Developmental Levels

of Personality Organization
 HISTORICAL CONTEXT:
DIAGNOSING LEVEL
OF CHARACTER PATHOLOGY
Kraepelinian Diagnosis: Neurosis versus Psychosis
Kraepelinian Diagnosis: Neurosis versus Psychosis
Kraepelinian Diagnosis: Neurosis versus Psychosis
Kraepelinian Diagnosis: Neurosis versus Psychosis
Ego Psychology Diagnosis:
Symptom Neurosis, Neurotic Character, Psychosis
Ego Psychology Diagnosis:
Symptom Neurosis, Neurotic Character, Psychosis
To assess whether they were dealing with a symptom neurosis or a character problem, therapists
were trained to pursue the following kinds of information when interviewing a person with neurotic
complaints:
1. Is there an identifiable precipitant of the difficulty, or has it existed to some degree as long as the
patient can remember?
2. Has there been a dramatic increase in the patient’s anxiety, especially pertaining to the neurotic
symptoms, or has there been only an incremental worsening of the person’s overall state of feeling?
3. Is the patient self-referred, or did others (relatives, friends, the legal system) send him or her for
treatment?
4. Are the person’s symptoms ego alien (seen by him or her as problematic and irrational) or are they
ego syntonic (regarded as the only and obvious way the patient can imagine reacting to current life
circumstances)?
5. Is the person’s capacity to get some perspective on his or her problems (the “observing ego”)
adequate to develop an alliance with the therapist against the problematic symptom, or does the
patient seem to regard the interviewer as either a potential attacker or a magic rescuer?
Ego Psychology Diagnosis:
Symptom Neurosis, Neurotic Character, Psychosis
• The significance of this distinction lay in its implications for treatment and prognosis
• If it was a symptom neurosis that the client suffered, then one suspected that
• something in the person’s current life had activated an unconscious conflict
• the patient was now using maladaptive mechanisms to cope with it—methods that may
have been the best available solution in childhood but that were now creating more
problems than they were solving
• The therapist’s task would be to determine the conflict, help the patient understand and
process the emotions connected to it, and develop new resolutions of it.
• The prognosis was favorable, and treatment might be relatively short
• One could expect a climate of mutuality during therapy, in which strong transference (and
countertransference) reactions might appear, but usually in the context of an even stronger
degree of cooperation.
Ego Psychology Diagnosis:
Symptom Neurosis, Neurotic Character, Psychosis
• If the patient’s difficulties amounted to a character neurosis or personality problem
• the therapeutic task would be more complicated, demanding, and time consuming
• the prognosis more guarded
Ego Psychology Diagnosis:
Symptom Neurosis, Neurotic Character, Psychosis
• In working with someone whose character was fundamentally neurotic, one could not take
for granted an immediate “working alliance” (Greenson, 1967).
• Instead, one would have to create the conditions under which it could develop.
• The working or therapeutic alliance refers to the collaborative dimension of the work
between therapist and client, the cooperation that endures in spite of the strong and often
negative emotions that may surface during treatment.
• Empirically, a solid working alliance is associated with good outcome (Safran & Muran, 2000),
and its establishment (or restoration after a rupture) takes precedence over other aims.
• With some patients, this process of building an alliance can take more than a year.
Object Relations Diagnosis: The Delineation
of Borderline Conditions
• By the middle 1950s, the mental health community had followed these innovators in noting the
limitations of the neurosis-versus-psychosis model
• Numerous analysts began complaining about clients who seemed character disordered, but in a
chaotic way
• Because they rarely or never reported hallucinations or delusions, they could not be considered
psychotic, but they also lacked the consistency of neurotic-level patients, and they seemed to be
miserable on a much grander and less comprehensible scale than neurotics.
• In treatment, they could become temporarily psychotic
• In 1953, Knight published a thoughtful essay about “borderline states”
• Kernberg (1975, 1976), Masterson (1976), and M. H. Stone (1980, 1986) - the concept of a
borderline level of personality organization attained widespread acceptance in the
psychoanalytic community
Object Relations Diagnosis: The Delineation
of Borderline Conditions
• Kernberg (1984) - differentiate between “borderline personality organization” (BPO) and the
DSM’s “borderline personality disorder” (BPD)

• The concept of “borderline” as a level of psychological functioning

• viewed as a stable instability on the border between the neurotic and psychotic ranges
• characterized by lack of identity integration
• reliance on primitive defenses without overall loss of reality testing
Object Relations Diagnosis: The Delineation
of Borderline Conditions
• People in a psychotic state seemed fixated at an unindividuated level in which they could not
differentiate between what was inside and what was outside themselves

• People in a borderline condition were construed as fixated in dyadic struggles between total
enmeshment, which they feared would obliterate their identity, and total isolation, which
they equated with traumatic abandonment

