Malignant Self-Regard as an Overarching Framework for the Theory and Treatment of Depressive and Masochistic...

Kernberg and McWilliams have spawned differing conceptualizations of the relationship between depressive and masochistic (self-defeating) personalities. Kernberg describes these personality styles as largely overlapping in features, whereas McWilliams accentuates important clinical differences that make up two distinct personalities. In this article, their theoretical perspectives are discussed and framed as more complementary than competitive. The malignant self-regard (MSR) construct is introduced and reviewed as an integrative self-representation that is shared by both depressive and masochistic personalities, as well as those often referred to as vulnerably narcissistic. We investigate developmental conflicts, motivations for perfectionism, countertransference patterns, and overall level of functioning as four primary clinical features through which a therapist may differentiate a depressive from a masochistic personality. We argue that depressive personalities tend to have more dependency-related conflicts and perfectionistic strivings motivated by lost object reunification, elicit more insidiously positive countertransference reactions in session, and are generally higher-functioning individuals. Masochistic personalities have more oedipal-related conflicts and perfectionistic strivings motivated by object control, elicit more aggressive countertransference reactions, and are relatively lower functioning. MSR is positioned as a bridge between Kernberg's and McWilliam's ideas. We close with a discussion of treatment implications for both disorders as well as how to understand and treat MSR.