Book Review
Psychotherapy
Aggression in Personality Disorders and Perversions. Otto F Kernberg. New Haven: Yale University Press; 1992. 316 p. US$17.00 (paperback).
Reviewer
rating*: Excellent
Review by: Paul Ian Steinberg, MD, FRCPC
Edmonton, Alberta
This book is extremely well organized and approaches the subject from a comprehensive point of view. It is divided into 5 sections, entitled “The Role of Affects in Psychoanalytic Theory,” “Developmental Affects of Broad-Spectrum Personality Disorders,” “Clinical Applications of Object Relations Theory,” “Technical Approaches to Severe Regression,” and “The Psychodynamics of Perversion.” First, Kernberg offers a revised psychoanalytic theory of drives and affects, carefully describing and distinguishing between drives, instincts, affects, emotions, and intrapsychic forces. He feels that object relations theoreticians who reject drive theory also seriously neglect motivational aspects of aggression. Parts of Chapter 1 are rather dense and completely theoretical and are difficult to read and to understand. Kernberg’s logic and theoretical rigor, however, are impressive. He tries to retain drive theory and to make object relations theory “fit” into it. “The Psychopathology of Hatred,” distinguishes between hatred and rage and focuses on fixations of the trauma. Kernberg adds comments about treatment of patients with severe aggression psychopathology.
“Clinical Dimensions of Masochism” describes normal masochism and the range of masochistic character pathology. Kernberg also describes syndromes of pathological infatuation and offers a hierarchy of masochistic sexual behaviour and perversion, describing these conditions at neurotic and borderline levels of personality organization. He concludes with implications of the proposed grouping. “Hysterical and Histrionic Personality Disorders” summarizes the literature and distinguishes between these conditions. Clinical descriptions of hysterical and histrionic personality in men and women follow, with comments on clinical course, prognosis, etiology, differential diagnosis, and treatment. “Antisocial and Narcissistic Personality Disorders” begins with “All patients with an antisocial disorder present features typical of the narcissistic personality disorder plus a specific pathology of their internalized systems of morality (their superego functions) and a particular deterioration of their world in internalized object relations” (p 67). Kernberg emphasizes the importance of pinpointing the dominant character pathology and the differential diagnosis of antisocial behaviour. He distinguishes among different diagnostic categories, which present with antisocial behaviours, offers prognostic and therapeutic considerations, and describes the psychodynamics of malignant narcissism and of the antisocial personality.
In “Object Relations Theory in Clinical Practice,” Kernberg outlines his approach: “a willingness to wait to intervene until the patient’s verbal communications and non-verbal behaviour...and my countertransference guide me to the affectively dominant theme” (p 88). He adds, “even at the neurotic level of pathology, a process may be observed that becomes prevalent with deeper psychopathology: the rapid reversal or alternation between the activation of the patient’s self representation with the object representation projected onto the analyst and other moments when the patient enacts an identification with that object representation while projecting the self representation onto the analyst” (p 92). “An Ego Psychology-Object Relations Theory Approach to the Transference” describes channels of communication of the transference. He emphasizes that, in patients with severe character pathology, the nonverbal communication acquires affective predominance in conveying information to the analyst. It is crucial to uncover the unconscious meanings of the transference on the here-and-now and to make the expression of this object relation in the transference fully conscious before attempting reconstructions of the past. Then, the previously repressed or projected object relation may be acknowledged and become ego-dystonic. Only then should questions about the genetic determinants of the currently activated unconscious intrapsychic conflict be considered.
