JEP - Number 5 - Spring-Fall 1997
Psychoanalysis in America

Otto Kernberg

Interview held by Sergio Benvenuto and Raffaele Siniscalco in July 1996 at Prof. Kernberg's office at Cornell University, for the Multi-Media Encyclopaedia of Philosophical Sciences by RAI (Italian Radio Television).

SINISCALCO-BENVENUTO: Can you give us a brief outline of American psychoanalysis?

KERNBERG: American psychoanalysis very much identified with Ego psychology, an approach which dominated American psychoanalysis through the 1940s and the 1960s. This approach came from Anna Freud and those closest to her, and was represented in the US by Hartmann, Kris, Loewenstein, Rapaport, Erikson, and later on by Jacobson and Mahlerthe giants of American psychoanalysis.
Isolated psychoanalysts working in this country were influenced by the British schools of Balint, Winnicott and Fairbarn, the so called middle group, on the one hand, and by the school of Melanie Klein, on the other. The latter constituted an opposite polarity to the school of Anna Freud, and the "middle group" was so-called because it fell between the two. But, beyond these isolated influences, Ego psychological thinking in the US had a near monopoly. The strong animosity in England between the school of Anna Freud and that of Melanie Klein, was transplanted to the US, where Anna Freud group dominated totally.
This changed under the influence of Heinz Kohut, who originated the "Self psychology," which questioned many of the tenets of the theory and technique of Ego psychology. Despite the fact that his approach has always been a minority view, his influence was very important becausein contrast to earlier divisions within psychoanalysis in this country, which led to a total separation of certain schools from the Ego-psychological mainstreamHeinz Kohut's group remained within the American Psychoanalytical Association (APA). The largest association of psychoanalysis in US, the APA grouped between thirty and forty psychoanalytic institutes and societies in various cities, and was also almost exclusively medical. This resulted from the decision in 1938 of the International Psychoanalytic Association (IPA) to give the APA the exclusive rights for training here; a right which was restricted practically to physicians.
When, in the 1970s, Kohut's Self-Psychology remained within the APA, a monopoly was no longer possible, other important currents started to develop, and American psychoanalysis became multi-centered; Ego Psychology, although still dominant, has begun to incorporate some of the tendencies from the other schools which emerged. In the US a culturalist psychoanalytic school centered around the teachings of Harry Stack Sullivan (and important psychoanalysts around thatOtto Will, Harold Searles, Frieda von Reichmann, Edith Weigert, Karen Horney et) existed, bearing varying different degrees of closeness or distance from the American mainstream, but constituting really a separate group for many years.
In the 1970s, the ideas of culturalist psychoanalysis began to enter the psychoanalytic mainstream, and there now exists a so-called "inter-personal psychoanalysis," an important current rooted in the culturalist psychoanalytic school, but influenced also by Ego psychology, and by British theories, which have also entered this country under the broad terminology of "British object relations theories", and which include both the schools of Melanie Klein and of Winnicott. So, in American psychoanalysis now there exists a theoretical and technical opening up to all these orientations.
French psychoanalysis is still relatively absent or little knownboth the Lacanian school, and the French psychoanalytic societies that, unlike Lacan, remained within the IPA and, in reaction to Lacan, developed a very special French approach. This approach, despite some influences from the British schools, is mostly centered around its own distinguished French theoreticians and clinicians (i.e., Didier Anzieu and Jean Laplanche), but is still quite unknown in the US. Exception are the works of André Green, of Janine Chasseguet-Smirgel (who has contributed to the study of the ego ideal, perversion, and early development) and of Joyce McDougall. The American attitude demands clearity and precision, hence the very strong criticism and rejection in general of Lacan's ideas, the writings of which are almost purposefully obscure. But, in my view, some of his ideas are very interesting, particularly his early contributions, which contain less of that willful mystification found in his later work.
So, the general tendency in psychoanalysis today is toward a theoretical opening up, and a learning from differences, rather than the dogmatic discussions of the past.

SINISCALCO-BENVENUTO: With which of the trends originating in England does American psychoanalysis have a special link?

