Introduction To Psychoanalysis: Otto Kernberg

I'm Doctor Are Kornberg. I'm professor of psychiatry at the Cornell University Medical School in New York and psychoanalyst at the Columbia University Center for psychoanalytic training and research in New York. I also direct an institute for the study of personality disorders at the Cornell University in New York. And I am here today to tell you something about psychoanalysis. Today is science in treatment.

But first of all, I should like to tell you a little about myself. I was born in Vienna, Austria, and emigrated with my parents to Chile in South America after the occupation of Austria by Nazi Germany. I had developed all my youth and early professional life in Santiago, Chile, before coming to the United States. I continued my studies in psychiatry and psychoanalysis, and research in those fields. I also worked in the organizational aspects of psychoanalytic work and became president of the International Psychological Association from 1997 to 2001.

So let me tell you something. We bring you an overview of what psychoanalysis is today. Let's start with three clinical cases that should help us understand some of the basic concepts of psychoanalysis.

First case is a young woman who had problems in her relation with men. She always was afraid that they were going to leave her. With her present boyfriend, she was anxious that something in her wouldn't be found right. Any extended separations made her afraid that he would never come back. This had happened to her in other relationships as well, and so that that fearfulness interfered with her capacity to enjoy her intimate relations. At the same time, she was also very worried about people being critical of her. Any minor criticism was experienced as a major disaster, and she tended to react getting depressed. And there was a chronic mild depression as a consequence of the fearfulness over being criticized, not being good enough, not doing things the right way.

In the past of this woman, there had been a childhood dominated by a rather strict, cold, distant, and very demanding mother who kept her on her toes all the time, who was critical, and who, when she felt that her daughter was not behaving well, would withdraw from her, leave her alone, and give her a sense of being abandoned. And so the the fear of abandonment and of loneliness was an important childhood experience which extended now in her will taught to her relations with other men. Her father was more understanding, but because of his work, he was not available. So there was no counterweight to this dominance of of mother. And this woman suffered from a chronic sense of insecurity and of wishes to be able to depend on somebody without other ever being sure that that dependency would be gratified.

Second case. This is a young man who was very friendly, actually sometimes excessively friendly, and very well-behaved, and and somewhat perfectionistic. Everything had to be right the way he would have to do things, very punctual, precise, and preoccupied with details. As I mentioned, very friendly except with people in authority, teachers, supervisors. He tended to become tends to become rather submissive over a period of time and then explode in angry protests when he felt that they were trying to dominate him. So that there was a kind of conflictual relation with authority and oscillating behavior between inhibition and anger in relating to authority that created difficulties for him.

In his past, um, there was a relationship that he had with his father, very much characterized by the same kind of issues. A strict, demanding, domineering father who expected his son to obey him, who was rigid and critical and demanding, and he had to watch it all the time not to get himself into trouble. And with his father, he gradually developed an effort to avoid punishment by being inhibited and submissive, and not being able to control his anger at other times and blowing up. And at the same time, he had internalized all these demands that were made on him, and he started to make these same demands on himself, which determined his perfectionistic behavior. While at the same time, with any other figures in authority, he repeated that same problem, saw them as if they were a representation of his father, taught whom he had to either submit or rebel, creating problems with authority and problems around an appropriate way to assert his autonomy.

Third case. This is again a young man who had difficulties in his relationship with his girlfriend, whom he loved very much, who who he felt represented an ideal woman that he had always wanted to have. It was an intense romantic relationship, but when she expected a more intimate, sexually intimate relation with him, he was unable to respond to that. He became very anxious or was unable to function sexually, became important at difficulties in an erection, in other words, a serious sexual inhibition. That however, he did not have when he had casual sex with women who were attractive sexually, but to whom he really didn't experience any love. And so that he had a number of experiences, kind of one-night stands, in which he functioned perfectly well, that was sexually satisfactory, but without any real relationship. While with his girlfriend, whom he really loved, he was unable to function. And the same thing had happened to him with another relation before.

