Otto Kernberg is one of the leading figures advocating a psychoanalytic theory of personality disorders, particularly within an object relations perspective (see Kernberg & Caligor, 2005). In important ways he has followed the model of Sigmund Freud, in that he has based much of this theory on experience psychoanalyzing patients. His theory has been developed in conjunction with the therapeutic approach that grew out of both that experience and his developing theory. Thus, Kernberg’s work represents an applied approach to the study of personality disorders.
Kernberg’s model of personality disorder emphasizes personality structures, which are derived from the interaction of constitutional (i.e., temperamental) and environmental factors during early childhood. These structures are relatively stable mental functions or processes that serve to organize an individual’s behavior and subjective experiences. Psychological structures that are conscious and observable are typically referred to as “surface” structures, whereas those that are primarily unconscious are called “deep” structures. The basic building blocks of these personality structures are internalized object relations. Internalized object relations are particular emotional states linked to a specific image of a particular relationship (e.g., anxiety linked with an image of a confused and unsure self and a critical, judgmental parent). These internal object relations are integrated and hierarchically organized into the higher-order structures that form the personality. At the core of this personality organization is the individual’s “identity.” According to Kernberg and Caligor (2005), a healthy, consolidated identity corresponds with a stable and realistic sense of self and others. In contrast, a pathological identity stems from an unstable, polarized, and unrealistic sense of self and others. This pathology arises because the emotional states of the internalized object relations are predominately negative; they are crude, intense, and poorly modulated. There is also a preponderance of aggression and defensive mechanisms based on primitive dissociation (splitting).
A normal personality, according to Kernberg, is characterized by an integrated concept of self and an integrated concept of significant others. Individuals with a normal personality can express a wide range of emotions, and even intense emotions do not lead to a loss of impulse control. Normal individuals have an integrated and mature system of internalized values, and they can appropriately manage their sexual, dependent, and aggressive motivations. The development of the normal personality depends to a large extent on the relationship the child has with its mother (the primary caregiver). If the mother is successful in helping the child transform highly emotional states into integrated experiences, then the child’s internalized object relations will be primarily positive. Erik Erikson first proposed this concept, and he believed that ego identity was not complete until adolescence (see Kernberg & Caligor, 2005).
The abnormal personality, in contrast, results from early childhood interactions with caregivers who do not help to transform highly emotional states into integrated experiences. On the contrary, caregiver’s failure to help the child integrate its emotional experiences can intensify the child’s anger and anxiety, perhaps leading to an increase in aggression. Consequently, a child who cannot integrate the good and bad aspects of its emotional states and object relations will come to depend on defense mechanisms that enhance continued splitting. The child becomes fixated at a poorly integrated level of development. One of the most important implications of this approach to personality disorders is the role that primary caregivers play. What constitutes a parent, or other caregiver, who cannot help the child to integrate its emotional states in a healthy, normal manner? Numerous studies in different countries have identified a high rate of physical and sexual abuse in patients with borderline disorders.
The level at which integration fails to occur results in the nature of the pathological personality organization. A psychotic personality organization occurs when the individual has not integrated a clear concept of self and significant others. They do not have a clear identity formation, they may not distinguish intrapsychic processes from external stimuli, and therefore there may be a lack of reality testing. According to Kernberg, psychotic personality organization represents an atypical form of psychosis (Kernberg & Caligor, 2005). Borderline personality organization is similar, but less severe. The individual has achieved a level of integration in which the self and others are seen as separate, but that integration is pathological. There is a great deal of defensive splitting, and the individual lacks a clearly developed set of internalized values (the superego). Emotion fluctuates from intense to superficial, emotion is generally negative, and there may be excessive aggression. There is also a lack of integration of the sense of others, making relationships particularly unstable and unrealistic. Curiously, achieving an integrated sense of self and others does not resolve all psychological problems associated with personality development. Even if an individual has moved beyond the stages of psychotic and borderline personality development, and developed an integrated sense of self and others, they may still be prone to neurotic personality organization. At this level, defenses are based primarily on repression and stable reality testing. This is the level at which Sigmund Freud studied personality and psychological disorders, according to Kernberg (2004).
With this perspective in mind, how then do we treat individuals with personality disorders? Kernberg’s primary focus is an exploration of the patient’s internal object relations. These pathological internal object relations play out in the patient’s current interpersonal relationships, and through the process of transference they play out in the therapeutic relationship as well. In patients with neurotic personality disorganization these transferences are relatively stable and understandable within a psychoanalytic context. With more severe personality organizations, the transferences are poorly organized, unstable, unrealistic, and the activation of the internal object relations can be immediate and chaotic. There is also a rapid interchange between the roles played by the patient with regard to which object of an internal object relation they identify with, and, accordingly, which object they attribute as the analyst. With severe borderline patients special attention must always be paid to the strong tendency toward acting out, which can lead to suicide attempts, drug abuse, self-mutilation, and other aggressive behavior (Kernberg & Caligor, 2005).
Therapy with these patients is a long and difficult task. In order for psychoanalysis to be successful, it may require multiple sessions each week for 4 to 6 years. This is necessary because the goal is no less ambitious than modifying personality organization and the quality of the patient’s internal object relations, all of which were laid down during the formative years of infancy and early childhood (Kernberg & Caligor, 2005). Within the context of this theory, the outcome for individuals with a neurotic personality organization is hopeful, whereas the outcome for those with a borderline personality organization remains challenging. Kernberg and Caligor (2005) do not propose an approach to the treatment of patients with a psychotic personality organization. Therefore, continued research and clinical application will be necessary if we hope to be able to treat all patients suffering from personality disorders.