Psychiatry & Psychotherapy Podcast - Transference Focused Psychotherapy & Personality Disorders with Dr. Otto Kernberg

Episode Date: April 25, 2025

In this episode, Dr. Otto Kernberg, a pioneer of Transference-Focused Psychotherapy (TFP), discusses personality disorders through a psychoanalytic lens. Explore key insights into Borderline Personality Disorder (BPD), identity diffusion, primitive defense mechanisms such as splitting and projective identification, and the complexities of narcissistic, paranoid, schizoid, and histrionic personalities. Dr. Kernberg also shares reflections on sexuality, aggression, reflective functioning, and why therapists choose to help others. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, I'm here with Dr. Odo Kernberg. He is a psychiatrist, born in Vienna, Austria, immigrated to Chile, subsequently came to America and is the founder of Transference Focus Therapy and was instrumental in our understanding of things like borderline level of organization. We're going to have a discussion today about his life, about the things that he wrote and ideas that he came up with and the evolution of it. So welcome to the podcast. Can we start by, I know you were born in Austria, Vienna in 1928, and you fled Nazi-occupied Austria with your family to Chile.

Tell me a little bit about that. Well, I was nine years and a half. Hitler invaded March 1938 and I left with my parents on July 16, 1939 my father didn't want to leave he happened to be an Austrian monarchist and he believed all of this was gold

just passing by Hitler was a transitory phenomenon he had a strong belief in Austria of Austrian survival. My mother had paranoid features. She was

frightened through death with the invasion, the anxl. And then after Crystal Night, which in Vienna occurred on December 10, 1938, she convinced

my father that we had to leave and so we got the visa to Chile and of course I didn't know anything. They didn't. I'm an only child. I was nine years and they have about. And on July 16, 1939, she told me, pack everything, all toys that you have into this suitcase.

We're leaving this afternoon and you are not supposed to tell a word to anybody. And by then, I was already acutely aware of the danger. and so that's how we left. I spent one year and a half under the Nazis and it was a bad experience, violent anti-Semitism naturally. And all Jewish kids were expelled from schools, put into Jewish schools,

forbidden to go to movies, parks everywhere, Jews and dogs forbidden. So although I was a child, I got the feeling for it. One day I was walking with my mother on the street and an SR man that was Hitler's lower military guards, the SR in contrast to the SS. forced my mother to wash the streets, the pavement. And so my mother was washing the pavement and the crowd gathered making fun of us and I was standing there. I mean, this kind of bad experiences.

And that was before the war started, the war started, I think October 1, 1939. So we just managed to escape in time because after that the border was closed. And the rest of my family all ended up in the concentration camps. They had except one cousin who managed to escape to England with the children's transport and then to the United States. And we spent then six months in Italy before our children's transport. before finally being the visa came and we emigrated to Chile, where I lived for more than 20 years, coming to the United States.

Wow. First of all, thank you, Dr. Kernberg for sharing, and I appreciate you being so honest with us about just that experience. I can imagine, in part, how awful that was. I imagine it was a huge loss to have to leave all of a sudden further loss through the war hearing about the concentration camps and the rest of your family that were stuck there. And I appreciate you sharing today.

I wonder if you could tell me a bit more about some of these formative experiences that you had in Chile, some of the mentors that guided you towards becoming a therapist. Well, I studied medicine in Chile and was fascinated by the psychiatry problem. Professor Ignacio Matablanco, who was trained in England. He was originally a neurologist trained in psychoanalysis by the Kleinian School in London. And he started the Psychonautic Society and Training Institute in Chile.

He was a very outstanding man and became a personal idea. I was interested actually in psychoanalysis since adolescence I had read Freud and in emigration to Chile, I came under the influence of a Jungian analyst and by the time I entered medical school I was already interested in psychoanalysis and within psychiatry then that culminated and I decided to study psychoanalysis in Chile under the leadership of Ignacio Mattovlanco and graduated there and before I came to the United States with the Rockefeller Foundation Fellowship to study research in psychotherapy. I was interested in psychotherapy. was it effective or not?

And I did my first research efforts in Chile and then came to the United States, spent a year at Johns Hopkins with Jerome Frank and his research group on psychotherapy and then at the Manning of Foundation in Topeka, Kansas. Well, I mean, in between, I went to Chile, did all the teaching that I had committed myself to the Rockefeller Foundation who gave me the fellowship.