Here, what was interesting in his past was a very intimate and into mutually gratifying relationship with his mother, whom he idealized, who in turn saw in him her ideal son. He was the youngest, or the older ones had left the home. He spent long periods of time with this mother. His father was very committed to his work, often they went on vacation, just his mother and himself with long talks together. And him at the same time, both parents were united in a prohibitive attitude. They taught his sexuality a strong prohibitive attitude towards masturbation, motivated in part by the religious identification of the parents. But that was so intense and consistent that he got to his university years without knowing that masturbation was a normal process in childhood and later on. So that here, the idealization of the relation of the love relation with an ideal mother, with whom naturally he couldn't tolerate any sexual feelings, was transferred to the relation with his girlfriend, who he treated as if unconsciously, if she represented his mother, and therefore sexual feelings were not permitted, and he couldn't function sexually.

This is what classically within psychoanalytic theory has been called the Oedipal constellation, a basic infantile situation in which unconscious infantile sexuality is directed toward the parent of the opposite sex, while the parent of the same sex appears as a major rival and and origin of potential punishment for forbidden sexual feelings. And this young man represented a particular form in which this frequent problem tends to show up.

In the first case, the mechanism by which the patient was trying to protect herself from her unconscious conflicts was projection, that is to say, attributing to other people what really was going on in herself. She herself was excessively critical with herself. She attributed to to others as if they were excessively critical with her, and she was afraid she was going to be abandoned. Her boyfriend was never going to come back. All of it as an expression of that mechanism that created more problems for her.

In the second case, the protection against the infantile conflict, the mechanism of defense, they was reaction formation, that is to say, the development of behavior opposite to that which was creating conflicts. In the early childhood, is being rebellious toward his father who was so dominant, well got him into trouble. So he was trying on the contrary to be extremely friendly, nice, subservient, if necessary. That was behavior through the opposite, that's called reaction formation. But of course, that created an enormous frustration and ended up with this blowing up in anger and reproducing the conflicts, the the conflict that he was trying to escape from.

And in the third case, the effort to escape from the conflicts around infantile sexual feelings, for him forbidden as part of the prohibition against masturbation, and at the same time, him forbidden from being experienced in the relation with an ideal person whom he loved, his mother, then led to on the one hand, total forgetting of the very problem that one can't love the person whom taught what one cannot have sexual feelings toward a person whom one loves. That was remained unconscious. We call that repressed repression. And at the same time, he also showed the mechanism of splitting, in other words, separating completely sexual feelings from love in order to avoid the conflict, but with the consequences of later conflict in his real life, in his love relation, not being able to perform sexually in the relation with the woman whom he loved.

So that those mechanisms, repression, reaction formation, splitting, projecting, don't really solve the problem, but contribute to further creating distorted and inhibited behavior for which patients come to see psychotherapists.

Freud gave a general theoretical structure to all these findings about the influence of unconscious issues from the childhood in a daily life. He proposed the existence of what he called a dynamic unconscious, an unconscious reality in which primitive impulses continued active. And he classified them into the drives of libido and aggression. Libido is the life drive, the sexual drive. Aggression, also called the death drive. The life drive including all the positive feelings of love, excitement, eroticism, dependency, warmth, closeness. And aggression, on the other hand, in cooperating or the relations of rage, hatred, envy, resentment, disgust. I saw a fight between these two principles is going on eternally in the repressed unconscious. In that dynamic unconscious, which he said did not know from passage of time, it treated time as if it were turn on, which did not know of the principle of contradiction, but treated all relations as if they were compatible, that didn't obey ordinary logic, that didn't obey considerations of ordinary space, that permitted displacement of conflicts from one issue to another, from one person to another. He called that the primary process, is opposed to the secondary process or the reality-oriented ordinary logic that determines adult life.

