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Wise Counsel Interview Transcript: An Interview with Otto Kernberg, MD on Transference Focused Therapy

David Van Nuys, Ph.D.
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Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I am a clinical psychologist and your host.

On today's show we will be talking about an approach known as Transference-Focused Therapy with Otto F. Kernberg, MD, who is the Director of the Personality Disorders Institute at the New York Presbyterian Hospital, Westchester Division, and Professor of Psychiatry at the Joan and Sanford Weill Medical College and Graduate School of the Medical Sciences of Cornell University.

He is a training and supervising analyst at the Columbia University Center for Psychoanalytic Training and Research and is currently the President of the International Psychoanalytic Association. He is the founder of the approach known as Transference-Focused Therapy. Now, here is the interview.

Dr. Otto Kernberg, welcome to the Wise Counsel podcast.

Dr. Otto Kernberg: Thank you.

Dr. Van Nuys: I read that in fine psychoanalytic tradition you were born in Vienna.

Dr. Kernberg: That's right.

Dr. Van Nuys: Then, you grew up in Chile. How did you come to this country?

Dr. Kernberg: I had my secondary education, university education, psychiatric education and psychoanalytic education in Chile. I was interested in research and clinical psychiatry. I felt that there were not enough possibilities to really develop cutting edge psychiatric research in the area of psychotherapy that I was interested in in Chile at that time.

Dr. Van Nuys: Among your many roles now, you are the Director of the Personality Disorders Institute. Maybe, we should begin with you having to say something about what constitutes a personality disorder, and how it differs from other sorts of psychological problems?

Dr. Kernberg: You are asking me the definition of personality disorders?

Dr. Van Nuys: Yes.

Dr. Kernberg: Well, personality disorders are a group of abnormal conditions that are characterized by distortion in the habitual character logical patterns of the individual instead of the normal flexibility and adaptation of character. There are rigidities. The individual is forced to behave in rigid ways.

While these patients have a very good grasp of reality, they have maintained good reality testing; they find it very difficult to adjust to their own needs, to social reality, to work, profession, intimate relations, social life, creativity. And so, they have a reduction in their capacity to enjoy life, to be effectively autonomous and adaptive to reality while still maintaining their feet on the ground, so to speak. They are perfectly aware of reality, but they cannot control certain aspects of their experiences, of their behavior that is stronger than they are.

One can sub-divide the personality disorders into two types. The relatively milder one that we call personality disorders on the neurotic level or neurotic personality organization where there are only restricted areas where there are problems.

All in all they are functioning pretty well, to severe personality disorders where all aspects of life are really affected. We call these patients with severe personality disorders as presenting borderline personality organization not to be confused with one specific disorder, the borderline personality disorder, which is one of several disorders at a more severe level.

Now, we are particularly interested in doing research on the severe personality disorders and on their treatment because their treatment so far has not been fully satisfactory. We have several effective treatments, both psychodynamic and cognitive behavioral ones that deal with their symptoms, such as anxiety, depression, recital and palace recital behavior, inappropriate excessive affect reaction, even bi-civity.

We have good treatment for that but not for the basic personality structure. The basic personality structure of all these patients is characterized by something called identity diffusion which refers to a lack of integration of their concept of themselves.

They oscillate between sharply contradictory views of themselves, and they also oscillate between sharply contradictory views of the important persons in their life. They don't have the capacity of an integrated view of significant others in the same way as they don't have the capacity for an integrated view of themselves.

That brings about serious difficulty in work, in profession, in deciding what to commit themselves to in terms of work or profession. In intimate relations they have difficulties in the normal synthesis between sexuality and love, sexuality and tenderness.

They have difficulty in predicting their own behavior as well as having a clear view of the people with whom they get involved so that very often there's poor choices of partners and chronic marital difficulties. They are prone to a number of complications that require specialized treatment. They are particularly prone to drug abuse, drug dependency and alcoholism. They are predisposed to chronic depressive reactions, anxiety, eating disorders, and some of the most severe ones to antisocial behavior that may land them in conflict with the law.

So we are interested in treating the total personality, and not only the symptoms, in my institute we have both studied these patients in terms of their diagnosis and the origin of these personality disorders. And in developing the specific treatment for the personality, which we call Transference-Focused Psychotherapy, it is a psychodynamically oriented treatment that we're doing research about, and that is geared to modify the total personality, rather than targeting isolated symptoms.

Dr. Van Nuys: Wow, thank you for such a complete answer. Now I'm under the impression that you have a whole theoretical understanding of how these things develop in childhood. Perhaps you can give us an overview of your approach to childhood development.

Dr. Kernberg: Well, there are many people have contributed to putting together elements of what we have tried to synthesize in one specific formulation.

