Transference Focused Psychotherapy & Personality Disorders with Dr. Otto Kernberg

In this episode, Dr. Otto Kernberg, a pioneer of Transference-Focused Psychotherapy (TFP), discusses personality disorders through a psychoanalytic lens. Explore key insights into Borderline Personality Disorder (BPD), identity diffusion, primitive defense mechanisms such as splitting and projective identification, and the complexities of narcissistic, paranoid, schizoid, and histrionic personalities. Dr. Kernberg also shares reflections on sexuality, aggression, reflective functioning, and why therapists choose to help others. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-239-transference-focused-psychotherapy-otto-kernberg-borderline-personality Link to YouTube video. https://youtu.be/uyPquOVhO-c

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:14David Puder?

  All right, I'm here with Dr. Odo Kernberg. He is a psychiatrist, born in Vienna, Austria, immigrated to Chile, subsequently came to America and is the founder of Transference Focused Therapy and was instrumental in our understanding of things like borderline level of organization. We're going to have a discussion today about his life, about the things that he wrote and ideas that he came up with and the evolution of it. So, welcome to the podcast. Can we start by, I know you were born in Austria-V Vienna in 1928 and you fled Nazi-occupied Austria

• 0:59David Puder?

  with your family to Chile. Tell me a little bit about that.

• 1:01Speaker 01

  Yeah, well, I was nine years and a half. Hitler invaded March 1938 and I left with my parents on July 16, 1939. My father didn't want to leave. He happened to be an Austrian monarchist and he believed all of this was gold just passing by. Hitler was a transitory phenomenon. He had a strong belief in Austrian survival. My mother had paranoid features.

• 1:44Speaker 01

  She was frightened to death with the invasion, the Anschluss. And then after Crystal Night, which in Vienna occurred on December 10, 1938, she convinced my father that we had to leave and so we got the visa to Chile and... Of course, I didn't know anything that in, I'm an only child, I was nine years and a half about. And on July 16th, 1939, she told me, "Pack everything, all toys that you have into this suitcase.

• 2:25Speaker 01

  We're leaving this afternoon and you are not supposed to tell a word to anybody." And by then, I was already acutely aware of the danger and so that's how we left. I spent one year and a half under the Nazis and it was a bad, a bad experience. Violent antisemitism naturally and all Jewish kids were expelled from schools, put into Jewish schools, forbidden to go to movies, parks, everywhere.

• 3:08Speaker 01

  Jews and dogs forbidden.

• 3:13Speaker 01

  So although I was a child, I got the feeling for it. One day, I was walking with my mother on the street and an SR man, that was Hitler's lower military guards, the SR in contrast to the SS,

• 3:34Speaker 01

  forced my mother to wash the streets, the pavement and so.

• 3:41Speaker 01

  My mother was washing the pavement and the crowd gathered, making fun of us and I was standing there. And these kind of bad experiences and that was before the war started. The war started, I think, October 1, 1939. So we just managed to escape in time because after that the border was closed. And the rest of my family all ended up in the concentration camps. They had except one cousin who managed to escape within to England with the children's transport and then to the United States.

• 4:24Speaker 01

  That's and we spent then six months in Italy before finally being the visa came and we emigrated to Chile where I lived for more than 20 years, coming to the United States.

• 4:40David Puder?

  Wow. First of all, thank you, Dr. Kernberg for sharing and I appreciate you being so honest with us about just that experience. I can imagine in part how awful that was. I imagine it was a huge loss to have to leave all of a sudden, further loss through the war, hearing about the concentration camps and the rest of your family that were stuck there. And I appreciate you sharing today. I wonder if you could tell me a bit more about some of these formative experiences that you had in Chile, some of the mentors that guided you towards becoming a therapist.

• 5:19Speaker 01

  Well, I studied medicine in Chile and was fascinated by the psychiatry professor, Ignacio Mate Blanco, who was trained in England. He was originally a neurologist trained in psychoanalysis by the Kleiner School in London. And he started the Psychoanalytic Society and Training Institute in Chile. He was a very outstanding man and became a personal idea. I was interested actually in psychoanalysis since adolescence.

• 6:01Speaker 01

  I had read Freud and in immigration to Chile, I came under the influence of a Jungian analyst. And by the time I entered medical school, I was already interested in psychoanalysis and within psychiatry, then that culminated and I decided to study psychoanalysis in Chile under the leadership of Ignacio Mate Blanco.

• 6:33Speaker 01

  And graduated there and before I came to the United States with the Rockefeller Foundation Fellowship to study research in psychotherapy. I was interested in psychotherapy, was it effective or not? And did my first research efforts in Chile and then came to the United States, spent a year at Johns Hopkins with Jerome Frank and his research group on psychotherapy and then at the Manninga Foundation in Topeka, Kansas.

• 7:07David Puder?

  Mm-hmm.

• 7:08Speaker 01

  Well, I mean, in between, I went to Chile, did all the teaching that I had committed myself to the Rockefeller Foundation who gave with the fellowship. So I fulfilled my obligation with the Rockefeller Foundation and then returned to the United States to participate in the psychotherapy research of the Manninga Foundation, a huge project that I participated in several ways until I became the director of it after Robert Wallerstein, who was the leader, left as professor of psychiatry in San Francisco.

• 7:50Speaker 01

  So during my work at the Manninga Foundation, it was there for about 12 years, I became interested and learned all I could about the diagnosis and treatment of severe personality disorders. And within the Manninga project, then I developed my own interest in studying outcome, comparing patients who were treated in supportive psychotherapy, in expressive

• 8:29Speaker 01

  or analytic psychotherapy and psychoanalysis, and came to the conclusion that patients with severe personality disorder, the so-called borderline patients who fell in between neurosis and psychosis. Really responded best to a treatment that was a well structured psychotherapy, not standard psychoanalysis, nor the usual supportive psychotherapy that was the fashion at that point.

