Clinical Social Work Journal Vol. 27, No.

1, Spring 1999

KERNBERG VERSUS KOHUT: A (CASE) STUDY IN CONTRASTS

Gildo Consolini, MSW

ABSTRACT: In this paper, the main concepts of Otto Kernberg and Heinz Kohuttwo theorists who have greatly influenced clinical social work practice with severely disturbed patientsare presented, and then compared by using a case from the practice of the author. The case illustrates the value of utilizing some of the treatment principles put forward by Kernberg and Kohut without becoming too wedded to either of the overall treatment approaches they have formulated. Some aspects of the manner in which the practitioner determines when the treatment approach needs to be modifiedto avoid the pitfalls of either being too wedded to an approach or too eclecticare discussed as well. KEY WORDS: borderline personality disorder; narcissistic personality disorder; self psychology; countertransference; self-analysis.

For more than two decades the two theorists who have had the greatest influence on psychoanalytic thinking about patients with more severe psychopathologywith the possible exception of Harold Searleshave been Otto Kernberg and Heinz Kohut. Both Kernberg and Kohut applied psychoanalytic theory to the treatment of patients often considered unsuitable for analytic treatment by those working from a classical analytic perspective. However, their conclusions about the etiology and psychic structure of borderline and narcissistic psychopathology, as well as the optimal treatment approach, are very different. Kernberg is considered a conflict theorist, who, like other American object relations theorists, has retained the use of the concept of instinctual drive along with other aspects of Freudian metapsychology; this places Kernberg in the psychoanalytic mainstream. He wrote extensively about both borderline and narcissistic psychopathology. Kohut, on the other hand, made a more radical break with the clas71
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sical tradition; he eventually rejected many classical conceptualizations and, with the help of his followers, developed his concepts about narcissism and the self into its own schoolself psychology. Although Kohut was not optimistic about self psychological treatment of the borderline patient (Kohut & Wolf, 1978) and he focused primarily on the treatment of narcissistic disorders, many analytically oriented clinical social workers and other analytically oriented psychotherapists rely heavily upon self psychological theory and treatment principles in their work with borderline patients. In the first part of this paper, the main concepts of both theorists will be presented and compared. In the second part, a case will be presented which will demonstrate the value of utilizing some of the treatment principles established by these theorists while at the same time attempting to develop an individualized approach attuned to the emotional needs of a rather troubled and difficult patient. As Goldstein (1990, 1995) has indicated, the therapist attempting to help patients with more severe difficulties who is too wedded to any one particular approach runs the risk of misattunement that will destroy any hope for therapeutic benefit. In the final part of the paper some aspects of the manner in which the therapist determines when the treatment approach needs to be altered will be discussed. OTTO KERNBERG Prior to the influence of Kernberg, the symptomatology of the borderline patient was not seen by most analytic writers as the result of a stable pathological structureits transient nature was emphasized and a more supportive treatment approach was generally recommended. Although Frosch (1970) described the borderline patient as a "psychotic character," that is, as someone with a range of modes of ego adaptation and responses to stress that is enduring and predictable, Kernberg went beyond this with his metapsychological explanation. While Stone (1954) recommended a cautious analytic approach using parameters to maintain a positive transference, Kernberg advocated an approach involving the use of traditional analytic methods, such as interpretation and the analyst's abstinence, that is far from cautious. In his 1967 paper and 1975 book, Kernberg established his position that borderline patients have a relatively stable form of psychic organization, a pathological ego structure that is distinctively different than the ego structure found in either neurosis or psychosis. He believes that very early in development the ego must not only learn to distinguish the self from othersthe task of differentiation of self- and other-representationsit must also integrate "affectively polarized" self- and object-

