Otto F. Kernberg

The book by Doctor of Medicine Otto Kernberg, one of the most authoritative modern psychoanalysts, is devoted to love relationships in normal and pathological conditions. Illustrating theoretical principles with practical cases, the author explores how unconscious experiences and fantasies associated with the past have a strong influence on a couple's relationship today. How love and aggression interact in complex ways in a couple's life. How to maintain passionate love in a long-term relationship. How the social environment influences loving relationships... This is a deep clinical and theoretical research will arouse undoubted interest among specialists - psychologists, psychotherapists, doctors, teachers.

Otto F. KERNBERG
LOVE RELATIONSHIPS:
Norm and pathology

ALL THIS IS ABOUT THE SECRETS OF LOVE

Oh if only I could
Although partly
I would write eight lines
About the properties of passion.
B. Pasternak

We are a long way from Otto Kernberg, one of the most prominent figures in modern psychoanalysis. He became a classic during his lifetime, developed new approach within psychoanalysis and A New Look for 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 related to psychoanalysis. We are so far from Kernberg that we can probably take some liberties in the preface. Moreover, a fairly complete overview 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 working on aggression, Kernberg was so often told: “Is love weak?” that he wanted to show: no, not weak, and so much so that now you cannot 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 stage of mature sexual love - perhaps this is partly why he wrote his book at almost seventy years of age. And How! More than two hundred pages about the properties of passion... Having stated at the beginning that poets and philosophers, of course, have better described human love than can be done with the help of any psychoanalytic research, Kernberg then seems to challenge - and describes all the secret nuances of love relationships . So in his text, as in good poetry, we recognize our own most intimate experience. You just feel uneasy and even somehow offended - what seemed like a precious unique experience, undeservedly given to you by fate, when you take your breath away and think: does this really happen, have other people also ever experienced something similar? - is described in a scientific book better than you could do it yourself, and it is also separately explained why it is typical.

And you remain perplexed: what to do now with all this knowledge? Yes, it is easier to understand what is happening to patients. But how can you love now, and even more so make love, if your every mental movement is dissected, classified, numbered, and also has several explanations of where it came from?

As if anticipating this 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 psychoanalytic relationships. It is a kind of ironic confirmation of the uniqueness of the experience of such experiences in countertransference that although psychoanalysts have an extraordinary opportunity to explore the love life of the opposite sex, this knowledge and experience tends to evaporate once it comes to understanding their own experiences of relationships with the opposite sex outside the psychoanalytic situation. That is, outside the analytic situation, the analyst’s love life is the same as that of other mortals.”

And now a few prosaic words about the actual merits of the book. Kernberg covers in detail the existing this issue literature, and a variety of authors, not only those close to him in spirit. He boldly and sometimes in the most original way connects ideas that, at first glance, express absolutely different approaches to the phenomena described.

Considering normal and pathological love relationships, he shows how the individual pathologies of the partners “interfere”, in some cases creating a pathology of the couple, which is not a simple superposition of them. In romantic relationships, the original psychopathology may persist or resolve. In addition, existing psychopathology is often disguised as something else through the efforts of both partners. Kernberg writes confidently and fearlessly about the secret of maintaining passionate love in a long-term relationship: in mature sexual love, a person finds the form for fulfilling all his infantile sexual fantasies.

Very interesting social aspect issue considered by Kernberg. The themes of couple and group, couple and society, sexual as initially opposed to conventional and social, are more often heard in novels than in psychological and psychoanalytic literature. And the chapter devoted to the depiction of love relationships in modern cinema will certainly be interesting anyone to the reader.

This book is, without a doubt, not an easy read. But not because it is difficult to write, but because of the extreme richness of the presentation - there are a lot of thoughts per unit of text. There was an old joke: “You know, Faulkner is so hard to read!” - “Yes, but when you read it, it’s such a relief!” So, I don’t promise relief at all, but that you won’t regret it, that’s for sure.

Maria Timofeeva

PREFACE

For centuries, love has been the object of close attention of poets and philosophers. Recently, sociologists and psychologists have joined them. But psychoanalytic literature still pays surprisingly little attention to love.

As I tried again and again to study the nature of love, I realized that it was impossible to avoid the connection with eroticism and sexuality. It turned out that in most studies the sexual response is considered from a biological point of view, and only a few speak about it as a subjective experience. Exploring this subjective aspect in my work with patients, I discovered that I was dealing with unconscious fantasies, the origins of which lay 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 “acts out” their past “scenarios” (unconscious experiences and fantasies) in their relationship and that fantasy and real mutual “molestations” originating from the infantile Super-Ego and the I-ideal associated with it have a powerful influence on a couple's life.

I have observed that it is almost impossible to predict the fate of love relationships and marriages based on the characteristics of a patient's psychopathology. Sometimes different forms and degrees of psychopathology in partners contribute to their compatibility; in another case, differences may cause incompatibility. Questions such as "What keeps a couple together?" or “What ruins relationships?” haunted me and prompted me to explore the dynamics behind the observed development of the couple’s relationship.

My background was the treatment of patients using 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.

Current page: 1 (book has 23 pages in total)

Otto F. KERNBERG

LOVE RELATIONSHIPS:

Norm and pathology

ALL THIS IS ABOUT THE SECRETS OF LOVE

Oh if only I could

Although partly

I would write eight lines

About the properties of passion.

B. Pasternak

We are a long way from Otto Kernberg, one of the most prominent figures in modern psychoanalysis. He 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 works were 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 related to psychoanalysis. We are so far from Kernberg that we can probably take some liberties in the preface. Moreover, a fairly complete overview 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 working on aggression, Kernberg was so often repeated: “Is love weak?” that he wanted to show: no, not weak, and so much so that now you cannot write a word about love without referring to me.

As if anticipating this 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 through the protection provided by the framework of the psychoanalytic relationship. It is a kind of ironic confirmation of the uniqueness of the experience of such experiences in countertransference that although psychoanalysts have an extraordinary opportunity to explore the love life of the opposite sex, this knowledge and experience tends to evaporate once it comes to understanding their own experiences of relationships with the opposite sex outside the psychoanalytic situation. That is, outside the analytic situation, the analyst’s love life is the same as that of 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, including a variety of authors, not only those close to him in spirit. He boldly and sometimes in a very original way connects ideas that, at first glance, express completely different approaches to the phenomena described.

The social aspect of the issue considered by Kernberg is very interesting. The themes of couple and group, couple and society, sexual as initially opposed to conventional and social, are more often heard in novels than in psychological and psychoanalytic literature. And the chapter devoted to the depiction of love relationships in modern cinema will certainly be interesting anyone to the reader.

