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Clinical Social Work JournalVol. 27, No. 1, Spring 1999
KERNBERG VERSUS KOHUT:A (CASE) STUDY IN CONTRASTS
Gildo Consolini, MSW
ABSTRACT: In this paper, the main concepts of Otto Kernberg and
HeinzKohuttwo theorists who have greatly influenced clinical social
work practicewith severely disturbed patientsare presented, and
then compared by using acase from the practice of the author. The
case illustrates the value of utilizingsome of the treatment
principles put forward by Kernberg and Kohut withoutbecoming too
wedded to either of the overall treatment approaches they
haveformulated. Some aspects of the manner in which the
practitioner determineswhen the treatment approach needs to be
modifiedto avoid the pitfalls of ei-ther being too wedded to an
approach or too eclecticare discussed as well.
KEY WORDS: borderline personality disorder; narcissistic
personality disor-der; self psychology; countertransference;
self-analysis.
For more than two decades the two theorists who have had
thegreatest influence on psychoanalytic thinking about patients
with moresevere psychopathologywith the possible exception of
Harold Sea-rleshave been Otto Kernberg and Heinz Kohut. Both
Kernberg andKohut applied psychoanalytic theory to the treatment of
patients oftenconsidered unsuitable for analytic treatment by those
working from aclassical analytic perspective. However, their
conclusions about the eti-ology and psychic structure of borderline
and narcissistic psychopathol-ogy, as well as the optimal treatment
approach, are very different.
Kernberg is considered a conflict theorist, who, like other
Americanobject relations theorists, has retained the use of the
concept of instinc-tual drive along with other aspects of Freudian
metapsychology; thisplaces Kernberg in the psychoanalytic
mainstream. He wrote exten-sively about both borderline and
narcissistic psychopathology.
Kohut, on the other hand, made a more radical break with the
clas-
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sical tradition; he eventually rejected many classical
conceptualizationsand, with the help of his followers, developed
his concepts about narcis-sism and the self into its own schoolself
psychology. Although Kohutwas not optimistic about self
psychological treatment of the borderlinepatient (Kohut & Wolf,
1978) and he focused primarily on the treatmentof narcissistic
disorders, many analytically oriented clinical social work-ers and
other analytically oriented psychotherapists rely heavily uponself
psychological theory and treatment principles in their work
withborderline patients.
In the first part of this paper, the main concepts of both
theoristswill be presented and compared. In the second part, a case
will be pre-sented which will demonstrate the value of utilizing
some of the treat-ment principles established by these theorists
while at the same timeattempting to develop an individualized
approach attuned to the emo-tional needs of a rather troubled and
difficult patient. As Goldstein(1990, 1995) has indicated, the
therapist attempting to help patientswith more severe difficulties
who is too wedded to any one particularapproach runs the risk of
misattunement that will destroy any hope fortherapeutic benefit. In
the final part of the paper some aspects of themanner in which the
therapist determines when the treatment ap-proach needs to be
altered will be discussed.
OTTO KERNBERG
Prior to the influence of Kernberg, the symptomatology of the
bor-derline patient was not seen by most analytic writers as the
result of astable pathological structureits transient nature was
emphasizedand a more supportive treatment approach was generally
recommended.
Although Frosch (1970) described the borderline patient as a
"psy-chotic character," that is, as someone with a range of modes
of ego adap-tation and responses to stress that is enduring and
predictable, Kern-berg went beyond this with his metapsychological
explanation. WhileStone (1954) recommended a cautious analytic
approach using parame-ters to maintain a positive transference,
Kernberg advocated an ap-proach involving the use of traditional
analytic methods, such as inter-pretation and the analyst's
abstinence, that is far from cautious.
In his 1967 paper and 1975 book, Kernberg established his
positionthat borderline patients have a relatively stable form of
psychic organi-zation, a pathological ego structure that is
distinctively different thanthe ego structure found in either
neurosis or psychosis. He believes thatvery early in development
the ego must not only learn to distinguish theself from othersthe
task of differentiation of self- and other-represen-tationsit must
also integrate "affectively polarized" self- and object-
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representations. Unlike the psychotic, the borderline is able to
establishboundaries between the self and others (though not without
difficulty,especially in the areas of intimate emotional and sexual
relations). How-ever, while the neurotic is eventually able to
integrate idealized "allgood" and devalued "all bad" objects in the
course of development, theborderline cannot.
In the case of the borderline, self- and object-representations
builtup under the influence of libidinal drive derivatives are not
integratedwith self- and object-representations built up under the
influence of ag-gressive drive derivatives by the ego, therefore
requiring this ego to relyheavily upon the defense mechanism of
splitting. Unlike the neurotic,who relies primarily upon repression
to handle ambivalence, the bor-derline relies primarily upon
splitting, reinforced by denial and the useof projective
mechanisms.
