Object Relations Theory and Clinical Psychoanalysis

Kernberg's second book sets out the theory that underlies his clinical work with borderline patients. Gathering papers from 1966 to 1975 with some new material, it offers what he calls a formulation of psychoanalytic object-relations theory within ego psychology. The starting point is clinical: borderline patients alternate between contradictory states of mind, each fully conscious and each held apart from the other, which neither repression, isolation nor denial explains. Kernberg reads this as splitting, and he builds a model of the mind in which the basic units are internalized object relations: a self-representation and an object-representation joined by an affect. Through introjection, identification and ego identity, these units form the ego, the superego and the id. The theoretical half traces how these units develop. It moves from an undifferentiated early stage, through a stage in which self and object images are still fused, to their differentiation and then to the integration of good and bad images into whole representations of the self and of others, ending in the consolidation of ego and superego. Psychosis, borderline pathology and neurosis are placed at successive points on this line. A chapter on instincts and affects argues that affects are the primary building blocks of motivation, and that libido and aggression are organized out of them over development. A historical chapter places the model among the object-relations theories of Klein, Fairbairn, Jacobson and Mahler, among others. The second half applies the model. Kernberg proposes a classification of character pathology on three levels, higher, intermediate and lower, according to the integration of the superego, whether the defences rest on repression or on splitting, and the quality of object relations and identity. The borderline conditions fall at the lowest level. He updates his approach to the transference and countertransference of borderline patients. In two chapters on love, he treats the capacity to fall in love and to stay in love as a developmental achievement that joins sexual desire with tenderness and with relations to a whole, real person, and he traces how narcissistic and borderline pathology limit it, including in adolescence and middle age. A final chapter extends the theory to small groups and hospital administration, sketching a psychiatric hospital in which treatment, group processes and a functional administration together make up a therapeutic community.