in many other parts of the country. Driving through downtown Los Angeles, it’s hard to believe that this is America. Conservative estimates are that around a third of the homeless population have severe mental illnesses – usually schizophrenia. 

So, although this disorder is a big problem, there has been little progress on how it is understood and treated over the last 50-100 years. The scientific understanding of the biological roots of schizophrenia has made great strides, but this has not yet translated into better treatment and care for people suffering from schizophrenia. 

But there are several new treatment possibilities on the horizon. Some of these new treatment methods include various types of psychotherapies. While psychoanalytic-derived treatments have been around for a while, these have not often been applied to psychotic individuals, especially in the United States. People like my dad have been working with those who suffer from schizophrenia in an in-depth way. He has learned a lot about schizophrenia and has important insights into how psychotherapy can be used to treat it. Our book is an attempt to communicate this insight as well as to document the state of schizophrenia research and treatment as it stands today.

AD: What is it like co-writing a book, especially as father and son?

VDV: One of the best things that ever happened for me. I felt very proud of my son, a great academician.

KV: Working on this book with my dad has been a wonderful experience. I was a bit nervous at first since he is such a luminary in the field. But the writing process went very well and was a chance for us to get to know each other and become closer.

AD: You note (p.19ff.) that cannabis use has been linked in a number of studies going back over a decade to increased rates of and risk for schizophrenia. Tell us a bit about some of those findings and your views on them. Given the increasing popularity and legalization of cannabis in North America, do clinicians need to be extra vigilant in screening for use? Are we as a society proceeding too fast in tolerating or even encouraging recreational use of cannabis?

KV: There are many studies that link the development of schizophrenia and cannabis use. The causal direction of the relationship is not entirely clear. For instance, do people who have a predilection to developing schizophrenia self-medicate with cannabis in a prodromal phase or do they use cannabis which then triggers the onset of psychosis? The latest research suggests that the latter is more likely especially among adolescents. Early age of cannabis use, and frequency of use seem to be predictive of significant risk for developing schizophrenia among vulnerable young people. 

Cannabis has not, as far as I know, been legalized anywhere for adolescents. Will legalization cause in increase in adolescent cannabis use? Maybe, maybe not. We are in the middle of a ‘natural experiment’. Will legalization cause a spike in first episode schizophrenia? A study by Vignault et al. in 2021 in Canada found that cannabis use among adolescents did increase when cannabis was legalized but did not seem to cause an increase in diagnoses of psychotic disorders (interestingly, there was a modest increase in personality disorder diagnoses). So, I think the jury is still out about the relationship of cannabis legalization to schizophrenia.

What I advise my undergraduate students and as well what I tell my clinical psychology graduate students to tell their patients is the following:

• Early cannabis use is bad. Children and adolescents should not use cannabis period, especially given the increased strength of the drug. 

• For people in their 20s there is some risk from cannabis use, especially if they are chronic users of strong cannabis. If there is no family history of psychoses and the use is occasional, the risk of developing schizophrenia is not zero, but is low.

• For people with a first-degree relative diagnosed with schizophrenia or another psychotic-adjacent illness they should not use cannabis at all. This is especially true for kids and young adults. 

• People who are diagnosed with schizophrenia or a psychosis adjacent illness should not use cannabis.

• Adults in their 30s -50s who do not have schizophrenia or something similar and who do not have first-degree psychotic relatives are not likely develop schizophrenia because of cannabis use.

• Adults older may find some cognitive benefit from cannabis use, again provided they do not have a schizophrenia or similar diagnosis.

These recommendations are speculative and subject to change when better research becomes available. (See Vignault, C., Massé, A., Gouron, D., Quintin, J., Asli, K. D., & Semaan, W. [2021]. The potential impact of recreational cannabis legalization on the prevalence of cannabis use disorder and psychotic disorders: A retrospective observational study. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 66, 1069–1076.)

AD: You mention (p.76) that Searles (whom I wrote about here) suggested clinicians treating schizophrenia need to pay attention to the counter-transference. But this theme is not much developed in the rest of the book. Would you want to elaborate some thoughts on that here?

VDV: The psychology of analysts and therapists undertaking intense work with people with schizophrenia needs consideration; for example, their ability “to regress in the service of the other” is crucial. The necessity of tolerance and therapeutic use of countertransference in treating patients with schizophrenia demands that the therapist meet the patient in his or her regressed state and, in a sense, validate it without intruding into the therapeutic space. The patient must feel that he or she is not alone in a strange place. This conduct helps change the patient’s regression from chaotic to therapeutic. Because of their own psychological make-up, certain analysts or therapists may be better equipped than others to use their personal responses to the patient’s primitive activities. Training is important, but most psychoanalytic institutes do not provide the necessary training.

