Integrating Kernberg’s Model of Personality Organization with Gestalt Therapy

Kernberg’s model of personality organization provides us with a helpful visual of how differently experienced psychological symptoms relate with each other. Symptoms of personality disorder are very individual and unique each client. The “severity” of the symptom is phenomena “felt” by other people in the community and the therapist. It is therefore more accurate to base our assessment of the client’s problems on the effect the client’s behavior has on others and therapist, and based on how fixated the client is on this behavioral pattern. It is assumed that the more fixated one is on a mode of behavior, the less one is able to function socially and economically.

Kernberg established 3 main group of personality organization. These are arranged in increasing order of “severity”: 1. the Neurotic Personality Organization (NPO), 2. The Borderline Personality Organization (BPO), and 3. the Psychotic Personality Organization (PPO).

Horizontally, Kernberg also categorizes the symptoms as a spectrum of introvertion and extrovertion. This describes how much the individual with such diagnosis interacts with the other. The more introverted would keep the self in isolation. This would range from shyness to complete fear of being with others (as in severe paranoid PD / schizoid PD). The extrovert range would range from being dependent on the presence of others ( as with the dependent PD) to victimizing others (as in malignant narcissism PD or antisocial PD).

Most severe condition is the psychotic condition.

Kernberg (2008) Model of Personality Organization

When we connect this with Melanie Klien’s (Kernberg is a Kleinian) model, we can see that the BPO represents the condition where an individual is stuck at the paranoid-schizoid phase. The NPO represents the individuals who have developed into the depressive phase. *Note* that the terminology here is very confusing, because “paranoid-schizoid” and “depressive” used in this context has not much to do with the absolute meaning, but rather serves to describe a phase.  Please refer to this article for clarification on this topic.

When we consider Kernberg’s diagram, we may be able to appreciate how if the individual is fixed to the BPO, he/she may be holding on to maintain an intact sense of self. The consequence of not having the symptoms may lead to breakdown and possibly psychosis. As therapists, we must be very aware of this “ability” of the client to support him/herself in this way, even though his/her behavior is hurtful/harmful/not helping. 

The Contact Cycle in Gestalt Therapy

In Gestalt therapy we talk about contact. Contact is a means of a organism (a person) getting in touch with his/her needs and being able to get his/her needs fulfilled. This is not unlike Marslow’s concept of the hierarchy of needs. Needs not met will end up in the individual being weakened or even harmed as a result of accumulated stress. A very simple example: if a person’s body is lacking in nutrients, the person needs food. If he does not get this food, he suffers. Needs are always present. We have to be able to first realize the needs. In Gestalt therapy, the work of the therapist, for example, is to help the client uncover his needs of the moment, how he denies his needs by numbing himself from the sensation of the need, how he attributes the needs to someone else by projecting the needs and how he is not able to feel satisfied once the need is met.

Below is my sketch of the contact cycle in gestalt therapy. It is complicated, but there are simpler diagrams on the net or in books.

When the need is recognized, acted upon and assimilated, the gestalt is closed. The client is relieved of a stressful condition (that may have pervaded his life).

Shame at the Pre-contact Phase: When we look at the contact cycle, we can see that the hinderance to pre-contact is desensitization. The client does not know about this need. Oftentimes this is attributed to shame: when it is too shameful to even tell oneself that one has this need. Many people do not feel shame also for this reason. They anesthetize themselves from the sensation.

Anxiety at the Action Phase: The next part of the cycle is when one feels a need but acts inappropriately so as not to be able to fulfill the need. This is a miss-action normally caused by projecting what one feels or needs to others. For example when one is completely angry at another, he/she instead thinks that the other is hostile. Oftentimes the projection is brought about by anxiety or a dreaded fear of acting accordingly, but instead act by splitting this action from the self onto the environment.

Guilt at the Assimilation Phase: At the end of the phase, problems arise when the person is not able to assimilate what he/she has felt and done. This is probably the problem with overeating (this a simple example): the person is hungry, eats, but cannot feel nourished. In the realm of personality disorder, it is often the problem of the individual not being able to recognized his deeds, and avoids the feeling by not being able to feel a sensation of satisfaction (lustfulness). There would be continued hunger for whatever the need may be.  In serious cases (perhaps antisocial PD) if one has committed a crime, one is not able to sense guilt or remorse.

Gestalt Therapy and Kernberg’s Personality Model

In the figure below, I try to fit the 2 models together. This is of course, like all models and classifications, a way of conceptualizing, and not fixed truism. One would be well served to look at all graphical representation of psychic phenomena as as spectrum rather than as in discreet boxes and lines.

Personalities “stuck” in the avoidance of guilt end of the contact cycle, for example is caricaturized by the cold-blooded malignant narcissist or sociopath. When we look closely at all other personality fixations we can also see avoidance of guilt. Ultimately, this is all related to context.

Connecting these concepts can be useful to the gestalt therapists who use the contact cycle as means of understanding the mental processes of the client. It also helps us to access what difficult emotions underlie the personality structure of the client. Work with personality disorder is extremely complex because it deals with contact, not only with the environment, but also with the therapist’s personality.

I hope this idea is useful.

Bibliography

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

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.