A Psychoanalytic Theory of Personality Disorders, Otto Kernberg and Eve Caligor (2005)
Introduction
A personality disorder reflects “specific pathological features of underlying psychological structures.” Consequently, if we’re going to treat a personality disorder, we need to alter their underlying psychological structure. All of this is based on Kernberg’s object relations model, a model which holds that our psychological structures are formed by both constitutional and environmental factors that occur early in life.
Internal Object Relations
Internal Object Relations
My psychological structure is composed of internal object relations. An internal object relation consists of “a particular affect state linked to an image of a specific interaction between the self and another person (e.g., fear, linked to the image of a small, terrified self and a powerful, threatening authority figure).” Internal object relations can be triadic, e.g., “an image of a sexual or loving couple and a third party who is excluded.”
Identity Consolidation
Identity Consolidation
One with a consolidated identity experiences “a stable and realistic sense of self and others.” Moreover, they experience “a broad array of affect dispositions,” primarily “positive affect states, reflecting the preponderance of loving, affiliative motivations, and the predominance of defensive operations based on repression.” In contrast, one with a pathological identity experiences “an unstable, polarized, and unrealistic sense of self and others.” Moreover, they experience “affects that are crude, intense, and poorly modulated, with the predominance of negative affect states, reflecting the preponderance of pathological aggression and the predominance of defensive operations based on primitive dissociation, or splitting.”
Normal Personality
Normal Personality
One’s personality is defined by their behavior patterns that themselves come from temperament, cognitive capacities, character/identity, and internalized values. A normal personality is characterized by four qualities. (1) Identity Consolidation. This means we have an integrated view of self and others. Some positive consequences of this: (a) an internal sense and external appearance of self-coherence; (b) possibility of self-esteem; (c) the capacity to realize one’s desires, capacities, and goals; (d) the capacity to have empathy and realistically evaluate others; (3) the capacity for mature dependency (i.e., “the capacity to make an emotional investment in others while maintaining a consistent sense of autonomy”).
(2) Capacity for Diverse and Regulated Affects. (3) Mature Value System. Our values are no longer “closed connected to parental prohibitions” but are “stable, ‘depersonified,’ relatively independent of external relations with others, and individualized.” (4) Management of Drives. That is, we find appropriate and satisfactory ways to manage our sexual, dependent, and aggressive strivings. For instance, we can express our sexual needs while also feeling tenderness and emotional commitment to our partner; we can express alternate between dependent and caretaking roles; and we channel our aggressive impulses “into expressions of healthy self-assertion.”
Development of Normal Personality
Splitting. In early life, we split our good experiences from our bad experiences, our positive representations of self and others linked together by positive emotions from our negative representations of self and others linked together by negative emotions. We engage in splitting to “maintain an ideal domain of experience characterized by the gratifying and pleasurable relation between self and others” and to escape “from the frightening experiences of negative affect states.” Splitting protects our idealized experiences from “contamination” with bad experiences. Splitting is accompanied by projection, “leading to a fear of painful and dangerous relationships with people in the environment.”
Identity Consolidation. If we have predominantly good object relationships, we’re able to eventually achieve identity consolidation, that is, integrate these all-good and all-bad internal object relations, seeing that self and others contain both good and bad aspects. Put differently, we’ve now achieved whole, as opposed to split, object relations.
Superego. The development of identity consolidation (in Mahler’s terms, object constancy) coincides with the development of the superego; this involves integrating harsh/punishing object representations with object representations “that promise the assurance of love and dependency if the child lives up to them.” By integrating these two object relations, we develop “the capacity for internalizing more realistic, toned-down demands and prohibitions from the parental figures.”
Repression. Even after we’ve achieved identity consolidation, our “”most highly affectively charged” representations are “dissociated from the representations that comprise the integrated, conscious sense of self.” The superego represses these representations, often referred to as the dynamic unconscious or the id. Repression does not “interfere with the integration of persecutory and idealized structures.” When we use repression, we’re not projecting, and thus we’re less likely to see the external world as destructive and more likely to see ourselves as destructive. I’m less likely to be afraid that you’ll hurt me and more likely to be afraid that I’ll hurt you. “It is [Kleinian] depressive anxiety that motivates repression of threatening internal object relations, relegating them to the dynamic unconscious.”
