Kohut vs Kernberg

A Facebook group post queried:

Is it concerning that Kernberg would diagnose borderline personality and Kohut would diagnose narcissism?

The post got many replies, most people indicating it was a concern about our diagnostic system or technology. My response was to highlight the difference was language and theory, not actually diagnosis. See more below!

Heinz Kohut and Otto Kernberg were contemporaries in pushing forward the psychoanalytic frontier. They were both lauded, and viciously at odds. While many can appreciate the work of both, opinions still remain divisive. Important questions are:

• Are their beliefs truly at odds, and thereby incompatible?

• What are their beliefs and how can we compare them?

• Why are their beliefs different?

• Practical Implications.

Kohut and Kernberg both built off of traditional psychoanalytic theory. Neither of them reject it, though Kernberg is arguably seen as an extension of it, while Kohut as an adjunct to it. Kohut does disagree that Id urges are found at the bedrock of analysis, but rather base needs for relatedness with parental figures. He also disagrees with the notion that narcissistic libido (psychological energy and motivation) either converts to object-related libido (interests in others) or we are locked and crystallized as a stage of psychological development in which the superego is precluded from notable formation; he reconciles this language coining the term self-object needs/libido to encapsulate both narcissistic and object related libido under one roof.

In other words, this idea opens the possibility of looking at narcissism - a pre-Oedipal stage - across the lifespan and across the continuum of wellness to psychotic personality organizations (see Kernberg's diagram of personality). Even "well" individuals (adapted, reasonably health personality formation and not excessively relying on a narrow range of defenses) still have narcissistic needs through adulthood - we all have wounds to esteem or experiences in which parental mirroring failed us by chance and not necessarily by gross negligence or abuse. Consequently the Psychodynamic Diagnostic Manual (PDM) indicates in it's opening that narcissism should be part of any psychological conceptualization - what are the clients need to maintaining self-esteem? This eludes to Kohut's beliefs as a psychologist and his Self-Psychology: it is a supportive therapy focused on attending to the clients self-esteem needs, and specifically the role we play in this as therapists. It is building the clients ego strength. Also see Blog on the term bipolar, covering Kohut's Bipolar-Self concept.

Kernberg's work incorporated psychosexual stages (traditional, Freudian Id Psychology, or psychoanalysis), defense mechanisms (ego psychology) and object relations (superego). In my reading of Kernberg, his approach is most reflective of post-Kleinian object relations therapists, utilizing very interpretive or expressive interventions, and interested in borderline personality organizations (BPO), a personality structure gleaning its name from being between the border of neuroses (the personality underlying symptom disorders, or what we could have called axis I disorders), and psychoses. Clients with BPO presented similarly to neurotic individuals until triggered, and then displayed marked departures from reality, primarily in the realm of interpersonal relatedness. There was a notably greater degree of aggression as compared to neuroses, and often a sense of bewilderment for therapists, confused by how a positive transference so rapidly and acutely turned negative. From a defense standpoint, there is a large focus on interpersonal defenses including splitting and related defenses such as projective identification. From a superego (object related) standpoint, the focus is on early-life parental-figure relationship damage that precludes adequate superego development and object-relatedness.

While the description of the superego may sound similar to Kohut, the stage (age) of this parental relationship damage would differ theoretically. Object relations theory indicates this damage occurs during the oral phase, resulting in oral aggression and the splitting defense: if a good mom and good baby can't, by experience, seem to exist / co-exist, either I'm bad / the aggressor, or mom (or mom's breast) is bad / aggressor; furthermore it would be threatening to perceive the good and bad breast (mom) as the same - they must be incompatible, and split (and the object parts are split: the frustrating breast that does not let-down and the soothing hand rubbing the babies back). This pattern of relating persists unconsciously through adulthood. These are seen as structural and defensive issues to be changed, not as hurt esteem to be mended and strengthened. Consequently, Kernberg took a notably expressive or interpretive approach to therapy, distinct from Kohut's decidedly supportive therapy.

Kernberg says "don't strengthen the personality until it is fix, otherwise you concretize the pathology." Kohut says "you can't hammer something that is structurally unsound - it needs to be strong enough to handle the narcissistic wounds of your interpretations."

How does Kohut's narcissism fit within Kernerg's model of personality organizations? There is no NPO (narcissistic personality organizations) on the diagram. The implication based upon the behavioral descriptions Kohut offers of his patient vignettes is that they would sit in the "high" BPO range - high referring to high functioning, or between neurotic and BPO. Kohut also distinguishes a more severe form, narcissistic behavior disorder with greater acting out of psychological symptoms including aggression and pathological sexual behavior. This would overlap Kernberg's "Low" BPO or sit between this and psychotic organizations, which also is marked by aggression, pathology that presents in sex-life, and poor social and occupational functioning (difficulty maintaining relationships and consequently holding jobs).

