He has sharp features and a tenacious, penetrating look. In a large carved chair with a high back on the stage of the Central House of Architects, he looks like Bulgakov's Woland. Only instead of a session of magic with subsequent exposure, he conducts a detailed analysis of cases from his own practice and the practice of psychotherapists present at the meeting.
But there is definitely something magical in the ease with which Otto Kernberg penetrates the depths of such a mysterious matter as sexuality. He created a modern psychoanalytic theory of personality and his own psychoanalytic method, proposed a new approach to the treatment of borderline personality disorders and a new look at narcissism. And then suddenly he changed the direction of research and amazed everyone with a book about love and sexuality. Understanding the subtle nuances of these delicate relationships can be envied not only by his fellow psychologists, but also by poets, perhaps.
psychology:
To what extent is human sexuality amenable to scientific study?
Difficulties arise with the study of physiological processes: it is necessary to look for volunteers who are ready to make love in sensors, with special equipment and under the supervision of scientists. But from a psychological point of view, I don't see any problems, except for one thing: psychologists and therapists are often embarrassed to ask the right questions about sex life.
Psychologists? Not their clients?
OK.:
In fact of the matter! It is not so much the clients who are shy, but the psychotherapists themselves. And it’s completely in vain: if you ask the right questions that follow from the logic of the conversation, then you will definitely get the information that you need. Apparently, many therapists lack the experience and knowledge to understand exactly what questions about the client's sex life should be asked - and at what point.
It happens that two healthy people connect, and it's a real hell. And sometimes partners have severe personality disorders, but great relationships
It is important that the therapist is intelligent, emotionally open, and has sufficient personal maturity. But at the same time, he needs the ability to perceive primitive experiences, not to be too tight and limited.
Are there areas of life closed to research?
OK.:
It seems to me that we can and should study everything. And the main obstacle is the attitude of society towards certain manifestations of sexuality. It is not scientists, psychoanalysts, or clients that hinder this kind of research, but society. I don’t know how it is in Russia, but in the USA today, for example, it is unthinkably difficult to study everything related to sexuality in children.
The irony is that it was American scientists who were once the pioneers in this field of knowledge! But try now to ask for funding for research related to child sexuality. At best, they will not give you money, and at worst, they can report you to the police. Therefore, this kind of research is almost non-existent. But they are important for understanding how sexuality develops at different ages, in particular, how sexual orientation is formed.
If we are not talking about children, but about adults: how much is the concept of mature sexual love, about which you write a lot, related to biological age?
OK.:
In a physiological sense, a person matures for sexual love in adolescence or in early youth. But if he suffers, for example, from a severe personality disorder, then reaching maturity may take longer. At the same time, life experience plays an important role, especially when it comes to people with a normal or neurotic personality organization.
Freud said that he would not write about love until it ceased to be a problem for him. But he didn't actually write anything. So he didn't solve the problem.
In any case, one should not think that mature sexual love is a relationship that is available only to people over 30 or 40 years old. Such relationships are quite accessible even to 20-year-olds. Once I noticed that the degree of personal pathology of each of the partners does not allow predicting how their life together will turn out. It happens that two absolutely healthy people are connected, and this is a real hell. And sometimes both partners have severe personality disorders, but a great relationship!
What role does the experience of living together with one partner play? Can three failed marriages "together" provide the necessary experience that will lead to mature sexual love?
OK.:
I think that if a person is able to learn, then from failures he also draws his lessons. Therefore, even unsuccessful marriages can help him become more mature. And ensure success in a new partnership. But if a person has serious psychological difficulties, then he does not learn anything, but simply continues to make the same mistakes from marriage to marriage. A constant relationship with the same partner can similarly lead to the achievement of mature sexual love. Or they may not lead - I repeat once again: a lot depends on the type of psychological organization of the individual.
What new things do you know about love and sexuality that Freud, for example, did not know or could not know?
OK.:
We need to start with the fact that we do not understand very well what Freud knew and did not know. He himself said that he did not want to write about love until it ceased to be a problem for him. But so, in fact, he did not write anything. From which we can conclude that he did not solve this problem in his entire life. You should not blame him for this: after all, this is very human and not at all surprising. A great many people cannot solve this problem all their lives.
