Otto Kernberg: A Contemporary Introduction, Yeomans, Diamond, Caligor (2024)
Model of Mind
Internal Object Relations
Our basic psychological structure consists of internal object relations. An internal object relation is “a mental representation of a relationship, consisting of an image of the self (self-representation) interacting with the image of another person (object representation) and linked to a particular affect state.” Different situations activate different internal object relations and in turn shape our experience of that situation.
For example, when interacting with an authority figure, I might have an internal object relationship of myself as helpless relating to a threatening authority figure that is linked to feelings of fear. This in turn leads me to feel “disempowered and threatened.”
Origins
Affects are “the inborn, biological drivers of human motivation,” and internal object relations are derived from “the interplay of affects and interactions with caretakers.” When we repeatedly experience a “high intensity affect” in a specific type of interaction,” we develop “memory structures that constitute internal object relations.” When we repeatedly experience interactions accompanied by low affect, we undergo cognitive learning.
Internal object relations “function as the basis of a system of psychological motivation, directing efforts” to increase positive affect states and decrease negative affect states. Example. (a) I repeatedly experience my mother caring for me, causing you to feel gratified; (b) I in turn internalize my mother caring for me, and this interaction is associated with feelings of gratification; (c) in the future, I need care and then expect receiving that care from my mother and approach her.
Splitting (Paranoid-Schizoid Position)
There are two major types of internal object relations: (1) positive representations of self and others linked by positive affects and affiliative behaviors and (2) negative representations of self and others linked by negative affects and aversive behaviors. In time, these two types of internal object relations come to be dissociated from one another and exaggerated, resulting in an all-good sector “characterized by purely positive representations of self and other associated with positive, affiliative, affect states” and (2) an all-bad sector “characterized by purely negative representations of other and threatened representations of self, associated with negative, aggressive, affect states.”
Splitting is motivated by a need “to maintain an ideal domain of experience characterized by the gratifying and pleasurable relation between self and others, while escaping from the frightening, paranoid experiences of negative affect states.” In other words, splitting “sequesters and protects the idealized experiences from ‘contamination’ with bad ones.” The cost of splitting is that it creates “a polarized, extreme, highly affectively charged, and distorted view of internal and external reality.”
Under splitting, both positive and negative sectors “have full access to consciousness.” At times this means they’re consciously experienced (“I am furious”) while at other times this means they’re experienced through behavior that we are denying (“I can be seen glaring at my therapist while denying any awareness of hostile feelings or behavior”). Positive and negative sectors are not experienced at the same time, meaning that at any given moment, self and other are experienced as either all-good or all-bad but not as “simultaneously having both good and bad parts.”
Under splitting, “representations of negatively charged, painful, and dangerous representations tend to be projected, leading to a paranoid orientation characterized by fear of painful and dangerous relationships” with actual people.
Psychological Integration (Depressive Position)
The next step in psychological development involves integrating these two sectors. Integration is facilitated by “the development of cognitive capacities and ongoing learning regarding realistic aspects of the interactions between self and others under circumstances of low affect activation, in conjunction with a predominance of positive over negative interactions with others in the environment.” As “the intensity of negative affects and persecutory experiences” gradually diminish, more integration occurs. The individual comes to learn that the relational world is not are not actually split, as others have both good and bad aspects.
At the same time, the individual realizes that she also has both good and bad parts, meaning that the good is not as consistently split off and projected. This means that “her aggression has been directed towards an object that is not ‘only bad’ but rather also has positive aspects. The capacity to maintain awareness of one’s own internal ‘badness’ white taking responsibility for it and experiencing guilt is a crucial step in relinquishing splitting and moving toward integration.” Rather than projecting “bad” aspects of self, you take responsibility for these aspects, “recognizing that the same mother who is the target of one’s aggression as a source of frustration and fear is also the mother who is loved as a source of gratification.” “Depressive” in this context refers both “to mourning of the possibility of finding an ideal object and to the experience of guilt and depression in relation to recognizing one’s own internal badness and that one’s aggression has been directed toward objects that have positive as well as negative aspects.”
Integrated views of self and others can be referred to as identity consolidation, whole object relations, normal ego identity (versus identity diffusion, Erikson), object constancy (Mahler).