Both explicitly address pathological sexual behavior. This is not to say that any specific sexual behavior is innately pathological or deviant, but that the underlying psychology in the vignettes offered is pathological and influences the sexual behavior in a manner that could also be potentially harmful to the psychology or maintain that psychological struggle.

In narcissistic behavior disorders, Kohut saw pathological sexual behaviors as a means to bolster esteem and voyeurism as a surrogate for more adaptive mechanisms to achieve mirroring and admiration. Excessive sexual discussion during session was often seen as attempting to garner closeness with the therapist through entertainment or as a sexual object to the therapist, or performing in a manner to present oneself as secure - all of which are geared toward maintenance of narcissistic homeostasis. Conversely, Kernberg's perspective of sexual behavior that was shaped by BPO pathology was perceived through the lens of splitting - the extreme polarities of good and bad, including intimate and aggressive, are not only split, but also confusingly co-occurring and consequently associated. This may be expressed sexually in terms of bondage and sadomasochistic or dominant and submissive sexual roles.

Some perspectives on trauma concur with Kernberg's description: even entirely unwanted sexual trauma can cause sexual arousal or be with an important figure, resulting in an awfully confusing and ambivalent experience that sets to shape all future sexual relationships in which now intimacy and aggression are confusingly interrelated. Conversely, what I would believe is the common perspective on sex addiction and infidelity is concurrent with Kohutian theory: the behaviors are not Id driven but rather esteem driven (and, beyond Kohut's theory, reinforced dopaminergically). Frequently, socially inappropriate sexual behavior does not respond to chemical treatment (such as Depo-Provera) that would, for a typical individual, eliminate sexual urges, which implies its motivation lies elsewhere than the Id.

Practical Implications

In the years following Kohut and Kernberg's debates, many have published on supportive and / or interpretive therapy. The general consensus is that there is a place for both, across various theoretical orientations, but that if a therapist had to pick one, supportive therapy would be the tool of choice. Solely relying on interpretive or expressive therapy risks overwhelming client's emotionally, damaging self-esteem (narcissistic wounds), not strengthening aspects of the client's personality, client attrition due to wounds or simply feeling bullied, encouraging submission (client putting up with this, enabling a power differential, etc), or reliance on unteachable therapist attributes such as charisma.

One take on the matter is that these two approaches are not polarities along a continuum, or opposing techniques, but rather than supportive therapy is an ambiance and way of empathizing while interpretations are the tools we use for change: in the supportive ambiance and relationship, we can do much more interpretative work than if there isn't warmth and rapport. Arguably the advancement in psychodynamic therapy is advancement in our ability to empathize and utilize that empathy therapeutically. I personally find I rarely have to hold back what I say if I empathize with the client's esteem needs, trust my use of language to be empathic, say it in a manner that reduces as much as possible any power dynamic, and work from surface to depth (see blog article).

Which diagnostic label would you use, though? See my blog article on diagnostic and conceptual models. I am intentionally not addressing DSM criteria as that is adequately covered elsewhere. In terms of a single factor, the underlying concern is distinct. Borderline personality disorder is marked by a persistent fear of abandonment. In Blatt's terms, the needs are for relatedness (anaclitic), not self-definition. Narcissism, is focused on self-definition, though obviously using others as mirrors of grandiosity and experiencing narcissistic wounds from real or perceived rejection, closeness is a means and not an ends. Object-relations are poorly developed in both presentations, correlation to the severity of the illness. While both conditions are extroverted, others are not experienced or perceived as wholly separate individuals, but as extensions of the self. In other words, the developmental stage at which pathology was inflicted prevented adequate development of the superego in order to appropriate differentiate between self-and-other. The superego is often graphically depicted as budding from or out of the ego until it develops as its own structure - this separation is halted. Defensively, both conditions frequently occupy the BPO range (see Kernberg's chart), marked by splitting as a characteristic defense. We frequently hear an alternative phrase for splitting when applied to narcissism - idealization and devaluation, implying the importance of self-definition in the splitting mechanism over simply good/bad or safe/unsafe in the borderline function of splitting. Regression is much more frequent in BPD, but seen floridly with notable narcissistic wounds when the grandiose identity can no longer be maintained through a primary defense of NPD: rationalization - the factual information about the self and world is distorted to maintain esteem and self-definition, and protect against fragmentation and regression. Projective identification is use to protect conscious ego from unacceptable thoughts, feelings and attributes. Differing from projection insofar as this defense, often powerfully, influences others actions, namely to take on the projected role. Both conditions at the more severe end of the presentation can include notable aggression, referred to respectively as narcissistic rage or oral aggression, and this is consistent with any typology in the BPO range, oral stage psychosexual hangups or marked splitting. In terms of Jung's temperament, individuals with both conditions tend to be highly extroverted, not surprisingly, as others are a major source of psychological stability, and both using active coping strategies to pull others into supporting their well-being. However, they differ in terms of cognitive style with BPD being the embodiment of highly emotional presentations and NPD being seated in the middle - for example, rationalization being a cognitive/intellectual distortion.