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This paper focuses on the functioning in psychotherapy of severely disturbed narcissistic personality disorders. To date, treatment issues involving the more primitive narcissistic personality disorders have received only limited attention in comparison, for example, with the vast literature on the treatment of borderline pathology. This relative neglect may reflect the fact that patients with severe narcissistic pathology often present chronic and intense rage reactions, which are usually seen as a significant obstacle to their involvement in an ongoing therapeutic relationship. It is the central thesis of this paper that the negative therapeutic outcome generally reported for this patient population reflects the lack of a therapeutic ambiance compatible with these patients’ limited ego resources and inadequate to the mobilization, unfolding, and working through of the variants of transference relationship these patients present.
Kernberg (1) has referred to this category of patients as narcissistic personality disorders who function at an overt borderline level. He indicated that they show “non-specific manifestations of ego weakness,” e.g.,” …severe lack of anxiety tolerance, generalized lack of impulse control, striking absence of subliminatory channeling, primary process thinking clearly noticeable on psychological tests, and proneness to the development of transference psychosis” (p. 266). Kernberg has seen severely disturbed narcissistic personality disorders as differing from borderline personality disorders in that the former possess a grandiose self, which, however, is lacking in sufficient integration to enable these individuals to function socially at the level of the majority of narcissistic personality disorders.
At this point in time, only Kernberg has addressed the need for a treatment paradigm specific to this population. His approach emphasizes the elaboration of the negative transference: it seems to differ from the modified