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representations. Unlike the psychotic, the borderline is able to establish boundaries between the self and others (though not without difficulty, especially in the areas of intimate emotional and sexual relations). However, while the neurotic is eventually able to integrate idealized "all good" and devalued "all bad" objects in the course of development, the borderline cannot. In the case of the borderline, self- and object-representations built up under the influence of libidinal drive derivatives are not integrated with self- and object-representations built up under the influence of aggressive drive derivatives by the ego, therefore requiring this ego to rely heavily upon the defense mechanism of splitting. Unlike the neurotic, who relies primarily upon repression to handle ambivalence, the borderline relies primarily upon splitting, reinforced by denial and the use of projective mechanisms. Why is it that the ego of the borderline must rely primarily upon these "primitive" defenses? Although Kernberg uses traditional Freudian energic concepts (drive energy is identified as the force which propels the individual in the direction toward and away from objects) he relied heavily upon the work of object relations theorists who locate the etiology of many forms of psychopathology during a much earlier period of development than did Freud. Kernberg follows Klein (1928, 1939, 1946, 1957) in his view of the importance of splitting and projective identification as the defenses that develop early in life that are relied upon by the borderline, as well as the role of destructive envy in the negative therapeutic reaction. Kernberg's view of the ego's early developmental tasks is similar to that of Fairbairn (1954), who postulated a critical first structural achievement whereby the infant is able to preserve within the ego his or her internalized mother as a whole person from his destructive impulses. By specifically locating the fixation during the rapproachement phase of separation-individuation (Mahler, 1971), Kernberg is able to identify the source of the borderline's unstable self concept, lack of object constancy, overdependence on external objects, and preoedipal influence on the oedipus complex. Kernberg also benefited from the work of Jacobson (1954, 1964), who preceeded him in combining the use of energic concepts with object relations concepts to explain more severe psychopathology. Kernberg recommends an approach to treatment of the borderline patient that appears consistent with his traditional orientation and theoretical formulations; he recommends in most cases an analytic approach (with parameters to provide missing structure to those with especially chaotic lives) that calls primarily for interpretation focusing upon the defensive splitting by the patient within the transference. The analyst is advised to be neutral and abstinent as he confronts the pa-

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tient with his or her destructivenessthe oral aggression of the patient must never be ignored. Kernberg believes the approach he advocates will eventually enable the patient to modify the pathological structure because it will lead to the integration of the split-off affectively-charged self- and object-representations within the ego and the formation of a more benign, less punitive superego (the ego will not be tormented by the more hostile preoedipal superego precursors). Kernberg discourages the use of supportive measures since he believes a supportive approach maintains the pathological structure, leading to an interminable treatment. Kernberg (1970, 1974) believes that these same treatment priniciples apply to the narcissistic personality since his view is that there is an underlying borderline organization to this personality. He views the apparent better social functioning of the narcissist as a superficial adaptation that conceals severely maladaptive behavior stemming from pathological internalized object relations. He also believes there is an underlying borderline organization to other personality syndromes, including schizoid and antisocial character disorders, as well as certain cases of substance abuse, alcoholism, and sexual perversion. HEINZ KOHUT Although trained classically and at one time president of the American Psychoanalytic Association, Kohut eventually so departed from traditional Freudian theory and treatment principles that he and his followers developed a new psychoanalytic schoolself psychology. Following Freud (1914), most analysts believed patients who were unable to develop transferences like those typically seen in cases of neurosis could not be analyzedtheir self-involvement was too great to allow transferences to develop. Kohut (1966, 1971) observed that it was not that narcissistic patients were unable to develop transferences but that they developed different kinds of transferences than did neurotics. These he identified as variations of "selfobject transferences." Whether it was an "idealizing," "mirror," or "twinship" transference that developed, the analyst's task was to use the particular transference as a clue to determine the vital selfobject functions he or she was being asked by the patient to provide, functions not provided by the original selfobjects. Due to their own narcissistic problems, the original selfobjectsin most cases, the parentslacked sufficient empathy to recognize and satisfy the healthy narcissistic needs of these individuals during their childhoods. As a result, a healthy "cohesive self fails to develop. Instead, pathological self states develop, such as the "fragmented" or "overburdened" self.