• People with neurotic difficulties were understood as having accomplished separation and
individuation but as having run into conflicts between, for example, things they wished for
and things they feared, the prototype for which was the oedipal drama
Object Relations Diagnosis: The Delineation
of Borderline Conditions
The etiology of borderline psychopathology
• developmental failures, especially in the separation–individuation phase
• parent–child interaction at an earlier phase of infantile development
• poor boundaries between members in dysfunctional family systems
• the infantile attachment styles
• traumatic experiences - especially incest; later experiences of sexual abuse
OVERVIEW OF THE
NEUROTIC–BORDERLINE–PSYCHOTIC SPECTRUM
• favored defenses
• level of identity integration
• adequacy of reality testing
• capacity to observe one’s pathology
• nature of one’s primary conflict
• transference and countertransference
Characteristics of Neurotic-Level Personality Structure
• The more mature or second-order defenses
• Primitive defenses are not nearly so prominent in their overall functioning and are evident
mostly in times of unusual stress

➢ While the presence of primitive defenses does not rule out the diagnosis of neurotic level
of character structure, the absence of mature defenses does

❑ The use of repression - basic defense

Characteristics of Neurotic-Level Personality Structure

• A somewhat integrated sense of identity (Erikson, 1968)

• Their behavior shows some consistency, and their inner experience is of continuity of self through
time
• When asked to describe themselves
• they are not at a loss for words
• nor do they respond one-dimensionally
• they can usually delineate their overall temperament, values, tastes, habits, convictions,
virtues, and shortcomings with a sense of their long-range stability

➢ They feel a sense of continuity with the child they used to be and can project themselves into the
future as well
➢ When asked to describe important others, such as their parents or lovers, their characterizations
tend to be multifaceted and appreciative of the complex yet coherent set of qualities that
constitutes anyone’s personality
Characteristics of Neurotic-Level Personality Structure

• Neurotic-level people are ordinarily in solid touch with “reality”

• They are strangers to hallucinatory or delusional misinterpretations of experience (except under
conditions of chemical or organic influence, or posttraumatic flashback)
• They also strike the interviewer or therapist as having comparatively little need to
misunderstand things in order to assimilate them.
• Patient and therapist live subjectively in more or less the same world

• Some portion of what has brought a neurotic patient for help is seen by him or her as odd
• much of the psychopathology of neurotically organized people is ego alien or capable of
being addressed
Characteristics of Neurotic-Level Personality Structure

• People in the neurotic range show early in therapy a capacity for called the “therapeutic split”
between the observing and the experiencing parts of the self

• For example, a paranoid man who is organized neurotically will be willing to consider the
possibility that his suspicions derive from an internal disposition to emphasize the destructive
intent of others

• Paranoid patients at the borderline or psychotic level will put intense pressure on the therapist
to join their conviction that their difficulties are external in origin; for example, to agree that
others may be out to get them
• Without such validation, they worry that they are not safe with the therapist
Characteristics of Neurotic-Level Personality Structure

• Their histories and their behavior in the interview situation give evidence that neurotic-level
people have more or less successfully traversed Erikson’s first two stages, basic trust and
basic autonomy, and that they have made at least some progress toward identity integration
and a sense of initiative.

• They tend to seek therapy because they keep running into conflicts between what they want
and obstacles to attaining it that they suspect are of their own making

➢ Freud’s contention that the proper goal of therapy is the removal of inhibitions against love
and work applies to this group; some neurotic-level people are also looking to expand their
capacity for solitude and play
Characteristics of Psychotic-Level Personality Structure

• People are much more internally desperate and disorganized

• Interviewing a deeply disturbed patient can range from being a participant in a pleasant, low-
key discussion to being the recipient of a homicidal attack
Characteristics of Psychotic-Level Personality Structure

• It is not difficult to diagnose patients who are in an overt state of psychosis: they express
hallucinations, delusions, and ideas of reference, and their thinking strikes the listener as
illogical
• There are many people walking around, however, whose basic psychotic-level internal
confusion does not surface conspicuously unless they are under considerable stress

➢ Devoted therapists do significant prevention -- Preempting psychotic breaks, preventing

suicides and homicides, and keeping people out of hospitals
Characteristics of Psychotic-Level Personality Structure

• The defenses they tend to use

• withdrawal, denial, omnipotent control, primitive idealization and devaluation, primitive
forms of projection and introjection, splitting, extreme dissociation, acting out, and
somatization

• These processes are preverbal and prerational

• Even the frightening distortions that the defenses themselves may create are a lesser evil
than that state of terror
Characteristics of Psychotic-Level Personality Structure
• Difficulties with identity—so much so that they may not be fully sure that they exist, much
less whether their existence is satisfying

• They are deeply confused about who they are, and they usually struggle with such basic
issues of self-definition as body concept, age, gender, and sexual orientation

• “How do I know who I am?” or “How do I know that I exist?”

