kohut vs kernberg

Clinical Social Work JournalVol. 27, No. 1, Spring 1999

KERNBERG VERSUS KOHUT:A (CASE) STUDY IN CONTRASTS

Gildo Consolini, MSW

ABSTRACT: In this paper, the main concepts of Otto Kernberg and HeinzKohuttwo theorists who have greatly influenced clinical social work practicewith severely disturbed patientsare presented, and then compared by using acase from the practice of the author. The case illustrates the value of utilizingsome of the treatment principles put forward by Kernberg and Kohut withoutbecoming too wedded to either of the overall treatment approaches they haveformulated. Some aspects of the manner in which the practitioner determineswhen the treatment approach needs to be modifiedto avoid the pitfalls of ei-ther being too wedded to an approach or too eclecticare discussed as well.

KEY WORDS: borderline personality disorder; narcissistic personality disor-der; self psychology; countertransference; self-analysis.

For more than two decades the two theorists who have had thegreatest influence on psychoanalytic thinking about patients with moresevere psychopathologywith the possible exception of Harold Sea-rleshave been Otto Kernberg and Heinz Kohut. Both Kernberg andKohut applied psychoanalytic theory to the treatment of patients oftenconsidered unsuitable for analytic treatment by those working from aclassical analytic perspective. However, their conclusions about the eti-ology and psychic structure of borderline and narcissistic psychopathol-ogy, as well as the optimal treatment approach, are very different.

Kernberg is considered a conflict theorist, who, like other Americanobject relations theorists, has retained the use of the concept of instinc-tual drive along with other aspects of Freudian metapsychology; thisplaces Kernberg in the psychoanalytic mainstream. He wrote exten-sively about both borderline and narcissistic psychopathology.

Kohut, on the other hand, made a more radical break with the clas-

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sical tradition; he eventually rejected many classical conceptualizationsand, with the help of his followers, developed his concepts about narcis-sism and the self into its own schoolself psychology. Although Kohutwas not optimistic about self psychological treatment of the borderlinepatient (Kohut & Wolf, 1978) and he focused primarily on the treatmentof narcissistic disorders, many analytically oriented clinical social work-ers and other analytically oriented psychotherapists rely heavily uponself psychological theory and treatment principles in their work withborderline patients.

In the first part of this paper, the main concepts of both theoristswill be presented and compared. In the second part, a case will be pre-sented which will demonstrate the value of utilizing some of the treat-ment principles established by these theorists while at the same timeattempting to develop an individualized approach attuned to the emo-tional needs of a rather troubled and difficult patient. As Goldstein(1990, 1995) has indicated, the therapist attempting to help patientswith more severe difficulties who is too wedded to any one particularapproach runs the risk of misattunement that will destroy any hope fortherapeutic benefit. In the final part of the paper some aspects of themanner in which the therapist determines when the treatment ap-proach needs to be altered will be discussed.

OTTO KERNBERG

Prior to the influence of Kernberg, the symptomatology of the bor-derline patient was not seen by most analytic writers as the result of astable pathological structureits transient nature was emphasizedand a more supportive treatment approach was generally recommended.

Although Frosch (1970) described the borderline patient as a "psy-chotic character," that is, as someone with a range of modes of ego adap-tation and responses to stress that is enduring and predictable, Kern-berg went beyond this with his metapsychological explanation. WhileStone (1954) recommended a cautious analytic approach using parame-ters to maintain a positive transference, Kernberg advocated an ap-proach involving the use of traditional analytic methods, such as inter-pretation and the analyst's abstinence, that is far from cautious.

In his 1967 paper and 1975 book, Kernberg established his positionthat borderline patients have a relatively stable form of psychic organi-zation, a pathological ego structure that is distinctively different thanthe ego structure found in either neurosis or psychosis. He believes thatvery early in development the ego must not only learn to distinguish theself from othersthe task of differentiation of self- and other-represen-tationsit must also integrate "affectively polarized" self- and object-

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representations. Unlike the psychotic, the borderline is able to establishboundaries between the self and others (though not without difficulty,especially in the areas of intimate emotional and sexual relations). How-ever, while the neurotic is eventually able to integrate idealized "allgood" and devalued "all bad" objects in the course of development, theborderline cannot.