Motivation
Affects are “the primary motivational system.” Positive internal object relations contain positive affect states that motivate approach behaviors (libido), including a wish for physical closeness and fusion. Negative internal object relations contain negative affect states that motivate aversive behaviors (aggression), including rage. Whereas severe personality disorders are primarily motivated by aggression, neurotic personality disorders are primarily motivated by sexuality and sexual inhibition related to Oedipal conflicts and pathological personality traits “acting out of unconscious guilt over childhood sexual impulses.”
Nosology
This classification is primarily based on one’s level of identity consolidation, defensive operations, and reality testing. Psychotic Personality Organization is characterized by identity diffusion, defenses based on splitting, and loss of reality testing.
Borderline Personality Organization is characterized by identity diffusion, defenses based on splitting, and reduced but intact reality testing “marked by a decreased capacity for subtle and tactful evaluation of interpersonal processes, particularly in the setting of more intimate relations.” This personality organization includes the following personality disorders: borderline, schizoid, schizotypal, paranoid, hypomanic, hypochondriac, narcissistic, and antisocial.
Neurotic Personality Organization is characterized by normal identity consolidation, defenses primarily based on repression, and stable reality testing. This personality organization includes the following personality disorders: hysterical, depressive-masochistic, obsessive, and avoidant/phobic.
Neurotic personality organization is different from the normal personality because it is marked by character rigidity. Character rigidity is “the automatic activation of organized constellations of personality traits that are more or less maladaptive and not subject to voluntary control.” In a neurotic personality disorder, “internal object relations that are threatening are split off from the integrated representations that comprise normal identity. The repression-based defensive operations that ensure that these particular internal object relations remain apart from the dominant, conscious sense of self introduce rigidity into the neurotic personality organization and are responsible ultimately, for neurotic character traits.”
Transference-Focused Psychotherapy for Borderline Organized Patients
Step #1. Diagnose good and bad object relations and describe the representations involved. For example, we tell the patient that “their momentary relationship resembles that of a sadistic prison guard with a paralyzed, frightened victim.”
Step #2. Clarify the self representation and the object representation in the current internal object relation as well as the dominant affect linking them. For example, the therapist points out that the patient is acting as if he were “a frightened, paralyzed victim while attributing to the therapist the behavior of a sadistic prison guard.” The patient might identify with the victim one day and the persecutor the next, and we must point out when his identification changes.
Step #3: Point out that the currently dominant internal object relation in the transference with the internal object relation that was previously dominant. For example, the therapist reminds the patient that even though he presently experiences the therapist as a sadistic prison guard, he previously experienced the therapist as a loving mother. The therapist also points out that the former experiences are associated with times he experienced his mother as rejecting and the latter experience associated with times he experienced his mother as loving.
The therapist might further hypothesize why the patient keeps these the good mother-therapist separate from the bad mother-therapist; for example, he might “interpret that the patient feels he needs to do this out of fear that if he allows the idealized relationship with the therapist to be contaminated by the persecutory relationship, the ideal relationship might be permanently destroyed, taking with it all hope.”
The goal is the integration of the good and bad internal object relations, which will also lead to the integration of primitive affects. “The integration of intense, polarized affects leads, over time, to affect modulation, an increase in the capacity for affect control” and “a heightened capacity for empathy with both self and others and a corresponding deepening and maturing of interpersonal relations.”
The therapist uses three basic tools.
(2) Capacity for Diverse and Regulated Affects. (3) Mature Value System. Our values are no longer “closed connected to parental prohibitions” but are “stable, ‘depersonified,’ relatively independent of external relations with others, and individualized.” (4) Management of Drives. That is, we find appropriate and satisfactory ways to manage our sexual, dependent, and aggressive strivings. For instance, we can express our sexual needs while also feeling tenderness and emotional commitment to our partner; we can express alternate between dependent and caretaking roles; and we channel our aggressive impulses “into expressions of healthy self-assertion.”