• 9:09Speaker 01

  And so I developed a project about an ideal treatment for severe personality disorders. And at the same time, had to differentiate severe personality disorders from non severe and had to deal with the entire diagnostic differentiation within psychiatry, in which Ignacio Mate Blanco helped me enormously. When he learned in Chile that I spoke German, he said I had to read German, classical German psychiatry book. I went to the library to get Bumke and I found out it was 12 volumes.

• 9:54Speaker 01

  I didn't dare to ask him which volume he wanted me to read. And I studied all 12 volumes of Bumke and it gave me a knowledge in classical German psychiatry that helped me enormously. Wow. With the, then of course in the United States, I got the American approach to diagnosis. But I became, I made myself an expert in differential diagnosis and concluded that the common features of severe personality disorders was a lack of integration of their concept of self and a lack of integration of their concept of significant others.

• 10:38Speaker 01

  What Eric Erickson had described as identity diffusion. I picked up Erickson's concept of identity diffusion, applied it to the differential diagnosis of severe personality disorders and.

• 10:56Speaker 01

  Develop simultaneously view of psychological development, depending not on the internalization of representation of significant others, as a kind of mental representation of others from reality. But under the influence of a lecture I heard from Talcott Parsons, a leading sociologist in the United States, I learned that what is internalized are not the representation of others, but representation of the relationship

• 11:40Speaker 01

  between self and others. So when we interact with others, we internalize our representation of the other in the self-interacting. This explains, for example, why children who have been physically abused, severely abused over years become abusers in turn. We say that they identify with the abuser, yes, but in a deep sense, they have internalized their whole experience and simultaneously internalizing in their mind

• 12:23Speaker 01

  the representation of abuser and abused. And are able then to, in order to avoid, so their world becomes a relation between abusers and abused. All relationships are between abusers and abused. And it's better to be the abuser rather than the abused. So they learn.

• 12:48Speaker 01

  Role reversals and take on the role of the abuser while the role of the abuse is projected onto somebody else. So the internalized relationship with others becomes the guiding principle that organizes habitual behavior, what we call character. So the character, what we now call personality, actually personality is a broader concept that includes cognitive functions and everything else. Character, habitual behavior patterns, but they are the essential part of personality.

• 13:32Speaker 01

  And so I defined borderline personality organization as those alterations, habitual alterations of the personality that had in common identity diffusion.

• 13:49David Puder?

  Mm-hmm.

• 13:50Speaker 01

  And developed a clinical instrument, a clinical interview, the so-called structural interview, to diagnose identity diffusion and differentiate severe personality disorders from non-severe personality disorders. And of course, the entire field of personality disorder from ordinary forms of psychosis, madness in the usual sense, and organic brain syndromes such as mental retardation and dementias.

• 14:31Speaker 01

  So I linked the specific instruments for diagnosing personality disorders with the general psychiatric diagnostic approach and placed personality disorder within the general area of psychiatric diagnosis. And regarding the treatment, as I mentioned to you, proposed the combination of the psychotherapy and the strictly

• 15:03Speaker 01

  Controlled circumstances, inspired by psychoanalysis, but different from psychoanalysis by modification of psychoanalytic instruments or methods,

• 15:17Speaker 01

  and different from supportive forms of psychotherapy. More generally speaking, I would say that transference-focused psychotherapy is a psychoanalytic psychotherapy, not psychoanalysis proper. Psychoanalysis is reserved by patients with less severe neurotic illness, but the severe personality disorders

• 15:45Speaker 01

  that we now call borderline personality organization can be treated with transference-focused psychotherapy, and that's preferable to treat them than to treat them with a supportive approach, which may be carried out within a psychoanalytic perspective or a cognitive behavioral approach. In general, you can divide treatments into cognitive behavioral ones that are very effective for some patients in some circumstances, in psychoanalytic psychotherapies that are effective with other patients in other circumstances.

• 16:27Speaker 01

  So I defined a specific psychotherapy for borderline patients, and this is how my career changed. In the middle of this, I became the head of the Psychotherapy Research Project of the Menninger Foundation, but then was appointed Director of the Menninger Hospital. So I, some years, was simultaneously Medical Director of the Hospital and Director of the Research Project. And then I felt I had nothing more to learn,

• 17:10Speaker 01

  but I felt I needed a learning atmosphere to find different approaches.

• 17:17Speaker 01

  Different ways of dealing with psychiatry and psychotherapy. The main of foundations seemed to be a more limited place. And I accepted invitation to become a professor at Columbia University, New York. Went to Columbia, where I really began to start out the treatment that I devised. I was in charge of their inpatient service for severe personality disorder. And I gathered a group of people who, after a few years, were accepted, moving to Cornell.

• 18:01Speaker 01

  And I became director of the Westchester Division Hospital of the Department of Psychiatry at Cornell. And together with the group, we formed the Personality Disorders Institute. And 20 years later, after I completed my directorship of the hospital, I dedicated myself exclusively to being the director of the Personality Disorders Institute at Cornell with the help of some distinguished scientists. John Clark, the director of our empirical research.

• 18:45Speaker 01

  Frank Jomans, whom you have interviewed, who is the director of overall training. He's a fantastic psychotherapist. And there were two or three more people, a group of six or seven, who we first developed the diagnosis more clearly, more sharply, and described different types of personalities functioning at that borderline level. The narcissistic personality.

