Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders

Otto Kernberg’s latest book, Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders, reflects and advances his contributions to psychotherapy theory and practice over the past 60 years. The book is by no means mere repetition of established thinking; rather, Kernberg moves forward spirally (mostly starting from his previous work), shedding new light on well-known ways of thinking and presenting a different perspective from which to view familiar concepts. For the reader, this new perspective has the immediate effect of unlocking new directions of thinking about the theories and practices discussed in the book. Then, suddenly, Kernberg provides a completely new thought. In every chapter of Hatred, Emptiness, and Hope, the reader is struck by how vivid and creative Kernberg’s mind is—one gets the impression that his theoretical work will only intensify after his retirement at the age of 93. Moreover, it is touching to see how the titles of his books have moved toward a certain lightness and positivity—in 2012, “love” made it onto the cover; in 2018, “resolution” appeared; and now “hope” is present.

The book contains four parts: theory, technique, psychopathology, and application of object relations theory. This reader found the psychopathology chapters to be particularly enlightening because they include numerous new perspectives and conceptualizations. A sophisticated analysis of schizoid personality disorders provides a deeper understanding of why fragmentation and confusion are unconsciously substituted for intense longing for closeness and dependency. Nowhere else do empathy and intuition of the therapist, in combination with access to discrete fantasies during countertransference, seem to be so urgently needed. Another highlight of the book is the chapter on psychotic personality structure. Ideas that have remained shrouded in mystery for many psychiatrists suddenly seem to be crystal clear when Kernberg distinguishes psychotic from borderline personality structure—as well as psychotic transference from transference psychosis—and elaborates treatment indication, prognosis, and phenomenological diagnosis. The third psychopathology chapter, on narcissistic love relations, covers more familiar ground, but for this reader, every other sentence evokes the image of a known person or patient, fostering a deeper understanding of the narcissistic dynamic.

Psychoanalytic object relations theory as well as transference-focused psychotherapy (TFP) are the leitmotifs of the book and of Kernberg’s thinking in general. Someone who has not encountered these concepts will find in this book a brief introduction, a reliable idea of the essence of the theory and of TFP, and a lot of inspiration for further reading. Those who are familiar with Kernberg’s thinking may be particularly interested in the chapter on neurobiology, which clarifies, in a clear and convincing way, the connection between psychoanalytic drive theory and contemporary concepts of affect and motivation.

Another highlight of the book is the chapter on technique dealing with transferences of different types of personality pathology. Kernberg describes borderline, narcissistic, schizoid, symbiotic, and psychotic transference patterns and how to handle them from a therapeutic point of view by using rich case material. In a separate chapter, Kernberg reflects on the concept of mentalization and its overlap with object relations theory and TFP. He points out that mentalization-based treatment aims to alter the patient’s distorted views of the therapeutic relationship and to allow the patient to see the perspective of the therapist, whereas TFP aims to foster a relational experience and to elicit from the patient a more interactive engagement as well as an introspective investigation of the distorted view and its origins.

The final chapters, on application, focus on inpatient treatment of patients with borderline personality disorder and on large-group phenomena in connection with malignant narcissistic leadership. Kernberg’s analysis is enlightening and demonstrates why large-group regression occurs and why dysfunctional, destructive leaders gain power in many societies amid national and global crises. Although these processes seem to be inevitable, Kernberg leaves the door open for some hope that enlightenment, awareness, and engagement can change the world for the better. Hope remains evident in the final chapter of the book, which highlights many deficiencies of psychoanalytic power structures and training institutes and examines where psychoanalysis stands in research and the academic world. Here, Kernberg conveys an optimistic realism that creates hope for positive change.

This book can be recommended to Kernberg connoisseurs, who will likely discover many new perspectives, details, and concepts, as well as to readers who are just beginning to dive into Kernberg’s thinking. The latter group may feel inspired to deepen their knowledge in many directions—not at all limited to Kernberg’s own works.