BOOK REVIEWS

BORDERLINE CONDITIONS AND PATHOLOGICAL NARCISSISM. By 0th

Kernberg. New York: Aronson, 1975, 361 pp., $25.00.

OBJECTRELATIONS THEORY A N D CLINICALPSYCHOANALYSIS. By Otto

Kernberg. New York: Aronson, 1976, 299 pp., $25.00.

In the ubiquitous appearance of secondary revision as related to the

dream work we see a universal aspect of our need to try to create a
unified gestalt out of disparate and possibly unrelated manifest dream
elements. It is also in the nature of our daily work as analysts that we
are ever alert for underlying themes and dynamics in the loosely
related free associative material of our patients. Some of us tolerate
ambiguity better than others, and at times all of us must tolerate it
because we simply lack the data or the necessary synthetic powers to
achieve the desired unification. Those fortunate enough to possess
the talent for integrative clarity are able to provide major theoretical
and clinical insights to the rest of us.
One cannot read Otto Kernberg's two books without recogniz-
ing one is in the presence of a very fine intellect who has sifted an
enormous quantity of clinical and theoretical material. There must
also be a tremendous need for integration and certainty powering this
drive not only to organize a very complex constellation of clinical
manifestations such as are reflected in the borderline conditions and
narcissism, but then to take on the even broader and more difficult
chore of unifying them under the umbrella of an object relations
theory.
I shall attempt to summarize this herculean effort and, if possi-
ble, to objectively evaluate the overall result in terms of its positive
achievements as well as areas that may be open to question or even
disagreement.
T o start with, there would seem to be formal aspects of these
books and their organization that might detract from their readability
or literary merits which are yet quite secondary to the scientific value

22 1

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222 BOOK SECTION

of the ideas under scrutiny. I a m referring to the fact that both

books, with only a few exceptions, consist of papers that were writ-
ten and published over a period of some ten years and presented in-
dividually. This has led to chapters that often contain duplications of
material that appeared in previous chapters, sometimes militating
against a smooth flow of ideas. Yet, because of the complexity of
many of the issues being discussed, even this repetition carries a
positive value. T h e same is true on a larger scale, i.e., aspects of the
material from one book reappear and are. intertwined with theories
in the other; conceivably the two volumes might have appeared in
one pruned version.
Certainly, the first book deals with what has formerly been a
wastebasket full of the symptoms and clinical problems from the
most vexing and confusing segment of the patient population that we
as analysts have dealt with in widening the scope of our psychoana-
lytic therapeutic efforts. As recently as 1978,Meissner summarized
some 84 articles on the borderline personality, concluding: “Just as
we may have to think in terms of a variety of forms of schizophrenia,
or a variety of forms of homosexuality, so, too, we may in fact be
dealing with a variety of forms of borderline pathology which resists
our attempts at integral theoretical formulation.” It is not difficult to
understand the vast following of anyone who seems to offer a solid
and relatively straight road through this wilderness, beset as it is
with fantastic transference manifestations that Stone (1954) once
referred to as “powerful tormented and tormenting transference” and
the guilt-laden countertransferences they so often evoke.
In his study of borderline conditions, Kernberg was struck by
the presence of a phenomenon which he was ultimately to see as the
essential defensive operation of such patients. This is the mechanism
he called splitting- the side-by-side or alternate appearance of op-
.posing ego states or “the active process of keeping apart introjections
and identifications of opposite quality” (I shall come back to this
term and his special use of it when discussing his more general object
relations theory). H e saw this so regularly that it led to the search for
other recurring features and to the ultimate conviction that the
borderline Personality, while often presenting a chaotic, impulse-
ridden picture, still represented on closer examination ‘a specific,
stable, pathological personality organization” unique and well
demarcated from both neurosis and psychosis.
Because of the presence of excessive amounts of aggressive in-
stinctual drive-due either to constitutional instinctual forces, a
weak ego unable to tolerate much anxiety, or external trauma of

