MANUAL FOR THE

STRUCTURED INTERVIEW OF PERSONALITY

ORGANIZATION-REVISED

(STIPO-R)

By

John F. Clarkin, Eve Caligor, Barry Stern, & Otto F. Kernberg

July, 2019

Revised July 2021

 This manual for the Structured Interview of Personality Organization-Revised (STIPO-R)
is composed of two sections. Section 1 provides a history, background and rationale, and review
of psychometric properties and utilization of the instrument. Section 2 provides an interview
guide to assist in the actual administration of the instrument.

SECTION 1: INTRODUCTION AND REVIEW OF STIPO-R

History and Background of the STIPO and STIPO-R

The STIPO (Clarkin, Caligor, Stern, & Kernberg, 2004), and its revision, the STIPO-R
(Clarkin, Caligor, Stern, & Kernberg, 2016) are semi-structured interviews constructed to
evaluate the structural domains of personality functioning that are central to understanding the
individual from an object relations model of personality and personality pathology (Kernberg,
1984; Kernberg & Caligor, 2005). The STIPO and the STIPO-R provide the clinician and
researcher with dimensional scores on key domains of personality functioning. The severity of
dysfunction in each domain can be used by the clinician for treatment planning, and by the
researcher for selection of subjects and measurement of change in relation to treatment
interventions.
Object Relations Orientation to Personality Pathology
Kernberg and colleagues at the Personality Disorders Institute have articulated a model of
personality pathology based in contemporary object relations theory (Kernberg & Caligor, 2005;
Caligor & Clarkin, 2010; Caligor, Kernberg, Clarkin, & Yeomans, 2018). This approach
combines a dimensional view of severity of personality pathology with a categorical or
prototypic classification based on descriptive phenomenology consistent with many of the
personality syndromes of DSM-5 (APA, 2013). Thus, the STIPO and STIPO-R provide both
severity scores on domains of functioning, and profiles of scores in the domains indicating
closeness/distance to prototypic descriptions of neurotic, high level borderline, middle level
borderline, and low-level borderline personality organization. Level of personality organization
has important prognostic implications and can be used to guide differential psychotherapeutic
treatment planning (Caligor, Kernberg, Clarkin, & Yeomans, 2018).

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 Core concept of identity. Kernberg’s object relations model of personality pathology is
organized around the core concept of “identity.” The universe of personality disorders is divided
into those characterized by consolidated identity and those characterized by pathology of identity
formation (sometimes referred to as the syndrome of “identity diffusion”).
The less severe (neurotic) level of personality organization (NPO), along with the normal
personality, is characterized by a consolidated identity associated with an experience of self and
of others that is stable, well differentiated, complex, realistic and coherent. The neurotic level of
personality organization is distinguished from the normal personality on the basis of rigidity of
personality functioning. Whereas the individual with normal personality organization is able to
flexibly and adaptively manage external stressors and internal conflicts, the individual with
neurotic personality organization tends to rely on rigid and to some degree maladaptive
responses, reflecting the impact of repression-based defenses on psychological functioning. As
in the normal personality, individuals organized at a neurotic level have the capacity for full,
deep and mutual relationships, though individuals in the NPO spectrum may have difficulty
combining intimate relations with sexuality. Moral functioning is consistent and fully
internalized in the neurotic personality, but may be excessively rigid, leading to a propensity to
excessive self-criticism.
Identity diffusion is a major characteristic of the borderline level of personality
organization (BPO). Poorly consolidated identity is associated with an experience of self and
others that is unstable, superficial, poorly differentiated, polarized (“black and white”), distorted
and discontinuous. Splitting-based defenses (e.g., splitting, idealization/devaluation, projective
identification, denial) are responsible for maintaining a fragmented and poorly integrated
experience of self and others that color the subjectivity of the individual with poorly integrated
identity. In contrast, consolidated identity in the neurotic personality disorders is associated with
the predominance of repression-based and mature defensive operations. Individuals organized at
a borderline level of personality organization are distinguished from those with atypical
psychotic disorders by virtue of having intact reality testing. However, clinically significant
pathology of identity formation is associated with deficits in social reality testing, the ability to
accurately infer the motivations and internal states of others and to accurately read social cues.
These deficits are associated with some impairment in accurate perception of others in
individuals organized at a borderline level of personality organization. In contrast, social reality

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testing is highly developed in individuals organized at a neurotic level, as well as in the normal
personality.
The borderline level of personality organization, characterized by identity pathology, the
predominance of splitting-based defenses and deficits in social reality testing, covers a relatively
broad spectrum of personality pathology. At the higher end of the BPO spectrum, patients have
some capacity for dependent, albeit troubled, relationships, generally have relatively intact or
only minor pathology of moral functioning and are not overtly aggressive in most settings. In
contrast, individuals at the lower end of the BPO spectrum have severe pathology of object
relations, clinically significant deficits in moral functioning, and are overly aggressive, while
those in the middle BPO spectrum have moderate pathology of object relations, variable moral
functioning and demonstrate pathology of aggression less severe than is characteristic of the low
BPO spectrum. Whereas individuals in the high BPO group have a relatively favorable
prognosis in structured psychodynamic treatments, and those in the middle BPO group have a
fair prognosis, those in the low BPO group are far more challenging to treat and have a more
guarded prognosis, even in exploratory psychodynamic treatments with established parameters
designed to ensure that the patient’s difficulties are expressed in the treatment situation and to
limit self-destructive and treatment-interfering behaviors outside the consulting room.
Determination of level of personality organization is essential to guiding differential
treatment planning. Psychodynamic intervention with high level personality functioning
(neurotic organization) is constructed differently (Caligor, Kernberg, & Clarkin, 2007; Caligor,
Kernberg, Clarkin, & Yeomans, 2018) than intervention with patients at borderline levels of
organization (Yeomans, Clarkin, & Kernberg, 2015) (see Table 1). Individuals organized at a
neurotic level of personality organization have a very favorable prognosis and can benefit from
relatively unstructured psychodynamic treatments. These patients typically do not have
difficulty establishing and maintaining a therapeutic alliance, and transference distortions tend to
be slowly developing, consistent, and subtle. In contrast, individuals organized at a borderline
level, particularly those in the low borderline spectrum, require a highly structured treatment
setting as described above. These individuals have great difficulty establishing and maintaining
a therapeutic alliance; transference distortions develop rapidly, and are highly affectively
charged and extreme, often leading to disruption of the treatment.

