Severe Personality Disorders: Psychotherapeutic Strategies

Severe Personality Disorders: Psychotherapeutic Strategies (Yale University Press, 1984) is Otto F. Kernberg's clinical companion to his earlier theoretical books on borderline conditions, pathological narcissism and object relations. Its stated aim is to make those formulations usable at the bedside: to give the clinician tools for diagnosing the difficult patient and for choosing and conducting a treatment. The book has five parts. Part One sets out structural diagnosis, which places a patient at a neurotic, borderline or psychotic level of personality organization according to identity integration, the kind of defences used and the state of reality testing, and the structural interview that elicits these features; it then applies the approach to adolescence and old age and to the classification of personality disorders. Part Two describes the treatment of borderline patients by a psychoanalytically based expressive psychotherapy centred on interpreting the transference, its adaptation for adolescents, a psychoanalytic form of supportive psychotherapy, and the indications for each modality. Part Three turns to narcissistic personalities, setting Kernberg's approach against other contemporary psychoanalytic views, above all Kohut's, and discussing technique, character analysis and the theory of self, ego, affects and drives. Part Four takes up severe regressions in treatment: stalemates, suicide risk, the incapacity to depend, superego pathology, paranoid regression and the syndrome of malignant narcissism, first formulated here. Part Five discusses hospital treatment, comparing philosophies of inpatient care, the therapeutic community model and long-term hospitalization of severe borderline and narcissistic patients. The book became a standard clinical reference, and its structural interview the basis of later assessment instruments.