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Kohut (Kohut & Wolf, 1978) understood the self to be the nuclear core of the personality, an enduring psychological structure in and of itself rather than simply a mental representation within the ego. He identified the "constituents" of the self as 1. the "pole of goals and ambitions" from which emanate basic strivings for power and recognition; 2. the "pole of ideals and standards" which maintains the ideals which guides one through life; and 3. the "arc of tension" between these two poles that activates the basic talents and skills of the individual. These constituents emerge into an enduring self structure through the interplay of inherited factors and the influence of the environment. The self is seen as the center of initiative, the recipient of impressions, and the depository of the ambitions, ideals, and skills of the individual. The patterns of these ambitions, ideals, and skills, the tension between them, the activity generated by them, and the responses of the environment that shape the life of the individual are all experienced as continuous in space and timethis provides the individual with his or her sense of selfhood. The individual comes to experience himself or herself as an independent center of initiative and processor of impressions received from outside the self. As his thinking about the etiology of narcissistic disorders evolved, Kohut ultimately decided he no longer required metapsychological concepts to explain how these disorders develop. He discarded the primary drive nature of aggression, distinguishing between ordinary aggressionwhich he understood to be the healthy forcefulness the cohesive self uses to eliminate an obstacle to a realistic goaland narcissistic rage, an intense reaction to narcissistic injury. Kohut postulated a line of development for narcissism that is distinct from that of object love, in contrast to Freud's progression in development from primary narcissism to mature object love; this formulation enabled him to identify various transformations of narcissism, such as mature humor, creativity, and wisdom. He contrasted the aims of "guilty man" with those of "tragic man," the latter seen as someone striving for fulfillment in endeavors beyond the pleasure-seeking and sublimations made possible through the resolution of neurotic conflict. What makes this quest tragic is that humanity's limitations are inevitably recognized when one pursues these endeavors. Kohut's is a theory of developmental deficit, which therefore calls for the analyst to work in a very different way than the analyst who adheres to the theory which views intrapsychic conflict as the source of psychopathology. For the self psychologist, empathy is not only the principal means of investigation, it is the primary therapeutic instrument. The analyst immerses himself or herself, through his or her empathy, in the patient's subjective experience while seeking to maintain attunement to the selfobject needs of the patient. Although this is considered

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in and of itselfto be therapeutic, the inevitable "empathic failures" on the part of the analyst are also handled in such a way as to promote further healing. First, the analyst must discern how he has injured the patient so that he can intervene in such a way as to restore the selfobject transference. The analyst can then use what he learns through further exploration to connect the current experience of narcissistic injury with the original injury inflicted by the selfobjects during childhood. A more cohesive self is developed as a result of "transmuting internalizations;" the analyst's optimal, nontraumatic frustration of the patient leads to structure formation since the self can now more easily tolerate disappointment. Although the need for selfobjects continues throughout life even in the healthiest of individuals, the self can now perform vital selfobject functions in the absence of the experience with the selfobject. KERNBERG VERSUS KOHUT Kohut believed that the borderline patient often lacks the resilience to benefit from analytic treatment; he believed that in some cases "reconstructing the genesis of both the central vulnerability and the chronic characterological defence" could help the borderline to rely somewhat less upon their maladaptive defenses (Kohut & Wolf, 1978, p. 179). On the other hand, the "significantly more resilient self of the "narcissistic behaviour disorders" and the "narcissistic personality disorders" generally makes an analytic approach possible with these disorders. When Kernberg discusses treatment of narcissistic personalities he is discussing the same patients as does Kohut, as Kernberg himself has indicated (Kernberg, 1974). Both men focus their attention upon the "grandiose self," however, it is hard to believe that the respective explanations of the psychopathology associated with this clinical picture or the treatment approaches advocated could be more different, as has already been indicated. Kernberg sees the emergence of the grandiose self as a pathological development that must be modified to achieve mental health; he believes it is imperative to confront the narcissist with the defensive maneuvers he or she employs to maintain split-off good and bad self- and object-representations. If the oral aggression which fuels this defensive activity is not addressed directly, modification of the pathology is impossible. An ego ideal is maintained that continues to torment the psyche; more realistic, less punitive aspects of the parents are not incorporated within the superego since the much less benevolent superego precursors retain their hegemony within the psychic structure. In the view of Kohut, since the presence of the grandiose self indi-