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 BOOK REVIEWS 223

considerable intensity from the parental sources, the patient is

unable to integrate self- and object images of positive and negative
valences leading to the existence of all-good or all-bad self- and ob-
ject images. The borderline condition is differentiated from the
psychosis in that in the former there is some differentiation of self
from object, even though it does not extend to the stage of total in-
tegration .of self-representations and object representations. For the
psychotic there is a fusion o r refusion of the self- and object represen-
tations.
The splitting that begins as a weakness of ego function ultimate-
ly is actively used defensively to protect the all-good self and objects
from being destroyed by the all-bad self and objects. It is joined in its
defensive work by what Kernberg calls other low-level defensive
operations such as projection, projective identifications, omnipo-
tence, primitive idealization, denial, and devaluation, in contrast to
repression and its allied defensive operations that are of higher level
and more typical of the neuroses. These low-level defenses are
associated with “nonspecific ego weaknesses” such as lack of impulse
control, inability to tolerate anxiety, or to use sublimation as a
significant channel for gratification and discharge. Because of the in-
ability to fuse or integrate aggressive and libidinally colored object
relations, there is interference with ego and superego development
as well as the perpetuation of primitive superego introjects of both
sadistic and overly idealized types.
It is as a n expansion of these ideas that Kernberg then took on
the much more ambitious project of attempting to revise the classifi-
cation of character pathology so that it would lend itself more readily
to accurate diagnosis, prognosis, and treatment. T o do this, he
broke down character pathology according to pathology in the ego
and superego structures, pathology of internalized object relations,
and pathology in the development of libidinal and aggressive drive
derivatives. Each of these was in turn subdivided into categories of
higher-level, intermediate-level, and lower-level pathological func-
tioning. They were then recombined so that instinctual develop-
ment, superego development, defensive ego operations, and the
vicissitudes of object relations were now compared at higher-level,
intermediate-level and lower-level organization of character
pathology. All of this gives the impression of a precise steplike march
from one level of clinical pathological organization to the next. The
precision, however, is more apparent than real, according to my
own clinical experience. In a similar chapter in the book on object
relations, I felt the implication of our being able to go from detailed

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structural formulations to normal and pathological hierarchies,

which in turn lent themselves to computerlike diagnoses, prognoses,
defensive operations, and then to matching and exact treatment
modalities, was again an unrealistic projection of the current state of
our theoretical and clinical knowledge. However, in spite of mild
disclaimers, this is the main thrust and implication one is left with in
these related chapters of both books.
While it must be amply clear that I have important reservations
about our ability to organize all the phenomena currently included
under the rubric of borderline conditions in so precise and uniform a
theoretical and clinical framework, I have much fewer reservations
and indeed considerable respect and admiration for Kernberg‘s
clinical contributions to the technical aspects of treating such pa-
tients. He carefully delineates where psychoanalysis, unmodified by
any parameters, can or should not be used; where psychoanalytic
psychotherapy is preferred; when structuring, including periods of
hospitalization, is indicated, and even discusses the use of medica-
tion. T h e early phases of treatment are seen to be loaded with
chaotic primitive transference elements where a great deal of projec-
tion and projective identification are used. Here, he follows Racker
(1957) in describing the ways in which the therapist experiences the
feelings provoked and evoked by the patient. There are both comple-
mentary and concordant identifications, depending on whether the
analyst experiences himself in the role of the patient as the small,
helpless child, or as one of the patient’s objects, a possibly sadistic,
threatening parent. T h e appropriate affects are experienced by the
analyst who, as a proxy for the patient, can feel small, impotent,
worthless, and terrified or as the fantasied object may be washed
over with feelings of disdain, anger, and wishes to impose his will.
What Kernberg adds to the picture (which I feel is a serious deficit in
Kohut) is that the former clearly recognizes that the patient’s projec-
tions of aspects of his primitive self-representations or object
representations may equally represent distorted amalgams of parts
of the self, parts of the object, and early fantasized aspects of both,
that were never true of either. Kernberg then, does not automatical-
ly assume that the markedly sadistic part object projections repre-
‘sent actual childhood objects o r experiences. In fact, it is the
separating out of these primitive transferences and the appropriately
timed interpretations that allow for a n integration of self- and object
representations that gradually enable one to achieve a more accurate
conception of the patient’s actual childhood experiences. I n the treat-
ment of such patients there is a need to address the “here-and-now”

