This fascinating book is a collection of papers by the American psychiatrist and psychoanalyst Otto F. Kernberg. He has a long track record in psychotherapy research and has written extensively on psychoanalytic theory (linking it to neurobiology) and contemporary issues facing psychoanalysis and psychoanalytic trainings. All of these areas are covered within this book, which is divided broadly into five sections.
Parts 1 and 2 describe aspects of the work involved in the diagnosis and treatment of the most severe personality disorders, particularly severe narcissistic psychopathology. This is not a description of the research work, which is well-referenced, but more a focus on clinical experience and the development of new psychotherapeutic techniques that have arisen from his research. One of the chapters in this section describes the way in which manualised transference-focused psychotherapy (TFP) principles have been applied to psychoanalytic group psychotherapy in both day hospital and in-patient settings. These initial chapters give very detailed theoretical aspects and clinical examples of this work and, usefully, contrast TFP with mentalisation-based therapy (MBT), the brief evidence-based treatment perhaps more commonly used in the UK for this group of patients.
The first part includes very useful chapters on the assessment and treatment of narcissistic personality disorder, which emphasises the pervasive nature of envy and the impact of this on the patient, treatment and therapist. Kernberg points out that when working with very severe personality disorder, the safety of the therapist is paramount and takes precedence. As he says, the work cannot be done if the therapist is not safe, and techniques need to be adjusted in line with this. He makes the point that although this might seem ‘obvious or trivial’, it is often the case that therapists finds themselves seduced into a treatment situation with these patients in which their safety is actually at risk. He goes on to describe how one might decide between different psychotherapeutic approaches ranging from supportive treatments and cognitive–behavioural therapy, to individual psychodynamic psychotherapy and psychoanalysis, depending on the psychopathology of the patient. Chapters on countertransference and the use of supervision bring together issues for the therapist and the supervisor in treating this patient group. I was interested to see that the use of videotapes of psychotherapy sessions is, as with MBT, seen to be the gold standard in terms of supervision of psychoanalytic psychotherapy with this patient group. Although limiting his comments to this particular patient group, he says that on the basis of 30 years’ clinical and research experience, his findings are that patients readily accept video recording, as long as they have been appropriately informed and reassured about confidentiality.
Parts 3–5 of this book range across a broader field. Part 3 is concerned with the psychology of sexual love, Part 4 with contemporary challenges for psychoanalysis and Part 5 with the psychology of religious experience. In these chapters he moves between describing sexual pathology in patients with borderline personality disorder to a powerful description of the factors involved in the capacity for mature sexual love. The chapters on the sexual couple and the limitations to the capacity to love are fascinating.
This attention to aspects of more ‘ordinary’ relationships is to my mind beautifully crystallised in the chapter titled ‘Some observations on the process of mourning’. This is a moving description of mourning the loss of a long, loving relationship. Kernberg acknowledges that this was initiated by his own painful experience of mourning his late wife. This led him to question what he felt were some generally assumed characteristics of grief and mourning in the psychoanalytic literature. He describes many questions stemming from this which he addressed both by reviewing his past clinical experiences and by interviewing a number of people who had experienced the loss of a spouse after a long, happy relationship. He describes an awareness of the relative paucity of work focusing on normal mourning in the analytic literature, particularly on the losses of spouses. Using many examples he crafts a beautifully direct, emotionally powerful description of this loss and the gradual incorporation of the lost object into the experiences and behaviours of the individual who has lost. He concludes by describing normal mourning as a:
‘permanent, not a transitional, process that leads to structural psychic changes manifest in typical conscious experiences and behaviours. This conclusion runs counter to the present psychoanalytic view of normal mourning and considers mourning as an ongoing psychological process that fosters emotional growth and increases the capacity for commitment to new love relationships’.
The questioning of psychoanalytic theory as described in this chapter is clearly present throughout this volume. It illustrates Kernberg’s ongoing curiosity and determination to research and question all levels of his craft. These include the minutiae of individual clinical interactions and range through the relationships of psychoanalysis with universities and the ways in which psychoanalytic organisations function and struggle. He moves fluidly between internal object relationships, patient–therapist relationships and organisational dynamics. The book ends with two chapters about religion and spirituality in relation to psychoanalysis. Again, these describe and critically review the psychoanalytic literature and end with a conclusion that there is a need for integrating and understanding of these areas into our understanding of normality and pathology rather than using science and reason as a way of replacing religion and spirituality. These are challenging notions but powerfully argued.
Overall this is a broadly ranging book. At times it is academically dense and at times emotionally moving. I was left with a picture of a man who was curious, intellectually challenging of established theory and practice, and unafraid to question deeply held views. His arguments are intellectually rigorous, extensively researched and intellectually erudite. Although not a book for reading from cover to cover, it does offer ample opportunities for visiting a wide variety of areas concerning love and aggression. The book is not always an easy read, but it does repay the effort involved.
- Royal College of Psychiatrists