Maria Timofeeva

PREFACE

As I tried again and again to study the nature of love, I realized that it was impossible to avoid the connection with eroticism and sexuality. It turned out that in most studies the sexual response is considered from a biological point of view, and only a few speak about it as a subjective experience. Exploring this subjective aspect in my work with patients, I discovered that I was dealing with unconscious fantasies, the origins of which lay 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 “acts out” their past “scenarios” (unconscious experiences and fantasies) in their relationship and that fantasy and real mutual “molestations” originating from the infantile Super-Ego and the ego associated with it ideal, have a powerful influence on the life of a couple.

I have observed that it is almost impossible to predict the fate of love relationships and marriages based on the characteristics of a patient's psychopathology. Sometimes different forms and degrees of psychopathology in partners contribute to their compatibility; in another case, differences may cause incompatibility. Questions such as “What keeps a couple together?” or “What ruins relationships?” haunted me and prompted me to explore the dynamics behind the observed development of the couple’s relationship.

It soon became clear to me that it was impossible to study changes in love relationships without studying changes in aggressive states both in couples and in individuals. The aggressive aspects of a couple's erotic relationship appear to be important in all intimate sexual relationships, as was first elucidated by the work of Robert J. Stoller in this area. But I have found that the aggressive components of the universal ambivalence of close object relations are no less important, as are the aggressive aspects of the superego pressure released in intimate life couples. The psychoanalytic theory of object relations facilitates the study of the dynamics of the conjugation of intrapsychic conflicts and interpersonal relationships, the mutual influence of the couple and those surrounding the couple social group and manifestations of love and aggression in all these areas.

Thus, despite the best of intentions, irrefutable arguments forced me to refocus on aggression in this work on love. Understanding the complex ways in which love and aggression merge and interact in the lives of couples also sheds light on the mechanisms by which love can integrate and neutralize aggression and, under certain circumstances, overcome it.

GRATITUDE

The first person to draw my attention to the work of Henry Dix was John D. Sutherland, for many years the chief consultant of the Menninger Foundation, and formerly the chief physician of the Tavistock Clinic in London. Dix's application of Fairbairn's object relations theory to the study of marital conflict helped me develop a frame of reference that I could later rely on when I first tried to understand the complex relationships of borderline patients with lovers and spouses. Work by Drs Denise Braunschweig and Michael Fain on group dynamics, in which erotic tension is played out on early stages life and in adulthood, pushed me into contact with the French psychoanalytic school and the study of normal and pathological love relationships. During my stay in Paris, where I conceived the thoughts that were later included in this book, in my free hours from lectures I had the good fortune to consult with many psychoanalysts who studied normal and pathological love relationships, especially with doctors Didier Anzieu, Denise Braunschweig, Janine Chasseguet-Smirgel, Christian David, Michael Fain, Pierre Fedida, Andre Green, Bela Grunberger, Joyce McDougall, Francois Roustan. I would like to express my gratitude to Drs. Serge Leibovici and Dr. Daniel Widlocker, who have been extremely helpful in clarifying my understanding of affect theory. Later, Drs. Rainer Krause (Saarbrücken) and Ulrich Moser (Zurich) helped me further develop the problem of pathology of affective communication in close relationships.

I am fortunate to count among my close friends the people who have made the greatest contribution to the psychoanalytic study of love relationships, Doctors Martin Bergman, Ethel Person and Robert Stoller (USA). Ethel Person opened up a lot for me important work on Nuclear Gender Identity and Sexual Pathology, written with Dr. Lionel Owesi. Thanks to Martin Bergman, I became acquainted with historical view on the nature of love relationships and their reflection in art. Robert Stoller inspired me to study the close relationship between eroticism and aggression, which he began so brilliantly. And the work in this area of doctors Leon Altman, Jacob Arlow, Martha Kirkpatrick, John Münder-Ross stimulated my thinking.

As before, close friends and fellow psychoanalysts provided me with invaluable help. Their criticism was always positive, their comments encouraged further work. These are doctors Harold Blum, Arnold Cooper, William Frosch, William Grossman, Donald Kaplan, Pauline Kernberg, Robert Michels, Gilbert Rose, Joseph and Anne-Marie Sandler, Ernst and Gertrude Tycho.

As always, I am deeply grateful to Louise Tait and Becky Whipple for their endless patience and support from the very beginning of the manuscript until the book was published. Miss Whipple's attention to the subtle nuances of the text was very helpful and important. My administrative assistant, Rosalind Kennedy, also provided tireless support, guiding and directing the work in my office, which allowed the manuscript to come to fruition despite the many pressing matters and worries.

This is the third book written in close collaboration with Natalie Altman, my editor for many years, and Gladys Topkie, the publisher's editor-in-chief. Yale University. Their critical comments, always to the point, always tactful, helped me a lot in my work.

I would like to once again express my gratitude to all the friends and colleagues whom I have already mentioned, as well as to the patients and students who shared with me their discoveries in this field, which allowed me to master in a few years information that without their help I would not have had enough life. Thanks to them, I realized how limited my knowledge and understanding of this vast and complex area of \u200b\u200bhuman feelings is.

I am also grateful to the publishers of my early works for kind permission to republish the material in the chapters below. All these materials have been significantly processed and modified.

Chapter 2: From “New Perspectives in Psychoanalytic Affect Theory” in Emotion: Theory, Research, and Experience editors: R. Plutchic, H. Kellerman (New York: Academic Press, 1989), 115–130, and from “Sadomasochism, Sexual Excitement, and Perversion,” Journal of the American Psychoanalytic Association 39 (1991): 333–362. Published with permission from Academic Press and the Journal of the American Psychoanalytic Association.

Chapter 3: From “Mature Love: Prerequisites and Characteristics,” Journal of the American Psychoanalytic Association 22 (1974): 743–768, and also from “Boundaries and Structure in Love Relationships,” Journal of the American Psychoanalytic Association 25 (1977) : 81-144. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 4: From “Sadomasochism, Sexual Exitement, and Perversion,” Journal of the American Psychoanalytic Association 39 (1991): 333–362, and from “Boundaries and Structure in Love Relationships,” Journal of the American Psychoanalytic Association 25 (1977) ): 81-144. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 5: From “Barriers to the Falling and Remaining in Love,” Journal of the American Psychoanalytic Association 22 (1974): 486–511. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 6: From “Aggression and Love in the Relationship of the Couple,” Journal of the American Psychoanalytic Association 39 (1991): 45–70. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 7: From “The Couple's Constructive and Destructive Superego Functions,” Journal of the American Psychoanalytic Association 41 (1993): 653–677. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 8: From “Love in the Analytic Setting,” accepted for publication by the Journal of the American Psychoanalytic Association. Published with permission from the Journal of the American Psychoanalytic Association.