AD: Your 13th chapter on object relations theory was one that I resonate deeply with. There, and in several other places in the book, you speak of schizophrenia patients as "object hungry." Would you elaborate a little bit on that concept for our readers?

VDV: The patient with schizophrenia is hungry for libidinal experiences, but this hunger is never satisfied. An attempt is made to collect "good" images in order to libidinalize the infantile and adult psychotic selves, but the patient also collects "bad" objects under the influence of repetition-compulsion, and certainly in the patients’ experience what is “eaten” as good might easily turn out to be bad.

Utilizing its available ego functions, the infantile psychotic self, like the early computer game character Packman, is doomed to “eat up” anything in front of it, without finding any food that is nourishing. The infantile psychotic self’s main ego function is internalization. 

But it also evacuates constantly what has been “eaten.” Therefore, its other main ego function is externalization. Here I am using the terms internalization and externalization to separate these functions from more sophisticated introjection and projection mechanisms in which there is some fit between what is projected and the target and between what is introjected and the reality of the object before it is taken in. Such fits do not exist in externalizations and internalizations. At times even these primitive ego mechanisms are not functional. The infantile psychotic self simply fuses with objects, only to separate from them.

AD: The number of chapters devoted to cross-cultural understandings of schizophrenia was itself hugely impressive, going far beyond what I've found in numerous other recent works. Why was it important for you to include this material?

KV: While the prevalence rates of schizophrenia are similar around the world, the ways in which it is related to specific cultures varies a lot. The relationship between schizophrenia and how specific cultures deal with the disorder can provide many insights into understanding, preventing, and possibly treating schizophrenia. 

These chapters also point out that there may be different kinds of schizophrenia with some versions having a more ‘physiological’ etiology (qi gong psychosis for example) with other versions deriving more from societal conditions (for instance Saora psychosis). The idea that people in the developing world are less likely to have subsequent psychotic breaks after their first episode has been floating around. This may be related to not being treated with antipsychotic medication on first presentation or may reflect something in the culture which provides some resilience. 

Additionally, there is a lot of research about the increased risk for schizophrenia among immigrants. Switching cultures may undermine cultural resilience in several ways. I am especially interested in cultural variation in early object relations as something that possibly can prevent schizophrenia from developing in people who have a propensity for the disorder.

AD: You note (pp.116-17) that it may be important for psychotherapists treating schizophrenia to have a more fully developed "potential for regression in the service of their patients." Would you elaborate a little bit on this? I'm wondering if it is similar to Harold Searles saying that therapists need to be in touch with their own psychotic elements when trying to treat schizophrenia?

VDV: When I was growing up on the island of Cyprus my paternal grandfather used a plow pulled by animals that thrashed the wheat. “Regression” was not a scary thing for me.

KV: I think we answered a lot of this question in the response to question 6 above. In essence regression allows us to walk with the patient in their experience without our countertransference getting in the way of this. One of my teachers calls this the ability to maintain dual consciousness – a regression into the chaotic unconscious of the patient while simultaneously maintaining a rational egoic consciousness that guides the therapeutic interaction. In my opinion, this requires a certain degree of talent that probably has to do with one’s early experiences. 

I can add that I have been involved with and studied several Asian religious and philosophical systems which include meditation as part of their practice. Most meditation techniques include some form of regression. Because of this experience I have not found working with people who suffer from schizophrenia especially difficult. I agree with my dad that training is important and training specifically to do psychotherapy (not behavioral or case management) with those suffering from schizophrenia doesn’t happen much. In a sense I was fortunate to begin my career working with people suffering from schizophrenia (I wrote a blog piece on this.) I also think that working with people who suffer from personality disorders like borderline personality disorder, etc., where the patient can experience temporary psychotic states, is also helpful in learning to treat schizophrenia. 

AD: I really found your concept of the "doughnut personality" (pp.86-89) insightful. Tell us a bit more about that.

VDV: I will focus on the patients’ descriptions of their changed personality soon after the loss of their existing personality. These patients, at least for a short time, describe a new personality, which I named a “doughnut personality.” My doughnut analogy refers to patients’ experience of an exaggeratedly fearsome or exaggeratedly idealized outer layer, which is the dough of the doughnut, and a middle part that is either perceived as empty or filled with unpalatable “bad” jelly. The patients experience the outer layer as a "monster" or the opposite, an "angel" (or some similar term) according to the degree this component is saturated with the derivatives of aggression or libido.