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cates that there has been an arrest in the development of the nuclear self, treatment should be geared to encouraging the narcissistic aspirations and needs of the patient to unfold fully in the transference. This unfolding will enable the patient to develop a more cohesive self with the support of the analyst, who is able to provide the vital selfobject functions that the original selfobjects were unable to provide to the developing self of the child. If the focus on all that which threatens the emergence of the self is not maintained, it will not be possible to achieve health since an enfeebled self will remain, making true mental health an impossibility. Kohut clearly identifies the environment as the source of disturbance for these personalities while Kernberg is equivocal in implicating constitutional factors along with environmental factors. Although the latter identifies a stronger aggressive drive and a "constitutionally determined lack of anxiety tolerence in regard to aggressive impulses" as contributory, he also has identified the presence of a mother or mother surrogate who functions well on the surface yet treats the child coldly, with very little regard for his or her emotional needs (Kernberg, 1970, pp. 219-20). Kernberg believes that the presence of an underlying borderline personality organization in the narcissist mandates his modifying approach, while Kohut's approach is consistent with his view that the narcissist suffers due to developmental arrest. For Kohut, the narcissistic agenda of the patient which emerges in the treatment situation reflects healthy narcissistic aspirations and needs that were thwarted by the parental figures during childhood and, therefore, it is imperative that the analyst support the emergence of this agenda so that it can eventually be transformed. Thus, as has been indicated throughout this paper, similar clinical phenomena are understood and addressed very differently by Kernberg and Kohut. At the same time, the psychoanalytic discourse has been greatly enriched by these theorists since each has been able to go further than did Freud in attempting to explain why some patients do not benefit from analytic treatment. While Freud identified a "narcissistic attitude" of some patients which "limits their accessibility to influence" in treatment (Freud, 1914, pp. 17-18), he left it to others to develop the clinical implications of this observation. Before Kohut, the transferences which develop in treatment of the narcissist were not described very well. Also, it seems that his work has led to a generally less judgemental attitude toward the narcissistic manifestations seen in many patients, not just those who present with obvious narcissistic pathology. Furthermore, the role of empathy in treatment is much more fully understood and accepted as a result of the work of Kohut and those who further developed his ideas (Goldstein, 1990).

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Both Kohut and Kernberg encouraged manifestations of narcissism to be brought into the treatment situation. The more traditional approach to these manifestations encouraged a repudiation or control of the narcissistic agenda of the patient which insured that, in most cases, this agenda would not become available for analytic investigation. Each has also made significant contributions to the understanding of the countertransference reactions typically evoked by borderline and narcissistic patients. It seems that there are patients who are now able to benefit as a result of the contributions of both theorists, however, it seems to this author that one can do more harm than good if one is too wedded to either approach. Although Kernberg claims that his recommended approach places the analyst in an objective, neutral position, his emphasis upon oral aggression does not seem either totally objective, in terms of the understanding of the pathology, nor neutral, in terms of the handling of the aggression that develops within the treatment situation. Kohut indicates that development can be severely arrested much later in childhood than Kernberg indicates (1979). Others have also questioned Kernberg's identification of the source of disturbance as exclusively preoedipal (Abend, Porder & Willick, 1983). It does not seem hard to conceive that a patient who was treated exclusively in the manner Kernberg advocates would experience the therapist as anything but neutral, that a patient could become so alienated by this approach that important material could be withheld from the therapist and, in the worst case, the treatment could have as iatrogenic effect (Brandchaft & Stolorow, 1984). With respect to Kohut, it does not seem hard to imagine that an exclusive reliance upon his self psychological approach could not only prevent a patient from recognizing and coming to terms with his or her aggression, it might also encourage the patient to hurt othersand ultimately himself or herselfthrough hostile behavior emanating from a sense of entitlement that has been unintentionally promoted by the therapist. In the case presentation which follows, the therapist's efforts to navigate between the Scylla of ignorance of the hostility of the patient and the Charybdis of the ignorance of the patient's libidinal needs will be highlighted. CASE ILLUSTRATION
Doug is a 33 year old white, Jewish male who entered treatment with the author three years ago, following Doug's break-up with his fiancee, Eileen. At that time, Doug described himself as vacillating between periods of intense anger and debilitating depression, the former which he attributed to the insensitive manner in which he had been treated by Eileen, and the latter to his discouragement about finding someone who could satisfy his perceived needs for