Why is it that the ego of the borderline must rely primarily
uponthese "primitive" defenses? Although Kernberg uses traditional
Freud-ian energic concepts (drive energy is identified as the force
which pro-pels the individual in the direction toward and away from
objects) herelied heavily upon the work of object relations
theorists who locate theetiology of many forms of psychopathology
during a much earlier periodof development than did Freud. Kernberg
follows Klein (1928, 1939,1946, 1957) in his view of the importance
of splitting and projectiveidentification as the defenses that
develop early in life that are reliedupon by the borderline, as
well as the role of destructive envy in thenegative therapeutic
reaction. Kernberg's view of the ego's early devel-opmental tasks
is similar to that of Fairbairn (1954), who postulated acritical
first structural achievement whereby the infant is able to
pre-serve within the ego his or her internalized mother as a whole
personfrom his destructive impulses.
By specifically locating the fixation during the
rapproachementphase of separation-individuation (Mahler, 1971),
Kernberg is able toidentify the source of the borderline's unstable
self concept, lack of objectconstancy, overdependence on external
objects, and preoedipal influenceon the oedipus complex. Kernberg
also benefited from the work of Jacob-son (1954, 1964), who
preceeded him in combining the use of energicconcepts with object
relations concepts to explain more severe psycho-pathology.
Kernberg recommends an approach to treatment of the
borderlinepatient that appears consistent with his traditional
orientation and the-oretical formulations; he recommends in most
cases an analytic ap-proach (with parameters to provide missing
structure to those with es-pecially chaotic lives) that calls
primarily for interpretation focusingupon the defensive splitting
by the patient within the transference. Theanalyst is advised to be
neutral and abstinent as he confronts the pa-
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tient with his or her destructivenessthe oral aggression of the
patientmust never be ignored.
Kernberg believes the approach he advocates will eventually
enablethe patient to modify the pathological structure because it
will lead tothe integration of the split-off affectively-charged
self- and object-repre-sentations within the ego and the formation
of a more benign, less puni-tive superego (the ego will not be
tormented by the more hostile preoedi-pal superego precursors).
Kernberg discourages the use of supportivemeasures since he
believes a supportive approach maintains the patho-logical
structure, leading to an interminable treatment.
Kernberg (1970, 1974) believes that these same treatment
prinici-ples apply to the narcissistic personality since his view
is that there isan underlying borderline organization to this
personality. He views theapparent better social functioning of the
narcissist as a superficial adap-tation that conceals severely
maladaptive behavior stemming from patho-logical internalized
object relations. He also believes there is an underly-ing
borderline organization to other personality syndromes,
includingschizoid and antisocial character disorders, as well as
certain cases ofsubstance abuse, alcoholism, and sexual
perversion.
HEINZ KOHUT
Although trained classically and at one time president of the
Ameri-can Psychoanalytic Association, Kohut eventually so departed
from tra-ditional Freudian theory and treatment principles that he
and his fol-lowers developed a new psychoanalytic schoolself
psychology.
Following Freud (1914), most analysts believed patients who
wereunable to develop transferences like those typically seen in
cases of neu-rosis could not be analyzedtheir self-involvement was
too great to al-low transferences to develop. Kohut (1966, 1971)
observed that it wasnot that narcissistic patients were unable to
develop transferences butthat they developed different kinds of
transferences than did neurotics.These he identified as variations
of "selfobject transferences."
Whether it was an "idealizing," "mirror," or "twinship"
transferencethat developed, the analyst's task was to use the
particular transferenceas a clue to determine the vital selfobject
functions he or she was beingasked by the patient to provide,
functions not provided by the originalselfobjects. Due to their own
narcissistic problems, the original self-objectsin most cases, the
parentslacked sufficient empathy to recog-nize and satisfy the
healthy narcissistic needs of these individuals dur-ing their
childhoods. As a result, a healthy "cohesive self fails todevelop.
Instead, pathological self states develop, such as the
"frag-mented" or "overburdened" self.
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Kohut (Kohut & Wolf, 1978) understood the self to be the
nuclearcore of the personality, an enduring psychological structure
in and ofitself rather than simply a mental representation within
the ego. Heidentified the "constituents" of the self as 1. the
"pole of goals and ambi-tions" from which emanate basic strivings
for power and recognition; 2.the "pole of ideals and standards"
which maintains the ideals whichguides one through life; and 3. the
"arc of tension" between these twopoles that activates the basic
talents and skills of the individual. Theseconstituents emerge into
an enduring self structure through the inter-play of inherited
factors and the influence of the environment.
The self is seen as the center of initiative, the recipient of
impres-sions, and the depository of the ambitions, ideals, and
skills of the indi-vidual. The patterns of these ambitions, ideals,
and skills, the tensionbetween them, the activity generated by
them, and the responses of theenvironment that shape the life of
the individual are all experienced ascontinuous in space and
timethis provides the individual with his orher sense of selfhood.
The individual comes to experience himself or her-self as an
independent center of initiative and processor of
impressionsreceived from outside the self.