KERNBERG: During the last ten years the Kleinian approachwhich was totally rejected by Ego psychology, and used to be considered un-Americanhas enjoyed an increasing interest, as have the ideas of the independent group, the Fairbairn-Winnicott orientation. Winnicott is widely accepted today, so that through his contributions to child analysis, object-relations theory has come to be integrated into American psychoanalysis. The Kleinian approach still has rather small roots and few contributors, although some Kleinian ideas have come to be incorporated, particularly by those American psychoanalysts working with sicker patients with severe personality disorders, whose serious regression in the transference illustrates some of the primitive mechanisms that Melanie Klein and her school explained and taught. The ideas of authors such as Wilfred Bion, Herbert Rosenfeld, Hanna Segal, and Betty Joseph are now beginning to enter the United States. Increasing contacts of the international psychoanalytic community has made object relations theories, and European and Latin-American psychoanalytic thinking in general better-known.
Italian, Spanish and Portuguese psychoanalytic contributions, with very few exceptions, are almost unknown, because these languages are affected even more than French by the language barrier. One exception is the important Italian study by Jacqueline Amati Mehler, Jorge Canestri and Simona Argentieri (The Tower of Babel) on the influence of poly-linguistic capabilities on the psychoanalytic process; the dynamic unconscious seemingly organizes itself in parallel within each of these languages that has been translated. But this interest for this study here is really almost an exception that confirms the rule. Another important contributor, Ignacio Matte Blanco (originally Chilean but later Italian), claims a small but dedicated group of followers in this country. Important contributions from Scandinavian, German speaking and Latin-American countries are very little-known.
So, psychoanalysis in its development has suffered from these linguistic barriers. English has been more than a lingua franca, it has been really a monopolistic language. And one of my intentions as future president of the IPA is to foster translations from other languages into English, to strengthen the presence of European and Latin American psychoanalytic thinking in North America.

SINISCALCO-BENVENUTO: In scientific fields, English is the language that everybody uses. Why is this not so among psychoanalysts?

KERNBERG: The large majority of psychoanalysts have been professionals in private practice, and only a minority have been actively involved in academic or research centres, where this function of English is understood. Thus, many psychoanalytic publications operate only in the original language, and many psychoanalysts don't speak English. But another major problem is a certain reluctance on the part of English-speaking psychoanalysts to learn foreign languages. This is changing, but not fast enough.

SINISCALCO-BENVENUTO: A very influential opinion among European psychoanalysts accuses American analysis of being politically conservative, aiming as it does to adapt patients to their social environment, to comformist ideals. Is this accusation justified?

KERNBERG: It is partially justified: the early generation of Ego psychologists of this country (in particular Hartmann) insisted, theoretically and technically, on adaptation and on the environment, on psychoanalysis becoming a general psychology, on the adaptive functions of the psychic apparatus for the individual, and on the adaptive functions of defensive operations. Psychoanalysis became very fashionable in the US, sweeping through the universities and the departments of psychiatry in the 1950s and the 1960s; this produced a conservative atmosphere within psychoanalytic institutes, and a tendency to adjust to the cultural norms of society.
But the accusation is only partially true. Some American psychoanalysts strongly criticized this tendency, and were concerned with the revolutionary nature of the knowledge of the unconscious. Even within psychoanalytic theory and technical approaches, there were counter-currents: Margaret Mahler, Edith Jacobson, Arthur Fennikel, and Hans Loewald from a different existential viewpoint, all criticized this adaptive quality of American psychoanalysis. Today the approach is less conformist, interpersonal psychoanalysis, in particular, questions conventional adaptation, accenting the importance of subjectivity and inter-subjectivity; and Kleinian psychoanalysis insists on the importance of the primitive manifestations of libido and agressionist drives. So, conservatism never was as absolute and complete as, for example, you find in the Lacanian or in the counter-culture critique of 1968.

SINISCALCO-BENVENUTO: Since the 1930s, what has been the relationship between American psychoanalysis and psychiatry? Has today psychiatry's shift toward a biological and neurological approach influenced the practice and theories of analysts in this country?