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nurturance of his artistic aspirations and for an intensive and thoroughly exciting sexual relationship. Doug had been in treatment previously, for less than a year, with a female therapist; he reported that she had helped him quite a bit until she began to become more "confrontational" with him. He was unable to elaborate, but indicated that the ending of that relationship also left him with strong feelings of indignation and discouragement. While still involved with each other, Eileena school psychologist who was working on her doctoratehad encouraged Doug to get back into treatment. Characteristically, Doug felt this was an effort on her part to use her knowledge of therapy to control him rather than help him. He resisted this idea until they broke up. Doug has a history of drug and alcohol abuse and seemed genuinely frightened that he would return to abuse of cocaine and alcohol to cope with his distress about the break-up. Doug's parents were divorced when he was eleven years old. He has a sister three years older who is perceived by him to be the favorite of his father. Doug's primary aspiration is to become a famous blues and rock composer, guitarist, and group leader; while waiting for this to happen, he is working for his father in his father's business. In contrast to his sister, a successful attorney who is married with two children, Doug reported that he is the "black sheep" of the family. He had not gotten very far with college, dropping out well before completion of his degree. It seemed that an empathic, nonjudgemental approach on the part of the author initially fostered the development of enough of a therapeutic alliance to keep Doug in treatment. He came in for some extra sessions, and for a time came twice per week. It seemed that his anger diminished somewhat and enabled him to concentrate better at his job and devote more time to his music. His father had been very unhappy with Doug's work performance, since Doug frequently missed work or came in very late because he had been "partying" the night before. Because he was able to stop doing this, Doug was no longer being threatened with being let go by his father, who seemed to be someone volatile enough himself to do this. The treatment "honeymoon" (Fine, 1982), however, was short-lived, in part due to the author's winter vacation, which took place after six months of treatment. During the author's vacation, Doug consulted another therapist, something he rationalized as necessary because of the very difficult time he had while the author was away. He reported he had difficulty not because he missed the author or was unable to rely upon him for assistance during the vacation, but because the author had not helped him enough prior to the vacation. His sister had encouraged him to see someone else and had given him the name of the therapist he consulted. He might have continued with this other therapist, Doug told the author, were it not for the fact that he was "getting a better deal" with the author, who was a provider in the managed care network used by his insurance company. As others have indicated (e.g., Maroda, 1994), use of the self psychological approach in the initial phase of treatment is oftentimes quite beneficial to both patient and therapist. The sustained empathic inquiry called for in this approach does much to establish basic trust on the part of the patient in the relationship. Not only does the patient experience the relief of "getting things off his/ her chest," but he or she feels genuinely cared about in the process of doing so. The therapist learns much about the patient's life because the patient feels safe and is eager to produce material to please the therapist. Although the above approach may be instrumental in enabling patients like

