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So ingrained is Otto Kernberg's theory within my own work that when I searched my bookshelves to find his book Psychodynamic Psychotherapy of Borderline Patients (Kernberg et al. 1989), after much looking I found it filed with reference books, that shelf we all have reserved for oversized tomes that are seldom consulted. But my dog-eared and annotated copy attests to my repeated use of this book and to my assimilation of Otto's perspective on object relations and severe character pathology into my own. It is so fully mine, in fact, that I might explain how I'm seeing a patient to a resident psychiatrist while forgetting to tell them that it's Otto's lens I'm looking through.
The year was 1991 when, as a PGY-2 psychiatry resident at Columbia, I stepped onto the so-called General Clinical Services (GCS) unit, informally known as the “Borderline Unit.” I'd had some psychotherapy myself but never before conducted any. I was up against the most storied of the difficult patients with borderline and narcissistic personality disorders, at least that's how it felt to me at the time. The patients I would treat for the next six months at a frequency of three times weekly could be living on the GCS unit for years at a time. I'd made a special trip downtown to the Barnes and Noble medical bookstore and now found myself nervously opening to the table of contents and then the first chapter of Kernberg's classic text. As I began to read, borderline personality disorder (BPD), according to DSM-III-R, displayed a tumult of confusing and scary-sounding symptoms: unstable and intense interpersonal relationships with alternations between devaluation and idealization; impulsivity;