KERNBERG: There have been important shifts in the overall psychiatric climate. American psychiatry has always tended to focus on the psycho-social aspects of psychological functioning and psychiatric illness. Pure neuropsychiatry, the organistic tradition of Europe, never became firmly established here because of innate American optimism: the possibility to change people, the determinancy of the environment, all of which was signalled by the psychobiology of Adolf Meyer and his followers.
Psychoanalysis built upon this and "invaded" the US in the 1930s, becoming very strong in university, psychiatric and cultural circles of the 1940s and 1950s, not just because of its emphasis on the psychological- unconscious to the detriment of biological determinance, but also because of its emphasis on subjectivity, on the existential approach to psychological illness, and on its cultural relation to surrealist anti-objectivist currents dominating both European and American culture at the end of WW2. Psychoanalysis strongly influenced American psychiatry to the extent that in the 1960s, the leading psychiatric institutionsdepartments of psychiatry at Harvard, Yale, UCLA, and even Johns Hopkins under John Whitehorn, etc.had a strong psychoanalytic orientation. At one point, the Menninger Foundationa private psychiatric institution that represented the very core of Ego-psychology psychoanalysistrained 8% of all the psychiatrists in the United States. So, most departments of psychiatry were under the leadership either of psychoanalysts or psychiatrists very favourable to psychoanalysis.
This changed in the 1970s, slowly at first and then dramatically, and the pendulum swung into the other extreme in the 1980s and early 1990s. Now, we are returning to a more balanced view and the pendulum is already swinging back toward the center.
A first major reason for that change: psychoanalysis exaggerated its claims regarding knowledge and therapeutic success. Psychoanalysis focused on symptomatic neurosis, on character pathology, on the relatively milder psychiatric illnesses, while not being of fundamental help to the more severe, chronic psychotic, organic and mentally retarded patients who constituted a large number of inmates in state institutions.
Moreover, the development of biological psychiatry, and in particular of psychopharmacologydue to the positive results obtained with the psychopharmacological treatment of chronic schizophrenic illness, of manic depressive psychosis, and later of depression and anxiety at all levels brought about the possibility of putting thousands of patients back into the community. There developments of biological psychiatry have excited departments of psychiatry and researchers, and gained a strong ascendence. In addition, psychoanalytic institutes became very conservative, rigid and dogmatic, isolated themselves from the university, and took on a kind of adversary role with relation to biological psychiatry. This initially made it difficult for biological psychiatry to gain acceptance, but when it eventually did triumph, it led to an isolation and rejection of psychoanalysis, which was practically eliminated as a major force from most departments of psychiatry in this country by the late 1980s. At the same time, psychiatric residence and training leaned ever more toward biological psychiatry, losing interest in psychoanalysis. So, the combination of new discoveries in psychobiology, the nature of the patient population not covered by psychoanalytic efforts, and the conservatism of psychoanalytic institutes in those years, all led to a gradual decrease of psychoanalysis's influence within the university and psychiatry.
At this point, the situation has reached an equilibrium: the best psychiatric training centers are aware of the fact that you cannot neglect the psychodynamic aspect, the normal psychological functioning. In my view, neurobiolgy and psychoanalysis are two basic sciences of normal and abnormal psychology, and they are mutually enriching; eliminating one altogether impoverishes the field. The boundary between the mental and the physical is the most interesting aspect not only of psychology but also of psychiatry. And so, psychoanalysis is now gradually being recognized as a highly specialized aspect of normal and abnormal psychology, and not as an overwhelming science that can incorporate all others: the same is true for neurobiology.
Another consequence of this shift in psychiatry has been a decrease in the interest of psychiatrists in inter-psychoanalytic training. So, following the enormous interest in psychoanalytic training in the 1950s and 1960s, there was a dramatic decrease in the number of psychiatrists entering psychoanalytic training.

SINISCALCO-BENVENUTO: Until a few years ago, the APA accepted only medical psychiatrists for its own psychoanalytic training; only following a court sentence was the APA forced, in 1989, to in some way open its door to non-MD analysts. Do you think the old politics, which aimed at a complete medicalization of psychoanalysiscontrary to what Freud himself believedimproved the quality of American psychoanalysis, or harmed it?