As his thinking about the etiology of narcissistic disorders
evolved,Kohut ultimately decided he no longer required
metapsychological con-cepts to explain how these disorders develop.
He discarded the primarydrive nature of aggression, distinguishing
between ordinary aggres-sionwhich he understood to be the healthy
forcefulness the cohesiveself uses to eliminate an obstacle to a
realistic goaland narcissisticrage, an intense reaction to
narcissistic injury.
Kohut postulated a line of development for narcissism that is
dis-tinct from that of object love, in contrast to Freud's
progression in devel-opment from primary narcissism to mature
object love; this formulationenabled him to identify various
transformations of narcissism, such asmature humor, creativity, and
wisdom. He contrasted the aims of "guiltyman" with those of "tragic
man," the latter seen as someone striving forfulfillment in
endeavors beyond the pleasure-seeking and sublimationsmade possible
through the resolution of neurotic conflict. What makesthis quest
tragic is that humanity's limitations are inevitably recognizedwhen
one pursues these endeavors.
Kohut's is a theory of developmental deficit, which therefore
callsfor the analyst to work in a very different way than the
analyst whoadheres to the theory which views intrapsychic conflict
as the source ofpsychopathology. For the self psychologist, empathy
is not only the prin-cipal means of investigation, it is the
primary therapeutic instrument.The analyst immerses himself or
herself, through his or her empathy, inthe patient's subjective
experience while seeking to maintain attune-ment to the selfobject
needs of the patient. Although this is considered
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in and of itselfto be therapeutic, the inevitable "empathic
failures" onthe part of the analyst are also handled in such a way
as to promotefurther healing. First, the analyst must discern how
he has injured thepatient so that he can intervene in such a way as
to restore the selfobjecttransference. The analyst can then use
what he learns through furtherexploration to connect the current
experience of narcissistic injury withthe original injury inflicted
by the selfobjects during childhood.
A more cohesive self is developed as a result of "transmuting
inter-nalizations;" the analyst's optimal, nontraumatic frustration
of the pa-tient leads to structure formation since the self can now
more easilytolerate disappointment. Although the need for
selfobjects continuesthroughout life even in the healthiest of
individuals, the self can nowperform vital selfobject functions in
the absence of the experience withthe selfobject.
KERNBERG VERSUS KOHUT
Kohut believed that the borderline patient often lacks the
resilienceto benefit from analytic treatment; he believed that in
some cases"reconstructing the genesis of both the central
vulnerability and thechronic characterological defence" could help
the borderline to relysomewhat less upon their maladaptive defenses
(Kohut & Wolf, 1978, p.179). On the other hand, the
"significantly more resilient self of the"narcissistic behaviour
disorders" and the "narcissistic personality disor-ders" generally
makes an analytic approach possible with these disor-ders.
When Kernberg discusses treatment of narcissistic personalities
heis discussing the same patients as does Kohut, as Kernberg
himself hasindicated (Kernberg, 1974). Both men focus their
attention upon the"grandiose self," however, it is hard to believe
that the respective expla-nations of the psychopathology associated
with this clinical picture orthe treatment approaches advocated
could be more different, as has al-ready been indicated.
Kernberg sees the emergence of the grandiose self as a
pathologicaldevelopment that must be modified to achieve mental
health; he be-lieves it is imperative to confront the narcissist
with the defensive ma-neuvers he or she employs to maintain
split-off good and bad self- andobject-representations. If the oral
aggression which fuels this defensiveactivity is not addressed
directly, modification of the pathology is impos-sible. An ego
ideal is maintained that continues to torment the psyche;more
realistic, less punitive aspects of the parents are not
incorporatedwithin the superego since the much less benevolent
superego precursorsretain their hegemony within the psychic
structure.
In the view of Kohut, since the presence of the grandiose self
indi-
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cates that there has been an arrest in the development of the
nuclearself, treatment should be geared to encouraging the
narcissistic aspira-tions and needs of the patient to unfold fully
in the transference. Thisunfolding will enable the patient to
develop a more cohesive self withthe support of the analyst, who is
able to provide the vital selfobjectfunctions that the original
selfobjects were unable to provide to the de-veloping self of the
child. If the focus on all that which threatens theemergence of the
self is not maintained, it will not be possible to achievehealth
since an enfeebled self will remain, making true mental healthan
impossibility.
Kohut clearly identifies the environment as the source of
distur-bance for these personalities while Kernberg is equivocal in
implicatingconstitutional factors along with environmental factors.
Although thelatter identifies a stronger aggressive drive and a
"constitutionally de-termined lack of anxiety tolerence in regard
to aggressive impulses" ascontributory, he also has identified the
presence of a mother or mothersurrogate who functions well on the
surface yet treats the child coldly,with very little regard for his
or her emotional needs (Kernberg, 1970,pp. 219-20).