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Table 1. Treatment Differences Related to Level of Personality Organization
NEUROTIC PERSONALITY BORDERLINE PERSONALITY
ORGANIZATION ORGANIZATION
Use of treatment frame Treatment frame includes a carefully
articulated treatment contract
Therapist operates from a stance of Therapist deviations from therapeutic
therapeutic neutrality neutrality are used in certain crises
Therapeutic techniques of clarification, More extensive use of clarification and then
confrontation, interpretation confrontation to set the stage for
interpretation
Focus on present, related to past Focus on the present

The origins of the STIPO: “The Structural Interview”

As part of articulating an object relations approach to personality pathology, Kernberg
(1984) described the structural interview, a clinical interview designed to evaluate not only the
patients’ symptoms and areas of difficulty, but also the level of personality organization. At that
time, Kernberg conceived of the structural interview in the context of existing psychodynamic
interviews. A number of analytic authors had constructed modified psychiatric interviews that
concentrated on the patient-therapist interaction as a major source of information (Whitehorn,
1944; Powdermaker, 1948; Fromm-Reichmann, 1950; Sullivan, 1954). Deutsch (1949)
advocated interviewing that would reveal the unconscious connections between current
difficulties and the patient’s past. MacKinnon and Michels (1971; MacKinnon, Michels, &
Buckley, 2006) described an evaluation that uses the patient-therapist interaction to reveal
character patterns useful for diagnosis. Kernberg’s structural interview was an organized
extension of these procedures. The interview focuses on the patient’s conflicts thereby creating
tension such that the patient’s predominant defensive and structural organization of mental
functioning emerges, and the structural diagnosis of personality organization can be made.
The sequence of the structural interview proceeds through three phases. The initial phase
invites the patient to discuss major difficulties, symptoms, and reasons for seeking treatment.
The middle phase focuses on potential pathological personality traits, and difficulties in
interpersonal relations and perceived interpersonal needs. In the termination phase, the
interviewer provides an opportunity for the patient to ask questions, and for the interviewer to
evaluate the patient’s motivation for continuation of the diagnostic process and treatment.

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 The yield of the structural interview is an assessment of both symptoms and the level of
personality organization, characterized by levels of organization from identity consolidation with
difficulties in object relations, to high level borderline personality organization with identity
diffusion, to low level personality organization with identity diffusion combined with aggression,
severe pathology of object relations, and deficits in moral functioning. The yield of the structural
interview depends upon the clinical acumen and skill of the interviewer. The interviewer must
make sophisticated decisions about which areas of the patients’ functioning to evaluate in detail.
The detailed examination of the patient’s relations with others provides the interviewer with an
opportunity to observe the patient’s functioning in a tense situation. There is no scoring system,
and the interviewer must make subjective judgments about the patient’s degree of personality
pathology and level of personality organization. With its dependence on interviewer skill,
flexibility in interview questions, and absence of an objective scoring system, it is difficult to
ascertain reliability among different interviewers in terms of focus and diagnostic conclusions.
These shortcomings of a sophisticated clinical interview led to the construction of the STIPO.
Need for a Semi-Structured Interview
The generation of the semi-structured interview (STIPO and STIPO-R) provides standard
questions, follow-up probes, and scoring guidelines to ensure reliability in the assessment1. What
the STIPO loses in the subtle interview maneuvers of an experienced clinician, the STIPO gains
in psychometric properties. With its structured questions, and equally structured probes
following vague or imprecise patient answers, and a structured scoring system, the STIPO lends
itself to investigation of its reliable administration and scoring. The standardization of procedure
and scoring in the STIPO-R enhances its usefulness in the teaching of personality assessment,
and it provides a vocabulary that clinicians can use to clearly communicate complicated clinical
constructs to each other and to those not involved in object relations theory.
Domains of the STIPO and STIPO-R
A key question in the generation of any assessment instrument concerns the selection of a
limited number of domains of functioning that are crucial to the adjustment of the individual (see

1
We wish to acknowledge the important contributions by multiple colleagues to the development of the STIPO and
STIPO-R. Armand Loranger, the author of the IPDE, was a consultant who helped guide the structure of the STIPO.
Mark Lenzenweger has provided valuable scoring and design advice. Susanne Hörz utilized the STIPO in her
dissertation and stimulated the profile analysis of the STIPO. She and her colleague Stephan Doering have advanced
the German version of the instrument. Emanuele Preti was instrumental in the transition of STIPO to STIPO-R, and
has initiated important research with the instrument in an Italian version.

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Clarkin, 2013). Object relations theory guides the assessor to two central phenomena in
understanding the individual patient: the structure and the organization of the personality. The
focus of our approach is on structural, functional domains rather than solely on the assessment of
difficulties and symptoms. Object relations theory guides the selection of the domains to be
assessed in the STIPO. As generated by clinical experience and psychoanalytic theory, the basic
structures of personality are identified as: 1) identity, i.e., an integrated concept of the self and
an integrated concept of significant others, 2) a capacity for a broad spectrum of affect
dispositions that are complex and well-modulated, 3) an integrated and mature system of
internalized values, and finally, and 4) an appropriate management of sexual, dependent, and
aggressive motivations which are experienced subjectively as needs, impulses, wishes, and fears
(Kernberg & Caligor, 2005). Following from this theoretical position, the STIPO was focused on
six domains: Identity, Defenses, Quality of Object Relations, Coping, Aggression and Moral
Values. With the accumulated experience with the longer STIPO, we have incorporated five key
domains in the STIPO-R: Identity, Defenses, Quality of Object Relations, Aggression, and Moral
Values (see Table 2).
The Identity domain is measured by questions concerning the individual’s capacity to
invest and be involved in studies and/or work and professional life, and recreation. The
individual’s sense or representation of self and of others is examined. The domain of Quality of
Object Relations involves the assessment of the individual’s interpersonal relations, intimate
relations and sexuality, and the internal or mental model of relationships. The domain of
Defenses provides an assessment of both more advanced and mature defenses, and more
primitive defenses such as splitting. The domain of Aggression focuses on both aggression
toward the self and aggression toward others. Finally, the domain of Moral Values or moral
functioning is an examination of the individual’s capacity for guilt and adherence to common
norms of interpersonal behavior.
STIPO Compared to Similar Instruments
Possibly the nearest clinical interview and scoring system to the STIPO is the Clinical
Diagnostic Interview (CDI; Westen & Muderrisoglu, 2003) that focuses on reasons for treatment,
symptoms, and interpersonal interaction patterns. It is a systematic diagnostic interview that can
be administered in two and one-half hours. The interview yields the clinical information
necessary to utilize the Shedler-Westen Assessment Procedure (SWAP-200; Shedler & Westen,

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2007) reliably. The SWAP-200 is an assessment instrument that consists of 200 statements that
may describe a patient very well, somewhat, or not at all. The statements reflect content
capturing personality traits in non-clinical populations, and interpersonal pathology consistent
with personality disorder (coping, defense, and affect-regulatory mechanisms) as well as
symptoms such as anxiety and depression. Utilizing the information from the CDI, the clinician
describes the patient with the 200 SWAP items based on a Q-sort method which requires the
clinician to distribute the 200 items into a fixed distribution, i.e., a set number that are least and
most descriptive of the individual (Shedler, 2015). The SWAP distribution provides the clinician
with dimensional scores for each of the personality disorders described in DSM. In addition, a
narrative case description is generated that can be used for case conceptualization and treatment
planning.
The Operationalized Psychodynamic diagnosis (OPD-2; OPD Task Force 2008), devised
by a group of psychoanalytic clinicians in Germany, Austria, and Switzerland is an instrument
consisting of four psychodynamic axes as well as the ICD-10 as a fifth axis: 1) Experience of
Illness and Prerequisites for Treatment, 2) Interpersonal Relations, 3) Conflicts, 4) Psychic
Structure and, 5) Psychic and Psychosomatic Disorders (ICD-10 diagnoses). The axis that most
closely relates to the STIPO is the fourth axis, which comprises dimensions of self and other
representation, attachment, affect differentiation or impulse regulation. OPD-2 was developed to
assess all levels of personality pathology, whereas the STIPO focuses specifically on the nuances
and levels of personality organization. As hypothesized, the STIPO level of personality
organization was significantly related with the OPD axis 4 total score (r=.68; p<.001) (Doering,
Burgmer, Heuft, et al., 2013).
Transition from STIPO to STIPO-R
The STIPO-R is a revision of the original STIPO, undertaken to both shorten the longer
STIPO to enhance its research and clinical usage, and to modify items that had less than
desirable psychometric properties. In addition, our clinical experience motivated us to amplify
the items in the original STIPO concerning narcissistic pathology into a full Narcissism scale.
Scope of the STIPO-R
Content
The STIPO-R contains 55 items covering five domains of functioning: 1) Identity, 2)
Object Relations, 3) Defenses, 4) Aggression, and 5) Moral Values. Three of the domains have

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ratings on important subdomains (see Table 2). From items embedded in the other domains, the
STIPO-R also has scoring for a Narcissism dimension.