KERNBERG: Since the 1980s, psychoanalytic institutes here become interested in training more than just psychiatrists. In the US, strong institutes inspired and directed by clinical psychologists developed their own psychoanalytic education and thinking, insistitutes which had been excluded from the IPA because of the 1938 agreement between the IPA and the APA, which gave the APA exclusive training rights in the US, and exclusive rights for membership in the IPA. These important and creative institutes, having challenged this infamous legal process and won, opening up membership in the IPA and the APA institutes to training psychologists. This was a very positive development. I had personally felt critical of the exclusion of clinical psychologists from psychoanalytic training, the reason being that the level of training of clinical psychologists in this country is excellent, probably the best training in clinical psychology in the world, not only for clinical skills, but also for research methodology, which is not as intensively taught in medical schools. Residents in psychiatry once again became interested in psychoanalysis to complement their training, and this has contributed to balancing out and renewing interest in psychoanalytic training on the part of psychiatrists in training, at least in some of the leading psychiatric centers, as we can see in New York very clearly.
American psychoanalysts feared that opening up to psychology would demedicalize psychoanalysis. But other fields of medicine, where psychologists are doing crucial research work, such as physiology, pharmacology, biology, and the basic sciences in general, have not become demedicalized. The relationship between psychoanalysis and medicine will depend on the scientific value of psychoanalysis, on its capacity to explain normal and abnormal psychic functioning and development. If psychoanalysis has something fundamental to contribute to the understanding of these areas of normality and abnormality, it will continue to have a strong bridge to medicine and to psychiatry. Psychoanalysis needs to expand its relationship both to psychiatry and psychology and the humanities, and not to link itself exclusively to any particular specialization, because psychoanalysis has boundary functions with many other sciences; for example, the psychoanalytic theory of drives and the neurobiology of affects are intimately linked. Treating patients in psychoanalysis requires making differential diagnoses with all kinds of other psychological and psychiatric conditions, which requires an intimate relation with psychiatry. Opening up to non-psychiatrists will not demedicalize the field.

SINISCALCO-BENVENUTO: What is your opinion of the Diagnostic Manual in Psychiatry (DSM) on which you collaborated? Do you think that the DSM IV has assimilated or misunderstood psychoanalysis' contribution?

KERNBERG: DSM III and DSM IV have positively influenced the development of an uniform, operationalized definition and delimitation of major psychiatric symptoms. But it is an irregular classification; with some excellent and other not so excellent areas. Unfortunately, the poorest area in DSM III and IV is that involving personality disorders and symptomatic neurosesthe field in which psychoanalysis has the most to say.
The DSM wants to classify descriptively major syndromes in an atheoretical way, although what is called atheoretical very often reflects a non-acknowledged theory underlying a somewhat simplistic empiricism and a non-acknowledged bias against psychoanalysis. Some of its significant weaknesses derived from its effort to dismantle psychoanalytic semiology and classificationhere it lacks the direct clinical relevance that the DSM classification has in other areas. The area of personality disorders is particularly weak in the DSM III; DSM IV has corrected some of the shortcomings, but has others.
It will take quite some time before the DSM system incorporates psychoanalytic knowledge. So, DSM has had both positive and negative influences. Efforts are now underway to modify and enrich DSM IV with the incorporation of psychodynamic finidings, and we will see significant changes in our classification system by the time it gets to DSM V and VI.

SINISCALCO-BENVENUTO: What has been American psychoanalysis's relationship to the great intellectual movements of the last decades which have in some way drawn on psychoanalysis, i.e. to Erich Fromm, Herbert Marcuse, Cristopher Lasch works, or to Marxist, Women's, Gay and Ethnic studies?