In the case of the borderline, self- and object-representations builtup under the influence of libidinal drive derivatives are not integratedwith self- and object-representations built up under the influence of ag-gressive drive derivatives by the ego, therefore requiring this ego to relyheavily upon the defense mechanism of splitting. Unlike the neurotic,who relies primarily upon repression to handle ambivalence, the bor-derline relies primarily upon splitting, reinforced by denial and the useof projective mechanisms.

Why is it that the ego of the borderline must rely primarily uponthese "primitive" defenses? Although Kernberg uses traditional Freud-ian energic concepts (drive energy is identified as the force which pro-pels the individual in the direction toward and away from objects) herelied heavily upon the work of object relations theorists who locate theetiology of many forms of psychopathology during a much earlier periodof development than did Freud. Kernberg follows Klein (1928, 1939,1946, 1957) in his view of the importance of splitting and projectiveidentification as the defenses that develop early in life that are reliedupon by the borderline, as well as the role of destructive envy in thenegative therapeutic reaction. Kernberg's view of the ego's early devel-opmental tasks is similar to that of Fairbairn (1954), who postulated acritical first structural achievement whereby the infant is able to pre-serve within the ego his or her internalized mother as a whole personfrom his destructive impulses.

By specifically locating the fixation during the rapproachementphase of separation-individuation (Mahler, 1971), Kernberg is able toidentify the source of the borderline's unstable self concept, lack of objectconstancy, overdependence on external objects, and preoedipal influenceon the oedipus complex. Kernberg also benefited from the work of Jacob-son (1954, 1964), who preceeded him in combining the use of energicconcepts with object relations concepts to explain more severe psycho-pathology.

Kernberg recommends an approach to treatment of the borderlinepatient that appears consistent with his traditional orientation and the-oretical formulations; he recommends in most cases an analytic ap-proach (with parameters to provide missing structure to those with es-pecially chaotic lives) that calls primarily for interpretation focusingupon the defensive splitting by the patient within the transference. Theanalyst is advised to be neutral and abstinent as he confronts the pa-

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tient with his or her destructivenessthe oral aggression of the patientmust never be ignored.

Kernberg believes the approach he advocates will eventually enablethe patient to modify the pathological structure because it will lead tothe integration of the split-off affectively-charged self- and object-repre-sentations within the ego and the formation of a more benign, less puni-tive superego (the ego will not be tormented by the more hostile preoedi-pal superego precursors). Kernberg discourages the use of supportivemeasures since he believes a supportive approach maintains the patho-logical structure, leading to an interminable treatment.

Kernberg (1970, 1974) believes that these same treatment prinici-ples apply to the narcissistic personality since his view is that there isan underlying borderline organization to this personality. He views theapparent better social functioning of the narcissist as a superficial adap-tation that conceals severely maladaptive behavior stemming from patho-logical internalized object relations. He also believes there is an underly-ing borderline organization to other personality syndromes, includingschizoid and antisocial character disorders, as well as certain cases ofsubstance abuse, alcoholism, and sexual perversion.

HEINZ KOHUT

Although trained classically and at one time president of the Ameri-can Psychoanalytic Association, Kohut eventually so departed from tra-ditional Freudian theory and treatment principles that he and his fol-lowers developed a new psychoanalytic schoolself psychology.

Following Freud (1914), most analysts believed patients who wereunable to develop transferences like those typically seen in cases of neu-rosis could not be analyzedtheir self-involvement was too great to al-low transferences to develop. Kohut (1966, 1971) observed that it wasnot that narcissistic patients were unable to develop transferences butthat they developed different kinds of transferences than did neurotics.These he identified as variations of "selfobject transferences."

Whether it was an "idealizing," "mirror," or "twinship" transferencethat developed, the analyst's task was to use the particular transferenceas a clue to determine the vital selfobject functions he or she was beingasked by the patient to provide, functions not provided by the originalselfobjects. Due to their own narcissistic problems, the original self-objectsin most cases, the parentslacked sufficient empathy to recog-nize and satisfy the healthy narcissistic needs of these individuals dur-ing their childhoods. As a result, a healthy "cohesive self fails todevelop. Instead, pathological self states develop, such as the "frag-mented" or "overburdened" self.