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 BOOK REVIEWS 225

aspects of the transference reactions, leaving for later the genetic

reconstructions. Although during moments of stress there may even
be psychotic transference manifestations, these are usually limited to
the therapeutic setting and are manageable in borderline conditions.
I n spite of this stress on the “here-and-now” aspects of the
transference, there are those who feel Kernberg‘s clinical vignettes
still show evidence of premature transference interpretations. In
borderline patients with especially fragile ego organization these
may even provoke psychotic defenses or flights into fantasy more
removed from their already tenuous hold on reality.
Kernberi describes, but does not subscribe to the use of the
totalists’ definition of countertransference, where all the therapist’s
reactions to the patient are considered to be countertransference. If
the therapist is not very stable in his own self-organization, or has
some unresolved problems in the area of narcissism, his own coun-
tertransference is more apt to be stirred up. However, what is cor-
rectly stressed is that these patients can evoke intense feelings that
are not a primary reflection of the therapist’s own problems. Kern-
berg, unlike Kohut, does not imply there has been an “empathic
failure” when the therapist is not immediately able to sort out the
fragmented self-object segments. It is undoubtedly in keeping with
the stress on the presence of such primitive, structural pathology that
the picture of the therapy that emerges is a form of nonverbal, affec-
tive communication by the patient similarly experienced in an em-
pathic form by the therapist, or what I once suggested was a form of
introjective identification on his part.’ It is only in formulating the
ensuing interpretation that secondary process seems to enter the pic-
ture. It is inconceivable to me that Kernberg or anyone else treating
borderline patients does not also use his secondary-process activities
more in assessing the associated material, the special metaphors
used by each patient, his acting in the transference, and dream
material. In the rich clinical examples cited, there was a not a sinile
dream reported. Further, there was no interpretation that did not
seem to stem primarily from the analyst’s own affective, empathic
identification with patient and his primitive part objects. I feel that
one of the basic distinctions between the neurotic and the borderline

* I thought I originated this term until I recently came across evidence that
Paula Heiman (1966) had already used it. We differed only in her seeing this as part
of the analyst‘s countertransference, while I feel it is only if we react to the feelings
being evoked in a defensive fashion that the essentially communicative, adaptive
aspect of the introjective identification is lost, and countertransferencereactions take
over.

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226 BOOK SECTION

patient in therapy is that in the former, the therapist more actively

initiates the empathic identifications that periodically illuminate the
transference, while in the latter, it is the patient who tends to evoke
and provoke us, especially via projective identifications, into ex-
perien’cing the introjective identifications that follow.* Yet, this is
not the level on which we constantly and exclusively relate. Thus
Loewald (1978), in dealing with the treatment of patients with nar-
cissistic disorders, also believes the therapist “must rely on his ability
to reactivate such archaic levels of mental functioning within
himself, at given moments during treatment” (italics mine). T h e im-
plication here is of a temporary, periodic need to suspend one’s ego
boundaries comparable to the state existing between the good-
enough mother and child in their symbiotic stage.
It is the last three chapters of his book on Borderline Condilions and
Pathological Narcissism that Kernberg devotes to delineating his
schema of normal and pathological narcissism, the treatment of the
latter condition, and especially to how his ideas differ from those of
Kohut. While pathological narcissism is included as a segment of the
borderline conditions, and some narcissistic personalities tend to
show a greater preponderance of the general borderline symp-
tornatology, there is stiIl a subgroup which Kernberg and others feel
show special characteristics and, hence, warrant special considera-
tion. Because these latter patients have a relatively integrated self-
representation, however pathological, they sometimes seem to func-
tion well socially and professionally, especially if they have unique
intellectual abilities or artistic talent. Their problems are in the
realm of their internalized object relations.
Where Kohut sees pathological narcissism stemming from fixa-
tions along the path of normal narcissistic development, Kernberg
sees it as reflecting the development of a special pathological struc-
ture, the “integrated grandiose self.” While admitting that he bor-
rowed the term from Kohut, he uses it quite differently. Kernberg‘s
grandiose self is a condensation of aspects of the real self (outstand-
ing positive features such as high intelligence or physical beauty),
the ideal self, and the ideal object. The presence of the ideal self
lends itself to fantasies of omnipotence, while the idealized object
allows primitive idealization of objects as long as they are really ex-
* Both because of their possible Kleinian implications and the difficulty in
precisely defining what is meant by both projective and introjective identifications,
the reviewer recognizes there may be more felicitous terms for describing these com-
plex and as yet poorly understood interactions between patient and therapist, even
though the clinical phenomena described are well documented.

