CHAPTER 1

An Object Relations Model

of Personality and
Personality Pathology

Eve Caligor, M.D.

John F. Clarkin, Ph.D.

C linicians treating patients with personality disorders commonly

grapple with several key questions:

◆ What is the relationship between normal personality functioning

and personality pathology?
◆ What are pathological aspects of personality functioning common to
many or most of the personality disorders?
◆ What relationships exist among the higher-level and the more severe
personality disorders?
◆ How can we evaluate and characterize the severity of pathology
among the different personality disorders?
◆ How can we evaluate and characterize the severity of pathology of
individuals within a particular diagnostic group?

The object relations theory model of personality disorders provides a

clinically based approach to answering them.

3
4 Psychodynamic Psychotherapy for Personality Disorders

To facilitate what will be a clinically based introduction to the object

relations theory model of personality disorders, we present four vi-
gnettes of patients with personality disorders:

Ms. N is a 28-year-old single, employed woman who was seen in con-

sultation with the complaint of “problems with men” and “difficulty
with confrontation.” Ms. N was attractive, charming, and quietly seduc-
tive, and she acknowledged that she was often surprised to find herself
the center of attention in social settings. Yet she noted that she tended to
feel inadequate and unattractive relative to her friends and co-workers,
and she described herself as shy with men and sexually inhibited. She
felt that these traits explained why she had not had a long-term relation-
ship since college. Ms. N also complained of difficulty with “confronta-
tion,” with a tendency to shy away from conflict. She felt that as a result
she was at times excessively accommodating. Though she did not have a
boyfriend, she had a close-knit group of friends. Ms. N described her
work as an elementary school teacher as both challenging and fulfilling.
She felt that she was, overall, an optimistic and level-headed person, but
she was demoralized about her inability to establish a long-term rela-
tionship with a man or to feel better about herself. By the end of an hour-
long interview, the consultant found himself feeling warmly toward
Ms. N, and he felt that he had a vivid impression of Ms. N, of her diffi-
culties, and of the important people in her life.

Ms. B is a 28-year-old single, employed woman who was seen in con-

sultation with the complaint of “problems with men” and “difficulty
with confrontation.” Ms. B was attractive and engaging; she wore a short
skirt and low-cut blouse, and her manner was sexually provocative in a
way that made the consultant vaguely uneasy. She described feeling un-
comfortable in settings in which she was not the center of attention.
Ms. B told the consultant that she found it difficult to control her anger
in the setting of conflicts with her boyfriends and that she was prone to
temper tantrums. Since graduating from college, Ms. B had held a series
of jobs; she was currently working as a receptionist. She found her work
dreary and boring, though she could not think of anything else she
would rather be doing. She lived alone and did not have a steady part-
ner. She described a series of relationships with men that, according to
Ms. B, always ended badly. She had a scattered group of friends, but her
sister was the only person she felt entirely trusting of and attached to.
She felt her life was “going nowhere,” and she was intermittently
plagued by feelings of emptiness and self-loathing. The consultant
found himself struck by the apparent contradiction between Ms B’s
composure in the interview and the history she provided of rageful, ac-
cusatory, and manipulative behavior with her boyfriends.
Object Relations Model of Personality and Personality Pathology 5

Mr. N is a 38-year-old married lawyer with two young children. He was

seen in consultation with a complaint of “problems with work” and
problems with self-esteem. Mr. N described his work as a junior partner
at a successful law firm as challenging and intellectually fulfilling. Nev-
ertheless, he complained of feeling inadequate in the workplace and not
as able as those around him, and he was troubled by a tendency to be
“too detail-oriented” and to put things off until the last minute. Mr. N
was emotionally constricted and extremely reserved but nevertheless
conveyed a deeply felt attachment to his wife and young children. He
understood that his loved ones experienced him as emotionally unavail-
able, but he felt unable to change his behavior. He had a few close friends
dating back to high school but was, by his own account, not especially
social. After hearing Mr. N’s story, the consultant found himself im-
pressed by Mr. N’s conscientiousness and his motivation for treatment.

Mr. B is a 38-year-old married, unemployed lawyer. He was seen in con-

sultation with a complaint of “problems with work” and problems with
self-esteem. He described himself as “a procrastinator” and complained
of being detail-oriented to a fault; he often found himself lost for hours
chasing irrelevant information. However, as the interview proceeded, it
emerged that since graduating from law school 10 years earlier, Mr. B
had been fired from a series of jobs because he had had difficulty com-
pleting projects and had often missed deadlines; he also had a history of
falsifying time sheets, frequently calling in sick, and getting into power
struggles with his bosses. He had most recently worked as a paralegal—
a job he found demeaning—and had been fired 6 months earlier. Mr. B
described himself as alternating between feeling smarter than everyone
and like a “dumb loser.” He was emotionally distant and constricted,
and his wife complained that he provided neither financial nor emo-
tional support. He explained that he had lost sexual interest in her early
in the marriage and that he periodically visited prostitutes. Mr. B com-
plained of feeling empty and restless. He wanted the consultant to tell
him how to feel less dysphoric and anxious, and how to have a more sta-
ble sense of himself as exceptional. At the end of an hour-long interview,
the consultant found himself with only a vague and superficial sense of
Mr. B and an even more shadowy image of his wife. The consultant felt
overwhelmed by the intractability of Mr. B’s difficulties and was con-
cerned that Mr. B had little genuine motivation for treatment.

While all of these patients have personality disorders, the differ-

ences among them are both striking and of great significance in a clinical
setting. By the end of this chapter, the reader will have a framework
within which to consider both the similarities and the differences
among these patients; the object relations theory model of personality
disorders provides a systematic and coherent approach to assessment,
6 Psychodynamic Psychotherapy for Personality Disorders

classification, and treatment of personality pathology across the spec-

trum of severity.

What Is Object Relations Theory?

In psychodynamic psychiatry, the term object is used, for historical rea-
sons and rather unfortunately, to refer to a person with whom the sub-
ject has a relationship. Similarly, the term object relations refers to the
quality of the subject’s relationships with others. Turning from the ex-
ternal, interpersonal world to the internal world of the subject, we use
the term internal object to refer to the representation or presence of an-
other within the mind of the subject. Object relations theory comprises a
cluster of somewhat loosely related psychodynamic and psychoanalytic
models of psychological motivation and functioning in which the inter-
nalization of early patterns of relating is viewed as a central feature of
psychological development and psychological functioning.
The particular object relations theory–based model of personality
disorders that we present was developed by Otto Kernberg and his col-
leagues at the Personality Disorders Institute of the Weill Cornell Med-
ical College (Kernberg and Caligor 2005). This approach represents an
integration of major contributions emerging from the Kleinian and Brit-
ish schools of psychoanalysis with developments within American ego
psychology—in particular, the work of Edith Jacobson, Margaret
Mahler, and Erik Erikson. An offshoot of object relations theory, attach-
ment theory (Shaver and Mikulincer 2005), is discussed in Chapter 2
(“Attachment and Personality Pathology”). In this chapter, we focus on
those aspects of Kernberg’s model that are most relevant to clinical prac-
tice. We cover the basic concepts underlying the object relations theory
approach to personality disorders, along with the system of classifica-
tion of personality pathology at the core of Kernberg’s model. We omit
discussion of Kernberg’s more controversial developmental theory, as
well as his exploration of the psychoanalytic construct of “drives.” Be-
cause the model we present is clinically based, emerging from experi-
ence with the psychodynamic treatment of patients with personality
disorders, it is not wedded to a specific model of etiology of personality
disorders.