“An Ego Psychology-Object Relations Theory of Structural Change” consists largely of clinical illustrations and discussion. “Transference, Regression, and Psychoanalytic Technique with Infantile Personalities” begins with a description of infantile personality characteristics, followed by case examples and technical considerations in treatment. “Projection and Projective Identification: Developmental and Clinical Aspects” includes a discussion of technical approaches, as well as more clinical illustrations. “Projective Identification, Countertransference, and Hospital Treatment” describes long-term in-patient treatments that illustrate regressive group processes. Kernberg notes, “given the great potential for activation of superego corruption in the large group under regressive conditions, a...potential exists for the replication in the hospital’s social system of patients’ specific superego pathology” (p 191). Kernberg’s detailed descriptions of his treatment of severely disturbed individuals are fascinating and remarkable in what they convey, given their relative brevity. “Identification and Its Vicissitudes as Observed in Psychosis” defines different forms of internalization and includes a lengthy case history with discussion. “Vicissitudes of and Pleasure in Hatred” deals with clinical manifestations of pleasure in experiencing and expressing primitive hatred, emphasizing secondary defences against hatred in the transference. Kernberg’s case vignette shows how he establishes parameters to block the patient’s destruction of the treatment. “Psychopathic, Paranoid, and Depressive Transferences” highlights deliberate deceptiveness in communication with the therapist in patients with psychopathic transferences. He describes the shift in the transference from a psychopathic into a paranoid frame. Melanie Klein’s influence on Kernberg is frequently evident.
“The Relation of Borderline Personality Organization to the Perversions” describes the projection of pregenital aggression onto parental figures in borderline patients and its clinical effects. This projection causes a paranoid distortion of early parental images, especially with the mother. It would be helpful for Kernberg to have expressed this in a more jargon-free manner. This chapter begins with an unnecessarily complicated description of the vicissitudes of aggression in borderline patients. Occasionally, Kernberg goes too far (for example, in a sentence that is 25 lines long). He deals with perversion and the relationship of the couple, malignant narcissism, perversion and perversity, and perversion and neurotic personality organization, and concludes with comments on polymorphous perverse sexuality and levels of personality organization. This chapter is less accessible than are earlier ones and is packed with psychoanalytic jargon and long, convoluted sentences. “A Theoretical Frame for the Study of Sexual Perversions”distinguishes 3 groups of formulations of the perversions. Kernberg concludes, “polymorphous perverse fantasies, activities, and capabilities are an essential part of human sexuality at all levels of pathology and normality. The consolidation of a specific perversion as an obligatory precondition for sexual gratification, to the detriment of ordinary freedom and flexibility of sexual gratification in a stable relation with a loved heterosexual object, may indicate a severe or moderate, or merely a mild degree of pathology, according to the patient’s predominant level of ego organization and object relations” (p 267). Kernberg considers polymorphous perverse features to be a crucial component of normal sexuality. He believes that patients with total inhibition of all polymorphous perverse fantasies and impulses that are derived not from repression, but from lack of activation of early eroticism, have the least favourable prognosis for treatment of their pathological sexuality. He feels that there exists not one homosexuality but a spectrum of homosexual pathology that patterns that of the other perversions, with individuals at the healthier end who have a capacity for integration of genital and tender impulses in the same object relation without the exclusive and rigid characteristics typical of other perversions. “A Conceptual Model for Male Perversion (With Particular Reference to Male Homosexuality)” describes male polymorphous perverse sexuality, homosexuality, and neurotic and borderline personality organization. Kernberg distinguishes between the consolidated homosexual perversion in a nonnarcissistic borderline patient and that of the narcissistic personality structure with a dominant homosexual identification. He offers a diagnostic frame for male perversion, including perversion and malignant narcissism and perversion in psychosis. He deals with male homosexuality and normality and describes some technical problems in the psychoanalysis of perversion.
This book comprises more than what the title suggests. Kernberg’s always highly organized thoughts are definitely worth considering. Much of the content, however, appears to only indirectly relate to the title. Kernberg relies heavily on case illustrations, demonstrating his thoughtful, determined, and skillful handling of difficult patients in psychotherapy and psychoanalysis.
To conclude, Kernberg demonstrates both his considerable strengths and, at a few points, weaknesses, which were more evident in his earlier works. He is organized, comprehensive, logical, and generally clear, and offers good clinical evidence for his conclusions. Occasionally he comes across as obscure and jargon-laden. This book is well worth reading for anyone interested in a modern psychoanalytic view of aggression and the treatment of severe personality disorders.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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