Kernberg believes that the presence of an underlying
borderlinepersonality organization in the narcissist mandates his
modifying ap-proach, while Kohut's approach is consistent with his
view that the nar-cissist suffers due to developmental arrest. For
Kohut, the narcissisticagenda of the patient which emerges in the
treatment situation reflectshealthy narcissistic aspirations and
needs that were thwarted by theparental figures during childhood
and, therefore, it is imperative thatthe analyst support the
emergence of this agenda so that it can eventu-ally be
transformed.
Thus, as has been indicated throughout this paper, similar
clinicalphenomena are understood and addressed very differently by
Kernbergand Kohut. At the same time, the psychoanalytic discourse
has beengreatly enriched by these theorists since each has been
able to go fur-ther than did Freud in attempting to explain why
some patients do notbenefit from analytic treatment.
While Freud identified a "narcissistic attitude" of some
patientswhich "limits their accessibility to influence" in
treatment (Freud, 1914,pp. 17-18), he left it to others to develop
the clinical implications of thisobservation. Before Kohut, the
transferences which develop in treat-ment of the narcissist were
not described very well. Also, it seems thathis work has led to a
generally less judgemental attitude toward thenarcissistic
manifestations seen in many patients, not just those whopresent
with obvious narcissistic pathology. Furthermore, the role of
em-pathy in treatment is much more fully understood and accepted as
aresult of the work of Kohut and those who further developed his
ideas(Goldstein, 1990).
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Both Kohut and Kernberg encouraged manifestations of
narcissismto be brought into the treatment situation. The more
traditional ap-proach to these manifestations encouraged a
repudiation or control ofthe narcissistic agenda of the patient
which insured that, in most cases,this agenda would not become
available for analytic investigation. Eachhas also made significant
contributions to the understanding of thecountertransference
reactions typically evoked by borderline and narcis-sistic
patients. It seems that there are patients who are now able
tobenefit as a result of the contributions of both theorists,
however, itseems to this author that one can do more harm than good
if one is toowedded to either approach.
Although Kernberg claims that his recommended approach placesthe
analyst in an objective, neutral position, his emphasis upon oral
ag-gression does not seem either totally objective, in terms of the
under-standing of the pathology, nor neutral, in terms of the
handling of theaggression that develops within the treatment
situation. Kohut indi-cates that development can be severely
arrested much later in childhoodthan Kernberg indicates (1979).
Others have also questioned Kernberg'sidentification of the source
of disturbance as exclusively preoedipal(Abend, Porder &
Willick, 1983). It does not seem hard to conceive that apatient who
was treated exclusively in the manner Kernberg advocateswould
experience the therapist as anything but neutral, that a
patientcould become so alienated by this approach that important
materialcould be withheld from the therapist and, in the worst
case, the treat-ment could have as iatrogenic effect (Brandchaft
& Stolorow, 1984).
With respect to Kohut, it does not seem hard to imagine that
anexclusive reliance upon his self psychological approach could not
onlyprevent a patient from recognizing and coming to terms with his
or heraggression, it might also encourage the patient to hurt
othersand ulti-mately himself or herselfthrough hostile behavior
emanating from asense of entitlement that has been unintentionally
promoted by thetherapist. In the case presentation which follows,
the therapist's effortsto navigate between the Scylla of ignorance
of the hostility of the patientand the Charybdis of the ignorance
of the patient's libidinal needs willbe highlighted.
CASE ILLUSTRATION
Doug is a 33 year old white, Jewish male who entered treatment
with theauthor three years ago, following Doug's break-up with his
fiancee, Eileen. Atthat time, Doug described himself as vacillating
between periods of intense an-ger and debilitating depression, the
former which he attributed to the insensi-tive manner in which he
had been treated by Eileen, and the latter to his dis-couragement
about finding someone who could satisfy his perceived needs for
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nurturance of his artistic aspirations and for an intensive and
thoroughly excit-ing sexual relationship. Doug had been in
treatment previously, for less than ayear, with a female therapist;
he reported that she had helped him quite a bituntil she began to
become more "confrontational" with him. He was unable toelaborate,
but indicated that the ending of that relationship also left him
withstrong feelings of indignation and discouragement.
While still involved with each other, Eileena school
psychologist who wasworking on her doctoratehad encouraged Doug to
get back into treatment.Characteristically, Doug felt this was an
effort on her part to use her knowledgeof therapy to control him
rather than help him. He resisted this idea until theybroke up.
Doug has a history of drug and alcohol abuse and seemed
genuinelyfrightened that he would return to abuse of cocaine and
alcohol to cope with hisdistress about the break-up.
Doug's parents were divorced when he was eleven years old. He
has a sisterthree years older who is perceived by him to be the
favorite of his father. Doug'sprimary aspiration is to become a
famous blues and rock composer, guitarist,and group leader; while
waiting for this to happen, he is working for his fatherin his
father's business. In contrast to his sister, a successful attorney
who ismarried with two children, Doug reported that he is the
"black sheep" of thefamily. He had not gotten very far with
college, dropping out well before comple-tion of his degree.
