Otto Kernberg's work on the nature and treatment of identity disturbance and narcissistic and borderline personality disorders stands as one of the most influential modern contributions to psychoanalysis and psychiatry as a whole. Entitled The Inseparable Nature of Love and Aggression, Kenrberg's new book impressively brings together his life's work on identity and narcissism, as well as delving into other interests including grief, sexuality, spirituality, education and disagreements between various schools of psychoanalysis. Kernberg describes his work as an ‘effort to carry out a boundary function between a psychoanalytic, a clinical psychiatric and a neurobiological approach’.
The book is divided into five sections: Severe Personality Disorders; Reflections on Psychoanalytical Theory and its Applications; The Psychology of Sexual Love; Contemporary Challenges for Psychoanalysis; and The Psychology of Religious Experience. The first section commences with a very useful summary of work by Kernberg and other notables such as Erik Ericsson, Wilfred Bion and Peter Fonagy, into identity diffusion and severe personality disorders. Different psychoanalytical ideas of narcissism such as those of Heinz Kohut are not really entertained. Later chapters in section 1 focus on the practicalities and mechanisms of change in the transference-focused psychotherapy (TFP) that Kernberg and colleagues have developed at the Institute for Personality Disorders in Cornell University and elsewhere. For those unfamiliar with TFP, it aims to integrate split-off parts of self and object representations through interpretation and transference analysis during intensive psychotherapy.
The effort to integrate psychoanalytical theories with neurobiological research comes in sections 2 and 3. Kernberg examines the effect of development in infancy and relates this to psychoanalytical theories of drives and current knowledge of neurodevelopment and neurotransmission. The death drive as an inborn disposition to self-destructive behaviours is one of the other areas covered in depth in this section. Another fascinating chapter is devoted to mourning, which is an area where Kernberg writes from personal experience and where his thinking clearly differs with Freud's. Libidinal drive and other psychoanalytic theories of human relationships and sexual love, as well as their pathological manifestations, are brought together expertly in section 3. This section also includes some linking of psychoanalysis to contemporary neurobiological findings, and a chapter focusing on sexual pathology in borderline patients.
The teaching of psychoanalysis and ideological disagreements between its theoreticians and practitioners are examined worthily in section 4. Kernberg is concerned by the isolation of psychoanalytic institutes within the university and their relative lack of emphasis on research and calls for greater integration. He regards this development of an authentically scientific atmosphere as key to psychoanalysis becoming more open and less wedded to the work of particular theoreticians. Kernberg's thoughts on these important matters were fascinating and sensible but seemed to me to be somewhat out of context in the book as a whole.
I found the final section in which Kernberg explores psychodynamic factors underpinning spirituality, and ethical value systems to be the most interesting and new. He is far more positively disposed towards religion than was Freud and he sees the potential for religiosity to be a mature desire for a transpersonal system of morality and ethical values. Kernberg goes on in his final chapter to propose a model of internal object relations that facilitates ‘the development of a spiritual realm that transcends the pragmatic aspects of mature object relations and opens the road to aspiration to universal ethical values’.
This is a monumental work synthesising Otto Kenrberg's important work on personality disorders and other diverse topics over many years. The book is dense and highly scholarly and is written in a rather high-brow manner that causes it to suffer a little in terms of general readability. There are some useful case studies, particularly in the chapter on The Almost Untreatable Narcissistic Patient, but more illustratively placed clinical examples in some of the more theoretical chapters would have been helpful. Those criticisms aside, in an age of poorly integrated textbooks written by a multitude of authors with varying styles and overlapping contents, it is awe inspiring and indeed a pleasure to read such a masterful individual work. Any psychiatrist or other person with an interest in personality disorders and psychodynamic psychotherapy should read this book.