But from a scientific point of view, today we know much more about love than Freud. For example, he believed that by investing libido in love relationships, we use up its “reserves”. This is a deep delusion. Libido is not oil or coal, so that its "reserves" can be depleted. By investing in relationships, we enrich ourselves at the same time.
Freud believed that the super-ego in women is not as pronounced as in men. This is also a mistake. Freud thought that penis envy is a powerful force that affects women. And this is true, but men are also affected by envy of the feminine nature, and Freud ignored this. In a word, psychoanalysis has not stood still all these years.
You argue that freedom in a mature sexual relationship allows you to treat your partner as an object.
OK.:
I mean only that in the context of a healthy, harmonious sexual relationship, all impulses of sexuality can be involved: manifestations of sadism, masochism, voyeurism, exhibitionism, fetishism, and so on. And the partner becomes the object of satisfaction of these sadistic or masochistic aspirations. This is absolutely natural, any sexual impulses always include a mixture of both erotic and aggressive components.
It is only important to remember that in a mature relationship, the partner who becomes the object of these impulses agrees to their manifestation and enjoys what is happening. Otherwise, of course, there is no need to talk about mature love.
What would you wish a young couple on the eve of the wedding?
OK.:
I would wish them to enjoy themselves and each other. Do not limit yourself to imposed ideas about what is right and wrong in sex, do not be afraid to fantasize, seek and find pleasure. In addition, it is important that their daily life is based on the coincidence of desires. So that they can share responsibilities, together solve the tasks facing them.
And finally, it would be great if their value systems at least did not come into conflict. This does not necessarily mean that they must vote for the same candidate in the presidential election. It is much more important that they have similar ideas about good and evil, spiritual aspirations. They can become the basis for a common system of values, for collective morality on the scale of one particular couple. And this is the most reliable foundation for strong partnerships and their most reliable protection.
9 signs of mature love
How to find out how successful the relationship is in our couple? Here are nine characteristics of mature love that the psychoanalyst Otto Kernberg names.
- Interest in partner's life plan (without destructive envy).
- Basic Trust: The mutual ability to be open and honest, even about their own shortcomings.
- The capacity for true forgiveness, as opposed to both masochistic submission and denial of aggression.
- Humility and gratitude.
- Common ideals as the basis of living together.
- mature addiction; the ability to accept help (without shame, fear or guilt) and provide assistance; a fair distribution of tasks and responsibilities - in contrast to the struggle for power, accusations and the search for right and wrong, which lead to mutual disappointment.
- Constancy of sexual passion. Love for another, despite bodily changes and physical defects.
- Recognition of the inevitability of loss, jealousy and the need to protect the boundaries of the couple. Understanding that another cannot love us in the same way that we love them.
- Love and mourning: In the event of a partner's death or departure, loss allows us to fully understand their place in our lives, leading to acceptance of new love without guilt.
About the expert
Otto Friedmann Kernberg, M.D., former President of the International Psychoanalytic Association, Trainer Analyst and Supervisor at the Center for Psychoanalytic Training and Research at Columbia University (USA), Professor of Psychiatry at Cornell University and Director of the Institute for Personality Disorders at Westchester. Author and co-author of 30 books. One of the leading experts in the field of borderline personality disorders. Creator of modern psychoanalytic theory of personality. He studied the issues of pathological narcissism, as well as aggression, destructiveness, love and sexuality in normal and pathological conditions. His work has been included in many textbooks on psychology and psychotherapy.
We thank the organizers of the Otto Kernberg seminar in Moscow:
A group of Psy-event partners and personally Konstantin Gutman.
The book of the doctor of medicine Otto Kernberg, one of the most authoritative modern psychoanalysts, is devoted to the relationship of love in norm and pathology. Illustrating theoretical positions with practical cases, the author explores how unconscious experiences and fantasies related to the past have a strong influence on today's couple's relationship. How intricately love and aggression interact in a couple's life. How to keep passionate love in a long-term relationship. How the social environment affects love relationships... This deep clinical and theoretical study will arouse undoubted interest among specialists - psychologists, psychotherapists, doctors, teachers.
Otto F. KERNBERG
LOVE RELATIONSHIPS:
Norm and pathology
ALL THIS IS ABOUT THE MYSTERIES OF LOVE
Oh if only I could
Although in part
I would write eight lines
About the properties of passion.