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Kohut (Kohut & Wolf, 1978) understood the self to be the nuclearcore of the personality, an enduring psychological structure in and ofitself rather than simply a mental representation within the ego. Heidentified the "constituents" of the self as 1. the "pole of goals and ambi-tions" from which emanate basic strivings for power and recognition; 2.the "pole of ideals and standards" which maintains the ideals whichguides one through life; and 3. the "arc of tension" between these twopoles that activates the basic talents and skills of the individual. Theseconstituents emerge into an enduring self structure through the inter-play of inherited factors and the influence of the environment.

The self is seen as the center of initiative, the recipient of impres-sions, and the depository of the ambitions, ideals, and skills of the indi-vidual. The patterns of these ambitions, ideals, and skills, the tensionbetween them, the activity generated by them, and the responses of theenvironment that shape the life of the individual are all experienced ascontinuous in space and timethis provides the individual with his orher sense of selfhood. The individual comes to experience himself or her-self as an independent center of initiative and processor of impressionsreceived from outside the self.

As his thinking about the etiology of narcissistic disorders evolved,Kohut ultimately decided he no longer required metapsychological con-cepts to explain how these disorders develop. He discarded the primarydrive nature of aggression, distinguishing between ordinary aggres-sionwhich he understood to be the healthy forcefulness the cohesiveself uses to eliminate an obstacle to a realistic goaland narcissisticrage, an intense reaction to narcissistic injury.

Kohut postulated a line of development for narcissism that is dis-tinct from that of object love, in contrast to Freud's progression in devel-opment from primary narcissism to mature object love; this formulationenabled him to identify various transformations of narcissism, such asmature humor, creativity, and wisdom. He contrasted the aims of "guiltyman" with those of "tragic man," the latter seen as someone striving forfulfillment in endeavors beyond the pleasure-seeking and sublimationsmade possible through the resolution of neurotic conflict. What makesthis quest tragic is that humanity's limitations are inevitably recognizedwhen one pursues these endeavors.

Kohut's is a theory of developmental deficit, which therefore callsfor the analyst to work in a very different way than the analyst whoadheres to the theory which views intrapsychic conflict as the source ofpsychopathology. For the self psychologist, empathy is not only the prin-cipal means of investigation, it is the primary therapeutic instrument.The analyst immerses himself or herself, through his or her empathy, inthe patient's subjective experience while seeking to maintain attune-ment to the selfobject needs of the patient. Although this is considered

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in and of itselfto be therapeutic, the inevitable "empathic failures" onthe part of the analyst are also handled in such a way as to promotefurther healing. First, the analyst must discern how he has injured thepatient so that he can intervene in such a way as to restore the selfobjecttransference. The analyst can then use what he learns through furtherexploration to connect the current experience of narcissistic injury withthe original injury inflicted by the selfobjects during childhood.

A more cohesive self is developed as a result of "transmuting inter-nalizations;" the analyst's optimal, nontraumatic frustration of the pa-tient leads to structure formation since the self can now more easilytolerate disappointment. Although the need for selfobjects continuesthroughout life even in the healthiest of individuals, the self can nowperform vital selfobject functions in the absence of the experience withthe selfobject.

KERNBERG VERSUS KOHUT

Kohut believed that the borderline patient often lacks the resilienceto benefit from analytic treatment; he believed that in some cases"reconstructing the genesis of both the central vulnerability and thechronic characterological defence" could help the borderline to relysomewhat less upon their maladaptive defenses (Kohut & Wolf, 1978, p.179). On the other hand, the "significantly more resilient self of the"narcissistic behaviour disorders" and the "narcissistic personality disor-ders" generally makes an analytic approach possible with these disor-ders.

When Kernberg discusses treatment of narcissistic personalities heis discussing the same patients as does Kohut, as Kernberg himself hasindicated (Kernberg, 1974). Both men focus their attention upon the"grandiose self," however, it is hard to believe that the respective expla-nations of the psychopathology associated with this clinical picture orthe treatment approaches advocated could be more different, as has al-ready been indicated.