• 19:21Speaker 01

  The most important one, which we have been studying in great depth. But we also studied the paranoid personality, the schizoid personality, the infantile or histrionic personality. So we did a general study of personality disorders, their description and differentiation into those with normal identity or neurotic personality organization, with identity diffusion or borderline personality organization, and those atypical psychotic cases

• 20:04Speaker 01

  that presented as if they were personality disorders, but with a more severe illness, a psychosis, as a potential that might blow up or not in different cases. So we did, we spent the time first on differential diagnostic studies and publications, and then set up empirical study comparing transference focused psychotherapy with supportive psychotherapy and with cognitive behavioral therapy, and confirmed the effectiveness of transference focused psychotherapy,

• 20:48Speaker 01

  both in research carried out in the United States, in New York, and then replicated in Europe under the direction of Stefan Döring, professor of psychonarism in psychiatry at the University of Vienna, who gathered internally group that carried out parallel empirical research in German-speaking countries. And of course, now we have groups in many different countries

• 21:30Speaker 01

  and are continuing both research, training, and treating patients.

• 21:38Speaker 01

  That's in a nutshell.

• 21:41David Puder?

  Nice. Can you specifically talk about how in the borderline level of functioning, you have identity diffusion and primitive defenses? And can you talk about the primitive defenses that you see? How do you identify them?

• 21:58Speaker 01

  Yes. Freud had defined the ego defenses against awareness of unconscious conflicts, particularly repression and related defenses of suppression, rationalization, intellectualization,

• 22:24Speaker 01

  reaction formation.

• 22:27Speaker 01

  Those were unconscious defenses to be discovered in the course of the treatment, of psychiatric treatment, searching for the unconscious conflicts of these patients. Melanie Klein, who influenced me very importantly in my psychiatric development, discovered a group of primitive defenses centering around splitting or primitive dissociation in which the way to deal with conflicts between love and aggression by sharp splitting of the emotional experience.

• 23:11Speaker 01

  So it is not a neurotic patient may act lovingly and represses his aggression. Or he may act aggressively and represses his loving potential. Borderline patients express simultaneously love and aggression, but under different emotional conditions.

• 23:35Speaker 01

  And they have memory of when they felt opposite to the way they feel now, but they can't but feel, can't help it and have to feel now the way they feel now. So when they feel enraged, they are all rage, that there's no love. And when they feel love, all love and no rage, and they may shift from one to the other rather easily. So that's the mechanism of splitting. And it creates chaos in their relationship because they are violent and brusque changes of mood and attitude. It creates difficulty with other people who in turn respond

• 24:20Speaker 01

  to that chaotic behavior with their own difficulties. And so personality disorders tend to create abnormal interactions with other people and distort all relationships. Another primitive mechanism is projective identification. Projective identification is a tendency to attribute to the other person what one cannot tolerate at the moment in oneself. So that while you are in a state of idealization, you project your own aggression onto somebody else,

• 25:02Speaker 01

  attribute somebody else as having aggressive motivation, aggressive behavior, and you induce it in him without being aware of it and then try to control it. So projective identification is perception combined with induction, efforted control, and it is the primitive form of what advanced mechanisms show in projection, which is attributing

• 25:38Speaker 01

  Something internal to somebody else, but without any internal contact anymore with what you are projecting. In projection, you just declare the other one is what you are not, and you don't feel like that. In projective identification, you attribute it to the other one, but you know how it feels to feel like the other one, and you produce it in the other one, and you have to control it. So, projective identification is primitive form of projection. Another mechanism is that of very primitive idealization

• 26:22Speaker 01

  that doesn't tolerate an opposite of modifying it with the realization of your own aggression toward the ideal object. The idealization, the higher-level idealization recognizes one's own limitations. The primitive one, there is somebody ideal, and you identified with that implicitly become ideal as well. And the wish to omnipotent control the other person, the effort to deny

• 27:08Speaker 01

  that you've had a feeling or an action that you've had, but it no longer exists because of splitting operation. This is the primitive mechanism. So, splitting, projective identification, omnipotent control, denial, these are typical primitive defensive operations. And they're showing the behavior of people. The advanced mechanism only showing the treatment. Primitive defenses show in the behavior, in the habitual behavior of people who use projective identification and splitting and omnipotent control and deny aspects of themselves

• 27:51Speaker 01

  that have been evident at other times. So, we can diagnose through these behaviors the personality disorder. How do we diagnose a personality disorder?

• 28:07Speaker 01

  We try to find out how the person is functioning in the work and profession, love and sex, social life, family relation, self-affirmation and free time, interests, hobbies. And what we, in the structural interview, what we ask people mostly: "How are you doing in your work? Are you happy or not? Are you effective or not? Do you get along with other people or not?" And we ask the same about their sexual life: "Are you happy?

• 28:52Speaker 01

  Do you have a relationship?" When sex becomes complicated, not only because it's a fundamental aspect of life that is in conventional reality is usually suppressed and highly privileged, but because it involves implicitly the integration of the erotic dimension, sexual excitement, orgasm and sexual behavior, with the emotional feelings of love and tenderness. And when we study sexuality, we study the extent

• 29:37Speaker 01

  to which the erotic and the emotional have been integrated, which is what happens materially, normally, in contrast to conflictual lack of integration by which the erotic and the emotional remain separate and create serious problems in intimate relations. So we try to find out about that. And regarding social life, we find out to what extent the person has friends, a social environment that enriches life or feels isolated, for whatever reason,

• 30:20Speaker 01

  incapable of establishing things such as social life, and to what extent is he able to establish relationship in depth?

• 30:31Speaker 01

  In friendship, not only in sexual love,

• 30:36Speaker 01

  or to what extent is this not possible? And with patients having borderline personality organization, usually they are serious problems in work and profession, in love and sex, and in their social life, family life, such as between parents and children.

• 31:01Speaker 01

  So the present, the careful study of functioning in present life leads to the diagnosis of the personality disorder.

• 31:14David Puder?

  Can you say a little bit more about when someone has this borderline level of organization and their sexual intimacy is separated from, or from more of the erotic side? Like, how does that show up? What would a patient be saying to let you know that they've separated those two things?

