Introduction To Psychoanalysis: Otto Kernberg

55:25, 10.12.2018, https://www.youtube.com/watch?v=UOkG8J9OxKs

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TRANSCRIPT

Introduction
I'm doctor Otto Kornberg I'm professor of psychiatry at the Cornell University Medical School in New York and
psychoanalyst at the Columbia University Center for psychoanalytic training and research in New York I also direct an
institute for the study of personality disorders at the Cornell University in New York and I am here today to tell you
something about psychoanalysis today as science and treatment. But first of all I should like to tell you a little about
myself I was born in Vienna Austria and emigrated with my parents to Chile in South America after the occupation of
Austria by Nazi Germany, and had developed all my youth and early professional life in Santiago Chile, before coming to
the United States. I continued my studies in psychiatry and psychoanalysis and research in those fields where also
worked in the organizational aspects of psychoanalytic work, and became president of the International Psychological
Association from 1997 to 2001. so let me tell you something we bring you an overview of what psychoanalysis is today

Clinical Case 1
let's start with three clinical cases that should help us understand some of the basic concepts of psychoanalysis

first case is a young woman who had problem in her relation with men. she always was afraid that they were going to
leave her. with her present boyfriend she was anxious that something in her wouldn't be found right any extended
separations made her afraid that he would never come back. this had happened to her in other relationships as well, and
so that that fearfulness interfered with her capacity to enjoy her intimate relations at the same time she was also very
worried about people being critical of her any minor criticism was experienced as a major disaster and she tended to react
getting depressed and there was a chronic mild depression as a consequence of the fearfulness over being criticized not
being good enough not doing things the right way. in the past of this woman there had been a childhood dominated by a
rather strict, cold, distant and very demanding mother, who kept on her toes all the time, who was critical, and who when
she felt that her daughter was not behaving well, would withdraw from her, leave her alone, and give her a sense of being
abandoned, and so the the fear of abandonment and of loneliness was an important childhood experiences which
extended now in her will taught to her relations with other men

him father was more understanding but because of his work he was not available, so there was no counterweight to this
dominance of of mother, and this woman suffered from a chronic sense of insecurity, and of wishes to be able to depend
on somebody without other ever being sure that that dependency would be gratified.

Clinical Case 2
second case. this is a young man who was very friendly, actually sometimes excessively friendly, and very well-behaved
and somewhat perfectionistic, everything had to be right the way he would have to do things very punctual, precise and
preoccupied with details, as I mentioned, very friendly, except with people in authority: teachers, supervisors he tended to
become tends, to become rather submissive, over a period of time and then explode in angry protests, when he felt that
they were trying to dominate him so that there was a kind of conflictual relations with authority and oscillating behavior
between inhibition and anger in relating to Authority that created difficulties for him in his past um there was a relationship
that he had with his father very much characterized by the same kind of issues if strict demanding domineering fathers
who expected his son to obey him who was bridgid and critical and demanding and he had to watch it all the time not to
get himself into trouble and with his father he gradually developed an effort to avoid punishment by being inhibited and
submissive and not being able to control his anger at other times and blowing up and at the same time he had
internalized all these demands that were made on him and he started to make these same demands on himself which
determined his perfectionistic behavior while at the same time with any other figures in authority he repeated that same
problem saw them as if they were a representation of his father taught whom he had to either submit or rebel creating
problems with authority and problems around an appropriate way to assert his autonomy

Clinical Case 3
third cas,e this is again a young men who had difficulties in his relationship with this girlfriend, whom he loved very much
who who he felt represented an ideal woman that he had always wanted to have it was an intense romantic relationship
but when she expected a more intimate sexually intimate relation with him he was unable to respond to that he became
very anxious or was unable to function sexually became important at difficulties in an array in erection in other words a
serious sexual inhibition that however he did not have when he had casual sex with women who were attractive sexually
but - at whom he really didn't experience any love and so that he had a number of experiences kind of one-night stands in
which he functioned perfectly well that was sexually satisfactory but without any real relationship while with his girlfriend
whom he really loved he was unable to function and the same thing had happened to him with another relation before
here what was interesting in his past was a very intimate and into mutually gratifying relationship with his mother whom he
idealized who in turn saw in him her ideal son he was the youngest or the older ones had left the home he spent long
periods of time with this mother his father was very committed to his work often they went on vacation just his mother and
himself with long talks together and him, at the same time both parents were united in a prohibitive attitude, they taught
his sexuality a strong prohibitive attitude towards masturbation, motivated in part by the religious identification of the
parents, but that was so intense and consistence, that he got to his university years without knowing that masturbation
was a normal process in childhood and later on. so that here the idealization of the relay of the love relation with an ideal
mother with whom natural he couldn't tolerate any sexual feelings was transferred to the relation with his girlfriend who he
treated as if unconsciously if she represented his mother, and therefore sexual feelings were not permitted, and he
couldn't function sexually. this is what classically within psycho lytic theory has been called the oedipal constellation, a
basic infantile situation in which unconscious infantile sexuality is directed toward the parent of the opposite sex, while the
parent of the same sex appears as a major rival, and origin of potential punishment for forbidden sexual feelings, and this
young men represented a particular form in which this frequent problem tends to show up.

Mechanisms
in the first case the mechanism by which the patient was trying to protect herself from her unconscious conflicts was
projection. that is to say, attributing to other people what really was going on in herself. she herself was excessively
critical with herself, she attributed to to others as if they were excessively critical with her, and she was afraid she was
going to be abandoned, her boyfriend was never going to come back, all of it as an expression of that mechanism that
created more problems for her.

in the second case the protection against the infantile conflict the mechanism of defense was reaction formation that is to
say the development of behavior opposite to that which was creating conflicts in the early childhood is being rebellious
toward his father who was so dominant well got him into trouble, so he was trying on the contrary to be extremely friendly,
nice, subservient if necessary, that was behavior through the opposit,e that's called reaction formation, but of course that
created an enormous frustration and ended up with this blowing up in anger and reproducing the the conflict that he was
trying to escape from

and in the third case the effort to escape from the conflicts around infantile sexual feelings for him forbidden as part of the
prohibition against masturbation, and at the same time him forbidden from being experienced in the relation with an ideal
person whom he loved his mother then led to on the one hand total forgetting of the very problem that one can't love the
person whom taught what one cannot have sexual feelings toward a person whom were loves that was remained
unconscious we call that repressed repression, and at the same time he also showed the mechanism of splitting in other
words separating completely sexual feelings from love, in order to avoid the conflict, but with the consequences of later
conflict in his real life, in his love relation, not being able to perform sexually in the relation with the woman whom he
loved.

so that those mechanisms repression, reaction formation, splitting ,projecting don't really solve the problem, but contribute
to further creating distorted and inhibited behavior for which patient come to see psychotherapists

Freuds Theory
Freud gave a general theoretical structure to all these findings about the influence of unconscious issues from the
childhood in adult life. he proposed the existence of what he called a dynamic unconscious, an unconscious reality in
which primitive impulses continued active, and he classified them into the drives of libido and aggression. libido is the life
drive, the sexual drive. aggression, also called the death drive. the life drive including all the positive feelings of love,
excitement, eroticism, dependency, warmth, closeness, and aggression on the other hand in cooperating or the relations
of rage, hatred, Envy, resentment, disgust. Freud saw a fight between these two principals is going on eternally in the
repressed unconscious that in that dynamic unconscious which he said did not know from passage of time, it treated time
as if it were eternal, which did not know of the principle of contradiction but treated all relations as if they were compatible
that didn't obey ordinary logic, that didn't obey considerations of ordinary space, that permitted displacement of conflicts
from one issue to another, from one person to another. he called that the primary process, as opposed to the secondary
process or the reality oriented ordinary logic that determines adult life. now what do we think about this general theory in
the light of contemporary knowledge of scientific developments that we are counting on today, That's our next subject

Neurobiological Research
let us examine what's known now from a from the viewpoint of a neurobiological research about the functioning of the
brain and how that fits with traditional psychoanalytic theories.

I have to summarize that very briefly, and can't do justice to all the details of what we know, and what we're doing in our
own research, but very briefly, we may conceive of a brain is an organ that has two big systems: one is the cortex, the
skin of the brain, and the other is a central part of it, the limbic system.