B. Pasternak
We are very far from Otto Kernberg, one of the most prominent figures in contemporary psychoanalysis. He became a classic during his lifetime, developed a new approach within psychoanalysis and a new approach to the treatment of patients with narcissistic and borderline personality disorders, his work was included in all textbooks. He is the current president of the IPA, the most influential and respected psychoanalytic organization in the world, membership in which is the blue dream of all Russian psychotherapists involved in psychoanalysis. We are so far from Kernberg that we can perhaps take some liberties in the preface. Moreover, a fairly complete review of Otto Kernberg's contribution to psychoanalysis was given by A. Uskov in the introductory remarks to Kernberg's monograph Aggression in Personality Disorders and Perversions, previously published by Klass.
One can imagine that after the work on aggression, Kernberg was so often repeated: “Is it weak about love?” That he wanted to show: no, it’s not weak, and so much so that now you can’t write a word about love without referring to me.
It is known that love is more difficult to express than aggression. According to Kernberg, it takes many years for a person to reach the phase of mature sexual love, which may be part of the reason he wrote his book at almost seventy years of age. And How! More than two hundred pages about the properties of passion ... Having made a reservation at the beginning that poets and philosophers, of course, described human love better than it can be done with the help of any psychoanalytic research, Kernberg then, as it were, challenges - and describes all the secret nuances of love relationships . So in his text, as in good poetry, we recognize our own most intimate experience. It just becomes uncomfortable and even somehow offensive - what seemed like a precious unique experience, undeservedly bestowed on you by fate, when it takes your breath away and you think: does it really happen, do other people also ever experience something like that? - is described in a scientific book better than you yourself could do it, and it is also separately explained why it is typical.
And you remain at a loss: what to do now with all this knowledge? Yes, it is easier to understand what is happening with patients. But how now to love, and even more so to make love, if your every spiritual movement is dissected, classified, numbered, and also has several explanations of where it came from?
As if anticipating such a reaction from readers, Kernberg writes: “The activation of a powerful and complex countertransference, held and applied in the work, is a unique feature of the psychoanalytic situation, possible only thanks to the protection provided by the framework of the psychoanalytic relationship. A kind of ironic confirmation of the uniqueness of experiencing such an experience in the countertransference is that although psychoanalysts have an extraordinary opportunity to explore the love life of the opposite sex, this knowledge and experience tends to vanish as soon as it comes to understanding one's own experiences of relationships with the other sex outside the psychoanalytic situation. like other mortals."
And now a few prosaic words about the actual merits of the book. Kernberg covers in detail the existing literature on this issue, and moreover by a variety of authors, not only close to him in spirit. He boldly and sometimes in the most original way connects ideas that at first glance express completely different approaches to the described phenomena.
Considering the relationship of love in norm and pathology, he shows how the individual pathologies of partners "interfere", in some cases creating a pathology of the couple, which is not their simple imposition. In love relationships, the underlying psychopathology may be fixed or resolved. In addition, the existing psychopathology is often disguised as something else through the efforts of both partners. Kernberg confidently and fearlessly writes about the secret to maintaining passionate love in long-term relationships: in mature sexual love, a person finds a form for the fulfillment of all his infantile sexual fantasies.
The social aspect of the issue considered by Kernberg is very interesting. The themes of the couple and the group, the couple and society, the sexual as originally opposed to the conventional and the social, are heard more often in novels than in psychological and psychoanalytic literature. And the chapter on the depiction of love relationships in modern cinema will certainly be interesting. anyone to the reader.
This book is definitely not easy to read. But not because it is difficult to write, but because of the extreme richness of the presentation - a lot of thoughts per unit of text. There was this old joke: "You know, Faulkner is so hard to read!" - "Yes, but when you read it, such a relief!" So, I don’t promise relief at all, but that you won’t regret it, that’s for sure.
Maria Timofeeva
FOREWORD
For centuries, love has been the object of close attention of poets and philosophers. Recently, sociologists and psychologists have joined them. But the psychoanalytic literature still pays surprisingly little attention to love.
