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).