Kernberg sees the emergence of the grandiose self as a pathologicaldevelopment that must be modified to achieve mental health; he be-lieves it is imperative to confront the narcissist with the defensive ma-neuvers he or she employs to maintain split-off good and bad self- andobject-representations. If the oral aggression which fuels this defensiveactivity is not addressed directly, modification of the pathology is impos-sible. An ego ideal is maintained that continues to torment the psyche;more realistic, less punitive aspects of the parents are not incorporatedwithin the superego since the much less benevolent superego precursorsretain their hegemony within the psychic structure.

In the view of Kohut, since the presence of the grandiose self indi-

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cates that there has been an arrest in the development of the nuclearself, treatment should be geared to encouraging the narcissistic aspira-tions and needs of the patient to unfold fully in the transference. Thisunfolding will enable the patient to develop a more cohesive self withthe support of the analyst, who is able to provide the vital selfobjectfunctions that the original selfobjects were unable to provide to the de-veloping self of the child. If the focus on all that which threatens theemergence of the self is not maintained, it will not be possible to achievehealth since an enfeebled self will remain, making true mental healthan impossibility.

Kohut clearly identifies the environment as the source of distur-bance for these personalities while Kernberg is equivocal in implicatingconstitutional factors along with environmental factors. Although thelatter identifies a stronger aggressive drive and a "constitutionally de-termined lack of anxiety tolerence in regard to aggressive impulses" ascontributory, he also has identified the presence of a mother or mothersurrogate who functions well on the surface yet treats the child coldly,with very little regard for his or her emotional needs (Kernberg, 1970,pp. 219-20).

Kernberg believes that the presence of an underlying borderlinepersonality organization in the narcissist mandates his modifying ap-proach, while Kohut's approach is consistent with his view that the nar-cissist suffers due to developmental arrest. For Kohut, the narcissisticagenda of the patient which emerges in the treatment situation reflectshealthy narcissistic aspirations and needs that were thwarted by theparental figures during childhood and, therefore, it is imperative thatthe analyst support the emergence of this agenda so that it can eventu-ally be transformed.

Thus, as has been indicated throughout this paper, similar clinicalphenomena are understood and addressed very differently by Kernbergand Kohut. At the same time, the psychoanalytic discourse has beengreatly enriched by these theorists since each has been able to go fur-ther than did Freud in attempting to explain why some patients do notbenefit from analytic treatment.

While Freud identified a "narcissistic attitude" of some patientswhich "limits their accessibility to influence" in treatment (Freud, 1914,pp. 17-18), he left it to others to develop the clinical implications of thisobservation. Before Kohut, the transferences which develop in treat-ment of the narcissist were not described very well. Also, it seems thathis work has led to a generally less judgemental attitude toward thenarcissistic manifestations seen in many patients, not just those whopresent with obvious narcissistic pathology. Furthermore, the role of em-pathy in treatment is much more fully understood and accepted as aresult of the work of Kohut and those who further developed his ideas(Goldstein, 1990).

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Both Kohut and Kernberg encouraged manifestations of narcissismto be brought into the treatment situation. The more traditional ap-proach to these manifestations encouraged a repudiation or control ofthe narcissistic agenda of the patient which insured that, in most cases,this agenda would not become available for analytic investigation. Eachhas also made significant contributions to the understanding of thecountertransference reactions typically evoked by borderline and narcis-sistic patients. It seems that there are patients who are now able tobenefit as a result of the contributions of both theorists, however, itseems to this author that one can do more harm than good if one is toowedded to either approach.

Although Kernberg claims that his recommended approach placesthe analyst in an objective, neutral position, his emphasis upon oral ag-gression does not seem either totally objective, in terms of the under-standing of the pathology, nor neutral, in terms of the handling of theaggression that develops within the treatment situation. Kohut indi-cates that development can be severely arrested much later in childhoodthan Kernberg indicates (1979). Others have also questioned Kernberg'sidentification of the source of disturbance as exclusively preoedipal(Abend, Porder & Willick, 1983). It does not seem hard to conceive that apatient who was treated exclusively in the manner Kernberg advocateswould experience the therapist as anything but neutral, that a patientcould become so alienated by this approach that important materialcould be withheld from the therapist and, in the worst case, the treat-ment could have as iatrogenic effect (Brandchaft & Stolorow, 1984).