So I fulfilled my obligation with the Rockefeller Foundation and then returned to the United States to participate in the psychotherapy research of the Manninger Foundation, a huge project that I participated in several ways until I became the director of it after Robert Wallerstein, who was the leader, left as professor of psychiatry. in San Francisco. So during my work at the Menninger Foundation, there was, they were about 12 years, I became interested and learned all how they could about the diagnosis and treatment of severe personality disorders. And within the Meninger project, then I developed my own interest in studying outcome, comparing patients who were treated in supportive psychotherapy, in expressive or analytic psychotherapy, and psychoanalysis,

and it came to the conclusion that patients with severe personality disorder, the so-called borderline, Patients who fell in between neurosis and psychosis really responded best to a treatment that was a well-structured psychotherapy, not standard psychoanalysis, nor the usual supportive psychotherapy that was the fashion at that point. And so I developed a project about an ideal treatment for severe. personality disorders and at the same time had to differentiate severe personality disorders from non-severe and had to deal with the entire diagnostic differentiation within psychiatry in which Ignacio Matte Blanco helped me enormously. When he learned in Chile that I spoke German, he said I had to read German, classical German psychiatry book. I went to the library to get Bumke and I found out it was 12 volumes. I didn't

dare to ask him which volume he wanted me to read and I studied all 12 volumes of Bumke and it gave me a knowledge in classical German psychiatry that helped me enormously with then, of course in the United States, I got the American approach to diagnosis, but I became I made myself an expert in differential diagnosis and concluded that the common features of severe personality disorders was a lack of integration of their concept of self and a lack of integration of their concept of significant others. What Eric Erickson had described is identity diffusion. I picked up Ericsson's concept of identity diffusion, applied it to the differential diagnosis of severe personality disorders, and developed simultaneously view of psychological development, depending not on the internalization of representation of significant others, is a kind of mental representation of others from reality. But under the influence of a lecture I heard from Talcund Parsons,

a leading sociologist in the United States, I learned that what is internalized are not the representation of others, but representation of the relationship between self and others. So when we interact with others, we internalize our representation of the other and the self-interacting. This explains, for example, why children who have been physically abused, severely abused over years, become abusers in turn. We say that they identify with the abuser, yes, but in a deep sense, they have internalized the whole experience and simultaneously internalizing in their mind the representation of abuser and abused and are able then to, in order to avoid. So their world becomes a relation between abusers and abused. All relationships are between abusers and abused,

and it's better to be the abuser rather than the abused. So they learn role reversals and take on the role of the abuser while the role of the abused is projected onto somebody else. So the internalized relationship with others becomes the guiding principle that organizes habitual behavior, what we call character. So the character, what we now call personality, actually personality is a broader concept that includes cognitive functions and everything else. character habitual behavior patterns but they are the essential

part of personality and so I defined borderline personality organization is those alterations habitual alterations of the

personality that had in common identity diffusion and developed a clinical instrument, the clinical interview, the so-called structural interview, to diagnose identity diffusion and differentiate severe personality disorders from non-severe personality disorders and of course the entire field of personality disorder from ordinary

forms of psychosis, madness in the usual sense. organic brain syndrome such as mental retardation and dementias. So I linked the specific instruments for diagnosing personality disorders with the general psychiatric diagnostic approach and placed personality disorder within the general area of psychiatric diagnosis. and regarding the treatment, as I mentioned to you, propose the combination of the psychotherapy under strictly controlled circumstances inspired by psychoanalysis, but different from psychoanalysis by modification of psychoanalytic instruments or methods

and different from supportive forms of psychotherapy. More generally speaking, I would say that transference-focused psychotherapy is a psychoanalytic psychotherapy, not psychoanalysis proper. Psychonanalysis is reserved by patients with less severe neurotic illness, but the severe personality disorders that, we now call borderline personality organization can be treated with transference-focused psychotherapy, and that's preferable to treat them, then to treat them with a supportive approach, which may be carried out within a psychoanalytic perspective or a cognitive behavioral approach.

In general, you can divide treatments into cognitive behavioral ones that are very effective, for some patients, in some circumstances, in psychoanalytic psychotherapies that are effective with other patients in other circumstances. So I defined a specific psychotherapy for borderline patients, and this is how my career changed in the middle of this. I became the head of the psychotherapy research project of the Menninger Foundation, but then it was appointed director of the Menninga Hospital. So some years I was simultaneously medical director of the hospital and director of the research project.

And then I felt I had nothing more to learn, but I felt I needed a learning. learning atmosphere to find different approaches, different ways of dealing with psychiatry and psychotherapy. The main foundation seemed to me a more limited place and I accepted invitation to become a professor at Columbia University in New York. Went to Colombia, where I really began to start out the tree. treatment that I had devised, I was in charge of their inpatient service for severe personality disorder, and I gathered a group of people who, after a few years, we accepted moving to Cornell, and I became director of the Westchester Division Hospital of the Department of Psychiatry at Cornell. And together with the group, we formed the Personality Disorders Institute.