Table 2. STIPO-R Domains and Subdomains

Domain Subdomain
Identity Capacity to invest in work/studies and
15 items recreation
Sense of self
Sense of others
Object Relations Interpersonal relations
15 items Intimate relationships and sexuality
Internal working model of relationships
Defenses Lower-level, primitive defenses
10 items Higher-level defenses
Aggression Self-directed aggression
9 items Other-directed aggression
Moral Values Experience of guilt; moral and immoral
6 items behavior

Format
The format of the STIPO-R is carefully modeled on the International Personality Disorder
Examination (IPDE; Loranger, 1999) constructed by our Cornell colleague, Dr. Armand Loranger.
Dr. Loranger served as a consultant to the construction of the STIPO. STIPO-R utilizes standard
questions, and additional probes that can be used when the answers are not clear or detailed enough
to rate.
Scorning System
The standardized format and scoring system allow the interviewer to rate the subject’s
responses (0, 1 or 2) at the individual item level as the interview proceeds. As with the IPDE, the
interviewer is encouraged to use not only information from the subject but also any additional
information from ancillary sources (e.g., family members, former therapists) that may be available
given the constraints of the interviewing situation, to arrive at the most accurate item ratings. Once
the interview is completed, the scores at the individual item level are summed within each domain
to give a total domain score. (An alternative method is to compute a mean rating from the 0-1-2
item scores across each domain.) This dimensional rating provides an indication of the total

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pathology in each domain. In order to directly compare the scores among domains, the total
dimensional rating can be transformed into a percentage score.
In addition to the dimensional sum scores for each domain, the interviewer is invited to
make an overall clinical rating (ranging from a 1-5 score) for each domain. This overall domain
rating allows the interviewer to use clinical judgment and impression about the subject that may
deviate somewhat from the item total dimensional rating for each domain.
The two rating systems complement each other. The item-based rating system adheres closely to
the individual item responses, whereas the 5-point rating system allows the interviewer to utilize
his clinical impression, allotting greater or lesser weight to items in the scale or subscale based on
his clinical impression of pervasiveness or severity, and/or adjusting the rating based on factors
(non-verbal, interpersonal) that he feels are clinical significant and relevant to the domain being
assessed. For both rating procedures we have found satisfactory inter-rater reliability (Stern et al.,
2010; Hörz et al., 2009). The scores in table 3 demonstrate the use of these clinically oriented
ratings.
Table 3 (updated 2021): STIPO Dimensional Scores and Level of Personality Organization

STIPO Normal PO Neurotic- Neurotic- High-level Middle-level Low-level

Dimensional level PO 1 level PO 2 BPO BPO BPO
Ratings
Identity 1 1 2 3 4 4 or 5
Range 3-5
QOR 1 2 3 3 4 5
Range 1-2 Range 2-3 Range 2-4 Range 3-5 Range 4-5
Defense 1 2 2 3 4 4 or 5
Range 2-3 Range 4-5
Aggression 1 2 2 3 4 4 or 5
Range 1-3 Range 1-3 Range 2-3 Range 3-4
Moral Values 1 2 3 3 3 4 or 5
Range 1-2 Range 2-3 Range 2-3 Range 3-4

Using either the dimensional summary score for each domain or the clinical 5-point ratings,
the interviewer can construct a profile of personality organization of the subject, based on the five
domains of interest. Patients can be classified as falling into normal, neurotic, or borderline range
of organization. Based on the STIPO-R dimensional ratings, this categorization can be made,
differentiating normal, neurotic, and borderline personality organization, which is differentiated
into three levels according to severity: high, mid, and low BPO (Hörz, Stern, Caligor, et al, 2009).
Subjects falling into normal and neurotic group have consolidated identity; show no use of

9
primitive defenses or disturbance in reality testing. Patients falling into Neurotic group have some
degree of superficiality in sense of self and/or others and might show some use of primitive
defenses. Patients located at borderline level of personality organization range from high to mid to
low, with an increase in identity diffusion, the use of primitive defense mechanisms, overt
manifestations of aggression, disturbance of object relations increase, and diminished use of
internal standards of morality. The following prototypical profiles aid the assignment of levels of
personality organization based on the dimensional scores.

NORMAL

Identity: 1 Consolidated
Object Relations: 1 Stable, complex, and enduring; able to integrate tender and
erotic feelings
Defenses: 1 Healthy defenses predominate; No evidence of primitive
defenses
Aggression: 1 No primitive aggression; control and modulation of aggression
Moral values: 1 Consistent and flexible; no antisocial behavior

NEUROTIC 1

Identity: 1 Consolidated
Object relations: 2 Stable, complex, and enduring; difficulty integrating tender and
erotic feelings
Defenses: 1 No evidence of primitive defenses, Repression-based and mature
defenses predominate; some rigidity.
Aggression: 2 No primitive aggression; some evidence faulty modulation of
aggression (e.g., minor self-neglect or occasional verbal
outbursts)
Moral values: 2 Overly harsh and/or inflexible but fully organized and
internalized; no antisocial behavior

NEUROTIC 2

Identity: 2 Consolidated; somewhat superficial sense of self and/or others

Object relations: 2, 3 Somewhat superficial, but enduring; some limitation in capacity
for empathy; difficulty integrating tender and erotic feelings

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Defenses: 2 Endorsement of primitive defenses is rare; Repression-based
defenses predominate; some rigidity.
Aggression: 2 No primitive aggression; evidence of faulty modulation of
aggression (e.g., minor self-destructive behaviors or controlling
interpersonal style)
Moral values: 2, 3 Organized and internalized but variable; self-critical attitudes
and demanding standards may co-exist with disavowal of
exploitative or minor self-destructive behaviors

BORDERLINE 1

Identity: 3 Identity diffusion, mild

Object relations: 3 Split and/or superficial but with some degree of stability and
integration, especially in non-conflictual domains
Defenses: 3 Combined use of splitting-based and repression-based defenses,
significant rigidity and compromised adaptation.
Aggression: 3 Primitive aggression; aggressive behaviors largely self-directed
Moral values: 2, 3 Variable

BORDERLINE 2

Identity: 4 Identity diffusion, moderate

Object Relations: 4 Superficial and based on need-fulfillment; empathy impaired; little
Ability to sustain interest over time; widely split and unstable
Defenses: 4 Predominance of primitive defenses with significant
impairment; severe rigidity and grossly maladaptive defensive
strategies
Aggression: 3, 4 Primitive aggression; aggressive behaviors directed against
others +/- against self
Moral values: 2, 3, Variable, generally poorly integrated and poorly internalized

