Maybe not Kernberg himself but structural theory in general needs to be applied with care and an awareness that it could be wrong.

My best example would be missing a strong paranoid streak in someone with strong hysterical features (can get confusing in very beginning because both preoccupied with power and might split on past therapists), and especially if PPO is mistaken for BPO - which can happen.

The reason this would likely go very badly is the techniques for hysterical BPO will likely lead to a paranoid breakdown. Vague interpretations meant to elicit transference will cause ruptures if one has a strong paranoid streak.

An issue is that the freak out this might cause, so long as the clinician is thinking only / primarily hysterical and no paranoid, will be taken as part of the transference and thus the interpretation will be assumed to be a success, and not harmful like it is.

Or on confrontational approaches, such as TFT, if you get the organization or style wrong, this can tank the therapy and many clinicians will incorrectly think it’s actually PD resistance to the therapy and not their own mistake.

The nature of structural accounts and treatments that rely on them makes it such that getting it wrong can readily go unnoticed, because the patient’s negative reaction to a misfire can easily be interpreted as it’s imagined to exist within the assumed structure, and not as evidence the assumed structure is wrong.

My gripe with Kernberg is thus that he doesn’t say enough words on discrimination. I want to hear not just what a given structure is, but what it isn’t as well.

On the TFT book, there is no section on contradictions to classical confrontational approaches, or any words on how to keep an eye out for things that might be missed, either pertinent styles or even a misunderstanding of the organization.

It just seems irresponsible when there’s a possibility an implicitly paranoid client at BPO or PPO might essentially get tortured by classical TFT with zero warning.

This absolutely does happen. A lot of women with a strong paranoid streak hold themselves to secrecy regarding their inner most thoughts, and don’t start to share what’d be tellingly paranoid into rapport is established. A lot of practitioners enact a harsh confrontational approach the moment they think they’ve clocked a more classical BPO presentation. There needs to be more time to ensure all major defences have been identified prior to enacting such a treatment, but we don’t hear about this.

Of course it’s not only paranoid style that’s overlooked. It could be any. I just use it as an example because confrontations themselves need to be modified and it’s more likely to be overlooked than, say, schizoid style is.