And 20 years later, after I completed my directorship of the hospital, I dedicated myself exclusively to being the director of the Personality Disorders Institute at Cornell, with the help of some distinguished scientist John Clark and the director, the director. of our empirical research, Frank Yeoman's, whom you have interviewed, who is the director of overall training. He's a fantastic psychotherapist. And there were two or three more people, a group of six or seven, who we first developed the diagnosis more clearly, more sharply, and described different types of person.

personalities functioning at that borderline level, the narcissistic personality, the most important one which we have been studying in great depth, but we also studied the paranoid personality, the schizoid personality, the infantile or histrionic personality. So we did a general study of personality disorders, their description and differentiation into those with normal identity or neurotic personality organization with identity diffusion or borderline personality organization. and those atypical psychotic cases that presented as if they were personality disorders, but with a more severe illness, a psychosis is a potential that might blow up or not in different cases. So we spent the time first on differential diagnostic studies and publications and then set up empirical study comparing transference focus psychotherapy with supportive psychotherapy

and with cognitive behavioral therapy and confirmed the effectiveness of transference focus psychotherapy both in research carried out in the United States in New York and then replicated in Europe under the direction of Stefan During, professor of psychoanalysis in psychiatry at the University of Vienna, who gathered internally a group that carried out parallel empirical research in the German-speaking countries. And of course, now we have. groups in many different countries and are continuing both research, training, and treating patients.

That's in a nutshell. Nice. Can you specifically talk about how in the borderline level of functioning, you have identity diffusion and primitive defenses? And can you talk about the primitive defenses that you see? How do you identify them? Yes. Freud had defined the ego defenses against awareness of unconscious conflicts,

particularly repression and related defenses of suppression, rationalization, intellectualization, reaction formation, those who were unconscious defenses to be discovered in the course of the treatment, of psychedelic treatment, searching for the unconscious conflicts of these patients. Melanie Klein, who influenced me very importantly in my psychotic development, discovered a group of primitive defenses centering around splitting or primitive dissociation in which the way to deal with conflicts between love and aggression by sharp splitting of the emotional experience. So it is not an erotic patient may act lovingly and represses his aggression,

or he may act aggressively and represses his loving potential. Borderline patients express simultaneously love and aggression, but under different emotional conditions. And they have memory of when they felt opposite to the way they feel now, but they can't help it and have to feel now the way they feel now. So when they feel enraged, they are all rage, there is no love. When they feel love or love and no rage, and they may shift from one to the other rather easily. So that's the mechanism of splitting, and it creates chaos in their relationship because they are violent and brusque changes of mood and attitude that creates difficulty with other men.

people who in turn respond to that chaotic behavior with their own difficulties. And so personality disorders tend to create abnormal interactions with other people and distort all relationships. Another primitive mechanism is projective identification. Projective identification is a tendency to attribute. to the other person what one cannot tolerate at the moment in oneself

so that while you are in a state of idealization, you project your own aggression onto somebody else, attribute somebody else as having aggressive motivation, aggressive behavior

and you induce it in him without being aware of it and then try to control it. So projectification is perception combined with induction, efforted control, and it is the primitive form of what advanced mechanisms show in projection, which is attributing something internal to somebody else but without any internal contact anymore with what you are projecting. In projection, you just declare the other one is what you are not and you don't feel like

that. In projective identification, you attribute it to the other one, but you know how it feels to feel like the other one and you produce it in the other one and you have to control it. So projective identification is primitive form of projection. Another mechanism is that of a very primitive idealization that doesn't tolerate an opposite of modifying it with the realization of your own aggression toward the ideal object. the idealization or the higher level idealization recognizes one's own limitations. The primitive one, there is somebody ideal and you identified with that implicitly become

ideal as well. And the wish to omnipotent control the other person. the effort to deny that you've had a feeling or an action that you've had, but it no longer exists because of splitting operation. This is the primitive mechanism. So splitting projective identification, omnipotent control, denial, these are typical primitive defensive operation, and they show in the behavior of people, the advanced mechanism only showing the treatment, primitive defenses show in the behavior, in the habitual

behavior of people who use projective identification and splitting and omnipotent control and deny aspects of themselves that have been evident at other times. So we can diagnose through these behaviors the personality disorder. How do we diagnose the personality disorder? We try to find out how the person is functioning in work and profession, love and sex, social life, family relation, self-affirmation, and free time interests, hobbies. And what we, in the structural interview, what we ask people mostly, how are you doing in your work? Are you happy or not?

Are you effective or not? How do you get along with other people or not? And we ask the same about their sexual life. Are you happy? Do you have a relationship? when sex becomes complicated not only because it's a fundamental aspect of life that is in conventional reality is usually suppressed

and highly privileged, but because it involves implicitly the integration of the erotic dimension, sexual excitement, orgas and sexual behavior with the emotional feelings of love and tenderness. And when we study sexuality,

we study the extent to which the erotic and the emotional have been integrated, which is what happens maturely, normally, in contrast to conflictual lack of integration,

by which the erotic and the emotional remain separate and create serious problems in intimate relations. So we try to find out about that. And regarding social life, we find out to what extent a person has a friend, a social environment that enriches life or feels isolated for whatever reason, incapable of establishing such as social life. And to what extent is he able to establish relationship in depth, in friendship, not only in sexual love, or to what extent is this not possible?