Development of Normal Personality
Splitting. In early life, we split our good experiences from our bad experiences, our positive representations of self and others linked together by positive emotions from our negative representations of self and others linked together by negative emotions. We engage in splitting to “maintain an ideal domain of experience characterized by the gratifying and pleasurable relation between self and others” and to escape “from the frightening experiences of negative affect states.” Splitting protects our idealized experiences from “contamination” with bad experiences. Splitting is accompanied by projection, “leading to a fear of painful and dangerous relationships with people in the environment.”
Identity Consolidation. If we have predominantly good object relationships, we’re able to eventually achieve identity consolidation, that is, integrate these all-good and all-bad internal object relations, seeing that self and others contain both good and bad aspects. Put differently, we’ve now achieved whole, as opposed to split, object relations.
Superego. The development of identity consolidation (in Mahler’s terms, object constancy) coincides with the development of the superego; this involves integrating harsh/punishing object representations with object representations “that promise the assurance of love and dependency if the child lives up to them.” By integrating these two object relations, we develop “the capacity for internalizing more realistic, toned-down demands and prohibitions from the parental figures.”
Repression. Even after we’ve achieved identity consolidation, our “”most highly affectively charged” representations are “dissociated from the representations that comprise the integrated, conscious sense of self.” The superego represses these representations, often referred to as the dynamic unconscious or the id. Repression does not “interfere with the integration of persecutory and idealized structures.” When we use repression, we’re not projecting, and thus we’re less likely to see the external world as destructive and more likely to see ourselves as destructive. I’m less likely to be afraid that you’ll hurt me and more likely to be afraid that I’ll hurt you. “It is [Kleinian] depressive anxiety that motivates repression of threatening internal object relations, relegating them to the dynamic unconscious.”
Motivation
Affects are “the primary motivational system.” Positive internal object relations contain positive affect states that motivate approach behaviors (libido), including a wish for physical closeness and fusion. Negative internal object relations contain negative affect states that motivate aversive behaviors (aggression), including rage. Whereas severe personality disorders are primarily motivated by aggression, neurotic personality disorders are primarily motivated by sexuality and sexual inhibition related to Oedipal conflicts and pathological personality traits “acting out of unconscious guilt over childhood sexual impulses.”
Nosology
This classification is primarily based on one’s level of identity consolidation, defensive operations, and reality testing. Psychotic Personality Organization is characterized by identity diffusion, defenses based on splitting, and loss of reality testing.
Borderline Personality Organization is characterized by identity diffusion, defenses based on splitting, and reduced but intact reality testing “marked by a decreased capacity for subtle and tactful evaluation of interpersonal processes, particularly in the setting of more intimate relations.” This personality organization includes the following personality disorders: borderline, schizoid, schizotypal, paranoid, hypomanic, hypochondriac, narcissistic, and antisocial.
Neurotic Personality Organization is characterized by normal identity consolidation, defenses primarily based on repression, and stable reality testing. This personality organization includes the following personality disorders: hysterical, depressive-masochistic, obsessive, and avoidant/phobic.
Neurotic personality organization is different from the normal personality because it is marked by character rigidity. Character rigidity is “the automatic activation of organized constellations of personality traits that are more or less maladaptive and not subject to voluntary control.” In a neurotic personality disorder, “internal object relations that are threatening are split off from the integrated representations that comprise normal identity. The repression-based defensive operations that ensure that these particular internal object relations remain apart from the dominant, conscious sense of self introduce rigidity into the neurotic personality organization and are responsible ultimately, for neurotic character traits.”
Transference-Focused Psychotherapy for Borderline Organized Patients
Step #1. Diagnose good and bad object relations and describe the representations involved. For example, we tell the patient that “their momentary relationship resembles that of a sadistic prison guard with a paralyzed, frightened victim.”
Step #2. Clarify the self representation and the object representation in the current internal object relation as well as the dominant affect linking them. For example, the therapist points out that the patient is acting as if he were “a frightened, paralyzed victim while attributing to the therapist the behavior of a sadistic prison guard.” The patient might identify with the victim one day and the persecutor the next, and we must point out when his identification changes.
