IDENTITY DIFFUSION IN SEVERE
PERSONALITY DISORDERS
OTTO F. KERNBERG
A FEW DEFINITIONS
To begin, I shall refer to temperament and character as crucial aspects of personality. Tem-
perament refers to the constitutionally given and largely genetically determined, inborn
disposition to particular reactions to environmental stimuli, particularly to the intensity,
rhythm, and thresholds of affective responses. I consider affective responses, particularly
under conditions of peak affect states, crucial determinants of the organization of the per-
sonality. Inborn thresholds regarding the activation of both positive, pleasurable, reward-
ing, and negative, painful, aggressive affects represent, I believe, the most important bridge
between biological and psychological determinants of the personality (Kernberg, 1994).
Temperament also includes inborn dispositions to cognitive organization and to motor be-
havior, such as, the hormonal-, particularly testosterone-derived differences in cognitive
functions and aspects of gender role identity that differentiate male and female behavior
patterns. Regarding the etiology of personality disorders, however, the affective aspects of
temperament appear as of fundamental importance.
In addition to temperament, character is another major component of personality. Char-
acter refers to the particular dynamic organization of behavior patterns of each individual
that reflect the overall degree and level of organization of such patterns. While academic
psychology differentiates character from personality, the clinically relevant terminology
of character pathology, character neurosis, and neurotic character refer to the same condi-
tions, also referred to as personality trait and personality pattern disturbances in earlier
DSM classifications, and to the personality disorders in DSM-III and DSM-IV. From a psy-
choanalytic perspective, I propose that character refers to the behavioral manifestations of
ego identity, while the subjective aspects of ego identity, that is, the integration of the self-
concept and of the concept of significant others are the intrapsychic structures that deter-
mine the dynamic organization of character. Character also includes all the behavioral
aspects of what in psychoanalytic terminology is called ego functions and ego structures.
From a psychoanalytic viewpoint, the personality is codetermined by temperament and
character, but also by an additional intrapsychic structure, the superego. The integration of
value systems, the moral and ethical dimension of the personality—from a psychoanalytic
c03.qxd 10/7/04 10:47 AM Page 39
40 Conceptual Issues
viewpoint, the integration of the various layers of the superego—are an important compo-
nent of the total personality. Personality itself, then, may be considered the dynamic inte-
gration of all behavior patterns derived from temperament, character, and internalized
value systems (Kernberg, 1976, 1980). In addition, the dynamic unconscious or the id con-
stitutes the dominant, and potentially conflictive, motivational system of the personality.
The extent to which sublimatory integration of id impulses into ego and superego functions
has taken place reflects the normally adaptive potential of the personality.
The normal personality is characterized by an integrated concept of the self and an inte-
grated concept of significant others. These structural characteristics, jointly called ego
identity (Erikson, 1956; Jacobson, 1964) are reflected in an internal sense and an external
appearance of self-coherence and are a fundamental precondition for normal self-esteem,
self-enjoyment, and zest for life. An integrated view of one’s self assures the capacity for a
realization of one’s desires, capacities, and long-range commitments. An integrated view of
significant others guarantees the capacity for an appropriate evaluation of others, empathy,
and an emotional investment in others that implies a capacity for mature dependency while
maintaining a consistent sense of autonomy as well.
IDENTITY AND OBJECT RELATIONS THEORY
At the Personality Disorders Institute of the Department of Psychiatry of the Weill Cornell
Medical College, we have studied the psychopathology, clinical diagnosis and psychothera-
peutic treatment of identity diffusion on the basis of the application of contemporary psy-
choanalytic object relations theory. I have applied this theory to the understanding of the
development of normal and pathological identity, and, in the process, defined and explored
further the characteristics of identity diffusion (Kernberg, 1976, 1984, 1992).