And with patients having borderline personality organization, usually there are serious problems in work and profession, in love and sex and in their social life, family life, such as between parents and children. So the careful study of functioning in present life leads to the diagnosis of the personality disorder. Can you say a little bit more about when someone has this borderline level of organization and their sexual intimacy is separated from more of the erotic side? Like how does that show up? What would a patient be saying to let you know that they've separated those two things?

No. First of all, I need to modify what I said in that there are patients on a higher level of functioning, on a neurotic level of functioning, who also have such separation between love and sex, namely people with the mesochistic personality, which is a non-borderland personality disorder. But the borderline personality organization, patients have the greatest difficulties. The most typical is presented by the narcissistic personality. The most typical cases, then, they have great difficulty for intimate relations. They can't maintain an intimate relation. The men have relation with women for a few months. all they tolerate before the relationship goes up in smoke.

So they replace the lack of intimacy of love with freedom in sex. So you find men, and the same thing holds for women. Men get involved with many women, have great sexual relation and infatuation that lasts for weeks or a few months. they get bored, fed up, end of relationship, on with the next, so that sex determines the capacity to maintain brief, repetitive relationships without a capacity for relation in depth. On the other hand, they may maintain a very dependent relationship with one woman who has a kind of a motherly function with whom they have no sexual interest that are very dependent

and exploitive. So they may be married men who act like children who are exploitive to women who tolerate that, while they have sexual pleasure with a number of women. That would be one way. Another possibility is that they have a full sexual relation, but in which there is an alternation between intense aggression and rejection and then re-encounter sex, permits them to encounter the relationship in which there is depth and dependency in contrast to narcissistic personality, the ordinary non-narcissistic borderline patient is capable of maintaining long-term

relationships, but within each of them chaos in which love and aggression shift rapidly and create chronic couple conflicts. They are patients who, of course there are some patients with a total, inhibition of their sexual impices in which there has been too much aggression in very early development to commit eroticism or develop or the strictly rigid, excessively rigid education has kind of severely inhibited their sexual behavior or forced it into remaining at the level of infantile sexuality. Sexual life begin with birth.

What we now know is that children, if you leave babies alone in the sense, you don't forbid sexual behavior, they start masturbating in the second half of the first year of life and during the second year of life. Boys and girls masturbate. Girls in general tend to end this first

masturbation phase around age three, around age three, but re-establish it later at age five or six, boys tend to, if not forbidden, tend to masturbate all through until adulthood. Mastubation is a normal sexual activity when there is no other sexual outlet. And we have learned that it's in normal aspects of infantile psychology has taken us, Sigmund Freud and 100 years later to this slowly sinking in, even in the modern forms of the various Western religion, masturbation is no longer a major sin. a major sin. And so science has been

able to modify our attitude towards sexuality. But in general, in borderline personality organization, either sexuality is combined so much with aggression that chronic, chaotic

conflict prevent a good sexual relationship, a stable one, with stable love, stable sexual erotic gratification, excitement. It's an alternative to not being able. A woman may be sexually excited and orgasmic with one man, totally non-responses to another one. So there may be sharp way of splitting or division within the erotic life.

Do you see with the narcissism, specifically more of the sadism in the sexuality, or is it specific to a certain personality type? Is it more, how do you see that play out in the work that you've done? We all have a potential for love and for aggression. That's universal. Usually love wins over aggression. From babyhood on, we have more experience of good relations than bad ones. But of course, they are traumatized children whose life has mostly bad experiences.

Everything goes wrong. And under ordinary circumstances, we use aggression constructively by self-affirmation, by endurance, by defending ourselves realistically. And sex also enters, aggression also enters sexuality in the sense that from the beginning of life, There is a pleasure in penetrating and being penetrated that already has an erotic quality. There is an erotic quality in biting, in being bitten, in fusing lovingly with the other by touching skin as well as feeling this one penetrates the body of the other or is being penetrated. So the erotic impires show from the beginning of life in the capacity to experience sexual excitement and to the erotic pleasure in watching one's partner, the baby watching mother and mother watching the baby, which is the origin of white. or sexual pleasure with seeing the sexually prohibited part of others.

And exhibitionism, which is the opposite, the erotic pleasure in showing one's forbidden parts to other to excite them. In mesochism, the slight pleasure in mild pain that is part of sexual excitement. and sadistic pleasure inducing pain in the other, which is part of sexual excitement when it is within a dominant, loving atmosphere and signals the erotic pleasure of mutual fusing. When there is an excessive degree of aggression, then these tendencies become dominant, and create problems. And the most important problem is that excessive aggression makes ordinary sexual intercourse

dangerous, dangerous to penetrate, dangerous to be penetrated. And so one remains with a childlike equivalence of masturbation, voyeurism, exhibitionism, fetishism, we call them perversion or parapherias when they become indispensable preludes to sexual intercourse when the individual only acquires the security of sexual excitement and orgasm after having fulfilled these pre-genital early erotic desire. So perversions are really sexual inhibitions of the ordinary sexual behavior. Retreat from it into the infantile equivalence. Normal sexual relation, however, includes all those infantile components.