With respect to Kohut, it does not seem hard to imagine that anexclusive reliance upon his self psychological approach could not onlyprevent a patient from recognizing and coming to terms with his or heraggression, it might also encourage the patient to hurt othersand ulti-mately himself or herselfthrough hostile behavior emanating from asense of entitlement that has been unintentionally promoted by thetherapist. In the case presentation which follows, the therapist's effortsto navigate between the Scylla of ignorance of the hostility of the patientand the Charybdis of the ignorance of the patient's libidinal needs willbe highlighted.

CASE ILLUSTRATION

Doug is a 33 year old white, Jewish male who entered treatment with theauthor three years ago, following Doug's break-up with his fiancee, Eileen. Atthat time, Doug described himself as vacillating between periods of intense an-ger and debilitating depression, the former which he attributed to the insensi-tive manner in which he had been treated by Eileen, and the latter to his dis-couragement about finding someone who could satisfy his perceived needs for

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nurturance of his artistic aspirations and for an intensive and thoroughly excit-ing sexual relationship. Doug had been in treatment previously, for less than ayear, with a female therapist; he reported that she had helped him quite a bituntil she began to become more "confrontational" with him. He was unable toelaborate, but indicated that the ending of that relationship also left him withstrong feelings of indignation and discouragement.

While still involved with each other, Eileena school psychologist who wasworking on her doctoratehad encouraged Doug to get back into treatment.Characteristically, Doug felt this was an effort on her part to use her knowledgeof therapy to control him rather than help him. He resisted this idea until theybroke up. Doug has a history of drug and alcohol abuse and seemed genuinelyfrightened that he would return to abuse of cocaine and alcohol to cope with hisdistress about the break-up.

Doug's parents were divorced when he was eleven years old. He has a sisterthree years older who is perceived by him to be the favorite of his father. Doug'sprimary aspiration is to become a famous blues and rock composer, guitarist,and group leader; while waiting for this to happen, he is working for his fatherin his father's business. In contrast to his sister, a successful attorney who ismarried with two children, Doug reported that he is the "black sheep" of thefamily. He had not gotten very far with college, dropping out well before comple-tion of his degree.

It seemed that an empathic, nonjudgemental approach on the part of theauthor initially fostered the development of enough of a therapeutic alliance tokeep Doug in treatment. He came in for some extra sessions, and for a time cametwice per week. It seemed that his anger diminished somewhat and enabled himto concentrate better at his job and devote more time to his music. His fatherhad been very unhappy with Doug's work performance, since Doug frequentlymissed work or came in very late because he had been "partying" the night be-fore. Because he was able to stop doing this, Doug was no longer being threat-ened with being let go by his father, who seemed to be someone volatile enoughhimself to do this.

The treatment "honeymoon" (Fine, 1982), however, was short-lived, in partdue to the author's winter vacation, which took place after six months of treat-ment. During the author's vacation, Doug consulted another therapist, some-thing he rationalized as necessary because of the very difficult time he had whilethe author was away. He reported he had difficulty not because he missed theauthor or was unable to rely upon him for assistance during the vacation, butbecause the author had not helped him enough prior to the vacation. His sisterhad encouraged him to see someone else and had given him the name of thetherapist he consulted. He might have continued with this other therapist, Dougtold the author, were it not for the fact that he was "getting a better deal" withthe author, who was a provider in the managed care network used by his insur-ance company.

As others have indicated (e.g., Maroda, 1994), use of the self psychologicalapproach in the initial phase of treatment is oftentimes quite beneficial to bothpatient and therapist. The sustained empathic inquiry called for in this ap-proach does much to establish basic trust on the part of the patient in the rela-tionship. Not only does the patient experience the relief of "getting things off his/her chest," but he or she feels genuinely cared about in the process of doing so.The therapist learns much about the patient's life because the patient feels safeand is eager to produce material to please the therapist.

Although the above approach may be instrumental in enabling patients like

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Doug get started, a different approach is required to address difficulties thatinevitably develop when a stage of dynamic conflict develops in the transference.At that point in treatment with patients like Doug the therapist benefits greatlyby turning to Kernberg for guidance. The author decided Doug's devaluation ofthe therapist (as a means of dealing with split-off negative self- and object-repre-sentations) needed to be confronted. Attempting to explore the libidinal aspectsof this behavior at this point were unsuccessful. When Doug was asked, "What isit that you need from me that I haven't been able to give you?" he was not able tosay very much about what it was he wanted from the author.