The cortex, the cover of the brain is a relatively thin layer, but in truth it's extremely complex and rich, and its function is to
provide our cognitive, conscious, intelligent perception and understanding of external reality, and of what's going on in
ourselves, it's the rational part of the brain.

The limbic system is the part of the brain that tends to activate affects as fundamental motivational systems affects are
feelings, good and bad, that tell us what kind of things to look for, because it feels good, what kind of thing to get away
from because it feels bad, and affects get activated on the basis of deeper centers the brain, particularly the
hypothalamus, that communicates to the brain the state of the organism in terms of what its needs are regarding
temperature, and feeding, and fighting, of dangers, or situations that are gratifying, basic biological needs. the
hypothalamus communicates to the limbic system, and according to whether there are needs that need to be satisfied, or
that are being satisfied, or that they are being frustrated, different affects are activated.

in what interests are us here is that particularly negative effects are activated when something is wrong, and we have to
signal to ourselves and the environment that we need help. it's the amygdala, a part of the limbic system, where negative
effects, anxiety, rage, fear get activated, irradiated to the cortex, where our intelligent, rational cognitive functions then
permit to clarify what is it that makes us anxious, or can we understand in what context this is happening, and what action
has to be taken.

So there's an equilibrium between affect activation, giving us our motivation, what we have to do taut, or away from
things, in the cortex which puts it all into a perspective. if there is excessive affect, and the cortex can't cope with it we get
panicky and disorganized. if there isn't not enough effect, we may miss the importance of a situation, and not react when
we should.

another part of the limbic system is the hippocampus. That's the memory chamber, so to speak, where memory of
affective experiences are deposited, are stored, and kept for comparison, and constitute a kind of registry that gets
alerted whenever we have a new experience that reminds us of something that we have already had before. So the
hippocampus permits us to establish affective memory, and react in the future according to experiences from the past,
which is a very important psychological functioning.

Now the affects tend to combine into systems, systems that have to do with basic needs of survival. one system is the
attachment system. the attachment system keeps the baby close to the mother. it's the origin of our needs for
dependency and closeness, not all aspects of closeness because there's an independent sexual system as well. but the
attachment system combines several affects in the sense of closeness, of intimacy. And then there's a sexual system that
combines sexual activation with the wish for closeness and play, but also a capacity to fight off rivals, so affects combined
in the sexual system, in the attachment system, in a play and affiliation system, in a fight flight system, in a panic system.

And in turn those combinations of systems then culminate in the final positive or negative motivation given by libido or
aggression, the life drives, the death drive. Ao Freud's conception of the drives really has to be based now, in the light of
our understanding of the underlying development of affects if as neuro-psychic structures, in which biology evolves into a
psychological experience.

Structural development of the mind. Formas of mental disorders.

Let's examine now how all of this comes together.

Let's go to the moment when the baby's born. Baby's hungry, calls for mother and mother comes. In the first moment
under the affect of low blood sugar, intense need of nourishment ,all the systems go to activate negative effect, intense
panic, fear, rage, anxiety, everything mixed up in an intense experience, the amygdala works like mad, and the cerebral
cortex is registering an extremely frightening situation. Mother comes, the baby is fed. Minutes later the baby's happy and
the situation changes totally to an ecstatic, almost orgasmic experience, and total happiness reigns.

What happens from the viewpoint of the build-up of psychic experience. We are not dealing only with effects, and we're
not dealing with the shift of one effect into another. We are dealing with two distinct experiences and each of them is quite
complex, because at the moment when the baby feels frustrated and tarry anxious, and frightened, there's a buildup of a
representation of self, interacting with an imaginary frustrating failing mother, who is not there when food should be there,
and after some weeks of experience the baby knows when he has that feelings mother should be there and feed him,and
if she is not there it's not that there's no mother, but it's like a bad mother who would be there in an extreme moment of
anxiety. A terrible image of self representation in acting with a terrible bad absence, and but presently or absently present,
or presently absent mother within the frame of a negative affect.