So a couple that has a good mature sexual relationship may have games and play. and fantasies and activities of a masochistic, sadistic, exhibitionistic, heterosexual and homosexual quality and apropore homosexuality and heterosexuality, unconsciousless. We have both tendencies, although usually one clearly predominates in most cases, but there are persons who of course, who maintain both homosexual and heterosexual impulses of various degrees. So sexuality becomes complicated, has been accentuated in recent fashions and political movements.

One thing that I really loved about when I read the Transference Focus Therapy articles is when they looked at reflective function before and after transference focus therapy. And I think transference focus therapy is one of the only therapies that has shown an improvement in reflective function. Reflective function being measured by the adult attachment interview.

Fonagy was the main originator of that manual. Do you have any thoughts on why transference focus therapy increases reflective function where things like dialectical behavioral therapy did not show any change in reflective function. Because transference focus psychotherapy permits the full expression of a conflict of a conflict in its positive and negative aspects. Patients who develop a negative transference, we don't try to read.

reduce it. To the contrary, we try for the patient to experience fully the negative transference in terms of identifying with the hostility of the object and the self as victim, and then with the hostility of the self and the object as victim. In other words, we try to familiarize the patient to make him a victim. to make him accept the extreme of his reaction, to then confront him with the opposite extreme that we also tolerate of the intensity of loving and erotic impulses to the therapist both is a duer and recipient of love, so that by permitting the full expression of the extreme,

of love and aggression, we facilitate the interpretive integration of them and permit the patient to tolerate the simultaneous contradictory impulses that are part of normal human ambivalence. And the patient then is able to see that yes, he has an idea. ideal view of himself as a very nice person, but part of him is also a nasty person. And introspectual insight consists in the capacity of an integrated view of all potential that one has, in contrast to remain splitting into a false, idealized version completely separate from all aggression. So self-reflection

signifies a realistic way of assessing one in one's strength and weaknesses, good and bad aspects. It's a mature distance from oneself is acting in any concrete interaction. Okay, okay. So a lot of people

do not like the idea that we all have aggression, right? And what I'm hearing from you is that you really allow the patient to feel the full weight of their aggressiveness, and that's very different than like trying to give them coping strategies or trying to tell them,

no, you're not really aggressive, or you're not really angry. So like, give me some examples or help me understand how you might help someone tolerate their own aggression? Take a marital conflict. A woman hates her man because he has been treating her badly

during breakfast, has not been coming home, has forgotten something important, gets enraged at him he in turn gets enraged defending himself there in the middle of a big fight but at the same time they both have a

consciousness that they love each other and that fight is going to end in a good way into a good relationship they have no doubts about that they tolerate bad momentary interaction with a deep conviction

of the consistency of the dominant love in contrast to another couple who when they are enraged they feel this is the end I'm walking out of this I don't want to see that man

never again or that woman never again so the the the tolerance of one's fighting mood when one is angry with the consciousness of the permanent of the deep relationship that transcends the momentary one,

that is what characterizes self-refractiveness, the capacity to see one's overall relationship rather than being victim of a certain mood and then having the sense that there is no other possibility is that particular mood. A man gets enraged

at the way his wife is treating the children and gets so enraged to say, you do this once again I walk out and he's ready to walk out and then drop the relationship.

So there is an intolerance of the bad unavoidable bad aspects of any relationship of daily life. Tolerance of ambivalence is really what marks

self-reflectiveness. What Kleinian psychoanalysis calls the depressive position which is the sense of the potential for sadness for treating badly

people one really loves. All of us have moments in which we don't treat those we love well. It takes a baby a year or two to realize that the mother that he hates when he hates her

is the same mother that he loves when he loves her and eventually has the capacity of feeling depressed when he is angry at the mother that he loves and is sad over losing

the mother that he loves because he's so angry. That is an indication of mature reflection the capacity for reaction with sadness about one's own reaction and the awareness

that one has a different general relationship with somebody with one is in a momentary mood very different

from the usual habitual one. The person who tends to be kind of rough and acting superior with subordinates has a kind of inappropriate grandiosity

may recognize that he has that tendency and accept that he has problem in the way and he treats others that he has to correct and that becomes part of his personality watching out what he knows are problems in his own tendencies that indicates self-reflection general intention, how we should behave with others, controls the immediate behavior, even if it's very different of what his general attitude is. This is what we mean by an integrated view of self