Psychological Structures
The cornerstone of the object relations theory approach to personality
disorders is that descriptive features of personality pathology that char-
acterize a particular personality disorder can be seen to reflect the nature
Object Relations Model of Personality and Personality Pathology 7

and organization of underlying psychological structures. Psychody-

namic treatments that lead to changes in psychological structures will at
the same time lead to changes in descriptive features of personality pa-
thology and to improvement in psychological functioning. This “bottom-
up” approach to treatment and therapeutic change can be contrasted
with (and can also be advantageously combined with) “top-down” cog-
nitive-behavioral approaches, which focus directly on changing mal-
adaptive behaviors and patterns of thinking.
Before proceeding, we want to say a word about the term structure as
it is used in psychodynamic psychiatry, as this is often cause for confu-
sion. In a psychodynamic frame of reference, structures are stable pat-
terns of psychological functioning that are repeatedly and predictably
activated in particular contexts.1 This is to say that psychological struc-
tures are not structures in the concrete sense but rather are psychologi-
cal processes that can be conceptualized as dispositions to organize
subjective experience and behavior in certain predictable ways. At the
level of cognitive neuroscience, the neural correlates of what we think of
as psychological structures can be conceptualized as associations
among neuronal circuits, or “associational networks,” that tend to be ac-
tivated in concert (Westen and Gabbard 2002). Motivational systems,
coping mechanisms, patterns of relating, and processes that function to
regulate mood and impulses are all examples of psychological struc-
tures. The nature and the organization of psychological structures are
characteristic of the individual and tend to be stable over time, though
they can be modified as a result of maturation, life experience, and suc-
cessful treatment.
It is important to appreciate that, in contrast to descriptive features
of personality, psychological structures as they are conceptualized
within a psychodynamic frame of reference can be neither directly ob-
served by the clinician nor reported by the patient. Rather, at the level of
clinical observation, the nature of psychological structures can be in-
ferred and also systematically assessed on the basis of their impact on
descriptive aspects of personality functioning, in particular an individ-

1 We distinguish between this usage of the term structure and the psychometric
concept of structure. In trait theory, personality structure refers to a factor struc-
ture that fits existing data. This statistical method is used to explore latent vari-
ables underlying different personality traits by identifying covariation among
traits. Trait theory identifies structures across a population. In contrast, psycho-
dynamics uses structures to refer to how psychological functioning is organized
within a particular individual.
8 Psychodynamic Psychotherapy for Personality Disorders

ual’s behavior, interpersonal relations, and subjective experience. For

example, conscience is a familiar psychological structure comprising the
psychological processes involved in moral functioning. Ethical (and un-
ethical) behavior, feelings of guilt, and commitment to moral values and
ideals are descriptive features of personality functioning that are or-
ganized by the various processes that constitute the structure termed
conscience. Similarly, the defensive operation denial is a psychological
process manifested descriptively in the predictable tendency to mini-
mize the emotional impact of painful experiences.
Our emphasis on the relationship between observable behavior and
internal, unobservable cognitive-affective structures is shared by many
contemporary theories of personality; one can discern the use of similar
and overlapping constructs across a wide array of models, all of which
point to the role of certain basic cognitive and emotional processes in
both normal personality functioning and personality pathology (see Len-
zenweger and Clarkin 2005). In particular, Mischel and Shoda (2008)
have conceptualized normal personality as a system of mediating units
(e.g., encodings, expectancies, motives, and goals) that operate at various
levels of consciousness to enable the individual to interact successfully
with the environment. According to this model, termed the Cognitive-
Affective Personality System (CAPS), particular cognitive-affective mental
representations are activated in response to environmental contingen-
cies, including those that emerge in the interpersonal environment. Thus,
according to this influential theory, the essential element in personality
functioning is the organization of cognitive-affective representations,
which are patterned, relate to behavior expression, accrue into a percep-
tion of self across situations, and motivate the selection of particular en-
vironments that the individual prefers and actively seeks.

Internal Object Relations

In the object relations theory approach, cognitive-affective units consist-
ing of an image of the self interacting with an image of another person,
with the entire interaction linked to a particular affect state, are consid-
ered to be the most basic psychological structures. These internalized re-
lationship patterns are referred to as internal object relations. In the object
relations theory model, internal object relations are the building blocks of
higher-order structures, and they are also seen to organize subjective ex-
perience. For example, the structure identity is conceptualized as an or-
ganization of internal object relations pertaining to the experience of self
and of others; conscience comprises object relations pertaining to prohibi-
tions and ideals. Different contexts will lead to the activation of different
Object Relations Model of Personality and Personality Pathology 9

internal object relations. The particular internal object relations that are
activated will organize the individual’s behavior and experience of that
setting and will be played out in his or her interpersonal relations.
As an example of how we conceptualize internal object relations and
their role in psychological functioning and subjectivity, consider an ob-
ject relation comprising the image of a small, childlike self interacting
with an image of a powerful, threatening authority figure in which the
interaction is linked to feelings of fear—or, alternatively, the image of a
small, childlike self and a caring, protective figure associated with feel-
ings of gratification and safety. In these illustrations, the internal object
relations described will become manifest in the adult to the degree that
they function to organize the individual’s expectations and experience
of dependent relations—coloring the experience of the self and of the
person depended upon, while activating, in the first case, an affective
experience of anxiety and fear and, in the second, an experience of grat-
ification and safety.
Kernberg (Kernberg and Caligor 2005) suggests that internal object
relations emerge from the interaction of inborn affect dispositions and
attachment relationships; from the earliest days of life, constitutionally
determined affect states are activated in relation to, regulated by, and
cognitively linked to interactions with caretakers. Over time, these in-
teractions are internalized as relationship patterns, which are gradually
organized to form the enduring, affectively charged psychological
structures that we refer to as internal object relations.
Our emphasis on internalized patterns of relating as central organiz-
ing features of psychological functioning is shared by many other ap-
proaches, including cognitive and behavioral theory, interpersonal
theory, and attachment theory. However, while there is much overlap
among these models, object relations theory is distinguished by virtue
of invoking a relatively complex, “dynamic” relationship between early
attachment relationships and the psychological structures that come to
organize adult experience. In the object relations theory model, we in-
voke not only early experience—colored by cognitive developmental
level—as affecting the nature of internal object relations, but also psy-
chodynamic factors, including the individual’s psychological conflicts,
defenses, and fantasies.
To illustrate the potential role of conflict and defense in determining
the nature of internal object relations, let’s return to our earlier example
of an internal object relation comprising a small, childlike self and a
powerful, threatening authority figure linked to feelings of fear. We are
suggesting that for a particular individual, the self experience of pow-
erlessness and fear in the setting of dependent relationships may reflect
10 Psychodynamic Psychotherapy for Personality Disorders

not only actual early experiences with a frightening parent but also de-
fensive needs or fantasy. For example, for someone like Ms. N, this ob-
ject relation might be a defensive construction in relation to conflictual
wishes to hurt a parental figure. Here we would speak of “projection,”
as if to say: “She is aggressive and sadistic, not me; I am weak and fright-
ened. Therefore I need not feel guilty for having sadistic feelings.”
Alternatively, for someone like Ms. B, a more extreme and highly affec-
tively charged version of this same object relation might function as part
of a defensive effort to protect a fantasy of a wished-for, perfectly grat-
ifying parental figure. This is an example of “splitting”: “This feels ter-
rible, but nevertheless it means that I can still hope to find a perfect
caretaker.” In sum, the internal object relations that organize subjective
experience in a particular setting may at the same time serve defensive
functions, protecting the subject from awareness of more threatening or
painful, conflictual experiences of self and other. In the object relations
theory model, the nature and quality of internal object relations are seen
to reflect temperamental factors (e.g., inborn affect dispositions), devel-
opmental experience, and also conflict and defense.