Now, what do we think about this general theory in the light of contemporary knowledge of scientific developments that we are counting on today? Let's our next subject. Let us examine what's known now from a from the viewpoint of a neurobiological research about the functioning of the brain and how that fits with traditional psychometric theories. I have to summarize that very briefly and can't do justice to all the details of what we know and what we're doing on in our own research. But very briefly, we may conceive of a brain is an organ that has two big systems. One is their cortex, the skin of the brain, and the other is a central part of it, the limbic system. The cortex, the cover of the brain, it's a relatively thin layer, but in truth, it's extremely complex and rich, and its function is to provide our cognitive, conscious, intelligent perception and understanding of external reality and of what's going on in ourselves. It's the rational part of the brain.

The limbic system is the part of the brain that tends to activate effects. It's fundamental motivational systems. Effects are feelings, good and bad, that tell us what kind of things to look for because it feels good, what kind of thing to get away from because it feels bad. And effects get activated on the basis of deeper centers of the brain, particularly the hypothalamus, that communicates to the brain the state of the organism in terms of what its needs are regarding temperature and feeding and fighting of dangers or situations that are gratifying basic biological needs. The hypothalamus communicates to the limbic system, and according to whether there are needs that need to be satisfied, or that are being satisfied, or that they are being frustrated, different effects are activated. And what interests us here is that particularly negative effects are activated when something is wrong, and we have to signal to ourselves and the environment that we need help. It's the amygdala, a part of the limbic system, where negative effects, anxiety, rage, fear, get activated, irradiated to the cortex, where our intelligent, rational, cognitive functions then permit to clarify what is it that makes us anxious, or can we understand in what context this is happening, in what action has to be taken. So there's an equilibrium between effect activation, giving us our motivation, what we have to do toward or away from things, and the cortex, which puts it all into a perspective. If there is excessive effect, and the cortex can't cope with it, we get panicky and disorganized. If there isn't not enough effect, we may miss the importance of a situation and not react when we should.

Another part of the limbic system is the hippocampus. That's the memory chamber, so to speak, where memory of affective experiences are deposited, are stored and kept for comparison, and constitute a kind of registry that gets alerted whenever we have a new experience that reminds us of something that we have already had before. So the hippocampus permits us to establish effective memory and react in the future according to experiences from the past, which is a very important psychological functioning.

Now, the effects tend to combine into systems. Systems that have to do with basic needs of survival. One system is the attachment system. The attachment system keeps the baby close to the mother. It's the origin of our needs for dependency and closeness. Not all aspects of closeness, because there's an independent sexual system as well, but the attachment system combines several effects in the sense of closeness, of intimacy. And then there's a sexual system that combines sexual activation with the wish for closeness and play, but also a capacity to fight, to fight off rivals. So effects combined in the sexual system, in the attachment system, in a play system, in an affiliation system, in a fight-flight system, in a panic system. And in turn, those combinations of systems then culminate in the final positive or negative motivation given by libido or aggression, the life drives, the death drive. So Freud's conception of the drives really has to be based now in the light of our understanding of the underlying development of effects, if as neuro-psychic structures in which biology evolves into a psychological experience.

Let's examine now how all of this comes together. Let's go to the moment when the baby's born. Baby's hungry, calls for mother, and mother comes. In the first moment, under the effect of low blood sugar, intense need of nourishment, all the systems go to activate negative effect, intense panic, fear, rage, anxiety, everything mixed up in an intense experience. The amygdala works like madam in the cerebral cortex is registering an extremely frightening situation. Mother comes, the baby's fed. Minutes later, the baby's happy, and the situation changes totally to an ecstatic, almost orgasmic experience, and total happiness reigns.

