In clinical practice, aggression rarely presents as a clear-cut or isolated phenomenon. What appears on the surface as anger or rage often reflects a more complex affective organization and leads to different consequences for the course of the therapeutic process.
Having offered a general theory of affects as the component substructures of drives, Dr. Otto Kernberg, MD, turns to a specific affect that occupies a central position in human behavior. I am referring to hatred, the core affect of severe psychopathological conditions, particularly severe personality disorders, perversions, and functional psychoses.
Dr. Kernberg notes that hatred derives from rage, the primary affect around which the drive of aggression clusters; in severe psychopathology, hatred may evolve into an overwhelming dominance directed against the self as well as against others. It is a complex affect that may become the major component of the aggressive drive, overshadowing other universally present aggressive affects such as envy or disgust.
A patient may, for example, erupt in rage in response to a canceled session and yet remain capable of restoring contact afterward. In other cases, aggression takes the form of a stable devaluing stance, in which every word of the therapist is experienced as a threat or an attack.
Distinguishing between these levels of aggression is essential for understanding both normative and pathological forms of human behavior.
Otto Kernberg describes hatred as an affect that occupies a central position in human psychology.
This is precisely what the therapist encounters when a patient’s aggression ceases to be episodic and begins to organize the entire transference—from the choice of topics to the very manner of silence within the session.
Clinically, the basic affect state characterizing the activation of aggression in the transference is that of rage.
In the transference, this may appear as a sudden eruption—a sharp rise in voice, impulsive accusations toward the therapist, or marked bodily tension emerging in response to an interpretation or the setting of a limit.
Irritation is a mild aggressive affect that signals the potential for rage reactions and, in chronic form, presents as irritability.
For example, a patient may repeatedly comment on the “inconvenient” timing of sessions, minor delays, or the therapist’s wording, seemingly unaware that these small remarks gradually saturate the therapeutic relationship with tension.
Anger is a more intense affect than irritation, usually more differentiated in its cognitive content and in the nature of the object relationship that is activated.
In such cases, the patient may clearly articulate what they are angry about while still maintaining a perception of the therapist as a separate person, rather than experiencing them as an entirely “bad” object.
A full-fledged rage reaction—its overwhelming nature, its diffuseness, its “blurring” of specific cognitive contents and corresponding object relations—may convey the erroneous idea that rage is a “pure” primitive affect.
Clinically, however, the analysis of rage reactions—as of other intense affect states—always reveals an underlying conscious or unconscious fantasy that includes a specific relation between an aspect of the self and an aspect of a significant other.
Infant research documents the early appearance of rage as an affect and its primordial function: to eliminate a source of pain or irritation.
A later developmental function of rage is to eliminate an obstacle to gratification; the original biological function of rage—signaling to the caregiver to facilitate elimination of an irritant—now becomes a more focused appeal to the caregiver to restore a desired state of gratification. In the unconscious fantasies that develop around rage reactions, rage comes to signify both activation of an all-bad object relation and the wish to eliminate it and restore an all-good one.
At a still later developmental stage, rage reactions may function as last-ditch efforts to restore a sense of autonomy in the face of highly frustrating situations unconsciously perceived as the threatening activation of all-bad, persecutory object relationships.
A violent assertion of will functions to restore a state of narcissistic equilibrium; this act of self-assertion represents an unconscious identification with an idealized all-good object. Clinically, the intensity of the aggressive affects—whether irritation, anger, or rage—correlates roughly with their psychological function: to assert autonomy, to eliminate an obstacle or barrier to a desired degree of satisfaction, or to eliminate or destroy a source of profound pain or frustration.
But the psychopathology of aggression is not limited to the intensity and frequency of rage attacks.
The most severe and dominant of the affects that together constitute aggression as a drive is the complex or elaborated affect of hatred. As we move from the transference developments of patients with neurotic personality organization to those of patients with borderline personality organization, particularly those with severe narcissistic pathology and antisocial features, we are increasingly faced not only with rage attacks in the transference but with hatred, which emerges along with certain typical secondary characterological expressions of and defenses against awareness of this affect.In such cases, aggression no longer appears as an event within the session but becomes its background.
Thus, when aggression repeatedly emerges in the session, the central question is not how intense it is, but what function it serves in the patient’s mental life. Rage may be loud, sharp, and exhausting for the therapist, yet still remain a reaction to frustration or psychic pain, after which contact can be restored. Hatred, however, follows a different trajectory: it does not dissipate with the outburst but settles and gradually begins to organize the very mode of being in the relationship.
In these situations, aggression is no longer something that merely “happens” in the session. It becomes the lens through which the patient listens, remains silent, responds, and experiences the therapist. It is precisely here that analytic work often becomes more difficult: interpretations fail to register, contact is devalued, and the therapist may find themselves drawn into the repetition of a familiar internal configuration for the patient. Recognizing this moment—when rage is no longer simply an affect but hatred has become an organizing principle—often allows for a clearer understanding of the level of psychic organization involved and why the work feels the way it does.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy