Transference Regression and Psychoanalytic Technique with Infantile Personalities
Otto F. Kernberg
Kernberg, O.F. (1991). Transference Regression and Psychoanalytic Technique with Infantile Personalities.(1991). International Journal of Psycho-Analysis, 72:189-200
Presented at the 36th International Psychoanalytical Congress, Rome, August 1989.
(MS. received July 1990)
Copyright . Institute of Psycho-Analysis, London, 1991
THE INFANTILE PERSONALITY AS AN 'HEROIC' INDICATION FOR PSYCHOANALYSIS
Some years ago Ernst Ticho (1966) described undertaking the psychoanalytic treatment of narcissistic personalities as an 'heroic' measure. In what follows, I am adding the infantile personality to this category. Until about twenty years ago, these patients were usually considered to be hysterical personalities. Easser & Lesser (1965), Zetzel (1968) and I (1975) saw them as regressive forms of the hysterical personality and have referred to them as infantile, histrionic, hysteroid, or Zetzel Types 3 and 4. I have dealt with the differential diagnosis of these personalities in earlier work (1975), (1985) and shall only summarize their salient characteristics before examining some typical developments they present in the course of psychoanalytic treatment.
Patients with an infantile personality present the three characteristics dominant in all borderline patients: identity diffusion, primitive defence mechanisms, and good reality testing. Because of identity diffusion—a lack of integration of the concepts of self and of significant others, their capacity for empathy with others and for a realistic evaluation and prediction of their own and other people's behaviour is reduced. In consequence, they present highly conflictual object relations, although they can engage in depth in the sense of lasting—though chaotic and clinging—relations with significant others. This capacity for deep involvement with others, even if highly neurotic in nature, differentiates these patients from other patients with borderline personality organization, such as the narcissistic personality, the schizoid personality and the paranoid personality.
Because these patients present a predominance of defensive operations centring around splitting, they evince fewer repressive mechanisms than would be typical of the hysterical personality proper. Thus, the sexual inhibition of the hysterical personality may be replaced by conscious persistence of polymorphous perverse infantile trends, even in patients who definitely do not present evidence of sexual perversion. Splitting operations underly these patients' contradictory, discontinuous, chaotic interpersonal behaviour.
These patients present the emotional lability and histrionic quality characteristic of hysterical patients, but it is present in all their object relations rather than specifically linked to their sexual relationships. They also show the extraverted, exhibitionistic behaviour of the hysterical personality, except that this behaviour has a childlike, clinging quality rather than an erotic one. Infantile patients convey the impression that erotic seductiveness is a means to gratify clinging and dependent rather than sexual needs.
From a psychodynamic viewpoint, infantile patients present the typical condensation of oedipal and pre-oedipal conflicts characteristic of borderline personality organization, but with an accentuation of later or advanced types of oedipal conflicts, which bring them much closer to the hysterical personality than would be true for all other borderline patients.
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As I suggested in earlier work (1985), one might indeed describe a continuum from the hysterical personality proper to the infantile personality proper, a point of view already implicit in Zetzel's (1968) classification of this syndrome into four types. In the light of my more recent experience, most of this spectrum of patients may be treated with psychoanalysis, thus constituting, together with the narcissistic personality, the important exceptions to the idea that psychoanalysis is not appropriate for the typical patient with borderline personality organization. However, in order for psychoanalysis to be indicated for an infantile personality, it is important that the patient present at least some motivation for treatment, some capacity for emotional introspection or insight, and a certain capacity for impulse control, anxiety tolerance, and for sublimatory functioning (non-specific aspects of ego strength). These requirements exclude from consideration for psychoanalysis the typical 'Zetzel type 4' patient with non-specific manifestations of ego weakness, apparently uncontrollable acting out, and a limited capacity for realistic self-reflection.
Some of the treatment failures of the psychotherapy research project of the Menninger Foundation (Kernberg et al., 1972) included patients of this kind, that is, with indications for analytic treatment, treated with what was apparently well-conducted psychoanalysis. I have since wondered whether what has since been discovered about the psychoanalytic treatment of borderline cases might explain those failures. I have therefore given considerable thought and attention to more recent psychoanalytic treatment of patients who might be characterized as Zetzel types two and three, and who had a more successful outcome. In what follows I present the salient aspects of two such cases, for the purpose of illustrating their technical management.
Mrs A
Mrs A, in her early thirties, was a skilled professional working in an industrial research laboratory exploring highly specialized circuitry design [whose main symptom, described below, I referred to briefly, in another context, in earlier work (1984) ]. She had entered the hospital because of a severe and acute depression, which responded rapidly to antidepressive medication, and entered treatment because she was dissatisfied with her relations with men and her obesity. She was a drug abuser and had phobic fears of driving on highways and bridges. She was not unattractive but dressed in a way that exaggerated her (moderate) obesity. She explained that she could be interested only in men who were unavailable. She was nonetheless interested in people and had close friends.
After great hesitation, she confessed to what she considered her most serious symptom: a tendency to falsify the results of her work in the laboratory, followed by several repetitions of certain experiments to demonstrate the error of the falsified findings that she herself had earlier presented, with the result that her actual contributions to her field were dramatically slowed down. She would work very hard, staying until late at night in order to undo the effects of a falsification of her work. Careful evaluation of her superego functioning in other areas—of antisocial tendencies—revealed only a transitory period of shoplifting in early adolescence; she was otherwise scrupulously honest.
She provided me with contradictory, even chaotic descriptions of her closest friends and relatives, and of herself. She presented identity diffusion, a predominance of primitive defensive operations, chaos in intimate sexual relations, and a multiplicity of neurotic symptoms—a typical borderline personality organization. I diagnosed her as an infantile personality with masochistic features, but her capacity for object relations in depth, the absence of anti-social features (other than the specific symptom at work mentioned), and the absence of non-specific manifestations of ego weakness seemed to justify attempting psychoanalytic treatment.