An Object Relations Theory–Based Approach

to Personality Pathology
A PSYCHODYNAMIC DESCRIPTION OF PERSONALITY AND
PERSONALITY PATHOLOGY
From a psychodynamic perspective, a comprehensive description of
personality pathology will include 1) the descriptive features of the dis-
order, 2) a formulation about the structural organization underlying de-
scriptive features, and 3) a theory about the patient’s psychodynamics.
Assessment of descriptive features provides information about pre-
senting complaints and problems, maladaptive personality traits, and
relationships with significant others, and such assessment can be used
to formulate a descriptive diagnosis. This is the approach taken by
DSM-IV-TR (American Psychiatric Association 2000). A structural for-
mulation provides information about the severity of personality pathol-
ogy through the lens of the individual’s experience of himself and his
significant others, object relations, defensive operations, and reality
testing (Kernberg 1984). Together, descriptive and structural assess-
ments offer the clinician a clear appreciation of the patient’s objective
and subjective difficulties and provide the information needed to make
a diagnosis and to guide treatment planning.
Object Relations Model of Personality and Personality Pathology 11

A comprehensive psychodynamic description of psychopathology

will also include an understanding of the psychological conflicts under-
lying the disorder. It is by exploring conflicts underlying maladaptive
behaviors and subjective states that the psychodynamic clinician gives
meaning to the seemingly irrational difficulties that bring patients with
personality disorders to treatment. And it is through the exploration
and working through of underlying meanings and motivations that
psychodynamic clinicians help their patients develop greater flexibility
and adaptation. Assessment of the descriptive, structural, and dynamic
dimensions of personality functioning (see also Chapter 4, “The Shedler-
Westen Assessment Procedure,” in this volume) will guide differential
treatment planning and enable the clinician to anticipate developments
in treatment.
When it comes to assessment, classification, and differential treat-
ment planning, the object relations theory model of personality disor-
ders combines a dimensional classification of personality disorders,
according to severity of structural pathology, with a second-order cate-
gorical or prototypical classification based on descriptive traits (i.e., the
type of diagnosis provided by DSM-IV-TR). Thus, both clinically and
conceptually, the object relations theory approach is first to characterize
the severity of personality pathology by assessing the nature, organiza-
tion, and degree of integration of psychological structures, and then to
characterize descriptive features of personality pathology to make a di-
agnosis of personality “type” or “style.”
Our two-axial approach reflects the clinical reality that similar per-
sonality styles or maladaptive traits may be seen across a broad spec-
trum of pathology, with markedly different prognostic implications;
from a clinical perspective, the nature and degree of severity of struc-
tural pathology are typically of greater importance with regard to prog-
nosis and differential treatment planning than is personality “type.” For
example, we would suggest that in the clinical setting, the similarities
between Ms. N and Mr. N on the axis of structural pathology are of
greater significance than are the manifest similarities in presenting com-
plaints and personality style that link Ms. N to Ms. B and Mr. N to Mr. B
on the descriptive axis. In this chapter, we focus largely on the structural
axis of the model, as this aspect is unique to object relations theory and
provides an overarching, integrative approach to personality pathology.

DESCRIPTIVE FEATURES OF PERSONALITY DISORDERS

When we refer to someone’s personality, we are referring to the enduring
and habitual patterns of behavior, cognition, emotion, motivation, and
12 Psychodynamic Psychotherapy for Personality Disorders

ways of relating to others that are characteristic of the individual. These

directly observable components of personality functioning constitute
the descriptive features of an individual’s personality and personality
pathology. From a descriptive perspective, an individual’s personality
is expressed as a particular personality style. For example, an individual
like Mr. N who has an obsessive-compulsive style is attentive to detail,
perfectionistic, risk-averse, and constricted in emotional expression,
where each of these descriptors is viewed as a “personality trait.”
As personality traits become more rigid and more extreme, we move
from a normal “personality style” to pathological personality function-
ing. When we speak of personality traits as “rigid,” we mean that the in-
dividual is unable to change his or her behavior, even when he or she
would like to do so and even when it is highly maladaptive not to do so.
Thus, Mr. N is unable to stop procrastinating, even though he is aware
that his behavior causes him unnecessary distress and might make it
difficult for him to excel. Rather than learning from experience and
modifying maladaptive patterns, the individual will activate the same
behaviors, emotional responses, and ways of relating time and time
again, and in a broad array of circumstances, regardless of whether or
not these behaviors are appropriate to the setting. When we describe
personality traits as “extreme,” we refer to an increasingly wide devia-
tion from commonly encountered and culturally normative behaviors
and ways of functioning. Thus, Mr. B’s procrastination routinely led
him to miss deadlines, whereas Mr. N’s did not; Ms. N’s seductiveness is
understated and socially appropriate, whereas Ms. B’s feels exagger-
ated and somewhat crude. Personality pathology exists on a spectrum,
with traits becoming more rigid and more extreme, and interfering with
the individual’s functioning more profoundly and more globally, as per-
sonality pathology becomes more severe. At the most severe end of the
spectrum, we see traits that are not only extreme but also mutually con-
tradictory. For example, Mr. B is excessively detail-oriented, yet at the
same time he routinely overlooked glaring typographic and spelling
errors in his work. When personality rigidity reaches the point that it
significantly, consistently, and chronically interferes with daily func-
tioning, and/or causes significant distress to the individual and those
around him or her, we speak of a personality disorder.

OVERVIEW OF THE STRUCTURAL APPROACH TO

PERSONALITY DISORDERS
The structural approach to personality disorders classifies personality
pathology on the basis of the nature of key psychological processes or
Object Relations Model of Personality and Personality Pathology 13

structures. (This classification is sometimes referred to as structural

diagnosis.) Specifically, the structural approach examines the following:

1. Identity (sense of self and others)

2. Predominant level of defensive operations (customary ways of cop-
ing with external stress and internal conflict)
3. Reality testing (appreciation of conventional notions of reality)
4. Quality of object relations (understanding of the nature of interper-
sonal relations)
5. Moral functioning (ethical behavior, ideals and values)

This view is consistent with the approach adopted by personality

disorder researchers (Livesley 2001; Parker et al. 2004; Verheul et al.
2008), who also focus on aspects of adaptive and maladaptive person-
ality functioning in order to characterize the severity of personality pa-
thology. In particular, these researchers identify a stable self-image, self-
reflective functioning, aggression regulation, purposefulness, and a
capacity for intimacy as core components of personality functioning rel-
evant to assessing severity of personality pathology.
At a conceptual level, the structural approach to personality pathol-
ogy is compatible with an emerging consensus among personality dis-
order researchers that difficulties in relation to a sense of self, or identity,
and chronic interpersonal dysfunction are essential elements in person-
ality disorders (Livesley 2001; Pincus 2005). Theoreticians and clinicians
representing cognitive (Pretzer and Beck 2005), interpersonal (Benjamin
2005), and attachment (Levy 2005; Meyer and Pilkonis 2005; see also
Chapter 2, this volume) perspectives, as well as those working within
the model of object relations theory, emphasize the centrality of these
key areas of functioning in personality pathology.

LEVELS OF PERSONALITY ORGANIZATION AND

CLASSIFICATION OF PERSONALITY PATHOLOGY
The structural approach to personality disorders was first developed by
Otto Kernberg and emerged from extensive clinical experience with the
psychodynamic treatment of patients with personality disorders. Kern-
berg (1984) divides the universe of personality pathology into two ma-
jor groups of disorders or levels of personality organization, the neurotic
level of personality organization (NPO) and the borderline level of personality
organization (BPO), based on severity of structural pathology.
In the less severe, neurotic level of personality organization, we see
maladaptive personality rigidity in the setting of 1) normal identity;
14 Psychodynamic Psychotherapy for Personality Disorders

2) the predominance of higher-level, repression-based, defensive oper-

ations; and 3) intact reality testing. This group of “higher-level” person-
ality disorders includes the obsessive-compulsive and depressive
personality disorders, the higher-level hysterical personality disorder
(omitted from DSM-IV-TR), a relatively healthy subset of patients with
avoidant personality disorder, and also the large group of patients seen
in clinical practice who present with personality pathology but not of
sufficient severity to meet criteria for a DSM personality disorder (Wes-
ten and Arkowitz-Westen 1998). Individuals organized at a neurotic
level generally function well in many domains, with maladaptive per-
sonality traits typically interfering predominantly in focal areas of func-
tioning and/or causing subjective distress. Ms. N and Mr. N are both
organized at an NPO. Ms. N’s personality rigidity has affected her
largely in the domain of romantic relations; she functions well at work,
does well socially, and maintains close friendships. Mr. N’s personality
rigidity causes inhibition in the expression of emotion but does not in-
terfere with his forming deep attachments; his tendencies to get lost in
detail and to procrastinate in his work cause distress and handicap him
to some degree, but he is nevertheless very successful professionally.
In the personality disorders organized at a borderline level,2 patients
present with severely maladaptive personality rigidity in the setting of
1) clinically significant identity pathology; 2) the predominance of
lower-level, splitting-based defensive operations; and 3) variable reality
testing in which ordinary reality testing is grossly intact, but the more
subtle capacities to appreciate social conventions and to accurately per-
ceive the inner states of others are impaired. In this more severe group of
personality disorders we find most of the personality disorders de-
scribed in DSM-IV-TR, including the dependent, histrionic, narcissistic,
borderline, paranoid, schizoid, and antisocial personality disorders. In-
dividuals organized at a borderline level have pervasive difficulties that
adversely compromise functioning in many, if not all, domains, and
maladaptive traits that are more extreme and more rigid than those of

