A conversation of Raffaele Siniscalco with Otto Kernberg

Keywords: Self-esteem - Infantile narcissism - Super-Ego - Psychopathic Personality - Borderline personality

Summary:
Kernberg considers narcissism both at a theoretical level as libidinal investment of the Self, and at a clinical level as regulation of self-esteem. The first precondition for normal narcissism is an integrated sense of self which, together with an internal world of significant others, strengthens normal self-esteem. If normal infantile narcissism persists into adulthood, it can become narcissistic personality disorder, characterized by an over-involvement with oneself and an inordinate envy of others. Internal morality is weakened because the positive aspects of the Super-Ego are incorporated into the Self, and the prohibitive ones are projected onto the environment which thus becomes critical and demanding. The most severe cases are those of 'malignant narcissism'-severe deterioration of the Super-ego, anti-social behavior, paranoid features, etc.-and the 'psychopathic personality' with a total destruction of the super-ego. Paradoxically there is a greater destruction of the world of internalized object relations in pathological narcissism than in ordinary borderline personality organization of which the former is a secondary complication.. Kernberg's approach, a combination of object relation and ego psychology, differs from Kohut's in that the latter's infantile grandiose self is rooted in normality. For the author this is an adaptive strengthening of the pathological structure whose effect is the stabilization of self esteem but not a deepening of object relationships.