BORDERLINE 3

Identity: 5 Identity diffusion, severe

Object Relations: 5 Based entirely on need-fulfillment, no empathy and no capacity to
sustain interest in others
Defenses: 5 Constant use of primitive defenses; extreme rigidity and failure
of adaptation
Aggression: 5 Primitive aggression with dangerous, aggressive behaviors
directed towards self and/or others
Moral values: 5 No organized moral value system; antisocial behavior

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Appropriate Subjects
All patients applying for treatment can be assessed with the STIPO-R, which provides an
overall picture of the level of personality organization that influences any treatment, including
those focused almost entirely on symptom constellations such as anxiety and depression.
However, the STIPO-R is most relevant in clinical situations in which the patient is suspected of
having personality pathology that will influence symptom treatment, or those whose treatment
will focus primarily on personality disorder of various levels of severity.
Examiner Qualifications and Training
Prior training in psychodynamic concepts central to the instrument, and clinical
experience with patients demonstrating various levels of severity of personality pathology are
prerequisites for STIPO-R interviewers. The interviewer must be trained to use the probes to
obtain ratable material from the patient. Training to reliability of scoring involves viewing of
videotaped STIPO-R interviews, and accomplishment of ratings in agreement with standards.
Reliability and Validity of the STIPO
The data presented here are related to the STIPO. The psychometric properties of the
STIPO-R are currently under evaluation. Preliminary unpublished data show acceptable reliability
and good convergence with external measures of personality functioning.
Reliability
English, German, and Italian versions of the STIPO have been developed concurrently and
have demonstrated good inter-rater reliability. Intraclass correlation coefficients (ICC) ranged
from .84-.97 in the English version (Stern et al, 2010), from .89-1.0 in the German version
(Doering et al, 2013), and from .82-.97 in the Italian version (Preti et al, 2012).
Validity
The STIPO domains show internal consistency across studies. Cronbach’s alpha for STIPO
domains of Identity (.86) and Primitive Defenses (.85) were high, whereas the shorter Reality
Testing domain (.69) was on the boarder of acceptability (Stern, Caligor, Clarkin, et al, 2010). In
a study using the German language version of the STIPO (Doering et al, 2013), Cronbach’s alpha
ranged from .93 for Identity to .69 for Reality Testing, with .97 for the total score.
STIPO domains of Identity and Primitive Defenses were closely related to personality disorder
symptom counts as assessed by the Schedule of Nonadaptive and Adaptive Personality (SNAP;
Clark, 1993), to measures of aggression, and to levels of positive and negative affect. In another

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study (Doering, Burgmer, Heuft, et al, 2013), significant correlations were found between the
STIPO Primitive Defenses and the primitive defenses scale of the self-report Borderline
Personality Inventory (Leichsenring, 1997).
Preti et al, (2012) found associations between the STIPO identity scale with measures of
stability of self-image and the capacity of pursuing goals. The STIPO Defenses domain was
associated with an external measure of primitive defenses, and another measure of lack of self-
control and emotional instability (SIPP-118; Verheul et al, 2008). All of the STIPO domains
discriminated between clinical and nonclinical subjects.
The STIPO demonstrates good construct validity in reference to DSM personality
diagnoses. Patients with DSM personality disorder were found to be on a lower level of personality
organization in all domains compared to patients without personality disorder (Baumer, 2010;
Doering, et al, 2013). In a study of patients with chronic pain, there was a significant correlation
between personality organization on the STIPO and the number of SCID-II diagnoses (Fischer-
Kern, et al, 2011). Likewise, a very close but not complete association was found between STIPO
structural diagnoses and DSM personality pathology in a sample of patients with opiate addiction
(Rentrop Zilker, Lederle, Birkhofer, & Hörz, 2014). There is a significant association between
STIPO structural characteristics and DSM diagnoses, but STIPO domains were able to identify
treatment dropout among dual-diagnosis patients more effectively than personality disorder
diagnoses (Preti, Rottoli, Dainese et al, 2015).
Clinical application of the STIPO: Measuring severity of personality pathology
The STIPO can be used as clinical tool to assess levels of severity of personality
pathology across normal, neurotic, and high- and low-level borderline personality organization.
In a study using the English version of the STIPO, based on the domain ratings of the STIPO, a
prototypical profile of BPO was developed and tested in its ability to discriminate between BPO
and non- BPO (Hörz, 2007). The presence of severe identity diffusion, use of primitive defenses
as well as disturbed object relations, along with overall maintained reality testing differentiated
between patients located at low BPO and non-BPO. Individuals with ratings that were close to a
prototypical profile of BPO, consisting of ratings of 3 or higher in the domains “Sense of Self”
and “Sense of others”, 4 or higher in “Object Relations” and “Primitive Defenses”, showed more
pathology in variables closely associated with borderline pathology, for example negative affect
and aggression. Similarly, an inverse relation between the profiles of individuals with BPO-

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prototypical ratings and variables of positive affect was found, e.g. serenity. In addition,
evidence of poorly integrated aggression and the deterioration of moral values were helpful in
differentiating between higher level and lower level BPO (Stern et al., 2010).
In a treatment study examining 104 patients with Borderline Personality Disorder (BPD),
the STIPO was employed and compared to results from the SCID-I and SCID-II as well as
indicators of clinical severity of the disorder (suicide attempts, self-injurious behavior, service
utilization) (Doering et al, 2010). Specific patterns were found, demonstrating the ability of the
STIPO to assess levels of severity. The patient group with one or more comorbid DSM-personality
disorders showed more pathology in the STIPO domains and overall level of personality
organization than the patient group with the sole diagnosis of BPD (e.g. Identity: M = 3.88 vs. M
= 3.59, t = -2.13, p < .04). Similar results were found for individuals with at least one suicide
attempt versus no suicide attempts, and also for patients with a history of emergency room visit
versus those without emergency room visits. Moreover, correlational analyses showed that several
indices of personality pathology, for example the number of BPD-criteria, was meaningfully
associated with more pathology in the STIPO domains of Identity, Primitive Defenses, Coping,
Aggression and with the overall level of personality organization (r = .29, p < .01). In sum, these
results demonstrate the clinical usefulness of the STIPO in that patients with clinically more severe
disorder revealed a more impaired level of personality organization (Hörz et al., 2017).
Clinical application of the STIPO: Using the STIPO as a measure of change
The usefulness of the STIPO as a measure to assess changes in personality organization
was examined in an RCT comparing the efficacy of Transference-Focused Psychotherapy (TFP)
to treatment by experienced community psychotherapists in a sample of 104 BPD patients
(Doering et al, 2010). The time frame in the STIPO usually refers to the prior five years.
However, in order to assess changes within one year of treatment the investigators chose the last
month as the time frame for the second STIPO interview in this study. Using this measure,
significant changes after one year of psychotherapy were found at the level of personality
organization. In this analysis, the overall level of personality served as the outcome variable,
using the STIPO levels of personality organization on a 6-point categorical scale, ranging from
normal (1) to Borderline 3 (6). In both treatment groups, the mean for the level of personality
organization pathology decreased after one year of therapy. This was the case both for patients in
TFP (pre: M=5.00, SD=0.56; post: M=4.46, SD=0.67; d=1.0, p<.001) and for patients in the