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 BOOK REVIEWS 227

tensions of the self. Thus, when a narcissistic patient temporarily

idealizes his therapist, he is still relating one aspect of his self with
another projected aspect of self temporarily residing in the therapist.
This grandiose self is essentially seen as a defense against intense
oral envy and rage due to excessive oral-aggressive drive derivatives
and/or frustrating, unempathic nurturing. The presence of a n in-
tegrated grandiose self helps to protect such patients against erup-
tions of narcissistic rage which would totally destroy their objects
and end forever any chance of achieving loving, dependent gratifica-
tion. T h e envy is also protected against and denied via the
mechanisms of devaluation, omnipotent control, or narcissistic
withdrawal. While they may relate to objects socially, it is their in-
ternalized object relations that are all but destroyed, and the incor-
poration of the ideal self and ideal object into the grandiose self leads
to defective superego integration as well. With this stress on the
presence of a pathological structure, and the underlying oral-
aggressive drive derivatives, Kernberg‘s therapeutic approach also
differs from Kohut’s in stressing the need to deal interpretively with
the defensive uses of the grandiose self and then going on to actively
deal with the negative transferences related to the oral envy and
rage. Although the oral conflict related to envy is stressed, it could
be objected that the grandiose self might equally be seen as a defense
against narcissistic humiliation as trauma from an unempathic
parent during the rapprochement crisis. This in turn would require
a different therapeutic focus.
I n a panel “Meet the Author” before the American Psychoana-
lytic Association in December of 1976, which I chaired, and where
Otto Kernberg participated in the discussiqn of his book on border-
line conditions, both Leo Rangell and Kenneth Calder (the reviewer-
discussants) had many positive reactions to Kernberg‘s formulations
but could not agree that the specifically delineated grandiose self
regularly appeared in the pathology of narcissistic personalities.
Calder, in addition, had questions about the regular occurrence of
splitting in these conditions, and even wondered if the phenomenon
could not be better understood using the concepts of isolation and
ambivalence. Rangell felt that fixation was emphasized over regres-
sion. Further, he made clear his feeling that splitting was not
diagnostic of the borderline personality nor pathognomonic of it,
since it appeared in many other clinical constellations. H e also saw
oedipal conflicts, and especially castration anxiety, playing a much
greater role than was here acknowledged. In this regard, too, it
might be cited that Mahler refers to castration anxiety already exist-

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228 BOOK SECTION

ing in the second half of the second year in such a way as to interfere
with sound integration of self-representations and libidinally
cathected idcntificatory processes (Mahler et a]., 1975, p. 119).
These were seen as a narcissistic blow to the little girl and a great
danger to the little boy's body integrity. I n my own clinical experi-
ence, a vastly underrated and unreported phenomenon is the inten-
sity of the narcissistic trauma resulting from the young child's in-
ability to successfully compete in the oedipal rivalry. If this occurs in
a boy who was especially cherished in the symbiotic and pregenital
stages by a mother whose own narcissistic needs were enhanced by
her male child, there is often a massive retreat to this earlier phase
with characterological investment in denying any unwanted aspects
of reality, while actively trying to re-establish a world where they are
still the narcissistic center of their self-object universe. In the same
panel, a very cogent comment was made from the floor by Harold
Blum. H e saw it as essential that the differences resulting from struc-
tural deficits be delineated from the effects of intrapsychic conflict
alone. Thus, while Kernberg heavily emphasized conflict and
especially preoedipal oral-sadistic conflict, the outcome of treatment
and the very nature of the therapeutic modality indicated might be
most affected by a n aFpreciation of the specific ego fragility andlor
deficiencies. This does not conflict with my own feeling that both
structural defects and conflicts must be carefully evaluated, since the
specific nature of the early deficits must affect how successfully any
given individual copes with any given intrapsychic conflict.
This leads me to a rather surprising omission in Kernberg's
delineation of the borderline conditions. I say surprising only
because he has been remarkably thorough in most aspects of his
review of the subject. A number of writers (Blum, 1974; Geleerd,
1958; Mahler, 1971; Weil, 1953) have stressed the importance of
developmental aspects in the adult borderline patient. No mention is
made of childhood borderline symptoms or the relation between
these symptoms and the adult syndrome. While Kernberg places the
essential pathology as originating during the rapprochement phase
in Mahlex's formulation, he nowhere specifically deals with symp-
toms arising from problems related to separation anxiety or the
rapprochement crisis. Perhaps it is because he must maintain the
picture of a relatively stable self-organization being present that the
problems of separation-individuation and of establishing or main-
taining object constancy are conspicuously absent in his formula-
tions. Yet it is the very panic about separation, as Blum has
reiterated, that accounts for the frequency with which borderline

