BORDERLINE PERSONALITY DISORDER 0193-953X/94 $0.00 + .

20

AGGRESSION, TRAUMA, AND

HATRED IN THE TREATMENT OF
BORDERLINE PATIENTS
Otto F. Kernberg, MD

The psychoanalytic critics of Freud's dual drive theory tend to focus

their criticism on the aggressive drive, proposing that aggression is a
secondary reaction to the frustration of basic needs of relatedness; these
critics also question the sexual aspects of libido, pointing to the relatively
secondary nature of the erotic as compared with the need for depen-
dency and closeness to the object. As Stephen Appelbaum (personal
communication) recently pointed out, the relatedness- for example, of
interpersonal psychoanalysts and self psychologists-that tends to re-
place Freud's aggression and libido, in turn carries out the function of a
"drive"-that is, a consistent individually developed and structured
motivational system determining conscious and unconscious internaliza-
tion of object relations and interactions in actual object relations.
Perhaps the most convincing theoretician in the line of reasoning
that rejects aggression as a drive is Fairbairn/ whose proposal that libido
is an object-related function of the ego is matched by his acknowledg-
ment of the practical importance of aggressively invested internalized
object relations. Fairbairn thus acknowledges the practical importance
of aggression although at the same time he assumes that aggression is

Presented at the Institute of Pennsylvania Hospital, Philadelphia, March 7, 1992.

From The New York Hospital-Cornell Medical Center, Westchester Division, White Plains,
New York; the Department of Psychiatry, Cornell University Medical College, New
York, New York; and the Columbia University Center for Psychoanalytic Training
and Research, New York, New York

PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 17 • NUMBER 4 • DECEMBER 1994 701

702 KERNBERG

secondary to the unavoidable development of frustration in the early

infant- mother relationship.
I have argued, in earlier work, 8 that the activation of libidinal
development in the infant- mother relationship presupposes an innate
disposition to attachment that requires an external stimulation to become
activated, and that the same reasoning may be applied to the develop-
ment of rage and angry protest when external circumstances frustrate
the infant's needs or desires: In both cases, an internal disposition to a
peak affect response is actualized by environmental stimuli- the care-
giving object. At the center of each of these basic responses, of a loving
response to a gratifying environment and a rageful response to a frus-
trating environment, are primitive affects.
I assume that from the onset of object relations the experience
of self-relating to an object during peak affective states generates an
intrapsychic world of affectively invested object relations of both a
gratifying and an aversive quality. The basic psychic experiences that
will enter the dynamic unconscious are specific dyadic relations between
self and object representation brought together in the framework of
extremes of elation and rage. Symbiotic states of mind, that is, experi-
ences of elation within which an unconscious fantasy of union or fusion
between the self and object easily are associated with the connotations
of the baby being satisfied at the breast, the elation of the baby in visual
contact with the mother's smiling face. That states of intense rage also
imply an experience of fusion between self and object under the influ-
ence of intense aversive affect is a conclusion derived from the transfer-
ence analysis of patients suffering from severe psychopathology charac-
terized by intense aggression.
On the basis of these considerations I have proposed8 that peak
affect states constitute the essential components of what eventually will
constitute libido and aggression as drives, that is, drives as hierarchically
supraordinate motivational systems that energize unconscious fantasy
and, embedded in repressed internalized object relations, determine the
content of unconscious fantasy. I believe primitive affect states are the
building blocks of the drives. I also see these affects as "signals" of the
activation of the drive in every clinical situation in which libido or
aggression emerges as the motivating aspect of the activation of an
internalized object relation in the transference.
I have argued that we still need a theory of drives because a theory
of motivation based on affects alone would unnecessarily complicate the
analysis of the relationship to the dominant objects of infancy and
childhood: There are multiple positive and negative affects expressed
toward significant objects, and an affect theory would miss the develop-
mental lines of libidinal and aggressive strivings that we have been able
to clarify in the context of psychoanalytic discoveries.
This theory of drives permits us to integrate the concept of inborn
dispositions to excessive or inadequate affect activation, therefore doing
justice to the genetic and constitutional variations of intensity of drives
reflected, for example, in the intensity, rhythm, and thresholds of affect
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 703