Doug began to harass Eileen, insisting that she should give their relation-ship another chance. He attempted to make contact with her and, when sheattempted to let him know that she had been quite serious about ending theirrelationship, he became rather nasty with her and began to shadow her whileEileen was with her new boyfriend. He would park near her house when herboyfriend's car was in the driveway, near enough so that Eileen could easilyrecognize Doug's car. Doug also began spending more and more time drinking,smoking pot, and watching pornographic movies as well as having sex with pros-titutes on a weekly basis. The author encouraged Doug to contact him when hefelt compelled to do these things, especially following calls made to the author byEileen, who at first threatened and then eventually went ahead and called thepolice to complain about Doug. Doug never called the author during any of thesetimes.

Instead, in addition to hearing from his ex-fiancee, Doug's mother called theauthor to express her concern about him and to insist she should come in to meettogether with Doug and the author. She asked the author during the call toreassure her that "my son is not suicidal." Although his mother was invited tocome in by herself (after her call was discussed with Doug) Doug was eventuallypersuaded to see how important it was for him to preserve his individual treat-ment. He had initially felt that he had no alternative but to accede to hismother's request, which he had experienced as another demand on her part tomake her feel better, not help him.

Doug initially did not feel that there was anything that really needed to bediscussed about these matters, prior to the author's questioning of his motivesfor defeating the therapy. Although he was initially somewhat confused and an-noyed by this questioning, he eventually admitted that he felt entitled to dowhatever he could to make himself feel better and have more successful relation-ships, no matter what the author thought. The author was able to then point outto Doug that he was acting the same way with the author as he acted in hisrelationships with women.

It seemed that this approach at this particular point in the therapy wasnecessary to preserve the therapy, that these interpretations, the limit-setting,and the frustration of what this patient asked for allowed the treatment frameto be preserved. There were times, for example, when Doug would use his ses-sion time to ruminate about the psychological reasons for his behavior, whileappearing to be somewhere else emotionally. At such times, the author com-mented about how abstract he sounded and asked him what was really bother-ing him. Although Doug was initially also put off by this observation and ques-tion, it helped him eventually to focus more easily upon what he was feeling.This kind of intervention corresponds to Kernberg's notion of attending to theneed to develop structure, as opposed to allowing a monologue resembling freeassociation take the patient further away from that which he was feeling, espe-cially any anger he might be experiencing.

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Despite all this, it became necessary at another point to shift gears onceagain and adopt a more tolerant stancein relation to Doug's grandiose aspira-tions. The author became aware that when he was using Kernberg to under-stand and address Doug's devaluation of the author and very strong sense ofentitlement, he began sessions himself feeling rather irritated with Doug andindignant about the manner in which he was being treated by Doug. At times, itwas difficult to hear themes in the material other than Doug's ruthless incor-poration of the author and others. Self-analysis of the author's counterresistanceto allowing other material to emergea process which included discussion of thecase with a colleagueenabled the author to realize that the transference hadbecome more positive and therefore there was much less need at that point toconcentrate on the patient's aggression.

Kohut has stated quite clearly that challenging the patient's grandiosity isnot only a useless endeavor, it will likely compel the patient to suppress verypowerful wishes and thus make them inaccessible to modification. Doug can beaccurately and usefully described as "mirror-hungry." The author decided that itwas important to attend in a particular way to manifestations of this hungerwhich developed in the transference.

Doug began to bring in notebooks filled with many, many pages of histhoughts and feelings about his struggles with women and his music, somepages of which he had copied and had attempted (unsuccessfully) to get Eileenand other women he pursued to read. It became clear to the author that it wouldbe necessary to gratify some of that which Doug wished for in asking the authorto listen to him read from these notebooks. The author initially simply listenedas Doug read, indicating interest in those passages which expressed strong feel-ing or indicated developing insight. Eventually, Doug was encouraged to discusshow he felt it was helping his therapy to do thissomething that was done in asnonjudgemental a manner as possible to indicate the interest of the author inwhat Doug wanted from him rather than what Doug was resisting by relating inthis manner.