Chapter 11: From “The Temptations of Conventionality,” International Review of Psychoanalysis 16 (1989): 191–205, and from “Erotic Element in Mass Psychology and in the Art,” Bulletin of the Menninger Clinic 58, no. l (Winter, 1980), published with permission from the International Review of Psychoanalysis and Bulletin of the Menninger Clinic.

Chapter 12: From “Adolescent Sexuality in the Light of Group Processes,” Psychoanalytic Quaterly 49, no. l (1980): 27–47, also from “Love, the Couple,” and the Group: A Psychoanalytic Frame” Psychoanalytic Quarterly 49, no. l (1980): 78-108. Published with permission from Psychoanalytic Quarterly.

1. SEXUAL RELATIONSHIPS

It's hard to argue with the fact that sex and love are closely related. Therefore, it will not be surprising that a book about love begins with reflections on the biological and psychological roots of sexual experience, which are also closely intertwined. Since biological roots provide a matrix within which psychological aspects can develop, we begin our discussion by examining biological factors.

BIOLOGICAL ROOTS OF SEXUAL EXPERIENCE AND BEHAVIOR

Tracing the development of human sexual behavior and moving up the biological ladder of the animal world (especially comparing lower mammals with the order of primates and humans), we see that the role of socio-psychological relationships between the baby and his teacher in the formation of sexual behavior is increasing, and the influence of genetic and hormonal factors, on the contrary, decreases. The primary sources for my review were the pioneering work in this area by Money and Erhardt (1972), subsequent studies by Kolodny (1979) et al., Bancroft (1989), and McConaghy (1993).

On early stages During its development, a mammalian embryo has features of both male and feminine. Undifferentiated gonads are modified into either testes or ovaries depending on the genetic code, represented by a set of 46 XY chromosomes for males or a set of 46 XX chromosomes for females. Primitive gonads in the human embryo can be identified starting from the 6th week of development, when, under the influence of the genetic code, testicular hormones are produced in males: Müllerian duct inhibitory hormone (MIH), which has a defeminizing effect on the structure of the gonads, and testosterone, which promotes the development of internal and external male genitalia, especially the bilateral Wolffian duct. In the presence of a female genetic code, ovarian development begins at the 12th week of fetal ripening.

Differentiation always occurs in the female direction, regardless of the genetic program, but only when there is no adequate testosterone level. In other words, even if genetic code inherent male structure, insufficient testosterone will lead to the development of female sexual characteristics. The principle of the predominance of feminization over masculinization will work. During normal female development, the primitive Müllerian vascular system is transformed into the uterus, fallopian tubes, and vagina. With development according to male type The Müllerian conducting system regresses, and the Wolffian duct system develops, evolving into the vasa deferentia (vas deferentia), seminal vesicles and ejaculatory ducts.

While there are precursors for both male and female internal genitalia, the precursors for external genitalia are universal, meaning the same “pre-organs” can develop into either male or female external genitalia. If adequate levels of androgens (testosterone and dehydrotestosterone) are not available during the critical period of differentiation, the clitoris, vulva and vagina will develop from the 8th week of fetal development. With the required amount of androgenic stimulation, a penis with testicles and scrotum, including seminiferous tubules in the abdominal cavity, will form. At normal development The fetal testicles move into the scrotum during the 8th or 9th month of pregnancy.

Under the influence of the circulation of embryonic hormones, following the differentiation of the internal and external genital organs, the dimorphic development of certain parts of the brain occurs. The brain has an ambitypical structure, and in its development, female characteristics also prevail if adequate levels of circulating androgens are not achieved. The specific functions of the hypothalamus and pituitary gland will be further differentiated into cyclical processes in women and non-cyclic in men. Formation of the male/female brain occurs only in the third trimester after the completion of the formation of the external genitalia and probably continues during the first postnatal trimester. In the case of non-primate mammals, prenatal hormonal differentiation of the brain determines subsequent mating behavior. However, if we are talking about primates, then here vital role Early socialization experiences and learning play a role in determining sexual behavior. The control of mating behavior is largely determined by early social interactions.

The development of secondary sexual characteristics that appear during puberty - the distribution of body fat, the development of female/male hair, voice changes, development of mammary glands and fast growth genitals - triggered by the central nervous system and controlled by a significantly increased amount of circulating androgens or estrogens; the presence of an adequate amount of estrogen determines such specific female functions as the menstrual cycle, pregnancy and milk production.

Hormonal imbalance can lead to changes in secondary sexual characteristics, which, in turn, can lead to gynecomastia (enlarged mammary glands in men) with insufficient androgens; hirsutism (excessive hair growth in women), clitoral hypertrophy, deepening of the voice - with an excess of androgens. But the influence of hormone levels of the opposite sex on an individual's sexual desire and behavior is much less clear.

It is still not entirely clear how the central nervous system influences the onset of puberty. One mechanism is thought to be decreased sensitivity of the hypothalamus to negative feedback (Bancroft, 1989). In men, insufficient circulating androgens significantly reduce the intensity of sexual desire, but with normal or slightly higher than normal levels of androgen hormones, sexual desire and behavior are completely independent of such fluctuations. Prepubertal castration in men who have not received testosterone replacement leads to sexual apathy. In young men with signs of primary androgen deficiency, the introduction of testosterone in adolescence restores normal sexual desire and behavior. However, at a later age, when sexual apathy becomes persistent, restorative therapy with testosterone is less successful: there seems to be a time limit in this process, after which the deviations are no longer eliminated. Likewise, despite the fact that studies show an increase in sexual desire in women immediately before and after the menstrual cycle, the revealed dependence of sexual desires on fluctuations in the amount of hormones is still insignificant in comparison with the influence of socio-psychological factors. McConaghy (1993), in particular, notes that women are more influenced by socio-psychological factors than men.

However, in primates and lower mammals, sexual interest and behavior are strictly determined by hormonal levels. Thus, mating behavior in rodents is entirely determined by hormonal status; and early postnatal hormonal injections can have significant consequences. Post-pubertal castration leads to a decrease in erection and sexual desire, which can progress over weeks and even years; Testosterone injections can almost immediately restore sexual function. Androgen injections in postmenopausal women increase sexual desire without affecting their sexual orientation.

