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Kernberg Versus Kohut: A (Case) Study in Contrasts: Gildo Consolini, MSW
Kernberg Versus Kohut: A (Case) Study in Contrasts: Gildo Consolini, MSW
ABSTRACT: In this paper, the main concepts of Otto Kernberg and Heinz
Kohuttwo theorists who have greatly influenced clinical social work practice
with severely disturbed patientsare presented, and then compared by using a
case from the practice of the author. The case illustrates the value of utilizing
some of the treatment principles put forward by Kernberg and Kohut without
becoming too wedded to either of the overall treatment approaches they have
formulated. Some aspects of the manner in which the practitioner determines
when the treatment approach needs to be modifiedto avoid the pitfalls of either being too wedded to an approach or too eclecticare discussed as well.
KEY WORDS: borderline personality disorder; narcissistic personality disorder; self psychology; countertransference; self-analysis.
For more than two decades the two theorists who have had the
greatest influence on psychoanalytic thinking about patients with more
severe psychopathologywith the possible exception of Harold Searleshave been Otto Kernberg and Heinz Kohut. Both Kernberg and
Kohut applied psychoanalytic theory to the treatment of patients often
considered unsuitable for analytic treatment by those working from a
classical analytic perspective. However, their conclusions about the etiology and psychic structure of borderline and narcissistic psychopathology, as well as the optimal treatment approach, are very different.
Kernberg is considered a conflict theorist, who, like other American
object relations theorists, has retained the use of the concept of instinctual drive along with other aspects of Freudian metapsychology; this
places Kernberg in the psychoanalytic mainstream. He wrote extensively about both borderline and narcissistic psychopathology.
Kohut, on the other hand, made a more radical break with the clas71
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Kohut (Kohut & Wolf, 1978) understood the self to be the nuclear
core of the personality, an enduring psychological structure in and of
itself rather than simply a mental representation within the ego. He
identified the "constituents" of the self as 1. the "pole of goals and ambitions" from which emanate basic strivings for power and recognition; 2.
the "pole of ideals and standards" which maintains the ideals which
guides one through life; and 3. the "arc of tension" between these two
poles that activates the basic talents and skills of the individual. These
constituents emerge into an enduring self structure through the interplay of inherited factors and the influence of the environment.
The self is seen as the center of initiative, the recipient of impressions, and the depository of the ambitions, ideals, and skills of the individual. The patterns of these ambitions, ideals, and skills, the tension
between them, the activity generated by them, and the responses of the
environment that shape the life of the individual are all experienced as
continuous in space and timethis provides the individual with his or
her sense of selfhood. The individual comes to experience himself or herself as an independent center of initiative and processor of impressions
received from outside the self.
As his thinking about the etiology of narcissistic disorders evolved,
Kohut ultimately decided he no longer required metapsychological concepts to explain how these disorders develop. He discarded the primary
drive nature of aggression, distinguishing between ordinary aggressionwhich he understood to be the healthy forcefulness the cohesive
self uses to eliminate an obstacle to a realistic goaland narcissistic
rage, an intense reaction to narcissistic injury.
Kohut postulated a line of development for narcissism that is distinct from that of object love, in contrast to Freud's progression in development from primary narcissism to mature object love; this formulation
enabled him to identify various transformations of narcissism, such as
mature humor, creativity, and wisdom. He contrasted the aims of "guilty
man" with those of "tragic man," the latter seen as someone striving for
fulfillment in endeavors beyond the pleasure-seeking and sublimations
made possible through the resolution of neurotic conflict. What makes
this quest tragic is that humanity's limitations are inevitably recognized
when one pursues these endeavors.
Kohut's is a theory of developmental deficit, which therefore calls
for the analyst to work in a very different way than the analyst who
adheres to the theory which views intrapsychic conflict as the source of
psychopathology. For the self psychologist, empathy is not only the principal means of investigation, it is the primary therapeutic instrument.
The analyst immerses himself or herself, through his or her empathy, in
the patient's subjective experience while seeking to maintain attunement to the selfobject needs of the patient. Although this is considered
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cates that there has been an arrest in the development of the nuclear
self, treatment should be geared to encouraging the narcissistic aspirations and needs of the patient to unfold fully in the transference. This
unfolding will enable the patient to develop a more cohesive self with
the support of the analyst, who is able to provide the vital selfobject
functions that the original selfobjects were unable to provide to the developing self of the child. If the focus on all that which threatens the
emergence of the self is not maintained, it will not be possible to achieve
health since an enfeebled self will remain, making true mental health
an impossibility.
