DEBATE  BETWEEN KOHUT (HK) AND KERNBERG (OK) 

HK: Of course. The patient must be indulged in this fantasy if he is to experience this developmental stage. His grandiosity must be permitted. This is difficult because for the patient to act out such fantasies alienates the therapist. It is a test of the therapist's capacity for empathy.

OK: No, that is not the countertransference problem. The countertransference problem is therapist's fear of the patient's anger. The therapist hesitates to confront the patient's fantasy for fear of provoking his rage. It is a test of whether the therapist can withstand the patient's rage. Indulging the patient's grandiosity only supports a defense against this rage. The rage is generated by the feelings of inferiority that the patient's grandiosity also defends against.

HK: Yes, well certainly that is a persuasive concept, and many eminent clinicians find it so. I formerly accepted it myself. However, I have since come to the conclusion that the patient's rage is reactive. He is angry because in interpreting his grandiosity you have, in reality, attacked his narcissism.

OK: Oh, but he can't enjoy his narcissism since he really feels inferior to the therapist.

HK: No, I think that is a later capacity. He really does not have the psychic structures necessary to support competitive feelings. To interpret as if he does, only becomes a demand from the therapist to be included in the patient's consciousness.

OK: There is no need for interpretations to be experienced as a demand by the therapist as long as the therapist is neutral.

HK: The word is empathic, not neutral. I don't think there is any way to be neutral from your position. Aren't you at risk for feeling like you have failed if you allow the patient to exclude you? Even if feeling excluded did not provoke you, is it not still up to you, for the patient's sake, to prevent him from ignoring and depreciating you?
        If I may say so, my model gives the therapist a way to accept what the patient is doing and so provides him with a way to cope with the countertransference.

OK: Wait a minute. What you say about empathy, after all, goes without saying. I have to say that what you are really doing here is advocating complicity with the patient's withdrawal into grandiosity that you are obviously not all that happy with yourself.

HK: [Falls silent at this point, permitting Kernberg's grandiosity.]

OK: [continuing] I cannot see that your complicity--call it what you will--your endless patience, is any more than a manipulation, a corrective experience. And one that is not likely to be very corrective since we are talking about severely regressed patients who will interpret your behavior in magical, omnipotent ways.

HK: Otto, Otto. You really cannot take empathy for granted. To sustain it is a demanding task that can never be completely successful. It does not simply mean being a good diagnostician. You seem to be overlooking the fact that these patients are constantly testing the therapist over a long period, both with their grandiosity and with their tantrums.

OK: Well, there you have it. We may just be talking about different patients. In what you just said it is clear that you want to let the transference develop. But many of the patients I describe would not be able to tolerate analysis. Those who can tolerate analysis, that is, who can tolerate your "empathy" are already accepting your authority. My patient's tantrums are the real thing.

HK: But those who have read my work realize that I do not think of these patients as capable of a transference. They experience the analyst as a selfobject. This must be allowed, which means not requiring the patient to take your interpretations lying down, if I may jest a bit here. The goal of treatment with such patients is for them to ultimately be able to experience the analyst as an authority; it cannot be a prerequisite for analysis.
      Also, you say that these patients will misinterpret my restraint, but I must take issue with your faith in their ability to not misinterpret your interpretations.

OK: Well, you are simply talking about the art of interpretation: timing, accuracy, and all the rest. 

HK: Now, there you have it. By insisting on your authority in this way, you are taking the traditional position, that you are right and the patient is wrong, and that the patient should learn to appreciate that fact. But what you are doing here is devaluing the patient's devaluation of you. I'm afraid that the more objective you try to be, the more that will prevent the patient from being able to experience an object relationship.

OK: Resistance to analyzing or to making interpretations takes many forms. You will admit, I'm sure, that you are not the first, nor will you be the last, to offer corrective experience, to use parameters--call it what you will--rather than to endure the rigors of the negative transference. 

HK: Obviously we each must work in our own way, and I hope there is something to be gained by such a debate. Analysts usually talk only to other analysts who agree with them, which can create the unfortunate impression that analytic training makes it difficult for us to accept criticism.

Endnote:

Kernberg gets the last word because Kohut has to respect his narcissism. Kohut has to fall silent at a key point because he obviously can't say to Kernberg that he does not want to injure his narcissism. The point is that since Kohut's views are not that different from Kernberg's, he has to avoid interpreting. He only has id analytic criticisms of Kernberg's id analysis.          Kohut's patients' "grandiosity" and their tantrums are just as iatrogenic as Kernberg's patient's rage. See the case of Miss F in Ego Analysis vs. Self Psychology          Intersubjectivists are much freer to bash Kernberg. Following Kohut's lead, they bash themselves first--but they see it as a counter- transference issue (hence "intersubjectivity"). This means they still miss (don't pick up on) subtle self-reproaches. They still take counterphobic behavior literally and so miss that their intolerance of the patient (that they have to "decenter" from) is a symptom of their missing the patient's subtle self-reproaches.

                                                                                                       Bernard Apfelbaum, PhD