In essence, the basic assumption of contemporary object relations theory is that all in-
ternalizations of relationships with significant others, from the beginning of life on, have
different characteristics under the conditions of peak affect interactions and low affect
interactions. Under conditions of low affect activation, reality-oriented, perception con-
trolled cognitive learning takes place, influenced by temperamental dispositions, that is,
the affective, cognitive and motor reactivity of the infant, leading to differentiated, grad-
ually evolving definitions of self and others. These definitions start out from the percep-
tion of bodily functions, the position of the self in space and time, and the permanent
characteristics of others. As these perceptions are integrated and become more complex,
interactions with them are cognitively registered, evaluated, and working models of them
established. Inborn capacities to differentiate self from nonself, and the capacity for
cross-modal transfer of sensorial experience play an important part in the construction of
the model of self and the surrounding world.
In contrast, under conditions of peak affect activation—be they of an extremely posi-
tive, pleasurable or an extremely negative, painful mode, specific internalizations take
place framed by the dyadic nature of the interaction between the baby and the caretaking
person, leading to the setting up of specific affective memory structures with powerful
motivational implications. These structures are constituted, essentially, by a representa-
tion of self interacting with a representation of significant other under the dominance of a
peak affect state. The importance of these affective memory structures lies in their con-
stituting the basis of the primary psychic motivational system, in the direction of efforts
to approach, maintain, or increase the conditions that generate peak positive affect states,
and to decrease, avoid, and escape from conditions of peak negative affect states.
c03.qxd 10/7/04 10:47 AM Page 40
Identity Diffusion in Severe Personality Disorders 41
Positive affect states involve the sensuous gratification of the satisfied baby at the
breast, erotic stimulation of the skin, the disposition to euphoric “in tune” interactions
with mother; peak negative affective states involve situations of intense physical pain,
hunger, or painful stimuli that trigger intense reactions of rage, fear, or disgust, and may
motivate general irritability and hypersensitivity to frustration and pain. Object relations
theory assumes that these positive and negative affective memories are built up separately
in the early internalization of these experiences and, later on, are actively split or dissoci-
ated from each other in an effort to maintain an ideal domain of experience of the relation
between self and others, and to escape from the frightening experiences of negative affect
states. Negative affect states tend to be projected, to evolve into the fear of “bad” external
objects, while positive affect states evolve into the memory of a relationship with “ideal”
objects. This development evolves into two major, mutually split domains of early psychic
experience, an idealized and a persecutory or paranoid one, idealized in the sense of a seg-
ment of purely positive representations of self and other, and persecutory in the sense of a
segment of purely negative representations of other and threatened representation of self.
This early split experience protects the idealized experiences from “contamination” with
bad ones, until a higher degree of tolerance of pain and more realistic assessment of exter-
nal reality under painful conditions evolves.
This early stage of development of psychic representations of self and other, with pri-
mary motivational implications—move toward pleasure and away from pain—eventually
evolves toward the integration of these two peak affect determined segments, an integration
facilitated by the development of cognitive capacities and ongoing learning regarding real-
istic aspects of self and others interacting under circumstances of low affect activation.
The normal predominance of the idealized experiences leads to a tolerance of integrating
the paranoid ones, while neutralizing them in the process. In simple terms, the child recog-
nizes that it has both “good” and “bad” aspects, and so does mother and the significant oth-
ers of the immediate family circle, while the good aspects predominate sufficiently to
tolerate an integrated view of self and others.
This state of development, referred to by Kleinian authors (Klein, 1940; Segal, 1964)
as the shift from the paranoid-schizoid to the depressive position, and by ego psychologi-
cal authors as the shift into object constancy, presumably takes place somewhere between
the end of the first year of life and the end of the third year of life. Here Margaret
Mahler’s (Mahler, 1972a, 1972b) research on separation-individuation is relevant, point-
ing to the gradual nature of this integration over the first three years of life. At the same
time, however, in the light of contemporary infant research, Margaret Mahler’s notion of
an initial autistic phase of development followed by a symbiotic phase of development
seem contradicted by the nature of the evidence. Rather than reflecting a symbiotic stage
of development, what seems relevant are “symbiotic” moments of fantasized fusion be-
tween self representation and object representation under peak affect conditions, momen-
tary fusions that are counteracted by the inborn capacity to differentiate self from
nonself, and the real and fantasized intervention of “third excluded others,” particularly
the representation of father disrupting the states of momentary symbiotic unity between
infant and mother. Here mother’s capacity to represent a “third excluded other” becomes
important: French authors have stressed the importance of the image of the father in the
mother’s mind.