14
community psychotherapist group (pre: M=4.77, SD=0.58; post: M=4.62, SD=0.53; d=0.3,
p=.004), with a significant superiority for the TFP group (F=12.136; df=1, 101; p=.001)
(Doering et al., 2010). A more detailed analysis of changes in the individual STIPO domains is
currently ongoing.
Use of the STIPO for Treatment Planning and Change
The diagnosis of personality disorders by categories or types without taking into
consideration the dimension of severity of dysfunction represents a serious lack in DSM-5,
diminishing the utility of DSM-based diagnoses for treatment planning. One unfortunate result of
this deficiency in DSM diagnosis is that existing psychotherapy treatment trials do not take into
account the severity of the personality dysfunction in data analysis. The ability to use the five
STIPO-R domains of functioning to match prototypic models of neurotic personality functioning,
and various levels of borderline personality organization and functioning, i.e., to speak to the
issue of severity within diagnostic categories, will, we hope, represent an improvement over the
DSM system and provide a tool for studying the impact of clinical severity as it relates to
diagnosis, and treatment process and outcome.
DSM 5, PDM2, and the STIPO-R
The DSM-5 description of personality disorder is based on lists of symptoms, traits and
problematic behaviors. This list adheres closely to reportable and observable behaviors with the
intent of ensuring reliability of assessment. This symptom-oriented description/assessment of
personality disorders is not guided by a theory of personality or an articulated theory of the
personality disorders.
In contrast, the STIPO and STIPO-R are theory driven in their conceptualization and
dimensional profiles. The advantage of a theory driven assessment is that the theory provides a
guide for efficient use of assessment time. A theory guided assessment also ensures that in the
limited time, one assesses essential areas of personality and personality disorder functioning. For
example, current theories of personality indicate that the major areas to consider are cognitive-
affective units, behavior, and the person’s unique pattern of relating to and seeking out certain
environments. A theory guided assessment of essential areas of personality functioning can
subsequently and logically lead to focused interventions on the areas of dysfunction.
The yield or product from the STIPO-R can be compared to that provided by semi-
structured interviews of personality pathology such as the SCID II. The yield or product from the

15
SCID II is a diagnosis of one or more of the ten personality disorders as described by DSM.
There is little theoretical basis behind the personality disorders in DSM-5, and the categories as
described do not hold up to empirical investigation. In contrast, the yield of a STIPO-R
interview is dimensional ratings of domains of personality functioning. Scores on these domains
provide a profile of the patients’ functioning that range from areas of adequate to inadequate
functioning. The resulting profile can be used to assist the interviewer to assess the closeness of
the patient to prototypic descriptions of patients at a neurotic, high- or low-level borderline
organization (Hörz, 2007). This approach to personality assessment is consistent with object
relations theory and is also consistent with the direction that the DSM-5 is taking with the
Section III approach to the dimensional assessment and diagnosis of personality pathology. In
fact, the STIPO-R is a reliable tool for obtaining patient information that can be used to make the
level of personality functioning ratings in DSM-5, Section III (Preti, Di Pierro, Costantini, et al,
2018).
The Psychodynamic Diagnostic Manual-2 (Lingiardi & McWilliams, 2017) is an effort to
bring diagnosis and related treatment planning closer to a theoretically coherent view of
personality functioning/dysfunctioning and related symptom disorders. The object relations
orientation to personality functioning is explicitly referenced in this system, and the STIPO is
noted as a key instrument related to the clinical assessment of patients.
Translations of the STIPO and STIPO-R
We have encouraged colleagues at other sites to translate the STIPO into their local
languages. There are established versions of the STIPO in English (Stern et al, 2010), German
(Doering et al, 2013), and Italian (Preti, Prunas, Sarno, & De Panfilis, 2012). Researchers are
working on versions of the STIPO-R in Poland, China, Turkey, Hungary, Czec Rebublic, Russia,
Argentina, and Brazil.
Limitations of the STIPO-R
Like all interviews, the STIPO-R is limited by the honesty and ability of the subject to
provide detailed and accurate information. However, unlike self-report questionnaires, the
interview format provides an opportunity for the interviewer to probe and obtain further
amplification from the subject and from significant others such as family and former therapists.

16
17
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 SECTION 2: STIPO-R INTERVIEW GUIDE
2.1 General Administration Issues
2.1.1 Periods of not being “one’s normal self”

If, at the start of the interview, a person reports not having been his or her “normal self”
for a significant period of time during the past five years, one must inquire about the nature of
the disturbance. One generally wants to score the interview only for the time period in which the
person was, in fact, his or her “normal self.” This may mean that the period of time over which
the respondent will be reporting will be less than the standard five years.
For our STIPO validation study we eliminated patients with lifetime diagnoses of
schizophrenia and Bipolar I disorder. Our experience with the interview in the clinical samples
we used, which initially included patients with these diagnoses, suggested that such patients, due
to the influence of their symptoms, could not accurately reflect upon the experience or idea of
their “normal self.”
Many patients, particularly borderline patients, but also depressed and bipolar II patients,
will answer this question affirmatively. This raises a question: is it that they are not their
“normal selves” during parts of the five years, or that their “normal self” is in fact highly
unstable, discontinuous, or otherwise disturbed? The key thing to discern at this point is the
amount of time within the past five years was the respondent not “his or her normal self,” and
how his or her functioning differed from his or her normal functioning during that time. If your
sense as the interviewer is that a discrete time can be identified in which the respondent’s
personality was discontinuous from what is normal for them, due to interference from acute
symptomatology or a severe traumatic event, then one should exclude that discrete period from
the five-year period. In the absence of a clear, discrete period of time in which the subject was
not his or her “normal self” due to an acute symptomatic mental illness or a severe traumatic
event, ask the subject to survey the entire five-year period.
The next question would be what is the minimum amount of “normal self” time upon
which an interview can be reliably scored. For example, if a subject says that he or she was
drug-addicted for two of the five years, would the remaining three years allow for a accurate
reflection of the respondent’s “normal self” or personality? At this point, we would say yes. For
the sake of standardization in administration and norming, we currently recommend that there be
at least a three-year period of “normal” functioning for the interviewer to assess; otherwise, we
recommend that the interview be discontinued as it is unlikely that the data will reflect a true
sense of respondent’s personality.

2.1.2 A guide to mandatory question stems, follow-up probes, and optional probes

a. Mandatory questions. All mandatory STIPO questions are bolded in the interview. The
interviewer must ask each of those item stems.

b. Probes. In several places in the interview you may see a prompt to Probe. This prompt will
provide some general language to use, in your own words, to get further clarification as the
primary item stem.

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c. Additional language, non-bolded. Almost every question in the interview has additional text
that can be added at the interviewer’s discretion to obtain further clarification as to the primary
item stem. Some of this additional language may be used, or none may be asked depending upon
the answer to the main item stem. The ultimate goal of the interviewer is to be able to score the
question, and the additional, non-bolded language is an attempt to standardize the language used
by the interviewers in seeking further clarification of initial interview responses.

d. Conditional questions If yes,… If no,…..

Certain questions must be asked in follow up if either a yes or no response is given, most
commonly “If yes, …..”. All “If yes” and “if no” questions are mandatory questions.

e. Notes (Note: ……..)