Trying again and again to study the nature of love, I realized that it is impossible to avoid connection with erotica and sexuality. It turned out that in most works the sexual reaction is considered from the point of view of biology, and only in a few it is referred to as a subjective experience. When I explored this subjective aspect in my work with patients, I found myself dealing with unconscious phantasies whose origins lie in infantile sexuality, in full accordance with Freud's point of view. From clinical experience, it turned out that through mutual projective identification, the couple "plays out" their past "scripts" (unconscious experiences and fantasies) in their relationship and that fantasy and real mutual "molestation" originating from the infantile Super-Ego and the self associated with it ideal, have a powerful influence on the life of a couple.
I have noticed that it is almost impossible to predict the fate of love relationships and marriage based on the characteristics of the patient's psychopathology. Sometimes different forms and degrees of psychopathology in partners contribute to their compatibility; otherwise, differences may cause incompatibility. Questions such as "What keeps a couple together?" or "What ruins a relationship?" haunted me and prompted me to explore the dynamics behind the couple's observed relationship development.
My initial data were the treatment of patients through psychoanalysis and psychoanalytic therapy, the observation and treatment of couples suffering from marital conflicts, and especially the longitudinal study of couples through the prism of psychoanalysis and individual psychoanalytic psychotherapy.
Ecology of Consciousness: Psychology. Otto Kernberg amazed everyone with a book about love and sexuality. Understanding the subtle nuances of these delicate relationships can be envied not only by his fellow psychologists, but also by poets, perhaps.
Otto Kernberg created a modern psychoanalytic theory of personality and his own psychoanalytic method, proposed a new approach to the treatment of borderline personality disorders and a new look at narcissism. And then suddenly he changed the direction of research and amazed everyone with a book about love and sexuality. Understanding the subtle nuances of these delicate relationships can be envied not only by his fellow psychologists, but also by poets, perhaps.
Nine Characteristics of Mature Love by Otto Kernberg
1. Interest in your partner's life plan(without destructive envy).
2.Basic trust: the mutual ability to be open and honest, even about their own shortcomings.
3. The ability to truly forgive, as opposed to both masochistic submission and denial of aggression.
4. Modesty and gratitude.
5. Common ideals as the basis for living together.
6. mature addiction; the ability to accept help (without shame, fear or guilt) and provide assistance; a fair distribution of tasks and responsibilities - in contrast to the struggle for power, accusations and the search for right and wrong, which lead to mutual disappointment.
7. Constancy of sexual passion. Love for another, despite bodily changes and physical defects.
8. Recognition of the inevitability of loss, jealousy and the need to protect the boundaries of the couple. Understanding that another cannot love us in the same way that we love them.
9. Love and mourning: in the event of the death or departure of a partner, the loss allows us to fully understand what place he occupied in our life, which leads to the acceptance of new love without guilt.published . If you have any questions on this topic, ask them to specialists and readers of our project
Otto F. Kernberg (born 1928) is one of the largest and best known active psychoanalysts. Born in Vienna, Kernberg and his family fled Nazi Germany in 1939, emigrating to Chile. He studied biology and medicine and subsequently psychiatry and psychoanalysis at the Chilean Psychoanalytic Society.
The first time Kernberg came to the US was in 1959 for a meeting of the Rockefeller Foundation to do research on psychotherapy with Jerome Frank at Johns Hopkins Hospital. In 1961 he emigrated to the USA and began working at the Menninger Clinic, later becoming director of the hospital.
He also became Supervisor and Training Analyst at the Topeka Institute for Psychoanalysis, and Director of Psychotherapy Research at the Menninger Foundation.
In 1973, Kernberg moved to New York, where he became director of the clinical department of the New York State Psychiatric Institute. In 1974 he became Professor of Clinical Psychiatry at Columbia University and Supervisor and Training Analyst at the University's Center for Psychoanalytic Training and Research. In 1976 he became Professor of Psychiatry at Cornwall University and Principal of the Institute for Personality Disorders at the New York Hospital of the Cornell Medical Center. Otto Kernberg was President of the International Psychoanalytic Association from 1997 to 2001.
Otto Kernberg is one of the largest specialists in the field of severe personality disorders that lie in the “gap” between neurosis and psychosis and have become available for psychoanalytic treatment, including through his personal efforts. One of the ways to expand the clinical spectrum of psychoanalysis, in particular, its application to patients with severe personality disorders, was the psychoanalytic expressive psychotherapy developed by Kernberg, which made it possible to achieve good results in the treatment of such patients by deviating from some parameters of classical psychoanalytic technique.