It seemed that an empathic, nonjudgemental approach on the part
of theauthor initially fostered the development of enough of a
therapeutic alliance tokeep Doug in treatment. He came in for some
extra sessions, and for a time cametwice per week. It seemed that
his anger diminished somewhat and enabled himto concentrate better
at his job and devote more time to his music. His fatherhad been
very unhappy with Doug's work performance, since Doug
frequentlymissed work or came in very late because he had been
"partying" the night be-fore. Because he was able to stop doing
this, Doug was no longer being threat-ened with being let go by his
father, who seemed to be someone volatile enoughhimself to do
this.
The treatment "honeymoon" (Fine, 1982), however, was
short-lived, in partdue to the author's winter vacation, which took
place after six months of treat-ment. During the author's vacation,
Doug consulted another therapist, some-thing he rationalized as
necessary because of the very difficult time he had whilethe author
was away. He reported he had difficulty not because he missed
theauthor or was unable to rely upon him for assistance during the
vacation, butbecause the author had not helped him enough prior to
the vacation. His sisterhad encouraged him to see someone else and
had given him the name of thetherapist he consulted. He might have
continued with this other therapist, Dougtold the author, were it
not for the fact that he was "getting a better deal" withthe
author, who was a provider in the managed care network used by his
insur-ance company.
As others have indicated (e.g., Maroda, 1994), use of the self
psychologicalapproach in the initial phase of treatment is
oftentimes quite beneficial to bothpatient and therapist. The
sustained empathic inquiry called for in this ap-proach does much
to establish basic trust on the part of the patient in the
rela-tionship. Not only does the patient experience the relief of
"getting things off his/her chest," but he or she feels genuinely
cared about in the process of doing so.The therapist learns much
about the patient's life because the patient feels safeand is eager
to produce material to please the therapist.
Although the above approach may be instrumental in enabling
patients like
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Doug get started, a different approach is required to address
difficulties thatinevitably develop when a stage of dynamic
conflict develops in the transference.At that point in treatment
with patients like Doug the therapist benefits greatlyby turning to
Kernberg for guidance. The author decided Doug's devaluation ofthe
therapist (as a means of dealing with split-off negative self- and
object-repre-sentations) needed to be confronted. Attempting to
explore the libidinal aspectsof this behavior at this point were
unsuccessful. When Doug was asked, "What isit that you need from me
that I haven't been able to give you?" he was not able tosay very
much about what it was he wanted from the author.
Doug began to harass Eileen, insisting that she should give
their relation-ship another chance. He attempted to make contact
with her and, when sheattempted to let him know that she had been
quite serious about ending theirrelationship, he became rather
nasty with her and began to shadow her whileEileen was with her new
boyfriend. He would park near her house when herboyfriend's car was
in the driveway, near enough so that Eileen could easilyrecognize
Doug's car. Doug also began spending more and more time
drinking,smoking pot, and watching pornographic movies as well as
having sex with pros-titutes on a weekly basis. The author
encouraged Doug to contact him when hefelt compelled to do these
things, especially following calls made to the author byEileen, who
at first threatened and then eventually went ahead and called
thepolice to complain about Doug. Doug never called the author
during any of thesetimes.
Instead, in addition to hearing from his ex-fiancee, Doug's
mother called theauthor to express her concern about him and to
insist she should come in to meettogether with Doug and the author.
She asked the author during the call toreassure her that "my son is
not suicidal." Although his mother was invited tocome in by herself
(after her call was discussed with Doug) Doug was
eventuallypersuaded to see how important it was for him to preserve
his individual treat-ment. He had initially felt that he had no
alternative but to accede to hismother's request, which he had
experienced as another demand on her part tomake her feel better,
not help him.
Doug initially did not feel that there was anything that really
needed to bediscussed about these matters, prior to the author's
questioning of his motivesfor defeating the therapy. Although he
was initially somewhat confused and an-noyed by this questioning,
he eventually admitted that he felt entitled to dowhatever he could
to make himself feel better and have more successful
relation-ships, no matter what the author thought. The author was
able to then point outto Doug that he was acting the same way with
the author as he acted in hisrelationships with women.
It seemed that this approach at this particular point in the
therapy wasnecessary to preserve the therapy, that these
interpretations, the limit-setting,and the frustration of what this
patient asked for allowed the treatment frameto be preserved. There
were times, for example, when Doug would use his ses-sion time to
ruminate about the psychological reasons for his behavior,
whileappearing to be somewhere else emotionally. At such times, the
author com-mented about how abstract he sounded and asked him what
was really bother-ing him. Although Doug was initially also put off
by this observation and ques-tion, it helped him eventually to
focus more easily upon what he was feeling.This kind of
intervention corresponds to Kernberg's notion of attending to
theneed to develop structure, as opposed to allowing a monologue
resembling freeassociation take the patient further away from that
which he was feeling, espe-cially any anger he might be
experiencing.
