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ABSTRACT In this paper, the main concepts of Otto Kernberg and Heinz Kohut-two theorists who have greatly influenced clinical social work practice with severely disturbed patients-are presented, and then compared by using a case from the practice of the author. The case illustrates the value of utilizing some of the treatment principles put forward by Kernberg and Kohut without becoming too wedded to either of the overall treatment approaches they have formulated. Some aspects of the manner in which the practitioner determines when the treatment approach needs to be modified-to avoid the pitfalls of either being too wedded to an approach or too eclectic-are discussed as well. KEY WORDS: borderline personality disorder; narcissistic personality disorder; self psychology; countertransference; self-analysis.
For more than two decades the two theorists who have had the greatest influence on psychoanalytic thinking about patients with more severe psychopathology-with the possible exception of Harold Searles-have been Otto Kernberg and Heinz Kohut. Both Kernberg and Kohut applied psychoanalytic theory to the treatment of patients often considered unsuitable for analytic treatment by those working from a classical analytic perspective. However, their conclusions about the etiology and psychic structure of borderline and narcissistic psychopathology, as well as the optimal treatment approach, are very different.
Kernberg is considered a conflict theorist, who, like other American object relations theorists, has retained the use of the concept of instinctual drive along with other aspects of Freudian metapsychology; this places Kernberg in the psychoanalytic mainstream. He wrote extensively about both borderline and narcissistic psychopathology
Kohut, on the other hand, made a more radical break with the classical tradition; he eventually rejected many classical conceptualizations and, with the help of his followers, developed his concepts about narcissism and the self into its own school-self psychology. Although Kohut was not optimistic about self psychological treatment of the borderline patient (Kohut & Wolf, 1978) and he focused primarily on the treatment of narcissistic disorders, many analytically oriented clinical social workers and other analytically oriented psychotherapists rely heavily upon self psychological theory and treatment principles in their work with borderline patients.
In the first part of this paper, the main concepts of both theorists will be presented and compared. In the second part, a case will be presented which will demonstrate the...