Kohut clearly identifies the environment as the source of disturbance for these personalities while Kernberg is equivocal in implicating
constitutional factors along with environmental factors. Although the
latter identifies a stronger aggressive drive and a "constitutionally determined lack of anxiety tolerence in regard to aggressive impulses" as
contributory, he also has identified the presence of a mother or mother
surrogate who functions well on the surface yet treats the child coldly,
with very little regard for his or her emotional needs (Kernberg, 1970,
pp. 219-20).
Kernberg believes that the presence of an underlying borderline
personality organization in the narcissist mandates his modifying approach, while Kohut's approach is consistent with his view that the narcissist suffers due to developmental arrest. For Kohut, the narcissistic
agenda of the patient which emerges in the treatment situation reflects
healthy narcissistic aspirations and needs that were thwarted by the
parental figures during childhood and, therefore, it is imperative that
the analyst support the emergence of this agenda so that it can eventually be transformed.
Thus, as has been indicated throughout this paper, similar clinical
phenomena are understood and addressed very differently by Kernberg
and Kohut. At the same time, the psychoanalytic discourse has been
greatly enriched by these theorists since each has been able to go further than did Freud in attempting to explain why some patients do not
benefit from analytic treatment.
While Freud identified a "narcissistic attitude" of some patients
which "limits their accessibility to influence" in treatment (Freud, 1914,
pp. 17-18), he left it to others to develop the clinical implications of this
observation. Before Kohut, the transferences which develop in treatment of the narcissist were not described very well. Also, it seems that
his work has led to a generally less judgemental attitude toward the
narcissistic manifestations seen in many patients, not just those who
present with obvious narcissistic pathology. Furthermore, the role of empathy in treatment is much more fully understood and accepted as a
result of the work of Kohut and those who further developed his ideas
(Goldstein, 1990).
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nurturance of his artistic aspirations and for an intensive and thoroughly exciting sexual relationship. Doug had been in treatment previously, for less than a
year, with a female therapist; he reported that she had helped him quite a bit
until she began to become more "confrontational" with him. He was unable to
elaborate, but indicated that the ending of that relationship also left him with
strong feelings of indignation and discouragement.
While still involved with each other, Eileena school psychologist who was
working on her doctoratehad encouraged Doug to get back into treatment.
Characteristically, Doug felt this was an effort on her part to use her knowledge
of therapy to control him rather than help him. He resisted this idea until they
broke up. Doug has a history of drug and alcohol abuse and seemed genuinely
frightened that he would return to abuse of cocaine and alcohol to cope with his
distress about the break-up.
Doug's parents were divorced when he was eleven years old. He has a sister
three years older who is perceived by him to be the favorite of his father. Doug's
primary aspiration is to become a famous blues and rock composer, guitarist,
and group leader; while waiting for this to happen, he is working for his father
in his father's business. In contrast to his sister, a successful attorney who is
married with two children, Doug reported that he is the "black sheep" of the
family. He had not gotten very far with college, dropping out well before completion of his degree.
It seemed that an empathic, nonjudgemental approach on the part of the
author initially fostered the development of enough of a therapeutic alliance to
keep Doug in treatment. He came in for some extra sessions, and for a time came
twice per week. It seemed that his anger diminished somewhat and enabled him
to concentrate better at his job and devote more time to his music. His father
had been very unhappy with Doug's work performance, since Doug frequently
missed work or came in very late because he had been "partying" the night before. Because he was able to stop doing this, Doug was no longer being threatened with being let go by his father, who seemed to be someone volatile enough
himself to do this.
The treatment "honeymoon" (Fine, 1982), however, was short-lived, in part
due to the author's winter vacation, which took place after six months of treatment. During the author's vacation, Doug consulted another therapist, something he rationalized as necessary because of the very difficult time he had while
the author was away. He reported he had difficulty not because he missed the
author or was unable to rely upon him for assistance during the vacation, but
because the author had not helped him enough prior to the vacation. His sister
had encouraged him to see someone else and had given him the name of the
therapist he consulted. He might have continued with this other therapist, Doug
told the author, were it not for the fact that he was "getting a better deal" with
the author, who was a provider in the managed care network used by his insurance company.
