He begins by offering a sensible formulation of affect theory, a developmental model which the clinician can use as a checklist: when the patient approaches an area of emotional sensitivity, is his affect primitive and disorganized or evolved enough to appear as an emotion? Is the somatic component there? The cognitive? And, since affect involves an object, is the object relation there too? If not, how far from consciousness? What defenses protect it?
The book is organized into sections on the role of affects, developmental aspects of broad-spectrum personality disorders (not necessarily (thank God) in the DSM sense), clinical applications of object relations theory (discusses the transference, structural change, and other such considerations), technical approaches to severe regression, and the dynamics of sexual perversion.
In this last section, Kernberg mentions that per classic analytic thought, homosexuality = unresolved Oedipal conflict. The man who loves a man is actually submitting to dad and thereby failing to identify with him and grow up. Explaining that the biological and clinical evidence is not yet in, Kernberg states, honestly enough, that in his clinical experience few homosexual men fail to present significant character pathology. But would a psychologically mature homosexual want to do therapy to begin with, especially within a tradition known to see homosexuality as infantile? And if the "I've always been like this" explanation given by my clients is true--and I think it is--then how is one to entirely escape significant pathology while growing up gay in a homophobic society? Unfortunately, these questions are not addressed in this otherwise indispensable work.
An extra gift is the author's obvious willingness to see beyond even the most destructive behaviors to the sense and suffering at their core.
Kernberg provides wonderfully candid descriptions of his own negative or inappropriate feelings towards patients, cases where pateints refuse to cooperate with treatment, and cases where these patients manage to use hospital politics (!) to thwart treatment.
My initial impression was that there seemed to be a bit too much jargon and the subsequent hair-splitting. As I read it, time and again I summarized long paragraphs by jotting down 5 to 10 words in the margin. But he does so as part of thorough overview of difficult literature, and considering the amount of ground he covers, this book could have been much longer.
Odd he doesn't mention Facism, when the description of violent narcissistic sadists who embrace tyrants is so evocative of strutting Nazis. And his final chapters on perversion versus healthy sexual function is strikingly similar to Krafft-Ebing's "An Attempt to Explain Masochism," who reached their conslusions long before Freud and developed a clearer definition of healthy functioning than Freud.