Step #3: Point out that the currently dominant internal object relation in the transference with the internal object relation that was previously dominant. For example, the therapist reminds the patient that even though he presently experiences the therapist as a sadistic prison guard, he previously experienced the therapist as a loving mother. The therapist also points out that the former experiences are associated with times he experienced his mother as rejecting and the latter experience associated with times he experienced his mother as loving.
The therapist might further hypothesize why the patient keeps these the good mother-therapist separate from the bad mother-therapist; for example, he might “interpret that the patient feels he needs to do this out of fear that if he allows the idealized relationship with the therapist to be contaminated by the persecutory relationship, the ideal relationship might be permanently destroyed, taking with it all hope.”
The goal is the integration of the good and bad internal object relations, which will also lead to the integration of primitive affects. “The integration of intense, polarized affects leads, over time, to affect modulation, an increase in the capacity for affect control” and “a heightened capacity for empathy with both self and others and a corresponding deepening and maturing of interpersonal relations.”
The therapist uses three basic tools.
(1) Interpretation. Interpretation is a three-step process, beginning with clarification, followed by confrontation, and leading finally to interpretation proper. Clarification entails systematic exploration of the details of the patient's subjective experience. Confrontation involves pointing out contradictions, inconsistencies, and omissions in the patient's verbal and nonverbal communications. Interpretation entails establishing hypotheses about the unconscious determinants of the patient's behavior, In contrast to standard psychoanalysis, in TFP the emphasis is on clarification and confrontatIon rather than on interpretation proper.”
(2) Systematic Transference Analysis. In addition to focusing on the transference, “the therapist must also maintain ongoing attention to the patient's long-range treatment goals and to the dominant, current conflicts in the patient's life outside the sessions. This is necessary because when bor-derline patients are in psychotherapy they tend to lose sight of treatment goals and to neglect the demands of external reality. This propensity on the part of borderline patients reflects the activation of defensive operations that lead to dissociation between external reality and treatment hours.”
(3) Technical Neutrality. “When we describe the TFP therapist as maintaining a ‘neutral’ stance, we mean that he or she makes an effort to avoid taking sides in the pa-dent's inner struggles.”
Transference-Focused Psychotherapy for Neurotic Organized Patients
This is much like traditional psychoanalysis with only a few modifications. The basic strategies “are to promote integration into the dominant sense of self of conflictual internal object relations that have been split off and repressed, while decreasing reliance on neurotic defenses relative to healthy or mature defenses. The overall approach is to bring repressed and dissociated internal object relations into consciousness where the underlying conflicts can be explored and worked through.”
Step #1: Facilitate “activation of conflictual representations of self and others and associated affects in the treatment. This is accomplished by the therapist maintaining a neutral stance while systematically exploring the internal object relations enacted in the session.”
Step #2: Diagnose “the affectively dominant internal object relation that is being enacted in the treatment” and “describe in as much detail and as accurately as possible the representations involved. For example, the therapist might point out to the patient that his discomfort with regard to speaking openly with the therapist appears connected to an experience of himself as a self-conscious child in the presence of an admired but potentially disapproving parent.”
Step #3: Clarify and interpret “the conflict embedded in the affectively dominant object relation activated in the treatment.” For example, the therapist might say that it would “make the patient feel anxious to experience himself as at all critical of the therapist or of the other important people in his life.”
Step #4: Explore “the repressed and dissociated, impulsive, internal object relations that underlie the defensively activated internal object relations, along with the anxiety associated with impulse expression.” For example, it might emerge that “the self-conscious child self and the admired but potentially disapproving parent defends against activation of the experience of a hurt and angry child who wants revenge in relation to a critical, derisive, and rejecting parent. The patient avoids consciously experiencing this internal object relation because feeling angry and vengeful, as well as critical and derisive, are unacceptable feelings, associated with guilt, depression, anxiety, and fear.”