He developed a modern psychoanalytic theory of personality, which briefly states that the “I” of a person consists of various representations (images, manifestations) of himself and his objects (primarily close people) and the affective states that connect them.
Kernberg is very interested in the questions of pathological narcissism, which sometimes turns into a separate structural category of pathology for him, along with the three mentioned. He is also interested in issues of aggression, destructiveness and hatred and, at the same time, love and sexuality in normal and pathological conditions. He is also concerned with the classification of mental disorders.
Otto Kernberg became a classic during his lifetime, developed a new approach within psychoanalysis and a new look at the treatment of patients with narcissistic and borderline personality disorders, his work was included in all textbooks.
Books (4)
Aggression in personality disorders
In this book, I present the latest results of my ongoing research into the origin, nature, and treatment of personality disorders. Central to these studies is understanding the dynamics of grossly pathological human behavior.
Therefore, my book begins with an exposition of the psychoanalytic theory of motivation, especially as it relates to aggression.
Relationships of love. Norm and pathology
The book of the doctor of medicine Otto Kernberg, one of the most authoritative modern psychoanalysts, is devoted to the relationship of love in norm and pathology. Illustrating theoretical positions with practical cases, the author explores how unconscious experiences and fantasies related to the past have a strong influence on today's couple's relationship. How intricately love and aggression interact in a couple's life. How to keep passionate love in a long-term relationship. How does the social environment affect the relationship of love ...
This deep clinical and theoretical study will arouse undoubted interest among specialists - psychologists, psychotherapists, doctors, teachers.
Borderline states must be distinguished, on the one hand, from neuroses and neurotic character pathology, and, on the other hand, from psychoses, especially schizophrenia and major affective psychoses.
HEAVY PERSONAL
DISORDERS
Psychotherapy strategies
Translation from English by M.I. Zavalova
edited by M.N. Timofeeva
OttoF. Kernberg
SEVERE PERSONALITY DISORDERS
Moscow
Independent firm "Class"
Kernberg O.F.
K 74 Severe personality disorders: Psychotherapy strategies / Per. from English. M.I. Zavalova. - M.: Independent firm "Class", 2000. - 464 p. - (Library of Psychology and Psychotherapy, issue 81).
ISBN 5-86375-024-3 (RF)
How to diagnose difficult cases, what type of psychotherapy is indicated for the patient, how to deal with impasses and especially difficult situations in therapy, whether the patient needs hospitalization and how the surrounding social system influences him - these are some of the problems, in detail, at the state of the art, described in book by the president of the International Psychoanalytic Association, Otto F. Kernberg.
This work is addressed primarily to practitioners, especially those who deal with the so-called borderline patients, who are between psychosis and neurosis.
Editor-in-Chief and Series Publisher L.M. Crawl
Scientific Advisor Series E.L. Mikhailova
ISBN 0-300-05349-5 (USA)
ISBN 5-86375-024-3 (RF)
© 1996, Otto F. Kernberg
© 1994 Yale University Press
© 2000, Independent firm “Class”, edition, design
© 2000, M.I. Zavalov, translation into Russian
© 2000, M.N. Timofev, foreword
© 2000, V.E. Korolev, cover
www.kroll.igisp.ru
Buy the book "At the KROL"
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Integrative psychoanalysis
end of the twentieth century
Do you happen to have someone like you with a red face, three eyes and a necklace of skulls? - he asked.
Maybe there is, - I said politely, - but I can't understand who exactly you are talking about. You know, very common features. Anyone can be.
Viktor Pelevin
This book can be called a program work and even a classic of modern psychoanalysis. It is held in all institutions, it is one of the most frequently cited in the world. Much makes it seem to reflect the spirit of the times:
approach in terms of structures;
the subject is pathology more severe than neurotic, plus special attention to narcissistic disorders;
special attention to transference relations, in particular to the peculiarities of countertransference that arises when working with patients of different nosologies, and its use as an additional diagnostic, if not a criterion, then at least a means;
and, finally, perhaps most importantly, the integrativity of the author's theoretical approach.