• They cannot depend on a sense of continuity of identity in themselves and do not experience
others as having continuity of self either:
• They live in fear of “malevolent transformations” (Sullivan, 1953) that will turn a trusted
person abruptly into a sadistic persecutor
• When asked to describe themselves or other important people in their lives, they tend to
be vague, tangential, concrete, or observably distorting
Characteristics of Psychotic-Level Personality Structure

• One feels that a patient with an essentially psychotic personality is not anchored in reality
• Although most of us have vestiges of magical beliefs, careful investigation will reveal that such
attitudes are not ego alien to psychotic-level individuals
• They are often confused by and estranged from the assumptions about “reality” that are
conventional within their culture
• Although they may be preternaturally attuned to the underlying affect in any situation, they
often do not know how to interpret its meaning and may assign highly self-referential
significance to it
❑“Evil people are going to kill me because they hate my lifestyle”
❑“I feel guilty about some aspects of my life.”
Characteristics of Psychotic-Level Personality Structure

• People with psychotic tendencies have trouble getting perspective on their psychological problems
• They lack the “reflective functioning” (Fonagy and Target, 1996)
• Those whose mental health history has given them enough jargon to sound like good self-
observers
e.g., “I know I tend to overreact” or even “My schizophrenia interferes with my judgment”
may reveal to a sensitive interviewer that in an effort to reduce anxiety they are compliantly
parroting what they have been told about themselves
Characteristics of Psychotic-Level Personality Structure

• Early psychoanalytic formulations about the difficulties that psychotic people have in getting
perspective on their realistic troubles stressed energic aspects of their dilemma; that is, they
were expending so much energy fighting off existential terror that none was left to use in
the service of coping with reality
• Ego psychology models emphasized the psychotic person’s lack of internal differentiation
between id, ego, and superego, and between observing and experiencing aspects of the ego
• Students of psychosis influenced by interpersonal, object relations, and self psychology
theories (e.g., Atwood, Orange, & Stolorow, 2002) have referred to boundary confusion
between inside and outside experience, and to deficits in attachment that make it
subjectively too dangerous for the psychotic person to enter the same assumptive world as
the interviewer.
Characteristics of Psychotic-Level Personality Structure

• The nature of the primary conflict in people with a potential for psychosis is literally
existential: life versus death, existence versus obliteration, safety versus terror.
• Their dreams are full of stark images of death and destruction
• “To be or not to be” is their recurrent theme
• Psychoanalytically influenced studies of the families of schizophrenic people in the 1950s and
1960s consistently reported patterns of emotional communication in which the psychotic
child received subtle messages to the effect that he or she was not a separate person but an
extension of someone else
Characteristics of Psychotic-Level Personality Structure

• Despite their unusual and even frightening aspects, patients in the psychotic range may
induce a positive countertransference
• One may feel more subjective omnipotence, parental protectiveness, and deep soul-level
empathy toward psychotic people than toward neurotic ones
• Psychotic people are so desperate for respect and hope that they may be deferential and
grateful to any therapist who does more than classify and medicate them.
• Their gratitude is naturally touching
Characteristics of Borderline Personality Organization

• The use of primitive defenses

• Because they rely on such archaic and global operations as denial, projective identification,
and splitting, when they are regressed they can be hard to distinguish from psychotic patients
• An important difference between borderline and psychotic people, though, is that when a
therapist confronts a borderline patient on using a primitive mode of experiencing, the
patient will show at least a temporary responsiveness
• When the therapist makes a similar comment to a psychotically organized person, he or she
will likely become further agitated
Characteristics of Borderline Personality Organization

• T: “You certainly love to cherish all my defects. Maybe that protects you from admitting that
you might need my help. Perhaps you would be feeling ‘one down’ or ashamed if you weren’t
always putting me down, and you’re trying to avoid that feeling.”
• A borderline patient might scorn such an interpretation, or grudgingly admit it, or receive it
silently, but in any event, he or she would give some indications of reduced anxiety
• A psychotic person would react with increased anxiety, since to someone in existential terror,
devaluation of the power of the therapist may be the only psychological means by which he
or she feels protected from obliteration. The therapist’s discussing it as if it were optional
would be extremely frightening
Characteristics of Borderline Personality Organization

• Their experience of self is likely to be full of inconsistency and discontinuity.

• When asked to describe their personalities, they may, like psychotic-level patients, be at a
loss.
• And when asked to describe important people in their lives, they may respond with anything
but three-dimensional, evocative descriptions of recognizable human beings.
• “My mother? She’s just a regular mother, I guess” is a typical response.
• They often give global, dismissive descriptions such as “An alcoholic. That’s all.”

