chapter  27
22 Pages

An Experiential Approach to Narcissistic and Borderline Patients

IN RECENT YEARS psychoanalysts, inspired principally by the clinical studies of Kohut and Kernberg, have delineated two major diagnostic entities-the narcissistic personality disorder and the borderline personality disorder. Patients suffering from these disorders lack the resilience in the face of stress of a normal person or that generally displayed by a patient suffering from a psychoneurosis. Their functioning suffers in ways that have been characterized as disturbed cohesion of the self by Kohut (1971) and by Kernberg (1975) as regression both of ego and superego functioning and of object relations. On the other hand, even in response to stress, narcissistic and borderline personality disorder patients display a resilience in the face of fragmented cohesion of the self and of regressive structural' and objectrelated functioning that is not present in the psychotic patient. Their more severe regressions are either relatively easily reversed or at the worst become stable, retaining some adaptive features. The diagnostic criteria for each illness have been delineated at length. The disagreements between Kohut and Kernberg have been aired in meetings and publicatons (see also chapter by Lang, this volume). Kohut's proposals, are, I believe, essentially a regulatory theory - one that holds the mother and child to be an interactional unit in which the mother's ministrations provide the necessary soothing, mirroring, confirming, and affirming in response to the child's excitements and displays. Successful regulation by the mother leads in time to increased internal capacity of the child to perform the function the mother served-for example, the child can soothe himself. Failure leaves the child seeking a socalled selfobject to ensure the regulation of self-esteem, to aid and control ambitions, and to provide an object for idealization. I believe Kohut's view that regulatory failures lead to the persistence of grandiose self-config-

urations and archaic, idealized, parental images is correct. I disagree with the distinction he makes between regulatory failures and the existence of conflicts. My observations indicate that patients with regulatory failures are particularly prone to conflicts. Kernberg's (1975, 1976) proposal is a creative synthesis of Hartmann's (1964) ego psychology as explicated by Jacobson (1964) in the Self and the Object World, and the theories of the English schools of object relations. In Kernberg's view the child internalizes object relations and develops psychic structures, including drives, in consonance with the affective nature of the relationships. Inevitable conflicts, in Kernberg's view, develop around the child's need to control oral envy and destructiveness.