Consequences of the Depressive Position
Repression. Even after we’ve achieved the depressive position, certain internal object relations remain largely incompatible with one’s sense of self. These “conflictual” internal object relations tend to be “poorly integrated, extreme, and highly affectively charged” and linked to “aggressive, sexual and dependent motivations.” We respond to these conflictual internal object relations by repressing them, that is, splitting them off and banishing them from consciousness. This act of repression allows further integration of self and others. These repressed internal object relations constitute the “dynamic unconscious.”
Superego. The superego is composed of “an integrated system of internalized morals and values.” To be more specific, it is composed of three layers of internal object relations. Layer #1 consists of “persecutory, split representations” that reflect the “demanding and prohibitive, primitive morality” experienced by our parents. Layer #2 consists of “ideal representations of self and others reflecting early childhood ideals that promise the assurance of love and dependency if the child lives up to them.”
Layer #3 consists of the integration of the first two layers, an integration that “modulates the intensity of both.” The more we integrate the first two layers, the less we “reproject these representations (i.e., the threat of internal disapproval replaces fear of disapproval or attack by others in guiding moral values and behavior).” Additionally, the more we integrate the first two layers, the more we develop “the capacity for internalizing more realistic, toned-down, demands and prohibitions from the parental figures, leading to a third layer of integration of internalized values.”
Drives. Whereas Freud believed that aggression and libido were the source of our basic motivations, Kernberg holds that “affects are the inborn components of motivational systems, and internal object relations, derived from the interplay of affects and interactions with caretakers, serve as the basic structures in the psychological development of motivational systems.” However, Kernberg maintains the concept of drives, believing that aggression and libido represent, not our basic motivational systems, but the highest level of organization of “internal object relations related to peak positive or negative affect states, relegated to the dynamic unconscious.”
Diagnosis and Classification
In the normal personality, “(1) identity is fully consolidated, corresponding with well integrated, stable, and realistic sense of self” and others, along with “the capacity to identify and pursue long-term goals; (2) relations with others are marked by a capacity for concern, mutual dependency, and intimacy; (3) mature defenses predominate and allow for adaptation to life and flexible management of psychological conflict; (4) moral functioning is internalized, stable, and linked to personality and consistently held values and ideals; (5) reality testing is stable even in areas of conflict or in the setting of affect activation; and (6) aggression is well integrated and well modulated.”
In personality disorders, “(1) identity is poorly consolidated, reflected in an experience of self and others that is distorted, superficial, unstable, and highly affectively charged, and in an impaired capacity to identify and pursue long-term goals; (2) relations with others are superficial, often based in need fulfillment, and increasingly exploitive as pathology becomes more severe; (3) lower-level, splitting-based defenses predominate and maintain a dissociated, black-and-white quality of experience while introducing severe rigidity and poor adaptation into personality functioning; (4) moral functioning is inconsistent and, at the most severe end of the spectrum, is characterized by antisocial features and an absence of internalized values or ideals; (5) reality testing is vulnerable in the setting of affect activation, psychological conflict, or interpersonal stressors; (6) aggression is not well modulated and is inappropriately expressed in relation to self and/or others.”
Those with personality disorders can benefit from psychodynamic therapy but also require “a more structured treatment approach such as TFP.” Those with psychosis benefit from therapy that provides but structure and support.
We determine the level of personality organization (normal, neurotic, borderline, by evaluating the domains of (1) identity, (3) defenses, and (5) reality testing, we can determine one’s level of personality organization. We determine one’s (2) quality of object relations, (4) moral functioning, and (6) quality of aggression, we can determine the levels of severity (for those organized at the borderline level, the levels are mild severity, moderate severity, and extreme severity).
Transference-Focused Psychotherapy
Kernberg developed TFP in an attempt to apply psychoanalytic concepts and techniques to BPO patients, a group that did not respond well to classical psychoanalysis. These patients are characterized by identity diffusion, pathology of object relations, splitting-based defenses, and inconsistent reality testing. TFP has modified to help out clients: Extended TFP treats all levels of personality organization (Caligor et al., 2018, Psychodynamic Therapy for Personality Pathology) and TFP-N treats narcissistic pathology (Diamond et al., 2022, Treating Pathological Narcissism with Transference-Focused Psychotherapy). TFP is sometimes used to train beginning therapists in psychodynamic therapy in a systematic way.