Peter Fonagy’s (Fonagy & Target, 2003) referral to the findings regarding mother’s ca-
pacity to “mark” the infant’s affect that she congruently reflects to the infant points to a
related process: mother’s contingent (accurate) mirroring the infant’s affect, while
marked (differentiated) signaling that she does not share it while still empathizing with it,
c03.qxd 10/7/04 10:47 AM Page 41
42 Conceptual Issues
contributes to the infant’s assimilating his own affect while marking the boundary between
self and other. Under normal conditions, then, an integrated sense of self (“good and bad”),
surrounded by integrated representations of significant others (“good and bad”), that are
also differentiated among each other in terms of their gender characteristics as well as their
status/role characteristics, jointly determine normal identity.
The concept of ego identity originally formulated by Erikson included in its definition
the integration of the concept of the self; an object relations approach expands this defi-
nition with the corresponding integration of the concepts of significant others. In con-
trast, when this developmental stage of normal identity integration is not reached, the
earlier developmental stage of dissociation or splitting between an idealized and a perse-
cutory segment of experience persists. Under these conditions, multiple, nonintegrated
representations of self split into an idealized and persecutory segment, and multiple rep-
resentations of significant others split along similar lines, jointly constituting the syn-
drome of identity diffusion. One might argue that, in so far as Erikson considered the
confirmation of the self by the representations of significant others as an aspect of normal
identity, he already stressed the relevance of that relationship between the self concept
and the concept of significant others, but he did not as yet conceive of the intimate con-
nection between the integration or lack of it on the part of the concepts of self and the
parallel achievement or failure in the corresponding concepts of others. It was the work of
Edith Jacobson (1954) in the United States, powerfully influencing Margaret Mahler’s
conceptualizations, and the work of Ronald Fairbairn (1954) in Great Britain, who
pointed to the dyadic nature of the development of early internalizations and created the
basis for the contemporary psychoanalytic object relations theory.
This formulation of the internalization of dyadic units under the impact of peak affect
states has significant implications for the psychoanalytic theory of drives, for the under-
standing of the etiology of identity diffusion, and for the psychoanalytic psychotherapy of
severe personality disorders or borderline personality organization. Regarding the psycho-
analytic theory of drives, this formulation supports the proposal I have formulated in recent
years, that affects are the primary motivational system, and that Freud’s dual drive theory
of libido and aggression corresponds, respectively, to the hierarchically supraordinate inte-
gration of positive and negative affect states. The integration of affects determines the
functions of the drives, and the drives, in turn, are manifest in each concrete instance in the
activation of an affect state that links a certain representation of self with a certain repre-
sentation of object. These include the wishful and frightening erotic fantasies of highly de-
sired and potentially forbidden relationships between self and others, as well as highly
threatening and potentially disorganizing fantasies of aggressive relationships.