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Doug get started, a different approach is required to address difficulties that inevitably develop when a stage of dynamic conflict develops in the transference. At that point in treatment with patients like Doug the therapist benefits greatly by turning to Kernberg for guidance. The author decided Doug's devaluation of the therapist (as a means of dealing with split-off negative self- and object-representations) needed to be confronted. Attempting to explore the libidinal aspects of this behavior at this point were unsuccessful. When Doug was asked, "What is it that you need from me that I haven't been able to give you?" he was not able to say very much about what it was he wanted from the author. Doug began to harass Eileen, insisting that she should give their relationship another chance. He attempted to make contact with her and, when she attempted to let him know that she had been quite serious about ending their relationship, he became rather nasty with her and began to shadow her while Eileen was with her new boyfriend. He would park near her house when her boyfriend's car was in the driveway, near enough so that Eileen could easily recognize Doug's car. Doug also began spending more and more time drinking, smoking pot, and watching pornographic movies as well as having sex with prostitutes on a weekly basis. The author encouraged Doug to contact him when he felt compelled to do these things, especially following calls made to the author by Eileen, who at first threatened and then eventually went ahead and called the police to complain about Doug. Doug never called the author during any of these times. Instead, in addition to hearing from his ex-fiancee, Doug's mother called the author to express her concern about him and to insist she should come in to meet together with Doug and the author. She asked the author during the call to reassure her that "my son is not suicidal." Although his mother was invited to come in by herself (after her call was discussed with Doug) Doug was eventually persuaded to see how important it was for him to preserve his individual treatment. He had initially felt that he had no alternative but to accede to his mother's request, which he had experienced as another demand on her part to make her feel better, not help him. Doug initially did not feel that there was anything that really needed to be discussed about these matters, prior to the author's questioning of his motives for defeating the therapy. Although he was initially somewhat confused and annoyed by this questioning, he eventually admitted that he felt entitled to do whatever he could to make himself feel better and have more successful relationships, no matter what the author thought. The author was able to then point out to Doug that he was acting the same way with the author as he acted in his relationships with women. It seemed that this approach at this particular point in the therapy was necessary to preserve the therapy, that these interpretations, the limit-setting, and the frustration of what this patient asked for allowed the treatment frame to be preserved. There were times, for example, when Doug would use his session time to ruminate about the psychological reasons for his behavior, while appearing to be somewhere else emotionally. At such times, the author commented about how abstract he sounded and asked him what was really bothering him. Although Doug was initially also put off by this observation and question, it helped him eventually to focus more easily upon what he was feeling. This kind of intervention corresponds to Kernberg's notion of attending to the need to develop structure, as opposed to allowing a monologue resembling free association take the patient further away from that which he was feeling, especially any anger he might be experiencing.

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Despite all this, it became necessary at another point to shift gears once again and adopt a more tolerant stancein relation to Doug's grandiose aspirations. The author became aware that when he was using Kernberg to understand and address Doug's devaluation of the author and very strong sense of entitlement, he began sessions himself feeling rather irritated with Doug and indignant about the manner in which he was being treated by Doug. At times, it was difficult to hear themes in the material other than Doug's ruthless incorporation of the author and others. Self-analysis of the author's counterresistance to allowing other material to emergea process which included discussion of the case with a colleagueenabled the author to realize that the transference had become more positive and therefore there was much less need at that point to concentrate on the patient's aggression. Kohut has stated quite clearly that challenging the patient's grandiosity is not only a useless endeavor, it will likely compel the patient to suppress very powerful wishes and thus make them inaccessible to modification. Doug can be accurately and usefully described as "mirror-hungry." The author decided that it was important to attend in a particular way to manifestations of this hunger which developed in the transference. Doug began to bring in notebooks filled with many, many pages of his thoughts and feelings about his struggles with women and his music, some pages of which he had copied and had attempted (unsuccessfully) to get Eileen and other women he pursued to read. It became clear to the author that it would be necessary to gratify some of that which Doug wished for in asking the author to listen to him read from these notebooks. The author initially simply listened as Doug read, indicating interest in those passages which expressed strong feeling or indicated developing insight. Eventually, Doug was encouraged to discuss how he felt it was helping his therapy to do thissomething that was done in as nonjudgemental a manner as possible to indicate the interest of the author in what Doug wanted from him rather than what Doug was resisting by relating in this manner. Later on, Doug began bringing in self-help books to discuss with the author. He was encouraged to talk about what he had discovered which resonated with him. This approach helped Doug see how much of his behavior, included its intellectualized aspects, was connected with his wishes for attachment with others and how upset he could become when his wishes were frustrated. As a result, Doug has developed enough insight and frustration tolerance to stop harassing not only his ex-fiancee but another woman he dated for a few months, to significantly cut back his drinking and pot use, and to end his dependence upon pornographic movies and prostitutes for sexual excitement and pleasure. Eventually, Doug was able to approach dating in a very different way, both with respect to the choices he made about whom to date and how he behaved with those with whom he attempted to connect. Initially, he attempted to date a prostitute he had seen on a regular basis. When the fantasy of where this would lead was analyzed, he ended this quest. He proceeded to date a series of unavailable womentwo married women and a very troubled young woman who eventually scared Doug off with her sadomasochistic sexual proclivitiesbefore attempting to connect with more suitable women. By the time of the writing of this paper, Doug had been involved with someone for several months who seemed a much better choice as a partner. He was able to use much of his session time to talk about his mixed feelings about committing himself in an intimate relationship, rather than impulsively acting out his negative feelings. During that time, the author realized that although the transference had

