Otto F. Kernberg

Notes on Countertransference

wo CONTRASTING approaches in regard to the concept of countertransference could be described. Let us call the first approach T the “classical” one, and define its concept of countertransference as the unconscious reaction of the psychoanalyst to the patient’s transference. This approach stays close to the use of the term as first proposed by Freud (8) and to his recommendation that the analyst overcome his countertransference (9). This approach also tends to view neurotic conflicts of the analyst as the main origin of the countertransference. Let us call the second approach the “totalistic” one; here countertransference is viewed as the total emotional reaction of the psychoanalyst to the patient in the treatment situation. This school of thought believes that the analyst’s conscious and unconscious reactions to the patient in the treatment situation are reactions to the patient’s reality as well as to his transference, and also to the analyst’s own reality needs as well as to his neurotic needs. This second approach also implies that these emotional reactions of the analyst are intimately fused, and that although countertransference should certainly be resolved, it is useful in gaining more understanding of the patient. In short, this approach uses a broader definition of countertransference and advocates a more active technical use of it. Some radical proponents of this approach

A psychoanalytic classification of character pathology.

111s PAPER IS A proposal for a classification of character patholT o n which integrates recent developments in our understanding of severe forms of character pathology, especially tlie so-called “borderline conditions,” with recent developments in psychoanalytic metapsychology. This classification attempts (1) to establish psychoanalytic criteria for differential diagnoses among different types and degrees of severity of character pathology; (2) to clarify the relationship between a descriptive characterological dihgnosis and a metapsychological, especially structural, analysis; and (3) to arrange subgroups of character pathology according to their degree of severity. This system of classification should help in the diagnosis of character pathology by providing the clinician with more systematic information about the descriptive, structural, and genetic-dynamic characteristics of the different forms of character pathology. It should also help in the treatment of patients suffering from character pathology by singling out the predominant constellations of character defenses and other defenses peculiar to the categories of character pathology which I propose to describe. Last, but not least, this proposed classification should help in determining the prognosis for psychological treatment in these conditions by differentiating types of character pathology with varying degrees of indication for psychoanalytic treatment and for psychoanalytically oriented psychotherapy.

Factors in the Psychoanalytic Treatment of Narcissistic Personalities

N THIS PAPER I shall discuss the etiology, diagnosis, prognosis, and some factors in the treatment of patients with narcissistic I personality structure. I do not expect to treat the subject exhaustively, but I hope to shed new light on certain areas. This paper deals mainly with the clinical problem of narcissism, and such metapsychological considerations as will be presented shortly have to do only with the etiology of pathological narcissism and not with the broader issue of the theory of narcissism in psychoanalysis. I suggested in an earlier paper (8) that narcissistic as a descriptive term has been both abused and overused, but that there does exist a group of patients in whom the main problem appears to be the disturbance of their self-regard in connection with specific disturbances in their object relationships, and whom we might consider almost a pure culture of pathological development of narcissism, It is for these patients that I would reserve the term narcissistic personalities. On the surface, these patients may not present seriously disturbed behavior; some of them may function socially very well, and they usually have much better impulse control than the infantile personality.

Institutional Problems of Psychoanalytic Education

I believe that psychoanalytic education is suffering from serious disturbances, which, by analogy, might be examined as an illness affecting the educational structures of psychoanalytic institutes and societies. After describing the symptoms of this illness, I shall explore its causes and suggest a possible course of treatment. My objective is not to present “ideal solutionsy” to problems, but to provide a theoretical frame that might facilitate such solutions.

Neural substrates of the interaction of emotional stimulus processing and motor inhibitory control: An emotional linguistic go/no-go fMRI study