Notes are to inform the interviewer about the essence of the question and to provide assistance
with and structure for the interviewer in querying respondents about unclear answers. In some
cases, the notes will contain general comments about the type of information that the interviewer
should probe for, and in other cases specific language for the interviewers’ questions is provided.

f. General, non-specified probes

In general, if the interviewer is uncertain about the scoring of a response, it is appropriate to ask
any of the following probes:

Does a recent example of this come to mind?

Is this something you do frequently?
Is this kind of behavior typical and frequent, or rare?

2.1.3 The 0-2 anchors

0 = pathology absent; the trait being queried is not present at all, or, if slightly present, has no
impact on respondent’s functioning.

1 = the trait being queried is present, and reflective of some pathology, sub-threshold; minor
impairment

2 = the trait being assessed is clearly present and reflects significant to severe pathology;
significant to severe impairment.

2 is really a broader category than 0 and 1 as it encompasses those who have the trait being
assessed and who manifest some impairment as a result, and those whose lives are severely
compromised by the trait.

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**Unless it is explicitly stated, the respondent is not expected to meet all of those features listed
under a given anchor in order to score at that level. We simply provide a listing of the features
that could, in various combinations, constitute a response at that level. When evaluating any of
those characteristics and trying to distinguish, for example, a score of 1 from a 2, the interviewer
should consider the frequency, intensity or severity, and pervasiveness of the particular behavior
or feeling being assessed.

2.1.4 How to deal with interdependent questions

For example, if the person has had no sexual relationships in the past 5 years, how does one
score the question about “preoccupied with evaluating how much you get out of the relationship
in relation to how much your partner gets out of it”? We concluded that we would score the
item “9”, which stands for “question skipped” or “not applicable” and that later in our computer
scoring we would recode the responses into 2’s, giving the person the lowest possible score.
This scoring rule takes place in the following areas: work/school, friendships, romantic
relationships, and sexual relationships.

2.1.5. Judgment calls and difficulty fitting a response to an anchor

From time to time a patient’s response does not either speak to the question being asked,
or neatly fit into the anchors provided. Under such circumstances, the interviewer should
consider the following: “what is this person’s response saying about the domain in question?”
For example, for question #2, about the importance of studies / work, and the relation of
studies/work to life goals; if the response does not answer the question precisely, or if it is not
clear how the response fits the anchors, after asking each of the probes and following up as
needed, then the interviewer should think “what is this response saying about the respondent’s
capacity to invest?”, insofar as in this instance, the item falls under that sub-domain of Identity.
Second example. If, a respondent indicates that he or she has been moving from part-
time job to part-time job, with no job lasting more than a few weeks or months, questions 1-3
make less sense than the overall notion that the person is simply not invested in work. In this
case, one should again “default to the domain,” scoring a 2 for each of the items 1-3, which
reflects both that there really is no primary role, and, that the person’s capacity to invest is
severly compromised.

2.1.6 0-2 scales versus 1-5 overall ratings

There are two types of ratings that the interviewer is asked to make while scoring the
STIPO. The 0-2 and the 1-5 systems are both linked closely to the content of the individual
questions.
The 0-5 rating scales should reflect the interviewer’s total clinical impression, based on
all available information, verbal, non-verbal, and the respondent’s level of superficiality across
the questions in a given section. Furthermore, the interviewer can use the 5-point scale to weight
questions differently; for example, the level of pathology expressed in one 2 rating may be

25
significantly more severe than that expressed in another response, also rated 2. Also, a subject
may receive a 2 one only one question in a given section, but the interviewer may feel that this
response alone reflects very significant pathology. This pathology would not be reflected as well
in the 0-2 ratings, where all items are weighted equally in calculating the score; in contrast, the
interviewer can weight that one item more heavily in determining calculating the level of
pathology reflected in the 1-5 scale. The interviewer should make these ratings without any
conscious effort to try and reconcile the 0-2 scores with the 1-5 ratings. The 1-5 rating should
simply be made based on the interviewer’s clinical judgment or sense of the respondent based on
the questions in that section.

2.2 Guidelines for Specific STIPO Items

General comments:
• We use all available, observable information during the interview process (verbal and behavioral)
to score a 0-2 rating. We do not make interpretations or inferences to help in scoring an item, but
if the respondent’s verbal report is contradictory across the interview, we want to confront the
discrepancy, and if the behavior contradicts a verbal report, we may choose to weight the
behavior, which is also valid clinical information.

• Even if one thinks that a second rater may not see it the same way, the task is to score it based on
the actual information presented (verbal or otherwise).

• One should always revisit prior questions if new information contradicts an older reply.

Overview probe:
• Convey that it is an extended period of time, not just a couple of days.

• Criteria for exclusion is a marked divergence from normal self, with a clear decrement in one’s
typical functioning (“were you unable to function as your ‘normal’ self during this period”?)

• In response to “grandmother died”, or some other focal stressor or trauma, assess the time period,
and whether it was a marked divergence from normal self and how quickly the subject returned to
baseline

Questions 1-3 Investment in Work / Studies, i.e., Primary Role:

• How to determine primary role:
If the subject has had a primary role as both a student and a worker in the 5-year period, with
substantial roles in both areas, then the interviewer is to choose one or the other based on:
- Either the amount of time
- Where the respondent would say their primary investment of time or energy was
- If all else fails, just choose one.

• If the subject has neither worked nor been in school during the time period, when one would
presume that either working or being in school should be their primary role, score all 9’s for both
sections.
Example: A graduate student who did some part-time odd jobs, like 10 hours per week of
temporary work, or worked in a student recreation center or retail shop during graduate
school – only score school for that person, with the rationale being that school was clearly

26
 the more significant primary role during that time. If, however, the person was a full-
time graduate student while also working in a 20-hour per week research or teaching
assistantship, that is also a significant work-role during that time, so one would need to
ask which role the respondent felt was primary, or have the respondent or interviewer
arbitrarily choose.

• If the subject is only working part-time (e.g., 10 hours per week) yet says that he/she is “very
effective, very ambitious”:
- The general impression might be that they are not as invested as they say, or perhaps
not capable of investing, which is the main point of the section. Ideally, probing more
on the individual items will reveal whether this is the case, which would result in a 1,
at most, and more likely a 2.
- Probe as to why they not working more. Question whether if they were working more
they might be as effective (e.g., “too much stress”, “I need my time”, etc.) or whether
they are just are “very ambitious” but only in a 10 hour per week way, i.e., which is
NOT that ambitious
- For sure, this warrants a lower score in the 5-point rating

• If respondent is doing family work, one can ask the same question. Probe effectiveness, ambition
(is this chosen, are there “goals”), and is there satisfaction (the score “0” here would be the
realistic one, e.g., “there are moments when I love it and moments when I want to kill myself out
of boredom or frustration.” This would be normal)

• Extenuating circumstances. It is important to query participants who are not currently working
as to why. For some, there may be legitimate, extenuating circumstances that have prevented
them from working for a period within the 5 years, for example, a severe economic downturn, or
an injury that removed them from the workplace. In such cases, the individual should not
necessarily be penalized for the time not working in the 5 year period. If the best assessment is
that the absence from work is unintentional, in circumstances like this the capacity to invest
would be best assessed using only the time within the 5 years on which the participant was
working, assuming there is a reasonable sample of a year or more over which to evaluate
effectiveness, consistency, and pleasure.
•

Questions 1 Effectiveness:
• If a person received good external reviews for work effectiveness but still says they are working
below their potential, one should separate out their poor self-esteem and self- criticism from the
actual, objective performance issue. So, we would still score this a “0” if all the other measures
of effectiveness check out, with exception of their self-evaluation.