activation that we designate as temperament. This theory equally permits

us to incorporate the effects of physical pain, psychic trauma, and severe
disturbances in early object relations as contributing to intensifying
aggression as a drive by triggering intense negative affects. The theory
does justice, in short, I believe, to Freud's statements that drives occupy
an intermediate realm between the physical and psychic.
Recent studies of alterations in neurotransmitter systems in severe
personality disorders, particularly the borderline personality disorder,
although still tentative and open to varying interpretations, point to the
possibility that they are related to specific distortions in affect activa-
tion.15, 18 Abnormalities in the adrenergic and cholinergic system, for
example, may be related to general affective instability; deficits in the
dopaminergic system may relate to the disposition toward transient
psychotic symptoms in borderline patients; and impulsive, aggressive,
self-destructive behavior may be facilitated by a lowered function of the
serotonergic system, In any case, genetic dispositions to temperamental
variations in affect activation would seem to be mediated by alterations
in neurotransmitter systems, providing a potential link between the
biologic determinants of affective response and the psychological trig-
gers of specific affects.
These inborn dispositions to the activation of aggression mediated
by the activation of aggressive affect states are complementary to the
now well-established findings that structured aggressive behavior in
infants may derive from early, severe, chronic physical pain, and that
chronically aggressive teasing interactions with the mother are followed
by similar behaviors of infants, as we know from the work of Galenson4
and Fraiberg. 3 Grossman's6, 7 convincing arguments in favor of the direct
transformation of chronic intense pain into aggression provides a theo-
retical context for the earlier observations of the battered-child syn-
drome, The impressive findings of prevalence of physical and sexual
abuse in the history of borderline patients confirmed by investigators
both here and in Europe14' 16 provides additional evidence of the influ-
ence of trauma on the development of severe manifestations of aggres-
sion,
Anger and rage, aversion and disgust, contempt and resentment
are affects integrated into and serving to express particular aspects of
aggression as a hierarchically supraordinate drive. In my view, rage is
the core affect of aggression, parallel to the role of sexual excitement as
the core affect of libido as a drive. If we accept a modified version of
Mahler's developmental schemata,13 in the sense that very early differen-
tiation taking place under conditions of low-level affect states alternates
with states of mind that reflect the development of the symbiotic phase
under conditions of peak affect states, Mahler's contributions to the
understanding of normal and pathologic symbiosis may be incorporated
into a present view of early development. In my view, these concepts of
ego maturation and development under conditions of low-level affect
states and the gradual construction of the dynamic unconscious under
conditions of peak affect states permits us to integrate infant observation
704 KERNBERG

with our growing understanding of the structural characteristics of the

dynamic unconscious derived from psychoanalytic exploration.

AGGRESSION

Aggressively invested self and object representations, initially not

differentiated from each other and built up separately from libidinally
invested self and object representations also initially not differentiated
from each other, characterize the basic layer of the dynamic unconscious.
They reflect early symbiosis, and eventually give rise to the differentia-
tion of self and object representations within both the libidinal and
aggressive domain, thus establishing the structural characteristics of
separation- individuation and the psychopathology of borderline person-
ality organization. Here I wish to stress the indissoluble connection
between internalization of early object relations and affect states, the
indissoluble unit of the self-representation/ object-representation dyad
and the affective context of this dyad. Again, early as well as later affect
always has an object relation connotation, namely, an implicit relation
between self and object exists within the frame of any particular affect.

HATRED

I now focus on the conditions under which aggression as a drive

dominates so powerfully the early development of the psychic apparatus
that it leads to the psychopathologic structures that we observe in
borderline personality organization. The most central clinical observa-
tion in such conditions from a psychoanalytic viewpoint is the activation
of intense, pervasive rage in the transference. From the mild, chronic
nature of irritation and irritability, to the acutely focused and intense
expression of anger, the patient easily shifts into the basic affect of rage
that, when its unconscious fantasy elements are explored, eventually
reveals the structural characteristics of hatred.
The earliest function of rage, one that maintains itself under condi-
tions of rage attacks in ordinary life, is the effort to eliminate, in a
violent mode of reaction, a source of irritation or pain. Rage is thus
always secondary to frustration or pain, although the intensity of the
rage response may depend upon temperamental features. A second
function of rage is to eliminate an obstacle or barrier to gratification.
Here the frustration is more complex: an obstacle has to be eliminated
to reach a fantasized or real source of gratification. This is the prototype
for a third, higher developmental level function of rage, namely the
elimination of a bad object; that is, a supposedly willful source of
frustration standing between the self and the gratification of a need.
Kleinian theory9• 10 postulated the immediate transformation of very
early states of severe frustration, the absence of mother, into the fanta-
sized image of a bad mother, the original bad inner and external object.
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 705