To summarize, we can say that androgenic hormones influence the intensity of sexual desire in men and women; however, the predominant role still belongs to psychosocial factors. Although in lower mammals such as rodents, sexual behavior is largely regulated by hormonal levels; Already in primates, an increase in the influence of the psychosocial environment on sexual behavior can be observed. For example, male rhesus monkeys react strongly to the smell of a vaginal hormone secreted during ovulation. Female rhesus macaques, showing the greatest sexual activity during ovulation, also do not lose sexual interest in other periods, while showing noticeable sexual preferences. Here again we observe the influence of androgen levels on the intensity of the occurrence of sexual representative behavior in females. Injecting testosterone into the preoptic zone of male rats induces maternal instinct in them, but at the same time they continue to copulate with females. Increasing testosterone levels appears to trigger maternal instincts, which are present in a latent state in the brain of males, and brings relevant information to the central nervous system, which is responsible for sexual behavior. This finding suggests that sexual behavior characteristic of one sex may be present in a latent state in the other.

The strength of sexual arousal, focus on sexual stimuli, physiological responses to sexual arousal: increased blood flow, swelling and lubrication in the genitals - all of these processes are influenced by hormone levels.

HEAVY PERSONALITY

DISORDERS

Psychotherapy Strategies

Translation from English by M.I. Zavalova

edited by M.N. Timofeeva

OttoF. Kernberg

SEVERE PERSONALITY DISORDERS

Moscow

Independent company “Class”

Kernberg O.F.

K 74 Heavy personality disorders: Strategies of psychotherapy / Transl. from English M.I. Zavalova. - M.: Independent company “Class”, 2000. - 464 p. - (Library of psychology and psychotherapy, issue 81).

ISBN 5-86375-024-3 (RF)

How to make a diagnosis in difficult cases, what type of psychotherapy is indicated for the patient, how to cope with dead-end and particularly 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 so-called borderline patients between psychosis and neurosis.

Editor-in-Chief and Series Publisher L.M. Crawl

Scientific consultant for the series E.L. Mikhailova

ISBN 0-300-05349-5 (USA)

ISBN 5-86375-024-3 (RF)

www.kroll.igisp.ru

Buy the book “From the KROL”

The exclusive right of publication in Russian belongs to the publishing house “Independent Firm “Class”. The release of a work or its fragments without the permission of the publisher is considered illegal and is punishable by law.

Integrative psychoanalysis

late twentieth century

Do you happen to know someone with a red face, three eyes and a necklace of skulls? - he asked.

“Maybe there is,” I said politely, “but I can’t figure out who exactly you’re talking about.” You know, very general features. Anyone could be.

Victor Pelevin

This book can be called a programmatic work and even a classic of modern psychoanalysis. It is taught in all institutions and is one of the most frequently cited in the whole world. There are many things that make it seem to reflect the spirit of the times:

approach from the point of view of structures;

subject - 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, integrativeness theoretical approach author.

When talking about various psychoanalytic theories in the most general terms, they are often divided into two main branches: drive theories and relationship theories, which supposedly mainly developed historically in parallel. It is significant that Otto Kernberg explicitly integrates both approaches. It proceeds from the presence of two drives - libido and aggression, any activation of which represents a corresponding affective state, including internalized object relations, namely a specific self-representation, which is in a specific relationship with a specific object-representation. Even the very titles of Kernberg’s two later books, dedicated to the two main drives (already published in Russian), are “Aggression [i.e. attraction, drive] in personality disorders” and “Love Relationships” - testify to the fundamental synthesis of the theory of drives and the theory of relationships inherent in Kernberg’s thinking. (We dare to assume that with big accent on drive in the case of aggression and on object relations in the case of love.)

Kernberg repeatedly cautions 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 belief, not directly expressed in words, 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. This philosophy denies the existence of unconscious intrapsychic causes of aggression and is in sharp contradiction with what staff and patients themselves can observe in residents of a psychiatric hospital.”

It is clear that the topic of aggression becomes especially important when discussing severe mental disorders and their treatment. For example, underestimating aggression and a complacent-naive attitude when treating 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 widely uses not only the ideas of almost universally accepted object relations theorists, such as Fairnbairn and Winnicott, but also the theory of Melanie Klein, which is much more difficult to perceive outside England. To a large extent, it is his merit that he introduced 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 idea of opposition between American and French psychoanalysis.

It is in this book that some of the most famous components of Kernberg's contribution to the development of psychoanalytic thought are outlined: the structural approach to mental disorders; the expressive psychotherapy he invented and indicated for borderline patients; a description of malignant narcissism and, finally, the famous “structural interview according to Kernberg.” It is, of course, an excellent diagnostic tool for determining the level of pathology of the patient - 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 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 throughout the 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 accepted” to apply for psychological help, and those who can no longer help but turn to psychotherapists come to them. So the patients described in the book are mainly “our” patients, with whom we most often deal.

To summarize, we can say: there is no doubt that everyone involved in psychotherapy simply needs to read this book, and it remains to be regretted that its translation is only now appearing. Until now, its absence has been felt as a kind of “blank spot” in psychoanalytic and psychotherapeutic literature in Russian.

Maria Timofeeva

Dedicated to my parents

Leo and Sonja Kernberg

to my teacher and friend

Dr. Carlos Wieting D'Andrian

Preface

This book has two purposes. First, it demonstrates the extent to which the knowledge and ideas expressed in my previous work, which focus on the diagnosis and treatment of severe cases of borderline pathology and narcissism, have evolved and changed. Secondly, it explores other, new approaches to this topic that have recently appeared 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 my theoretical formulations practical value and develop for clinicians a specific technique for diagnosing and treating complex patients.

That's why I'm trying to bring clarity to one of the most difficult areas from the outset - offering the reader a description of a special approach to differential diagnosis and a technique for conducting what I call the structured diagnostic interview. In addition, I identify the connection between this technique and criteria for prognosis and selection of the optimal type of psychotherapy for each case.

I then detail treatment strategies for borderline patients, focusing on the most severe cases. This section of the book includes a systematic exploration of expressive and supportive psychotherapies, two approaches developed from the psychoanalytic framework.

In several chapters devoted to the treatment of narcissistic pathology, I focus on the development of techniques that I believe are especially useful when working with severe and deep-seated character resistances.

Another major challenge is working with treatment-resistant or otherwise difficult patients: what to do when they develop deadlock how to deal with a patient who is suicidal; 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 regression in the transference reaches the level of psychosis? Similar questions are discussed in the fourth part.

