Book
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.
Main ideas
- Structural diagnosis: personality organization is judged neurotic, borderline or psychotic by three criteria, the degree of identity integration as against identity diffusion, the predominance of higher-level or primitive defences such as splitting, and the presence or loss of reality testing.
- The structural interview joins the psychiatric examination to psychoanalytic exploration: by clarifying, confronting and interpreting what emerges in the encounter itself, the interviewer elicits the structural features that decide the diagnosis, the prognosis and the treatment to recommend.
- The structural approach is extended to special diagnostic problems: telling the identity crisis of adolescence from the identity diffusion of borderline organization, the course of personality disorders in old age, and the classification of personality disorders, which Kernberg argues should combine the level of organization with the type of character.
- For most borderline patients Kernberg recommends an expressive psychotherapy derived from psychoanalysis: face to face and less intensive than analysis, it interprets the primitive transference in the here and now from a stance of technical neutrality, which the therapist departs from when needed and then restores by interpretation.
- Supportive psychotherapy is presented as a distinct, psychoanalytically informed treatment for patients whose prognosis rules out expressive work; it uses clarification, suggestion and help with the patient's environment rather than transference interpretation, and the book sets out the indications and contraindications for psychoanalysis, expressive and supportive therapy.
- Narcissistic personalities are understood as built around a pathological grandiose self that defends against dependence and envy; against Kohut's self psychology, Kernberg argues for systematically interpreting this structure, and the aggression bound up in it, in the transference, linking the work to character analysis.
- Kernberg formulates malignant narcissism as the most severe form of narcissistic pathology short of antisocial personality: a narcissistic personality combined with antisocial behaviour, ego-syntonic aggression or sadism, and a paranoid orientation, with a correspondingly guarded prognosis.
- Severe regressions in treatment, stalemates, suicidal risk, the incapacity to depend on the therapist and paranoid regression, are read through transference and countertransference, and the degree of superego pathology is treated as a central indicator of prognosis and of whether psychotherapy is possible at all.
- For the most disturbed patients the book weighs philosophies of hospital treatment, examines the therapeutic community model, and describes long-term hospitalization of severe borderline and narcissistic patients organized on psychoanalytic object-relations principles.
What it shows
- 1981
Otto F. Kernberg introduced Structural interview
Kernberg devised the structural interview to diagnose the level of personality organization; he published it as "Structural Interviewing" (1981) and as a chapter of Severe Personality Disorders (1984).
- 1984
Otto F. Kernberg developed Malignant narcissism
Kernberg took up the phrase malignant narcissism, used earlier by Erich Fromm, and made it a clinical syndrome of severe narcissistic pathology marked by aggression, antisocial traits and paranoia, set out in Severe Personality Disorders (1984).
Malignant narcissism derives from Grandiose self
Kernberg described malignant narcissism as the pathological grandiose self of the narcissistic personality infiltrated by aggression, so that cruelty and the wish to dominate become part of the inflated self-image.