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become more positive overall, he was neglecting to address indications that Doug was not just having difficulty with intimate relations with his girlfriend, that Doug was struggling with similar feelings in the transference. The author recognized that he was struggling himself with feelings in his counter-transference to Doug. How else could he explain his delay in discussing some obvious indications that Doug was feeling displeased with the author? Through self-analysis, the author was able to see that he was using theory to rationalize an approach to his patient that, at this particular time, stemmed more than anything else from his counter-transference. As Doug began making a habit of arriving ten to fifteen minutes late for his appointment, paying his bill late, and shaking hands with the author at the end of the session, the author rationalized that confronting Doug with this behavior was not necessary. Essentially, he allowed himself to believe that empathy was enough. Of course, the truth was that the author was feeling uncomfortable about dealing directly with Doug's disappointment, very powerful sense of entitlement, and anger. When the author realized he was resisting the analysis of these feelings in the transference, he was then able to confront Doug tactfully. That is, the author was then able to bring the behavior to Doug's attention and in an empathic manner to explore the feelings which motivated the behavior. As the analysis proceeded, Doug became more aware of the kind of relationship he wished to have and not have with the author. He became much more comfortable as well with his girlfriendhe began to feel less deprived and controlled in both relationships. DISCUSSION

The clinical vignette presented above illustrates the value of utilizing the contributions of both Kernberg and Kohut, based upon that which may be needed by one's patient at various points in treatment. Both theorists have advanced psychoanalytic thinking about borderline and narcissistic psychopathology and treatment. However, it is imperative that the therapist recognize that what is needed by his or her patient may change significantly as the treatment proceeds (Pine, 1988). Therefore, the therapist needs to make a corresponding shift in his or her approach. Perhaps those with a background in social work, with the social worker's appreciation of the situational factors associated with psychological distress, are especially adept in this regard. The kind of treatment situation presented above is commonplace for many clinical social workers. Clinical social workers who are analytically oriented attempt to develop effective analytic approaches to help patients who are both very troubled and very demanding. Although guided by their analytic knowledge and convinced of its usefulness, the clinical social worker must recognize the fact that most people now come for "help" rather than for "analysis" (Herbert Strean, 1993, personal communication). Both Kernberg and Kohut have received much praise for their contributions, as well as a great deal of criticism for developing points of