Otto Kernberg: Narcissism refers to two kinds of concepts: one at a very theoretical level and one at a very clinical level. At the theoretical level-within psychoanalytic metapsychology-it refers to the libidinal investment of the Self. At the clinical level, it means the normal or pathological regulation of self-esteem. Those two definitions are related in the sense that a normal Self and its normal investment with libido assures the regulation of self-esteem. Normally the regulation of self-esteem is assured by an integrated concept of Self in contrast to a split or disorganized concept of Self that gives a general sense of uncertainty and lack of capacity for internal well-being and safety. So, an integrated sense of Self is a first precondition for normal narcissism. Second, we normally incorporate the images of those who are close to us, we internalize them, and develop an internal world where we feel surrounded by our friends and the people whom we love and who love us, and who support the representation of our Self that we have. So normal self-esteem is strengthened by an integrated representation of Self and an internal world of significant others whose representations we have internalized. Third, normal self-esteem is also regulated by our internal consciousness: the super-ego and the ego ideal, in psychoanalytic metapsychology, that is to say an internal mental structure which tells us you are doing all right, you deserve to think well about yourself, you can be proud of yourself. Normal self-esteem is also supported by our expressing instinctual needs in an acceptable way, by our sexual and aggressive impulses. Normal self-esteem is finally and obviously supported by our being effective, successful in pursuing our tasks, ambitions and ideals. So, there are many sources that regulate normal self-esteem and protect it.
When everything is in order, we call it normal narcissism. There are many individuals whose internal value system, whose super-ego, has remained at a childlike level. They feel good not because they live up to adult values of maturity, intelligence, depth, compassion, friendliness, tact, and concern invested in others, but they feel good if they are beautiful, admired, have shining clothes, bright cars, in other words, ideals that are normal for a little child, but childish for an adult. We call this normal infantile narcissism, and it only becomes a problem if it persists into adulthood, which is the case when there is a general non-specific personality disorder or character pathology as a by-product of unresolved psyche conflicts causing a fixation at infantile values. For example, it is normal for a little girl to feel that if she is clean and doesn't touch her genitals in public, she is a good girl. But in general, this is not something that any woman of forty does, otherwise it may become a disaster, an unconscious repression of all her sexuality. So the adult's superego creates unconscious conflicts. In other words, the absence of an adult superego and the dominance of infantile superego values creates unconscious conflicts and symptoms, with a by-product being a fixation at infantile narcissistic values. So, I have talked about normal adult and normal infantile narcissism, and a certain infantile narcissistic attitude in individuals who are stuck with unconscious conflicts.
A particular pathology of narcissism is the narcissistic personality disorder, the prototype of pathological narcissism that is a major source of pathology. About 30% of all patients with significant personality disorders have such pathological narcissistic features. And this is an area where we have gained a lot of understanding both in diagnosis and treatment. It is one area where psychoanalysis has made a significant contribution to the understanding of personality disorders and their treatment, because the psychoanalysis of the narcissistic personality is capable of resolving them. Interestingly enough, the narcissistic personality was the only narcissistic pathology that Freud did not describe in his seminal article On Narcissism of 1914, where he initiated the whole study of normal and pathological narcissism. Freud described all other areas in great detail, except for the narcissistic personality. Abraham, in an article of 1919 on a particular resistance to psychoanalytic treatment, describes the characteristics of these patients, but without being aware that he was describing a major character pathology. It was only in the 1960s and 1970s that psychoanalytic thinking really developed a clear understanding of these disorders and methods for their treatment. What then is pathological narcissism and what are the problems of the narcissistic personality?
Clinically, these individuals show an abnormal self-love and way of loving others, as well as problems with their internal morality system and their superego. What is abnormal self love? Individuals who are over-involved with themselves, who are grandiose, who have excessive ambitions regarding their capabilities, who are exhibitionist, self-centered, selfish, and have great difficulty in depending on other people desperately need the admiration of others. They live on admiration, but not on real dependency. They tend to oscillate between a sense of grandiosity and episodes of severe feelings of inferiority and failure they develop when that grandiosity is punctured. There is a combination of grandiosity, over-involvement with themselves, sometimes to the extent of recklessness, arrogance and simply acting in inappropriate ways, which oscillates with feelings of insecurity. So, while they seem to love themselves excessively, it is in a frail way. With regard to others, perhaps the most important aspect is an inordinate envy of others, both conscious and unconscious. They have a dominance of oral problems from very early stages of development, and particularly intense oral aggression derived from conflicts in the infant-mother and child-mother relationship. And the form that this aggression takes is envy, the hatred of something that another person has: they want what they don't have, and so they try to spoil it, to destroy it in the other person. The envy of others leads to a number of severe problems: first, the need to devalue what others have as a defense against envy. They devalue that which they think is great, what they would like to have but not have. And that devaluation is an unconscious process which interferes with learning. For example, they may want to learn something from another person, but they can't because they envy the knowledge of the other person, so they cannot learn. Their incapacity to depend on others derives from that envy. To depend on somebody else, we have to appreciate that person, that that would generate envy. They cannot depend, they can only accept admiration. They tend to be exploitive of others, they tend to steal others' ideas, they have difficulty in accepting things from others because it gives them a sense of inferiority, and they are always so concerned with who is superior and who is inferior that it rules their significant relationships to others. So their relations with others are superficial, shallow; they lack empathy, and have difficulties in committing themselves. There are practical consequences: they fall in love, but envy the person with whom they fall in love, and so fall out of love as fast as they fall in love. There is a narcissistic form of promiscuity, traditionally seen only in men, but now also in women, as women's liberation facilitates women's imitation of men's behavior. Typically, a man falls in love with a woman, has sex with her, and then devalues her: she is no longer interesting, he has to go on to the next, and so the same process repeats itself endlessly. Their difficulties in appreciating what they get from others because they devalue it, also makes it impossible for them to enjoy what they themselves have, and there is a chronic sense of emptiness that they try to compensate for with exciting experiences, sometimes with drugs or alcohol.