Later on, Doug began bringing in self-help books to discuss with the author.He was encouraged to talk about what he had discovered which resonated withhim. This approach helped Doug see how much of his behavior, included its intel-lectualized aspects, was connected with his wishes for attachment with othersand how upset he could become when his wishes were frustrated. As a result,Doug has developed enough insight and frustration tolerance to stop harassingnot only his ex-fiancee but another woman he dated for a few months, to signifi-cantly cut back his drinking and pot use, and to end his dependence upon por-nographic movies and prostitutes for sexual excitement and pleasure.

Eventually, Doug was able to approach dating in a very different way, bothwith respect to the choices he made about whom to date and how he behavedwith those with whom he attempted to connect. Initially, he attempted to date aprostitute he had seen on a regular basis. When the fantasy of where this wouldlead was analyzed, he ended this quest. He proceeded to date a series of unavail-able womentwo married women and a very troubled young woman who even-tually scared Doug off with her sadomasochistic sexual proclivitiesbefore at-tempting to connect with more suitable women. By the time of the writing of thispaper, Doug had been involved with someone for several months who seemed amuch better choice as a partner. He was able to use much of his session time totalk about his mixed feelings about committing himself in an intimate relation-ship, rather than impulsively acting out his negative feelings.

During that time, the author realized that although the transference had

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become more positive overall, he was neglecting to address indications that Dougwas not just having difficulty with intimate relations with his girlfriend, thatDoug was struggling with similar feelings in the transference. The author recog-nized that he was struggling himself with feelings in his counter-transference toDoug. How else could he explain his delay in discussing some obvious indicationsthat Doug was feeling displeased with the author?

Through self-analysis, the author was able to see that he was using theoryto rationalize an approach to his patient that, at this particular time, stemmedmore than anything else from his counter-transference. As Doug began making ahabit of arriving ten to fifteen minutes late for his appointment, paying his billlate, and shaking hands with the author at the end of the session, the authorrationalized that confronting Doug with this behavior was not necessary. Essen-tially, he allowed himself to believe that empathy was enough.

Of course, the truth was that the author was feeling uncomfortable aboutdealing directly with Doug's disappointment, very powerful sense of entitlement,and anger. When the author realized he was resisting the analysis of these feel-ings in the transference, he was then able to confront Doug tactfully. That is, theauthor was then able to bring the behavior to Doug's attention and in an empa-thic manner to explore the feelings which motivated the behavior. As the anal-ysis proceeded, Doug became more aware of the kind of relationship he wished tohave and not have with the author. He became much more comfortable as wellwith his girlfriendhe began to feel less deprived and controlled in both rela-tionships.

DISCUSSION

The clinical vignette presented above illustrates the value of utiliz-ing the contributions of both Kernberg and Kohut, based upon thatwhich may be needed by one's patient at various points in treatment.Both theorists have advanced psychoanalytic thinking about borderlineand narcissistic psychopathology and treatment. However, it is impera-tive that the therapist recognize that what is needed by his or her pa-tient may change significantly as the treatment proceeds (Pine, 1988).Therefore, the therapist needs to make a corresponding shift in his orher approach. Perhaps those with a background in social work, with thesocial worker's appreciation of the situational factors associated withpsychological distress, are especially adept in this regard.

The kind of treatment situation presented above is commonplace formany clinical social workers. Clinical social workers who are analyt-ically oriented attempt to develop effective analytic approaches to helppatients who are both very troubled and very demanding. Althoughguided by their analytic knowledge and convinced of its usefulness, theclinical social worker must recognize the fact that most people now comefor "help" rather than for "analysis" (Herbert Strean, 1993, personalcommunication).

Both Kernberg and Kohut have received much praise for their con-tributions, as well as a great deal of criticism for developing points of

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view which challenge mainstream psychoanalytic thinking. Unfortu-nately, there has been a tendency within psychoanalysis to engage in awholesale embracing or repudiation of different points of view whichseems similar to the defensive splitting employed by very troubled pa-tients to ward off the anxiety associated with taking in the analyst as areal person. Instead, the analyst is experienced as either "all-good" or"all-bad" rather than as a real person who, despite his or her very realhuman limitations, has something very valuable as well as very real tooffer in the analytic relationship.