Several of my patients going into schizophrenia described the two components of a changed personality by comparing them to a doughnut. After a while, the outer component of the dough changes; a sense of extra omnipotence (megalomania) infiltrates the dough. For example, patients now declare that they are Jesus or another prophet, the greatest musician or the best terrorist. This corresponds to classical observations on the development of “world construction fantasies.” But here I am describing a new construction in these patients’ perceived sense of their internal world. When omnipotence settles, their references to the "bad seed" or "emptiness" seem to lessen a great deal or disappear altogether.

AD: Sum up your hopes for the book, and who especially would benefit from reading it.

KV: I’ll just repeat what I said in my blog piece: The book can serve as a textbook for graduate clinical psychology students, psychiatry residents, as well as students in counseling, clinical social work students, psychiatric nurse practitioners, and other mental health graduate programs. The book is also written for the lay reader who seeks to understand more about schizophrenia, as well as the theory and process of psychoanalysis and psychoanalytic-based therapies. 

AD: Having finished this book, Schizophrenia: Science, Psychoanalysis, and Culture, what do you both have in the pipeline next?

KV: I have been working on a book about demonic possession. This will be a predominately psychoanalytic exploration that will be an expansion of a paper I published recently. I am also working on a paper looking at the latest social cognition research on schizophrenia and its implication for psychoanalysis and psychoanalytic psychotherapies with people suffering from schizophrenia. My dad and I have talked about working on a book on psychoanalytic therapy that is based on work he has done in China, which would be a fun project.

Notes on Kernberg and Borderline Patients

I have of course been aware of Otto Kernberg's work for years, and read the occasional essay or article of his, but nothing more. Though he is well into his 90s now, Kernberg apparently has another book coming out this year, Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders. 

Kernberg is, and has been for decades, especially well-known for his pioneering efforts in transference-focused psychotherapy for borderline personality disorder. I have known of this work for a while but only recently had occasion to read some of it, starting with the chapter "Psychotherapy with Borderline Patients: An Overview," which is available free of charge at this wonderful site. What follows are my notes from reading Kernberg's overview, which is very cogently written and useful. (This was originally published in 1980, so I will expect to see later developments as I read more recent works by Kernberg and others on BPD.) 

Prevalence of Sadistic Transferences:

Though he is too elegant to say it, Kernberg early on issues what amounts to a blunt warning that will be echoed several times: prepare for hard and painful sailing. This is likely to begin almost immediately--no leisurely leaving of harbor in bright, sunny skies for this therapy! Thus he notes that after psychotherapy has begun, there will be increased effort by the patient "to defend himself against the emergence of the threatening primitive, especially negative, transference reactions by intensified utilization of the very defensive operations which have contributed to ego weakness in the first place. One main 'culprit' in this regard is probably the mechanism of projective identification" (p.20), which of course goes back to Melanie Klein.

The transference will be one of intense distrust of the therapist and an attempt to "control" him in a "sadistic, overpowering way" (21). The patient's aggression and attempts to control will, Kernberg calmly warns, almost certainly provoke a counter-transference respond of like kind. 

But the relationship will not be steady or move in one direction only. The inner instability means that borderline patients tend to oscillate (sometimes rapidly in the same session) between projecting object representations and self-representations. Kernberg gives the example here of "a primitive, sadistic mother image may be projected onto the therapist while the patient experiences himself as the frightened, attacked, panic-stricken little child; moments later, the patient may experience himself as the stern, prohibitive, moralistic (and extremely sadistic) primitive mother image, while the therapist is seen as the guilty, defensive, frightened but rebellious little child" (p.21).

Breakdown of Ego Boundaries and Possible Psychosis:

Such oscillations bespeak a breakdown of ego boundaries and reality testing. Its most severe form is something Kernberg strikingly calls a "transference psychosis" in which delusional material appears that does not, however, appear to affect the patient's functioning outside of session.

Slow Progress and Shallow Pseudo-Insights:

The acting out of the transference is the biggest obstacle to progress, according to Kernberg. The transference very closely mirrors past conflicts. But do not, he cautions, mistake repeated transference material and manifestations for "working through." The repetition of these dynamics may in fact be precisely as a means of getting sadistic needs met through and from you and doing so in a way that overruns your capacity to "maintain a climate of abstinence" (23).