As others have indicated (e.g., Maroda, 1994), use of the self psychological
approach in the initial phase of treatment is oftentimes quite beneficial to both
patient and therapist. The sustained empathic inquiry called for in this approach does much to establish basic trust on the part of the patient in the relationship. Not only does the patient experience the relief of "getting things off his/
her chest," but he or she feels genuinely cared about in the process of doing so.
The therapist learns much about the patient's life because the patient feels safe
and is eager to produce material to please the therapist.
Although the above approach may be instrumental in enabling patients like
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Despite all this, it became necessary at another point to shift gears once
again and adopt a more tolerant stancein relation to Doug's grandiose aspirations. The author became aware that when he was using Kernberg to understand and address Doug's devaluation of the author and very strong sense of
entitlement, he began sessions himself feeling rather irritated with Doug and
indignant about the manner in which he was being treated by Doug. At times, it
was difficult to hear themes in the material other than Doug's ruthless incorporation of the author and others. Self-analysis of the author's counterresistance
to allowing other material to emergea process which included discussion of the
case with a colleagueenabled the author to realize that the transference had
become more positive and therefore there was much less need at that point to
concentrate on the patient's aggression.
Kohut has stated quite clearly that challenging the patient's grandiosity is
not only a useless endeavor, it will likely compel the patient to suppress very
powerful wishes and thus make them inaccessible to modification. Doug can be
accurately and usefully described as "mirror-hungry." The author decided that it
was important to attend in a particular way to manifestations of this hunger
which developed in the transference.
Doug began to bring in notebooks filled with many, many pages of his
thoughts and feelings about his struggles with women and his music, some
pages of which he had copied and had attempted (unsuccessfully) to get Eileen
and other women he pursued to read. It became clear to the author that it would
be necessary to gratify some of that which Doug wished for in asking the author
to listen to him read from these notebooks. The author initially simply listened
as Doug read, indicating interest in those passages which expressed strong feeling or indicated developing insight. Eventually, Doug was encouraged to discuss
how he felt it was helping his therapy to do thissomething that was done in as
nonjudgemental a manner as possible to indicate the interest of the author in
what Doug wanted from him rather than what Doug was resisting by relating in
this manner.
Later on, Doug began bringing in self-help books to discuss with the author.
He was encouraged to talk about what he had discovered which resonated with
him. This approach helped Doug see how much of his behavior, included its intellectualized aspects, was connected with his wishes for attachment with others
and how upset he could become when his wishes were frustrated. As a result,
Doug has developed enough insight and frustration tolerance to stop harassing
not only his ex-fiancee but another woman he dated for a few months, to significantly cut back his drinking and pot use, and to end his dependence upon pornographic movies and prostitutes for sexual excitement and pleasure.
Eventually, Doug was able to approach dating in a very different way, both
with respect to the choices he made about whom to date and how he behaved
with those with whom he attempted to connect. Initially, he attempted to date a
prostitute he had seen on a regular basis. When the fantasy of where this would
lead was analyzed, he ended this quest. He proceeded to date a series of unavailable womentwo married women and a very troubled young woman who eventually scared Doug off with her sadomasochistic sexual proclivitiesbefore attempting to connect with more suitable women. By the time of the writing of this
paper, Doug had been involved with someone for several months who seemed a
much better choice as a partner. He was able to use much of his session time to
talk about his mixed feelings about committing himself in an intimate relationship, rather than impulsively acting out his negative feelings.
During that time, the author realized that although the transference had
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become more positive overall, he was neglecting to address indications that Doug
was not just having difficulty with intimate relations with his girlfriend, that
Doug was struggling with similar feelings in the transference. The author recognized that he was struggling himself with feelings in his counter-transference to
Doug. How else could he explain his delay in discussing some obvious indications
that Doug was feeling displeased with the author?