In essence, there are multiple causes. It starts out with a genetic disposition, reflected in hyperactivity of negative effects. They have a predominance of negative effects, rage, anger, irritation, and derived effects. And lack of impulse control over their effects, so there is affective discontrol, and lack of cognitive control of their effects.

And this has to do first of all, as I mentioned, to a genetic disposition that translates in certain abnormalities of neurotransmitters that effect activation and certain decreased function of brain centers, particularly the prefrontal cortex, and the singulum, which is the portion of the brain normally involved with cognitive analysis control, and affects modulation, and there is a hyperactivity of the amygdala, part of the limbic brain system that activates particularly negative effects.

So that's one cause, but that expresses itself in a certain temperate, meaning a certain general reactivity of the personality that is an inborn disposition. But that's an interesting interrelation with the conducts that infants from the beginning of life on, and then these patients have experiences of abnormal attachment.

In other words, normality in the very early relation between baby and mother that normally helps to modulate effects, so if you have a bad mother-infant relation on top of the dominance of negative effects, that reinforces negative affects significantly.

To this may come other issues, such as severe physical illness in the first year of life, with intense chronic pain. Chronic pain also generates very intense negative effects. And to this come added purely psychological traumatic situations, such as chronic chaos and unpredictability of family structure, particularly during the early years of life, and then directly physical abuse or sexual abuse, chronic witnessing of physical and sexual abuse.

And if all of this adds up to a very strong dominance of the psychic structures that are dominated by negative effects, there's the potential for an aggressive reaction for attributing that to others so that the world becoming frightening. There is so-called basic paramount orientation, which these patients defend against by a protective idealization of other experiences. So their mind starts dividing, what we call splitting up, experiences into all-good and all-bad ones.

And this splitting up of experiences into all-good and all-bad ones and not tolerating the more moderate combination of such experiences -- because everything has to be perfect because if not it becomes dangerously frightening -- then leads the syndrome of identity diffusion that I described before. The basic difficulty in integrating the concept of self, the concept of significant others, with all its consequences.

So it's a combination of causes that go from the biological, to the psycho-social, I'm saying social because, of course, children who grow up in severely disadvantaged family structures that contributes to chaos and lack of an organized protective situation during early childhood are at particular risk. So the causes are multiple and the different causes have different intensity for individual patients.

So each patient has a particular pattern of causative factors that have come together.

Dr. Van Nuys: Yes. Well, you know, as I listen to that very rich description that you've just given us, I was struck, in the beginning, as you were talking about the various brain mechanisms that are known to be involved in this - I was struck by the fact that your early training originally was as a psychoanalyst and how Freud also was trained as a neurologist.

And it's interesting that the field has evolved to the place where you can talk in such detail about the neurological processes and structures that are involved in disorders. I think Freud would have been thrilled with these developments. What do you think?

Dr. Kernberg: I think so, too. He was an excellent neurologist. And, at a certain point, he abandoned his efforts to link psychological conflicts to underlying neurobiological structures, because the neurobiology of his time was so primitive that he couldn't do it. It was a very wise step, on his part, to develop the psychological field, expecting that, somewhere in the future, psychodynamic and psychobiological fields would again converge - which, I think, is beginning to happen at this time.

Dr. Van Nuys: Yes, that's really fascinating. Now, not only for borderline-personality disorder, but you're also very well known for your work on narcissism. Is there a relationship between these two disorders?

Dr. Kernberg: Yes. In fact, narcissistic-personality disorders are really a particular complication of basic borderline-personality organization, in the sense that one way to protect oneself against the chaos of our experiences, and against these primitive splits between paranoid and idealizing relationship, is the setting up of an idealized version of oneself, what we call "pathological grandiose self", with a deep sense that one doesn't need anybody and that one's superiority is the best protection against the uncertainty, chaos, and dangers of relationships.

And this is the basic structure of the narcissistic personality, with the buildup of an idealized view of oneself as a defense against profound conflicts around aggression, with particular dominance of conflicts around a deep, unconscious envy, which is one secondary derived negative effect.

So that narcissistic personalities constitute, one might say, a secondary complication of the development of psychological structures that provide the individual with a certain surface security and confidence in himself, but at the cost of a severe decrease of the capacity for intimate relations with others.

So there is an intimate isolation of this individual; and they can function very well in the area of work and profession, but, in intimate relationships, they have terrible difficulties and end up suffering greatly. And so that is really the main problem in the treatment of narcissistic personalities: how to undo that pathological grandiose self, normalize their capacity for intimate relations with others.

Dr. Van Nuys: I see that you wrote a book, titled "Love Relations: Normality and Pathology". Is that essentially what we've just been speaking about? What's the central thesis of that book?