I spoke about abnormal relations to others, to the Self and, thirdly, about abnormal relations to the internal conscious. What in psychoanalysis is called the Ego Ideal-ideals and aspirations incorporated into one's superego-is absorbed into their Self. They don't have a normal Self, they have an abnormal, grandiose Self, constituted by real Self-representations, ideal representations of Self-as they would like to be ideally-and ideal representation of others. They incorporate what they see as ideal in others and see themselves that way. They live on the incorporation of everything that is ideal into a false Self-structure. That, at the same time, implies a devaluation of others, so the internal world of representation of others does not reconfirm them, as happens in normal narcissism. The superego is weak because the ideal part of the superego is incorporated into the Self. What remains are the prohibitive aspects of the superego; and so the superego become so severe that, to protect themselves against their superego, they reproject it onto the environment, by seeing other people as critical and demanding; and they do not make demands on themselves. So, their internal moral structure is weakened. The price they pay is that they lose the normal regulation of self-esteem. The normal superego tells us "you did well" or "you didn't do well", so our self-esteem oscillates. But their weak superego can't perform that function, so they either feel great or, if the superego finally tells them "you made a fool of yourself", their self-esteem collapses totally. Their self-esteem fluctuates widely because they don't have the compensating representation of significant others, nor a good superego. They have a sense of aloneness, they need others, but can't appreciate them.
Under mild circumstances this means severe mood swings, and a tendency to depression. They have a shame morality, not a guilt morality: this means that they don't do things they shouldn't do just because they are terribly afraid of getting caught and of being humiliated. They don't do bad things not out of a sense of guilt and morality, but out of a sense of shame. These are relatively mild phenomena, but severe cases have a severe deterioration of the superego, where you find a combination of severe narcissism: anti-social behavior, ego-symptomatic aggression, and severe paranoid features, suspiciousness and distrust of others. This is called the syndrome of malignant narcissism. And there is still the most severe form of narcissism, wherein there is a total destruction of the superego, that constitutes the anti-social personality or the psychopathic personality. Severe criminals, whether aggressive or passive-stealing, murdering, exploiting-have a total incapacity for any guilt feelings or concern for others, and are practically and unfortunately untreatable. So, the narcissistic personality operates on a broad spectrum. The typical case has an excellent prognosis for treatment, the most serious cases, with severe anti-social behavior, a bad one.
Now, in their psyche's structure, instead of a normal Self they have an abnormal grandiose one with a projection outside of all undesired, unacceptable parts of the Self, a weakening of the superego, and the absence of an internal world of object relations. It is a serious pathology of the psyche's structures. How does that look during the treatment? First of all, why do these patients come to treatment? Normally they feel great, but if they have any symptom or difficulty, they feel like collapsing, because they have to be perfect to feel well, they cannot tolerate the normal weaknesses of life. The most severe cases appear already in childhood between ages five and ten; these are children who become very dominant and controlling, who have to be number one among their friends whom they treat as slaves, who have difficulty at school, who don't have mutuality, who do not show gratitude, and who have difficulty with learning because of this process of unconscious envy for knowledge, so they have learning difficulties.
Later on, you find some cases in early adolescence, because of their arrogance, grandiosity and inter-personal difficulties. A very typical syndrome is that they are either the best students or the worst. If they are intelligent they are great because, when something comes easy, they love it because they are on top and they learn very easily. But they reject anything that is more difficult, because it would generate envy, so they never learn it. All the brothers of a patient of mine learned to ski, but my patient never learned to ski because he couldn't do it immediately as well as his brothers, so he stopped. He became an excellent swimmer, since nobody in his family swam, but he could never learn skiing. This illustrates that many school failures are derived from narcissistic pathology. During adolescence, they may have many friends at school. But, as an adult, your friends depend on your personality, so they have more serious difficulties at work and with others, and come to treatment because they don't understand why others don't love them. They don't see that their arrogance, grandiosity and lack of consideration puts others off. Other patients come because in intimate relations they are terribly selfish. For example, a narcissistic man marries a beautiful woman because she is so stunning that everybody will envy him. But once married, because of his unconscious envy, he loses all interest in her and can't appreciate her. He feels her demands as terrible, and treats her as if she were willing to be a slave. If she is not, there is a terrible marital conflict. So, they come because of difficulties with others. Later in life, those who have done well in the past come for treatment because with age they have lost their beauty, their attractiveness, their power, their health, and they have great difficulties in accepting these normal losses in life because their self-esteem is so frail.
What happens in treatment? The psychoanalytic treatment of these patients first of all permits us to see their incapacity to depend on the analyst. They treat the analyst either as if the analyst were the greatest man in the world and they depend on him, or as if they were the greatest patients and the analyst were their admirer. There is always a one-sided great admiration rather than any mutuality, and that has to be analyzed. These patients tend to exert omnipotent control on the analyst, the analyst must be as good as they, because if he is not, they feel depreciated. But he can't be better than them, because they would become envious, so he has to be as good as them. So, they tend to be very controlling, and cannot imagine that the analyst might be interested in treating them for themselves, instead of for their prestige or the money. They project onto the analyst their own difficulty in investing in others. So in the transference, you analyze all these aspects and gradually undo the pathological grandiose Self, decomposing it into its component internal relationships that can be worked through in the transference. As you do that, these patients develop intense envy, all the unconscious comes out into the open, and they become-as they must-aware of their aggression and exploitiveness. They experience great suffering. But, as they learn to tolerate those feelings, they can gradually see the infantile origin of this, free themselves from it, and eventually establish an in-depth relationship, developing feelings of gratitude, and of guilt for their own aggression, which permits them gradually to incorporate what they receive from others, to not feel envious any more, and to be able to establish in-depth relationships and resolve their pathological narcissism.