2 We want to make clear the distinction between DSM-IV-TR borderline person-

ality disorder (BPD) and the borderline level of personality organization (BPO).
BPD is a specific personality disorder, diagnosed on the basis of a constellation
of descriptive features. BPO is a much broader category based on structural fea-
tures—in particular, pathology of identity formation. The BPO diagnosis sub-
sumes the DSM-IV-TR BPD as well as all of the severe personality disorders.
We refer the reader to Figure 1–1 for further clarification of the relationship
between the DSM-IV-TR Axis II diagnostic categories and level of personality
organization.
Object Relations Model of Personality and Personality Pathology 15

individuals in the NPO group. Ms. B and Mr. B are both illustrative of the
difficulties encountered in the BPO group; one can see that their person-
ality pathology affects virtually all areas of functioning. In Figure 1–1,
we orient the reader unfamiliar with this system by illustrating the rela-
tionship between the structural approach to personality disorders, em-
phasizing the dimension of severity, and the more familiar DSM-IV-TR
personality disorders.
Despite the apparently categorical nature of our framework as it is
described above and represented in Figure 1–1, in fact, our approach
assumes a dimensional perspective on personality pathology. At the
healthiest end of the spectrum are individuals with normal identity, pre-

FIGURE 1–1. Relationship between level of personality

organization and DSM-IV-TR Axis II diagnoses.
Severity ranges from mildest, at the top of the figure, to extremely severe, at the bottom.
Vertical arrows indicate ranges of severity for each DSM-IV-TR personality disorder.
16 Psychodynamic Psychotherapy for Personality Disorders

dominantly higher-level defenses, and stable reality testing, while at the

most pathological end are those with severe identity pathology, pre-
dominantly lower-level defenses, and shaky reality testing. In between
we find a range of psychopathology. This is to say that the classification of
personality disorders presented in this chapter is most accurately concep-
tualized as describing a continuous spectrum of personality pathology.
As a result, the demarcation between the neurotic and borderline levels of
personality organization is not categorical, and there are patients with
very mild identity pathology who present with mixed features.
The structural classification of personality pathology, dividing per-
sonality disorders into those associated with a neurotic and those asso-
ciated with a borderline level of organization, is further refined on the
basis of characterization of 1) quality of object relations and 2) moral
functioning (Kernberg and Caligor 2005). Within the BPO group, eval-
uation of these additional dimensions leads to identification of high-level
borderline organization (i.e., healthier, with less pathology of object rela-
tions and more intact moral functioning, and having a better prognosis)
and low-level borderline organization (i.e., having more severe personality
pathology, with grossly impaired object relations and significant pathol-
ogy of moral functioning, and having a poorer prognosis) (see Figure 1–1;
see also Table 1–1). An essential distinction between the high- and low-
level borderline groups is the role played by aggression in psychological
functioning and pathology. Psychopathology in the low-level border-
line group is characterized by the expression of poorly integrated forms
of aggression, which may be inwardly and/or outwardly directed; ag-
gression is less central in high-level borderline pathology. The high-
level BPO group includes dependent, histrionic, more disturbed
avoidant personalities, and the healthier end of the narcissistic spec-
trum. Ms. B is organized at a high borderline level; she presents with
identity pathology, in the setting of some capacity for mutually depen-
dent relations and largely intact moral functioning. Mr. B is organized at
a low borderline level; he presents with more severe identity pathology,
in the setting of relationships based on exploitation and deficits in moral
functioning.
The distinctions between NPO and BPO and between high and low
levels of borderline personality organization have important implica-
tions for prognosis and differential treatment planning. These three
groups of patients (NPO, high-level BPO, low-level BPO) have different
clinical needs, and patients in each group benefit from treatments spe-
cifically tailored to their psychopathology. At the end of this chapter we
address some of these issues, and they are further developed in other
chapters in this volume and in our suggested readings.
Object Relations Model of Personality and Personality Pathology 17

Table 1–1 outlines the structural approach to the classification of per-

sonality pathology. In the rest of this chapter, we elaborate on the mate-
rial outlined in Table 1–1. We cover the constructs of identity, defenses,
reality testing, quality of object relations, and moral functioning, focus-
ing on their differential manifestations among the three levels of person-
ality organization. We then introduce psychodynamic considerations,
and we end with comments on implications for treatment.

Identity
The construct of identity anchors the object relations theory model of
personality disorders. Normal identity distinguishes the normal per-
sonality and neurotic-level personality disorders on the one hand from
the personality disorders organized at a borderline level on the other
(Table 1–1). Identity is the structural correlate of both the subjective sense
of self and the experience of significant others, which in this model are
viewed as inextricably linked. (The intimate relation between self expe-
rience and the experience of others has been empirically examined and
supported in a series of studies conducted by Andersen [Andersen and
Chen 2002].) As mentioned earlier, in the object relations theory model,
internal object relations are conceptualized as the building blocks of
higher-order structures. Kernberg (Kernberg and Caligor 2005) sug-
gests that in normal identity formation, internal object relations associ-
ated with the experience of self and others are organized in relation to
one another in a stable but flexible fashion. This organization corre-
sponds with an integrated sense of self, which is manifested subjec-
tively in experiences of both the self and significant others that are
complex, well differentiated, characterized by subtlety and depth, con-
tinuous over time and across situations, flexible, and realistic. In ad-
dition, normal identity is associated with the ability to accurately
appreciate the internal experience of others; to invest, over time, in pro-
fessional, intellectual, and recreational interests; and to “know one’s
own mind” with regard to one’s values, opinions, tastes, and beliefs.
Kernberg contrasts normal identity with pathological identity for-
mation; following Erikson (1956), he refers to the latter as the syndrome
of identity diffusion. In identity diffusion, internal object relations mak-
ing up the sense of self are polarized, by which we mean “all good” or
“all bad,” associated with strongly positive or strongly negative affect
states, and extreme. These highly affectively charged internal object re-
lations are poorly and unstably organized in relation to one another. At
a descriptive level, the outcome of this structural organization is the ab-
sence of an overarching, coherent sense of self or of significant others.
 18
TABLE 1–1. Structural approach to classification of personality pathology
Normal personality Neurotic personality High-level borderline Low-level borderline
Structural domain organization organization personality organization personality organization

Psychodynamic Psychotherapy for Personality Disorders

Personality rigidity None Mild to moderate Extreme Very extreme

Identity Consolidated Consolidated Mild to moderate Severe pathology

pathology

Dominant defensive Mature Repression-based Splitting-based, Splitting-based

functioning repression-based

Reality testing Intact, stable Intact, stable Intact; some social deficits Intact; social deficits
(transient psychotic states)

Object relations Deep, mutual Deep, mutual Some mutual Need-fulfilling

Moral functioning Internalized, flexible Internalized, rigid Inconsistent Pathology

