Otto F. Kernberg

Kernberg designed TFP especially for patients with BPO. According to him, these patients suffer from identity diffusion, primitive defense operations and unstable reality testing.

Identity diffusion results from pathological object relations and involves contradictory character traits, discontinuity of self and either very idealized or devalued object relations. Defense operations often applied by BPO patients are splitting, denial, projective identification, primitive devaluation / idealization and omnipotence. Reality testing is negatively influenced by the primitive defense mechanisms as they change a person's perception of self and others.

The major goals of TFP are better behavioral control, increased affect regulation, more intimate and gratifying relationships and the ability to pursue life goals.[2] This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations and the resolution of identity diffusion that perpetuate the fragmentation of the patient's internal representational world.[2] To do this, the client's affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference.[3] Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.[2]

The treatment begins with the development of the treatment contract, which consists of general guidelines that apply for all clients and of specific items developed from problem areas of the individual client that could interfere with the therapy progress. The contract also contains therapist responsibilities. The client and the therapist must agree to the content of the treatment contract before the therapy can proceed.

TFP consists of the following three-steps:

• (a) the diagnostic description of a particular internalized object relation in the transference
• (b) the diagnostic elaboration of the corresponding self and object representation in the transference, and of their enactment in the transference /countertransference and
• (c) the integration of the split-off self representations, leading to an integrated sense of self and others which resolves identity diffusion.

During the first year of treatment, TFP focuses on a hierarchy of issues:

• the containment of suicidal and self-destructive behaviors
• the various ways of destroying the treatments
• the identification and recapitulation of dominant object relational patterns (from unintegrated and undifferentiated affects and representations of self and others to a more coherent whole).[2]

In TFP, hypothesized mechanisms of change derive from Kernberg's[4] developmentally based theory of Borderline Personality Organisation, conceptualized in terms of unintegrated and undifferentiated affects and representations of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relation dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a 'split' psychological structure in which totally negative representations are split off/segregated from idealized positive representations of self and other (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is the integration of these polarized affect states and representations of self and other into a more coherent whole.[4]

This is a normal self-esteem based on normal structures of the self. The individual has introjected whole representations of objects, has stable objects relationships and a solid moral system. The superego is fully developed and individualized.

Regulation of self-esteem occurs through gratifications related to the age, which include or imply a normal infantile system of values, demands or prohibitions.

Three subtypes

• Regression to the regulation of infantile self-esteem. The ideal ego is dominated by infantile pursuits, values and prohibitions. The regulation of self-esteem is overly dependent on expressions or defences against infantile pleasures, which are discarded in adult life. This is the mildest type of narcissistic pathology.
• Narcissistic choice of object. This type is more severe than the first one but more rare. The representation of the infantile self is projected on an object and then identified through that same object. Thus, a libidinal association is generated, where the functions of the self and the object have been exchanged.
• Narcissistic personality disorder. This type is different from both normal adult narcissism and from regression to normal infantile narcissism. It is the most severe type and is suitable for psychoanalysis.

In Kernberg's view, narcissistic personalities are differentiated from both normal adult narcissism and from fixation at or regression to normal infantile narcissism. Fixation at a primitive stage of development or lack of development of specific intrapsychic structures is not adequate to explain the characteristics of narcissistic personalities. Those characteristics (through a process of pathological differentiation and integration of ego and superego structures) are the consequence of pathological object relationships. Pathological narcissism is not merely the libidinal investment in the self but in a pathological, underdeveloped structure of the self. This pathological structure presents defences against early self and object images, which are either libidinally or aggressively invested. The psychoanalytic process brings to the surface primitive object relations, conflicts and defences, which are typical of the developmental stages that precede the stability of the object.

One of the main disagreements between the two theorists revolves around their conceptualization among narcissistic and borderline disorders. According to Kernberg,[5] the defensive structure of the narcissistic individual is quite similar to that of the borderline person since the former has a fairly underlying borderline personality organization which becomes obvious when one looks at the defenses of splitting and projective identification. He identifies constitutional along with environmental factors as the source of disturbance for these individuals by stressing the important role of the mother surrogate who treats the child on the surface (callously) with little regard for his/her feelings and needs. Kohut on the other hand, sees borderline personality as totally distinct from the narcissistic one and less able to benefit from the analytic treatment. Equally, a narcissistic personality is more apt for analysis since it is characterized by a more resilient self. According to Kohut , the environment alone is the major cause of troubles for these persons. Moreover, although both focus on the concept of the "grandiose self" in their narcissistic personality theorizing, they provide different explanations for it. For Kohut, "grandiose self" reflects the "fixation of an archaic 'normal' primitive self" while for Kernberg it is a pathological development, different from normal narcissism. For Kohut treatment should be primarily centered on encouraging the patient's narcissistic desires, wishes, and needs to open up during the process of transference. For Kernberg, the goal of treatment should be to use confrontation strategies so as to help the patient integrate his/her internal fragmented world.

