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Treatment of Severe Personality Disorders

Resolution of Aggression and Recovery of Eroticism


Journal of Psychiatric Practice®: May 2019 - Volume 25 - Issue 3 - p 237–238
doi: 10.1097/PRA.0000000000000380
Book Reviews

Eve Caligor, MD, is Clinical Professor of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and Director of the Psychotherapy Division, Columbia University Center for Psychoanalytic Training and Research, New York, NY

Marcia L. Verduin, MD, Book Editor

Reviewed by EVE CALIGOR, MD

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Otto Kernberg is without question one of the most influential psychoanalysts of our time. His work provides a bridge between the often rarified world of psychoanalysis and the practical challenges of clinical work with patients with severe personality disorders. Dr Kernberg’s contributions have been wide ranging and, in many cases, groundbreaking. He has been a thought leader in the classification of personality pathology, developing a system organized in relation to self and interpersonal functioning that is mirrored in the DSM-5 Section III Alternative Model for Personality Disorders. He was one of the first to study the syndrome of borderline personality disorder (BPD), and he has been a pivotal contributor to our current understanding of pathologic narcissism. In collaboration with John Clarkin and their team at the Personality Disorders Institute of the Weill Cornell Medical College, Kernberg built on his understanding of severe personality disorders to develop transference-focused psychotherapy (TFP), a manualized, evidence-based individual outpatient treatment for BPD. TFP is now considered one of the “big 3” treatments for BPD, along with dialectical behavior therapy and mentalization-based treatment.

In Treatment of Severe Personality Disorders: Resolution of Aggression and Recovery of Eroticism, Kernberg further develops these themes, all in an accessible, reader-friendly format. In part I, “Personality Disorders,” Kernberg emphasizes in particular the importance of integrating genetic and temperamental aspects of personality with psychological perspectives. For the reader unfamiliar with Kernberg, the chapter, “What is Personality?” is a succinct and up-to-date summary of his approach to the constructs of personality and personality disorder. Part II, “Spectrum of Psychoanalytic Psychotherapies,” the longest section of the book, is composed of 5 chapters on the psychodynamic treatment of personality pathology. Kernberg begins with 2 chapters that provide an overview of basic psychodynamic techniques, clearly describing them and elaborating their differential application in different types of treatment and with different forms of pathology. For the reader interested in developing an understanding of contemporary psychoanalytic clinical models, this may be the most accessible and contemporary summary available. This section also includes a chapter on TFP, focusing on recent empirical and clinical developments, and in addition introduces a psychodynamically informed approach to supportive psychotherapy. In part III, “Narcissistic Pathology,” Kernberg turns to the topic of severe narcissistic pathology, a domain in which his contributions have been seminal. Throughout this section he highlights the variable presentation of narcissistic personality disorder, as he characterizes different clinical syndromes across the dimension of severity. In elaborating his approach to treatment of narcissistic personality disorder and the clinical challenges it presents, Kernberg emphasizes the central role played by interpersonal and moral functioning in determining prognosis and clinical course. Part IV, “Erotism in the Transference,” covers problems with intimacy and sexuality in patients with severe personality pathology and describes how these difficulties play out in the treatment setting. The final section of the book, part V, “Denial of Reality, Mourning, and the Training of Psychotherapists,” is composed of 3 brief essays covering first, the role of reality in the treatment of severe personality pathology, next the process of normal mourning, and finally, comments on clinical training.

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Otto Kernberg has been a prolific and highly influential contributor to the psychiatric literature over many decades. This book is perhaps the most accessible of his many contributions, well curated, nicely organized, and well edited. While comprised of individual essays that stand alone and make for bite-size reading, the individual chapters hang together and tell an overall story of the current status of severe personality disorders, their classification, dynamics, and treatment within a psychodynamic frame of reference, with special reference to borderline and narcissistic pathology.

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Recommended Readership

This book has something for everyone—clinicians who work with patients with personality disorders, students of psychodynamics and psychoanalysis, and those with expertise in dynamic therapies will all find something of interest. General clinicians are likely to benefit in particular from Kernberg’s discussion of personality pathology and its classification, and also will be interested in his model of supportive psychotherapy. Readers who wish a quick overview of the state of psychoanalytic and dynamic clinical technique will discover an unusually specific and succinct summary of a contemporary psychoanalytic approach. For those familiar with TFP, the chapter on denial of reality is a wonderful exploration of the central role played by denial of reality in the treatment of severe personality pathology, and how a clinical focus on the patient’s external functioning is not only compatible with the nondirective stance of the TFP therapist but in fact is central to clinical technique. Finally, Kernberg’s vivid descriptions of the internal struggles confronting individuals with narcissistic personality are likely to be of interest to all.

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