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Despite all this, it became necessary at another point to shift
gears onceagain and adopt a more tolerant stancein relation to
Doug's grandiose aspira-tions. The author became aware that when he
was using Kernberg to under-stand and address Doug's devaluation of
the author and very strong sense ofentitlement, he began sessions
himself feeling rather irritated with Doug andindignant about the
manner in which he was being treated by Doug. At times, itwas
difficult to hear themes in the material other than Doug's ruthless
incor-poration of the author and others. Self-analysis of the
author's counterresistanceto allowing other material to emergea
process which included discussion of thecase with a
colleagueenabled the author to realize that the transference
hadbecome more positive and therefore there was much less need at
that point toconcentrate on the patient's aggression.
Kohut has stated quite clearly that challenging the patient's
grandiosity isnot only a useless endeavor, it will likely compel
the patient to suppress verypowerful wishes and thus make them
inaccessible to modification. Doug can beaccurately and usefully
described as "mirror-hungry." The author decided that itwas
important to attend in a particular way to manifestations of this
hungerwhich developed in the transference.
Doug began to bring in notebooks filled with many, many pages of
histhoughts and feelings about his struggles with women and his
music, somepages of which he had copied and had attempted
(unsuccessfully) to get Eileenand other women he pursued to read.
It became clear to the author that it wouldbe necessary to gratify
some of that which Doug wished for in asking the authorto listen to
him read from these notebooks. The author initially simply
listenedas Doug read, indicating interest in those passages which
expressed strong feel-ing or indicated developing insight.
Eventually, Doug was encouraged to discusshow he felt it was
helping his therapy to do thissomething that was done in
asnonjudgemental a manner as possible to indicate the interest of
the author inwhat Doug wanted from him rather than what Doug was
resisting by relating inthis manner.
Later on, Doug began bringing in self-help books to discuss with
the author.He was encouraged to talk about what he had discovered
which resonated withhim. This approach helped Doug see how much of
his behavior, included its intel-lectualized aspects, was connected
with his wishes for attachment with othersand how upset he could
become when his wishes were frustrated. As a result,Doug has
developed enough insight and frustration tolerance to stop
harassingnot only his ex-fiancee but another woman he dated for a
few months, to signifi-cantly cut back his drinking and pot use,
and to end his dependence upon por-nographic movies and prostitutes
for sexual excitement and pleasure.
Eventually, Doug was able to approach dating in a very different
way, bothwith respect to the choices he made about whom to date and
how he behavedwith those with whom he attempted to connect.
Initially, he attempted to date aprostitute he had seen on a
regular basis. When the fantasy of where this wouldlead was
analyzed, he ended this quest. He proceeded to date a series of
unavail-able womentwo married women and a very troubled young woman
who even-tually scared Doug off with her sadomasochistic sexual
proclivitiesbefore at-tempting to connect with more suitable women.
By the time of the writing of thispaper, Doug had been involved
with someone for several months who seemed amuch better choice as a
partner. He was able to use much of his session time totalk about
his mixed feelings about committing himself in an intimate
relation-ship, rather than impulsively acting out his negative
feelings.
During that time, the author realized that although the
transference had
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become more positive overall, he was neglecting to address
indications that Dougwas not just having difficulty with intimate
relations with his girlfriend, thatDoug was struggling with similar
feelings in the transference. The author recog-nized that he was
struggling himself with feelings in his counter-transference
toDoug. How else could he explain his delay in discussing some
obvious indicationsthat Doug was feeling displeased with the
author?
Through self-analysis, the author was able to see that he was
using theoryto rationalize an approach to his patient that, at this
particular time, stemmedmore than anything else from his
counter-transference. As Doug began making ahabit of arriving ten
to fifteen minutes late for his appointment, paying his billlate,
and shaking hands with the author at the end of the session, the
authorrationalized that confronting Doug with this behavior was not
necessary. Essen-tially, he allowed himself to believe that empathy
was enough.
Of course, the truth was that the author was feeling
uncomfortable aboutdealing directly with Doug's disappointment,
very powerful sense of entitlement,and anger. When the author
realized he was resisting the analysis of these feel-ings in the
transference, he was then able to confront Doug tactfully. That is,
theauthor was then able to bring the behavior to Doug's attention
and in an empa-thic manner to explore the feelings which motivated
the behavior. As the anal-ysis proceeded, Doug became more aware of
the kind of relationship he wished tohave and not have with the
author. He became much more comfortable as wellwith his
girlfriendhe began to feel less deprived and controlled in both
rela-tionships.
DISCUSSION
The clinical vignette presented above illustrates the value of
utiliz-ing the contributions of both Kernberg and Kohut, based upon
thatwhich may be needed by one's patient at various points in
treatment.Both theorists have advanced psychoanalytic thinking
about borderlineand narcissistic psychopathology and treatment.
However, it is impera-tive that the therapist recognize that what
is needed by his or her pa-tient may change significantly as the
treatment proceeds (Pine, 1988).Therefore, the therapist needs to
make a corresponding shift in his orher approach. Perhaps those
with a background in social work, with thesocial worker's
appreciation of the situational factors associated
withpsychological distress, are especially adept in this
regard.