And separately from that, the built up of a positive extremely pleasurable happy self-representation interacting with the
giving, wonderful, perfect mother representation, the object representation, the term object is used to refer to significant
others, so we have two extreme experiences that then are followed by thousands of similar extreme experiences under
moments of frustration, and under moments of gratification, and at first these are completely split. they are split because
there are different affect systems are activated, different memories and their stores differently in the hippocampus.

Gradually, under the experience of a predominance of good experiences, when love predominates over hatred, when
good care by mother predominates over bad moments, the baby tolerates those bad moments. they become less
impressive, and an integration takes place by which then gradually the cognitive function, remember the cortex, integrates
good and bad experiences, and the baby is able to bring together the bad representation of mother, and the good one in
an integrated representation of her, and the bad images of self, and good images of self into an integrated image of
himself, and what builds up gradually is an integrated representation of self, an integrated self, and an integrated
representation of significant others.

That constitutes normal ego identity. Normal identity that permits one to feel that one is the same person all the time, and
significant people are the same people, even if they behave differently at different moments. It feeds into normality. If, on
the other hand, the bad experiences are so dominant that this integration is impossible, babies who are neglected, there
is no mother, they are terribly physical or sexual abuse, terrible traumatic experiences, but which the negative segment
builds up to an extent that it can't be tolerated, there's not enough good experiences to permit that, then a permanent split
is maintained. The world continues to be split into an idealized one, and a persecutory one. Why a persecutory one?
Because there's an effort to rid oneself of the bad experiences by projection, and projection means that the external world
is seen as persecutory, it's not once internal bad states. And the world continues divided between ideal people and
terrible people, and once image shifts from wonderful to bad, back to wonderful back to bad, and personalities who have
these chronic characteristics are called borderline personalities, or borderline personality disorders.

You may have heard that term, and they have a terrible time because they can't predict their own behavior, they can't
commit themselves to relationships in depth, to work, to a profession. Their lives are chaotic. They sure need treatment.

There are other situations in which such bad situations evolve into serious personality disorders, one in which projection
of a bad world is so overwhelming, that the main issue is how to deal with with all these potential enemies, the person
becomes hyper-alert, suspicious, distrustful, isolated. We call that a paranoid personality.

Or else, when there are very few ideal experiences, and the rest is terrible there may be a temptation to take refuge into
an idealized version, into an idealized vision of oneself, while at the same time in one's fantasy one incorporates that ideal
good parent that one has had in fleeting moments as if it were part of oneself, one becomes a pathological grandose self
with devaluation of everybody else. These are people who seem to love only themselves. They are grandiose, they are
omnipotent, and they seem to have very little capacity for investment in relation with others, and we call that the
narcissistic personality.

So, we've seen a number of serious developments of abnormal personalities ,because the experiences of frustration of
basic needs by a negative environment lead to abnormal solutions, that are embedded in the personality structure,
showing the character, that is to say in the person's habitual behavior patterns, and so we have the paranoid personality,
and the borderline personality, and the narcissistic personality, and remember, the depressive personality, the woman
whom we talked about, who was so afraid of being abandoned, and the obsessive personality, that young men who had
to have everything so precise and exact, and was so very nice, except from time to time, it kind of blew up, so we have
the obsessive personality as well.

And there is still an extreme case, when there is a lack of sufficient good persons who at the same time communicate a
moral value system or when there is such a negative environment that no good demands and prohibitions can be
accepted within that totally negative world that one is trying to do water off, and then we have personalities whose internal
moral structure suffers. they are called antisocial personalities, and they are the most severe personality disorders, and
while many patients with serious personality disorders can be treated, some of the extreme cases cannot.
We call the whole theory that I've just explained psychoanalytic object relations theory. it is the theory that explains how
affects are activated, the internal disposition of activation of affect, that we call temperament, how temperament interacts
with relation with significant others, with object relations, and how the interaction of temperament and object relations
creates such permanent patterns of relation between self and others, that determine either normal identity, or if,
integration doesn't take place, severe identity diffusion. And by the same token, either in normal harmonious personality,
or one of the serious personality disorders that I've mentioned to you.

So that's how psychoanalytic object relations theory brings together affects and drives and the defensive reactions
against them, with the vicissitudes of the internalization of relation with significant others, and explains the different
personality disorders.