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 BOOK REVIEWS 229

patients are unable to tolerate total termination and “may require

continuing periods of therapeutic support to maintain ego integra-
tion.”
It is time now to turn our attention more exclusively to Kern-
berg‘s book on object relations theory. Perhaps because Kernberg is
so scrupulous in giving credit to those whose ideas have contributed
to his own ultimate formulations, he might even be accused by some
of presenting essentially derivative ideas. I would, however, deem
this to be unwarranted and unfair, because it is the way that Kern-
berg weaves together the pieces, and the unique finished product on
which he deserves to be judged. If there were any tendency toward
theoretical leakage, it would be most likely to occur at the point of
union of concepts derived from these differing theoretical orienta-
tions. Among the many writers and theoreticians who have con-
tributed building blocks to the finished structures are Bion, Erikson,
Fairbairn, Guntrip, Jacobson, Klein, Mahler, Rice, Sutherland,
Ticho, van der Waals, and Winnicott, to name those most often
mentioned. Although it is rare that Melanie Klein is mentioned
without some stress on their points of difference, there is no question
in my mind that her ideas infiltrate many aspects of the finished pro-
duct in the form of splitting, projective identification, the depressive
position, etc.
While the topic of object relations theory may be second only in
volume in recent publications to those dealing with some aspect of
self, there is much difference of opinion about what it represents and
whether it supplants drive theory, or can in any way incorporate
aspects of it. One has only to read the papers from the panel on ob-
ject relations (December, 1977) that took up most of Volume 27,
1979 of the Journal of the American Psychoanalytic Association, or
Spruiell’s excellent summary of that panel (Volume 26, 1978) to
realize how diverse are the positions of various analysts on this issue.
Near the end of his summary, Spruiell expressed this as follows: “In
the face of a general consensus about the importance of studies of
early life and the importance of early developmental events to those
of later periods, what divided the panel were attitudes toward basic
concepts of drive, the relationship of experiential events to the
development of nonexperiential structure, the problems of concep-
tualizing ‘self and ‘object,’ and, finally, the basic strategies used in
approaching the subject of object relations.”
As has been noted before, Kernberg was especially impressed
by what he saw as the regular appearance of what he calls “splitting“
in his borderline patients. This led not only to his conceptions of bor-

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230 BOOK SECTION

derline pathology, but ultimately toward the broader outline of what

might almost be called a unified field theory of object relations. The
successive activation of “contradictory ego states” led him to wonder
about the ego’s apparent “predisposition” toward this defensive
operation and later to the question of the relations between splitting
and repression. The field of his interest gradually broadened to in-
clude the question of the relation between splitting or “the split-off
ego states and the more general mechanisms of introjection and
identification.” His answers may be summarized as follows. Via the
autonomous processes of memory traces and perception, aspects of
the earliest mother-child field, o r unity, in the autistic and symbiotic
stages, gain representation in units that at first contain undifferen-
tiated aspects of self and object linked by an affective valence that is
positive or negative, i.e., having a subjective quality. These first
units do not differentiate self from object, nor inner from outer. It is
important here to introduce the mechanisms and types of internali-
zation that gradually are involved in building up these experiences
into their final structural forms. Here we are presented with a n in-
creasingly complex series that starts with introjection, proceeds to
identifications, and finishes with Erikson’s concept of ego identity.
Identifications differ from the most primitive internalizations, or in-
trojections, insofar as they already contain elements of the role
played by both the object and the subject-whether one mothers or
is mothered. Clearly, the last and most complex state, ego identity,
is achieved only after there has been a sorting out and differentiation
of the self and object introjections into stable self- and object
representations that includes a n ability to integrate both positively
and negatively charged introjections of self- or of object representa-
tions.
Kernberg already calls the earlier sorting of positively and
negatively charged valences a splitting operation by the ego, albeit a
normal one, reflective of the primitive ego’s inability to integrate or
neutralize aggressively and libidinally charged instinctual deriva-
tives in the affects of the earliest introjections. H e places the initial
appearance of this splitting as occurring by the third month of life,
and beginning to fade by the end of the first year. It is this same
splitting which later is used defensively to keep apart “all-good” from
“all-bad” introjects. He states, “The psychic derivatives of drives, as
they enter into object relations, are integrated into identifications as
well as into introjections, and, in more general terms, it is suggested
that the original penetration of the psychic apparatus with drive de-
rivatives is achieved through these internalization processes” (p. 3 1).