When one speaks of various psychoanalytic theories in the most general terms, one often divides them into two main branches: drive theories and relational theories, which supposedly developed in the main historically in parallel. It is significant that Otto Kernberg explicitly integrates both approaches. He proceeds from the presence of two drives - libido and aggression, any activation of which is a corresponding affective state, including internalized object relations, namely, a specific I-representation that is in certain relations with a specific object-representation. Even the very titles of Kernberg's two later books on the two main drives (already published in Russian) are Aggression [i.e. attraction, drive] in personality disorders” and “Relationships of love” - testify to the fundamental synthesis of the theory of drives and the theory of relationships inherent in Kernberg's thinking. (We dare to suggest that with more emphasis on attraction in the case of aggression and on object relations in the case of love.)
Kernberg constantly warns the reader against underestimating the motivational aspects of aggression. From his point of view, authors (for example, Kohut, associated with Kernberg as his opponent), who reject the concept of drives, often (especially not in theory, but in practice) simplify mental life, emphasizing only the positive or libidinal elements of attachment:
“There is also the unspoken belief that by nature all people are good and that open communication eliminates distortions in the perception of oneself and others, and it is these distortions that are the main cause of pathological conflicts and structural pathology of the psyche. Such a philosophy denies the existence of unconscious intrapsychic causes of aggression and is in sharp contrast to what the staff and patients themselves can observe in the inhabitants of a psychiatric hospital.
It is clear that the topic of aggression becomes especially important when discussing severe mental disorders and their therapy. For example, underestimation of aggression and a complacently naive attitude in the treatment of patients with an antisocial personality type can lead to tragic consequences. Thus, it is known (see J. Douglas, M. Olshaker, Mindhunter. New York: Pocket Book, 1996) that several serial killers in the United States were released from prison, including on the basis of reports from their psychotherapists, and committed their next murders. while in therapy.
Note that Kernberg makes extensive use not only of the ideas of practically universally accepted object relations theorists such as Fairbairn and Winnicott, but also of Melanie Klein's theory, which is much more difficult to perceive outside of England. To a large extent, it is his merit that the introduction of her ideas into “non-Kleinian” psychoanalysis. In addition, he also draws on the work of leading French authors such as A. Green and J. Chasseguet-Smirgel, contrary to the popular notion of the confrontation between American and French psychoanalysis.
It is in this book that almost the most famous components of Kernberg's contribution to the development of psychoanalytic thought are outlined: a structural approach to mental disorders; the expressive psychotherapy he invented, shown to borderline patients; a description of malignant narcissism; and, finally, the famous “structural Kernberg interview.” It is certainly an excellent diagnostic tool for determining the level of a patient's pathology - psychotic, borderline or neurotic - and this is one of the most important factors in choosing the type of psychotherapy. By the way, here Kernberg gives a very clear description supportive psychotherapy and its distinctive features. This seems to be very useful due to the fact that in professional jargon this phrase has almost lost its specific meaning and is often a negative assessment.
I would like to draw the attention of the Russian reader to one more point that makes this book especially relevant for us. The increase in the number of non-neurotic (i.e. more disturbed) patients in psychotherapy and psychoanalysis is typical for the whole world and has various reasons, but in our country this trend is even more pronounced due to the psychological illiteracy of the population. Unfortunately, it is still “not customary” to seek psychological help, and psychotherapists come to those who can no longer help but turn. So the patients described in the book are predominantly “our” patients, with whom we most often deal.
Summing up, we can say: there is no doubt that reading this book is simply necessary for everyone involved in psychotherapy, and it remains to be regretted that its translation appears only now. Until now, its absence has been felt as a kind of "blank spot" in the psychoanalytic and psychotherapeutic literature in Russian.
Maria Timofeeva
Dedicated to my parents
Leo and Sonia Kernberg
my teacher and friend
Dr. Carlos Whiting D'Andrian
Foreword
This book has two purposes. Firstly, it demonstrates how developed and what changes the knowledge gained by experience and ideas set forth in my previous works have undergone - and here I focus on the diagnosis and treatment of severe cases of borderline pathology and narcissism. Second, it explores other new approaches to the topic that have recently emerged in clinical psychiatry and psychoanalysis, and gives them a critical review in the light of my current understanding. In this book, I have tried to give practical value to my theoretical formulations and to develop for clinicians a certain technique for diagnosing and treating difficult patients.