Object Relations Model of Personality and Personality Pathology 19

Instead, the subjective experience of both self and others is fragmented,

lacking in continuity, extreme, and unstable.3 For example, Ms. B’s view
of herself and her mood state shifted dramatically depending on
whether or not there was a man in her life; a new romantic interest lifted
her from dysphoria and self-loathing and left her feeling “like a new
person.” With his wife, Mr. B was withdrawn and passive, but when he
was socializing at his gym he behaved entirely differently—he was out-
going, affable, and funny. In the setting of identity pathology, the indi-
vidual’s subjective experience of others tends to be poorly differentiated
(lacking in subtlety and depth), affectively polarized (“black and
white”), extreme, and/or superficial. Mr. B described his wife as “bor-
ing,” “dowdy,” “nagging,” and “no fun.” His image of her was vague
and one-dimensional, more of a caricature than a complex and realistic
view of another person. When prompted, Mr. B could think of nothing
positive to say about her, though he acknowledged that she “makes a lot
of money.”
Individuals with identity pathology typically lack the capacity to ac-
curately “read” others (Donegan et al. 2003; Wagner and Linehan 1999)
and may be unable to respond tactfully to subtle social cues. Poorly con-
solidated identity is associated with feelings of emptiness and chronic
dysphoria, along with a paucity of meaningful investments in profes-
sional, intellectual, and recreational pursuits. Tastes, opinions, and val-
ues are inconsistent, typically adopted from others in the environment,
and may shift easily and dramatically with changes in milieu. For ex-
ample, Ms. B changed her style of dress, taste in music, and patterns of
speech to suit her latest boyfriend. While most clearly evident in DSM-
IV-TR borderline personality disorder, some degree of identity pathol-
ogy characterizes all severe personality disorders (see Table 1–1).
There are different degrees of identity pathology and different ways
in which identity pathology may become manifest. Borderline person-
ality disorder is in many ways the prototype of the personality disorders
characterized by identity disturbance; both sense of self and sense of
others are polarized, vague, unrealistic, and unstable. Temporal discon-
tinuity tends to be an especially prominent subjective manifestation of
identity pathology in this group. In contrast, in narcissistic personality
disorder, a more stable sense of self, albeit distorted and often fragile,

3 We refer the reader to Westen and Cohen (1993) for empirical support for the
transitory, split, poorly integrated, and “black-and-white” quality of the self-
representation in severe personality pathology described by Kernberg.
20 Psychodynamic Psychotherapy for Personality Disorders

coexists with what is often a dramatically superficial, shadowy, or cari-

cature-like experience of others, even in individuals who are highly in-
telligent and accomplished. Feelings of inauthenticity tend to be an
especially prominent subjective manifestation of identity pathology in
the narcissistic group. In the schizoid personality, in contrast, we see a
capacity to appraise others in the absence of any integrated or stable
sense of self, in conjunction with prominent feelings of emptiness. In
personality disorders falling in the high-level BPO range, identity dis-
turbance can be relatively mild, characterized by a sense of self that is
less unstable than that characteristic of individuals organized at a low
borderline level, along with a better-developed capacity to realistically
experience and sustain relationships with significant others.

Clinical Illustration of Identity Pathology

Ms. B had worked at a series of jobs since graduating from college; none
had been particularly interesting to her and she couldn’t think of any-
thing she wanted to do. She told the consultant when he inquired that,
typically, the men she dated seemed wonderful at first but quickly be-
came controlling and abusive. She described herself as having many
friends, but her descriptions of the people in her life were vague and
general—for example, characterizing someone as “nice,” or “pretty,”
“funny,” or “selfish.” When the consultant asked Ms. B to describe her-
self, she could come up with little to say but did comment that she felt
empty and aimless.

Comments. Ms. B’s poorly developed sense of herself as a person, her

lack of investment in her work, and her feelings of emptiness and aim-
lessness, coupled with the superficial, extreme, poorly differentiated,
and at times unstable nature of her experience of the people in her life,
are emblematic of identity pathology. These features can be evaluated in
the clinical setting by asking the patient to describe himself or herself as
a person and to describe a significant other. Patients with identity pa-
thology generally find it difficult to provide a complex and realistic de-
scription of themselves, and they typically convey a shadowy or
cartoonlike picture of significant others; descriptions of self and other
are most often some combination of vague and superficial on the one
hand and extreme and contradictory on the other. In contrast, individ-
uals with normal identity, like Ms. N and Mr. N, are able to leave the
clinician with a vivid and complex sense of themselves and of their sig-
nificant others.
Object Relations Model of Personality and Personality Pathology 21

Defensive Operations
Defenses are an individual’s automatic psychological responses to stres-
sors or emotional conflict. Different levels of personality pathology are as-
sociated with different dominant defensive operations, and defenses
operate differently in individuals with consolidated identity than in those
whose identity is not consolidated. At the healthiest end of the spectrum,
defenses are flexible and adaptive and involve little or no distortion of in-
ternal or external reality. At the most pathological end of the spectrum,
defenses are highly inflexible and maladaptive, involving increasing de-
grees of distortion of reality (Vaillant 1993). Across the spectrum of per-
sonality pathology, defensive operations protect the individual from
anxiety and pain associated with the expression of conflictual object rela-
tions, but at the same time they introduce maladaptive rigidity and un-
derlying structural pathology into personality functioning.
Kernberg (1976) presents an approach to the classification of defen-
ses that divides them into three groups: 1) mature defenses, 2) repres-
sion-based or “neurotic” defenses, and 3) splitting-based or lower-level
(also referred to as “primitive”) defenses. This classification is in many
ways consistent with current consensus within the research community
(Perry and Bond 2005), while placing greater emphasis on the psycho-
logical mechanisms underlying defensive operations.
Mature defenses4 are the predominant defensive style in the normal
personality and are associated with flexible and adaptive functioning.
Mature defenses do not bar any aspect of a conflict from consciousness,
nor do they maintain a distance between aspects of emotional life that
are in conflict. Rather, mature defenses allow all aspects of an anxiety-
provoking situation into subjective awareness, with little or no distor-
tion, but in a fashion that minimizes psychological distress while opti-
mizing coping (Vaillant 1993).
Repression-based, or neurotic, defenses 5 avoid distress by repress-
ing, or banishing from consciousness, aspects of the subject’s psycho-
logical experience that are conflictual or a potential source of emotional
discomfort. Individuals organized at a neurotic level rely predomi-
nantly on a combination of repression-based and mature defenses
(Kernberg and Caligor 2005). While there are a variety of neurotic

4 Mature defenses include anticipation, suppression, altruism, humor, and sub-

limation.
5 Repression-based, or neurotic, defenses include repression, reaction formation,

neurotic projection, displacement, isolation of affect, and intellectualization.

22 Psychodynamic Psychotherapy for Personality Disorders

defenses that work in different ways, they all involve repression; in the
setting of a relatively well-integrated sense of self, repression-based de-
fenses ensure that conflictual aspects of experience are split off from the
dominant sense of self and remain more or less permanently out of con-
scious awareness. This process protects against awareness of conflictual
experiences of self and other but at the same time introduces rigidity
into personality functioning (e.g., “I never get angry”). Thus, Ms. N is
unaware of having competitive or aggressive motivations, which are
conflictual, but the rigidity introduced by her repressive defenses leaves
her compelled to shy away from confrontation and to have difficulty ap-
propriately asserting herself. Repression-based defenses alter the sub-
ject’s internal reality, but they typically do so without grossly distorting
the subject’s sense of external reality. Although repression-based de-
fenses result in personality rigidity, influence cognitive processes, and
lead to subtle distortions of experience, and may cause discomfort or
distress, they typically do not lead to grossly abnormal or disruptive be-
haviors.
Whereas neurotic defenses make use of repression, the lower-level,
or splitting-based, defenses6 make use of dissociation,7 or splitting, to
avoid psychological conflict and emotional distress. When we use the
terms dissociation and splitting, we refer to a psychological process in
which two aspects of experience that are in conflict are both allowed to
emerge fully into consciousness, but either not at the same time as, or
not in conjunction with, the same object relation (Kernberg 1976). Thus,
splitting-based defenses, in contrast to repression-based defenses, do
not banish mental contents from consciousness per se, but instead com-
partmentalize or maintain at a distance conscious aspects of experience
that are in conflict or whose approximation would generate psycholog-
ical discomfort.
Kernberg (1984) suggests that splitting-based defenses are inti-
mately tied to identity pathology and that splitting is the prototypical
defense seen in patients with severe personality disorders. In patients