Neural substrates of behavioral inhibitory control have been probed in a variety of animal model, physiologic, behavioral, and imaging studies, many emphasizing the role of prefrontal circuits. Likewise, the neurocircuitry of emotion has been investigated from a variety of perspectives. Recently, neural mechanisms mediating the interaction of emotion and behavioral regulation have become the focus of intense study. To further define neurocircuitry specifically underlying the interaction between emotional processing and response inhibition, we developed an emotional linguistic go/no-go fMRI paradigm with a factorial block design which joins explicit inhibitory task demand (i.e., go or no-go) with task-unrelated incidental emotional stimulus valence manipulation, to probe the modulation of the former by the latter. In this study of normal subjects focusing on negative emotional processing, we hypothesized activity changes in specific frontal neocortical and limbic regions reflecting modulation of response inhibition by negative stimulus processing. We observed common fronto-limbic activations (including orbitofrontal cortical and amygdalar components) associated with the interaction of emotional stimulus processing and response suppression. Further, we found a distributed cortico-limbic network to be a candidate neural substrate for the interaction of negative valence-specific processing and inhibitory task demand. These findings have implications for elucidating neural mechanisms of emotional modulation of behavioral control, with relevance to a variety of neuropsychiatric disease states marked by behavioral dysregulation within the context of negative emotional processing.

Changes in Prefrontal-Limbic Function in Major Depression after 15 Months of Long-Term Psychotherapy

Neuroimaging studies of depression have demonstrated treatment-specific changes involving the limbic system and regulatory regions in the prefrontal cortex. While these studies have examined the effect of short-term, interpersonal or cognitive-behavioural psychotherapy, the effect of long-term, psychodynamic intervention has never been assessed. Here, we investigated recurrently depressed (DSM-IV) unmedicated outpatients (N = 16) and control participants matched for sex, age, and education (N = 17) before and after 15 months of psychodynamic psychotherapy. Participants were scanned at two time points, during which presentations of attachment-related scenes with neutral descriptions alternated with descriptions containing personal core sentences previously extracted from an attachment interview. Outcome measure was the interaction of the signal difference between personal and neutral presentations with group and time, and its association with symptom improvement during therapy. Signal associated with processing personalized attachment material varied in patients from baseline to endpoint, but not in healthy controls. Patients showed a higher activation in the left anterior hippocampus/amygdala, subgenual cingulate, and medial prefrontal cortex before treatment and a reduction in these areas after 15 months. This reduction was associated with improvement in depressiveness specifically, and in the medial prefrontal cortex with symptom improvement more generally. This is the first study documenting neurobiological changes in circuits implicated in emotional reactivity and control after long-term psychodynamic psychotherapy.

Transference focused psychotherapy: Overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non‐analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.

An approach to the psychobiology of personality disorders

Human variability in temperament allows a unique natural experiment where reactivity, self-regulation, and experience combine in complex ways to produce an individual personality. Personality disorders may result from changes in the way past memories filter new information in situations of emotional involvement with others. According to this view, disorders are specific to their initiating circumstances rather than a general difficulty that might extend to classes of information processing remote from triggers for the disorder. A different view suggests a more general deficit in attentional control mechanisms that might extend to a wide range of situations far from those related to the core abnormality. This paper outlines methods for examining these views and presents data from the study of borderline personality disorder, arguing in favor of high negative emotionality being combined with a deficit in an executive attentional control network. Because this attentional network has already been well described in terms of anatomy, the cognitive operations involved, development, chemical modulators, and effects of lesions and candidate genes, these findings may have implications for understanding the disorder and its treatment. We consider these implications in terms of a general approach to the study of personality development and its disorders.

Regression in Organizational Leadership

The choice of good leaders is a major task for all organizations. Inforamtion regarding the prospective administrators personality should complement questions regarding his previous experience, his general conceptual skills, his technical knowledge, and the specific skills in the area for which he is being selected. The growing psychoanalytic knowledge about the crucial importance of internal, in contrast to external, object relations, and about the mutual relationships of regression in individuals and in groups, constitutes an important practical tool for the selection of leaders.

Projection and projective identification: developmental and clinical aspects

Projective identification and projection are defined, described, and contrasted. Projective identification is seen as an early or primitive defensive operation, and projection as later or more advanced and derivative in nature. The developmental origins and adaptive functions of projective identification are examined with an emphasis on the cognitive preconditions for the operation of this defense. The varying functions of both defensive operations are described within the context of psychotic, borderline, and neurotic personality organization. Case material is presented to illustrate the diagnostic approach to and the clinical functions of projective identification, particularly its importance in contributing to complementary identification in the countertransference. Also illustrated is the technical management of severe transference regression under the impact of projective identification. Finally, alternative approaches to the diagnosis and interpretation of projective identification are discussed.