Finally, I propose an approach to hospital-based therapy, based on a slightly modified therapeutic community model, for patients hospitalized for long periods of time.

This book is largely clinical. I would like to offer psychotherapists and psychoanalysts wide range 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 complemented by new hypotheses about severe superego pathology. Thus, this work reflects the most modern ideas of Ego psychology and the theory of object relations.

My theoretical perspectives, mentioned in the preface, draw heavily on the later work of Edith Jacobson. Her theories, as well as their creative continuation in the works of Margaret Mahler, who used Jacobson’s ideas in studying child development, continue to inspire me.

A small group of wonderful psychoanalysts and my close friends kept with me constantly feedback, making critical comments and providing all possible support, which was infinitely important to me. I am especially grateful to Dr. Ernst Tycho, with whom I have been collaborating for 22 years, and to Drs. Martin Bergman, Harold Bloom, Arnold Cooper, William Grossman, Donald Kaplan, Pauline Kernberg and Robert Michels, who not only generously gave me their time, but also They considered it necessary to argue and point out dubious places in my formulations.

Thanks to Drs. William Frosch and Richard Muenich for expressing their views on my ideas about hospital therapy and the therapeutic community, and to Drs. Anne Appelbaum and Arthur Carr for their endless patience in helping me formulate my ideas. Finally, thanks to Dr. Malcolm Pines, who supported me in my critique of therapeutic community models, and to Dr. Robert Wallerstein for his wise critique of my views on supportive psychotherapy.

Drs. Steven Bauer, Arthur Carr, Harold Koenigsberg, John Oldham, Lawrence Rockland, Jesse Schomer and Michael Silzar of the Westchester Division of New York Hospital contributed to the clinical methodology for the differential diagnosis of borderline personality disorder. More recently, they, along with Drs. Anne Appelbaum, John Clarkin, Gretchen Haas, Pauline Kernberg, and Andrew Lotterman, participated in the creation of operational definitions regarding the distinction between expressive and supportive treatment modalities 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 grateful to Mrs. Shirley Grunenthal, Miss Louise Tait, and Mrs. Jane Carr for their endless patience in typing, collating, proofreading, and compiling countless versions of this work. I would especially like to note the efficiency of Mrs. Jane Carr, with whom we have been collaborating recently. The librarian at the Westchester Division of the New York Hospital, Miss Lillian Varou, and her associates, Mrs. Marilyn Bothier and Mrs. Marcia Miller, provided invaluable assistance in compiling the bibliography. Finally, Miss Anna-Mae Artim, my administrative assistant, has once again accomplished the impossible. She coordinated the publishing work and preparation of my work; she anticipated and averted endless potential problems and, in a friendly but firm manner, ensured we met our deadlines and produced this book.

For the first time, I was lucky enough to work simultaneously with my editor, Mrs. Natalie Altman, and the senior editor of Yale University Press, Mrs. Gladys Topkis, who guided me in my quest to express ideas clearly and in an acceptable manner. English language. As we collaborated, I began to suspect that they knew much more about psychoanalysis, psychiatry, and psychotherapy than I did. I can't express how grateful I am to both of them.

Do you happen to know someone with a red face, three eyes and a necklace of skulls? - he asked.

“Maybe there is,” I said politely, “but I can’t figure out who exactly you’re talking about.” You know, very general features. Anyone could be.

Victor Pelevin

This book might be called programmatic work and even classics of modern psychoanalysis. It is taught in all institutions and is one of the most frequently cited in the whole world. There are many things that make it seem to reflect the spirit of the times:

approach from the point of view of structures;

subject - pathology more severe than neurotic, plus special attention to narcissistic disorders;

and finally, perhaps most importantly, the integrative nature of the author's theoretical approach.

When talking about various psychoanalytic theories in the most general terms, they are often divided into two main branches: drive theories and relationship theories, which supposedly mainly developed historically in parallel. It is significant that Otto Kernberg explicitly integrates both approaches. It proceeds from the presence of two drives - libido and aggression, any activation of which represents a corresponding affective state, including internalized object relations, namely a specific self-representation, which is in a specific relationship with a specific object-representation. Even the very titles of Kernberg’s two later books, dedicated to the two main drives (already published in Russian), are “Aggression [i.e. e. attraction, drive] in personality disorders” and “Love Relationships” - 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 a greater emphasis on drive in the case of aggression and on object relations in the case of love.)

It is in this book that some of the most famous components of Kernberg's contribution to the development of psychoanalytic thought are outlined: the structural approach to mental disorders; the expressive psychotherapy he invented and indicated for borderline patients; a description of malignant narcissism and, finally, the famous “structural interview according to Kernberg.” It is, of course, an excellent diagnostic tool for determining the level of pathology of the patient - 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 of supportive psychotherapy and its distinctive features. This seems 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 throughout the 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 “accepted” to seek psychological help, and those who can no longer help but turn to psychotherapists come to them. So the patients described in the book are mainly “our” patients, with whom we most often deal.

Maria Timofeeva

PREFACE

Dedicated to my parents

Leo and Sonja Kernberg

to my teacher and friend

Dr. Carlos Wieting D'Andrian

This book has two purposes. First, it demonstrates the extent to which the knowledge and ideas expressed in my previous work, which focus on the diagnosis and treatment of severe cases of borderline pathology and narcissism, have evolved and changed. Secondly, it explores other, new approaches to this topic that have recently appeared in clinical psychiatry and psychoanalysis, and gives them a critical review in the light of my current understanding. In this book, I tried to give my theoretical formulations practical value and develop for clinicians a specific technique for diagnosing and treating complex patients.

That's why I'm trying to clarify from the very beginning one of the most difficult areas - offering the reader a description special approach to differential diagnosis and techniques for conducting what I call the structured diagnostic interview. In addition, I identify the connection between this technique and criteria for prognosis and selection of the optimal type of psychotherapy for each case.

Another serious problem is working with treatment-resistant or other difficult patients: what to do when a deadlock situation develops, how to deal with a patient seeking suicide; 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 regression in the transference reaches the level of psychosis? Similar questions are discussed in the fourth part.

Finally, I propose an approach to hospital-based therapy, based on a slightly modified therapeutic community model, for patients hospitalized for long periods of 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 complemented by new hypotheses about severe superego pathology. Thus, this work reflects the most modern ideas Ego psychology and object relations theory.

