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Aggression in Personality Disorders and Perversions
In this important new book, Dr. Otto F. Kernberg, one of the world's foremost psychoanalysts, explores the role of aggression in severe personality disorders and in normal and perverse sexuality, integrating new developments in psychoanalytic theory with findings from clinical work with severely regressed patients. The book also integrates Dr. Kernberg's recent studies of the descriptive, structural, and psychodynamic features of problems stemming from pathological aggression with the vicissitudes of their psychoanalytic treatment. Finally, Dr. Kernberg demonstrates the importance of differential diagnosis for effective psychoanalytically inspired treatment of these disorders, providing a rich variety of clinical illustrations.
The book begins by relating the dual-drive theory of libido and aggression to contemporary developments in affect theory. Dr. Kernberg then applies this general theory of affects to aggression, which in its pathological form centers on the affect of hatred. He analyzes sado-masochistic, hysterical-hysteroid, and narcissistic-antisocial spectrums of personality disorders, emphasizing how aggression is structured in each group. Dr. Kernberg next describes and updates the theoretical frame underlying his approach to the treatment of these disorders, outlines their clinical manifestations, and illustrates their diagnosis and treatment, ranging from standard psychoanalysis with infantile personalities, to psychoanalytic psychotherapy with borderline personalities, to the psychotherapeutic approach to the treatment of psychosis and hospital milieu treatment in the management of highly regressed patients. In the final section, Dr. Kernberg links the findings from psychoanalytic approaches to personality disorders with those from the psychoanalytic study of sexual perversions.
The book begins by relating the dual-drive theory of libido and aggression to contemporary developments in affect theory. Dr. Kernberg then applies this general theory of affects to aggression, which in its pathological form centers on the affect of hatred. He analyzes sado-masochistic, hysterical-hysteroid, and narcissistic-antisocial spectrums of personality disorders, emphasizing how aggression is structured in each group. Dr. Kernberg next describes and updates the theoretical frame underlying his approach to the treatment of these disorders, outlines their clinical manifestations, and illustrates their diagnosis and treatment, ranging from standard psychoanalysis with infantile personalities, to psychoanalytic psychotherapy with borderline personalities, to the psychotherapeutic approach to the treatment of psychosis and hospital milieu treatment in the management of highly regressed patients. In the final section, Dr. Kernberg links the findings from psychoanalytic approaches to personality disorders with those from the psychoanalytic study of sexual perversions.
326 pages, Paperback
First published January 1, 1992
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About the author
Otto F. Kernberg
107 books101 followersOtto Friedmann Kernberg (born 10 September 1928) is an Austrian-born American psychoanalyst and professor of psychiatry at Weill Cornell Medicine. He is most widely known for his psychoanalytic theories on borderline personality organization and narcissistic pathology.
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March 22, 2020
Considered by many psychiatrists and psychoanalysts of my generation and older to be Kernberg's masterpiece, this 1992 entry by the prolific and influential ego-psychologist may be a bit dated in some places, but is overall still as innovative and refreshing today.
Works like this really need to be revisited and cherished by psychiatrists in modern practice. My psychiatric training was in one of the last residencies that still incorporated equal focus on psychotherapies, including psychoanalysis, and pharmacotherapies. Now, psychoanalysis barely exists outside academic institutions in big cities, and the experience that patients now have with psychiatry is one of 10 minute med checks while less experienced therapists take on the tricky and sometimes dangerous roles of solidifying ego strength and improving distress tolerance. Particularly when it comes to aggressive patients, which is the obvious subject of this book, psychiatrists today are like babes in the woods, with little proper teaching on how to handle aggression in their short sessions. I have been supervising mental health professionals for most of my career, and found that if an interaction with a patient becomes uncomfortable for the practitioner, the outcomes are usually not good. The patient either is dismissed from the practice or transferred to another provider, or worst of all, the professional unwittingly takes on the aggression that the patient is projecting in a masochistic or sadistic way by identifying with the intrapsychic object. You hear cringy and condescending comments from professionals when this happens like, "Oh, he's nothing but a sociopath," or "She's a borderline--go figure!" This is not only unproductive but harmful to both parties. You don't have to be an analyst to be mindful of transference and corresponding countertransference, and all mental health professionals should know how to manage these dynamics to enrich understanding of the client and their needs.