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view which challenge mainstream psychoanalytic thinking. Unfortunately, there has been a tendency within psychoanalysis to engage in a wholesale embracing or repudiation of different points of view which seems similar to the defensive splitting employed by very troubled patients to ward off the anxiety associated with taking in the analyst as a real person. Instead, the analyst is experienced as either "all-good" or "all-bad" rather than as a real person who, despite his or her very real human limitations, has something very valuable as well as very real to offer in the analytic relationship. Although many classially trained analysts would regard self psychologists, along with many others, as heretics (in Bergmann's [1993] usage of the term), there have in fact been a number of important contributions made by theorists who have either somewhat covertly (e.g., Winnicott) or quite overtly, (e.g., Klein) challenged Freud, and in so doing, advanced mainstream psychoanalytic thinking and approaches to treatment. According to Bergmann's way of categorizing psychoanalytic thinkerswhich seems quite usefulKernberg and Kohut would be identified as modifiers rather than heretics, as important thinkers who demand that theory change as a result of their findings. As Bergmann has said, modifiers have threatened the continuity of psychoanalysis and created much controversy, however, they have also kept psychoanalysis alive. As a result of the insights offered by modifiers, psychoanalysis has been able to stretch enough to improve its understanding of the etiology of many disorders as well as develop more effective treatment approaches. More recently, Bergmann stated that modifiers demand that analysts "give up their cherished belief that psychoanalytic theorizing has developed along a straight line, with every new generation simply adding their findings to that of the previous generation" (1997, p. 82). In fact, psychoanalytic theory and technique have evolved dialectically. This can be seen very clearly with regard to how psychoanalytic thinking about severe psychopathology has evolved, as this paper has indicated. The intention of the author in this paper has not been either to defend or to attack either theorist, but rather to highlight the need on the part of the practitionerwhen he or she turns to either Kernberg or Kohut for guidanceto recognize the limitations of relying too much on either approach when he or she is attempting to engage patients who are especially difficult to engage in a meaningful psychodynamic treatment. If this is accepted, of course, a related matter must be considered very carefullythe issue of what determines the shift from the use of one approach to another. As Strean (1994) has described, theoretical arguments can be made to rationalize interventions motivated primarily by the practitioner's countertransference. Strean suggests that this defensive maneuver can

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be employed by well-trained, seasoned analysts as well as by those still in training. In working with more troubled patients, it can be especially tempting for the practitioner to cling uncritically to a particular way of working as a means of warding off the anxiety associated with hearing very disturbing material and observing very self-destructive behavior. It is also possible that the practitioner can become too eclectic, shifting too quickly to a different approach as a means of warding off anxiety stemming from his or her countertransference. As Maroda (1994) has indicated, perhaps the best way to know when one is either too wedded to a particular approach or too eclectic is to carefully study one's counter-transference. It is in fact quite possible to get back on track when one's countertransference has taken one off course, as Strean (1993, 1995) has shown in his description of analysts and other therapists who were able to use supervision to resolve their counterresistances. In an earlier paper (Consolini, 1997), this author was able to demonstrate, with three case examples, that self-analysis enabled him to determine when his countertransferences were limiting his effectiveness and to take the necessary steps to resolve the counterresistances stemming from these countertransferences. CONCLUSION Clinical social workers are often called upon to treat very troubled and demanding patients during times of crisis, crisis often precipitated by the psychopathology of these individuals. These patients are often highly resistant to aspects of the analytic process usually associated with positive treatment outcomes, such as meeting several times per week and accepting a long-term commitment to their personal growth. Financial constraints and the influence of managed care reinforce resistance to the analytic process. In short, patients may now feel more entitled than ever to fast and dramatic improvement because of the current economic and social climate. It may sometimes seem that the well-trained clinician must forget much about what he or she learned to be successful with many of those seeking treatment in the current climate. Actually, there is good reason to continue to employ analytic approaches, especially as conceived by Kernberg and Kohut, with many patients. Both theorists have a great deal to offer to therapists working with very disturbed individuals during periods of crisis. If the author of this paper has succeeded, he has demonstrated that it possible to utilize selectively aspects of both of the approaches of these two theorists to find ways to help individuals as demanding and troubled as Doug. To do so, the therapist must be aware of the strengths and

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limitations of these approaches. And, perhaps most importantly, the therapist must be aware of what compels him or her to adopt a particular approach at a particular time with a particular patient. Ideally, the therapist can accept and work with the possibility that countertransference plays a role in his or her clinical decision-making.

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