One of the main arguments between Kohut and Kernberg is about normal and pathological narcissism. As mentioned earlier, Kohut assumes that a narcissistic personality suffers from developmental arrest. Specifically, he assumes that this type of personality mirrors adaptive narcissistic wishes, needs, and objectives that, nevertheless, have not been satisfied during childhood development by the parental environment. Here, the grandiose self is nothing more than an archaic form that prospectively ought to become the normal self. When this does not occur then pathological narcissism emerges. In his explanation of pathological narcissism, he pays attention on the libidinal forces or charges in order to provide an etiology of how this disorder develops. For him the aggression drive is of secondary importance in respect to the libidinal drive and that is why one should differentiate between ordinary aggression and narcissistic rage. The first, according to him, is adaptive for eradicating obstructions when heading toward a realistic goal whereas the second is the forceful response to narcissistic injury. Kernberg however, sees Kohut's ideas as de-emphasizing the power of aggression. He allies more to the Freudian conceptualization, by proposing that narcissistic behavior results from pathological development in which aggressive drives play a central role. He argues that narcissism on the whole involves a strong aggressive drive that cannot possibly be analyzed separately from the libidinal one. As he says, "one cannot study the vicissitudes of normal and pathological narcissism without relating the development of the respective internalized object relations to both libidinal and aggressive drive alternatives."

Kohut departed from the classical Freudian view, which suggested that some patients could not be analyzed given that they lacked the ability to develop transferences. He postulated that narcissistic patients are capable of presenting transferences but these are somewhat different from those of other patients, such as the neurotics. He distinguished three types, namely the idealizing, the mirror, or the twinship transference. His debate with Kernberg concerns mostly the idealizing transference, which, according to Kohut, relates to a fixation at an archaic level of normal development. Still Kernberg believed that the idealizing transference is nothing more than a pathological type of idealization that is produced as a response to the substantial instigation of the grandiose self in the transference.

Otto F. Kernberg and Heinz Kohut regard the analytic process as well as the role of the analyst in quite different terms.

Kernberg requests a methodological and persistent interpretation of the defensive function of grandiosity and idealization as they emerge in transference.[6] The role of the analyst should be neutral rather than supportive, especially during the confrontation process, in order to modify the narcissist's pathological structure. "The analyst must be continuously focusing on the particular quality of the transference in these cases and consistently counteract the patient's efforts toward omnipotent control and devaluation".[5] This traditional emphasis on aggressive interpretation of narcissistic phenomena derives from and is wholly consistent with Freud's early view of narcissistic neuroses as unanalysable and narcissistic defenses as generating the most recalcitrant resistances to the analytic process.

In contrast to seeing primitive grandiosity or idealization as a representation of a defensive retreat from reality, Heinz Kohut regards narcissistic illusions within the analytic situation as representations of the patient's attempt to establish crucial developmental opportunities.[7] These narcissistic illusions thus give an opportunity for revitalization of the self.[7] Therefore, Heinz Kohut advocates that the analyst's position within treatment should be one where a full narcissistic transference should be encouraged instead of being challenged. To establish this, the analyst should be able to show empathic comprehension, which entails a receptivity to the narcissistic illusions and an avoidance at all costs of anything which would challenge them or suggest they are unrealistic.[7] Heinz Kohut used the concepts of narcissistic transference and self-object needs. He also stressed the significance of infantilism and what appear to be excessive demands on the analyst and everyone else. Rather than instinctual wishes to be renounced, they are missed developmental needs to be warmly received and understood. The patient is groping toward self-cure, by trying to extract from others what was missing early in his development. Heinz Kohut feels the patient knows what he needs, regardless of what the analyst may think he knows. He stresses the importance of hopes in maturity and throughout development. There is an enduring need for ideals and idealization that vitalizes self experience.[8] In his work with narcissistic patients, the defining feature of Heinz Kohut's psychoanalytic methodology became therefore empathic immersion (or vicarious inspection),[9] whereby he tried to put himself in his patient's shoes.[10] This view is certainly in contrast with Freud's early view of the analyzability of narcissistic defenses as discussed above.