Laplanche 12 believes, however, that later traumatic experiences may

retrospectively transform earlier experiences into secondarily traumatic
ones, and that, therefore, at what point the internalized object relation
related to rage crystallizes into the unconscious wish to destroy a bad
object is not so essential.
At a still more advanced developmental level, the wish is no longer
to destroy the bad object, but to make it suffer: Here, we are definitely
in the complex developmental area in which pleasure and pain combine;
sadism expresses a condensation of aggression with pleasure; and the
original affect of rage appears transformed into hatred with new, stable,
structural characteristics. At a further level of development, the wish to
make the bad object suffer shifts into the wish to dominate and control
the bad object in order to avoid fears of persecution from it, and,
psychopathologically, now obsessive mechanisms of control may regu-
late the suppression or repression of aggression. Finally, in sublimatory
aspects of the aggressive response, there is a search for autonomy and
self affirmation and freedom from external control, reflect sublimatory
characteristics of the original, self affirmative ,implications of rage.
Hatred, I propose, is a complex, structured derivative of rage, that
expresses the combined wishes to destroy a bad object, to make it suffer,
and to control it on the part of an enraged self. In contrast to the acute,
transitory, and disruptive quality of rage, it is a chronic, stable, usually
characterologically anchored affect. The object relationship framing this
affect expresses concretely the desire to destroy or dominate the object.
An almost unavoidable consequence of hatred is its justification as a
revenge against the frustrating object, and revengefulness is a typical
characterologic form of hatred. Paranoid fears of retaliation also are
usually unavoidable accompaniments of intense hatred, so that paranoid
characterologic features, revengefulness, and sadism go hand in hand.
One very early complication of hatred derives from the fact that
frustration and gratification are experienced as stemming from the same
source. Hence, the obstacle to gratification is the source. Here we ap-
proach the psychopathology of envy. I am referring to Melanie Klein's 11
explanation of envy as a major manifestation of human aggression. Very
early frustration-in Melanie Klein's terms, the absence of the good
breast- is experienced by the baby as if the breast withheld itself, with
an underlying projection into the breast of the baby's aggressive reaction
to that frustration. The baby's aggression takes the form of greedy
wishes to incorporate. The breast that aggressively withholds itself is in
turn hated, and its fantasized contents are spoiled and destroyed. A
vicious circle may ensue, in which the destructed and destructive breast
is experienced in a persecutory way, thus exaggerating and prolonging
further the experience of frustration and rage. Here lies the origin of
envy, the need to spoil and destroy the object that is also needed for
survival, and, in the end, the object of love. The introjection of the image
of a spoiled, destroyed breast leads to a sense of internal emptiness and
destruction, which may damage the previous introjection of the good
breast that was lost, so that the effects of envy and the related develop-
706 KERNBERG

ment of greed corrode both the good external and the good internal
object.
We do not need to accept Klein's contention of inborn envy, nor of
the specific relationship of envy to the mother's breast, to consider envy
a basic consequence of very early hatred of the good object that is also
a frustrating and teasing one, and, for practical purposes, envy emerges
clinically as a dominant form of hatred in clinical conditions character-
ized by preoedipal aggression. I consider envy a complex, relatively
elaborated type of structured rage derived from the basic characteristics
of hatred. Envy is, in my experience, the most typical manifestation of
aggression in the transference of narcissistic personalities, expressed
both as unconscious envy of the analyst experienced as a good object,
and in greedy incorporation of what the analyst has to offer, both of
them leading to a sense of emptiness and frustration. Unconscious envy
in the analytic situation is a source of the negative therapeutic reaction,
more primitive and severe than unconscious guilt, which expresses
more advanced superego pressures and conflicts. But unconscious envy,
projected onto the analyst and reintrojected into superego functions,
may lead to unconscious envy directed against the self.
Another consequence of the structural fixation of rage in the form
of hatred is the unconscious identification with the hated object. Insofar
as the internalized object relation of hatred is that of a frustrated,
impoverished, pained self relating to a powerful, withholding, teasing,
sadistic object, the unconscious identification with both victim and vic-
timizer brings about an intensification of the actual relationship with the
frustrating object; that is, an increased dependency in reality on the
hated object in order to influence, control, punish, or transform it into a
good object, and, at the same time, the unconscious tendency to repeat
the relationship with the hated object with role reversals, becoming the
hateful object dominating, teasing, frustrating, and mistreating another
object onto which the self representation has been projected.
Here we reach the impact of physical and sexual abuse on the
development of the psychopathology of hatred. Trauma as the actual
experience of sadistic behavior of a needed, inescapable object instanta-
neously shapes the rage reaction into the hatred of the sadistic object.
The heightened prevalence of physical abuse, sexual abuse, and wit-
nessing of violence in patients with severe psychopathology including
borderline personality disorder, affective disorders, dissociative disor-
ders, post-traumatic stress disorders, antisocial personality disorders,
and severe forms of eating disorders has been confirmed in this country
and abroad. Even granting the distortion of statistical analyses under
the impact of current, ideologically motivated stress on incest and sexual
abuse, the evidence of such abuse as one significant etiologic factor in
the development of severe personality disorders is convincing. The
underlying mechanism, I am suggesting, is precisely the establishment
of an internalized object relationship under the control of structured
rage, that is, hatred.
The overwhelming dominance by hatred of an unconscious world
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 707