What happens from the viewpoint of the build-up of psychic experience? We are not dealing only with effects and we're not dealing with the shift of one effect into another. We are dealing with two distinct experiences, and each of them is quite complex. Because at the moment when the baby feels frustrated and terribly anxious and frightened, there's a buildup of a representation of self interacting with an imaginary frustrating, failing mother who is not there when food should be there. And after some weeks of experience, the baby knows when he has that feelings, mother should be there and feed him. And if she is not there, it's not that there's no mother, but it's like a bad mother who would be there in an extreme moment of anxiety, a terrible image of self-representation in acting with a terrible bad absence, and but presently or absently present or presently absent mother within the frame of a negative effect. And separately from that, the built-up of a positive, extremely pleasurable, happy self-representation interacting with the giving, wonderful, perfect mother representation, the object representation. The term object is used to refer to significant others. So we have two extreme experiences that then are followed by thousands of similar extreme experiences under moments of frustration and under moments of gratification. And at first, these are completely split. They are split because there are different effect systems are activated, different memories, and their stores differently in the hippocampus. Gradually, under the under the experience of a predominance of good experiences, when love predominates over hatred, when good care by mother predominates over bad moments, the baby tolerates those bad moments. They become less impressive, and an integration takes place by which then gradually the cognitive function, remember the cortex, integrates good and bad experiences, and the baby is able to bring together the baddest representation of mother and the good one in an integrated representation of her, and the bad images of self and good images of self into an integrated image of himself. And what builds up gradually is an integrated representation of self, and integrated self, and an integrated representation of significant others that constitutes normal ego identity, normal identity that permits one to feel that one is the same person all the time, and significant people are the same people, even if they behave differently at different moments. It it feeds into normality.

If on the other hand, the bad experiences are so dominant that this integration is impossible, babies who are neglected, there is no mother, they are terribly physical or sexual abuse, tell me traumatic experiences, but which the negative segment builds up to an extent that it can't be tolerated, there is enough not enough good experiences to permit that, then a permanent split is maintained. The world continues to be split into an idealized one, into a penta persecutory one. Why a persecutory one? Because there's an effort to rid oneself of the bad experiences by projection, and projection means that the external world is seen as persecutory. It's not one's internal bad states, and the world continues divided between ideal people and terrible people, and one's image shifts from wonderful to bad, back to wonderful, back to bad. And personalities who have these chronic characteristics are called borderline personalities or borderline personality disorders. You may have heard that term, and they have a terrible time because they can't predict their own behavior, they can't commit themselves to relationships in depth, to work, to a profession. Their lives are chaotic. They sure need treatment.

The other situations in which such bad situations evolve into serious personality disorders. One in which projection of a bad world is so overwhelming that the main issue is how to deal with with with all these potential enemies. The person becomes hyper alert, suspicious, distrustful, isolated. We call that a paranoid personality. Or else, when there are very few ideal experiences, and the rest is terrible, there may be a temptation to take refuge into an idealized version, into an Indianized vision of oneself, while at the same time, in one's fantasy, one incorporates that ideal good parent that one has had in fleeting moments as if it were part of oneself. One becomes a pathological grand yourself with devaluation of everybody else. These are people who seem to love only themselves. They are grandiose, they are pre-potent, they are omnipotent, and they seem to have very little capacity for investment in relation with others. And we call that the narcissistic personality.

So we've seen a number of serious developments of abnormal personalities because the experiences of frustration of basic needs by a negative environment lead to abnormal solutions that are embedded in the personality structure, showing the character, that is to say, in the person's habitual behavior patterns. And so we have the paranoid personality, and the borderline personality, and the narcissistic personality. And remember the depressive personality, the woman whom we talked about who was so afraid of being abandoned, and the obsessive personality, that young man who had to have everything so precise and exact and was so very nice except from time to time it kind of blew up. So we have the obsessive personality as well.

And there is still an extreme case in when there is a lack of sufficient good person so at the same time communicate a moral value system, or when there is such a negative environment that no good demands and prohibitions can be accepted within that totally negative world that one is trying to do water off. And then we have personalities whose internal moral structure suffers. They are called antisocial personalities, and they are the most severe personality disorders. And while many patients with serious personality disorders can be treated, some of the extreme cases cannot.

We call the whole theory that I've just explained psychoanalytic object relations theory. It is the theory that explains how effects are activated, the internal disposition of activation of affect that we call temperament, how temperament interacts with relation with significant others, with object relations, and how the interaction of temperament and object relations creates such permanent patterns of relation between self and others that determine either normal identity or if integration doesn't take place, severe identity diffusion. And by the same taken by the same token, either in normal harmonious personality or one of the serious personality disorders that I've mentioned to you. So that's how Socratic object relations theory brings together effects and drives and the defensive reactions against them with the vicissitudes of the internalization of relation with significant others and explains the different personality disorders.