KERNBERG: Psychoanalysis has been intimately linked with many cultural currents, and psychoanalytic methodology has been used, both here and in Europe, in an attempt to understand different cultures, including the primitive societies. For example, Pahrin and Morgenthaler in Switzerland have studied West African tribes in a psychoanalytic way.
At the same time, there has been what I consider a more questionable tendency to use psychoanalysis as a universal remedy for social, cultural and political conflict, which I think is utopian. This kind of very American cultural optimism Erich Fromm, although of German origin, represents. So, the Utopian utilisation of psychoanalysis has been questioned and forms part of the critique of American psychoanalysis as being too adaptive and conventional.
Psychoanalysis had linkages with existentialism and surrealism. This linkage has been relatively weak in the United States. Herbert Marcuse used a psychoanalytic approach to discuss the repressive nature of the capitalist system, linking a psychoanalytic perspective with a Marxist one. Of course, a very particular counter-culture approach led him to talk about a repressive de-repression of sexuality as an escape from social conflict, and he linked this with a Utopian revolutionary approach to the totalitarian developments as he saw them within both capitalism and communism. He was very critical of the Russian regime as well as of Western democracy.
European Marxists had a more sophisticated approach; the Frankfurt school in particular tried to link psychoanalytic thinking with the Socialist approach, considering psychoanalysis a science that could be incorporated in what they called a "critical approach" to social conflictthe influence of which has continued to this day in France, Germany and Italy. At the same time, the Utopian tendency to apply psychoanalysis to the social sciences has been a strong temptation for social psychologists. Important psychoanalytic theoreticians have warned against the adaptive aspect of psychoanalysis, and stressed that one of Freud's fundamental contributions was his insistence on the pervasiveness, the unavoidability, and the profound nature of aggression in the individual and in society. French theoreticians, especially André Green, have focused on the importance of aggression as a basic human reality that operates in self-destructive ways within the individual, groups and nations. This is a potentially interesting contribution of psychoanalysis to the social sciences, and runs counter to the optimistic, social, psychological, Marxist-inspired approach.
In short: psychoanalysis has made important contributions to social psychology, even if its Marxist elements have been criticized in recent yearsparticularly in light of the disappointment in Communist regimes. And psychoanalysis has important contributions yet to make to understanding the development of irridentist and cultist ideologies inspired by severe, aggressive tendenciessuch as of the Pol Pot regime's mass murder, the Shining Path in Peru, the small religious extremists and cults in this country, and the Maoist terrorist groups in Europe and the Middle East. Psychoanalysis can tell us something about the psychology of these groups, and about important social phenomena where intense violence prevailsin the inner cities of this country more than in Europe.
Psychoanalysis was also incorporated into Eurocommunist theories;in France, Althusser drew inspiration from Lacan. Lacan's sharp critique of the American adaptational psychoanalytic style, the revolutionary nature of psychoanalysis itself, and Lacan's closeness to surrealism made the Marxist left, particularly in France, become interested in psychoanalysis. And Althusser, a major theoretician of the Communist party, incorporated Lacanian thinking into a psychoanalytic perspective on ideology: the capitalist ideology was part of the infantile Super-Ego. This fell apart with the downfall of Communist doctrine in Western Europe. Of course, in the Soviet Union all of this was completely forbidden; as an aside, there is now a beginning of interest in psychoanalysis in Russia and in Eastern Europe.
About feminism. On the one hand, more than in probably most other sciences, several major psychoanalytic theoreticians were women: Melanie Klein, Anna Freud, Edith Jacobson, Margaret Mahler, Clara Thompson, etc. Freud himself, in his revolutionary questioning of bourgeois morality, contributed to the theoretical dismantling of traditional bourgeois culture with its patriarchal aspects. From this viewpoint, psychoanalysis has had a pro-feminist approach. On rhe other hand, Freud was undoubtedly influenced by conventional views on male and female roles, and held certain beliefs that were strongly questioned by feminist psychoanalysts: for example, that women had a less devoloped Super-Ego than men. While Freud described women's irrational feelings of inferiority in connection with the fantasy of infantile penis envy, he left an uncertainty as to what extent these were pathological fantasies or whether all sexuality really was centred around the penis. This led to a strong critique of Freud's description of female psychology by leading psychoanalysts, ranging from Melanie Klein and Edith Jacobson to all the culturalist psychoanalysts, such as Chasseguet-Smirgel, or Clara Thompson in this countrythe entire cadre of major contributors to the understanding of the psychodynamics of women. So within psychoanalysis, the traditional patriarchal nature which influenced early psychoanalytic thinking was met by strong opposition on the part of later psychoanalytic theoreticians. Lacan, who strongly supported feminist ideology, developed a notion of the archaic Oedipal complex that completely reformulated some psychoanalytic ideas on early development and became the theoretical basis of psychoanalytic feminism, particularly in France and Germany, and to some extent in the US.