• Fonagy (2000) writes that borderline clients are insecurely attached and lack the “reflective
function” that finds meaning in their own behavior and that of others. They cannot
“mentalize”; that is, they cannot appreciate the separate subjectivities of other people. In
philosophical terms, they lack a theory of mind.
Characteristics of Borderline Personality Organization

• Clients in the borderline range may become hostile when confronted with the limited
continuity of their identity.
➢ “I am the kind of person who ____________.”
➢ “How can anybody know what to do with this shit?”
• Borderline patients have trouble with affect tolerance and regulation, and quickly go to
anger in situations where others might feel shame or envy or sadness or some other more
nuanced affect.
Characteristics of Borderline Personality Organization

• In two ways, the relation of borderline patients to their own identity is different from that of
psychotic people.
➢ First, the sense of inconsistency and discontinuity that people with borderline organization
suffer lacks the degree of existential terror of the schizophrenic.
• Borderline patients may have identity confusion, but they know they exist.
➢ Second, people with psychotic tendencies are much less likely than borderline patients to
react with hostility to questions about identity of self and others.
• They are too worried about losing their sense of ongoing being, consistent or not, to resent
the interviewer’s focus on that problem.
Characteristics of Borderline Personality Organization

• It used to be standard psychiatric practice to assess the degree of the patient’s “insight into
illness” in order to discriminate between psychotic and nonpsychotic states
• A borderline patient may relentlessly deny psychopathology yet still show a level of discrimination
about what is real or conventional that distinguishes him or her from a psychotic peer
• Kernberg (1975) proposed that “adequacy of reality testing” be substituted for that criterion
Characteristics of Borderline Personality Organization

• The capacity of someone at the borderline level to observe his or her own pathology is quite
limited
• People with borderline psychologies come to therapy for complaints such as panic attacks or
depression or illnesses that a physician has insisted are related to “stress,” or they arrive at
the therapist’s office at the urging of an acquaintance or family member, but they rarely come
with the agenda of changing their personalities in directions that outsiders readily see as
advantageous.
Characteristics of Borderline Personality Organization

• In nonregressed states, because their reality testing is fine and because they may present
themselves in ways that compel our empathy, they do not look particularly “sick”

• Sometimes it is only after therapy has proceeded for a while that one realizes that a given
patient has a borderline structure
Characteristics of Borderline Personality Organization

Masterson (1976) has vividly depicted, and others with different viewpoints report similar
observations, how borderline clients seem caught in a dilemma:
• When they feel close to another person, they panic because they fear engulfment and total
control; when they are alone, they feel traumatically abandoned
• This central conflict of their emotional experience results in their going back and forth in
relationships, including the therapy relationship, in which neither closeness nor distance is
comfortable
• Living with such a basic conflict, one that does not respond immediately to interpretive
efforts, is exhausting for borderline patients, their friends, their families, and their therapists.
• They are famous among emergency psychiatric service workers, at whose door they
frequently appear talking suicide, for manifesting “help seeking–help rejecting behavior”
Characteristics of Borderline Personality Organization

• Masterson saw borderline patients as fixated at the rapprochement subphase of the

separation–individuation process (Mahler, 1972b), when the child has attained some
autonomy yet still needs reassurance that a caregiver remains available and powerful.

• Masterson (1976) believed that borderline patients have had mothers who discouraged them
from separating in the first place or neglected them when they needed to regress after
attaining some independence.
Characteristics of Borderline Personality Organization

• Transferences in borderline clients tend to be strong, unambivalent, and resistant to ordinary

kinds of intervention.
• The therapist may be perceived as all good or all bad.
• If a well-intentioned but clinically naive therapist tries to interpret transference as one would
with a neurotic person (e.g., “Perhaps what you’re feeling toward me is something you felt
toward your father”), he or she will find that no relief or helpful sense of insight follows; in
fact, often the client will simply agree that the therapist is actually behaving like the earlier
object.
• Also, it is not uncommon for a borderline person in one state of mind to perceive the
therapist as godlike in power and virtue, and in another (which may appear a day later) as
weak and contemptible.
Characteristics of Borderline Personality Organization

• Not surprisingly, countertransference reactions with borderline clients tend to be strong and
upsetting.
• Even when positive (e.g., dominated by fantasies of rescuing the devastated patient), they may
have a disturbing, consuming quality.

• Analysts in hospital settings (Gabbard, 1986; Kernberg, 1981) have noted that with some
borderline patients, staff tend to be either oversolicitous (seeing them as deprived, weak, and in
need of extra love to grow) or punitive (seeing them as demanding, manipulative, and in need of
limits)

• Outpatient practitioners may move internally between one position and the other, mirroring each
side of the client’s conflict at different times. It is not unusual for the therapist to feel like the
exasperated mother of a 2-year-old who will not accept help yet collapses in frustration without it.