ETIOLOGY OF IDENTITY DIFFUSION
In short, the major proposed hypothesis regarding the etiological factors determining se-
vere personality disorders or borderline personality organization is that, starting from a
temperamental predisposition to the predominance of negative affect and impulsivity or
lack of effortful control, the development of disorganized attachment, exposure to physical
or sexual trauma, abandonment, or chronic family chaos predispose the individual to the ab-
normal fixation at the early stage of development that predates the integration of normal
identity: a general split persists between idealized and persecutory internalized experi-
ences under the dominance of corresponding negative and positive peak affect states. Clin-
ically, this state of affairs is represented by the syndrome of identity diffusion, with its lack
c03.qxd 10/7/04 10:47 AM Page 42
Identity Diffusion in Severe Personality Disorders 43
of integration of the concept of the self and the lack of integration of the concepts of sig-
nificant others. The question still remains, what other temperamental, psychodynamic, or
psychosocial factors may then influence the development of the specific constellations of
pathological character traits that differentiate the various constellations of severe person-
ality disorder from each other, a subject that remains to be explored. The fact that much of
the relevant research involves borderline personality disorder points to the need to carry out
such studies involving other severe personality disorders.
From a clinical standpoint, the syndrome of identity diffusion explains the dominant
characteristics of borderline personality organization. The predominance of primitive dis-
sociation or splitting of the idealized segment of experience from the paranoid one is natu-
rally reinforced by primitive defensive operations intimately connected with splitting
mechanisms, such as, projective identification, denial, primitive idealization, devaluation,
omnipotence and omnipotent control. All these defensive mechanisms contribute to dis-
torting interpersonal interactions and create chronic disturbances in interpersonal rela-
tions, thus reinforcing the lack of self reflectiveness and of “mentalization” in a broad
sense, decreasing the capacity to assess other people’s behavior and motivation in depth,
particularly, of course, under the impact of intense affect activation. The lack of integra-
tion of the concept of the self interferes with a comprehensive integration of one’s past and
present into a capacity to predict one’s future behavior, and decreases the capacity for
commitment to professional goals, personal interests, work and social functions, and inti-
mate relationships.
The lack of integration of the concept of significant others interferes with the capacity
of realistic assessment of others, with selecting partners harmonious with the individual’s
actual expectations, and with investment in others. All sexual excitement involves a dis-
crete aggressive component (Kernberg, 1995). The predominance of negative affect dispo-
sitions leads to an infiltration of the disposition for sexual intimacy with excessive
aggressive components, determining, at best, an exaggerated and chaotic persistence of
polymorphous perverse infantile features as part of the individual’s sexual repertoire, and,
at worst, a primary inhibition of the capacity for sensual responsiveness and erotic enjoy-
ment. Under these latter circumstances, severely negative affects eliminate the very ca-
pacity for erotic response, clinically reflected in the severe types of sexual inhibition that
are to be found in the most severe personality disorders.
The lack of integration of the concept of self and of significant others also interferes
with the internalization of the early layers of internalized value systems, leading particu-
larly to an exaggerated quality of the idealization of positive values and the ego ideal, and
to a persecutory quality of the internalized, prohibitive aspects of the primitive superego.
These developments lead, in turn, to a predominance of splitting mechanisms at the level
of internalized value systems or superego functions, with excessive projection of internal-
ized prohibitions, while the excessive, idealized demand for perfection further interferes
with the integration of a normal superego. Under these conditions, antisocial behavior may
emerge as an important aspect of severe personality disorders, particularly in the syn-
drome of malignant narcissism, and in the most severe type of personality disorder,
namely, the antisocial personality proper, which evinces most severe identity diffusion as
well (Kernberg, 1984, 1992). In general, normal superego formation is a consequence of
identity integration, and, in turn, protects normal identity. Severe superego disorganiza-
tion, in contrast, worsens the effects of identity diffusion.
The treatment of personality disorders depends, in great part, on their severity, re-
flected in the syndrome of identity diffusion. The presence or absence of identity diffu-
sion can be elicited clinically in initial diagnostic interviews focused on the structural
c03.qxd 10/7/04 10:47 AM Page 43
44 Conceptual Issues
characteristics of personality disorders. The dimensional aspects—greater or lesser de-
grees of identity diffusion—still require further research. From a clinical standpoint, the
extent to which ordinary social tact is still maintained or lost is the dominant indicator of
the severity of the syndrome. The diagnosis of identity diffusion or of normal identity, in
short, acquires fundamental importance in the clinical assessment of patients with per-
sonality disorders.