and an integrated view of others. I mean, a man comes home with a serious mind and his wife thinks, oh, he doesn't love me anymore. Then he comes home with a friendly face, ah, he loves me. She doesn't have the capacity to know that he loves her, whether it's a good mood or a bad mood. The integration of his present mood into his general relation with her

indicates maturity, integration of the object representation. So integration of self-representation and integration of object representation mark normality, normal identity, and capacity for refractiveness. And we develop that throughout the treatment that tends to resolve primitive defensive operations,

normalize identity, and therefore normalize the capacity of dealing with a major task of work and profession, love and sex, social life and one's own creativity. Tell me about your thoughts on envy and how someone with maybe more narcissistic, borderline level functioning, how envy shows up for them versus maybe normal people. A very good question. Envy is a normal aggressive affect with very specific characteristics. It is anger at somebody who has something that we want and we don't have.

So we want something that we don't have and are angry at whoever has it, when we don't. It is a normal way in which a baby sees another baby has a toy, he wants to have that toy and gets angry if he doesn't get that toy or something exactly like it. So it is a human emotion that is one of the negative aspects of our potential that normally we have, we tolerate, it doesn't control our lives. With narcissistic personality, the problem is they present very intense aggression that takes the form of envy.

Usually the cause of that is a lack of loving, sufficiently loving relationship in very early life in the first time. two or three years of life. When one feels loved, one feels, one internalizes a good representation of others and feels fulfilled by the people who have been good to one. If one doesn't have any of this, there's a sense of emptiness, and one gets painful, the painful observer that other people feel so good. so good about their relation with others while we feel so bad.

So envy becomes a very strong motivation because basically we don't feel the internalization of love that others have. And envy then grows to the extent that whatever, we like and don't have enrages us. It destroys our relationship because whomever we could love and be friendly with turns out to have things that we don't have to begin with the very capacity to love.

So the way and envy is very, gives one a painful sense of lacking of everything, of emptiness and the way to fight it off is to devalue what one envy this. Normally when we get a good response to our behavior from others, we feel very happy that others love us and we see it as a gift. In other words, normally we have a feeling of gratitude for love that we get. Envious person lack their capacity of gratitude because what they get gives them a sense what they didn't have.

It reminds them of what they didn't have with colors what they get. They are happy they get it, but they don't have. that feeling of happiness with the happiness that the other feels in giving them something. So envy tends to spoil what one envy is, which means that narcissistic personality fall in love with a woman unconsciously hate what they admire on her, from her physical appearance to her capacity, to her potential and so unconsciously they tend to devaluate and that makes this woman indifferent and boring and they have to drop her.

So unconscious envy, the defenses, the defense against it by devaluation is what motivates the sexual promiscuity of narcissistic personalities. The counterpart of envy is an unconscious destruction of the values that others have and that one doesn't.

Students with a narcissistic personality can learn only what they feel they learn because they take over what others know. They incorporate the knowledge from other. That's kind of, it's like stealing from other. makes them feel good. But when they have to acknowledge that they depend on the other,

it spoils it because then envy is unavoidable. Parasic personalities can learn from what they learn by what they feel they are learning by themselves without anybody giving them anything. They take it from others.

But they can't read a book, they can't learn from a book because they have to There is independent knowledge from them and they've resented. So you find very intelligent people who can't read a book or spoil their own capacity of interest in a certain field. So envy tends to ruin the capacity to absorb good things, establish good relationship In the worst case, in a area, one cannot enjoy anything except being admired, which is recognizing of one's greatness by the others.

And one of the predisposition to the narcissistic personality are parents who really don't love the children, but they are happy with admirable things that children have that others admire. the child, the parent, the narcissistic parent who uses a child is something great that look what beautiful children I have.

So they admire their child but they don't love it. So when love is replaced by admiration is the only source of what love one receives, it fosters narcissistic personality.

One has no hope for love, only when others admire one, one can feel good about oneself. So the psychopathology of envy is very damaging and a major issue in the treatment that one solves by analyzing all its causes and consequences. I'm also curious about, you mentioned. and histrionic personality before. Do you see this on the borderline level of functioning or more of the neurotic or both?

There is a confusion in the literature about this. There exists a high level personality disorder, the hysterical personality disorder, which has normal identity, And the main problem is sexual inhibition and efforts to overcome the sexual inhibition by various means. Sexuality is a great problem. They act quite maturely, except when it comes to sex, when they become quite childish. Now, because politically hysterical personality usually went together with an attack.

of women because the impression was that only women had hysterical personality which is false men also present hysterical personalities the official classification of personality disorders called it

histrionic personality disorder so to take it away from its political implication and the histrionic personality disorder in the official classification covers both the hysterical and the histrionic in a strict sense equivalent to the infantile personality, which are patients who have sexual difficulties but part of a general severe personality disorder with identity diffusion. so that the histrionic personality, how it is used generally refers to a broad spectrum,

most of them are really a borderline personality organization, when in fact a subgroup is part of a higher level neurotic organization. How do we make that differentiation? The histrionic personality disorder is childlike or infantile in all aspects of life. Work, professional school, love, sex, social life. And is part of this childlike regression, feelings are expressed through behavior more than verbally. And the exaggeration of behavior is what from the outside looks at theatricality and exaggeration. Theatrical exaggerated behavior, which has an infantile quality to it and is important aspects of those personality disorders.