What insights can an analysis of narcissism give to understanding syndromes like psychosis, criminal behavior, borderline pathologies and perversions?

I have already mentioned how criminal behavior may reflect the most severe types of narcissism with the most severe deterioration of the superego, so that the theory of narcissism opens out to an understanding of anti-social behavior and to the understanding of the psychopath. When Freud described narcissism, he also thought that psychosis developed from narcissistic conditions, because the libido was withdrawn from the environment. We don't think in that simple way any more. We think that psychotic patients are much more invested in their surroundings and that their conflicts have more to do with primitive aggression than with a pathology of the libido. And so the term narcissism is more and more used for narcissistic personalities, and less and less to talk about psychosis.
Regarding borderline pathology, when you analyze the pathological grandiose Self, you find underneath a lack of integration of the concept of Self, and of the concept of the significance of others. This is characteristic of borderline personality organization, and common to all severe personality disorders. In other words, underneath the pathological grandiose Self is a lack of integration of a normal Self, which is called identity's diffusion. And when you dissolve the pathological grandiose Self in the treatment, the identity's diffusion comes to the surface. So, in the middle of the treatment, narcissistic patients look like borderline patients, already on the road to improvement. So, pathological narcissism is a secondary complication to borderline personality organization. Narcissistic patients may look better on the surface, because the pathological grandiose Self helps them to adjust better superficially, but paradoxically they are sick because there is a greater destruction of the world of internalized object relations than in the ordinary borderline case. The ordinary borderline case is more like impulse, control, anxiety intolerance, and chaos, yet it is better able to relate to people and to be clingingly dependent, in contrast to the narcissistic personality. Thus, the narcissistic personality is a secondary development out of borderline personality organization, and in the course of treatment, the borderline pathology emerges in the transference and can then be treated like any borderline pathology.

Our modern concept of perversion covers a broad spectrum of pathology. In DSM IV the term paraphilias replaces the word perversion. What is called perversion in the United States is sexual behavior restricted to one particular part of polymorphous perverse infantile sexuality, so that the patient can obtain sexual excitement and orgasm only if he performs that particular activity, in contrast to normal sexuality, which can integrate fetishistic, sadistic, masochistic, exhibitionistic, voyeuristic tendencies, with homosexual and heterosexual feelings. An exhibitionist must exhibit himself to be able to obtain sexual gratification. A shoe fetishist must have a shoe to smell and caress. Freud described the dynamics of these patients.
But the personality structure of patients with perversions varies from normal or neurotic to borderline, narcissistic and psychotic. The study of narcissism has permitted us to better understand patients who have a perversion with a narcissistic personality structure which they need to resolve as a precondition to cure their perversion. Thus, an understanding of pathological narcissism has permitted us to make inroads in the treatment of those perversions that are based upon a narcissistic personality structure.

Can you describe briefly the most important approaches to narcissism today in the United States and abroad?

The psychoanalytic treatment of narcissistic personalities in the United States is probably dominated by the combination of ego psychological and object relations theory. I myself have tried to integrate British object relations theories with American ego psychology, and I have developed over the years some of the work on pathological narcissism that I have summarized here. This is probably the dominant approach to narcissism at the present in the US.
Another important current for the treatment of pathological narcissism is Kohut's Self psychology. In fact, Heinz Kohut's original contributions centered very much at first on the study of narcissistic personalities, which he then broadened into a general review of psychoanalytic theory. Kohut's approach differs from mine very markedly in that for him the grandiose Self is not pathological, but rather a normal archaic grandiose Self on which the individual is fixated. And in treatment, the patient must be helped to develop it and to mature, rather than to dissolve it in order to discover the underlying primitive conflicts. Kohut achieves this by managing the two dominant or major transferences, as he describes them in his patients. What Kohut calls mirroring transferences are when the patient perceives the analyst and himself as one, when the patient needs to be mirrored, and when the analyst accepts and does not question the patient's grandiosity, but on the contrary helps him gradually to mature through the development of this mirror transference. On the other hand, what he calls idealizing transferences are when the patient idealizes the analyst, with the expectation that the patient will gradually internalize that idealized analyst who, at the same time, is the one who mirrors the patient. The patient's Self will become surrounded by what Kohut calls Self-objects, namely, the internalization of the idealized mirroring analyst. The analyst confirms the patient's grandiosity-disappointing it only bit by bit so that the patient can tolerate it--analyzing all the frustrations that he himself unwillingly, unwittingly produces while at the same time lending himself as an idealized figure to be internalized by the patient, thus bringing about the transmuting internalization of the ego ideal. The patient is helped to constitute an ego ideal, and at the same time to strengthen that grandiose Self that for Kohut really is rooted in normality. As you see, it is a very different approach, in which the management of mirroring and idealizing transferences leads to a very positive relationship in which the unconscious negative transference is not analyzed, and in which Kohut sees the emergence of aggression as derived not from unconscious drives, but from the temporary fragmentation of the grandiose Self that has been frustrated, because of its frailty. It is an approach that permits the patient to improve his view of himself and his relations with others, because the Self psychologist, in a very understanding, empathetic way, helps the patient to come to terms with himself and to mature in the process. For critics of Kohut, such as myself, it is a very sophisticated application of psychoanalysis to have a supportive approach that in fact strengthens the pathological structure while making it more adaptive, but that neglects the underlying conflicts surrounding both libido and aggression. In my view, the effect of Kohut's treatment is a stabilization of the patient's self esteem, but not a deepening of object relationships such as that obtained by the more classical approach which I described earlier.
A third approach to narcissism is the classical Kleinian technique that has been applied to the treatment of the narcissistic personality by Herbert Rosenfeld in England. I have incorporated many aspects of this extremely interesting technique, although there are differences between my approach and that of Rosenfeld, too detailed to specify here. Another different approach on narcissism derives from French psychoanalysis. There have been very important French contributions, particularly from Béla Grunberger, who described the narcissistic features of the various stages of development-oral, anal, genital-their manifestations in transference, and the importance of incorporating them in analytic work with patients. It is an approach that deals less with narcissistic personalities, but more generally with the integration of narcissistic tendencies. Another very important French contribution is that of André Green, who talks about narcissisme de vie, narcissisme de mort: narcissism of life, narcissism of death. He refers to a negative narcissism in which well-being does not derive from a grandiosity of being admired and at the center of attention, but is a narcissism of total staticity, of negative entropy, of a radical discontinuation of all relationships and all connections, and in which all anxieties and conflicts are eliminated by a total denial of one's psyche's life. It is really a narcissism of death which underlies the most severe self-destructive tendencies. André Green has made a very important contribution for patients with very severe chronic, self-destructive and suicidal tendencies.
In practice, the first approach, the combination of object relations and ego psychology, is probably the prevalent one, and also extends into psychoanalytic psychotherapies with narcissistic patients who cannot be analyzed because of various contraindications. It is an approach that helps to improve the narcissistic pathologies significantly, although it does not have the totally satisfactory result that one obtains with the psychoanalytic treatment of these patients. I believe that the ideal approach to very sick patients is to start out with a psychoanalytic psychotherapy and, when they are ready for psychoanalytic treatment, then continue with psychoanalysis, perhaps with another analyst to maintain an ideal analytic structure.

Why do you think that American psychoanalysis has focused especially on narcissism? Is it perhaps because it is the most prevalent type of pathology in the United States?

It is quite prevalent, although I don't know whether it is more prevalent in the United States than in other countries. We don't have sufficient studies to really answer that. It has been studied here because ego psychology was very interested in character pathology, so that from an ego-psychological viewpoint, to study pathological character-i.e., personality disorders-was a natural development and, with all due modesty, I have contributed a little with my work in this direction. But there have also been important contributions from other ego psychological authors-Anne Rich, Edith Jacobson, Ellen Tartackov, Peter Wannerwaltz, etc. The fact that Christopher Lash, a social psychologist, used the psychoanalytic theory of narcissism to explain aspects of American culture contributed enormously to generalize the concept. But what the relationship between a narcissistic culture and a narcissistic individual pathology consists of, this is not clear. It is tempting to describe certain cultures in terms of certain pathologies of character. But one has to keep in mind that while character is influenced by culture, those relationships are more indirect and complex than meets the eye. For example, to say that the Victorian age with its sexual repression produced an hysterical culture and the age of hysteria is fine as a first approach, but misses the complexity of sexuality during the Victorian era. Or to say that Czarist Russia had a culture of depressive personalities because of Russian psyche misses the complexity, just like saying that American culture is narcissistic. Certainly narcissism is exploited by a consumer society that appeals to the consumers' narcissistic wishes, but from there to describe the culture as narcissistic is a big step. So, there are connections, but they are more indirect and complex than simply the prevalence of the narcissistic personality in this culture.