Through self-analysis, the author was able to see that he was using theory
to rationalize an approach to his patient that, at this particular time, stemmed
more than anything else from his counter-transference. As Doug began making a
habit of arriving ten to fifteen minutes late for his appointment, paying his bill
late, and shaking hands with the author at the end of the session, the author
rationalized that confronting Doug with this behavior was not necessary. Essentially, he allowed himself to believe that empathy was enough.
Of course, the truth was that the author was feeling uncomfortable about
dealing directly with Doug's disappointment, very powerful sense of entitlement,
and anger. When the author realized he was resisting the analysis of these feelings in the transference, he was then able to confront Doug tactfully. That is, the
author was then able to bring the behavior to Doug's attention and in an empathic manner to explore the feelings which motivated the behavior. As the analysis proceeded, Doug became more aware of the kind of relationship he wished to
have and not have with the author. He became much more comfortable as well
with his girlfriendhe began to feel less deprived and controlled in both relationships.
DISCUSSION
The clinical vignette presented above illustrates the value of utilizing the contributions of both Kernberg and Kohut, based upon that
which may be needed by one's patient at various points in treatment.
Both theorists have advanced psychoanalytic thinking about borderline
and narcissistic psychopathology and treatment. However, it is imperative that the therapist recognize that what is needed by his or her patient may change significantly as the treatment proceeds (Pine, 1988).
Therefore, the therapist needs to make a corresponding shift in his or
her approach. Perhaps those with a background in social work, with the
social worker's appreciation of the situational factors associated with
psychological distress, are especially adept in this regard.
The kind of treatment situation presented above is commonplace for
many clinical social workers. Clinical social workers who are analytically oriented attempt to develop effective analytic approaches to help
patients who are both very troubled and very demanding. Although
guided by their analytic knowledge and convinced of its usefulness, the
clinical social worker must recognize the fact that most people now come
for "help" rather than for "analysis" (Herbert Strean, 1993, personal
communication).
Both Kernberg and Kohut have received much praise for their contributions, as well as a great deal of criticism for developing points of
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view which challenge mainstream psychoanalytic thinking. Unfortunately, there has been a tendency within psychoanalysis to engage in a
wholesale embracing or repudiation of different points of view which
seems similar to the defensive splitting employed by very troubled patients to ward off the anxiety associated with taking in the analyst as a
real person. Instead, the analyst is experienced as either "all-good" or
"all-bad" rather than as a real person who, despite his or her very real
human limitations, has something very valuable as well as very real to
offer in the analytic relationship.
Although many classially trained analysts would regard self psychologists, along with many others, as heretics (in Bergmann's [1993]
usage of the term), there have in fact been a number of important contributions made by theorists who have either somewhat covertly (e.g.,
Winnicott) or quite overtly, (e.g., Klein) challenged Freud, and in so doing, advanced mainstream psychoanalytic thinking and approaches to
treatment. According to Bergmann's way of categorizing psychoanalytic
thinkerswhich seems quite usefulKernberg and Kohut would be
identified as modifiers rather than heretics, as important thinkers who
demand that theory change as a result of their findings.
As Bergmann has said, modifiers have threatened the continuity of
psychoanalysis and created much controversy, however, they have also
kept psychoanalysis alive. As a result of the insights offered by modifiers, psychoanalysis has been able to stretch enough to improve its
understanding of the etiology of many disorders as well as develop more
effective treatment approaches. More recently, Bergmann stated that
modifiers demand that analysts "give up their cherished belief that psychoanalytic theorizing has developed along a straight line, with every
new generation simply adding their findings to that of the previous generation" (1997, p. 82). In fact, psychoanalytic theory and technique have
evolved dialectically. This can be seen very clearly with regard to how
psychoanalytic thinking about severe psychopathology has evolved, as
this paper has indicated.
The intention of the author in this paper has not been either to
defend or to attack either theorist, but rather to highlight the need on
the part of the practitionerwhen he or she turns to either Kernberg or
Kohut for guidanceto recognize the limitations of relying too much on
either approach when he or she is attempting to engage patients who
are especially difficult to engage in a meaningful psychodynamic treatment. If this is accepted, of course, a related matter must be considered
very carefullythe issue of what determines the shift from the use of one
approach to another.
As Strean (1994) has described, theoretical arguments can be made
to rationalize interventions motivated primarily by the practitioner's
countertransference. Strean suggests that this defensive maneuver can
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