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.
Review of key points
- The neo-Freudians, also known as ego psychologists, remained true to much of Freud’s original theory, but they shifted their focus from the id to the ego.
- Anna Freud began her career as a teacher. This concern for children continued throughout her career, much of which was spent caring for children at the Hampstead War Nursery (which later became the Hampstead Clinic, and is now called the Anna Freud Centre, as a tribute to the career of Anna Freud).
- Anna Freud established ego psychology, believing that it made more sense to focus on the conscious ego, which we can observe directly, than on the unconscious id.
- As her father had, Anna Freud described defense mechanisms as the means by which the ego avoids the anxiety associated with being unable to meet the demands of the id or the constraints of the superego.
- There are a wide variety of defense mechanisms, which are generally oriented toward protecting us from internal threats (id impulses) or external threats (the rules and expectations of society).
- Anna Freud was one of the first psychoanalysts to work with children, and she used the same basic approach that she did with adults.
- Later in her career, Anna Freud accepted that even very young children (under the age of 6) could benefit from psychoanalysis, but she insisted that they could not cooperate with the psychoanalyst in the same way as an adult.
- When working with children, Anna Freud felt it was important to fill in gaps that the child could not (such as connecting manifest and latent content in dreams). She also believed that the psychoanalyst should help to educate the child with regard to his/her relationships.
- Object relations theory emphasizes that children are born with the capacity and drive to relate to others.
- Since all aspects of relationships have importance, Melanie Klein proposed that the death-instinct and aggression are just as important as the life-instinct (Eros) and libido.
- Splitting is an important process that involves recognizing the good and bad aspects of objects.
- Klein proposed that an infant goes through two developmental orientations: the paranoid-schizoid position later develops into the depressive position.
- One of Klein’s major contributions was the method of play analysis. She felt that observing the play of children could reveal as much unconscious material as free association by adults.
- Anna Freud and Melanie Klein disagreed about how fully the child could be psychoanalyzed, and how young they could be during psychoanalysis.
- According to Winnicott, a child must transition from a state of subjective omnipotence toward one of objective reality.
- In order for a child to develop a healthy personality and realize their true self, according to Winnicott, the child must have a good enough mother (and good enough parents).
- When development does not follow a healthy path, children can develop a false self disorder.
- The transitional experience that children must go through may be facilitated by transitional objects (such as a blanket or teddy bear).
- For Winnicott, the primary purpose of therapy is to provide an opportunity for the patient to re-experience the relationship of a good enough mother.
- Winnicott was an advocate of the Squiggle Game, a therapeutic technique that allows children to draw pictures to represent their thoughts and feelings.
- Mahler believed that children begin life in a state of primary narcissism known as the normal autistic phase. As they become aware of their mother they enter into normal symbiosis.
- In order for the child to develop a sense of individuality, according to Mahler, the child must go through a process known as separation-individuation.
- Louise Kaplan, a student and colleague of Mahler, suggested that much of the stress experienced during development is the result of societal changes, and that modern cultures exacerbate this stress.
- Kohut believed that a certain measure of narcissism was necessary for the development of individuality.
- According to Kohut, children need several types of selfobjects. They will see themselves mirrored in the eyes of others, they will idealize others, and they will develop a realistic sense of self-esteem through relationships with others.
- During psychoanalysis, the analyst can provide each of these types of relationships through mirroring transference, idealizing transference, and twinship transference. This allows the patient to feel more real and more substantial.
- Kohut questioned Freud’s rejection of religion. He offered a point of view in which religion fulfills a variety of basic psychological needs for people.
- Otto Kernberg has offered a perspective that blends all of the neo-Freudian and object relations theories together, suggesting that they represent a continuum of stages in human development.