So, in general there is a growing confluence and harmony between feminist strivings and psychoanalytic theory. Of course, feminism encompasses a broad spectrum ranging from the demand for social, economic and cultural equality for women, to the declaration, by some extreme lesbian theoreticians in the US, proclaiming a self-contained femininity, wherein all sexual intercourse is rape. But the mainstream of feminism deals with a more objective study of communalities and differences in psychological developments in order to study the mutual relationships of the sexes, without using an ideology of female superiority to respond to traditional patriarchical psychology.
So, psychoanalysis has been very important in providing a theoretical and clinical basis for reviewing traditional views about the psychology of women, the nature of sexual relations and intimate relations. I myself have tried to bring together some of these psychoanalytic studies in a recent book on love relations that I published in 1995.
There is a currently big controversy within psychoanalysis about the nature of homosexuality. To what extent is homosexuality a normal form of sexual development parallel to that of heterosexuality, or to what extent is it always a pathological developmentwhich raises the question of what are the causes and origins of homosexuality. Intense studies are going on, in both the biological and the psychodynamic fields, with opinions sharply divided. Traditionally, psychoanalysis viewed homosexuality as always pathological. Nowadays, many psychoanalysts believe that homosexuality operates along a broad spectrum, with its causes varying from biological to psychological, in varying degrees of combination in each individual, and that in general, psychological causes are much more important than biological; I agree with this perspective.
Clinically, we now know that there does not exist only one type of homosexuality, but rather a broad spectrum ranging from patients who are very sick, to those who are practically normal, if you exclude their sexual orientation as part of the definition of abnormality. There are differences also in the homosexuality of men and women: in men, there is generally a sharper divide between homosexual and heterosexual identities, so that in men bisexuality is usually coupled with significant character pathology. By contrast, in women there are more graded transitions between homosexuality and heterosexuality, a continuum which makes it easier to see a group of women at the transitional field, with nothing abnormal except for a flexible orientation towards homosexuality or heterosexuality. What I here said is a simplification, things are much more complex.
Why this difference between men and women? Again, we have no definite answer. It may derive from early identification. Some psychoanalytic theoreticians believe that it may derive from the infant's early, first identification with the mother, which makes female identity stronger than that of the male. Women can more freely tolerate more freely, and not be threatened by, homosexual impulses than men, unless they are homosexuals. Another theory proposes that there are cultural reasonsderived from traditional patriarchal society which strongly opposes male homosexuality to female infidelity (in contrast to matriarchal society which opposes male infidelity and incest)that make homosexuality so forbidden and suppressed that the transition between homosexuality and heterosexuality does not appear in males. And in this field all research is influenced by ideological features.
The large majority of psychoanalysts probably still feel that there are biological and unconscious tendencies to bisexuality, and that the individual becomes oriented and fixated to either a homosexual or heterosexual direction in the first five years of life. Up to this point most analysts would agree. But opinions are sharply divided between psychoanalysts for whom a homosexual definition always indicates a psychological pathology, a non-resolution of the normal Oedipal challenges and conflicts, and a minority for whom homosexuality may in itself be as normal a solution to Oedipal issues as a heterosexual one.
The position that homosexuality is a normal variant is perhaps most importantly represented in the US. The traditional positionall homosexuality is an illness to be treated and changedis represented by Socaredes. I very much agree with Richard Friedman's intermediate position, which insists on a broad spectrum approach on biological as well as psychodynamic features, and on a willingness to leave controversial questions open until we have more information, from both clinical psychoanalytic, as well as other, areas of research.
Ethnic issues. Psychoanalysis can contribute to understand the psychology of ethnic minorities, of persecution and racial bias. Psychoanalytic contributions to the understanding of ideology and individual Super-Ego formation, and of the identification with the national, social, racial, religious or political groups, and how regressive phenomena may bring about splitting between in-group and out-group, and generate enormous paranoid tensions and aggression in conflict, are still not fully explored. But to understand does not necessarily mean to control. One can of course apply psychoanalytic thinking to the particular ideological formation that effects certain national, social or racial groups as a consequence of their particular socio-cultural circumstances. But psychoanalysis's contribution to understand social conflicts should not be interpreted as a way to resolve conflicts, even if other sciences can use that understanding to try to find solutions. So, I do not underestimate the potential of psychoanalytic thinking, I am concerned about overestimating this potential, and the disappointment that that necessarily brings about.

