Factors in the Psychoanalytic Treatment of Narcissistic Personalities

In this paper Otto Kernberg describes a group of patients whose central disturbance is the regulation of self-regard, bound up with a characteristic pathology of their object relations, and considers how they can be treated psychoanalytically. Narcissistic personalities show an unusual degree of self-reference, grandiosity alongside feelings of inferiority, an insatiable need for admiration, little empathy, intense envy, and an emotional life that is shallow and lacks the capacity for genuine sadness and mourning. They idealize those from whom they expect admiration and depreciate those from whom they expect nothing. Many of them function socially much better than other patients with severe character pathology, yet Kernberg argues that beneath this surface they share the defensive organization of borderline patients, dominated by splitting, denial, projective identification, omnipotence and primitive idealization. Their distinctive feature is a pathological grandiose self, a fusion of the actual self, the ideal self and the ideal object, which shields them from dependence on others while the devalued images of self and others are projected outward. He traces this structure to early experiences with cold yet overprotective parental figures and to intense oral rage and envy. He sets it against normal infantile narcissism and against Heinz Kohut's recent view of it as an arrest in normal development. In treatment, the grandiose self is activated in the transference: the analyst is alternately idealized and devalued or treated as nonexistent, and is often left bored or reduced to an extension of the patient. Kernberg recommends standard psychoanalysis for most of these patients, but for those who function on an overtly borderline level he proposes expressive psychoanalytic psychotherapy. In both he calls for the systematic interpretation of the grandiose self and of the envy, rage and fear of dependence it wards off, rather than accepting the idealization, and he reviews the factors that bear on prognosis.