Before Therapy
Diagnosis. TFP begins, not with therapy, but diagnosis, the structural interview.
Sharing Diagnosis. The therapist shares his diagnostic impression of the patient, communicating his belief that “the patient’s difficulties are centered around problems in the patient’s sense of self and experience of others and that such difficulties are at the core of what we call ‘personality disorders.’”
Treatment Recommendation. The therapist explains different treatment options and why he recommends psychoanalytic, exploratory treatment. He then explains the nature of treatment, “explaining that the root of the patient’s emotional and behavioral difficulties is believed to be in conflicting emotional states within the patient’s mind and that the therapy will seek to help the patient become aware of elements in their mind of which they are not aware that have an impact on how they feel, think, and behave.” The therapist further explains that his role is “not to provide direct support or opinions since doing so would detract from the goal of increasing the patient’s autonomy.”
Frame. The frame serves several purposes. (1) It limits acting out behaviors. (2) It allows transference to develop. (3) It makes it harder for the therapist to “deviate from the exploratory treatment frame when emotionally charged internal object relations dyads are enacted,” e.g., extending the duration of a session.
Contracting, Part I. You describe your respective roles. The patient’s role is to attend regularly, to freely share what comes to her mind, and to make payments. The therapist’s role is to accept the patient’s feelings and help the patient become aware of unknown parts of the self. The patient’s deviations from her agreed-upon role provides “material for the work of transference analysis.” Contracting, Part II. The therapist establishes parameters around acting out based on their history of acting out.
Goals. The therapist and patient establish specific goals beyond “I want to understand myself better” and beyond symptom reduction. Examples of goals: “being able to maintain a stable intimate relationship or invest consistently in studies or work.”
Therapy
The patient is asked to report what thoughts and feelings come to mind. The therapist is encouraged to think of therapy on three levels: strategies, tactics, and techniques.
Strategies. The therapist remembers the overarching goal, to achieve integration of their split internal world (to shift from the schizoid-paranoid to depressive position). To achieve this goal, the therapist must keep the following strategies in mind: (a) to discern and help the patient be aware of the object relations dyad that is active in the session, (b) to make the patient aware of role reversals when they occur within the dyad being experienced, and (c) to make the patient aware of “the radically polarized experiences that they have at different times in relation to the therapist and to help them understand the motivations for this separation of extreme affect states.”
Tactics. These are “those elements of treatment that need to be in place to effectively employ the treatment techniques.” The most important tactics are “maintaining the frame and choosing the most important material around which to intervene.” As the therapist points out the patients defenses as they arise in sessions, the patient will get anxious and be tempted to act out. Material should be selected based on (a) what is most affectively charged, (b) what prioritizes safety, and (c) respect of the principle proceeding from surface to depth.
Techniques. These four techniques “underlie all psychoanalytically inspired work,” the difference between psychoanalysis, exploratory psychoanalytic therapy, and supportive psychoanalytic therapy being the emphasis put on each technique.
(a) Technical Neutrality. This means the therapist avoids siding with any of the elements of the patient’s internal conflict and insteads helps the patient to reflect on them instead of acting out or projecting. This does not mean having an indifferent attitude toward the patient.
(b) Use of Countertransference.
(c) Interpretation. (i) Clarification. (ii) Confrontation. (iii) Interpretation Proper.
(d) Transference Analysis. This focuses on the here-and-now of the therapeutic relationship. Transference analysis examples: “Am I a cold therapist if I end the session on time?” (frame)
Narcissistic Personality Disorder. While BPD patients tend to present with “a predominant dyad of victim in relation to persecutor with frequent role reversals,” “the core dyad in NPD patients is typically of the superior self in relation to the devalued other.” The NPD patient “does not provide the therapist with the frequent windows into internal fragmentation” that are common with BPD patients. Additionally, NPD patients “are more likely to present with a dismissing internal model of attachment in contrast to the preoccupied unresolved attachment” common in BPD patients.
Internal Object Relations
Our basic psychological structure consists of internal object relations. An internal object relation is “a mental representation of a relationship, consisting of an image of the self (self-representation) interacting with the image of another person (object representation) and linked to a particular affect state.” Different situations activate different internal object relations and in turn shape our experience of that situation.
For example, when interacting with an authority figure, I might have an internal object relationship of myself as helpless relating to a threatening authority figure that is linked to feelings of fear. This in turn leads me to feel “disempowered and threatened.”
Origins
Affects are “the inborn, biological drivers of human motivation,” and internal object relations are derived from “the interplay of affects and interactions with caretakers.” When we repeatedly experience a “high intensity affect” in a specific type of interaction,” we develop “memory structures that constitute internal object relations.” When we repeatedly experience interactions accompanied by low affect, we undergo cognitive learning.
Internal object relations “function as the basis of a system of psychological motivation, directing efforts” to increase positive affect states and decrease negative affect states. Example. (a) I repeatedly experience my mother caring for me, causing you to feel gratified; (b) I in turn internalize my mother caring for me, and this interaction is associated with feelings of gratification; (c) in the future, I need care and then expect receiving that care from my mother and approach her.
Splitting (Paranoid-Schizoid Position)
There are two major types of internal object relations: (1) positive representations of self and others linked by positive affects and affiliative behaviors and (2) negative representations of self and others linked by negative affects and aversive behaviors. In time, these two types of internal object relations come to be dissociated from one another and exaggerated, resulting in an all-good sector “characterized by purely positive representations of self and other associated with positive, affiliative, affect states” and (2) an all-bad sector “characterized by purely negative representations of other and threatened representations of self, associated with negative, aggressive, affect states.”
Splitting is motivated by a need “to maintain an ideal domain of experience characterized by the gratifying and pleasurable relation between self and others, while escaping from the frightening, paranoid experiences of negative affect states.” In other words, splitting “sequesters and protects the idealized experiences from ‘contamination’ with bad ones.” The cost of splitting is that it creates “a polarized, extreme, highly affectively charged, and distorted view of internal and external reality.”
Under splitting, both positive and negative sectors “have full access to consciousness.” At times this means they’re consciously experienced (“I am furious”) while at other times this means they’re experienced through behavior that we are denying (“I can be seen glaring at my therapist while denying any awareness of hostile feelings or behavior”). Positive and negative sectors are not experienced at the same time, meaning that at any given moment, self and other are experienced as either all-good or all-bad but not as “simultaneously having both good and bad parts.”
Under splitting, “representations of negatively charged, painful, and dangerous representations tend to be projected, leading to a paranoid orientation characterized by fear of painful and dangerous relationships” with actual people.
Psychological Integration (Depressive Position)
The next step in psychological development involves integrating these two sectors. Integration is facilitated by “the development of cognitive capacities and ongoing learning regarding realistic aspects of the interactions between self and others under circumstances of low affect activation, in conjunction with a predominance of positive over negative interactions with others in the environment.” As “the intensity of negative affects and persecutory experiences” gradually diminish, more integration occurs. The individual comes to learn that the relational world is not are not actually split, as others have both good and bad aspects.
At the same time, the individual realizes that she also has both good and bad parts, meaning that the good is not as consistently split off and projected. This means that “her aggression has been directed towards an object that is not ‘only bad’ but rather also has positive aspects. The capacity to maintain awareness of one’s own internal ‘badness’ white taking responsibility for it and experiencing guilt is a crucial step in relinquishing splitting and moving toward integration.” Rather than projecting “bad” aspects of self, you take responsibility for these aspects, “recognizing that the same mother who is the target of one’s aggression as a source of frustration and fear is also the mother who is loved as a source of gratification.” “Depressive” in this context refers both “to mourning of the possibility of finding an ideal object and to the experience of guilt and depression in relation to recognizing one’s own internal badness and that one’s aggression has been directed toward objects that have positive as well as negative aspects.”
Integrated views of self and others can be referred to as identity consolidation, whole object relations, normal ego identity (versus identity diffusion, Erikson), object constancy (Mahler).