• 31:36Speaker 01

  No.

• 31:38Speaker 01

  First of all, I need to modify what I said that in that there are patients on a higher level of functioning, on the neurotic level of functioning, who also have such separation between love and sex, namely, people with the mesochistic personality, which is a non borderline personality disorder. But the borderline personality organization, the patients have the greatest difficulties. The most typical is presented by the narcissistic personality.

• 32:22Speaker 01

  The most typical cases, then, they have great difficulty for intimate relations. They can't maintain an intimate relation. The men have relation with women for a few months, that's all they tolerate before the relationship goes up in smoke. So they replace the lack of intimacy of love with freedom in sex. So you find men, and the same thing holds for women. Men get involved with many women, have great sexual relation and infatuation that lasts for weeks or a few months. Then they get bored, fed up,

• 33:07Speaker 01

  end of relationship, on with the next. So that sex determines the capacity to maintain brief, repetitive relationships without a capacity for relation in depth. On the other hand, they may maintain a very dependent relationship with one woman who has a kind of a motherly function, with whom they have no sexual interest, but are very dependent and exploitive. So they may be married men who act like children who are exploitive to women who tolerate that,

• 33:51Speaker 01

  while they have sexual pleasure with a number of women. That would be one way.

• 33:59Speaker 01

  Another possibility is that they have a full sexual relation, but in which there is an alternation between intense aggression and rejection, and then re-encounter. Sex permits them to re-encounter the relationship in which there is depth and dependency. In contrast to narcissistic personality, the ordinary, non-narcissistic borderline patient is capable of maintaining long-term relationships, but within each of them, chaos in which love and aggression shift rapidly and create chronic couple conflicts.

• 34:49Speaker 01

  There are patients who, of course, there are some patients with the total inhibition of their sexual impulses, in which there has been too much aggression in very early development to permit eroticism or develop, or the strictly rigid, excessively rigid education has severely inhibited their sexual behavior, or forced it into remaining at the level of infantile sexuality. Sexual life begins with birth.

• 35:32Speaker 01

  What we now know is that children, if you leave babies alone, in the sense you don't forbid sexual behavior, they start masturbating in the second half of the first year of life, and during the second year of life, boys and girls masturbate. Girls in general tend to end this first masturbation phase around age three, around age three, but re-establish it later, at age five or six. Boys tend to, if not forbidden, tend to masturbate all through until adulthood.

• 36:14Speaker 01

  Masturbation is a normal sexual activity when there is no other sexual outlet, and we have learned that it's a normal aspect of infantile psychology, because it's taken us, Sigmund Freud, and a hundred years later, to this slowly sinking in, even in the modern forms of the various Western religions, masturbation is no longer a major sin, and so, science has

• 36:54Speaker 01

  been able to modify our attitude towards sexuality. But in general... Then in borderline personality organization, either sexuality is combined so much with aggression that chronic chaotic conflict prevent a good sexual relationship, a stable one with stable love, stable sexual erotic gratification, excitement.

• 37:28Speaker 01

  It's an alternative to not being able. A woman may be sexually excited and orgasmic with one man, totally non-responses to another one. So there may be sharp way of the splitting or division within the erotic life.

• 37:56David Puder?

  Do you see what the narcissism, specifically more of the sadism in the sexuality? Or is it, is it specific to a certain personality type? Is it more? How do you see that play out in your, in the work that you've done?

• 38:11Speaker 01

  We all have a potential for love and for aggression. That's universal. Usually, love wins over aggression. From babyhood on, we have more experience of good relations than bad ones. But of course, they are traumatized children whose life has mostly bad experiences. They are, everything goes wrong. And under ordinary circumstances, we use aggression constructively, by self-affirmation, by endurance, by defending ourselves realistically.

• 38:54Speaker 01

  And sex also enters, and aggression also enters sexuality in the sense that

• 39:05Speaker 01

  From the beginning of life, there is a pleasure in penetrating and being penetrated that already has an erotic quality. There is an erotic quality in biting, in being bitten, in fusing lovingly with the other by touching skin as well as feeling this one. It penetrates the body of the other or is being penetrated. So, the erotic impulses show from the beginning of life

• 39:44Speaker 01

  in the capacity to experience sexual excitement and to the erotic pleasure in watching one's partner, the baby watching mother and mother watching the baby, which is the origin of voyeurism or sexual pleasure with seeing the sexually prohibited part of others. And exhibitionism, which is the opposite, the erotic pleasure in showing one's forbidden parts to others to excite them.

• 40:25Speaker 01

  In mesochism, the slight pleasure in mild pain that is part of sexual excitement. And sadistic pleasure in inducing pain in the other, which is part of sexual excitement when it is within a dominant, loving atmosphere and signals the erotic pleasure of mutual fusing. When there is an excessive degree of aggression, then these tendencies become dominant and create problems.

• 41:09Speaker 01

  And the most important problem is that excessive aggression makes ordinary sexual intercourse dangerous, dangerous to penetrate, dangerous to be penetrated. And so one remains with a childlike equivalence of masturbation, voyeurism, exhibitionism, fetishism. We call them perversion or paraphilia when they become indispensable preludes to sexual intercourse, when the individual only acquires the security

• 41:54Speaker 01

  of sexual excitement and orgasm after having fulfilled these pre-genital early erotic desires. So perversion is really sexual inhibitions of the ordinary sexual behavior, retreat from it into the infantile equivalence. Normal sexual relation, however, includes all those infantile components. So a couple that has a good, mature sexual relationship may have games and plays and fantasies and activities

• 42:38Speaker 01

  of a masonicistic, sadistic, exhibitionistic, voyeuristic, heterosexual and homosexual quality and a pre-sexuality and heterosexuality unconsciousness. We have both tendencies, although usually one clearly predominates in most cases. But there are persons who, of course, who maintain both homosexual and heterosexual impulses of various degrees. So sexuality becomes complicated, as has been accentuated in recent fashions and political movements.