The kind of treatment situation presented above is commonplace
formany clinical social workers. Clinical social workers who are
analyt-ically oriented attempt to develop effective analytic
approaches to helppatients who are both very troubled and very
demanding. Althoughguided by their analytic knowledge and convinced
of its usefulness, theclinical social worker must recognize the
fact that most people now comefor "help" rather than for "analysis"
(Herbert Strean, 1993, personalcommunication).
Both Kernberg and Kohut have received much praise for their
con-tributions, as well as a great deal of criticism for developing
points of
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view which challenge mainstream psychoanalytic thinking.
Unfortu-nately, there has been a tendency within psychoanalysis to
engage in awholesale embracing or repudiation of different points
of view whichseems similar to the defensive splitting employed by
very troubled pa-tients to ward off the anxiety associated with
taking in the analyst as areal person. Instead, the analyst is
experienced as either "all-good" or"all-bad" rather than as a real
person who, despite his or her very realhuman limitations, has
something very valuable as well as very real tooffer in the
analytic relationship.
Although many classially trained analysts would regard self
psy-chologists, along with many others, as heretics (in Bergmann's
[1993]usage of the term), there have in fact been a number of
important con-tributions made by theorists who have either somewhat
covertly (e.g.,Winnicott) or quite overtly, (e.g., Klein)
challenged Freud, and in so do-ing, advanced mainstream
psychoanalytic thinking and approaches totreatment. According to
Bergmann's way of categorizing psychoanalyticthinkerswhich seems
quite usefulKernberg and Kohut would beidentified as modifiers
rather than heretics, as important thinkers whodemand that theory
change as a result of their findings.
As Bergmann has said, modifiers have threatened the continuity
ofpsychoanalysis and created much controversy, however, they have
alsokept psychoanalysis alive. As a result of the insights offered
by mod-ifiers, psychoanalysis has been able to stretch enough to
improve itsunderstanding of the etiology of many disorders as well
as develop moreeffective treatment approaches. More recently,
Bergmann stated thatmodifiers demand that analysts "give up their
cherished belief that psy-choanalytic theorizing has developed
along a straight line, with everynew generation simply adding their
findings to that of the previous gen-eration" (1997, p. 82). In
fact, psychoanalytic theory and technique haveevolved
dialectically. This can be seen very clearly with regard to
howpsychoanalytic thinking about severe psychopathology has
evolved, asthis paper has indicated.
The intention of the author in this paper has not been either
todefend or to attack either theorist, but rather to highlight the
need onthe part of the practitionerwhen he or she turns to either
Kernberg orKohut for guidanceto recognize the limitations of
relying too much oneither approach when he or she is attempting to
engage patients whoare especially difficult to engage in a
meaningful psychodynamic treat-ment. If this is accepted, of
course, a related matter must be consideredvery carefullythe issue
of what determines the shift from the use of oneapproach to
another.
As Strean (1994) has described, theoretical arguments can be
madeto rationalize interventions motivated primarily by the
practitioner'scountertransference. Strean suggests that this
defensive maneuver can
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be employed by well-trained, seasoned analysts as well as by
those stillin training. In working with more troubled patients, it
can be especiallytempting for the practitioner to cling
uncritically to a particular way ofworking as a means of warding
off the anxiety associated with hearingvery disturbing material and
observing very self-destructive behavior. Itis also possible that
the practitioner can become too eclectic, shifting tooquickly to a
different approach as a means of warding off anxiety stem-ming from
his or her countertransference.
As Maroda (1994) has indicated, perhaps the best way to knowwhen
one is either too wedded to a particular approach or too eclectic
isto carefully study one's counter-transference. It is in fact
quite possible toget back on track when one's countertransference
has taken one offcourse, as Strean (1993, 1995) has shown in his
description of analystsand other therapists who were able to use
supervision to resolve theircounterresistances. In an earlier paper
(Consolini, 1997), this authorwas able to demonstrate, with three
case examples, that self-analysisenabled him to determine when his
countertransferences were limitinghis effectiveness and to take the
necessary steps to resolve the counter-resistances stemming from
these countertransferences.
CONCLUSION
Clinical social workers are often called upon to treat very
troubledand demanding patients during times of crisis, crisis often
precipitatedby the psychopathology of these individuals. These
patients are oftenhighly resistant to aspects of the analytic
process usually associatedwith positive treatment outcomes, such as
meeting several times perweek and accepting a long-term commitment
to their personal growth.Financial constraints and the influence of
managed care reinforce resis-tance to the analytic process. In
short, patients may now feel more en-titled than ever to fast and
dramatic improvement because of the cur-rent economic and social
climate.
It may sometimes seem that the well-trained clinician must
forgetmuch about what he or she learned to be successful with many
of thoseseeking treatment in the current climate. Actually, there
is good reasonto continue to employ analytic approaches, especially
as conceived byKernberg and Kohut, with many patients. Both
theorists have a greatdeal to offer to therapists working with very
disturbed individuals dur-ing periods of crisis.