Consequences of the Depressive Position
Repression. Even after we’ve achieved the depressive position, certain internal object relations remain largely incompatible with one’s sense of self. These “conflictual” internal object relations tend to be “poorly integrated, extreme, and highly affectively charged” and linked to “aggressive, sexual and dependent motivations.” We respond to these conflictual internal object relations by repressing them, that is, splitting them off and banishing them from consciousness. This act of repression allows further integration of self and others. These repressed internal object relations constitute the “dynamic unconscious.”
Superego. The superego is composed of “an integrated system of internalized morals and values.” To be more specific, it is composed of three layers of internal object relations. Layer #1 consists of “persecutory, split representations” that reflect the “demanding and prohibitive, primitive morality” experienced by our parents. Layer #2 consists of “ideal representations of self and others reflecting early childhood ideals that promise the assurance of love and dependency if the child lives up to them.”
Layer #3 consists of the integration of the first two layers, an integration that “modulates the intensity of both.” The more we integrate the first two layers, the less we “reproject these representations (i.e., the threat of internal disapproval replaces fear of disapproval or attack by others in guiding moral values and behavior).” Additionally, the more we integrate the first two layers, the more we develop “the capacity for internalizing more realistic, toned-down, demands and prohibitions from the parental figures, leading to a third layer of integration of internalized values.”
Drives. Whereas Freud believed that aggression and libido were the source of our basic motivations, Kernberg holds that “affects are the inborn components of motivational systems, and internal object relations, derived from the interplay of affects and interactions with caretakers, serve as the basic structures in the psychological development of motivational systems.” However, Kernberg maintains the concept of drives, believing that aggression and libido represent, not our basic motivational systems, but the highest level of organization of “internal object relations related to peak positive or negative affect states, relegated to the dynamic unconscious.”
Diagnosis and Classification
In the normal personality, “(1) identity is fully consolidated, corresponding with well integrated, stable, and realistic sense of self” and others, along with “the capacity to identify and pursue long-term goals; (2) relations with others are marked by a capacity for concern, mutual dependency, and intimacy; (3) mature defenses predominate and allow for adaptation to life and flexible management of psychological conflict; (4) moral functioning is internalized, stable, and linked to personality and consistently held values and ideals; (5) reality testing is stable even in areas of conflict or in the setting of affect activation; and (6) aggression is well integrated and well modulated.”
In personality disorders, “(1) identity is poorly consolidated, reflected in an experience of self and others that is distorted, superficial, unstable, and highly affectively charged, and in an impaired capacity to identify and pursue long-term goals; (2) relations with others are superficial, often based in need fulfillment, and increasingly exploitive as pathology becomes more severe; (3) lower-level, splitting-based defenses predominate and maintain a dissociated, black-and-white quality of experience while introducing severe rigidity and poor adaptation into personality functioning; (4) moral functioning is inconsistent and, at the most severe end of the spectrum, is characterized by antisocial features and an absence of internalized values or ideals; (5) reality testing is vulnerable in the setting of affect activation, psychological conflict, or interpersonal stressors; (6) aggression is not well modulated and is inappropriately expressed in relation to self and/or others.”
Those with personality disorders can benefit from psychodynamic therapy but also require “a more structured treatment approach such as TFP.” Those with psychosis benefit from therapy that provides but structure and support.
We determine the level of personality organization (normal, neurotic, borderline, by evaluating the domains of (1) identity, (3) defenses, and (5) reality testing, we can determine one’s level of personality organization. We determine one’s (2) quality of object relations, (4) moral functioning, and (6) quality of aggression, we can determine the levels of severity (for those organized at the borderline level, the levels are mild severity, moderate severity, and extreme severity).
Transference-Focused Psychotherapy
Kernberg developed TFP in an attempt to apply psychoanalytic concepts and techniques to BPO patients, a group that did not respond well to classical psychoanalysis. These patients are characterized by identity diffusion, pathology of object relations, splitting-based defenses, and inconsistent reality testing. TFP has modified to help out clients: Extended TFP treats all levels of personality organization (Caligor et al., 2018, Psychodynamic Therapy for Personality Pathology) and TFP-N treats narcissistic pathology (Diamond et al., 2022, Treating Pathological Narcissism with Transference-Focused Psychotherapy). TFP is sometimes used to train beginning therapists in psychodynamic therapy in a systematic way.