THE CLINICAL ASSESSMENT OF IDENTITY
At the Personality Disorders Institute at Cornell we have developed a particular mental
status examination designated “structural interviewing,” geared to the differential diag-
nosis of personality disorders. In essence, this interview, that ordinarily takes up to one
and one half-hours of exploration, consists of various steps of inquiry into the patient’s
functioning. The first step evaluates all the patient’s symptoms, including physical, emo-
tional, interpersonal and generally psychosocial aspects of malfunctioning, inappropriate
affect experience and display, inappropriate behavior, inordinate difficulties in assessing
self and others in interactions and in negotiating ordinary psychosocial situations. This
inquiry into symptoms is pursued until a full differential diagnosis of prominent symp-
toms and characterological difficulties has been achieved.
The second step of this interview explores the patient’s present life situation, including
his or her adaptation to work or a profession, the patient’s love life and sexual experi-
ences, the family of origin, the patient’s friendships, interests, creative pursuits, leisure
activities, and social life in general. It also explores the patient’s relation to society and
culture, particularly ideological and religious interests, and his or her relationship to
sports, arts, and hobbies. In short, we attempt to obtain as full a picture as possible of the
patient’s present life situation and interactions, raising questions whenever any aspect of
the patient’s present life situation seems obscure, contradictory, or problematic. This in-
quiry complements the earlier step of exploration of symptoms and, at the same time,
makes it possible to compare the patient’s assessment of his or her life situation and po-
tential challenges and problems with the patient’s interaction with the diagnostician as
this exploration proceeds. At this point, we obtain an early assessment of pathological
character traits, be they predominantly inhibitory, reaction formations, or contradictory
and conflictual behavior patterns.
A third step of this structural interview consists in raising the question of the person-
ality assessment by the patient of the two or three most important persons in his or her
present life, followed by the assessment of his or her description of himself or herself as a
unique, differentiated individual. The leading questions here are: “Could you now de-
scribe to me the personality of the most important persons in your present life that you
have mentioned, so that I can acquire a live picture of them?” “And now, could you also
describe yourself, your own personality, as it is unique or different from anybody else, so
that I can acquire a live picture of it?”
As the fourth step of this interview, and only in cases with significant disturbances in
the manifestations of their behavior, affects, thought content, or formal aspects of verbal
communication during the interview, the diagnostician raises, tactfully, questions about
that aspect of the patient’s behavior, affect, thought content, or verbal communication that
has appeared as particularly curious, strange, inappropriate, or out of the ordinary, war-
ranting such attention. The diagnostician communicates to the patient that a certain aspect
of his or her communication has appeared puzzling or strange to the diagnostician, and
c03.qxd 10/7/04 10:47 AM Page 44
Identity Diffusion in Severe Personality Disorders 45
raises the question, whether the patient can see that, and what his or her explanation would
be for the behavior that puzzles the diagnostician.
Such a tactful confrontation will permit the patient with good reality testing to be aware
of what it is in himself or herself that has created a particular reaction of the interviewer,
and provide him or her with an explanation that reduces the strangeness or puzzling aspect
of that behavior. This response, in other words, indicates good reality testing. If, to the con-
trary, such inquiry leads to an increased confusion, disorganization, or abnormal behavior
in the interaction with the diagnostician, reality testing is presumably lost. The mainte-
nance of reality testing is an essential aspect of the personality disorders, who may have
lost the subtle aspects of tactfulness in social interactions, but maintained good reality test-
ing under ordinary social circumstances. Loss of reality testing presumably indicates an
atypical psychotic disorder or an organic mental disorder: that finding would lead to further
exploration of such behavior, affect, or thought in terms of a standard mental status exami-
nation. In any case, a clear loss of reality testing indicates that an active psychotic or or-
ganic mental disorder is present, and that the primary diagnosis of a personality disorder
cannot be established at this time.
