Otto Kernberg, a giant in the field of psychoanalysis, has published a compendium of his recent works on topics including sexual love, religion, narcissism, and mourning, as they relate to the interface of psychoanalysis and neurobiology. The book’s title The Inseparable Nature of Love and Aggression refers to the two basic instincts that Freud believed to underlie all human behavior, the two primary outlets of biological energy.
In part I, Kernberg discusses his extensive clinical experience in the diagnosis and treatment of the most severe personality disorders, particularly narcissistic psychopathology. This section begins with a discussion of the relationship between identity and personality organization. According to Kernberg, “identity diffusion is the most important, etiologically and symptomatically relevant, fundamental feature common to all severe personality disorders” (p. 4). Rich clinical cases are interwoven with techniques on how to clinically assess the level of identity integration in a structured diagnostic interview developed by Kernberg and his colleagues at the Personality Disorders Institute at Cornell. To treat patients with identity diffusion and “low ego strength,” Kernberg and his colleagues developed an intensive form of psychoanalytic psychotherapy known as transference-focused psychotherapy (TFP). TFP involves using systematic transference interpretations to enable these patients to reintegrate into their identity previously split-off parts of themselves, or “split-off internalized object relations of contrasting persecutory and idealized natures” (p. 34). The consistent interpretation of these distorted and contradictory perceptions in the transference becomes one of the mechanisms of therapeutic change, along with mentalization, mindfulness, insight, and empathy. In compelling clinical cases, Kernberg presents the “almost impossible” and often untreatable patients with severe narcissism and other psychopathologies in which aggression trumps love. In his essay, titled “The Destruction of Time in Pathological Narcissism,” Kernberg writes that “one aspect of the function of the grandiose self is precisely denial of the passage of time, the fantasy of eternal youth, and the very denial of death as an ultimate threat of their grandiosity” (p. 148). He adds that “narcissistic patients will often find themselves ‘waking up’ at age 40, 50 or 60 with a desperate sense of years lost” (p. 144).
In part II, Kernberg illuminates the complex interaction of neurobiological substrates and intrapsychic conflict in the formation of affects, drives, and personality. He addresses the controversial psychoanalytic theory of the death drive, the human drive toward self-destructive motivation and behavior, and its manifestation in the clinical setting. Severely sadistic and masochistic pathology is explored with illustrative clinical material. An inevitable part of the death drive is the process of mourning over destruction and loss, in which guilt feelings and concern serve as a reparative and potentially creative counterpart to death and loss. In a moving and brilliant essay, Kernberg discusses how his view of mourning and grief was fundamentally altered by his own mourning process for his wife of 52 years: “rather than being completed after a reasonable time, by the process of identification and letting go,” he saw that “the mourning process had evolved into significant characterological change [like superego restructuring, and] maintenance of an internal relationship with his wife” (p. 225). On the basis of personal interviews with colleagues and patients, Kernberg presents insightful phenomenological observations of the mourning process, such as “persons with severe, chronic conflicts with the person they lost and who were conscious of rather than denying their own ambivalence seem to show fewer feelings of guilt, in contrast to cases where a profound repression of the aggression against the lost person would emerge as the syndrome of pathological mourning, an expression of unconscious guilt” (p. 231).
Part III, The Psychology of Sexual Love, discusses the preconditions for the capacity of a mature love relationship, the inhibition of this capacity, and the manifestations of sexual problems in couples and patients with severe personality disorders. In this section, Kernberg moves from the organization of brain structures and neurotransmitters to the overall system of erotic activation, attachment, and bonding to consider the nature of passionate love and the psychodynamic features of a couple’s love relationship. He discusses how an individual’s capacity to integrate erotic desire, passionate love, and idealization evolves to the conditions that permit the establishment of a mature love relationship. Various psychopathologies and their effect on mature love relationship are discussed with clinical illustrations. For instance, in discussing a couple with a severe degree of superego pathology, Kernberg writes: “the most frequent expression of severe, chronic, mutual superego projection is one partner’s experience of the other as a relentless persecutor, a moralistic authority who sadistically enjoys making the other feel guilty and crushed, while that second partner experiences the first as unreliable, deceitful, irresponsible, and treacherous and feels enraged because the other is attempting to ‘get away with it’” (p. 267).
Part IV, Contemporary Challenges for Psychoanalysis, identifies the serious problems facing psychoanalytic education, institutions, and the profession of psychoanalysis and proposes solutions, such as strengthening ties of academic institutions, to energize the field and increase its contributions to scientific research and progress.
Part V, The Psychology of Religious Experience, addresses psychodynamic factors and object relations involved in religious and spiritual experiences and the role of universal ethical values in this context. In contrast to Freud’s view of religion as an expression of underlying psychological conflicts and distress, Kernberg views the psychological function of religiosity to be an expression of the development of the capacity for an internalized, integrated ethical guidance system akin to the development of a mature superego. Although psychoanalysis cannot make any pronouncement about the objective truth of religion or the existence of God, it can identify the origin of religion in the psychology of object relations: “… there exists a point at which experiences, judgments, and values derived from the internal world of object relations acquire a sense of universality [… and …] transcendence, of universal value within their respective domain. This development evolves into a spiritual realm” (p. 382). Kernberg likens the aforementioned transcendence to the mourning process and references a personal communication with Rabbi Moshe Berger: “It is only in the point of infinite absence where it is possible to fully recognize the full value of the time of finite presence in love” (p. 384).
As with all books by Otto Kernberg, this bold yet nuanced book possesses an unbelievable depth of wisdom, clarity, and brilliance. Although the prose can be Germanically dense at times, it is well worth the effort to extract every ounce of penetrating insight.
Anna Yusim, MD
Upper East Side Psychiatry
The author declares no conflict of interest.