6 Splitting-based,or lower-level, defenses include splitting, primitive idealiza-

tion, devaluation, projective identification, omnipotent control, and primitive
denial. (These defenses are sometimes referred to as primitive defenses in the psy-
chodynamic literature.)
7 We distinguish between dissociation as a defensive operation and dissociative

states. Dissociative states involve the defensive operation of dissociation, but

they also involve an altered state of consciousness; dissociation as a defensive
operation does not involve an altered state of consciousness.
Object Relations Model of Personality and Personality Pathology 23

organized at a borderline level, splitting most commonly involves sep-

arating sectors of experience associated with positive affects along with
idealized representations of self and others, on the one hand, from sec-
tors associated with negative affects and devalued or paranoid (also re-
ferred to as persecutory) object relations, on the other. In the setting of
identity pathology, splitting-based defenses are responsible for experi-
ences of others that are polarized (“black or white”), experienced as ei-
ther “all good” (i.e., idealized) or “all bad” (i.e., paranoid or devalued)—
loving, gratifying, and secure, on the one hand, or frustrating, frighten-
ing, or worthless, on the other. These polarized experiences of self and
other are both superficial and unrealistic—for example, a perfectly grat-
ifying caretaker or an unbearably frustrating caretaker, a perfect protector
or an object who threatens to obliterate the self, an omnipotent self or a fee-
ble self devoid of any power. Because in the setting of identity pathology
these object relations cannot be contextualized in relation to an inte-
grated view of significant others or of the self, these extreme images of
self and other are often concretely experienced, as though “how I expe-
rience it now is all there is, and there is no room to think about alter-
native perspectives; it is not that you are frustrating me now, but rather
that you are a frustrating person.”
Splitting-based defenses in the setting of identity pathology are typ-
ically unstable and may lead to abrupt and rather chaotic shifts between
idealized and persecutory experiences of self and other (Kernberg
1984). In individuals organized at a BPO, splitting-based defenses cause
severe personality rigidity and are responsible for flagrant distortion of
interpersonal reality. In this setting, these defenses typically have be-
havioral manifestations and frequently result in disruptive behaviors.
Individuals falling in the high-borderline range rely on a combina-
tion of repression-based and splitting-based defenses. This defensive
organization is typically characterized by stable functioning in many
domains and relatively well integrated experience much of the time.
However, in the setting of stress or in areas of psychological conflict, the
individual is subject to the abrupt intrusion into consciousness of more
highly affectively charged, “split” internal object relations as they break
through repressive defenses.
Individuals organized at an NPO also make use of splitting and dis-
sociation. However, in contrast to the situation in the severe personality
disorders, we are now seeing the impact of splitting and dissociation on
the psychological experience of an individual who has a consolidated
identity and a relatively well integrated sense of self. In this setting,
splitting and dissociation are less extreme and more stable than in more
severe personality pathology and do not lead to the highly polarized,
24 Psychodynamic Psychotherapy for Personality Disorders

rapidly shifting, and affectively charged experiences of internal and ex-

ternal reality characteristic of the severe personality disorders. Thus, in
individuals organized at a neurotic level, splitting and dissociation are
not typically associated with “primitive” mental states, but rather with
the segregation of aspects of psychological experience that are in con-
flict and with the more or less subtle dissociation of conflictual motiva-
tions from dominant self experience (Caligor et al. 2007).
For example, a young woman with conflicts around sexuality was
extremely emotionally and sexually inhibited with men she became
emotionally involved with. She would occasionally pursue brief affairs
with men toward whom she felt no attachment; in this setting she was
both a passionate and a sexually adventurous lover. Here, while con-
flictual motivations are consciously experienced and enacted, they re-
main at the same time split off from other motivations and aspects of self
experience with which they are in conflict. As in the severe personality
disorders, splitting and dissociation are supported by denial; the indi-
vidual organized at a neurotic level denies the significance of dissoci-
ated aspects of conscious experience that are incompatible with his or
her dominant sense of self. Thus, the young woman in our example
viewed herself as inhibited and not especially interested in sex, denying
the significance of her sexual adventures: “They don’t really mean any-
thing.”

Clinical Illustration of Splitting-Based Defenses in

Severe Personality Pathology
Mr. B was referred for dynamic therapy. He spent the first month of the
treatment apparently working very happily with his therapist while re-
peatedly telling the therapist how brilliant she was and how she was the
one who was finally “solving” his problems. In this setting, Mr. B’s
mood improved and he felt less anxious. About 4 weeks into the treat-
ment, the therapist had to take care of an emergency and, as a result, be-
gan Mr. B’s session five minutes late. As soon as Mr. B entered the
therapist’s office, he began to viciously attack her: the therapist was
heartless and incompetent, and Mr. B had been a fool to be in treatment
with someone who clearly cared nothing about his welfare and was just
using him to make money. The therapist managed to contain her anger
and her impulse to defend herself. Instead, she listened to Mr. B, put her
understanding of Mr. B’s experience into words, and then commented
that she was struck by the contradiction between Mr. B’s current expe-
rience of her, on the one hand, and, on the other hand, the positive atti-
Object Relations Model of Personality and Personality Pathology 25

tude that had characterized their interactions up until this point, and the
certainty Mr. B had expressed in previous sessions that she cared about
him and was helping him. Mr. B responded that he remembered those
sessions, but they were irrelevant now; he now saw the therapist for
who she truly was, and that was the only thing that mattered.

Comments. Mr. B’s unstable, widely polarized, superficial, and unre-

alistic views of his therapist are typical manifestations of splitting, in
which “all-good,” idealized views of significant others temporarily
ward off awareness of “all-bad,” paranoid and hateful object relations.
Initially, Mr. B enacts an idealized relationship with the therapist. When
the therapist keeps Mr. B waiting, we see his view of her, and of himself
in relation to her, undergo a dramatic shift, and highly negatively
charged, paranoid object relations flood Mr. B’s experience. Note that
both the idealized and the paranoid images of the therapeutic are con-
sciously experienced, though at different times. This vignette also illus-
trates how splitting is supported by denial; when the therapist calls
Mr. B’s attention to the rapid shift in his view of her, Mr. B denies the
emotional significance of his earlier, idealized view of their relationship.
This enables Mr. B to continue to separate the idealized and paranoid as-
pects of his experience.

Reality Testing
Sustained loss of perceptual reality testing is not a feature of personality
disorders. However, transient loss of reality testing can be seen in some
of the more severe personality disorders, especially in highly stressful or
affectively charged settings or in the context of alcohol or substance
abuse. When a patient presents with frank loss of reality testing, the
evaluation and treatment of psychosis becomes the highest priority, and
the issue of personality pathology is deferred until psychotic symptoms
resolve.
If we turn from reality testing proper to what we refer to as social re-
ality testing, we see that individuals organized at a BPO frequently
present with deficits in this area. Social reality testing is responsible for
the ability to read social cues, understand social conventions, and re-
spond tactfully in interpersonal settings, all of which are characteristic
of the normal personality and are also seen in the NPO. Deficits in social
reality testing can lead individuals who are organized at a borderline
level to behave inappropriately in social settings, typically without be-
ing aware of doing so, and misinterpretation of social cues may lead to
transient feelings of paranoia or fears of being abandoned.
26 Psychodynamic Psychotherapy for Personality Disorders

Clinical Examples of Deficits in Social Reality Testing

In social settings, Mr. B often got into heated political arguments, during
which his behavior was inappropriately aggressive for the setting.
Ms. B. was routinely late for work, and she often arrived inappropri-
ately dressed, in a fashion that was either excessively casual or exces-
sively revealing.

Comments. Mr. B was unaware of the inappropriateness of his behav-

ior and of the discomfort he elicited in others, both common manifesta-
tions of deficits in social reality testing. Ms. B demonstrated a lack of
appreciation of social conventions; she did not understand the impor-
tance of arriving on time to work (she felt it “didn’t really matter”), and
she did not have an appreciation of what is and what is not suitable
work attire.

Quality of Object Relations

Quality of object relations refers to the individual’s understanding of the
nature of relationships and to his or her capacity to establish and sustain
mutual and intimate attachments. In the normal personality, we see the
capacity to appreciate and care about the needs of the other, indepen-
dent of the needs of the self, and the ability to maintain mutually depen-
dent relationships based on an understanding of give and take. The
NPO is also associated with the capacity for mutual dependency and
concern, but often with a failure to fully integrate intimate and mutually
dependent relations with sexuality. Thus, Ms. N has deep and mature
relationships with her friends, but she is unable to sustain a relationship
of this kind in the setting of sexual intimacy.
In contrast, the BPO is characterized by pathology of object relations.
In low-level BPO, pathology of object relations is severe, and we see the
predominance of a need-fulfilling understanding of interpersonal rela-
tions. By this we mean it is assumed that all relations are organized on a
quid pro quo basis—that is, “If I do something for you, I expect to re-
ceive something in return,” and a particular relationship is valued pre-
cisely to the degree that it meets the needs of the subject. Pathology of
quality of object relations is most extreme in the antisocial personality,
for whom all human interactions are based on usage and exploitation of
others. Individuals organized at a high level of borderline personality
organization are distinguished from the low borderline group by virtue
of their demonstration of at least some capacity for mutual dependency
and for maintaining relationships that transcend a self-serving orienta-
Object Relations Model of Personality and Personality Pathology 27

tion. Pathology of object relations that is severe relative to overall level

of functioning is characteristic of narcissistic pathology.

