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.