• 43:25David Puder?

  One thing that I really loved about the, when I read the transference-focused therapy articles, is when they looked at reflective function before and after transference-focused therapy. And I think transference-focused therapy is one of the only therapies that has shown an improvement in reflective function. Reflective function being measured by the Adult Attachment Interview. Fonagy was the main originator of that manual. Do you have any thoughts on why transference-focused therapy increases reflective function where things like dialectical behavioral therapy did not show any change in reflective function?

• 44:11Speaker 01

  Because transference-focused psychotherapy permits the full expression of a conflict in its positive and negative aspects. Patients who develop a negative transference, we don't try to reduce it. To the contrary, we try for the patient to experience fully the negative transference in terms of identifying with the hostility of the object and the self as victim, and then with the hostility of the self

• 44:55Speaker 01

  and the object as victim. In other words, we try to familiarize the patient to make him accept the extreme of his reaction, to then confront him with the opposite extreme that we also tolerate of the intensity of loving and erotic impulses toward the therapist, both as doer and recipient of love. So that by permitting the full expression of the extremes of love and aggression,

• 45:35Speaker 01

  we facilitate the interpretive integration of them and permit the patient to tolerate the simultaneous contradictory impulses.

• 45:50Speaker 01

  That are part of normal human ambivalence. And the patient then is able to see that, yes, he has an ideal view of himself as a very nice person, but in part of him is also a nasty person. And introspective insight consists in the capacity of an integrated view of all potential that one has, in contrast to remain splitting into a false idealized version, completely separate from all aggression.

• 46:34Speaker 01

  So self-reflection signifies a realistic way of assessing one in one's strengths and weaknesses, good and bad aspects. It's a mature distance from oneself, is acting in any concrete interaction.

• 46:54David Puder?

  Okay, okay. So a lot of people do not like the idea that we all have aggression, right? And what I'm hearing from you is that you really allow the patient to feel the full weight of their aggressiveness. And that's very different than like trying to give them coping strategies or trying to tell them, no, you're not really aggressive, you're not really angry. So like, give me some examples or help me understand how you might help someone tolerate their own aggression.

• 47:36Speaker 01

  Take marital conflict.

• 47:42Speaker 01

  Una mujer se odia a su mar porque lo ha tratado mal durante la comida, no ha venido a casa, ha olvidado algo importante, se enojó con él. Él en cambio, se enojó defendiéndose en medio de un gran pele, pero al mismo tiempo, ambos tienen la consciencia de que se aman, y que la pelea va a terminar de una buena manera, en una buena relación. No tienen dudas de eso.

• 48:25Speaker 01

  Toleran la interacción momentánea con la profunda convicción de la consistencia del amor dominante, en comparación con otro pareja que, cuando se enojan, sienten que esto es el fin, "Estoy saliendo de esto", "No quiero ver a ese hombre nunca más", o "a esa mujer nunca más". Así que, la tolerancia de la actitud de pelea cuando se enojan con la consciencia de la relación permanente, que transciende la momentánea,

• 49:10Speaker 01

  eso es lo que caracteriza la auto-reflectividad. La capacidad de ver la relación en general en lugar de ser víctima de una cierta actitud y luego tener el sentido de que no hay otra posibilidad de ese estado particular.

• 49:32Speaker 01

  A man gets enraged at the way his wife is treating the children and gets so enraged, he says, "You do this once, again I walk out." And he's ready to walk out and then drop the relationship. So there is an intolerance of the bad, unavoidable bad aspects of any relationship of daily life. The tolerance of ambivalence is really what marks self-reflectiveness. What Kleinian psychoanalysis calls the depressive position,

• 50:16Speaker 01

  which is the sense of the potential for sadness for treating badly people one really loves. All of us have moments in which we don't treat those we love well. It takes a baby a year or two to realize that the mother that he hates, when he hates her, is the same mother that he loves when he loves her. And eventually, he has the capacity of feeling depressed when he's angry at the mother that he loves

• 50:59Speaker 01

  and is sad over losing the mother that he loves because he's so angry. That is an indication of mature reflection, the capacity for reaction with sadness about one's own reaction and the awareness that one has a different general relationship with somebody, with one is in a momentary mood very different from the usual habitual one. A person who tends to be kind of rough

• 51:42Speaker 01

  and is acting superior with subordinate, has a kind of inappropriate grandiosity, may recognize that he has that tendency and...

• 51:56Speaker 01

  Accepts that he has problem in the way he treats others that he has to correct. And that becomes part of his personality. Watching out what he knows are problems in his own tendencies. That indicates self-reflection. General intention, how we should behave with others, controls the immediate behavior, even if it's very different of what his general attitude is.

• 52:30Speaker 01

  This is what we mean by an integrated view of self and an integrated view of others. I mean, a man comes home with a serious mind and his wife thinks, "Oh, he doesn't love me anymore." Then he comes home with a friendly face, "Ah, he loves me." She doesn't have the capacity to know that he loves her, whether it's a good mood or a bad mood. The integration of his present mood into his general relation with her indicates maturity, integration of the object representation.

• 53:15Speaker 01

  So, integration of self-representation and integration of object representation mark normality, normal identity and capacity for reflectiveness. And we develop that throughout the treatment that tends to resolve primitive defensive operations, normalize identity and therefore normalize the capacity of dealing with the major tasks of work and profession, love and sex, social life and one's own creativity.

• 53:56David Puder?

  Tell me about your thoughts on envy and how someone with maybe more narcissistic, borderline-level functioning, how envy shows up for them versus maybe normal people?