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 BOOK REVIEWS 23 1

But, as will be seen later, one of the most difficult tasks Kernberg
faced was to be specific as to the exact relation between drives and
affects, and the primacy of these in relation to the basic units of in-
ternalized self and object. Did object relations organize drives and
affects, or vice versa?
Kernberg, in his thorough manner, traces the integration of in-
creasingly complex and stable self- and object representations into
their ultimate ego and superego structures, defining along the way
how idealized self- and idealized object representations go into the
development of the ego-ideal aspect of the superego, and how the
component identifications in these structures are gradually Kdeper-
sonified” or separated off from their object origins as the psychic
structures become more stable.
It would be impossible, and even fruitless, in this review to
detail the way Kernberg uses this schema to outline both normal and
pathological development and then parlays it into a psychoanalytic
classification of character pathology with important diagnostic,
prognostic, and therapeutic implications. This is the ultimate edifice
he erects, so it would seem important here to examine some of the
constituent parts as a way of arriving a t some conclusions about the
solidity of the entire structure.
Because splitting is central to many of his concepts, it will be
discussed first. He does insist that it is indeed the essential
mechanism of the ego, before it is sufficiently integrated to be able
to use repression to relegate unacceptable, anxiety-laden or guilt-
ridden self-object-affect unit introjections into the id, which is in the
process of differentiating out of the undifferentiated ego-id matrix.
So it is the defense par excellence of the infant and, later, the
primary defense of the borderline conditions, just as repression is
active only in the child with more differentiated, integrated and
more stable psychic structure, and is the primary defensive opera-
tion in the neuroses. Although he cites Freud several times as con-
tributing to his notions of splitting, it is my impression that Kern-
berg owes much more to Klein and to his own idiosyncratic expan-
sion of her ideas than to Freud. Before elaborating on this, I might
mention that when Paula Heiman (1966) discussed his paper,
“Structural Derivatives of Object Relations” with special reference
to his clinical material where patients were presented as having
“alternating ego states” as a result of splitting, she stated, “In my view
the defensive process consists of repression combined with other
mechanisms, and above all, a shift of energic cathexis.” It is my con-
tention that Freud (1923, 1927, 1940a, 1940b) was talking of some-

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232 BOOK SECTION

thing quite different when he. discussed splitting. Actually, it is

clear in all his references that the defensive process he was describ-
ing was “disavowal,” not splitting, and that it was only the eJect of
disavowal on the ego that he referred to as a splitting of the ego.
Further, he was talking about a mechanism he felt paralleled
repression and co-existed with it at. a time when the ego was
already functioning as a stable structure. Freud first noted the
tendency toward disavowal in relation to some intensely traumatic
situations, such as the awareness of the absence of a penis in
women or girls, o r the early death of a father. Thus he (1923) states
“We know how children dream their first impressions of the
absence of a penis. They disavow the fact and believe that they do
see a penis all the same.” H e adds, “They gloss over the contradic-
tion between observation and pre-conception” (p. 123). Later
Freud (1927) speaks of two young men whose fathers had died and
experienced this as so traumatic that they “scotomized” the ex-
perience. “Thus, a piece of reality which was undoubtedly impor-
tant had been disavowed by the ego, just as the unwelcome fact of
women’s castration is disavowed in fetishists.” It was not opposing
ego states that were represented but ”The attitude which fitted in
with the wish and the attitude which fitted in with reality existed
side by side” (p. 155). In the splitting as cited by Kernberg, neither
of the alternating o r antagonistic states of the patient need to repre-
sent reality. Thus narcissistic patients are described who alternately
show attitudes of haughty omnipotence or shy worthlessness. I n
reviewing what he found in fetishists, Freud (1940a) first states in
regard to their two contrary premises, “The two attitudes persist
side by side throughout their lives without influencing each other.
Here is what may rightly be called a splitting of the ego” (p. 203).
But further along, he elaborates, “Let us return to our thesis that
the childish ego under the domination of the real world, gets rid of
undesirable instinctual demands by what are called repressions.
We will now supplement this by further asserting that, during the
same period of L$e [italics added] the ego often enough finds itself in
the position of fending off some demand from the external world
which it feels distressing and that this is effected by means of a
disavowal of the perceptions which bring to knowledge this demand
from reality. Disavowals of this kind occur often and not only with
fetishists.. .” (pp. 203-204). We must conclude then, that if a pro-
cess of splitting such as postulated by Kernberg does indeed exist,
separate from, and earlier than, repression, it is at least quite
different from what Freud was describing. .