of internalized object relations determines the persistence of primitive

splitting operations consolidating a borderline personality organization,
and maintains an internalized world of idealized and persecutory object
relations with a dominance of persecutory object relations and their
corollary paranoid tendencies, characterologically structured ego-syn-
tonic hatred, sadism, and revengefulness, with dissociated efforts to
escape from a persecutory world by illusory and dissociated idealiza-
tions. Under traumatic conditions, then, the basic mechanisms would
include the immediate transformation of pain into rage and rage into
hatred; hatred consolidates the unconscious identification with victim
and victimizer.

CLINICAL PROBLEMS

I explore now clinical problems of patients dominated by hatred

and the related, urgent, and essential desire to destroy the origin of their
suffering, as they perceive it; that is, the hated and hateful, persecutory
object. The most important clinical consequence of the dominance of
hatred in the transference is the attribution, by the patient, to the thera-
pist of an equally intense, relentless degree of hatred. By means of the
mechanism of projective identification, the internal world of torturer
and tortured, tyrant and slave are enacted in the forms of attribution to
the therapist of the role of sadistic tyrant, and, by means of unconscious
efforts to provoke the therapist into such a role and to control him in
order to limit his dangerousness, and the induction of conditions in
the countertransference that eventually tend to activate whatever role
responsiveness the therapist has to fulfill the patient's fearful expecta-
tions.
Under most extreme circumstances, typically seen in schizophrenic
panic and rage attacks, but also under conditions of transference regres-
sion in borderline patients, the patient's fear of his or her own hatred
and of the hatred projected onto the therapist is such that reality itself
becomes intolerable. If, under conditions of symbiotic regression in the
transference or even intense activation of projective identification in
nonsymbiotic conditions, the entire world becomes a sea of hatred. The
most primitive and dominant mechanism for dealing with this situation
is to block out the perception of reality. Such efforts to destroy the very
awareness of reality may lead to psychotic confusional states, or, in
nonpsychotic patients, to a malignant transformation of the therapist-
patient dyad in which all honest communication is suppressed, and
what I have called psychopathic transferences prevail: The patient is
deceptive, expects the therapist to be deceptive, all communication is
pseudocommunication, and violent affect storms are expressed in disso-
ciated forms .
Under less extreme conditions, such as one may see in patients with
the syndrome of malignant narcissism, the patient may manifest intense
curiosity about the therapist, to the extent of active spying on the
708 KERNBERG