Step #5: Work through “the guilt and regret associated with acknowledging and taking responsibility for formerly unconscious impulses, represented as affectively charged internal object relations. In this process, the patient will make amends, in fantasy and reality, for the potential harm to others associated with the expression of his conflictual impulses. For example, the patient we have been describing, now aware of his potential hostility and derision as well as his anger and wishes for revenge, might experience a new level of concern for the important people in his life. He might pay special attention to the needs of his employees or his children or his parents, and he might demonstrate similar feelings and efforts in relation to the therapist in the transference. The outcome of this process of uncovering unacceptable impulses, taking responsibility for them and making reparation, repeated over time, is that representations associated with expression of hostile, derisive impulses become more complex and differentiated and associated affects become less intense and less anxiety provoking. As the internal object relations associated with expression of hostile and derisive impulses become better integrated, they will become part of the patient's dominant sense of self. These changes in psychological structures correspond with a decrease in character rigidity in relation to the expression of hostifity and greater freedom to enjoy intimacy and interdependence.”
(2) Systematic Transference Analysis. In addition to focusing on the transference, “the therapist must also maintain ongoing attention to the patient's long-range treatment goals and to the dominant, current conflicts in the patient's life outside the sessions. This is necessary because when bor-derline patients are in psychotherapy they tend to lose sight of treatment goals and to neglect the demands of external reality. This propensity on the part of borderline patients reflects the activation of defensive operations that lead to dissociation between external reality and treatment hours.”
(3) Technical Neutrality. “When we describe the TFP therapist as maintaining a ‘neutral’ stance, we mean that he or she makes an effort to avoid taking sides in the pa-dent's inner struggles.”
Transference-Focused Psychotherapy for Neurotic Organized Patients
This is much like traditional psychoanalysis with only a few modifications. The basic strategies “are to promote integration into the dominant sense of self of conflictual internal object relations that have been split off and repressed, while decreasing reliance on neurotic defenses relative to healthy or mature defenses. The overall approach is to bring repressed and dissociated internal object relations into consciousness where the underlying conflicts can be explored and worked through.”
Step #1: Facilitate “activation of conflictual representations of self and others and associated affects in the treatment. This is accomplished by the therapist maintaining a neutral stance while systematically exploring the internal object relations enacted in the session.”
Step #2: Diagnose “the affectively dominant internal object relation that is being enacted in the treatment” and “describe in as much detail and as accurately as possible the representations involved. For example, the therapist might point out to the patient that his discomfort with regard to speaking openly with the therapist appears connected to an experience of himself as a self-conscious child in the presence of an admired but potentially disapproving parent.”
Step #3: Clarify and interpret “the conflict embedded in the affectively dominant object relation activated in the treatment.” For example, the therapist might say that it would “make the patient feel anxious to experience himself as at all critical of the therapist or of the other important people in his life.”
Step #4: Explore “the repressed and dissociated, impulsive, internal object relations that underlie the defensively activated internal object relations, along with the anxiety associated with impulse expression.” For example, it might emerge that “the self-conscious child self and the admired but potentially disapproving parent defends against activation of the experience of a hurt and angry child who wants revenge in relation to a critical, derisive, and rejecting parent. The patient avoids consciously experiencing this internal object relation because feeling angry and vengeful, as well as critical and derisive, are unacceptable feelings, associated with guilt, depression, anxiety, and fear.”
Step #5: Work through “the guilt and regret associated with acknowledging and taking responsibility for formerly unconscious impulses, represented as affectively charged internal object relations. In this process, the patient will make amends, in fantasy and reality, for the potential harm to others associated with the expression of his conflictual impulses. For example, the patient we have been describing, now aware of his potential hostility and derision as well as his anger and wishes for revenge, might experience a new level of concern for the important people in his life. He might pay special attention to the needs of his employees or his children or his parents, and he might demonstrate similar feelings and efforts in relation to the therapist in the transference. The outcome of this process of uncovering unacceptable impulses, taking responsibility for them and making reparation, repeated over time, is that representations associated with expression of hostile, derisive impulses become more complex and differentiated and associated affects become less intense and less anxiety provoking. As the internal object relations associated with expression of hostile and derisive impulses become better integrated, they will become part of the patient's dominant sense of self. These changes in psychological structures correspond with a decrease in character rigidity in relation to the expression of hostifity and greater freedom to enjoy intimacy and interdependence.”
Comments
Post a Comment