Concept
Borderline personality organization
Otto Kernberg's term for a level of personality structure lying between the neurotic and the psychotic. It is marked by identity diffusion, by reliance on primitive defences centred on splitting, and by reality testing that is generally kept but gives way under stress. The term names an underlying structure rather than a set of symptoms, and covers a wide range of severe personality disorders, the borderline disorder among them.
Development
1967
introduced by Otto F. Kernberg
Kernberg set out borderline personality organization in his 1967 paper as a stable structure between neurosis and psychosis, defined by identity diffusion, primitive defences and preserved reality testing, and expanded it in Borderline Conditions and Pathological Narcissism (1975).
In Borderline Conditions and Pathological Narcissism (1975);Borderline Personality Organization (1967)
Relations
- 1967 introduced by Otto F. Kernberg
Kernberg set out borderline personality organization in his 1967 paper as a stable structure between neurosis and psychosis, defined by identity diffusion, primitive defences and preserved reality testing, and expanded it in Borderline Conditions and Pathological Narcissism (1975).
- gave rise to Transference-focused psychotherapy
Transference-focused psychotherapy was built as the treatment for borderline personality organization: its aim of integrating split images of self and others follows directly from the structural account of the disorder.
- derives from Identity diffusion
Kernberg built borderline personality organization on Erikson's identity diffusion, which he made the first of its three defining structural features.
- derives from Splitting
The concept rests on the Kleinian notion of splitting: Kernberg made the predominance of splitting and related primitive defences the second defining feature of borderline organization.
Works
- 1967
Borderline Personality Organization
In this paper Otto Kernberg argues that the patients loosely called "borderline" do not occupy an unstable zone between neurosis and psychosis but share a specific and remarkably stable pathological organization of the personality, which he names borderline personality organization. He examines it from three angles. Descriptively, he lists symptoms that should raise the suspicion of it: chronic diffuse anxiety, polysymptomatic neuroses, polymorphous perverse sexual trends, prepsychotic (paranoid, schizoid, hypomanic) personalities, impulse neuroses and addictions, and lower-level character disorders such as the infantile, narcissistic, "as if" and antisocial personalities. He insists, however, that no symptom is decisive. The diagnosis is made structurally, from nonspecific ego weakness, a shift toward primary-process thinking seen mainly in unstructured psychological testing, a characteristic constellation of primitive defenses centred on splitting, and a pathology of internalized object relations in which good and bad images of the self and of others remain unintegrated, while reality testing is largely preserved. Genetically and dynamically, he traces the organization to an excess of pregenital, especially oral, aggression, constitutional or the result of early frustration, which drives a premature and distorted oedipal development. By joining Melanie Klein's ideas on splitting and projective identification to Edith Jacobson's ego psychology of self and object representations, the paper became the founding statement of Kernberg's structural approach to borderline and narcissistic pathology and the ground of his later work on its treatment.
- 1975
Borderline Conditions and Pathological Narcissism
Kernberg's first book gathers and reworks the papers he wrote in the late 1960s and early 1970s, largely out of his clinical and research work at the Menninger Foundation, into a single account of the patients who fall between the neuroses and the psychoses. Its first part argues that these patients have a borderline personality organization: a specific and stable structure, not a passing state on the way to psychosis. Behind a wide range of symptoms (diffuse anxiety, multiple phobias, perverse and impulsive trends, addictions, lower-level character disorders) Kernberg finds a common structure: nonspecific ego weakness, a pull toward primary-process thinking, primitive defences centred on splitting, and a pathology of internalized object relations that leaves the patient without an integrated identity, while reality testing is largely kept. He traces it to excessive early aggression, especially oral aggression, which prevents the loving and hating images of self and others from being brought together and draws pregenital conflicts into the oedipal ones. The book draws practical conclusions from this. It weighs the factors that make the prognosis better or worse, and sets out an expressive psychoanalytic psychotherapy for most of these patients: the primitive defences are confronted and interpreted as they emerge in the transference, the negative transference is taken up in the here and now, and acting out is limited, with the patient's life structured from outside when necessary. A chapter on countertransference argues for treating the analyst's whole emotional response as a source of knowledge about such patients. The second half turns to the narcissistic personality, which Kernberg sees as a special form of the same organization, its surface held steady by a pathological grandiose self that fuses the real self, the ideal self and the ideal object and wards off envy, rage and dependence. He distinguishes it from normal adult and normal infantile narcissism, describes its idealizing and devaluing transferences, recommends psychoanalysis proper with systematic interpretation of the grandiose self for those who do not function at an overt borderline level, and sets his views against Heinz Kohut's.
- 1999
Psychotherapy for Borderline Personality
Psychotherapy for Borderline Personality (New York: Wiley, 1999) is the first full treatment manual of transference-focused psychotherapy (TFP), written by John F. Clarkin, Frank E. Yeomans and Otto F. Kernberg at the Personality Disorders Institute of Weill Cornell. It turns the expressive psychoanalytic psychotherapy that Kernberg had described for patients with borderline personality organization into a manualized, teachable treatment, held twice weekly within a firm frame. Its premise is object-relational: the borderline patient's inner world is split into polarized, affect-laden pairs of self and other representations, idealized and persecutory, victim and destroyer. In the relationship with the therapist these pairs are enacted, and the therapist is drawn into shifting roles. The book is in three parts. The first sets out the ingredients of the treatment: its theory, its overarching goals, the strategies that prevail over weeks and months, the tactics of each session, and the techniques by which they are carried out. The second follows the phases of treatment: assessment and the negotiation of a treatment contract, early tests of the frame and the containment of impulsive and self-destructive acting out, a middle phase of growing integration interrupted by regressions, and an advanced phase leading to termination. The third deals with special problems such as crises, suicidal and parasuicidal behaviour, hospitalization and medication. Throughout, the authors teach the therapist to identify and name the dominant object-relational dyad in the here-and-now, to clarify, confront and interpret it from a stance of technical neutrality, and to use the countertransference as information. The aim is not only to reduce symptoms but to integrate split-off parts of the self, so that the patient comes to experience self and others as whole, complex people. Verbatim clinical vignettes illustrate each step. The manual underlay the randomized trials of TFP that followed, was translated into German in 2001, and was revised in 2006 as Psychotherapy for Borderline Personality: Focusing on Object Relations.
See also
Linked from
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References
- Borderline Conditions and Pathological Narcissism1975Evidence for a relation
- Borderline Personality Organization1967Evidence for a relation
- Psychotherapy for Borderline Personality1999Evidence for a relation