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 BOOK REVIEWS 233

T h e chapter most difficult for me to follow and to integrate with

ideas he has expressed in other chapters is the one on “Instincts,
Affects, and Object Relations.” O n reading that chapter and harking
back to other references to instincts, drives, and affects, it was
difficult for me to follow which organized which, and whether object
relations were organized by affects or vice versa. These are par-
tjcularly troublesome and relevant issues, since some of the earliest
adherents of object relations theory seemed to come to it out of a
wish to exclude drive theory from any significant role in psychic
development and structure. There are times when the statements
made by Kernberg, however, would seem to offer equal validity for
him to entitle his book and his theory as an “affect theory” of develop-
ment rather than a n “object relations theory.” I believe I can best
illustrate my own confusion and perhaps the shifting valences of
Kernberg‘s view, by quoting directly some of the references that oc-
cur at different points in his Objeci Relations Theory and Clinical Psycho-
analysis: “I propose that the units of internalized object relations
constitute subsystems on the basis of which both drives and the
overall psychic structures of ego, superego, and id are organized as
integrating systems.” Here, clearly, the primacy is given to inter-
nalized object relations. I n a sentence or two later the units of inter-
nalized object relations are confirmed as an “integrating system” for,
among other things, “affect dispositions.” Yet he then says, “A
general implication is that instincts in the human being develop
gradually out of the assembly of these ‘building blocks,’ so that the
series of pleasurable affect-determined units and the series of
unpleasurable affect-determined units gradually evolve into the
libidinally invested and aggressively invested constellations of
psychic drive systems- that is, into libido and aggression, respec-
tively, as the two major psychological drives. I n other words, affects
are at first primary organizers of instinctive components. . .” (p. 87).
In this instance affects seem to be a necessary forerunner and
organizer of drives or instinctive components and constitute the
“general intrapsychic motivational systems.” This is put quite suc-
cinctly later (p. 104) as, “Affect states first determine the integration
of both internalized object relations and the overall drive systems. . .”
A slightly different version occurs next (p. 109) where he speaks of
libido and aggression arising “out of the undifferentiated matrix
common to the ego and the id. These two intrapsychic drives are
organized under the influence of the developing internalized object
relations which, in turn, are integrated (starting from the original
units described) under the organizing influence of affects.” Now we

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234 BOOK SECTION

have affects integrating object relations which in turn organize

drives. Similarly, Kernberg says (p. 114), “From a different view-
point, one may say that affects organize internalized object relations
into the overall structures of the mind and, simultaneously, organize
aggression and libido as the major drives.” Certainly, this would
seem to make affects the essential organizers and worthy of having
the theory named after them. However, if we go back to the first
chapter of this book (p. 29) we get a different impression of affects
wherein “primitive affect states representing drive derivatives” might
suggest that affects are just psychic representations of the drives
which themselves are still the organizing or integrating force. A
paragraph on the next page would seem to reinforce this under-
standing.
T h e affective coloring of the introjection is an essential
aspect of it and represents the active valence of the introjection,
which determines the fusion and organization of introjections
of similar valences. Thus, introjections taking place under the
positive valence of libidinal instinctual gratification, as in loving
mother-child contact, tend to fuse and become organized in
what has been called somewhat loosely but suggestively “the
good internal object.” Introjections taking place under the
negative valence of aggressive drive derivatives tend to fuse with
similar negative valence introjections and become organized in
the “bad internal objects” [p. 301.
Clearly, there exists a confusion in the instances cited between
the varying roles and relationships of instincts, affects, and object
relations. I n fairness to Kernberg, the last paragraph cited was part
of the paper he originally presented in 1965, while the earlier quota-
tions were essentially from Chapter 3, which stems from a talk in
September 1973, and certainly represents later views. It is unfor-
tunate, and detracts from the clarity, that there is no direct indica-
tion of how his thinking evolved and hence altered earlier versions.
T h e last three chapters of his book on object relations may not
have the same broad significance as the more general concepts
developed in the earlier sections; yet they do contain important con-
tributions to mature love, to the barriers to falling and remaining in
love, and a very ambitious attempt toward an integrative theory of
hospital treatment. In his chapters on mature and pathological love
relations, he sheds light on why higher-level functioning neurotics
may in fact have greater inhibitions and problems in functioning
sexually than patients with a narcissistic and borderline organization,