It was at the peak of popularity of this book that I had the pleasure to meet Otto Kernberg in the flesh and experience some of his teaching firsthand. He became one of my heroes, and though my own approach to patients eventually evolved into a more Kohutian one, I incorporated many of Kernberg's theories despite how seemingly opposed the Kohutian and Kernbergian philosophies are. Stephen A. Mitchell's own brilliant work offered an integrative approach combining the two models, and I have found this to be invaluable to my success with my own addiction clients, who have many comorbid personality disorders from previous traumas and pathological family dynamics that continue to drive the addictive behaviors.
This book contains the best overall examples of Kernberg's style and treatment approaches all summarized in one place. Where the book really shines is that it was one of the first to break the professional stigma that mental health professionals had (and still do) about patients with "unanalyzable" and even "untreatable" personality disorders. It allowed for new conversations and renewed interest in helping people diagnosed with dreaded labels like "antisocial," "narcissist," or "borderline." Perhaps no other work in psychoanalysis has had such a positive impact.
The book also does something that many in the healthcare field still fail to do. It differentiates antisocial personality disorder proper from antisocial behavior. The latter can come about in any kind of person if traumatic and/or chaotic relationships and experiences devastate the internalization of object relations, or if the general environment forces the release of sadistic behaviors in the presence of an otherwise healthy superego in order to survive. Thus, Kernberg attempts to explain why children and young men enter violent gangs, or why Nazi soldiers showed no outward sign of their sadistic acts in their daily functioning before or after the Holocaust. A therapist or physician cannot label every patient with the antisocial moniker who exhibits such behaviors, as the approach is different for various personalities and situations in which antisocial traits are exhibited. In regards to the variety of reasons and causes for the intrapsychic transformation of intrapsychic internalizations of "bad objects," Kernberg quotes Fairbairn here very poignantly:
"It is better to be a sinner in a world ruled by God than to live in a world ruled by the Devil..."
Kernberg discusses many types of disordered personality that today you will not find in a DSM-5, such as "hysterical" personality as opposed to histrionic personality, and "malignant" narcissism as different from narcissistic personality disorder. I have found these descriptions of the various shades of gray between the official DSM diagnoses very helpful in my clinical practice through the years, and it often helps to retrospectively anticipate what types of formative experiences a patient may have had based on their presentation and also to anticipate what kinds of interpersonal problems the patient is having, even if the verbal information you get from the patient is confusing, vague, or disjointed. Speaking of the past, reconstructions of a patient's past is deemphasized in this work, as Kernberg encourages the therapist to focus on the patient's experience and functioning in the "here-and-now." Helping the patient be aware of the meaning of their behaviors in the transference via interpretations by the therapist helps unlock the unconscious past. This awareness helps the patient consciously shift the nature of their object relations activated in the transference in order to have lasting changes in how they relate to others outside of the therapy sessions.
I also really appreciated the discussion halfway through the book about how behavioral changes from psychoanalytic object-relation restructuring differs from behaviorally induced changes seen in supportive psychotherapy or cognitive-behavioral therapy. The psychoanalytic process lends itself to the spontaneous provision of new information by the patient during the exploration of the transference, while on the other hand, the patient lacks specific and individualized insights through compliance with direct instructions and assignments during behavioral modification techniques and other non-analytic therapies. Kernberg supplies several interesting clinical vignettes demonstrating this advantage, as he does for all insights he makes in this incredible volume.
Though this book is written for readers with advanced psychoanalytic backgrounds, I still strongly recommend anyone in the mental health field to study this work and absorb it into your practice, whether or not you have patients on the couch!
