INTERVIEW Otto F. Kernberg, M.D., F.A.P.A.," Developer of Object Relations Psychoanalytic Therapy for Borderline Personality Disorder.

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1 INTERVIEW Otto F. Kernberg, M.D., F.A.P.A.," Developer of Object Relations Psychoanalytic Therapy for Borderline Personality Disorder. LATA K. McGINN, Ph.D."" During this interview, I would like to focus on your conceptualization and application of object relations theo y for borderline personality disorder. Since your treatment for borderline personality disorder is based on object relations theoy, it may be helpful if you begin with a summay of object relations theo y for our readers who may not be familiar with it. Maybe I could start out by saying that psychoanalytic object relations theory, which is a specialized theory within psychoanalysis, deals with how you internalize relationships, particularly with significant people, for example, parents or siblings, starting in infancy. In fact, the way you understand and absorb these relationships is intimately linked with other psychoanalytic concepts, such as love and aggression, as the essential motivating forces in our lives, and those of the id, ego, and superego that Freud described as the basic psychological building blocks. So how do humans internalize relationships from birth onwards? Relationships are internalized at two levels. The first occurs at, what I call, low affective levels when emotions are not at their peak. Under ordinary circumstances, babies slowly become aware of their surroundings, "Otto F. Kernberg, M.D., F.A.P.A. is Director of the Personality Disorders Institute and the Cornell Psychotherapy Program at the New York Hospital-Cornell University Medical Center, Professor of Psychiatry at the Cornell University Medical Center, and President of the International Psychoanalytical Association. Dr. Kernberg has made seminal and groundbreaking contributions to the diagnosis and treatment of Borderline Personality Disorder, and he is universally recognized as the leading authority in this field. In addition, his work on the larger area of severe personality disorders has significantly advanced our understanding of both the origins and treatment of these debilitating clinical conditions. In recognition of his monumental clinical and theoretical contribution, he received the Distinguished Senice Award from the American Psychiatric Association in ""Dr. Lata K. McGinn is Assistant Professor and Assistant Director of the Cognitive Behavior Therapy Program in the Department of Psychiatry at the Albert Einstein College of Medicine/ Montefiore Medical Center. AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 52, No. 2, Spring 1998

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3 Interview with Otto E Kernberg, M.D. Does this explain normal and abnormal psychological development? Yes, it also explains pathological development. For example, if a child has extremely frustrating or traumatic experiences with significant others, these experiences are built into the mind as significantly traumatic or frustrating relationships that cannot be integrated and that remain in what we call a "dissociated or split-up state" which can lead to psychological problems later on. Perhaps, a prototype of such a pathological internalization is what happens as a consequence of severe aggressive trauma or sexual trauma, physical abuse or sexual abuse, extreme long-term physical or sexual abuse. What we find in these cases is that, say in the case of physical abuse, individuals unconsciously identify themselves both as victim, i.e. internalize the selfthat has been attacked, and as abuser, i.e.,internalize the memory of the abusing figure. Internalizing both these memories as a dyadic self representation-object representation unit brings about the unconscious temptations to reenact these roles again and again as if the only relationships that count in the world are those between the abuser and the victim. Although this is beyond the individuals' awareness and against their will, they are forced into a position again and again of both victim and abuser. This is the strange quality of it, so that we find that battered children become battering adults or that women who have been victims of incest again become victims of rape or become sexually promiscuous and seductive. Ordinary patterns of behavior become disturbed and disorganized. How would these conditions be treated in psychotherapy? In object relations psychoanalytic psychotherapy, the treatment is geared toward obtaining fundamental resolution of the underlying character or personality pathology by means of the controlled reactivation and resolution of these pathogenic internalized object relations. This is what constitutes transference, namely, the unconscious repetition in the therapeutic situation of past pathogenic internalized relationships. So let us say that these individuals unconsciously repeat the past pathological relationship over and over again during their social interactions in an attempt to overcome it, but they are unable to do so. They fail because they constantly repeat that vicious circle. In therapy, they relate to the therapist in the same way, in other words, as a transference to the therapist. However, the therapist does not react the way other people would because rather than responding to the patients' provocations, the therapist helps to understand them. 193

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5 Interview with Otto F. Kernberg, M.D. psychological split between love and hatred. This "dissociation" is a typical consequence of severe unconscious conflicts and traumatic experiences and leads patients to either idealize people or treat them as if they are all-bad. This tendency to consider people all-bad or all-good is gradually overcome in therapy by pointing out how patients tend to avoid ambivalence in their significant relationships, how they tend to avoid conflict by making one relationship all perfect and another one all bad. In treatment, the effort is to integrate these two types of mutually contradictory internalized object relations to bring about a gradual coalescence. Therapy attempts to gradually incorporate or fuse these disparate aspects of the patients' self-image, and, simultaneously their image of others. This, in essence, is the theory of treatment derived from object relations theory, and it has numerous implications for the techniques of psychotherapy. Could you give us an idea about actual techniques that you use in therapy to accomplish this? Well, the essential techniques may be classified as interpretation, transference analysis and technical neutrality. Interpretation consists in helping patients to understand the unconscious meanings of their behavior in their transferential relationship with the therapist. Interpretation has various phases. In the first phase, the therapist clarifies what is going on in the patients' mind. In the second, the therapist tactfully confronts the patients with the unconscious nonverbal behaviors they display during sessions. Finally, in the third phase, the therapist provides what we call a "genetic interpretation" which means that the therapist uses his interpretations of the current relationship between himself and the patients and links it to unconscious 'meanings from the patients' past. The patients' past Another technique, transference analysis, consists of the systematic analysis of the relationship patterns between therapist and patients, patterns that are based on, as I said, the patients' pathological relationship with significant persons from their past. Transference analysis is carried out by looking at significant issues or problems that come up between patient and therapist and linking them to similar issues or problems that come up for patients in their relationships with others outside the therapeutic environment. These relationship problems are then tied to or related to the patients' initial limitations, symptoms, conflicts and treatment goals. Patients may come in for treatment with many symptoms and