Although many classially trained analysts would regard self psy-chologists, along with many others, as heretics (in Bergmann's [1993]usage of the term), there have in fact been a number of important con-tributions made by theorists who have either somewhat covertly (e.g.,Winnicott) or quite overtly, (e.g., Klein) challenged Freud, and in so do-ing, advanced mainstream psychoanalytic thinking and approaches totreatment. According to Bergmann's way of categorizing psychoanalyticthinkerswhich seems quite usefulKernberg and Kohut would beidentified as modifiers rather than heretics, as important thinkers whodemand that theory change as a result of their findings.

As Bergmann has said, modifiers have threatened the continuity ofpsychoanalysis and created much controversy, however, they have alsokept psychoanalysis alive. As a result of the insights offered by mod-ifiers, psychoanalysis has been able to stretch enough to improve itsunderstanding of the etiology of many disorders as well as develop moreeffective treatment approaches. More recently, Bergmann stated thatmodifiers demand that analysts "give up their cherished belief that psy-choanalytic theorizing has developed along a straight line, with everynew generation simply adding their findings to that of the previous gen-eration" (1997, p. 82). In fact, psychoanalytic theory and technique haveevolved dialectically. This can be seen very clearly with regard to howpsychoanalytic thinking about severe psychopathology has evolved, asthis paper has indicated.

The intention of the author in this paper has not been either todefend or to attack either theorist, but rather to highlight the need onthe part of the practitionerwhen he or she turns to either Kernberg orKohut for guidanceto recognize the limitations of relying too much oneither approach when he or she is attempting to engage patients whoare especially difficult to engage in a meaningful psychodynamic treat-ment. If this is accepted, of course, a related matter must be consideredvery carefullythe issue of what determines the shift from the use of oneapproach to another.

As Strean (1994) has described, theoretical arguments can be madeto rationalize interventions motivated primarily by the practitioner'scountertransference. Strean suggests that this defensive maneuver can

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be employed by well-trained, seasoned analysts as well as by those stillin training. In working with more troubled patients, it can be especiallytempting for the practitioner to cling uncritically to a particular way ofworking as a means of warding off the anxiety associated with hearingvery disturbing material and observing very self-destructive behavior. Itis also possible that the practitioner can become too eclectic, shifting tooquickly to a different approach as a means of warding off anxiety stem-ming from his or her countertransference.

As Maroda (1994) has indicated, perhaps the best way to knowwhen one is either too wedded to a particular approach or too eclectic isto carefully study one's counter-transference. It is in fact quite possible toget back on track when one's countertransference has taken one offcourse, as Strean (1993, 1995) has shown in his description of analystsand other therapists who were able to use supervision to resolve theircounterresistances. In an earlier paper (Consolini, 1997), this authorwas able to demonstrate, with three case examples, that self-analysisenabled him to determine when his countertransferences were limitinghis effectiveness and to take the necessary steps to resolve the counter-resistances stemming from these countertransferences.

CONCLUSION

Clinical social workers are often called upon to treat very troubledand demanding patients during times of crisis, crisis often precipitatedby the psychopathology of these individuals. These patients are oftenhighly resistant to aspects of the analytic process usually associatedwith positive treatment outcomes, such as meeting several times perweek and accepting a long-term commitment to their personal growth.Financial constraints and the influence of managed care reinforce resis-tance to the analytic process. In short, patients may now feel more en-titled than ever to fast and dramatic improvement because of the cur-rent economic and social climate.

It may sometimes seem that the well-trained clinician must forgetmuch about what he or she learned to be successful with many of thoseseeking treatment in the current climate. Actually, there is good reasonto continue to employ analytic approaches, especially as conceived byKernberg and Kohut, with many patients. Both theorists have a greatdeal to offer to therapists working with very disturbed individuals dur-ing periods of crisis.

If the author of this paper has succeeded, he has demonstrated thatit possible to utilize selectively aspects of both of the approaches of thesetwo theorists to find ways to help individuals as demanding and trou-bled as Doug. To do so, the therapist must be aware of the strengths and

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limitations of these approaches. And, perhaps most importantly, thetherapist must be aware of what compels him or her to adopt a particu-lar approach at a particular time with a particular patient. Ideally, thetherapist can accept and work with the possibility that countertransfer-ence plays a role in his or her clinical decision-making.

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