Otherwise, with reality testing maintained, the interview would permit the diagnosis
of a personality disorder, the predominant constellation of pathological character traits,
and its severity in terms of the presence or absence of the syndrome of identity diffusion.
The capacity to provide an integrated view of significant others and of self indicates nor-
mal identity. Good interpersonal functioning, that does not even raise the question of any
strange or puzzling aspect of the present interaction would not warrant the exploration of
reality testing. Patients with borderline personality organization, who present identity
diffusion, also typically evince behaviors reflecting primitive defensive operations in the
interaction with the diagnostician. These findings are less crucial than the diagnosis of
the identity diffusion, but they certainly reinforce that diagnostic conclusion.
While this method of clinical interviewing has proven enormously useful in the clinical
setting, it does not lend itself, unmodified, for empirical research. A group of researchers
at our Institute is presently transforming this structural interview into a semi-structured
interview, geared to permit the assessment of personality disorders by way of an instru-
ment (Structured Interview for Personality Organization [STIPO]; Clarkin, Caligor, Stern,
& Kernberg, 2003) geared to empirical research. The clinical usefulness of the structural
interview, however, may be illustrated by typical findings in various characterological
constellations.
To begin, in the case of adolescents, structural interviewing makes it possible to differ-
entiate adolescent identity crises from identity diffusion. In the case of identity crises,
the adolescent may present with a sense of confusion about the attitude of significant oth-
ers toward himself, and puzzlement about their attitude that does not correspond to his
self-assessment. Asked to describe the personality of significant others, however, partic-
ularly from his immediate family, their description is precise and in depth. By the same
token, while describing a state of confusion about his relationships with others, the de-
scription of his own personality also conveys an appropriate, integrated view, even in-
cluding such confusion about his relationships that corresponds to the impression that the
adolescent gives to the interviewer. In addition, adolescents with identity crisis but with-
out identity diffusion usually show a normal set of internalized ethical values, interests,
and ideals, commensurate with their social and cultural background. It is remarkable that,
even if such adolescents are involved in intense struggles around dependence and inde-
pendence, autonomy and rebelliousness with their environment, they have a clear sense of
these issues and their conflictual nature, and their description of significant others with
c03.qxd 10/7/04 10:47 AM Page 45
46 Conceptual Issues
whom they enter in conflict continues to be realistic and cognizant of the complexity of
the interactions.
To the contrary, in the case of identity diffusion, the descriptions of the most impor-
tant persons in his or her life on the part of an adolescent with borderline personality or-
ganization are vague and chaotic, and so is his or her description of the self, in addition to
the emergence of significant discrepancies in the description of the adolescent’s present
psychosocial interactions, on the one hand, and the interaction with the interviewer, on
the other. It is also typical for severe identity diffusion in adolescence that there exists a
breakdown in the normal development of ideals and aspirations. The adolescent with iden-
tity diffusion may display a severe lack of internalized value systems, or a chaotic and
contradictory attitude toward such value systems.
In contrast to the diagnostic value of exploring identity and internalized value systems,
other aspects of the mental status examination are less important in the case of adolescents.
Thus, particularly, the dominance of primitive defensive operations is less important than it
would be in adult patients. The reason is that, with a reactivation of oedipal conflicts, and
conflicts about sexuality in general, primitive defensive operations may emerge, particu-
larly in the area of conflicts with the parents. Severe conflicts with intimate members of
the family are diagnostically much less important than they would be later on. Chaotic ex-
periences in the sexual realm, manifestations of polymorphous perverse infantile sexuality,
rather extreme oscillations between inhibited, puritanical attitudes and impulsive sexual
behavior also are not necessarily indicative of identity diffusion at this time.