Now, Freud originally had already captured these structures of the mind in the proposal that one could divide the mind
into three major structures: the Id, the dynamic unconscious as such, the Ego, or let's say, the Self in contemporary
psychology, and the Super-ego. And these structures of the mind, that interact consistently and with the environment,
reflect the consequences of the internalization of the object relations that I mentioned.

The Id, that Freud originally describes as a cauldron of aggressive and sexual impulses, is really the combination of all
those primitive internalized object relations that can't be tolerated, of the extremely negative aggressive nature, and also
some of them because of their sexual nature, because of the prohibitions against infantile sexuality that we've talked
about.

The Ego is really derived from the functions, that we have described, of the cerebral cortex: consciousness, perception,
control of motility, conscious historical continuity. conscious memory. but also the deeper structure of the concept of self,
and the concept of significant others, are central constituency's of the ego.

And the Super-ego is the internalized, largely unconscious, but also conscious system of moral or ethical structures,
derived from the do's and don'ts that come from the interaction with the parents. And here what we find is that a normal
Super-ego permits regulation of one's relationships way beyond those of practicality, of interaction, in terms of general
moral and ethical systems. It is what gives depth to our relations: depth to love, depth to our convictions and experiences
of values in the sense of aesthetics, there arts in the sense of ideology, religion, philosophy. But the Super-ego is also
endangered of being a source of pathology, because if it becomes excessive, if there's an excessive severity of the
demands and prohibitions of the parents, with the buildup of an excessive internal demands, such as we saw in our first
patient, that woman, and also in the second patient, the man with the obsessive behavior, and also in the third one, who
had to split sex from love, then it creates an origin of pathology, and origin of abnormal simptoms, and behavior, and
personality structure. So that's an excessive Super-ego. We say of some patients that they have a Super-ego like a
cathedral, and tend to get buried in there. The opposite is true also. If there has been a total lack of any consistent
parental structure, a lack of parents who have communicated a realistic and deep and integrated moral system, or if there
has been such a severity on the part of the parents that has led to a defensive rejection of anything coming from them, a
lack of Super-ego builds up. These are precisely the cases, well then, antisocial behavior may develop, for example, as
particularly, narcissistic personalities are prone, and then we have a serious problem of persons who do not have such an
internalized guidance system, with antisocial behavior, the antisocial personality. So that here the structures that Freud
described represent the superstructure of their component internalized object relations in the same way as the drives that
Freud described were the superstructure of the component affect systems.

Treatment and Research. Areas of application and healthy personality

I would like to discuss psychoanalysis as treatment.

Now, I'm not talking talking only about standard classical psychoanalysis, three to five sessions a week, but a broad
spectrum of psychoanalytic psychotherapy, that have been developed in recent years, and that have expanded the scope
of psychoanalytic treatments, particularly in the treatment of severe personality disorders, that were too severe to really
be able to benefit from psychoanalysis.

So I'm talking about the treatment in development and expanding its indications, and I'll talk jointly about psychoanalysis
and psychoanalytic psychotherapies.

So what are the main indications for treatment?

First of all, chronic depressive conditions, characterological depressions, and not major depressions or major affective
illness that are treated mostly by psycho-pharmacological means, but the kind of chronic depressions based on the
personality distortion, distortions of patients, or chronic anxiety states with the same basis, sexual inhibitions and all kind
of sexual difficulties, and difficulties in intimacy, in the sexual life, patients who have difficulty of loving, or are unable to
love normally. Only psychoanalysis really can help these patients. There are no other alternatives when it comes to
serious pathology of the subjective experience of love, and the integration of love and sexuality in all its forms.

Psychoanalysis treats multiple symptoms, so-called conversion symptoms, that represent physical symptoms based on
unconscious symbolic meanings related to unconscious conflicts, but most of all, psychoanalysis treats personality
disorders, all kinds of them, typically the patient's in the three cases that I mentioned to you at the beginning of our
conversation, and the complications that we have with severe personality disorders, particularly drug dependency,
alcoholism, eating disturbances, antisocial behavior, within certain limits, and chronic suicidal behavior, not based upon
depression, but based on profound characterological dispositions.