That is why, from the very beginning, I try to clarify one of the most difficult areas - I offer the reader a description of a special approach to differential diagnosis and a technique for conducting what I call a structural diagnostic interview. In addition, I identify the relationship between this technique and the criteria for predicting and choosing the optimal type of psychotherapy for each case.
I then describe in detail the treatment strategies for borderline patients, focusing on the most severe cases. This section of the book includes a systematic study of expressive and supportive psychotherapy, two approaches developed from the psychoanalytic framework.
In the several chapters on the treatment of narcissistic pathology, I have focused on the development of a technique that I believe is particularly useful in dealing with severe and deep character resistances.
Another major problem is dealing with refractory or other difficult patients: what to do when an impasse develops, how to deal with a suicidal patient; how to understand whether it is worth applying therapy to an antisocial patient or whether he is incurable; how to work with a patient whose paranoid transference regression reaches the level of psychosis? These questions are dealt with in the fourth part.
Finally, I propose an approach to therapy in the hospital setting, based on a slightly modified therapeutic community model, which is indicated for patients who are hospitalized for a long time.
This book is largely clinical. I wanted to offer psychotherapists and psychoanalysts a wide range of specific psychotherapeutic techniques. At the same time, in the context of reliable clinical data, I develop my previous theories, my ideas about such forms of psychopathology as ego weakness and diffuse identity are supplemented by new hypotheses about severe superego pathology. Thus, the present work reflects the most modern ideas of ego psychology and object relations theory.
My theoretical ideas, mentioned in the preface, are largely based on the later work of Edith Jacobson. Her theories, as well as the creative continuation of them in the writings of Margaret Mahler, who used the ideas of Jacobson in the study of child development, continue to inspire me.
A small group of wonderful psychoanalysts and my close friends constantly kept feedback with me, making critical remarks and providing all sorts of support, which was of utmost importance to me. I am especially grateful to Dr. Ernst Tycho, with whom I have been collaborating for 22 years, and Drs. Martin Bergman, Harold Blum, Arnold Cooper, William Grossman, Donald Kaplan, Polina Kernberg, and Robert Michels, who not only generously gave me their time, but also considered it necessary to argue and point out dubious passages in my formulations.
Thanks to Drs. William Frosch and Richard Münich for expressing their opinions on my ideas about therapy in the hospital setting and the therapeutic community, and to Drs. Ann Appelbaum and Arthur Carr for the endless patience with which they helped me formulate my ideas. Finally, thanks to Dr. Malcolm Pines for supporting me in my critique of the therapeutic community model, and to Dr. Robert Wallerstein for his wise critique of my views on supportive psychotherapy.
Drs Stephen Bauer, Arthur Carr, Harold Koenigsberg, John Oldham, Larence Rockland, Jesse Schomer, and Michael Silzar of the New York Hospital Westchester Unit have contributed to the clinical methodology for the differential diagnosis of borderline personality organization. More recently, they, together with Drs. Ann Appelbaum, John Clarkin, Gretchen Haas, Pauline Kernberg, and Andrew Lotterman, have contributed to the development of operational definitions regarding the distinction between expressive and supportive modalities of therapy in the context of the Borderline Psychotherapy Research Project. I want to express my gratitude to everyone. As before, I release all my friends, teachers and colleagues from responsibility for their views.
I am deeply indebted to Mrs. Shirley Grünenthal, Miss Louise Taite, and Mrs. Jane Carr for their endless patience in reprinting, collating, proofreading, and compiling the countless versions of this work. I would especially like to note the efficiency of Mrs. Jane Carr, with whom we have recently collaborated. Miss Lillian Warow, librarian of the Westchester Department of the New York Hospital, and her associates, Mrs. Marilyn Botier and Mrs. Marcia Miller, were invaluable in assisting me in the selection of the bibliography. Finally, Miss Anna-Mae Artim, my administrative assistant, did the impossible once again. She coordinated the publishing work and the preparation of my work; she anticipated and averted endless potential problems and, acting kindly but firmly, ensured that we met our deadlines and produced this book.
For the first time, I had the privilege of working alongside my editor, Mrs. Natalie Altman, and senior editor at Yale University Press, Mrs. Gladys Topkis, who guided me in my quest to express myself clearly in acceptable English. In the course of our collaboration, I began to suspect that they knew much more about psychoanalysis, psychiatry, and psychotherapy than I did. I cannot express how grateful I am to both of them.