• 54:13Speaker 01

  A very good question.

• 54:16Speaker 01

  Envy is a normal aggressive affect with very specific characteristics. It is anger at somebody with something that we want and we don't have. So we want something that we don't have and are angry at whoever has it when we don't.

• 54:45Speaker 01

  It is a normal way in which a baby sees another baby has a toy. He wants to have that toy and gets angry if he doesn't get that toy or something exactly like it.

• 55:02Speaker 01

  So it is a human emotion that is one of the negative aspects of our potential that normally we tolerate, it doesn't control our lives. With narcissistic personality, the problem is they present very intense aggression that takes the form of envy. Usually, the cause of that is a lack of loving, sufficiently loving relationship in very early life, in the first two or three years of life. When one feels loved,

• 55:46Speaker 01

  one feels, one internalizes a good representation of others and feels fulfilled by the people who have been good to one. If one doesn't have any of this, there's a sense of emptiness and one gets painful.

• 56:06Speaker 01

  The painful observer that other people feel so good about their relation with others, while we feel so bad. So envy becomes a very strong motivation, because basically we don't feel the internalization of love that others have. And envy then grows to the extent that whatever we like and don't have enrages us.

• 56:46Speaker 01

  It destroys our relationship because whomever we could love and be friendly with turns out to have things that we don't have to begin with the very capacity to love. So the way and envy is very gives one a painful sense of lacking, of emptiness. And the way to fight it off is to devalue what one envisions. Normally, when we get a good response to our behavior from others,

• 57:30Speaker 01

  we feel very happy that others love us and we see it as a gift. In other words, normally we have a feeling of gratitude for love that we get. Envious person lack their capacity of gratitude, because what they get gives them a sense what they didn't have. It reminds them of what they didn't have, which colors. What they get, they are happy that they get it, but they don't have that feeling of happiness with the happiness that the other feels in giving them something.

• 58:16Speaker 01

  So envy tends to spoil what one envies, which means that narcissistic personality fall in love with a woman, unconsciously hate what they admire in her, from her physical appearance to her capacity, to her potential. And so unconsciously they tend to devalue it and that makes this woman indifferent and boring and they have to drop her. So unconscious envy, the defenses, the defense against it by devaluation is what motivates the sexual promiscuity of narcissistic personalities.

• 59:01Speaker 01

  The counterpart of envy is an unconscious destruction of the values that others have and that one doesn't. Students with a narcissistic personality can learn only what they feel they learn because they take over what others know. They incorporate the knowledge from other. That's a kind of, it's like stealing from other. It makes them feel good. But when they have to acknowledge that they depend on the other,

• 59:44Speaker 01

  it spoils it because then envy is unavoidable. Narcissistic personalities can learn from what they learn by what they feel they are learning by themselves, without anybody giving them anything. They take it from others. But they can't read a book, they can't learn from a book because they have to, there is independent knowledge from them and they resent it.

• 1:00:11Speaker 01

  So you find very intelligent people who can't read a book or spoil their own capacity of interest in a certain field.

• 1:00:23Speaker 01

  So envy tends to ruin the capacity to absorb good things, establish good relationship. In the worst case, in a area, one cannot enjoy anything except being admired,

• 1:00:42Speaker 01

  which is recognizing of one's greatness by the others. And one of the predisposition to the narcissistic personality are parents who really don't love their children, but they are happy with admirable things that children have, that others admire. The child, the parent, the narcissistic parent uses the child as something great. That, you say, "Look what beautiful children I have." So they admire their child, but they don't love it.

• 1:01:21Speaker 01

  So when the, when love is replaced by admiration as the only source of love one receives, it fosters narcissistic personality. One has no hope for love. Only when others admire one, one can feel good about oneself. So the psychopathology of envy is very damaging and a major issue in the treatment that one solves by analyzing all its causes and consequences.

• 1:02:01David Puder?

  I'm also curious about, you, you mentioned histrionic personality before. Do you, do you see this on the borderline level of functioning or more the neurotic or both?

• 1:02:16Speaker 01

  There is a confusion in the literature about this.

• 1:02:21Speaker 01

  There exists a high-level personality disorder, the hysterical personality disorder, which has normal identity. And the main problem is sexual inhibition and efforts to overcome the sexual inhibition by various means. Sexuality is a great problem. They act quite maturely, except when it comes to sex, when they become quite childish. Now, because politically hysterical personality usually went together with an attack of women

• 1:03:04Speaker 01

  because the impression was that only women had hysterical personality, which is false. Men also present hysterical personalities. The official classification of personality disorders called it "histrionic personality disorder", so to take it away from its political implication. And the histrionic personality disorder in the official classification covers both the hysterical and the histrionic in a strict sense equivalent to the infantile personality,

• 1:03:46Speaker 01

  which are patients who have sexual difficulties but part of a general severe personality disorder with identity diffusion. So that the histrionic personality, how it is used generally, refers to a broad spectrum. Most of them are really a borderline personality organization, when in fact a subgroup is part of a higher-level neurotic organization. How do we make that differentiation?

• 1:04:27Speaker 01

  The histrionic personality disorder is childlike or infantile in all aspects of life:

• 1:04:36Speaker 01

  work, profession, school, love, sex, social life. And is part of this childlike regression, feelings are expressed through behavior more than verbally. And the exaggeration of behavior is what from the outside looks at theatricality and exaggeration, theatrical exaggerated behavior, which has an infantile quality to it

• 1:05:16Speaker 01

  and is an important aspect of those personality disorders. Histrionic means behavioral exaggeration of real feelings one has and conveys a sense of artificiality in contrast to the expression of real feelings in a profound sense. So these are patients who give the feeling that they exaggerate, that they do theater with what they feel to impress others,

• 1:05:56Speaker 01

  as if it were a profound, it's lack of sincerity, lack of honesty, when it is really part of a general childlike regression to childlike communication of affect. So the histrionic personality are personalities with childlike behavior in all their interactions that may include sexual inhibitions, but very often, surprisingly, doesn't. So often, the histrionic personality on a borderline level are freer sexually than the hysterical personality on an erotic level,

• 1:06:40Speaker 01

  because the hysterical personality using the mechanism of repression.