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 BOOK REVIEWS 235

who function freely sexually, although with only the most superficial
interest in their objects. The former may be inhibited almost to the
point of total sexual impotence as a result of oedipal guilt, while the
latter have no problems with the mechanics of functioning or of
achieving orgasm because the “libidinal trends have not been inte-
grated with total object relations and hence can be expressed as split-
off, instinctual derivatives at the service of pregenital needs in part-
object relations.”
In his final chapter, Kernberg attempts to integrate the ideas of
Guntrip, Sutherland, Bion, Rice, and others in a fashion that might
allow a fusion of object relations theory, small-group theories, and
systems theories. I feel he is at his best when giving practical sugges-
tions on how to use the various hospital personnel and treatment
modalities in a hospital organized around the understanding of basic
psychoanalytic principles. O n important theoretical positions, I feel
he again runs into opposing principles that are difficult to reconcile.
Thus, a n important dynamic that seems to emerge in group situa-
tions is the earlier and quicker evocation of primitive transference
reactions reflecting earlier and less integrated self, object, and affect
units. Hence, group therapy is considered a positive addition to in-
dividual therapy in mobilizing and presenting for therapeutic inter-
pretation, and hence integration, aspects of early object relations.
This is contrasted with classical psychoanalysis where the evolution
of these early units of object relations emerge only after very pro-
longed analytic work.’While it would seem to suggest the value of
regularly combining group and individual psychoanalytic treatment
to hasten the process, this does not follow because of the new prob-
lems introduced by splitting the transference. In the same way, he
cites Bion’s theory of regressive phenomena occurring in groups
when their “task structure fails” as support for the value of group
therapy in more quickly evoking certain regressive object relations
units, and yet does not see a contradiction in comparing the work of
a group led by a trained and effective group therapist with the work
of groups who manifest regressive phenomena only when “their task
structure fails.”
I hope this review has conveyed not only the areas of my differ-
ing with Otto Kernberg, but also my gratitude for the monumental
integrative task he undertook and the many positive contributions it
contains. His work has stimulated me to highlight and define for
myself the many as yet unresolved metapsychological problems that.
still confront us all, and toward whose successful integration we
must all strive continually. We are all in his debt for his awesome

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236 BOOK SECTION

efforts, even if we must conclude that the goal he reached for, that of
a unified psychoanalytic cosmos, is still beyond his grasp in the cur-
rent state of our knowledge.

REFERENCES

BLUM,H. P. (1974). The borderline childhood of the LVolf Man. J. A m . Pychoanal.

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FREUD, S. (1923). T h e infantile genital organization. S. E., 19.
-(1927). Fetishism. S. E., 21.
-(1940a). An outline of psycho-analysis. S.E., 23.
-(1940b). Splitting of the ego in the process of defence. S.E., 23.
GELEERD, E. (1958). Borderline states in childhood and adolescence. Pychoanal.
Study Child, 13979-295.
HEIMAN, P. (1966). Comments on Dr. Kernberg's paper ["Structural derivatives of
object relations"]. Int. J . Psyhoanal., 47:254-260.
LOEWALD, H . (1978). Instinct theory, object relations and psychic structure for-
mation. J . Amer. Pychoanat. Assn., 26:5-29.
MAIiLER, M. S . (1971). A study of the separation-individuation process and its
possible application to borderline phenomena in the psychoanalytic situation.
Pychoanal. Study Child, 26:403-424.
-PINE, F. & BERGMAN, A. (1975). The PvcholoEical Birth ofthc Human Infant:
+mbiosis and Individuation. New York: Basic Books.
MEISSNER, W. W. (1978). Theoretical assumptions of concepts of the borderline
personality. J. Amer. Pychoanal. A m . , 26:559-598.
RACKER, N. (1957). The meanings and uses of countertransferences. Psychoanal.
Q.,26~303-357.
STONE,L. (1954). T h e widening scope of indications for psychoanalysis. J. Amer.
Pychoanal. Assn., 2:567-594.
WEIL,A. (1953). Certain severe disturbances of ego development in childhood.
Pychoanal. Stdy Child, 8:27 1-287.

Nathan P. Segel, M.D.

Farmington, Mich.

BORDERLINE PERSONALITY DISORDERS: THECONCEPT,THE SYN-

DRohfE, THE'PATIENT. Edited by Pefer Hartocollis. New York: In-
ternational Universities Press, 1977, xiv + 535 pp., $24.95.

There seems to be little doubt that borderline personality disorders

are among the topics most actively debated currently by profes-
sionals in psychoanalytic, psychiatric, and related disciplines. The
International Conference on Borderline Disorders, sponsored by the
Menninger Foundation and the National Institute of Mental Health

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