Question 2 Ambition / Goals:

• If responded says something along the lines of “I want to put my kids through college,” or “I just
want to make money to support my family,” this still scores a “0”as it reflects a capacity to invest
in something for a goal, which indeed reflects ambition. Shifts within a field, e.g., from professor
of finance to financial consulting can be scored a “0” or “1”.

Question 4 Recreation:
• What the interviewer is looking for here is not just something the subject does, but something
they do and learn about, spend time thinking about, and engaging in it even when they’re not
doing it. Let’s say they cook; to score a 0, we’d ask if they are researching food and cooking

27
 blogs, magazines, etc.? Just because it is something that they do, even if they do it regularly and
consistently over time, that may not be sufficient for it to be a bonafide, deep, recreational
investment. At best, such interests would be scored a “1”.

• Yoga, pilates, gym, reading, movies: Not in itself scored a “0”, even if it is consistent over
time and takes up considerable, regular time. If yoga, pilates, gym, running, for example, are just
to stay in shape, that’s not a recreational investment that qualifies for a 0. If the person says that
they take an avid interest in the gym, such that they read about fitness, make efforts regularly to
learn about fitness and healthy living, i.e., that it is in a way more than just working out for one’s
health but a broader interest, then this is moving more into the lines of a fitness / health interest,
i.e., a score of “0”. If they read or watch movies for pleasure because they “like the movies”,
that’s something they do, not something they’re necessarily invested in; that also is not a
recreational investment. If, however, they read about literature, follow specific writers, belong to
book / reading groups, i.e., something more than “I just like to read”, this moves towards a 0. If
they just are avid readers, this would be scored a “1”.

• AA: People sometimes talk about their involvement in Alcoholics Anonymous. This could either
be seen as treatment, which is not a recreational interest, or, depending on how involved the
person is in AA, a more serious recreational investment. For example, a person who has been
sober for many years, who attends several meetings a week, not out of necessity but because of
his or her commitment to AA, who takes on leadership roles and sponsors other alcoholics – this
is clearly moving in the direction of a serious investment, i.e., a score of “0”.

• If no sustained interest is identified, one might follow up asking: “Tell me about your free time;
do you enjoy it and find your recreational time fulfilling, or is there is a lot of unstructured free
time that you find yourself not knowing what to do, and feeling unsatisfactory or unenjoyable to
you?” If the respondent enjoys his or her free time, keeps oneself occupied socially or
recreationally but without a sustained interest as defined above, but without significant boredom
or distress, that can also be scored a 0.

• If a person does not have clear activities, but feels somewhat engaged and experience some pleasure in free
/ recreational time, score this a “1”. If a person has significant unstructured free / recreational time
from which they derive little to no satisfaction score this a “2”.

Questions 5/6 Sense of Self, Coherence and Continuity/ Ambivalence; 12/13 Representation of
Other, Superficiality vs. Depth/ Ambivalence:
• Open ended representation of self-probe. Items # 5/6 and 15/16 are scored for three qualities,
reflecting representations that are:
- Superficial vs. Deep / Nuanced. Descriptions consisting only of superlatives, e.g.,
“the most amazing”, “so wonderful”, points to some defensive distortion or
idealization. One should ask for greater elaboration (elicit example per the probes),
but if no greater depth is elicited, this scores a 2.
- Realistic / Integrated vs. Distorted / Polarized (idealized / devalued), whether the
person can identify both positive and negative qualities in more than a caricatured
manner. This does not have to be the deepest, most nuanced description of each.
What one is after here is the ability to think about and describe both positive and
negative in a manner that is somewhat realistic and elaborated. This alone scores a 0

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 for items 6 and 13.. Descriptions with less depth, it score a 1. Inability to think of
either positive or negative scores a 2.

• Do not deviate from the script. Ask the first question (“Tell me about yourself as a person….”)
and then wait for the respondent’s full reply. Then move onto the second probe (Is there
anything else you can…..), and ask it exactly as it is listed.

• Next, the interviewer needs to probe for depth and elaboration. If the respondent simply lists
qualities, the interviewer can probe or depth with probe #1 (“you’ve used several adjectives to
describe yourself….). Similarly, if one or two qualities were discussed but not in sufficient
depth, the interviewer can respond with probe #2 (inquire about one or more adjectives…). In
either case, as if the respondent can “fill in the description a bit, perhaps bringing it to life with
an example or story that illustrates that quality.”
•
• This should be done (eliciting example or story) for one positive and one negative quality.

• Ratings for both 5 and 6 are made after ALL probes are given.

• Beware of false “negative” qualities, e.g.., “I'm too modest”, “I’m very self-critical”, which could
be disguised expression of grandiosity or underscoring positive qualities without any owning of
something negative

• If deciding between a score of “0” and a “1”, the ease with which one can bring an example
would tilt to scoring to a “0”, whereas a poverty in the narrative or difficulty bringing an example
would tilt to a “1”.

Question 7 Consistent Sense of Self in Presence:

• If respondent behaves in an unpredictable/ erratic manner during interview this can either be
inquired about or taken into consideration by the interview in scoring the item, even if it
contradicts the verbal report.

• The respondent may report playing different roles as called for by specific situations, e.g.,
needing to be aggressive in a business or legal setting, versus being more accommodating and
sensitive in one’s intimate relationships – but does not report feeling like a different person across
those situations. The key to this item is indeed whether they begin to feel like a different person
or try to take on a different personality or self in a given situation, such that their sense of self and
who they are actually is different in those situations.

• Some people will say that they are “predictably unpredictable.” That is the definition of what
we’re looking for in this item and would generally qualify as a score of “2”. If the person says
“No, I’m not seen as erratic, my friends know that I’m all over the place, they expect me to act
erratic”, that’s either a score of a “1” or “2” depending on how erratic, severe, or pervasive this
quality is.

• It is normal for people to present somewhat differently across work and personal lives. The
question would be whether they present differently within those settings, and whether they feel
like a different person across those settings. Feeling like a different person across those settings,
and/or presenting variably within each setting, suggests identity diffusion, i.e. a score of “2”.

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Question 8 Self-Tastes/ Opinions:
• Open versus impressionable. Do you take on the opinions of others as if they were your own, not
really having a sense of what tastes and preferences come from inside yourself. The key is
whether you look to the outside because you have no sense at all inside. If opinions are
unformed this does not necessarily score as a “2”; it would score as a “2”, however, if the person
consistently looked to the outside to get a sense of those opinions and then took them as his or her
own. The key here is judging whether the person needs to consistently look to the outside to get a
sense of what he or she feels inside, or whether most of the person’s opinions, tastes, preferences
are internally derived. Again, it’s totally fine if a person says that they don’t have strong opinions
– what the interviewer is looking for is how comfortable they are with that, and whether they take
on as their own the opinions of others to cover up for their lack of opinions or tastes.

Question 9 Narcissistic Supplies:

• If the respondent indicates that they feel empty or down when they are not getting
attention/admiration, one may follow up by asking: “When you get deflated like that, how long
can that last, and how badly does it feel?”