Histrionic means behavioral exaggeration of real feelings one has and conveys a sense of artificiality in contrast to the expression of real feelings in a profound sense. So these are patients who give the feeling that they exaggerate that they do theater with what they feel to impress others, as if it were a profound lack of sincerity, lack of honesty, when it is really part of a general childlike regression to childlike communication of affect.

So the histrionic personality are personalities with childlike behavior in all their interaction, that may include sexual inhibitions, but very often, surprisingly, doesn't. So often the histrionic personality on a borderline level are freer sexually than the hysterical personality on an erotic level, because the hysterical personality, using the mechanism of repression inhibits totally the sexual response, while the borderline person, by the splitting mechanism is able to have great sex with one partners and zero with others. So in a strange way, borderline patients may be freer of them sexually than higher level neurotic

patients. The main problem is in the relationship with others. And of course, borderline patients who, on top of all their problems, have an extent. extremely severe sexual innovation with zero capacity for any sexual excitement or enjoyment constitute the most serious part, the most serious part of sexual inhibition that requires long-term treatment. Do you want to talk about borderline level of functioning with the paranoid personality type? What is kind of like the thing that is most common with that group? Paranoid personalities are using the mechanism of projective identification as a dominant mechanism.

They are part of Waterland Personality Organization with intense aggression that they attribute to others. because of that mechanism, meaning that they are hypersensitive to anything that can be interpreted as a negative attitude toward them. They are suspicious that others' behavior indicates hostility toward the person, hostility or the effort to disguise or hide hostility. At the same time, they tend to be very aggressive because they have excessive aggression, and they tend to use omnipotent control efforts to control the other person whom they see is dominated by aggression toward them. So the combination of aggressive behavior, hyper suspiciousness, and efforts of sadistic control of others

are the main characteristics of the paranoid personality. And you touched on schizoid a little bit. Schizoid with borderline level of functioning? Yeah. The schizoid personality uses predominantly the mechanism of splitting. in effort to avoid conflicts by such generalized splitting of the expression of all affects, that it is as if they had no affects, there is a kind of a fragmentation of affect as extreme forms of splitting.

So they fragment both their aggressive affects and withdraw from contacts in order not to be tempted to become aggressive. And they fragment the view of themselves as aggressive to avoid it. And sometimes they show a very sharp perception of others because they are so suspicious and so observant, nothing escapes them. They are very good in spite of the identity diffusion to know exactly what to expect from others. but about self they have a complete confusion because of the fragmentation of all affective experience. So the identity diffusion shows in sharp description of others while they look an integrated view of them. They see the trees but they don't see the wood. and they withdraw prospectively from avoiding aggressive interaction with others.

They look as if they didn't need affective relation and love. That's a mistake. They do need love, but they are afraid that their own aggression will destroy the affective potential of a good relation with significant others. So the withdrawal protects them from direct search for love. And to the contrary, they have to do a tremendous effort to be able to express any close relationship with others. So their relationships are distant,

The affect is dispersed, so it's hard for them to know what they really want and they are ignorant of their own deep needs for love that they have to reject out of fear of being rejected. and so there is hyper alertness to what's going on but without the aggression of the paranoid personality social withdrawal rather than omnipotent control and a sense of uncomfort and loneliness and distance in group situations. So a sense of loneliness, confusion about the self, not clear awareness of their need, of significant others, and their capturing of the great details of the personality of others without really putting it together in an integrated view.

These are the main characteristics of the schizoid personality. and the so-called schizotypical is just a more severe form of that, except that in the schizotypal, there is a stronger genetic, erratory disposition than in the schizoid personality. What role does fantasy play for schizotipel and schizoid? They, in withdrawing from immediate social reality for the reasons that I mentioned, they replace their interaction with others by an intense fantasy life. They find in their intense fantasy life an expression of their needs of relating to others. So they are particularly prone to create their own intense,

world gratifying their needs because they don't dare to express it in external reality out of the fear of their own aggression. How about someone who's classically borderline personality disorder? How do you make of their intense fear of disconnection, of the withdrawal of the other? Well, because the splitting operation and the activation of the activation of intense aggression toward people whom they love, they project the aggression and any real frustration creates an exaggerated reaction. They are afraid of being left, of being dropped, of being abandoned because they see others with the intense aggression that they can't tolerate in themselves. So they take one way to solve the dilemma between love and aggression is to look for an ideal relation with the other. a protection against the feared aggressive rejection by the other.