SINISCALCO-BENVENUTO: Is there any relationship or dialogue between American psychoanalysis and other forms of psychotherapy influential in the USA todayfor example, cognitive, family, behavioral or systemic psychotherapies, Junghian analysis, New Age therapies, etc.? Do American psychoanalysts always consider themselves the aristocratic élite of psychotherapy, or are they often interested in the theoretical and practical contributions from other schools?

KERNBERG: The contemporary attitude of American psychoanalysts is that psychoanalytic psychotherapy is of great value for particularly severe personality disorders that have contra-indications for psychoanalysis proper, or for mild conditions that may be helped by a psychoanalytically inspired psychotherapy without having to undergo a long psychoanalysis. Psychoanalysis has derived psychotherapeutic techniques. I myself and my research group have over many years developed a psychoanalytic psychotherapy for borderline conditions. Using brief procedures, we have also applied these psychoanalytic psychotherapies to couple and group psychotherapy, to family therapy, and certainly these procedures have influenced systemic group psychotherapy, which has a psychoanalytic background. There are also growing contacts between psychoanalytic psychotherapy, on the one hand, and cognitive behavioral therapy on the other, in the treatment of a specific patient group. For example, research has shown that cognitive and dialectic behavior therapya particular method of combined cognitive and behavioural therapyis very effective with chronically suicidal borderline patients, who also respond very well to psychoanalytic psychotherapy. The effects and methods are different; there is growing interest for comparing psychotherapeutic approaches to learn what kind of symptoms respond or don't respond to each approach, and through which mechanisms.
The relationship between schools is opening up, with less of an élitist thinking"only psychoanalysis is gold and the others are various second grade mixtures"and more appreciation of the fact that modified psychoanalytic psychotherapy may be the treatment of choice for many patients. So, psychoanalysis as a technique has an enormous capability for generating psychotherapeutic techniques with individuals, groups, families, and these techniques are being developed in various areas in this country, as well as in Europe.
Because we know better about indications and contraindications, we know that certain significant personality disorders are best treated by psychoanalysis. One might say, psychoanalysis represents a major surgery, to be reserved for certain cases, but for those cases able to obtain more improvement and change than any other methods of treatment. The Psychotherapy Research Project of the Menninger Foundation, directed first by Dr. Robert Wallenstein and then by myself for many years, found that where psychoanalysis is really an optimal indication, its effects are by far superior to other methods of treatment.

SINISCALCO-BENVENUTO: Why has American psychoanalysis focused especially on narcissism? Is it perhaps the most prevalent type of pathology in the US?

KERNBERG: It is quite prevalent, although I don't know whether more so in the US than in other countries. It was a natural development because Ego psychology was very interested in character pathology, which means personality disorders. My work has contributed a little in this direction, but important contributions have also been made by other ego psychological authors: Andy Reich, Edith Jacobson, Helen Tartakoff, Herman Bandavals, etc. As a social psychologist, Cristopher Lasch used the psychoanalytic theory of narcissism to explain aspects of American culture contributed enormously to generalize the concept. But the exact relationship between a narcissistic culture and a narcissistic individual pathology is not clear. It is tempting to describe certain cultures in terms of certain pathologies of character, but one must keep in mind that while character may be influenced by culture, these relationships are more indirect and complex than meets the eye. For example, to say that the Victorian age, with its sexual repression, produced a hysterical culture is a fine first approach, but it misses the complexity of sexuality during the Victorian era. Or to say that tzarist Russia had a culture of depressive personalities may say something about Russian psycholgy, but again it misses the complexity. Certainly a consumer society like that in America appeals to consumers' narcissistic wishes, but from there to describe the culture as narcissistic is a big step. So, there are more indirect and complex connections between American consumerism and narcissistic personalities.