Works like this really need to be revisited and cherished by psychiatrists in modern practice. My psychiatric training was in one of the last residencies that still incorporated equal focus on psychotherapies, including psychoanalysis, and pharmacotherapies. Now, psychoanalysis barely exists outside academic institutions in big cities, and the experience that patients now have with psychiatry is one of 10 minute med checks while less experienced therapists take on the tricky and sometimes dangerous roles of solidifying ego strength and improving distress tolerance. Particularly when it comes to aggressive patients, which is the obvious subject of this book, psychiatrists today are like babes in the woods, with little proper teaching on how to handle aggression in their short sessions. I have been supervising mental health professionals for most of my career, and found that if an interaction with a patient becomes uncomfortable for the practitioner, the outcomes are usually not good. The patient either is dismissed from the practice or transferred to another provider, or worst of all, the professional unwittingly takes on the aggression that the patient is projecting in a masochistic or sadistic way by identifying with the intrapsychic object. You hear cringy and condescending comments from professionals when this happens like, "Oh, he's nothing but a sociopath," or "She's a borderline--go figure!" This is not only unproductive but harmful to both parties. You don't have to be an analyst to be mindful of transference and corresponding countertransference, and all mental health professionals should know how to manage these dynamics to enrich understanding of the client and their needs.
It was at the peak of popularity of this book that I had the pleasure to meet Otto Kernberg in the flesh and experience some of his teaching firsthand. He became one of my heroes, and though my own approach to patients eventually evolved into a more Kohutian one, I incorporated many of Kernberg's theories despite how seemingly opposed the Kohutian and Kernbergian philosophies are. Stephen A. Mitchell's own brilliant work offered an integrative approach combining the two models, and I have found this to be invaluable to my success with my own addiction clients, who have many comorbid personality disorders from previous traumas and pathological family dynamics that continue to drive the addictive behaviors.
This book contains the best overall examples of Kernberg's style and treatment approaches all summarized in one place. Where the book really shines is that it was one of the first to break the professional stigma that mental health professionals had (and still do) about patients with "unanalyzable" and even "untreatable" personality disorders. It allowed for new conversations and renewed interest in helping people diagnosed with dreaded labels like "antisocial," "narcissist," or "borderline." Perhaps no other work in psychoanalysis has had such a positive impact.
The book also does something that many in the healthcare field still fail to do. It differentiates antisocial personality disorder proper from antisocial behavior. The latter can come about in any kind of person if traumatic and/or chaotic relationships and experiences devastate the internalization of object relations, or if the general environment forces the release of sadistic behaviors in the presence of an otherwise healthy superego in order to survive. Thus, Kernberg attempts to explain why children and young men enter violent gangs, or why Nazi soldiers showed no outward sign of their sadistic acts in their daily functioning before or after the Holocaust. A therapist or physician cannot label every patient with the antisocial moniker who exhibits such behaviors, as the approach is different for various personalities and situations in which antisocial traits are exhibited. In regards to the variety of reasons and causes for the intrapsychic transformation of intrapsychic internalizations of "bad objects," Kernberg quotes Fairbairn here very poignantly:
"It is better to be a sinner in a world ruled by God than to live in a world ruled by the Devil..."
Kernberg discusses many types of disordered personality that today you will not find in a DSM-5, such as "hysterical" personality as opposed to histrionic personality, and "malignant" narcissism as different from narcissistic personality disorder. I have found these descriptions of the various shades of gray between the official DSM diagnoses very helpful in my clinical practice through the years, and it often helps to retrospectively anticipate what types of formative experiences a patient may have had based on their presentation and also to anticipate what kinds of interpersonal problems the patient is having, even if the verbal information you get from the patient is confusing, vague, or disjointed. Speaking of the past, reconstructions of a patient's past is deemphasized in this work, as Kernberg encourages the therapist to focus on the patient's experience and functioning in the "here-and-now." Helping the patient be aware of the meaning of their behaviors in the transference via interpretations by the therapist helps unlock the unconscious past. This awareness helps the patient consciously shift the nature of their object relations activated in the transference in order to have lasting changes in how they relate to others outside of the therapy sessions.
I also really appreciated the discussion halfway through the book about how behavioral changes from psychoanalytic object-relation restructuring differs from behaviorally induced changes seen in supportive psychotherapy or cognitive-behavioral therapy. The psychoanalytic process lends itself to the spontaneous provision of new information by the patient during the exploration of the transference, while on the other hand, the patient lacks specific and individualized insights through compliance with direct instructions and assignments during behavioral modification techniques and other non-analytic therapies. Kernberg supplies several interesting clinical vignettes demonstrating this advantage, as he does for all insights he makes in this incredible volume.
Though this book is written for readers with advanced psychoanalytic backgrounds, I still strongly recommend anyone in the mental health field to study this work and absorb it into your practice, whether or not you have patients on the couch!
Displaying 1 of 1 review