The nature of adolescent school failure also includes a broad spectrum of diagnostic
possibilities and does not reflect directly the syndrome of identity diffusion: depressive
reactions, attention-deficit-hyperactivity disorder, physical, sexual or emotional abuse,
significant inhibitions of many origins, the characteristic pattern of narcissistic person-
alities of being the best student in some courses and the worst in others, and generalized
breakdown in the functioning at school as a reflection of identity diffusion have to be
differentiated from each other. The capacity to fall in love and to maintain a stable love
relation, in general, is related to normal identity, but some adolescents may be delayed
in their capacity to establish sexual intimacy out of inhibition, and the absence of that
capacity is not necessarily diagnostic. Sexual promiscuity, on the other hand, may or
may not reflect identity diffusion in adolescence. Significant changes in mood and emo-
tional lability are also less important in the diagnosis of identity diffusion in adoles-
cence than in adults. Finally, the relationship of an adolescent with his or her particular
psychosocial group may provide important clues to both identity and superego develop-
ments. The capacity for a harmonious participation in group structures needs to be dif-
ferentiated from the blind adherence to an isolated social subgroup, and from the
incapacity to function outside the protective structure of such a group. Chronic social
isolation, in contrast to the capacity to adjust to group situations also may point to sig-
nificant character pathology. The relationship to groups permits us to clarify the poten-
tial presence of a negative identity.
The most typical manifestations of the syndrome of identity diffusion, that is, a clear
lack of integration of the concept of self and of the concept of significant others can be
found in patients with borderline personality disorder, and, to a somewhat lesser degree,
in patients with histrionic or infantile personality disorder. In contrast, in the case of
the narcissistic personality disorder, what is most characteristic is the presence of an
apparently integrated, but pathological, grandiose self, contrasting sharply with a se-
vere incapacity to develop an integrated view of significant others: the lack of the ca-
pacity for grasping the personality of significant others is most dramatically illustrated
c03.qxd 10/7/04 10:47 AM Page 46
Identity Diffusion in Severe Personality Disorders 47
in the narcissistic personality disorder. An opposite situation may emerge in patients with
schizoid personality disorders, where a lack of integration of the concept of the self may
be matched by very subtle observations of significant others. In the case of schizotypal
personality, in contrast, both the concept of self and the concept of significant others are
severely fragmented, similar to the case of the borderline personality disorders. It is inter-
esting to observe that in the rare cases of multiple personalities, a careful evaluation of the
personality structure of the alters reflects the mutually split off fragmentation of the pa-
tient’s self concept, while a similar lack of integration of the concept of significant others
permeates all the alters of the patient’s personality.
THE TREATMENT OF IDENTITY DIFFUSION
The transference focused psychotherapy (TFP) that we have developed over the past
twenty-five years at the Personality Disorders Institute at the Weill Cornell University
Medical College is specifically geared to resolve the identity diffusion of patients with bor-
derline personality organization (Clarkin, Yeomans, & Kernberg, 1999; Kernberg, 1984;
Koenigsberg et al., 2000; Yeomans, 1992). It is the central objective of the corresponding
treatment strategies. Transference focused psychotherapy is a specialized form of psycho-
analytic or psychodynamic psychotherapy, that has been manualized. The efficacy of this
manualized treatment has been empirically confirmed and further empirical studies of it
are under way (Clarkin et al., 2001). This treatment can be characterized by its defined
techniques, strategies, and tactics. The techniques are, in essence, those of standard psy-
choanalysis, modified quantitatively for these patients, including interpretation, transfer-
ence analysis, and technical neutrality. Transference focused psychotherapy requires a
minimum of two sessions per week and is carried out in “face to face” sessions. The pa-
tient receives instructions for carrying out a modified form of free association, and the
therapist’s interventions are limited to psychoanalytic techniques, as mentioned before,
and avoids supportive technical interventions to facilitate full and in depth analysis of the
transference.