If the author of this paper has succeeded, he has demonstrated
thatit possible to utilize selectively aspects of both of the
approaches of thesetwo theorists to find ways to help individuals
as demanding and trou-bled as Doug. To do so, the therapist must be
aware of the strengths and
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limitations of these approaches. And, perhaps most importantly,
thetherapist must be aware of what compels him or her to adopt a
particu-lar approach at a particular time with a particular
patient. Ideally, thetherapist can accept and work with the
possibility that countertransfer-ence plays a role in his or her
clinical decision-making.
REFERENCES
Abend, S., Porder, M. & Willick, M. (1983). Borderline
patients: Psychoanalytic perspec-tives. New York: Int. Univ.
Press.
Bergmann, M. (1993). Reflections of the history of
psychoanalysis. JAPA, 41:929-953.Bergmann, M. (1997). The
historical roots of psychoanalytic orthodoxy.
Int.J.Psychoanal.,
78:69-86.Brandchaft, B. & Stolorow, R. (1984). The
borderline concept: Pathological character or
iatrogenic myth. In J. Lichtenberg, et al., Empathy II.
Hillsdale, N.J.: Analytic Press.Consolini, G. (1997). Self-analysis
and resistance to self-analysis of countertransference.
Journal of Analytic Social Work, 4:61-82.Fairbairn, W.R.D.
(1954). An object-relations theory of the personality. New York:
Basic
Books.Fine, R. (1982). The healing of the mind. New York: Free
Press.Freud, S. (1914). On narcissism. In A. Morrison, ed.,
Essential papers on narcissism. New
York: New York Univ. Press.Frosch, J. (1970). Psychoanalytic
considerations of the psychotic character. JAPA, 18:24-
50.Goldstein, E. (1990). Borderline disorders: Clinical models
and techniques. New York:
Guilford Press.Goldstein, E. (1994). Ego psychology and social
work practice. New York: Free Press.Greenberg, J. & Mitchell,
S. (1983). Object relations in psychoanalytic theory.
Cambridge,
MA: Harvard.Jacobson, E. (1954). Contribution to the
metapsychology of psychotic identifications. JAPA.
2:239-67.Jacobson, E. (1964). The self and the object world. New
York: Int. Univ. Press.Kernberg, O. (1967). Borderline personality
organization. JAPA 15:641-85.Kernberg, O. (1970). Factors in the
psychoanalytic treatment of narcissistic personalities.
In A. Morrison, ed., Essential papers on narcissism. New York:
New York Univ. Press.Kernberg, O. (1974). Further contributions to
the treatment of narcissistic personalities.
In A. Morrison, ed., Essential papers on narcissism. New York:
New York Univ. Press.Kernberg, 0. (1975). Borderline conditions and
pathological narcissism. New York: Jason
Aronson.Klein, M. (1928). Early stages of the oedipus complex.
In J. Mitchell, ed., The selected
Melanie Klein. New York: Free Press.Klein, M. (1935). A
contribution to the psychogenesis of manic-depressive states. In
P.
Buckley, ed., Essential papers on object relations. New York:
New York Univ. Press.Klein, M. (1946). Notes on some schizoid
mechanisms. In J. Mitchell, ed., The selected
Melanie Klein. New York: Free Press.Klein, M. (1957). A study of
envy and gratitude. In J. Mitchell, ed., The selected Melanie
Klein. New York: Free Press.Kohut, H. (1966). Forms and
transformations of narcissism. In A. Morrison, ed., Essential
papers on narcissism. New York: New York Univ. Press.Kohut, H.
(1971). The analysis of the self. New York: Int. Univ. Press.Kohut,
H. (1979). The two analyses of Mr. Z. UP. 60: 3-27.Kohut, H. &
Wolf, E. Disorders of the self and their treatment. In A.Morrison,
ed., Essen-
tial papers on narcissism. New York: New York Univ. Press.
-
86
CLINICAL SOCIAL WORK JOURNAL
Mahler, M. (1971). On human symbiosis and the vicissitudes of
individuation. In P. Buck-ley, ed., Essential papers on narcissism.
New York: New York Univ. Press.
Maroda, K. (1994). The power of countertransference. Northvale,
N.J.: Jason Aronson.Moore, B. & Pine, B. (1990). Psychoanalytic
terms and concepts. New Haven: Yale.Pine, F. (1988). The four
psychologies of psychoanalysis and their place in clinical
work.
JAPA. 36:571-96.Stone, L. (1954). The widening scope of
indications for psychoanalysis. JAPA. 2:567-94.Strean, H. (1993).
Resolving counterresistances in psychotherapy. New York:
Brunner-
Mazel.Strean, H. (1993). Personal communication.Strean, H.
(1995). Counter-transference and theoretical predilections as
observed in some
psychoanalytic candidates. Canadian J.Psychoanal. 3:105-24.
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