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7 Interview with Otto F. Kernberg, M.D. emotions in him or herself and use them for understanding the issues with which patients are struggling. So, the analysis of countertransference is an important instrument for understanding what is going on in the transference. You had said that this applies to the treatment of severe personality disorders. Can you give us an idea of what kinds of personality disorders? All severe personality disorders, what Michael Stone and myself have called borderline personality organization, which is the not the same as borderline personality disorder. Borderline personality disorder is only one specific personality disorder. Borderline personality organization includes all severe personality disorders, including borderline personality disorder in a strict sense, infantile or histrionic personality disorder, narcissistic personality disorder, paranoid personality disorder, schizoid personality disorder, sadomasochistic personality disorder, and a number of less frequent personality disorders, some of which are included in our official classification and some of which are not. Do you have a conceptualization of the dzfierent types of traumatic experiences that lead to the development of each personality disorders? Our knowledge about this is still incomplete. I think what we do know is that, in general, the most important cause of severe personality disorders is severe chronic traumatic experiences in early childhood. For example, physical or sexual abuse? Physical abuse, sexual abuse, severe deprivation of love, unavailable parental objects, as well as severe neglect. All these are environmental, familial dispositions that can lead to the development of personality disorders. But, there are also internal dispositions of which we know less as yet, which have to do with biological, genetic dispositions that translate into constitutional, inborn dispositions having to do with abnormal emotional arousal that can also contribute toward the development of personality disorders. I mentioned how important the emotional nature of the early relationship is in forming the personality. People who are born with a pathological emotional response, an excessive emotional reactivity or a complete lack of emotional reactivity can, in certain circumstances, distort these early relationships with parents, siblings, etc. For example, there are some people with excessive inborn dispositions who react with intense

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9 Interview with Otto F. Kernberg, M.D. And what was the Psychotherapy Research Project? The Psychotherapy Research Project of the Menninger Foundation was a major project directed by Dr. Robert Wallerstein for many years and eventually by myself. We studied 42 patients; 21 in psychoanalysis and 21 in various forms of psychoanalytic psychotherapy. Practically all of the patients had severe neurotic illnesses and personality disorders. Anyhow, my work at that project, and the publications that derived from it, gave me insight into the psychopathology of the borderline personality organization and permitted me to develop and elaborate the treatment approach for these conditions. What was the object of the study? The object was to study the effectiveness of different types of psychotherapy with patients having severe psychopathology. t And what did you find? We found that patients with ego strength, what I would now call neurotic personality organization, responded to all the different psychotherapies derived from a psychoanalytic model with most improvement obtained with pure psychoanalysis. In contrast, patients with ego weakness, what I would now call borderline personality organization, responded most to psychoanalytic psychotherapy focused on transference analysis within the sessions and with as much support as the patient needed outside the sessions to tolerate the treatment. Pure psychoanalysis as well as purely supportive psychotherapy, were less effective with these cases. So, you came to develop your treatment approach by observing and studying = these patients? Yes. That is how I came to focus on transference analysis as a dominant! therapeutic tool. I continued these studies after coming to New York in 1973; first at the College of Physicians and Surgeons at Columbia University where I was in charge of the general clinical service that was mostly dedicated to the long-term inpatient treatment of personality disorders. I developed a team of professionals at Columbia who later accompanied me in 1976 to the Westchester division of New York Hospital and helped me set up a specialized borderline unit. I came as medical director and, at this point, I am director of the Personality Disorders Institute here at New York Hospital where I provide education regarding personality disorder, psychotherapy, clinical training, supervision, and teaching as part of our program

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11 Interview with Otto F. Kernberg, M.D. What would you consider to be your greatest accomplishments? What satisfies you the most? I am very happy that I have been able to help to treat patients with such severe conditions, conditions that were considered to be untreatable years ago. I am also happy that not only have I helped to broaden the spectrum of patients who can be helped but also have provided a better understanding of their underlying psychopathologies. I have also contributed, I think, to contemporary psychoanalytic thinking, which is also a source of gratification to me. Another approach in treating borderline personality disorder, Marsha Linehan's dialectical behavior therapy for borderline personality disorder, has gained popularity more recently. What opinion do you have on Dr. Lineban's approach? We also have an inpatient unit specializing in dialectical behavior therapy here at New York Hospital. I think it is an excellent treatment geared toward the treatment of parasuicidal and suicidal behaviors in patients with severe personality disorders, particularly borderline personality disorder. And that is borderline personality disorder in the narrow sense? Yes, in the narrow sense. I consider it to be an effective treatment in reducing suicidal and parasuicidal behaviors. I consider it to be an important part of the armamentarium for treating these patients. But, I think that we still have the task of finding out what patients respond best to what treatment because there is good evidence that not all patients respond to the same treatment. One last question. What do you see as the future of psychoanalysis, or psychotherapy, in general, in the current healthcare environment. I think that psychotherapy, particularly dynamic therapy, is a limited option these days for segments of the population that are dependent on managed care insurance to pay for treatment. However, I do see the present crisis in managed care as a transition. The restriction of health care can only escalate problems in the long run and cannot last as an effective way to solve the healthcare problem. Well, it certainly has been a pleasure, thank you. You are quite welcome.