Dr. Kernberg: The central thesis is that, in normal love relations, one has to achieve synthesis between the capacity of sexual enjoyment and to relations in depth, so that love and sex can go hand in hand. Many patients with severe personality disorders don't have that capacity. And where they love, they can't have sex; and, where they have sex, they can't love. And so life becomes severely complicated, particularly when it comes to intimate, long-term relationships.

So, on the basis of my work with personality disorders, I felt, I could pinpoint more clearly what is involved in the normal solution of all the dilemmas of early development.

Now, again, I was basing myself in the work of many others, particularly all of the work of a British author who has done these kinds of studies in great detail, Henry Dix. And I computed that one has to be able to integrate positive and negative feelings.

Again, it's the basic function, and the basic task, the basic challenge, of life: to be able to bring together the positive and the negative. And one has to bring that together in the area of sex; in the area of intimate, emotional relations; in the area of value systems.

And so I described the conditions that bring about satisfactory long-term relationships, which is the capacity of the couple to gratify freely its needs for sexual freedom in the relationship; to be able to adjust the level of their day-to-day interactions, interests, and expectations from their daily life; and to reach a harmonious agreement at the basis of their ethical systems and moral systems, their relationships with family and group and society.

And I also described that the major threats to that are, again, unresolved conflicts from the past, because, in intimate long-term relationships, one unconsciously tends to reactivate unresolved unconscious conflicts of the relations of early childhood, so that, unconsciously, couples recreate, mutually, conflicts that haven't been resolved in the past, both being forced to repeat them and in an effort to solve them.

Now, under ordinary circumstances, couples can have good times and bad times, and they gradually learn to live together and resolve their difficulties, and that becomes very successful. Somebody has said that each marriage are really several marriages. But, under conditions of excessive conflicts, excessive character pathology, they may get locked into an unconscious repetition of problems of the past that are repeated endlessly; and that constitutes the essential nature of chronic marital conflicts.

And we have developed, also, methods to treat couples, based upon these ideas.

David Van Nuys: OK. Earlier, you mentioned transference-focused therapy; and you're recognized as the developer of transference-focused psychotherapy. But I thought all psychoanalytic therapy was transference-oriented. What's different about your approach?

Dr. Kernberg: Your point is very well taken. All psychodynamic or psychoanalytically based treatments indeed focus on the transference. What's specific about our approach is a highly specific focus on primitive transferences from the very early beginning of the treatment, and an ongoing effort to clarify them in the relationship between patient and therapist and to connect them immediately with the dominant problem in the patient's life.

So, we focus both on the transference and on dominant life problems that the patient has not been able to resolve, and do all of this in a very strict frame of treatment in a controlled treatment situation that protects the treatment and the patient from the acting out of excessive aggression, primitive aggression, that necessarily has to come into the treatment situation because it's around such painful, negative affect that the problems first came about.

So the combination of systematic transference analysis, systematic relation of the [tonalities?] to the external reality of the patient, outside the treatment sessions, and ongoing control of the treatment situation, which goes hand in hand with an ongoing analysis of how the patient reacts to such a treatment situation: these are specific aspects of the treatment.

In comparison to standard analysis, it is a much more intensive treatment, carried out with less time commitment: we need about two sessions a week, rather than the three to five that psychoanalysis takes. And the specific methods that we have developed to deal with very serious primitive transferences give the treatment a specific coloring. So it can be compared to other psychoanalytic types of treatment and derived treatment, but has this particular emphasis.

Dr. Van Nuys: OK. Well, you are a very busy professional, with lots of projects and responsibilities; so I want to thank you very much for the time that you've taken out of your day to speak with me. And I wonder if you have any last thoughts you'd like to leave our listeners with.

Dr. Kernberg: Maybe I should mention that there are important treatments that come from the cognitive-behavioral, as well as from a general psychodynamic, direction, and ours is not the only approach in this field.

But, as I said, it is geared to try to modify their personality per se. I don't think that there is any ideal treatment for all patients; and what we have to do practically today is to match patients and the optimal treatment from case to case. And how to obtain such an optimum matching is another one of our tasks.

Dr. Van Nuys: OK. Well, that's a great place for us to close. Dr. Otto Kernberg, thanks so much for being my guest today on Wise Counsel.

Dr. Kernberg: You're most welcome.


Dr. Van Nuys: I hope you enjoyed this interview with my guest, Dr. Otto Kernberg, of the Cornell University Medical School. I'm impressed both by his comprehensive command of the complexities of the disorders we discussed and by his openness to cognitive-behavioral approaches.

I've always tended to think of psychoanalysis and cognitive-behavioral therapy as more or less polar opposites; but here is one of the foremost psychoanalytic thinkers of our time declaring that both approaches have their place. That's a pretty impressive development, a testament, I think, both to how far we've come and to this remarkable man.

You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.