Now, Freud originally had already captured these structures of the mind in the proposal that one could divide the mind into three major structures: the id, the dynamic unconscious is such, their ego, or let's say the self in contemporary psychology, and the super-ego. And these structures of the mind that interact consistently and with the environment reflect the consequences of the internalization of the object relations that I mentioned. They ain't that right. Originally, the id is a cauldron of aggressive and sexual impulses. It is really the combination of all those primitive internalized object relations that can't be tolerated of the extremely negative aggressive nature, and also some of them because of their sexual nature, because of the prohibitions against infantile sexuality that we've talked about. The ego is really derived from the functions that we have described of the cerebral cortex: consciousness, perception, control of motility, conscious historical continuity, conscious memory, but also the deeper structure of the concept of self and the concept of significant others, a central constituency's of the ego. And the super-ego is the internalized, largely unconscious, but also conscious system of moral or ethical structures derived from the do's and don'ts that come from the interaction with the parents. Until what we find is that a normal super-ego permits regulation of one's relationships way beyond those or practicality of interaction in terms of general moral and ethical systems. It is what gives depth to our relations, depth to love, depth to our convictions and experiences of values in the sense of aesthetics, there arts, in the sense of ideology, religion, philosophy. But the super-ego is also in danger of being a source of pathology because if it becomes excessive, if there's an excessive severity of the demands and prohibitions of the parents with the built upon of an excessive internal demands, such as we saw in our first pair patient, that woman, it also in the second patient, the man with the obsessive behavior, and also in the third one who had to split sexes from from from love, then it creates an origin of pathology, an origin of abnormal sim and behavior and personality structure. So that's an excessive super-ego. We say of some patients that they have a super-ego like a cathedral and tend to get buried in them. The opposite is true also. If there has been a total lack of any consistent parental structure, a lack of parents who have communicated in realistic and deep and integrated moral system, or if there has been such a severity on the part of the parents that has led to a defensive rejection of anything coming from them, a lack of super-ego builds up. These are precisely the cases well then antisocial behavior may develop, for example, is particularly narcissistic personalities are prone. And then we have a serious problem of persons who do not have such an internalized guidance system with antisocial behavior, the antisocial personality. So that here the structures that Freud described represent the superstructure of their component internalized object relations, in the same way as the drives that Freud described were the superstructure of the component effect systems.

I would like to discuss psychoanalysis as treatment. I'm not talking talking only about standard classical psychoanalysis, three to five sessions a week, but a broad spectrum of psychoanalytic psychotherapy that have been developed in recent years and that have expanded the scope of psychoanalytic treatments, particularly in the treatment of severe personality disorders that were too severe to really be able to benefit from psychoanalysis. So I'm talking about the treatment in development and expanding its indications, and I'll talk jointly about psychoanalysis and psychoanalytic psychotherapy.

So what are the main indications for treatment? First of all, chronic depressive conditions, characterological depressions, and not major depressions or major affective illness that are treated mostly by psychopharmacological means, but the kind of chronic depressions based on the personality distortion distortions of patients, or chronic anxiety states with the same basis, sexual inhibitions and all kind of sexual difficulties and difficulties in intimacy in the sexual life, in patients who have difficulty of loving or unable to love normally. Only psychoanalysis really can help these patients. There are no other alternatives when it comes to serious pathology of the subjective experience of love and the integration of love and sexuality in all its forms. Psychoanalysis treats multiple symptoms, so-called conversion symptoms, that represent physical symptoms based on unconscious symbolic meanings related to unconscious conflicts. But most of all, psychoanalysis treats personality disorders, all kinds of them. Typically, the patients, if the three cases that I mentioned to you at the beginning of our conversation, and the complications that we have with severe personality disorders, particularly on drug dependency, alcoholism, eating disturbances, antisocial behavior within certain limits, and chronic suicidal behavior, not based upon depression, but based on profound characterological dispositions.