* * *

My theoretical perspectives, mentioned in the preface, draw heavily on the later work of Edith Jacobson. Her theories, as well as their creative continuation in the works of Margaret Mahler, who used Jacobson's ideas in the study of child development, continue to inspire me.

A small group of wonderful psychoanalysts and close friends gave me constant feedback, criticism and support, which was infinitely important to me. I am especially grateful to Dr. Ernst Tycho, with whom I have been collaborating for 22 years, and to Drs. Martin Bergman, Harold Bloom, Arnold Cooper, William Grossman, Donald Kaplan, Pauline Kernberg and Robert Michels, who not only generously gave me their time, but also They considered it necessary to argue and point out dubious places in my formulations.

Drs. Steven Bauer, Arthur Kapp, Harold Koenigsberg, John Oldham, Lawrence Rockland, Jesse Schomer and Michael Silzar of the Westchester Division of New York Hospital contributed to the clinical methodology for the differential diagnosis of borderline personality disorder. More recently, they, along with Drs. Anne Appelbaum, John Clarkin, Gretchen Haas, Pauline Kernberg, and Andrew Lotterman, participated in the creation of operational definitions regarding the distinction between expressive and supportive treatment modalities 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 grateful to Mrs. Shirley Grunenthal, Miss Louise Tait, and Mrs. Jane Kapp for their endless patience in typing, collating, proofreading, and compiling countless versions of this work. I would especially like to note the efficiency of Mrs. Jane Kapp, with whom we have recently collaborated. The librarian at the Westchester Division of the New York Hospital, Miss Lillian Varou, and her associates, Mrs. Marilyn Bothier and Mrs. Marcia Miller, provided invaluable assistance in compiling the bibliography. Finally, Miss Anna-Mae Artim, my administrative assistant, has once again accomplished the impossible. She coordinated the publishing work and preparation of my work; she anticipated and averted endless potential problems and, in a friendly but firm manner, ensured we met our deadlines and produced this book.

For the first time, I was fortunate to work simultaneously with my editor, Mrs. Natalie Altman, and the senior editor of Yale University Press, Mrs. Gladys Topkie, who guided me in my quest to express my thoughts clearly in acceptable English. As we collaborated, I began to suspect that they knew much more about psychoanalysis, psychiatry, and psychotherapy than I did. I can't express how grateful I am to both of them.

Part I. DIAGNOSTICS

1. STRUCTURAL DIAGNOSIS

One of the most difficult problems in psychiatry is the problem of differential diagnosis, especially in cases where borderline character disorder may be suspected. Borderline states should be distinguished, on the one hand, from neuroses and neurotic character pathologies, on the other, from psychoses, especially schizophrenia and basic affective psychoses.

When making a diagnosis, both a descriptive approach, based on symptoms and observed behavior, and a genetic approach, focusing on mental disorders in the patient's biological relatives, are important, especially in the case of schizophrenia or in the main affective psychoses. But both of them, taken together or separately, do not give us a clear enough picture in those cases when we are faced with personality disorders.

I believe that understanding the structural features of the psyche of a patient with a borderline personality orientation, combined with the criteria based on a descriptive diagnosis, can make the diagnosis much more accurate.

Although a structural diagnosis is more complex, requires more effort and experience from the clinician, and carries certain methodological difficulties, it has clear advantages, especially when examining those patients who are difficult to classify into one of the main categories of neuroses or psychoses.

A descriptive approach to patients with borderline disorders can lead to dead ends. For example, some authors (Grinker et al., 1968; Gunderson and Kolb, 1978) write that intense affect, especially anger and depression, are characteristic features of patients with borderline disorders. Meanwhile, a typical schizoid patient with a borderline personality organization may not show anger or depression at all. The same applies to narcissistic patients with a typical borderline personality structure. Impulsive behavior is also considered a characteristic common to all borderline patients, but many typical hysterical patients with a neurotic personality organization are also prone to impulsive behavior. Therefore, it can be argued that, from a clinical point of view, in some cases of borderline disorders, a descriptive approach alone may not be sufficient. The same can be said about the purely genetic approach. The study of genetic relationships between severe personality disorders and manifestations of schizophrenia or major affective psychoses is still in its very early stages; perhaps they are still waiting for us in this area important discoveries. At present, the patient's genetic history is of little help to us in solving the clinical problem when we try to distinguish between neurotic, borderline or psychotic symptoms. It is possible that a structural approach will help to better understand the relationship between genetic predisposition to a given disorder and its specific manifestations.

The structural approach also helps to better understand the interrelationship of various symptoms in borderline disorders, in particular, the combination of pathological character traits that is so typical for this group of patients. I have already indicated in my early works(1975, 1976) that the structural characteristic of borderline personality organization is important both for prediction and for determining the therapeutic approach. The quality of object relations and the degree of integration of the Super-Ego are the main criteria for prognosis in intensive psychotherapy of patients with borderline personality organization. The nature of the primitive transference that these patients develop in psychoanalytic psychotherapy and the technique of working with this transference are directly related to the structural features of internalized object relations in such patients. Even earlier (Kernberg et al., 1972) we found that nonpsychotic patients with ego weakness benefited from an expressive form of psychotherapy but did not respond well to conventional psychoanalysis or supportive psychotherapy.

Thus, the structural approach enriches psychiatric diagnosis, especially in those patients who are not easily classified into one category or another, and also helps to make a prognosis and plan the optimal form of therapy.

MENTAL STRUCTURES AND PERSONAL ORGANIZATION

The psychoanalytic concept of personality structure, first formulated by Freud in 1923, is associated with the division of the psyche into the Ego, Super-Ego and Id. From the point of view of psychoanalytic ego psychology, we can say that structural analysis is based on the concept of the ego (Hartman et al., 1946; Rapaport and Gill, 1959), which can be thought of as (1) slowly changing “structures” or configurations that determine the course of mental processes, like (2) these mental processes themselves or “ functions” and (3) as “thresholds” for the activation of these functions and configurations. Structures, according to this theory, are relatively stable configurations of mental processes; The superego, ego, and id are structures that dynamically integrate substructures such as the cognitive and defensive configurations of the ego. Recently I have begun to use the term structural analysis to describe the relationships between the structural derivatives of internalized object relations (Kernberg, 1976) and various levels of organization of mental functioning. I believe that internalized object relations form the substructures of the ego, and these substructures, in turn, also have a hierarchical structure (see Chapter 14).