Mrs A had enormous difficulties in conveying a realistic picture of her parents and her two sisters. She described her father as distant and unavailable, cold and withdrawn and, yet, as warm and engaged with her—in fact, almost openly seductive. In the course of the treatment the patient remembered her own direct sexual seductiveness towards her father. In fact, it became apparent quite soon after the analysis had started that it was not clear to her whether
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It was almost impossible for me to obtain an image of her mother, who remained an almost mythical, unavailable person during several years of the analysis. In contrast, the image of a much older aunt, who carried out the functions of a maternal figure, became prominent from early treatment on, in the context of Mrs A's longing for the childhood relationship with this warm, understanding, and giving relative.
In the transference, there were long stretches during which she presented oedipal material, fears of and wishes for being seduced by me that gradually shifted into wishes to seduce me as a father figure, with a parallel uncovering of deep, dissociated unconscious guilt over this seductiveness, expressed in severely self-defeating patterns in her relationships with other men in her life. In fact, one might say that her oedipal conflicts showed up not in a dynamic equilibrium involving unconscious, repressed positive oedipal longings and guilt feelings over them, but in simultaneous, mutually dissociated or split-off acting out of unconscious guilt over good relations with men outside the analysis, and direct expression of conflicts around sexual seductiveness and fear of being rejected in the analytic situation itself.
Several months later a new theme emerged which gradually took over significant periods in the transference. Mrs A mentioned a colleague, X, who was carrying out work somewhat related to hers in the laboratory, a woman the patient found extremely attractive and, at the same time, a potential serious professional rival. Gradually, she developed strong homosexual feelings towards X, together with intense fear that X was trying to steal her ideas in order to promote herself.
Mrs A's fears of X impressed me as having a paranoid quality: X was a horrible witch with unusual powers, dedicated to destroying the patient by ruining her work, tampering with electronic circuits, and producing mischief in many ways. As I attempted to clarify to what extent the patient recognized all this as reality or fantasy, Mrs A immediately became suspicious of my attitude and intentions, and considered the possibility that I might either know X or have been approached by her in an effort to influence me against the patient. In any case, Mrs A felt really threatened of my becoming an enemy in alliance with X.
I first considered the possibility that an image of a threatening, revengeful oedipal mother was being projected on to X and on to me in the transference, but it was impossible to link these paranoid developments in the here-and-now with significant aspects of the patient's past. In fact, for extended periods of the analysis, for weeks at a time, it was as if Mrs A had no past, no personal history that I might work with in constructive or reconstructive ways, and as if everything was being played out in the relationship with X and myself. Indeed there were times that made me think the patient might be psychotic. Any efforts to link these developments in the transference with the patient's past not only failed, but ended up increasing the confusion in the hours, so that, in certain sessions, I felt as if I were being threatened by a crazy 'witch' who was attempting to transform my efforts to understand what was going on into a destructive scrambling of my own thoughts. Bion's (1959) description of the destructive attacks of the patient on anything which is felt to link one object with another, as an expression of the 'psychotic' part of the personality, seems pertinent here. The analytic situation would become totally chaotic, and now I might experience in my countertransference towards Mrs A (I was being bewitched …) what she was telling me was occurring in her relationship with that other woman, with a simultaneous loss of capacity on her part and, to some extent, on my part, to sort out reality from fantasy.
I would like to stress the confusing effects on me of rapid alternations in the treatment between 'crazy times' in which 'witch hunting' seemed to go on, with the dominant question being who was the hunter and who was the hunted, and 'oedipal times' when Mrs A behaved like a typical neurotic patient: associating satisfactorily while exploring the positive oedipal transference and her relationships with other people in the present and in her past in the light of these transference developments.
It was only after many months of clarification of these transference developments that I was able to interpret to Mrs A that regardless of the reality of X's behaviour, the patient had projected
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on to her an internal reality consisting of a mad 'witch' woman who was trying to steal her thoughts, destroy her work and her future, and whose power was related to the
patient's own intense admiration and sexual attraction for such a dangerous witch woman. That same 'witch' woman was forcing her to undo her own creative work in the laboratory. It was only then that very early memories came to mind in which Mrs A perceived her mother as both intensely protective and yet invasive—controlling the patient and implying that she could read her mind. It became apparent that Mrs A had always felt penetrated by this image of mother. She felt that her body, her movements, her speech, her intentions could no longer be trusted because they might really represent her mother's intentions.
Then the idealized figure of the aunt emerged as a split-off image of an ideal mother, loving without being invasive, and who would tolerate distance without aggressively punishing her daughter. Mrs A had lived in the fantasy (or reality) that her mother could not tolerate any independence or autonomy of the patient during her childhood years. The fear of driving on highways or over bridges now became clarified as fears of being taken over by a mother who would punish her with death for attempts to escape from mother by racing through highways or over bridges. I was now able to analyse with Mrs A the repetition of her relationship with mother in her relationship with me, experiencing me, on the one hand, as an invasive witch-mother who was assaulting her simultaneously in the sessions and in a replica of mine at her work place, while, on the other hand, without being aware of it, she herself was identifying herself with this invasive mother at other times in attempting to prevent me from contributing with my autonomous work to her understanding and from thinking independently at the same time. I suggested to Mrs A that the terrible confusion of whether her rival was indeed creating a 'gaslight' situation at work, or whether the patient only fantasized such a development, was part of this pattern. The analysis of Mrs A's identification with a primitive, overwhelming witch-mother who had parasitically taken over the patient's superego gradually led to the resolution of the symptom of self-defeating falsifications of findings in the patient's work.