What are the basic features of psychoanalytic treatment? And again, I'm talking about the broad spectrum of psychology psychotherapy. The basic technique of the treatment is the analysis of the transference. What is the transference? The transference is the unconscious repetition in the hiren of now, in the here-and-now, of a foregenic conflicts of the past. The unconscious conflicts of the past that we've talked about tend to reproduce itself if that is in this in the sessions with the analyst or the therapist, if that is facilitated by a particular attitude of the therapist that we call technical neutrality, which is not a kind of a a cold indifference, but in a concerned objectivity, in which the patient is invited to speak freely, everything that comes to his mind without any control, without any suppression, as much as he can, in order to facilitate the gradual emergence of deeper contents of the mind, what we call free association. And the analyst listens to free association while at the same time observing the behavior of the patient in the treatment session and observing his own emotional reaction to the emotional reaction that the patient's gradually develops in the treatment situation is called the countertransference. And the patient tends to repeat under such circumstances past conflicts. For example, the first patient I mentioned to you, the woman with depression with the cold mother, may very easily and soon experience the analyst is somebody who is cold and rejecting, afraid that he doesn't like her, feeling rejected, in other words, reproducing the past conflict that anyhow she tends to reproduce all the time in her daily life because of her characterological distortions. But the big difference that here this reaction will be explored, will be contrasted with the objectivity of the nature of the relationship, so that she will have it opportunity of gradually recognize that past origin of a behavior that presently is in a inappropriate and learn how to understand it, how to change it. This may be much more complicated than it sounds because she may be activating not only her past self-representation as a rejected or criticized child and project on to the analyst the image of her mother, but to the contrary, she may treat the analyst in a cold and rejecting way without being aware of it, while he in his countertransference may experience himself as a rejected child. In other words, the relationship with mother is activated with role reversals, which permits in the analysis, in the transference, to more deeply resolve the total identification, the total permanence of that particular pathogenic, that means illness generating, past relationship. That in a nutshell is sense of the psychoanalytic treatment, and it permits really an analysis of the character, and with it, an analysis of the total personality and personality change as such, in a way that is not possible with other type of treatments.

Now, I'd like to mention briefly that all of this going on when empirical research is testing the psychoanalytic methods, its effectiveness, comparing psychoanalysis with other treatments. I myself am involved, its director of an institute that does research on personality disorders. We studying the effectiveness of a specific type of psychology psychotherapy we have developed for severe personality disorders called transference-focused psychotherapy, and we have demonstrated in empirical research the effectiveness of transference-focused psychotherapy is compared with cognitive behavioral therapies and supportive psychotherapy, particularly its effectiveness in modifying the representations of self and significant others, in other words, in working on identity diffusion to normalize identity, and with it, profoundly the personality functioning.

Psychoanalysis has also had other applications. It has been applied to the treatment of couples, to group psychotherapy, to sex therapy, and has been very effective in developing new knowledge regarding the psychology of small group and large groups and mass movements. It has had application to the study of ideology and religion, social psychology, and in their art. You see here an example of the influence of psychoanalysis on the arts that has been remarkable in 20th century art, in the schools of Dada, surrealism, the school of fantastic realism, and others. Cy Twombly has been trying to apply the understanding of unconscious reality in his own paintings. Here, in the painting of the Battle of Lepanto, in 12 individual paintings, he has attempted to use the objective subject to free his own deeper fantasy, infantile and and fantastic unconscious inspirations, and let it dominate in the effort to reproduce that deep human experiences in his work.

Psychoanalysis, finally, has been important in helping to understand further the functioning of the normal personality and in helping to develop it. And by normal personality, we refer to the capacity to freedom and enjoyment in committing to work and a profession, to an intimate relationship of love in which love, tenderness, and sex can be integrated, to commit them oneself to friendship and his social life, to a combination of the capacity for autonomy and independence and mature dependency, and Gravatt creativity.

Thank you very much.