And finally, for the modern psychoanalytic way of thinking, structural analysis is also analysis permanent organization the content of unconscious conflicts, in particular the Oedipus complex as the organizing principle of the psyche, which has its own history of development. This organizing principle is dynamically organized - that is, it does not reduce simply to the sum of individual parts and includes early childhood experiences and drive structures in new organization(Panel, 1977). This concept of mental structures is related to the theory of object relations, since it takes into account the structuring of internalized object relations. Fundamental themes of mental content, such as the Oedipus complex, reflect the organization of internalized object relations. Modern points perspectives suggest the existence of hierarchically organized cycles of motivation, as opposed to simply linear development, and the discontinuous nature of hierarchical organizations, as opposed to a purely genetic (in the psychoanalytic sense of the word) model.

I apply all these structural concepts to the analysis of the basic intrapsychic structures and conflicts of borderline patients. I have suggested that there are three basic structural organizations corresponding to the personality organizations of the neurotic, the borderline, and the psychotic. In each case, the structural organization performs the functions of stabilizing the mental apparatus and is an intermediary between etiological factors and direct behavioral manifestations of the disease. Regardless of what factors - genetic, constitutional, biochemical, familial, psychodynamic or psychosocial - are involved in the etiology of the disease, the effect of all these factors is ultimately reflected in the mental structure of the person, and it is the latter that becomes the soil from which behavioral symptoms develop.

The type of personality organization—neurotic, borderline, or psychotic—is the most important characteristic of the patient when we consider (1) the degree of integration of his identity, (2) the types of his habitual defense operations, and (3) his capacity for reality testing. I believe that neurotic personality organization, as opposed to borderline or psychotic personality organization, presupposes an integrated identity. The neurotic personality organization is a defensive organization based on repression and other high-level defensive operations. We see borderline and psychotic structures in patients who mainly use primitive defense mechanisms, the main one of which is splitting. The ability to test reality is preserved in neurotic and borderline organizations, but is seriously impaired in psychotic organizations. These structural criteria complement well the usual behavioral or phenomenological description of the patient and help to sharpen the differential diagnosis of mental illnesses, especially in cases where the illness is not easily classified.

Additional structural criteria that help distinguish borderline personality organization from neurosis are: the presence or absence of nonspecific manifestations of ego weakness, a decrease in the ability to tolerate anxiety and control one's impulses and the ability to sublimate, and also (for the differential diagnosis of schizophrenia) the presence or absence of primary processes thinking in a clinical situation. I will not consider these criteria in detail, since when trying to distinguish a borderline state from a neurosis, nonspecific manifestations of ego weakness are not clinically significant and when distinguishing between borderline and psychotic ways of thinking, psychological testing is more effective than a clinical interview. The degree and quality of superego integration are very important for prognosis, since they are additional structural characteristics that make it possible to distinguish a neurotic personality organization from a borderline one.

STRUCTURAL INTERVIEW AS A DIAGNOSTIC METHOD

Traditional interviewing in psychiatry arose from the medical examination model and is largely tailored to work with psychotics or organics (Gill et al., 1954). Under the influence of the theory and practice of psychoanalysis, the main emphasis gradually shifted to the interaction between the patient and the therapist. A set of fairly standard questions gave way to a more flexible exploration of the core issues. This approach explores the patient's understanding of his conflicts and links the study of the patient's personality with his actual behavior during the interview. Karl Menninger leads good examples this approach (Menninger, 1952) to different patients.

Whitehorn (1944), Powdermaker (1948), Fromm-Reichmann (1950), and especially Sullivan (1954) contributed to the development of a type of psychiatric interview that focuses on the interaction between patient and therapist. as the main source of information. Gill (Gill et al., 1954) created a new model of psychiatric interview aimed at comprehensively assessing the patient's condition and increasing his desire to get help. The nature of the disorder and the extent to which the patient is motivated and ready for psychotherapy can be assessed through actual interaction with the therapist. This approach allows us to see a direct connection between the patient’s psychopathology and the extent to which he is indicated for psychotherapy. It also helps to assess which forms of resistance may become a central problem early in therapy. This approach makes it possible to highlight positive traits patient, but may hide some aspects of his psychopathology.

Deutsch (1949) emphasized the value of the psychoanalytic interview, which reveals unconscious connections between current problems the patient and his past. Starting from a different theoretical framework, Rogers (1951) proposed an interview style that helps the patient explore his emotional experiences and the relationships between them. This unstructured approach, if we talk about its shortcomings, reduces the opportunity to obtain objective data and does not allow a systematic examination of the patient's psychopathology and his health.

MacKinnon and Michels (1971) describe psychoanalytic diagnosis as based on the interaction between patient and therapist. Used for diagnostics clinical manifestations character traits that the patient demonstrates during the interview. This approach allows for the careful collection of descriptive information while remaining within a psychoanalytic conceptual framework.

All of the above types of clinical interviews have become powerful tools for assessing descriptive and dynamic features patients, but it seems to me that they do not allow us to evaluate the structural criteria by which we judge borderline personality organization. Bellak et al. (1973) developed a structured clinical interview form for differential diagnosis. This approach allows us to distinguish between normal people, neurotics and schizophrenics on the basis of a structural model of ego functioning. Although their studies did not examine borderline patients, these authors found significant differences between the three groups using scales measuring ego structures and functions. Their study shows the value of a structural approach for differential diagnosis.

In collaboration with S. Bauer, R. Blumenthal, A. Carr, E. Goldstein, G. Hunt, L. Pessard and M. Ston, I developed an approach that Blumenthal (personal communication) proposed to call structured interviewing - in order to emphasize structural characteristics three main types of personal organization. In this approach, attention is directed to the symptoms, conflicts, and difficulties specific to the patient, and especially to how they manifest themselves in the here-and-now of interaction with the therapist.

We suggest that focusing on the patient's core conflicts creates the necessary tension that allows his core defenses and structural organization mental functions. By focusing on the patient's defensive actions during the interview, we obtain the necessary data that allows us to classify him into one of three types of personality structure. To do this, we assess the degree of integration of his identity (integration of Self and object representations), the type of basic defenses and the ability to test reality. To activate and evaluate these structural characteristics, we created an interview form that combines traditional psychiatric examination with psychoanalytic oriented approach, focused on the interaction between patient and therapist, and on the clarification, confrontation and interpretation of identity conflicts, defense mechanisms and reality testing dysfunctions that manifest themselves in this interaction - especially when elements of the transference are expressed in it.

Before moving on to the description of the structured interview itself, we will give a few definitions that will help us further.