So they become very dependent and intolerable of being separate. That intolerance of separation has to do with the fact that any separation is immediately translated into a sense of an aggressive rejection of the patient. Good, good. What do you think of most therapists who come into practice? Do you find them more of the depressive personality type, or what kind of range have you seen? Well, I've had a long professional life,

and I've seen, I think, a very broad spectrum of patients. Yes. I believe I've seen probably most patients described in the literature. Is there a commonality of the helper, of the person that wants to help? Maybe if the person where there was a role reversal early on in their childhood, where they were the ones who were like the family therapist, even at a very young age, like what is, like, how do those, where do those people fit in your sort of? I think that therapists may have many reasons for becoming a therapist.

Very often persons who have had strong personal problems that they have overcome, then want to become therapist out of an experience of gratitude and identification with the people who help them. Some people are looking for solution of their own problems. in helping others. For some people, it is a source of great gratification to have a profession

that helps others and there go all the motivations for medical professions, nursing, psychology, including that of psychotherapist interested in the psychological functioning of self and others and how to modify it. There are some people who become psychotherapists secondary to their interest in neurobiology,

in the functioning of the brain. Sometimes psychotherapists have the unconscious motivation of helping others out of the situation in which the therapist had been in the past, broadening the effect of his treatment. And one thing that was important for me was that sense of being able to change one's way of behavior. I had ways of behaving I was not happy with and I had difficulty changing and I wanted to know how much change can one or ten

in self and in others that drew me to get into a personal psychoanalysis first and then became interested in psychotherapy in general and how much did you change? I changed significantly. I changed significantly. I had two personal analysis, so I had people helping me.

And I had the luck of great teachers, really an unusual luck with met a number of the leaders of the field and we some of them became real friends. and that was very important. I owe a great deal to people such as Adi Jacobson and Andre Green and Betty Joseph and many others. But it sounds like you were also a great student

because when he tells you to read the book, read the 12 volumes. Sounds like you, which it's an unusual student to come back and said, I read the 12 volumes. I read the 12 volumes. I admired him

greatly and it was worth it. I learned descriptive psychiatry more than most psychiatrists of my generation. It helped me to become very observant about small issues of behavior. It really was a, I got a specialized training.

What would you say is something that you feel a lot of therapists don't understand that you wish they would understand at this point? It's very difficult to generalize. My experience is mainly, with psychodynamic psychotherapists, I have limited experience of working with cognitive behavioral therapists, although I do have some and I'm very impressed by what some cognitive behavior therapy can achieve. But for psychoanalytic psychotherapist, I think the most

important issue is, first of all, comfort with one's own aggression. Theroglists have to be comfortable with their own aggression, not having to act it out nor being afraid of it. That's one important issue. One, of course, a crucial issue is having a real interest in people and getting to know about people, being curious about how other people are functioning. There are many therapists who don't pay sufficient attention to that. Then I think psychotherapists need to have a great common sense, a great common sense.

Psychotherapy starts where common sense ends. and in order to deal with the subtlety of conflicts, one has to have first a good hold of solid reality. I think the therapist can come from many areas. They can come from a very intuitive, emotional direction or very intellectual ones, and they have to learn to complement what comes natural. bit what they have to learn. The very intellectual one have to learn

about expression of emotions and the most emotional, intuitive one, have to learn how to formulate things cognitively. And a really

strong wish to help other people. I think these are the most important ingredients. Yeah. Yeah, that's good. Well, as we kind of, I don't want to take too much of your time today,

and I feel like almost a part two is necessary to hash out some more of these ideas, or part 10 or part 11. But I'm curious, as we've talked today, if any lingering ideas are going through your mind that you haven't had adequate time to express? Yeah, I think the great goal of treatment are to help people to become more effectively self-affirmative

and at the same time more capable to develop relationship in depth with others. These are two basic issues of normal, functioning, to take care of one's relations with others, and to take care of oneself in a reasonable way, require full responsibility for one's behavior in one's life. Okay, so one more question. Do you feel like there's any room to explore the thing that you were doing before, you did the psychoanalysis two times that you wanted to change, and did you actually feel it changed?

Are you asking me whether I was considering some other profession? No, no, no, no. You said earlier there was something about yourself that you wanted to change through psychoanalysis. Is there anything else you would be willing to share about that publicly? Well, I don't want to share too many personal issues, but I used to be quite obsessive, excessively intellectual, and I have become much freer with my emotions. Well, I thank you for that. And thank you for coming on. I've really enjoyed my time talking to you, Dr. Kernberg. It's a pleasure. I'm very grateful for your many articles and books. And there was just a recent

biography that was written about you. I think Yeoman's wrote it in part that I've appreciated. And I know the people that I've been listening to my podcast for a while have been grateful for his expertise and I'm sure they'll be grateful for you coming on today. So thank you so much. One goes to welcome. It's been a pleasure. I'm glad it worked out.