Borderline Conditions and Pathological Narcissism

1. Borderline Personality: A Stable, Not Transient, Disorder

The term borderline personality organization, rather than "borderline states" or other terms, more accurately describes these patients who do have a specific, stable, pathological personality organization; their personality organization is not a transitory state fluctuating between neurosis and psychosis.

Beyond the Border. The term "borderline" often implies a temporary state, but Kernberg argues that Borderline Personality Organization (BPO) is a distinct, stable personality structure, not a fleeting phase between neurosis and psychosis. This distinction is crucial for understanding the specific challenges and treatment approaches required for these patients.

Chronic, not acute. BPO is characterized by a chronic pattern of unstable relationships, self-image, and affect, along with marked impulsivity. These are not simply transient symptoms but deeply ingrained patterns of behavior and thought. This chronic nature necessitates a long-term treatment approach.

Specific organization. BPO is not just a collection of symptoms but a specific organization of personality, with its own unique defensive mechanisms, object relations, and instinctual conflicts. This organization requires a tailored therapeutic approach that addresses these specific features.

2. Splitting: The Core Defense Mechanism

This defensive division of the ego, in which what was at first a simple defect in integration is then used actively for other purposes, is in essence the mechanism of splitting.

Keeping it separate. Splitting is a primitive defense mechanism where contradictory ego states are kept separate to avoid anxiety. This active process of keeping apart "good" and "bad" introjections and identifications prevents the integration of conflicting aspects of the self and others.

Consequences of splitting:

• Unstable self-image: Rapid shifts between contradictory self-concepts
• Unstable object relations: Seeing others as either all-good or all-bad
• Lack of emotional integration: Difficulty experiencing complex emotions

Beyond a simple defect. Splitting is not just a lack of integration but an active defense mechanism used to protect the ego from overwhelming conflict. This active nature of splitting makes it a central focus of therapeutic intervention.

3. Countertransference: A Diagnostic Tool

The diagnostic use of the countertransference reactions that borderline patients frequently evoke in the therapist are described in Chapter 2.

More than just a reaction. Countertransference, the therapist's emotional response to the patient, is not just a personal issue but a valuable diagnostic tool. It provides insights into the patient's internal world and the specific ways they interact with others.

Totalistic approach. A "totalistic" view of countertransference considers all of the therapist's emotional reactions, both conscious and unconscious, as relevant to the therapeutic process. This includes reactions to the patient's reality, transference, and the therapist's own needs and conflicts.

Empathic regression. The therapist's emotional reactions, particularly with severely regressed patients, often involve a form of empathic regression, where the therapist temporarily identifies with the patient's internal state. This can provide valuable information about the patient's experience.

4. Modified Psychoanalysis: A Tailored Approach

Borderline personality organization requires specific therapeutic approaches which can only derive from an accurate diagnostic study.

Beyond classical analysis. Classical psychoanalysis, with its emphasis on free association and neutrality, is often not suitable for borderline patients. These patients require a modified approach that addresses their specific challenges.

Key modifications:

• Systematic elaboration of the negative transference
• Confrontation and interpretation of primitive defenses
• Structuring of the therapeutic situation to limit acting out
• Selective focus on areas of ego weakness and reduced reality testing

Not just supportive. This modified approach is not simply supportive psychotherapy, which aims to reinforce existing defenses. Instead, it is an expressive approach that seeks to uncover and resolve underlying conflicts and pathological patterns.

5. The Importance of the Negative Transference

The negative transference aspects, especially the extremely severe latent negative transference dispositions, tend to mobilize even further the pathological defenses of these patients.

The power of the negative. The negative transference, which includes feelings of anger, distrust, and devaluation toward the therapist, is a crucial area of focus in the treatment of borderline patients. Ignoring or avoiding the negative transference can lead to a shallow therapeutic relationship and acting out.

Transference as a mirror. The negative transference often reflects the patient's early, conflict-laden object relationships. By exploring these negative feelings, the therapist can gain insights into the patient's internal world and help them work through their past traumas.

Deflection, not avoidance. The negative transference should not be avoided but rather "deflected" away from the immediate therapeutic interaction by examining its manifestations in the patient's relationships with others. This approach helps to reduce the intensity of the transference and allows for more effective interpretation.