Question 10 Self in Intimate Relationships:

• As being “flexible” can be adaptive, accommodating one’s partner still can score a “0”. Regular
to exclusive submission to one’s partner to avoid conflict, even if stated as “being flexible”,
moves scores to a “1” or “2” depending on severity and pervasiveness. Regular submission to
one’s partners preferences / needs scores a “1”, almost exclusive submission to one’s partner’s
preferences / needs scores a “2”.

Question 11 Self-Esteem:
• This is about the degree of fluctuation, the sense of stability in the sense of self-esteem (not
valence but stability).

Question 15 Others’ Feelings about the Self:

• This is about cognitive confusion related to the difficulty a person experiences in assessing how
others view him or her. One thing we tend to pick up here is the subject’s projected self-
criticism, which is different.

Questions 16-18 Friendships:

• If there are no friends at all, or the friends described result in a score of “2” on #16, then score
both #17 and #18 “2”.

Question 16 Friendships Presence:

• As the item is simply a measure of social connectedness versus isolation one may wish to ask
additionally if respondent feels socially isolated or connected.

• If deciding between a score of “1” and “2”, take participants feelings of social connectedness
versus isolation into account.

Question 17 Friendships Closeness:

• Probe the question for the two people closest to the respondent.

Question 18 Friendships Temporal Stability:

• If having difficulty discerning between a score of “1” and “2”, one may follow up with: “Why is
it that your friend group over time has shifted in this way?”

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Questions 20 and 21 Intimate Relations:
• If the respondent has had no significant romantic relationships in the past 5 years (#20), then skip
question 21. Similarly, if question #20 is scored a “2”, meaning the romantic “relationship” was
significantly brief or flawed, then we score #21 also as a “2”.

• “Sexual” is not limited to intercourse.

• In determining a “significant” relationship in terms of duration, to allow for standardization

across interviewers, we are proposing a relationship lasting 8 months or longer.

Question 22 Sexual Activity:

• By satisfaction we typically mean some combination of frequency, pleasure, comfort and
connection.

• Some theoretical notes: Normal = sexual love + sexual pleasure; Neurotic = less frequent sexual
activity, inhibition in pleasure, difficultly combining love and sex; Borderline = polymorphously
perverse, sex in service of aggression. What is intended here is attempting to strike a balance
between several issues: Is the person having sex, is the sex in the context of an ongoing
relationship, and is the subject satisfied by and able to enjoy the sexual experience. If any of
these aspects are seriously flawed, the response should lean towards a score of “2”.

Question 23 Shyness about Sex:

• One may follow up with: “Would you consider yourself inhibited?”

• If not sexually active (#22) at all in the past 5 years, then skip question 23.

Question 26 Boredom:
• What the interviewer is after here is the subject’s ability to sustain relationships over time.
Losing interest relates to patterns of idealization / devaluation, as opposed to either growing apart,
or realizing over time that the relationship was not working or meant to be.

• Similarly, some respondents report feeling “disgusted” by their partners over time. Although not
related to boredom per se, this response still reflects a difficulty with the capacity for an internal
investment in the other, and thus one would score this a “2”.

Question 29 Economic View of Relationships:

• Here one is looking for respondents who either take a pervasively exploitive attitude or approach
in their object relations, always needing to be getting the most out of their relationship partners in
relation to what they are giving themselves, i.e., the exploiter attitude, OR, the respondent who is
pervasively masochistic, always in a giving position, i.e., preoccupied with getting less out of the
relationship.

• If the respondent is always insistent on the partner getting more, or of submitting oneself, score
this a “2”.

Question 31 Paranoia:
• The distinction to draw between a score of “1” and a “2” might be shame over aspects of self
they do not want to reveal (“1”), versus the need to guard versus manipulation, which is a more
narcissistic / borderline tendency (“2”).

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 • One may wish to clarify by: “I’m speaking here not just about your close relationships, but about
your general approach to people and the world; would you characterize yourself as more open, or
closed off?”

Question 33 Black and White Thinking:

• One may follow up with: “Are you the kind of person who can easily see both sides of an issue,
the nuance in things?”

Question 35 Idealization / Devaluation II:

• One may follow up with: “Some people tend to be “prickly” or hypersensitive or reactive, and
others tend to be more easygoing; which is more characteristic of you?”

Question 37 Anticipation / Planning:

• If the respondent is not proactive with planning, one may follow up with: “Is your life generally
well organized and effective, specifically, are you losing things, always running late, missing
deadlines, etc.?”

• A respondent who does not endorse proactive planning as described, but copes effectively still
scores a “0”.

• Some of our study participants do not have lives that involve significant commitments or
expectations, i.e., there is not much to be organized or proactive about (no job, no school, no
responsibilities for child-care, etc.). Thus, they say that they don’t engage in proactive coping,
but do not experience stress or because of this. These participants should still score “2” due to
the presumption that having a life devoid of stress and commitment reflects significant rigidity
and poor coping.

Question 38 Suppression:
• One may follow up with: “Some people call this compartmentalizing, where you can put
troubling things away long enough to go on and get stuff done; is that something you can do?”

Question 40 Perfectionism:
• If a person is not conscientious at all or there are no circumstances in life where such ambition
can reasonably be applied, score this a “2”.

Question 41 Aggression Self-Neglect:

• “I don’t get enough sleep,” “I don’t eat as well as I should” score as “0”.

Question 44 Suicidality:
• If a person indicates that they have not made any sucide attempts in the last year, one may follow
up by asking: “Do you frequently fantasize about suicide?”

• A significant preoccupation with suicidality scores a “1”, a significant to severe preoccupation

with suicidality scores a “2”.

Question 46 Envy:
• One may also ask whether the respondent feels resentful towards others who succeed or
accomplish something.

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Question 50 Moral Action:
• The interviewer is attempting to assess the presence of an internalized, yet flexible, moral code,
internal to that respondent. Example: A religious respondent who says it is wrong to have pre-
marital sex, but engages in some sexual activity, would still score a “0”, to the extent to which he
or she is engaged and wrestling with an internal moral code.

Question 51 Internalized Moral Values:

• Individuals governed by “religious” codes of moral conduct may still score a “1” if that code is
governed by a fear of punishment more than an articulated sense of right and wrong.

Question 52 Guilt:
• Guilt means, “I have wronged / hurt someone else and I feel badly for how I have hurt them with
emphasis on concern for the other.” NOT: “I feel badly b/c I let myself down.” VERSUS - “I
feel guilty” but meaning, I know I behaved poorly and am focused on how bad I am, or how
wrong I was and feel a need to punish or to avoid myself, which is a paranoid / shame dynamic.
One is looking for a capacity for guilt in the depressive position sense: I have hurt others, and
am regretful and concerned about damage done to them; there should be reflection/effort on doing
things differently in the future or on making amends.

• Needs a clear examples to get a score of “1”; where there is some concern that the behavior has
adversely impacted others.

• The example may actually be less guilt than self-criticism, e.g., “I don’t go gym”, “I should have
been a better mother when my kids were young.” This does not score a “0” but a “1”.

• If subject says “Others have said that i’m guilty of x”: follow up with “well how do you feel
about that?”

• If the respondent does not provide an expample at all we score this a “9”.

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