• 1:06:46Speaker 01

  Inhibits totally the sexual response, while the borderline personality, by the splitting mechanism, is able to have great sex with one partner and zero with others. So in a strange way, borderline patients may be freer often sexually than higher level neurotic patients. The main problem is in the relationship with others. And of course, borderline patients who on top of all their problems have an extremely severe sexual inhibition with zero capacity for any sexual excitement

• 1:07:30Speaker 01

  or enjoyment, constitute the most serious part, the most serious part of sexual inhibition that requires long-term treatment.

• 1:07:46David Puder?

  Do you want to talk about borderline level of functioning with the paranoid personality type? Like, what is kind of like the thing that is most common with that group?

• 1:08:00Speaker 01

  Paranoid personalities are using the mechanism of projective identification as a dominant mechanism. They are part of borderline personality organization with intense aggression that they attribute to others because of that mechanism, meaning that they are hypersensitive to anything that can be interpreted as a negative attitude toward them. They are suspicious that others' behavior indicates hostility toward the person,

• 1:08:42Speaker 01

  hostility or the effort to disguise or hide hostility. At the same time, they tend to be very aggressive because they have excessive aggression and they tend to use omnipotent control, efforts to control the other person whom they see is dominated by aggression toward them. So the combination of aggressive behavior...

• 1:09:16Speaker 01

  Hypersuspiciousness and efforts of sadistic control of others are the main characteristics of the paranoid personality.

• 1:09:33David Puder?

  And you touched on schizoid a little bit, schizoid with borderline level of functioning?

• 1:09:40Speaker 01

  Yeah, the schizoid personality uses predominantly the mechanism of splitting in effort to avoid conflicts by such generalized splitting of the expression of all affects, that it is as if they had no affects. There is a kind of a fragmentation of affect as if

• 1:10:12Speaker 01

  extreme forms of splitting. So they fragment both their aggressive affects and withdraw from contacts in order not to be tempted to become aggressive. And they fragment the view of themselves as aggressive to avoid it. And sometimes they show a very sharp perception

• 1:10:54Speaker 01

  of others because they are so suspicious and so observant, nothing escapes them. They are very good in spite of the identity diffusion to know exactly what to expect from others. But about self, they have a complete confusion because of the fragmentation of all affective experience. So the identity diffusion shows in sharp description of others while they look an integrated view of them. They see the trees, but they don't see the wood.

• 1:11:41Speaker 01

  And they withdraw protectively from avoiding aggressive interaction with others. They are in, they look as if they didn't need affect, affective relation and love. That's a mistake. They do need love, but they are afraid that their own aggression will destroy the affective potential of a good relation with significant others. So the withdrawal protects them from direct search for love.

• 1:12:24Speaker 01

  And to the contrary, one has, they have to do a tremendous effort to be able to express any

• 1:12:34Speaker 01

  close relationship with others. So their relationships are distant. The affect is dispersed.

• 1:12:45Speaker 01

  So it's hard for them to know what they really want and they are ignorant of their own deep needs for love that they have to reject out of fear of being rejected.

• 1:13:05Speaker 01

  And so there is hyper alertness to what's going on, but without the aggression of the paranoid personality.

• 1:13:20Speaker 01

  Social withdrawal rather than omnipotent control. And, and a sense of uncomfort and loneliness and distance in group situations. So a sense of loneliness, confusion about the self, not clear awareness of their need of significant others. And they are capturing of the great details of the personality of others without really putting it together in the integrated view. These are the main characteristics of the schizoid personality.

• 1:14:04Speaker 01

  And the so-called schizotypal is just a more severe form of that, except that in the schizotypal there is a genetic, stronger genetic hereditary disposition than in the schizoid personality.

• 1:14:27David Puder?

  What role does fantasy play for schizotypal and schizoid?

• 1:14:31Speaker 01

  They, in withdrawing from immediate social reality for the reasons that I mentioned, they replace their interaction with others by an intense fantasy life. They find in their intense fantasy life an expression of their need of relating to others. So they are particularly prone to create their own eternal world, gratifying their needs, because they don't dare to express it in external reality out of the fear of their own aggression.

• 1:15:15David Puder?

  How about someone who's classically borderline personality disorder? How do you make of their intense fear of disconnection, of the withdrawal of the other?

• 1:15:29Speaker 01

  Well, because the splitting operation

• 1:15:39Speaker 01

  and the activation of intense aggression toward people whom they love, they project the aggression. And any real frustration creates an exaggerated reaction. They are afraid of being left, of being dropped, of being abandoned, because they see others with the intense aggression that they can't tolerate in themselves.

• 1:16:13Speaker 01

  So they take one way to solve the dilemma between love and aggression is to look for an ideal relation with the other is a protection against the feared aggressive rejection by the other. So they become very dependent and intolerable of being separate. That intolerance of separation has to do with the fact that any separation is immediately translated into a sense of an aggressive rejection of the patient.

• 1:16:53David Puder?

  Good, good. What do you think of most therapists who come into practice? Do you find them more of the depressive personality type? Or what kind of range have you seen?

• 1:17:07Speaker 01

  Well, I've had a long professional life. And I've seen, I've seen, I think, a very broad spectrum of patients, yes. I believe I've seen probably most patients described in the literature.

• 1:17:31David Puder?