Clarification is the exploration, together with the patient, of anything vague, unclear, mysterious, contradictory or incomplete in the information presented to him. Clarification is the first, cognitive, step in which everything the patient says is not questioned, but discussed in order to find out what follows from it, and to assess how much he himself understands his problem or how much confusion he feels about what remains unclear. Through clarification we obtain conscious and preconscious information without challenging the patient. Ultimately, the patient himself clarifies his behavior and his inner experiences, thus leading us to the boundaries of his conscious and preconscious understanding.

Confrontation, the second step in the interview process, exposes the patient to information that appears contradictory or inconsistent. Confrontation draws the patient's attention to those aspects of his interaction with the therapist that seem to indicate inconsistencies in functioning - therefore, there are defense mechanisms at work, there are contradictory friends to a friend I am both an object-representation and a reduced awareness of reality. First, the patient is pointed out something in his actions that he was not aware of or considered quite natural, but which the therapist perceives as something inadequate, contradictory to other information, or leading to confusion. For confrontation, it is necessary to compare those parts of conscious and preconscious material that the patient imagines or experiences separately from each other. The therapist also raises the question of possible meaning given behavior for the patient's functioning in currently. In this way it is possible to explore the patient's ability to see things from a different point of view without subsequent regression, and it is possible to establish internal relationships between various topics, collected together, and especially to evaluate the integration of ideas about the Self and others. The patient’s reaction to confrontation is also important: does his awareness of reality increase or decrease, does he experience empathy for the therapist, what does his understanding reflect? social situation and the ability to test reality. Finally, the therapist relates the actual here-and-now behavior to the patient's similar problems in other areas, thereby establishing a connection between the behavior and complaints - and the structural characteristics of the personality. Confrontation requires tact and patience; it is not an aggressive intrusion into the patient’s psyche and is not a move toward polarizing the relationship with him.

Interpretation, as opposed to confrontation, relates conscious and preconscious material to presumed or possible unconscious functioning or motivation in the here-and-now. Through interpretation, the origin of conflicts between dissociated ego states (split self and object representations), the nature and motives of the defense mechanisms in place, and the defensive refusal to test reality are explored. In other words, interpretation deals with hidden, activated anxieties and conflicts. Confrontation collates and reorganizes what has been observed; interpretation adds to this material a hypothetical dimension of causality and depth. In this way, the therapist connects the patient’s current behavior with his deep-seated anxieties, motives and conflicts, which allows him to see the main difficulties behind the current behavioral manifestations. For example, when a therapist tells a patient that he seems to see signs of suspicion in his behavior and explores the patient's awareness of this fact, this is confrontation; when the therapist suggests that the patient’s suspicion or anxiety is due to the fact that he sees something “bad” in the therapist that he himself would like to get rid of (and that the patient was not aware of until now), this is already an interpretation.

Transference is a manifestation of inappropriate behavior during the patient's interaction with the therapist - behavior that reflects the unconscious repetition of pathological and conflictual relationships with significant others in the past. Transference reactions provide context for interpretation by connecting what is happening to the patient now with what happened in the past. Telling the patient that he is trying to control the therapist and is suspicious of him is to resort to confrontation. To suggest out loud that he perceives the therapist as an oppressive, harsh, rude and suspicious person and is therefore wary himself because he is struggling with the same tendencies in himself is already an interpretation. To say that the patient is fighting with the therapist who represents his inner “enemy” because he has experienced similar relationships in the past with a parental figure is an interpretation of the transference.

In short, clarification is a gentle cognitive tool for exploring the limits of the patient's awareness of this or that material. Confrontation seeks to bring into the patient's consciousness potentially conflicting and incompatible aspects of the material. Interpretation seeks to resolve this conflict by suggesting the unconscious motives and defenses behind it, which gives controversial material a certain logic. Transference interpretation applies all of the above aspects of the technique to the actual interaction between patient and therapist.

Because the structured interview focuses on confrontation and interpretation defenses, identity conflicts, the ability to test reality and disturbances in internalized object relations, as well as affective and cognitive conflicts, it is quite stressful for the patient. Instead of helping the patient to relax and reduce the level of his defenses by accepting or ignoring them, the therapist seeks to get the patient to show pathology in the organization of ego functions in order to thereby obtain information about the structural organization of his disturbances. But the approach I am describing is in no way a traditional “stress” interview, during which they try to create artificial conflicts or anxieties in the patient. On the contrary, clarification of reality, which in many cases is necessary in the first confrontations, requires tact from the therapist, expresses respect and concern for the emotional reality of the patient, is honest communication, and is by no means the indifference or patient condescension of an “elder”. The technique of structured interviews will be discussed in the second chapter, and below are the clinical characteristics of the borderline personality organization that are revealed with this approach.

Ecology of consciousness: Psychology. Otto Kernberg amazed everyone with a book about love and sexuality. His understanding of the subtlest 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 personality and own psychoanalytic method, proposed a new approach to the treatment of borderline personality disorder and a new perspective on narcissism. And then he suddenly changed the direction of his research and amazed everyone with a book about love and sexuality. His understanding of the subtlest nuances of these delicate relationships can be envied not only by his fellow psychologists, but also by poets, perhaps.

Nine Characteristics of Mature Love According to Otto Kernberg

1. Interest in life plan partner(without destructive envy).

2.Basic trust: mutual ability to be open and honest, even about one's own shortcomings.

3. The ability to truly forgive, in contrast to both masochistic submission and denial of aggression.

4. Modesty and gratitude.

5. General ideals as the basis for living together.

6. Mature addiction; the ability to accept help (without shame, fear or guilt) and provide help; fair distribution of tasks and responsibilities - as opposed to power struggles, accusations and searches for right and wrong, which lead to mutual disappointment.

7. Constancy of sexual passion. Love for another, despite bodily changes and physical disabilities.

8. Recognition of the inevitability of losses, jealousy and the need to protect the boundaries of the couple. Understanding that another cannot love us in the same way we love him.

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 feelings of guilt.published . If you have any questions about this topic, ask them to the experts and readers of our project

Otto F. Kernberg

Otto F. KERNBERGLOVE RELATIONSHIPS: Norm and pathology

ALL THIS IS ABOUT THE SECRETS OF LOVE

PREFACE

PREFACE

* * *

Part I. DIAGNOSTICS

1. STRUCTURAL DIAGNOSIS

MENTAL STRUCTURES AND PERSONAL ORGANIZATION

STRUCTURAL INTERVIEW AS A DIAGNOSTIC METHOD

Nine Characteristics of Mature Love According to Otto Kernberg

Otto F. KERNBERG
LOVE RELATIONSHIPS:
Norm and pathology