Clinical Example of Pathology of Object Relations

Mr. B explained to the consultant that even though he no longer had any
positive or sexual feelings for his wife, he stayed with her because she
had the means to support him financially; he avoided close friendships
because he didn’t want anyone to feel he “owed” them anything.

Comments. Mr. B’s relationship with his wife is frankly exploitative.

His concerns about the dangers of friendship illustrate a quid pro quo
view of relationships; there is no comfortable sense of give and take, but
only giving in order to get back. In contrast, though not a social person,
Mr. N was deeply attached to his wife and children, and he went to great
lengths to ensure that they were well taken care of.

Moral Values
The normal personality is associated with a commitment to values and
ideals and a “moral compass” that is consistent, flexible, and fully inte-
grated into the sense of self. In the NPO also, we see commitment to val-
ues and ideals and the absence of antisocial behavior, reflecting a fully
integrated and internalized sense of values and ideals. However, moral
rigidity, a tendency to hold the self to unreasonably high standards—
to be excessively self-critical or to anguish over the temptation to stray—
is a common feature of personality disorders organized at a neurotic
level. In contrast, the BPO is characterized by a variable degree of pa-
thology in moral functioning. At one end of the spectrum, we find a rel-
atively well developed but rigid and excessively severe level of moral
functioning characterized by severe anxiety and subjective distress, in
the form either of self-criticism or of anticipated criticism from others, in
relation to not adhering to internal standards. At the other end of the
spectrum, we see the absence of any internal moral compass and a lack
of capacity for guilt, characteristic of patients organized at a low border-
line level, and in particular those with antisocial personality disorder or
severe narcissistic pathology.

Clinical Example of Pathology in Moral Functioning

Mr. B prided himself on having extremely high ethical standards, and he
was contemptuous of those who “bend the rules.” At the same time, he
routinely lied to both his wife and his therapist about using prostitutes.
He experienced no discomfort in relation to lying to them, never giving
28 Psychodynamic Psychotherapy for Personality Disorders

his behavior a second thought. When his therapist brought Mr. B’s lying
to his attention, Mr. B denied the significance of his behavior and ratio-
nalized that he did it to “smooth things out.”

Comments. It is common for individuals organized at a borderline

level to demonstrate excessively harsh moral standards that may com-
fortably coexist with glaring “lacunae” in moral functioning. Splitting
and denial underlie the capacity to maintain frankly contradictory atti-
tudes toward moral functioning.

DYNAMIC FEATURES OF PERSONALITY DISORDERS AND

THE DEGREE OF INTEGRATION OF MOTIVATIONAL SYSTEMS
In the object relations model, psychological conflicts are seen to be or-
ganized around “conflictual motivations”—that is, motivations whose
direct expression would be threatening or painful to the individual.
Kernberg (Kernberg and Caligor 2005) suggests that an important dis-
tinction between the neurotic and borderline levels of personality orga-
nization is the degree of integration and accessibility to consciousness of
conflictual motivations, and he focuses in particular on the role of ag-
gressive motivations in psychological functioning in the personality
disorders. When motivations are well integrated, they are associated
with affects that are relatively complex and well modulated, lending
subtlety and depth to affective experience. In contrast, poorly integrated
motivations are associated with affects that are intense, extreme, shal-
low, and poorly modulated.
In the normal personality and the NPO, the motivational systems
that color conscious experience are relatively well integrated; conflict-
ual motivations that are more poorly integrated are for the most part re-
pressed. In the low-level BPO, in contrast, psychological functioning is
dominated by the impact of poorly integrated, aggressive, and destruc-
tive motivational systems. Further, the predominance of splitting-based
defenses means that highly charged object relations associated with
poorly integrated aggression are not repressed, but are fully accessible
to consciousness; when splitting and idealization fail, aggressively col-
ored internal object relations flood subjective experience with over-
whelming negative affect states. For example, consider the quality of the
hatred and paranoia Mr. B experienced in relation to his therapist when
he was no longer able to idealize her. Contrast this with the quality of
hostility we would expect of Mr. N were he to become angry. In the high-
level BPO the quality of aggression is intermediate between that seen in
the NPO and in the low-level BPO. The combination of repressive and
Object Relations Model of Personality and Personality Pathology 29

splitting-based defenses characteristic of the high-level BPO means that

much of the time, more highly charged, less well integrated aggressive
motivations and associated object relations are repressed. However, in
areas of conflict or in times of stress, more poorly integrated, paranoid
internal object relations can abruptly emerge into consciousness.
In the NPO, psychological conflicts commonly involve the expres-
sion of sexual, dependent, competitively aggressive, and sadistic moti-
vations. For example, if we were to put Ms. N’s conflicts around the
expression of aggression into words, they might sound like this: “If I
were to express hostile or competitive feelings toward people I care
about, it would make me a bad or unlovable person. In the face of this
conflict, I automatically defend against recognizing hostile feelings by
repressing or projecting them. As a result, I do not consciously experi-
ence myself as hostile or competitive.” Subjectively, we see a dominant
sense of self that is relatively complex and realistic but that has been
stripped of aggression.
In the BPO, conflicts are typically organized somewhat differently.
As has been already described, Kernberg (1984) suggests that the central
dynamic feature of the low-level BPO is the predominance of poorly
integrated aggression in the setting of splitting-based defenses. The
dominant anxiety associated with the low-level BPO is that poorly inte-
grated forms of aggression, associated with powerful negative affect
states and paranoid object relations, will overwhelm positive sectors of
experience. In this setting, to protect positive object relations, positive
and negative feelings toward the same person must be kept apart. This
is accomplished by splitting-based defenses, which segregate idealized
object relations from negative, aggressively infiltrated object relations.
As a result of this process, positively colored object relations are pro-
tected, but at the expense of interfering with processes of psychological
integration that would lead in the long term to a tempering of aggres-
sion by the simultaneous experience of positive object relations and af-
fect states, and to identity consolidation. In this setting, the tendency to
project “all-bad” object relations often leads to intense paranoia, over-
whelming anxiety and fear, and an inability to assume responsibility for
one’s affect states or one’s actions, which typically feel justified on the
basis of perceived (often misperceived) provocation. 8 For example,

8 There is empirical support for the predominance of malevolent representations

of relationships in individuals with borderline personality disorder (see Bell et

al. 1998; Nigg et al. 1992; Westen et al. 1990).
30 Psychodynamic Psychotherapy for Personality Disorders

when Mr. B’s therapist frustrated him by starting late, Mr. B felt fully
justified in attacking and devaluing her.
Where paranoid concerns are preeminent in the low-level BPO, in
individuals organized at a high-level BPO anxieties typically have more
to do with fears of closeness and dependency, and paranoid concerns
are secondary. Here, in the setting of a combination of repression-based
and splitting-based defenses, we typically see condensation of conflicts
in relation to dependency, sexuality, and self-esteem maintenance,
along with conflicts around aggression. In less conflictual areas of func-
tioning, repressive defenses are generally able to manage anxiety and to
protect the individual from the emergence into consciousness of poorly
integrated motivational states. However, in settings that activate core
conflicts or stimulate significant anxiety (often, depending on the indi-
vidual, these settings involve dependent relations, sexual intimacy,
competitive struggles in relation to authority and power, and/or ex-
treme threats to self-esteem), repressive defenses may fail, at times lead-
ing to episodes of intensely felt rage, hatred, and paranoia that seem
discontinuous with the individual’s overall level of psychological func-
tioning. For example, Ms. B was often able to maintain stable and mu-
tual relations with her friends; with her boyfriends, she would also do
well for a time. But as she became more dependent she also became
more brittle and volatile; if she felt that her boyfriend was not taking
care of her as she would like, she could hatefully turn on him in an in-
stant. In this setting, activation of core conflicts around dependency
overwhelmed otherwise stable repressive defenses.

