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Kernberg, O.F. (1971). Prognostic Considerations Regarding Borderline Personality Organization. J. Amer. Psychoanal. Assn., 19:595-635.

(1971). Journal of the American Psychoanalytic Association, 19:595-635

Prognostic Considerations Regarding Borderline Personality Organization

Otto F. Kernberg, M.D.

SUMMARY

The prognosis for intensive, long-term psychotherapeutic treatment of patients with borderline personality organization has been dealt with. The prognostic elements reflected by the patient's presenting illness and personality have been outlined. Summarizing these prognostic elements briefly, the prognosis of patients with borderline personality organization depends on: (1) the descriptive diagnosis of the predominant type of character pathology, and the extent of ego and superego pathology revealed by pathological character traits; (2) the nonspecific manifestations of ego weakness present, especially the degree of impulse control, anxiety tolerance, and sublimatory potential; (3) the degree to which integrated, abstracted, depersonified superego structures are present, as reflected in patients' capacity for concern, guilt, depression, insight, and the extent and structural implications of antisocial trends; (4) the quality of object relationships.

I have stressed that the prognostic indicators available in the initial examinations facilitate the selection of those patients for intensive psychotherapeutic treatment who can better use the limited therapeutic resources presently available. These initial prognostic indicators also highlight areas of prognostic uncertainty which may then be clarified during the treatment process.

I have also stressed that the prognosis further depends on several process or transactional variables. These variables refer to developments and changes that occur as part of the psychotherapeutic relationship, and include the extent to which previously ego-syntonic pathological character traits may become ego dystonic, the extent to which capacities for self-awareness, introspection, and concern develop under the influence of the treatment process, the extent to which patients are able to develop authentic object relationships with their therapists, and the extent to which patients' potential for negative therapeutic reaction can be resolved.

Finally, I have examined the prognostic implications of one further, and crucial process variable which does not depend on the patient: the therapist's skill and personality. I have stressed

that patients with low ego strength require a highly skilled therapist whether in supportive or expressive treatment. Creating just the necessary structuralization—and not more—in the hours and/or in the patient's life, while preserving an essentially neutral position vis-à-vis the patient requires much skill and experience on the therapist's part. Every patient tests the skill of the therapist in new ways, thus determining a unique "fit" which constitutes a prognostic process variable. It is very difficult to separate the influence of personality characteristics of the psychotherapist from countertransference factors and from his technique. Clinically, the personality of the psychotherapist or the analyst is a crucial prognostic variable in treating borderline patients.

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