The tactical principles of the treatment include rules and procedures that apply in each
session, the consideration of particular priorities of interventions, and management of
complications in the treatment. These tactics involve, first of all, special modes of con-
tract setting geared to protecting, at all times, the patient’s life, the lives of others, the
continuity of the treatment, and, above all, the maintenance of the treatment frame. This
frame usually is severely tested by regressive transference developments. In addition, tac-
tics involve a series of priorities of interventions in the light of frequent complications in
the treatment, including severe suicidal behavior, threats to the continuity of the treat-
ment, severe acting out in and outside the sessions, patients’ mendacity, blocking of treat-
ment development by severe narcissistic resistances, and defensive trivialization of the
content of the hours.
Particular tactics are geared to deal with the manifestation of extreme aggression in
the hours, the management of affect storms, psychopathic transferences, paranoid micro-
psychotic episodes, chronic sado-masochistic acting out, and the threat to the treatment
by drug or alcohol abuse, eating disorders, and other psychopathologies frequently com-
plicating severe personality disorders. Treatment tactics also involve the application of
general psychoanalytic techniques as mentioned before, such as the dynamic, economic,
and structural considerations regarding when, how, and what to focus upon and in what
order to intervene interpretively in each session. The severity of the fragmentation of the
c03.qxd 10/7/04 10:47 AM Page 47
48 Conceptual Issues
communicative process, the dominance of nonverbal communication and intense counter-
transference activations are other aspects of typical treatment developments that are in-
cluded in setting these tactical principles for technical interventions in each hour.
The overall strategy consists of the focus on the diagnosis and resolution of identity dif-
fusion. This strategic objective guides the nature of transference interpretations from the
beginning of the treatment, throughout its entire duration. This strategy is expressed in three
successive steps of interpretive interventions: first, the clarification, at each point of each
session, of the now dominant, primitive, fantasized, enacted or acted out interpersonal rela-
tionship emerging in the session, and the affect expressing it in the transference. A second
step is the clarification of the representation of self and the representation of the other in the
activation of this object relation in the transference, and of the dominant affect state fram-
ing the relationship between self and object representations at that point. In addition, as part
of this second step, the therapist interprets consistently the interchange between representa-
tion of self and representation of object that is characteristic for the primitive transference
developments of borderline patients, a result of their primitive defensive operations, partic-
ularly projective identification. The third step is the interpretive integration of mutually
split off internalized object relations activated in the transference, so that the idealized ob-
ject relationships and their corresponding split off, paranoid counterparts are brought to-
gether in the therapist’s interpretive comments, thus leading to an integration of the concept
of self and the integration of the concept of significant others.
The fact that the dominant object relations are clarified in step one, and then, in step
two, systematically analyzed throughout time, including their frequent role reversals, fa-
cilitates the patient’s growing capacity to accept his or her unconscious identifications
with mutually split off self and object representations, thus also facilitating that third
step of integrative interpretive interventions.
Step one of this procedure evolves, practically, from the first session of treatment on,
and constitutes a consistent effort throughout the entire treatment. Step two requires ex-
tensive work over many weeks and even months, before a situation evolves that permits
the therapist to move into the interpretive stance of step three. The entire cycle of this
movement, therefore, may at first last for many months, only to repeat itself as part of the
working through of the same transference predispositions, in cycles that gradually reduce
their length to weeks, and, eventually, days. Toward the termination of the treatment, the
entire cycle of interventions—the three steps—might be condensed within the same hour.
As a result of this strategy and the gradual integration of the concept of self and of sig-
nificant others, there also evolves a gradual integration, modulation, and cognitive com-
plexity of affect states, together with a greater capacity of the patient to reduce affective
impulsivity, and a deepening of his or her object relations in the context of the consistent
increase in the capacity for self reflectiveness that evolves as a major consequence of this
strategic approach. The manual published by our Institute describing transference fo-
cused psychotherapy explains in detail and illustrates clinically this entire treatment ap-
proach (Clarkin et al., 1999).
Originally Posted by Subteigh
Reply With Quote