Implications for Treatment

Evaluation of level of personality organization will guide differential
treatment planning and enable the clinician to anticipate problems that
may arise in treatment, along with the nature of transference and coun-
tertransference reactions likely to emerge. Personality pathology falling
in the NPO range has an excellent prognosis, and the neurotic-level per-
sonality disorders typically do well in conventional psychodynamic
psychotherapies. In the clinical setting, patients with consolidated iden-
tity typically demonstrate the ability to commit to and invest in a long-
term treatment; a fairly well-developed capacity for self-observation
and self-reflection; a capacity to establish and maintain a therapeutic re-
lationship with relative ease; an appreciation of the symbolic nature of
thought; and adequate impulse control (Caligor et al. 2007). In psycho-
therapy, transferences generally develop slowly and evolve gradually
over the course of treatment, and they are realistic, relatively subtle, and
Object Relations Model of Personality and Personality Pathology 31

associated with well-modulated affect states; the individual organized

at a neurotic level is typically able to maintain a view of his or her ther-
apist that remains anchored in the realistic aspects of the doctor-patient
relationship despite transference distortions that may arise. Clinicians
generally find individuals falling in the NPO group to be gratifying to
work with and relatively easy to understand and to empathize with.
Countertransference reactions tend to be mild, chronic, and specific to
the therapist’s and patient’s conflicts. (See McWilliams 1994, in our rec-
ommended readings, for a description of transference-countertransfer-
ence paradigms characteristic of the different personality disorders.)
In contrast, personality pathology in the BPO range has a more vari-
able prognosis. Patients organized at a borderline level generally do
poorly in unmodified dynamic therapies; they fare better in modified
psychodynamic treatments that provide structure, limit setting, atten-
tion to the role of splitting in the patient’s difficulties, and careful man-
agement of the patient’s relationship with the therapist. In the clinical
setting, low-level borderline pathology is associated with a high rate of
treatment dropout; an impaired capacity for self-reflection; difficulty
maintaining a therapeutic alliance; a tendency for concrete thinking
with the possibility of transient compromise of reality testing; and a ten-
dency for destructive and self-destructive acting out (Clarkin et al.
2006). The transference and countertransference reactions that char-
acterize treatment of patients organized at a low BPO level reflect the
impact of splitting-based defenses, and in particular of projective
identification, on the clinical situation. Transferences develop quickly
and often chaotically, and they are highly affectively charged, extreme,
polarized, unrealistic, unstable, and often paranoid; the concrete quality
of these transferences easily compromises the patient’s capacity to
maintain a realistic sense of the doctor-patient relationship (Caligor et
al. 2009). Countertransference reactions tend also to be highly affec-
tively charged, as well as confusing, uncomfortable, and difficult to con-
tain, associated with powerful pressures on the therapist to turn to
action. Clinicians generally find individuals organized at a low BPO
level to be challenging and emotionally taxing patients, and maintain-
ing empathy with patients in this group can be difficult.
In contrast to the low-level BPO group, patients organized at a high
borderline level have a relatively favorable prognosis in modified psy-
chodynamic therapies. These patients may present with complaints that
superficially resemble those of patients organized at an NPO. However,
as treatment progresses, we often see the emergence of milder versions
of the kinds of problems that characterize the treatments of patients
with more severe identity pathology; in particular, at times of high affect
32 Psychodynamic Psychotherapy for Personality Disorders

activation, we often see a tendency toward concrete thinking and com-

promise of the patient’s capacity to self-reflect, especially in relation to
emotionally charged interactions with the therapist. Anticipation of
these difficulties, in conjunction with attention to splitting-based de-
fenses, can prevent an unexpected crisis in treatment. Countertransfer-
ence reactions tend to be less overwhelming and confusing than those
experienced with patients in the low-level BPO group but are neverthe-
less more affectively charged and more likely to lead to action than are
the countertransferences typically encountered in treatments of patients
falling in the neurotic range.
The object relations theory model of personality disorders not only
guides treatment planning but also leads naturally to specific ap-
proaches to treatment. Our group has developed long-term, twice-
weekly psychodynamic psychotherapies for personality disorders on
this basis. Transference-focused psychotherapy (TFP), described in this
book (see Chapter 7, “Transference-Focused Psychotherapy and Border-
line Personality Disorder”), is organized around the clinical needs of pa-
tients with a BPO. Also described in this volume is a modified version of
TFP for treatment of patients with narcissistic pathology (Chapter 9,
“Narcissistic Personality Disorder”). Dynamic psychotherapy for
higher-level personality pathology (Caligor et al. 2007) targets the diffi-
culties characteristic of individuals organized at a neurotic level, along
with those at the interface between neurotic and high BPO levels of or-
ganization, while making use of the psychological assets associated
with higher-level personality pathology.
For patients organized at a borderline level, who present with clini-
cally significant identity pathology, treatment is organized around pro-
moting the integration of dissociated, idealized and paranoid, internal
object relations, with the goal of establishing a more coherent, stable,
better-differentiated, and complex experience of self and others (Kern-
berg and Caligor 2005). For patients organized at a neurotic level, who
present with personality rigidity in the setting of normal identity for-
mation, treatment is organized around promoting the integration of
repressed or dissociated internal object relations into an already
consolidated, stable, and relatively complex sense of self, with the goal
of reducing personality rigidity (Caligor et al. 2007). Across all levels of
severity of personality pathology, psychotherapy is organized around
exploration of the patient’s internal object relations as they are played
out in current interpersonal relationships, including the relationship
with the therapist. Therapeutic inquiry focuses on the here and now,
attending closely to the patient’s current life situation and to his or her
immediate and affectively dominant experience in the treatment hour.
Object Relations Model of Personality and Personality Pathology 33

Key Clinical Concepts

◆ Object relations theory grew out of clinical observation and
practice and has led to the development of psychodynamic
treatments for personality disorders.
◆ The object relations theory model of personality disorders
attends to descriptive, structural, and dynamic aspects of
personality disorders.
◆ Structural assessment focuses on identity, defenses, reality
testing, object relations, and moral functioning.
◆ Assessment of descriptive and structural features of person-
ality disorders enables the clinician to characterize severity of
personality pathology and will guide treatment planning.
◆ The object relations theory model of personality disorders is
compatible with many recent developments in personality
disorder research.

Suggested Readings
Akhtar S: Broken Structures: Severe Personality Disorders and Their Treatment.
Northvale, NJ, Jason Aronson, 1992
Caligor E, Kernberg OF, Clarkin JF: Handbook of Dynamic Psychotherapy for
Higher Level Personality Pathology. Washington, DC, American Psychiat-
ric Publishing, 2007
Clarkin JF, Yeomans FE, Kernberg OF: Psychotherapy for Borderline Personal-
ity: Focusing on Object Relations. Washington, DC, American Psychiatric
Publishing, 2006
McWilliams N: Psychoanalytic Diagnosis. New York, Guilford, 1994
PDM Task Force: Psychodynamic Diagnostic Manual: Personality Patterns and
Disorders. Silver Spring, MD, Alliance of Psychoanalytic Organizations,
2006
The Structured Interview for Personality Organization (STIPO). The STIPO is a
semistructured interview based on the clinical structural interview de-
scribed in this chapter. The STIPO is available on the Web site http://
www.borderlinedisorders.com.
Symphoratapes: Master Clinicians at Work. A video presentation of Dr. Otto
Kernberg conducting a diagnostic interview focusing on structural features
of personality can be seen on a DVD that is part of this series produced by
Drs. Henk-Jan Dalewijk and Bert van Luyn. This DVD set also includes
interviews of the same patient by Marsha Linehan, Michael Stone, Larry
Rockland, Solomon Aktar, and Lorna Benjamin. The set of DVDs creates a
teaching tool for demonstrating clinical interviewing skills and illustrating
34 Psychodynamic Psychotherapy for Personality Disorders

different theoretical orientations for understanding severe personality dis-

orders. Information about ordering this set of DVDs can be obtained at
http://www.bpdresourcecenter.org.

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