What are the basic features of psychoanalytic treatment? And again, I'm talking about the broad spectrum of
psychoanalythic psychotherapy.

The basic technique of the treatment is the analysis of the transference. What is the transference? The transference is the
unconscious repetition in the here-and-now of pathogenic conflicts of the past. The unconscious conflicts of the past, that
we've talked about, tend to reproduce itself, if that is in the sessions with the analyst or the therapist, if that is facilitated by
a particular attitude of the therapist, that we call technical neutrality, which is not a kind of a a cold indifference, but a
concerned objectivity, in which the patient is invited to speak freely everything that comes to his mind, without any control,
without any suppression, as much as he can, in order to facilitate the gradual emergence of deeper contents of the mind,
what we call free association.

Counter-transference
And the analyst listens to free associations, while at the same time observing the behavior of the patient in the treatment
session, and observing his own emotional reaction to the emotional reaction that the patient's gradually develops in the
treatment situation, what is called the counter-transference. And the patient tends to repeat under such circumstances
past conflicts, for example the first patient I mentioned to you, the woman with depression with the cold mother, may very
easily and soon experience the analyst as somebody who is cold and rejecting, afraid that he doesn't like her, feeling
rejected. In other words, reproducing the past conflict that anyhow she tends to reproduce all the time in her daily life
because of her characterological distortions, but the big difference is that here this reaction will be explored, will be
contrasted with the objectivity of the nature of the relationship, so that she will have the opportunity to gradually recognize
that past origin of a behavior that presently is inappropriate, and learn how to understand it, how to change it.

This may be much more complicated than it sounds, because she may be activating not only her past Self-representation
as a rejected or criticized child, and project on to the analyst the image of her mother, but to the contrary, she may treat
the analyst in a cold and rejecting way, without being aware of it, while he in his counter-transference may experience
himself as a rejected child. In other words, the relationship with mother is activated with role reversals, which permits in
the analysis of the transference to more deeply resolve the total identification, the total permanence of that particular
pathogenic, that means illness generating past relationship.

That, in a nutshell, is essence of the psychoanalytic treatment, and it permits really an analysis of the character, and with
it an analysis of the total personality, and personality change as such, in a way that is not possible with other types of
treatments.

Now, I'd like to mention briefly that all of this going on when empirical research is testing the psychoanalytic methods, its
effectiveness, comparing psychoanalysis with other treatment, I myself am involved as director of an institute that does
research on personality disorders. We are studying the effectiveness of a specific type of psychoanalythic psychotherapy,
we have developed for severe personality disorders, called Transference Focused Psychotherapy, and we have
demonstrated in empirical research the effectiveness of Transference Focused Psychotherapy, as compared with
cognitive behavioral therapies, and supportive psychotherapy, particularly its effectiveness in modifying the
representations of self and significant others, in other words, in working on identity diffusion to normalize identity, and with
it profoundly the personality functioning.

Applications. Conclusion
Psychoanalysis has also had other applications. it has been applied to the treatment of couples, to group psychotherapy,
to sex therapy, and has been very effective in developing new knowledge regarding the psychology of small groups and
large groups, and mass movements. It has had application to the study of ideology and religion, social psychology and in
the arts. You see here an example of the influence of psychoanalysis on the arts that has been remarkable in 20th
century art, in the schools of Dada surrealism, the school of fantastic realism and others. Cy Twombly has been trying to
apply the understanding of unconscious reality in his own paintings. Here, in the painting of the Battle of Lepanto in 12
individual paintings, he has attempted to use the objective subject to free his own deeper fantasy, infantile and fantastic
unconscious inspirations, and let it dominate in the effort to reproduce that deep human experiences in his work.
psychoanalysis finally has been important in helping to understand further the functioning of the normal personality, and in
helping to develop it, and by normal personality we refer to the capacity to freedom and enjoyment, in committing to work
and a profession, to an intimate relationship of love, in which love, tenderness and sex can be integrated to commit the
oneself to friendship and his social life, to a combination of the capacity for autonomy and independence and mature
dependency, and creativity.

Thank you very much.