Before Therapy
Diagnosis. TFP begins, not with therapy, but diagnosis, the structural interview.
Sharing Diagnosis. The therapist shares his diagnostic impression of the patient, communicating his belief that “the patient’s difficulties are centered around problems in the patient’s sense of self and experience of others and that such difficulties are at the core of what we call ‘personality disorders.’”
Treatment Recommendation. The therapist explains different treatment options and why he recommends psychoanalytic, exploratory treatment. He then explains the nature of treatment, “explaining that the root of the patient’s emotional and behavioral difficulties is believed to be in conflicting emotional states within the patient’s mind and that the therapy will seek to help the patient become aware of elements in their mind of which they are not aware that have an impact on how they feel, think, and behave.” The therapist further explains that his role is “not to provide direct support or opinions since doing so would detract from the goal of increasing the patient’s autonomy.”
Frame. The frame serves several purposes. (1) It limits acting out behaviors. (2) It allows transference to develop. (3) It makes it harder for the therapist to “deviate from the exploratory treatment frame when emotionally charged internal object relations dyads are enacted,” e.g., extending the duration of a session.
Contracting, Part I. You describe your respective roles. The patient’s role is to attend regularly, to freely share what comes to her mind, and to make payments. The therapist’s role is to accept the patient’s feelings and help the patient become aware of unknown parts of the self. The patient’s deviations from her agreed-upon role provides “material for the work of transference analysis.” Contracting, Part II. The therapist establishes parameters around acting out based on their history of acting out.
Goals. The therapist and patient establish specific goals beyond “I want to understand myself better” and beyond symptom reduction. Examples of goals: “being able to maintain a stable intimate relationship or invest consistently in studies or work.”
Therapy
The patient is asked to report what thoughts and feelings come to mind. The therapist is encouraged to think of therapy on three levels: strategies, tactics, and techniques.
Strategies. The therapist remembers the overarching goal, to achieve integration of their split internal world (to shift from the schizoid-paranoid to depressive position). To achieve this goal, the therapist must keep the following strategies in mind: (a) to discern and help the patient be aware of the object relations dyad that is active in the session, (b) to make the patient aware of role reversals when they occur within the dyad being experienced, and (c) to make the patient aware of “the radically polarized experiences that they have at different times in relation to the therapist and to help them understand the motivations for this separation of extreme affect states.”
Tactics. These are “those elements of treatment that need to be in place to effectively employ the treatment techniques.” The most important tactics are “maintaining the frame and choosing the most important material around which to intervene.” As the therapist points out the patients defenses as they arise in sessions, the patient will get anxious and be tempted to act out. Material should be selected based on (a) what is most affectively charged, (b) what prioritizes safety, and (c) respect of the principle proceeding from surface to depth.
Techniques. These four techniques “underlie all psychoanalytically inspired work,” the difference between psychoanalysis, exploratory psychoanalytic therapy, and supportive psychoanalytic therapy being the emphasis put on each technique.
(a) Technical Neutrality. This means the therapist avoids siding with any of the elements of the patient’s internal conflict and insteads helps the patient to reflect on them instead of acting out or projecting. This does not mean having an indifferent attitude toward the patient.
(b) Use of Countertransference.
(c) Interpretation. (i) Clarification. (ii) Confrontation. (iii) Interpretation Proper.
(d) Transference Analysis. This focuses on the here-and-now of the therapeutic relationship. Transference analysis examples: “Am I a cold therapist if I end the session on time?” (frame)
Narcissistic Personality Disorder. While BPD patients tend to present with “a predominant dyad of victim in relation to persecutor with frequent role reversals,” “the core dyad in NPD patients is typically of the superior self in relation to the devalued other.” The NPD patient “does not provide the therapist with the frequent windows into internal fragmentation” that are common with BPD patients. Additionally, NPD patients “are more likely to present with a dismissing internal model of attachment in contrast to the preoccupied unresolved attachment” common in BPD patients.
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