Don't fall for false and shallow insights! If the insight comes without three things Kernberg highlights--effort, change, and concern by the patient for the obvious pathology--it won't count for or do much. Authentic insight is a combination of the intellectual and emotional and it takes some work and costs something. 

The Here and Now:

Point out transference reactions regularly in the here-and-now without trying to link to the past, as the patient probably has little capacity for that. 

Firm and High Boundaries:

You must as therapist maintain firm and high boundaries to preserve neutrality and your freedom to act. Do not allow extra sessions, or running over, or extra calls, etc. The patient's acting out of a transference of neediness must be contained as much as possible by and within the session.

Three Steps to Handling Transference Material:

Transference, Kernberg recognizes, ordinarily reflects infantile object relations and the infants needs, defenses, and deprivations. These can usually be discerned as semi-coherent at least. 

Not so with BPD: it's just fragments and extreme distortions all the time. Your job is to take the baseless distortions and move them closer to actual experiences and reality in childhood. This is not easy as such patients cannot integrate libidinal and aggressive impulses and representations. Massive splitting is found here with strong defenses against integrating good and bad objects.

The work here may take years. It has three steps for the therapist:

First, you need to help reconstruct and evaluate, from the fragments and chaos, what "is of predominant emotional relevance in the patient's present relation with him [the psychotherapist], and how this...material can be understood in the context of the patient's total communications" (p.27).

Second, seek to clarify emerging self and object images and the interaction between them.

Third, surface and begin to integrate other part self objects, leading to greater unity of the true self.

Summed up, these three steps entail "integration of self and objects, and thus of the entire world of internalized object relations, is a major strategic aim in the treatment of patients with borderline personality organization" (p.28). 

Three Types of Negative Therapeutic Reaction

Repeatedly Kernberg lets the reader know this work will be slow-going at best. BPD patients may go for years with little change, and a lot of negative therapeutic reaction may regularly be present which thwarts change. Most of this shows up in attacks on the therapist driven by:

1) masochism and guilt at the unconscious level;

2) envy and the need to destroy the therapist because of it;

3) primitive sadism and the need to destroy the therapist because object relations can only be maintained in a situation of suffering.

All these, Kernberg says, reveal the "deepest levels of human aggression" (p.35). Such aggression is not at all above trying to destroy the therapist's love with cruelty, which is projected onto the therapist. 

Overcoming Attacks and Threatened Collapses:

Such negative reactions and threatened collapses may be alleviated by four things Kernberg recommends:

1) Extended patience over the treatment but decisive impatience in the session directed at any attempts to attack the work. The patient's acting out of severe aggression needs to be actively countered by the therapist without loss of neutrality.

2) Though he doesn't quote him here, Kernberg's second counsel puts me in mind of Winnicott's famous "Hate in the Counter-Transference" paper where he says you must get a firm grip on and be able to contain your aggression and not let it become action, but only fruit for reflection. The temptations here, however, will be considerable, and the risk of counter-transferential enactments a regular danger. 

3)  Kernberg has an interesting point I've not seen elsewhere about BPD and the relationship to time. He says that as therapist you need to "focus sharply on the patient’s omnipotent destruction of time. The therapist needs to remind the patient of the lack of progress in treatment, to bring into focus again and again the overall treatment goals established at the initiation of treatment and how the patient appears to neglect such goals" (p.36). Balance this by sharp focus on immediate reality.

4) Finally and consistently you need to interpret all attempts at destroying the patient's life and treatment. (He says elsewhere that in any given session the order of items addressed must always be, first, any suicidal ideation or attempts; second, any attacks on the treatment; and third anything else the patient brings up.)

Counter-Transference Reactions:

Rather early on you will experience a sense of chaos from the patient. That makes the counter-transference "an important diagnostic tool," allowing insights into that chaos and into the degree of regression in the patient, their emotional relationship to you, and any changes in that relationship (p.37).

In general, Kernberg cautions the psychotherapist, you should expect to react sooner, and more intensely and chaotically, than with just about anybody else (outside of psychosis). You will get a sense of primitive object relations here. 

Accept Ambivalence Everywhere:

Finally--and wisely, it seems to me--Kernberg says that you must accept your own ambivalence, and recognize its prevalence in all human relationships, which is precisely something the BPD patient often struggles greatly with: "the therapist’s thoroughly understood awareness of the aggressive components of all love relations, of the essentially ambivalent quality of human interactions, may be a helpful asset in the treatment of extremely difficult cases." (p.40).