Both Kohut and Kernberg regarded each other's approaches as counterproductive. From Kohut's point of view, the methodical interpretive approach recommended by Kernberg is interpreted by the narcissistically vulnerable patient as an assault and generates intense narcissistic rage. As Kernberg instead recommends this methodology for treating these patients, self-psychology regards Kernberg as creating narcissism instead of treating it.[7] On the other hand, Kernberg (from the more traditional point of view) sees the approach of Kohut as leading to nothing. An unquestioning acceptance of the patient's illusions with the assumption that they will eventually diminish of their own accord represents a collusion with the patient's defenses. The analytic process is thereby subverted and the analyst never emerges as a figure who can meaningfully help the patient.[7]

However, Stephen A. Mitchell offers an integrative relational approach in which the perspectives of both Kernberg and Kohut are connected. In his opinion, "the more traditional approach to narcissism highlights the important ways in which the narcissistic illusions are used defensively, but misses their role in health and creativity and in consolidating certain kinds of developmentally crucial relationships with others. The developmental-arrest approach (Kohut) had generated a perspective on narcissism which stresses the growth-enhancing function of narcissistic illusions, but overlooks the extent to which they often constrict and interfere in real engagements between the analysand and other people, including the analyst". Mitchell recommends a "subtle dialectic between articulating and embracing the analysand's illusions on the one hand, and the provision of larger context in which they can be experienced, on the other".[7]

Kernberg saw the infant in the first months of his life as struggling to sort out his experience on the basis of the affective valence of this experience. The infant moves back and forth between two different affective states. One state is characterized as pleasurable and gratified; the other state is unpleasurable, painful and frustrating. Regardless of what one is in, no distinction is made between self and other.

The first developmental task embodies being able to make a distinction between what is self and what is other. When this task would not be accomplished, one cannot develop a dependable sense of the self as separate and distinct because one cannot make a distinction between one's own experience and the experience of others. This failure is hypothesized to be the major precursor for all psychotic states. In schizophrenic symptoms (hallucinations, delusions, psychic fragmentation) we can see a lack of being able to separate between internal and external world, own experience and experience of others, own mind and the mind of another.

The second developmental task is to overcome splitting. When the first developmental task is accomplished, one is able to differentiate between self-images and object images; however, these images remain segregated affectively. Loving self images and images of good objects are held together by positive affects, or libidinal affects. Hateful images of the self and bad, frustrating object images are held together by negative or aggressive affects. The good is separated from the bad. The developmental task is accomplished when the child is able to see objects as "whole", meaning that the child can see objects as being both good and bad. Next to seeing "whole" objects, the child is required to see the self as being loving and hating, as being good and bad at the same time. When one fails to accomplish this second developmental task, this will result in a borderline pathology, meaning that objects or the self cannot be seen as both good and bad; something is good, or it is bad, but both affects cannot be in the same object together.

Kernberg's model of self and object development rests on five stages that delineate the growth of the internalized object relations units, some of which already start taking place during the precipitating stage. The stages are not static, but fluent.

• Stage 1 (0 to 1 month): Normal autism

This stage is marked by undifferentiated self-object representations. This stage is equated with Mahler, Pine and Bergman's conception of autism.

• Stage 2 (2 months to 6–8 months): Normal symbiosis

In the beginning of this stage the child is unable to integrate opposing affective valences. Libidinally invested and aggressively invested representations are strictly separated into a 'good' self-object representation and a 'bad' self-object representation.

• Stage 3 (6–8 months to 18–36 months): Differentiation of self from object relations

In this stage the 'good' self-object representation differentiates into a 'good' self and a 'good' object and shortly thereafter the 'bad' self-object representation differentiates into a 'bad' self and a 'bad' object. A failure of the child to differentiate between self and other results in a psychotic personality organization; one has failed to accomplish the first developmental task and is stuck in stage II. Although in this stage differentiation between self and object has taken place the good and bad self and object representations are strictly separated through the mechanism of splitting in order to protect the ideal, good relationship with the mother from contamination by bad self representations and bad representations of her.

• Stage 4 (36+ months through the oedipal period): The integration of self representations and object representations

During this stage the 'good' (libidinally invested) and 'bad' (aggressively invested) self and object representations are integrated into a definite self-system and a total object representation. One is able to comprehend the possibility of the self or other containing both positive and negative characteristics. A failure of this results in a borderline personality organization; one has failed to accomplish the second developmental task and is stuck in stage III. Consequently, the good self and object must still be protected from the aggression by the splitting of good and bad.

• Stage 5: Consolidation of superego and ego integration

In this stage ego, superego and id are consolidated in definite intrapsychic structures.

By successfully completing all the developmental tasks, the child has developed a neurotic personality organization, which is the strongest personality structure.