Kernberg: Working with the Antisocial and Malignant Narcissistic Personality Disorder Spectrum

Kernberg (2008) writes that for the treatment of any case in which antisocial features of the personality disorder (PD) are suspect, the following should be evaluated by the therapist. Such evaluation makes it possible to access his/her ability to rely on the patient’s ability to sustain the therapeutic relationship and also to access the safety of the sessions:

• The presence or absence of pathological narcissism.
• The extent to which the superego pathology dominates (i.e. which part of the spectrum of the triad).
• The intensity of egosytonic aggression and whether it is directed against the self in the form of suicidal/self mutilating behavior, or violent behavior against others / sadistic perversion.
• Severity of paranoid tendency.
• Stability of the person’s reality testing (ibid. p. 130).

The prognosis for Antisocial PD is not expected to be good in psychotherapy, in particular, if the client has severe aggressive pathologic behavior, and /or if the patient has no social support which the therapist can work with. According to Kernberg, therapists should begin work with client only after gathering the facts surrounding the clients’ coming for therapy, social support, ability to proceed with therapy in safety.

The treatment of malignant narcissistic PD (MNPD) has somewhat better prognosis than APD. A precondition for treatment is also strict control of antisocial behavior, and removal from social environment that facilitates his/her current behavior—e.g. exposure to the street gang.

General Psychotherapeutic Strategies

Kernberg’s suggestions are:

• Establishment of solid, unbreakable treatment frame.
• Systematic interpretation of psychopathic transference.
• Guiding the patient to communicate honestly (if at all possible) about their behavioral problems outside the session.
• Combining the above narrative with the developed regressive behaviors experienced during the sessions.
• Gradually making it possible to connect the pathological behaviors interpretively into cognitive and affective experiences in the transference.

Highly deceptive clients make this work almost impossible. In such cases family members or other informants may be of help. The therapist should always make it prioritize urgency of intervention:  1. Danger to self/others, 2. Threats of treatment disruption, 3. Dishonesty in communication, 4. Acting outside and inside sessions, and 5. Trivialization of the communication.

Kernberg also states that it is essential to look for affects through verbal and nonverbal communication, nonverbal behavior, and the transference. The content of what the client says is usually a weaker source of affective information than what goes in these realms (ibid. p.140).

Treating Personality Disorders with Gestalt Therapy

Considering Kernberg’s suggestion, I notice the congruence of his method to Gestalt therapy practice:

Gestalt therapy is focussed on the process of the therapeutic dialogue, i.e. non-verbal interaction / body language. Therapist also encourages the client to enact situations that cannot be talked about. Poor functioning personality disorders prevents the individual from communicating with the therapist on a contactful level. As Kernberg notes, there is a tendency for such a client to deceive / idealize and devalue/ play victim or rescuer or persecutor with the therapist. The awareness of the therapist of this phenomena is essential. He /she is most effective when he/she can contain the clients behavior without getting roped into the game.

For this reason, in gestalt work, we focus of body language / tone of voice together with what is said, and we also focus on our (the therapists) own personal reactions. What the therapist tells the client is not analysis, but a descriptive reflection of what the therapists sees hears and senses.

The client benefits from this kind of honest interaction, because he/she too are not going to be caught up in games. In the beginning, there will of course be discomfort and frustration. If the client sticks to the work, there will be progress made.

Read also

Symptom Relief in Psychotherapy

Psychotherapy is about Uncovering the Truth of the Self

Former Patients’ Conception of Psychotherapy 

Bibiliography

Kernberg, O. (2008). Aggressivity, Narcissism, and Self-Destructiveness in the Psychotherapeutic Relationship: New Developments in the Psychopathology and Psychotherapy of Severe Personality Disorders. Yale University Press.