6. The Crucial Role of Structure

Borderline personality organization requires specific therapeutic approaches which can only derive from an accurate diagnostic study.

Limits and boundaries. Borderline patients often struggle with impulse control and may act out their transference feelings within the therapeutic setting. Establishing clear limits and boundaries is essential for creating a safe and productive environment.

Structuring the environment:

• Setting clear expectations for behavior in sessions
• Using hospitalization or day treatment programs when necessary
• Establishing limits on contact outside of sessions

Beyond control. The goal of structure is not simply to control the patient's behavior but to create a framework within which they can safely explore their emotions and develop more adaptive coping mechanisms.

7. Narcissistic Personality: A Unique Challenge

"Narcissistic" as a descriptive term has been both abused and overused. There does exist, however, a group of patients in whom the main problem appears to be the disturbance of their self-regard in connection with specific disturbances in their object relationships, and whom we might consider almost a "pure culture" of pathological development of narcissism.

Beyond self-love. Narcissistic personality disorder (NPD) is not simply about excessive self-love but a complex disturbance of self-regard linked to specific problems in object relations. These patients present a unique set of challenges in treatment.

Key characteristics:

• Grandiose sense of self-importance
• Need for admiration and praise
• Lack of empathy for others
• Exploitative and parasitic relationships

A "pure culture." NPD represents a distinct form of psychopathology, not just a variation of other personality disorders. This distinction is crucial for understanding the specific treatment approaches required for these patients.

8. The Grandiose Self: A Pathological Structure

On a deeper level, their interactions reflect very intense, primitive, internalized object relationships of a frightening kind and an incapacity to depend on internalized good objects.

Beyond normal narcissism. The grandiose self is not simply an inflated sense of self-worth but a pathological structure that serves as a defense against underlying feelings of inadequacy and vulnerability. It is a fusion of ideal self, ideal object, and actual self-images.

Defensive function. The grandiose self protects the patient from the pain of their underlying self-doubt and their fear of dependency on others. It also serves as a defense against paranoid traits related to the projection of oral rage.

Consequences of the grandiose self:

• Shallow emotional life
• Lack of empathy for others
• Exploitative relationships
• Inability to depend on others

9. The Interplay of Narcissism and Object Relations

On a deeper level, their interactions reflect very intense, primitive, internalized object relationships of a frightening kind and an incapacity to depend on internalized good objects.

Not just self-love. Pathological narcissism is not simply about self-love but is intimately linked to disturbances in object relations. The way these patients relate to others reflects their internal world of fragmented and distorted object representations.

Exploitative relationships. Narcissistic patients often treat others as extensions of themselves, using them to fulfill their own needs for admiration and validation. They are unable to form genuine, reciprocal relationships based on mutual respect and empathy.

Internalized object relations. The pathology of narcissistic personalities is rooted in their inability to integrate positive and negative aspects of their internalized object relations. This leads to a lack of capacity to depend on internalized good objects and a constant search for external validation.

10. The Prognostic Value of Superego Integration

The presence of "all good" and "all bad" object images which cannot be integrated interferes seriously with superego integration.

Beyond guilt. The degree and quality of superego integration is a crucial prognostic factor in the treatment of borderline and narcissistic patients. The capacity for guilt, concern, and remorse is a sign of a more integrated superego.

Superego pathology:

• Primitive forerunners of the superego: Sadistic and punitive
• Lack of integration of realistic parental demands
• Tendency to project superego components onto the external world

Implications for treatment. The better the integration of the superego, the higher the level of character pathology and the better the prognosis. Patients with a more integrated superego are more likely to benefit from psychoanalytic psychotherapy.

11. The Therapist's Role: Skill, Personality, and Concern

The diagnostic use of the countertransference reactions that borderline patients frequently evoke in the therapist are described in Chapter 2.

Beyond technique. The therapist's skill and personality are crucial factors in the treatment of borderline and narcissistic patients. These patients require a therapist who is not only technically proficient but also emotionally attuned and resilient.

Key qualities of the therapist:

• Capacity for empathy and concern
• Ability to tolerate intense emotional reactions
• Awareness of their own countertransference
• Capacity for self-criticism and ongoing learning

The importance of concern. The therapist's genuine concern for the patient's well-being is a crucial factor in the therapeutic process. This concern must be balanced with a commitment to maintaining a neutral and objective stance.

Last updated: January 21, 2025