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In Changing Places, David Lodge's comedic novel of academic life, the junior faculty in literature at a provincial English university play a game called Humiliation. In turn, each names a classic that all professors should have read but have not. Finally, one junior lecturer gets carried away, admits that he's never read Hamlet, and gets fired.
Everyone has these guilty secrets . . . there are just too many books. Moreover, many of the best books are lengthy, densely argued, and studded with long Latinate words. In our attentionally challenged era of blogs and twitters, sitting down to read such worthy tomes seems ever less feasible.
Book reviews have long been a first defense against scholastic overload. Generations of high school students have bypassed Wuthering Heights and The Scarlet Letter in favor of CliffsNotes, and now Wikipedia. Many people use the New York Times Book Review less to plot future reading than to pick up enough talking points about this week’s bestseller that they can skip it but still sound intelligent. Recently, litterateur and psychoanalyst Pierre Bayard anatomized this art of faked literary chat in his nearly serious study, How to Talk About a Book You Haven’t Read.
Psychiatrists, like everyone else, bear shameful educational omissions. We’re all short of time and the required reading list gets longer every year. This new column aims to review important books you may have passed over. No confession required. Maybe it will inspire you to actually read a book. If not, at least you’ll have some clever opinions on the ready.
Otto Kernberg was born, appropriately, in Vienna in 1928 and fled to Chile in 1939, one step ahead of the greatest pathological narcissist of them all. He’s now been in the United States for 50 years, first at Menninger and now Cornell, devotedly leading meticulous, long-term studies of intensive psychotherapy for patients with personality disorders.
Borderline Conditions and Pathological Narcissism (New York: Jason Aronson; 1975) is the archetypal unread classic. It’s an acknowledged landmark; the culminating and most characteristic expression of generations of psychodynamic observation and theorizing about severe personality disorders. But reading Kernberg is a hellacious experience.
First, he’s a true-believing psychoanalyst, so your reaction to him will follow your opinion of analysis; if you’re allergic, stop reading now. Kernberg takes for granted the causal and explanatory power of infantile sexuality and unconscious mental processes. He ignores biology; hypomania, for him, is character pathology. He blithely lumps homosexuality among the personality disorders. He prescribes intensive psychotherapy for almost everyone, and recommends a few months of hospitalization for regressed patients. I can’t sign on to all of this. And yet, I admire psychoanalysts’ willingness to immerse themselves in the lives of severely disordered patients. I wouldn’t do it. And I wouldn’t trek to the South Pole or ride a diving bell to the floor of the Pacific either. But I’m curious about what these extreme explorers bring back.
The second barrier is stylistic. Kernberg is an analyst speaking to other analysts. He’s logical and well organized but offers no concessions to outsiders. He writes an argot, not quite English. It’s page after page of “oral rage,” “pregenital strivings,” “structural derivatives of object relations,” “sadistic precursors of the superego,” and “pathological refusion of self and object images.” You don’t read Kernberg, you decipher him.
If you’re still with me, recall that our now ubiquitous DSM isn’t all of psychiatry but only the current incarnation of the “objective-descriptive” tradition, tracing back to Kraepelin. The focus is on clear and reliable observation with a minimum of speculation. Diagnostic categories bubble up from observed clusterings of symptoms rather than being imposed by a preordained theory. The results are familiar but also mysterious: Why do extremely sad people wake up too early? Why is unipolar depression common but unipolar mania rare? Why do the female relatives of sociopaths become somatizers? What’s the link between tics and obsessions?
If these questions persist, at least the boundaries of the major DSM Axis I syndromes are clear. But everybody knows that Axis II doesn’t work as well. The clustering breaks down. Patients drift from one personality disorder to another or qualify for 3 at a time. And the diagnostic criteria seem devoid of an inner logic. What do identity diffusion, brief psychotic episodes, and intolerance of solitude have to do with one another? Personality disorders stretch the purely observational framework of DSM past the breaking point.
Kernberg elides these dilemmas by switching attention from borderline personality disorder to borderline personality organization (BPO). BPO extends across many DSM categories; on Kernberg’s accounting, it’s found in most DSM borderline narcissistic and antisocial personalities but also in most addicts, some histrionic characters, and many people with chronic depression. It comes complete with a developmental theory, an explanation of characteristic interpersonal relations and defense mechanisms, and even recommended modes of treatment. BPO explains a lot, but at a price; it’s a theoretical entity—distant from observation.
BPO arises, we are told, in infants who can’t integrate their positive and negative experiences, either because of high innate aggressiveness, excessive anxiety, or harmful early experiences. (All explanations must stop somewhere and Kernberg stops here. Margaret Mahler and others propose that borderline parents reproduce the disorder in their children because they can’t tolerate their infant’s healthy aggression or later need to separate. Still others assert the etiological primacy of childhood abuse and molestation and emphasize the importance of dissociation in borderline symptoms.) To protect their good experiences from “contamination,” future borderlines come to rely on splitting—the desperate device of sequestering good and bad internal representations of self and others—rather than on repression as their primary defense mechanism. Secondarily, they employ the primitive defenses of projective identification, denial, omnipotence, and devaluation. (For a catalog of defense mechanisms, try Adaptation to Life by George Vaillant.
Dependence on these primitive defenses gives rise to “ego weakness”—lack of anxiety tolerance, impaired impulse control, and a paucity of conflict-free spheres of expression. Kernberg ingeniously and economically explains how BPO explains the “surface” borderline symptoms we’re all familiar with—splitting as a defense, of course, but also intense, unstable, and exploitative relationships, identity diffusion, boredom, intolerance of solitude, global anxiety, and self-destructiveness.
Kernberg also describes the common missteps in treating borderline patients: the uncritically “nice” therapist mistakenly allows the patient to gratify his other aggressive urges. At the other extreme, under the influence of projective identification, the unwitting therapist may sadistically re-enact the patient’s disastrous early relationships.
Kernberg famously advocates early confrontation and interpretation of the patient’s hidden or overt aggressiveness, and this gives his writing a tough, almost angry tone. In this, and especially in the treatment of narcissistic personality disorder, he contrasts markedly with his great rival Heinz Kohut. Kohut viewed pathological narcissism as a stop on the road to healthy narcissism rather than as a pathological deviation (see his The Analysis of the Self), and encouraged idealization and “mirroring”—a shared bubble of grandiosity—between patient and therapist.
Is Kernberg’s theory true? It cannot be the final word, because it disregards neuroscience and the real world of social relations. Despite Kernberg’s laudable emphasis on empirical research, his work is unconvincing by the scientific standards of hypothesis generation and falsifiability. No one will ever conduct a double- blind, placebo-controlled study of psychodynamic psychotherapy, much less of psychodynamic metapsychology. But, for sympathetically understanding the experiences of our most primitive and difficult patients, Kernberg is essential.