  Is there a commonality of the helper, of the person that wants to help? Maybe, maybe of the person where there was a reversal early on in their childhood, where they were the ones who were like the family therapist, even at a very young age? Like, what is, like, how, what do those, where do those people fit in your sort of?

• 1:17:51Speaker 01

  I think that therapists may have many reasons for becoming a therapist. Very often, persons who have had strong personal problems that they have overcome, then want to become therapists out of an experience of gratitude and identification with the people who helped them.

• 1:18:18Speaker 01

  Some people are looking for solution of their own problems in helping others.

• 1:18:25Speaker 01

  For some people,

• 1:18:28Speaker 01

  it is a source of great gratification to have a profession that helps others. And there go all the motivations for medical professions, nursing, psychology, including that of psychotherapist, interested in the psychological functioning of self and others and how to modify it. There are some people who become psychotherapists secondary to their interest in neurobiology, in the functioning of the brain.

• 1:19:13Speaker 01

  Sometimes, psychotherapists have the unconscious motivation of helping others out of the situation in which the therapist had been in the past, broadening the effects of his treatment. And

• 1:19:39Speaker 01

  one thing that was important for me was that sense of being able to change one's way of behavior. I had ways of behaving I was not happy with, and I had difficulty changing. And I wanted to know how much change can one obtain in self and in others. That drew me to get into personal psychoanalysis first, and then became interested in psychotherapy in general.

• 1:20:14David Puder?

  And how much did you change?

• 1:20:17Speaker 01

  I changed significantly. I changed significantly. I had two personal analysis, so I had people helping me. And I had the luck of great teachers, really, an unusual luck that met a number of the leaders of the field.

• 1:20:42Speaker 01

  And we some of them became real friends and that was very important. I owe a great deal to people such as Eddie Jacobson and Andre Green and Betty Joseph and many others.

• 1:21:09David Puder?

  But it sounds like you were also a great student because when he gives, when he tells you to read the book, you read the 12 volumes, it sounds like you, which it's an unusual, unusual student to come back and said, I read the 12 volumes.

• 1:21:26Speaker 01

  I read, I admired him greatly and it was worth it. I learned descriptive psychiatry more than most psychiatrists of my generation. It helped me to become very observant about small issues of behavior. It really was, I got a specialized training.

• 1:21:58David Puder?

  What would you say is something that you feel a lot of therapists don't understand that you wish they would understand at this point?

• 1:22:09Speaker 01

  It's very difficult to generalize. I, my experience is mainly with psychodynamic psychotherapists. I have limited experience of working with cognitive behavioral therapists, although I do have some and I'm very impressed by what some cognitive behavior therapy can achieve. But for psychoanalytic psychotherapist, I think the most important issue is, first of all, comfort with one's own aggression.

• 1:22:53Speaker 01

  Therapists have to be comfortable with their own aggression, not having to act it out, nor being afraid of it. That's one important issue.

• 1:23:06Speaker 01

  One, of course, crucially, was having a real interest in people and getting to know about people. Being curious about how how other people are functioning. There are many therapists who don't pay sufficient attention to that. Then I think psychotherapists need to have a great sense, a great common sense. Common sense. Psychotherapy starts where common sense ends. And in order to deal with the subtlety of conflicts,

• 1:23:46Speaker 01

  one has to have first a good hold of solid reality.

• 1:23:54Speaker 01

  I think the therapists can come from many directions. They can come from a very intuitive, emotional direction or a very intellectual ones. And they have to learn to complement what comes natural with what they have to learn. The very intellectual one have to learn about expression of emotions. And the most emotional intuitive one have to learn how to formulate things cognitively.

• 1:24:29Speaker 01

  And a really a strong wish to help other people.

• 1:24:38Speaker 01

  I think these are the most important ingredients.

• 1:24:43David Puder?

  Yeah. Yeah, that's good. Well, as we kind of, I don't want to take too much of your time today. And I'm, I could, I feel like almost a part two is necessary to hash out some more of these ideas. Or a part 10 or a part 11. But I'm curious, as we've talked today, if any lingering ideas are going through your mind that you haven't had adequate time to express.

• 1:25:12Speaker 01

  Yeah. I think the the great goal of treatment are to help people to become more effectively self-affirmative and at the same time, more capable to develop relationship in depth with others.

• 1:25:35Speaker 01

  These are

• 1:25:38Speaker 01

  two basic issues of normal functioning. To take care of one's relations with others

• 1:25:47Speaker 01

  and to take care of oneself in a reasonable way.

• 1:25:53Speaker 01

  Acquire full responsibility for one's behavior in one's life.

• 1:26:00David Puder?

  Do you, okay, so one more, one more question. Do you, do you feel like there's any room to explore the thing that you were doing before you did the psychoanalysis two times that you wanted to change? And did you actually feel it changed?

• 1:26:17Speaker 01

  Are you asking me whether I was considering some other profession?

• 1:26:22David Puder?

  No, no, no, no. You, you said earlier there was something about yourself that you wanted to change through, through psychoanalysis. Do you, is there anything else you would be willing to share about that publicly?

• 1:26:40Speaker 01

  Yeah, well, I, I don't want to share too many personal issues, but I used to be quite obsessive, excessively intellectual and I have become much freer with my emotions.

• 1:27:03David Puder?

  Well, I, I thank you for that. And thank you for coming on. I've really enjoyed my time talking to you, Dr. Kernberg. It's a, it's a pleasure. I, I'm very grateful for, for your, your many articles and books and

• 1:27:20David Puder?

  there was just a recent biography that was written about you. I think Yeoman's wrote it in part. That I've appreciated. And I know the people that I've been listening to my podcast for a while have been grateful for his expertise. And I'm sure they'll be grateful for you coming on today. So, thank you so much.

• 1:27:41Speaker 01

  You're most welcome. It's been a pleasure. I'm glad it worked out.