Borderline Conditions and Pathological Narcissism

Kernberg's first book gathers and reworks the papers he wrote in the late 1960s and early 1970s, largely out of his clinical and research work at the Menninger Foundation, into a single account of the patients who fall between the neuroses and the psychoses. Its first part argues that these patients have a borderline personality organization: a specific and stable structure, not a passing state on the way to psychosis. Behind a wide range of symptoms (diffuse anxiety, multiple phobias, perverse and impulsive trends, addictions, lower-level character disorders) Kernberg finds a common structure: nonspecific ego weakness, a pull toward primary-process thinking, primitive defences centred on splitting, and a pathology of internalized object relations that leaves the patient without an integrated identity, while reality testing is largely kept. He traces it to excessive early aggression, especially oral aggression, which prevents the loving and hating images of self and others from being brought together and draws pregenital conflicts into the oedipal ones. The book draws practical conclusions from this. It weighs the factors that make the prognosis better or worse, and sets out an expressive psychoanalytic psychotherapy for most of these patients: the primitive defences are confronted and interpreted as they emerge in the transference, the negative transference is taken up in the here and now, and acting out is limited, with the patient's life structured from outside when necessary. A chapter on countertransference argues for treating the analyst's whole emotional response as a source of knowledge about such patients. The second half turns to the narcissistic personality, which Kernberg sees as a special form of the same organization, its surface held steady by a pathological grandiose self that fuses the real self, the ideal self and the ideal object and wards off envy, rage and dependence. He distinguishes it from normal adult and normal infantile narcissism, describes its idealizing and devaluing transferences, recommends psychoanalysis proper with systematic interpretation of the grandiose self for those who do not function at an overt borderline level, and sets his views against Heinz Kohut's.