therapist's life; the patient shows consistent arrogance and contempt for
the therapist, and an incapacity to understand cognitive communication
from the therapist that may amount to a form of pseudostupidity. 1 I
have described in earlier work8 how the gradual working through of
such conditions in the transference may eventually allow the patient to
tolerate his or her hatred rather than project it. Such conscious tolerance
of hatred then may be expressed as joyful attacks, insults, depreciation,
and teasing of the therapist, which then may be gradually traced to its
origins, into traumatic situations from the past and intense envy of the
therapist as an individual not controlled by the same terrifying internal
world of the patient.
Another manifestation of primitive hatred that the patient cannot
tolerate in conscious awareness is the transformation of hatred into
somatization in the form of primitive, chronic self-mutilation: These are
patients who chronically pick at their skin or mucosas, self-mutilate, and
present other patterns of primitive sadomasochistic behavior. Character-
ologically anchored suicidal tendencies in borderline patients are another
expression of self-directed hatred.
The antisocial personality proper may be conceived as a charactero-
logic structure so dominated by hatred that primitive, split-off idealiza-
tions are no longer possible, the world is populated exclusively by hated,
hateful, sadistic persecutors, and to triumph in such a terrifying world
can only occur by becoming oneself a hateful persecutor as the only
alternative to destruction and suicide. Under less extreme conditions,
unconscious identification with the hated object and its characterologic
translation into antisocial tendencies, cruelty, contempt, and sadism may
present in many forms. A restricted, encapsulated sadistic perversion
may represent one outcome of these conflicts. As Stoller17 pointed out,
sexual excitement always includes an element of aggression, and an
organized perversion typically expresses the need to undo in fantasy an
experienced trauma or humiliation from the past in the sexual realm.
Progressing toward still less severe types of characterologic forms
of hatred, the drive for power and control, the sadistic implications of
certain obsessive-compulsive personality structures contain this dy-
namic. This also is true for certain personality structures in patients
with reaction formations against dependency within whom there is the
unconscious fear that all dependent relationships imply a submission to
a sadistic object. Masochistic reaction formations against identification
with a hateful object internalized into the superego reflect relatively less
severe outcomes of these dynamics. More frequently, the internalization
of a hated, sadistic object into the superego may reveal itself in the form
of sadistic moralism, the tendency toward "justified indignation," and
moralistic cruelty.
At a truly sublimatory level of transformation of hatred, self-asser-
tion, courage, independent judgment, moral integrity, the capacity for
self-sacrifice all may include, on analytic exploration, traces of the dy-
namics we are exploring.
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 709

INCEST

I explore now somewhat further the psychodynamics of incest, as a

traumatic situation that has received much recent interest and which
illustrates the basic dynamic of internalization of an object relation
dominated by hatred. It is important when investigating the psychody-
namics of incest to keep in mind the normal role of sexual excitement
in neutralizing aggression by the erotic potential of mild physical pain.
The sadomasochistic component of sexual excitement permits the re-
cruitment of aggression at the service of love, but it is a response that,
under conditions of a sexual response overwhelmed by rage and hatred
may be transformed into the organization of sexual sadomasochism in
which, we might say, love is recruited into the service of aggression. In
other words, sexual intercourse may become a symbolic gratification of
sadomasochistic tendencies replicating, in the sexual area, the interac-
tions I have described under ordinary conditions of relationships domi-
nated by hatred.
All sexual abuse, however, is not experienced as aggressive-
unconscious infantile sexuality; the excitement, gratification, and tri-
umph resulting from breaking oedipal barriers; as well as the guilt that
such triumph produces complicate the psychological effects of sexual
trauma and abuse. Nevertheless, the distortion of superego structures
brought about when cross-generational, particularly parent-child incest
occurs destroys the potential for the integration of sadistic parental
images into the superego, and thus transforms the conflict between
sexual excitement and guilt into one between frail idealization and
overwhelming aggression, thus creating a truly traumatic situation in
which libidinal and aggressive strivings can no longer be differentiated.
Here, the unconscious identification of the victim with the victimizer
may confuse the clinical picture. The repetition compulsion of incest
victims who transform their later sexual lives into a chain of traumato-
philic experiences often makes it difficult to differentiate when the
patient is the victim or the victimizer?
It is important to distinguish what might have been experienced
originally as a traumatic situation in which a child is raped from the
retrospective transformation of a memory of incest into a traumatic
situation under the impact of later superego developments. When incest
and sexual abuse occur in the context of clearly violent aggressive
behavior, the sadomasochistic aspects of sexual excitement transform
the experience into one that is experienced as even more violently
destructive. The reason is that the potential for an erotic response to
painful stimuli is recruited into the service of aggression, in contrast to
the normal situation in which erotic excitement may absorb aggression
as part of its affective implications.
Symbolically, sexual abuse destroys the child's confidence in the
loving relationship with the caregiver, and evokes an experiencing of
aggressive affects that, under the impact of the associated guilt (because
the sexual invasion violates essential superego prohibitions) convinces
710 KERNBERG

the victim of his or her devastating badness. At the same time, insofar
as the sexually abusive other represents a parental image ordinarily
introjected into superego prohibitions and demands, a disorganization
of early superego structures may occur that transforms the experience
of an orderly world in which good and bad, what is permitted and
what is forbidden, into a world of terror and moral unpredictability.
Paraphrasing Fairbairn (1943), it is the experience of living in the world
of Satan rather than in the world of a cruel God.
In other words, severe superego distortion destroys further the
possibility of isolating and working through the sexually traumatic
experiences into an eventual ego integration that protects essential func-
tions of ego identity and facilitates superego integration. Under these
circumstances, primitive splitting operations are reinforced, a regression
from depressive to paranoid defensive mechanisms ensues,8 and a con-
solidation of a borderline personality organization may evolve with the
typical dominance of aggressive affect, dissociated internalized object
relations, and the syndrome of identity diffusion.
To the contrary, a retrospective transformation of an early memory
of sexual abuse into a traumatic situation permits the activation of severe
guilt feelings, and a potential mourning process over the loss of the
idealized parental image. Under these circumstances, the experience of
severe guilt may dominate over the experience of diffuse aggression,
and a mourning reaction over the loss of the good object may dominate
over the fear and hatred of the abusing object.
Patients with experiences of unmitigated physical or sexual abuse
present relatively fewer manifestations of unconscious guilt, and a domi-
nance of intense reactions of rage and hatred. Unconsciously identifying
with both victim and victimizer, they tend to reproduce the traumatic
relationship again and again in an effort to free themselves from their
uncontrollable hatred and to overcome the fear of being a victim by
unconsciously identifying with the aggressor. The degree of superego
distortion or deterioration is reflected in the extent to which antisocial
behavior dominates the clinical picture. Some of these patients present
the syndrome of malignant narcissism, and their prognosis is quite
guarded.
To the contrary, patients in whom there were at least some compen-
sating positive aspects of the relationship with the abusing parental
image, with less distortion in superego structures and more of a retroac-
tive interpretation of the traumatic experience present dominant conflicts
around unconscious guilt and unresolved mourning processes relating
to the parental objects.
In the clinical situation, all incest victims reactivate identification
with the dyad of victim and victimizer and unconsciously attempt to
reproduce the traumatic situation in order to undo it and to recover the
ideal object behind the persecutor. In addition, the repetition compulsion
allows the expression of the desire for revenge, the rationalization of
hatred of the seducer, and a potential sexualization of the hatred in the
form of efforts to seduce the seducer. The psychoanalytic treatment
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 711

of incest victims who had sexual experiences with former therapists

sometimes repeats these experiences with uncanny clarity. The uncon-
scious envy of the present therapist not involved in the chaotic mixture
of hatred and sexuality, aggression and perversity in which the patient
experiences him- or herself to be hopelessly mired is another source of
negative therapeutic reactions.

TREATMENT

I now present a few considerations regarding the treatment of

patients whose transferences are dominated by hatred. It is important,
first of all, to establish a rigorous, flexible, yet firm frame for the thera-
peutic relationship that controls life-threatening and treatment-threaten-
ing acting out. The therapist has to experience him- or herself as safe to
be able to analyze the severe regression in the transference. Initial
contract setting for patients with severe suicidal behavior, dangerous
sexual behavior, other types of destructiveness and self-destructiveness
may provide such a structure, which facilitates the expression of hatred
in the transference rather than into the alternative channels of somatiza-
tion or acting out. This contract provides a safe "space" within which the
patient may then have the freedom to enact and explore the unconscious
identification with victim and victimizer in the transference, and be able
to acquire full awareness of his or her unconscious identification with
both victim and victimizer, thus gradually becoming able to assume full
awareness of and responsibility for these conflicting identifications. As
Andfe Green5 has pointed out, it is extremely important to facilitate the
transformation of somatization and acting out into psychic experience
in the transference.
In the case of severe distortion of verbal communication, psycho-
pathic transferences need to be resolved first; that is, deceptiveness in
the communication is reduced sufficiently for the underlying paranoid
tendencies in the transference to emerge more clearly, thus facilitating
their working through. The therapist should remain alert to the activa-
tion of a victim-victimizer paradigm, analyzing in the transference this
dyadic relationship as it is repeated, again and again, with role reversals;
that is, with the patient's unconscious identification in the transference
with both victim and victimizer, as well as projecting, at different mo-
ments, these representations onto the therapist. This means that the
therapist has to be extremely alert to his or her countertransference:
Painful experiences of him- or herself as victim, and the temptation to
act out strong aggressive countertransference reactions as victimizer
may alternate.
The most typical danger in the treatment of patients who have been
victims of severe past traumas is to avoid the analysis of the patient's
identification with the aggressor, treating the patient consistently as
victim, thus facilitating the projection of the aggressor role outside
the transference. This perpetuates an idealized transference situation
712 KERNBERG

dissociated from the basic dyad controlled by hatred, and thus perpetu-
ates the patient's psychopathology. To treat the patient as a responsible
adult rather than a perennial victim will include the painful need for
the patient to become aware how, in reaction to the trauma, he or she
identified with the persecutor, perhaps the most painful aspect of the
treatment of severely traumatized patients.
In very severe cases, self-directed aggression and aggression toward
others may combine, such as with the patient who, because the therapist
did not fulfill her expectations for discharging her from the hospital
when she expected it, cut the arteries of her forearms in his presence,
and, when help arrived to take care of her profuse bleeding, physically
attacked those who were attempting to help her. Another patient, who
hurt her vagina with knives and blunt objects, initiated such behavior
after feeling that she was being treated unfairly by authorities at work
or by her therapist, thus unconsciously attempting to reverse the perse-
cutory situation by becoming her own torturer, and sexualizing the
attack in the process. In less severe cases, discrete self-cutting may have
a more pronounced sexual meaning, reflecting the activation of the
normal capacity for experiencing erotic pleasure with discrete pain in
an effort symbolically to maintain a needed object relationship that is
basically frustrating. In these cases, profound sexualized sadomasochis-
tic fantasies eventually are expressed and may be worked through in
the transference.
In short, the psychodynamics of severe sexual trauma include the
transformation of the normal function of erotic arousal to absorb aggres-
sion into its opposite- the deterioration of the erotic response under the
dominance of aggression and the development of "perversity"; that is,
an unconscious and often also conscious transformation of sensual
arousal into an instrument of aggression. Together with the incapacity
to link tenderness and sexual intimacy, there develops a combination of
severe sexual inhibition, hatred, and further interference with the capac-
ity for tenderness. The more the sexual abuse from a parental figure is
experienced as intrinsically aggressive, without compensating protective,
stable loving relationships with any parental object, the more there is a
risk of severe superego distortion interfering with the normal protective
superego functions, and a reinforcement of primitive splitting into unre-
alistically idealized and persecutory internalized object relations. In a
worst case scenario, an identification with the aggressor is the only
alternative to fantasized, permanent victimization. Primitive dissociative
reactions, to the extent of the development of multiple personality disor-
der, reflect the extreme of such primitive splitting mechanisms, and the
effort to enact mutually dissociated, idealized, and persecutory relation-
ships with extreme barriers between them.
It is important to keep in mind that, under ordinary circumstances,
traumatic memories originally recovered in the treatment situation that
provoke a post-traumatic stress syndrome gradually will be resolved
and worked through as part of the mourning process involved in the
psychotherapeutic exploration of the transference. Chronic "revenge"
 AGGRESSION, TRAUMA, AND HATRED IN BORDERLINE PATIENTS 713

syndromes, the secondary exploitation of victimization, as well as end-

lessly repeated re-enactment of traumatic experiences should alert the
therapist to the possibility of secondary gain of the illness and an acting
out of the identification with the aggressor split off from the analysis of
the segment of victimization. The possibility that unconscious envy,
another dominant affect of primitive aggression, may complicate the
relationship with the therapist also needs to be kept in mind.
There are limits, I believe, in the treatment of conditions derived
from severe hatred. The most fundamental one, in my experience, is
that of the severe deterioration or absence of superego functions that
we find in antisocial personalities in a strict sense, a diagnosis that,
unfortunately, has been overextended in DSM-III and DSM-IV. Patients
with a syndrome of malignant narcissism, that is, narcissistic personality
structures with antisocial tendencies, paranoid trends, and severe forms
of self-directed or other-directed ego-syntonic aggression, constitute
presently the limit of what I believe can be reached with analytically
oriented approaches. The entire area of characterologically anchored
hatred is becoming more important as severely disadvantaged social
groups, inner-city populations exposed to chronic violence, trauma, ra-
cial bias, and, above all, severe disorganization of family life present a
frightening, almost pure culture of the preconditions for hatred as struc-
tured rage. Therefore, while accepting our limitations as clinicians, it
seems to me of great interest that we continue attempting to expand the
boundaries of reachable cases, a still unfinished task.

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