mcwilliams_psychoanalytic_diagnosis.pdf

 Psychoanalytic Diagnosis Understanding Personality Structure in the Clinical Process 1 second edition 1 Nancy McWilliams ~ THE GUILFORD PRESS New York London PSYCHOANALYTIC DIAGNOSIS © 2011 The Guilford Prcss A Di...

 Psychoanalytic Diagnosis Understanding Personality Structure in the Clinical Process 1 second edition 1 Nancy McWilliams ~ THE GUILFORD PRESS New York London PSYCHOANALYTIC DIAGNOSIS © 2011 The Guilford Prcss A Division of Guilford Publications, Inc. 72 Spring Street, Ncw York, NY 10012 www.guilford.com All rights rcscrved No part of rhis book may be reproduced, translared, srored in a rettieval s)'&tem, or rransrnirted, in o.ny form or by any means, clectronic, mcchankal, phorocopying, mitroli.lming, rccording, or otherwise, without wriucn permission from the Publishcr. Printcd in the United 51:1.tes of Ametica This book i~ princed on acid·frcc p:ipcr. Last digit is print number: 9 8 7 6 S 4 3 2 1 Library of Congress Ca1aloging-in-Publication Data McWilliams, Nam;y. Psychoanalytíc diagnosis : undcrs1anding personality structurc in thc clinical proccss I Nam;y McWilliams. - 2nd cd. p.;cm. lndudcs bihliographical reforences and index. ISBN 978-1-60918-494-0 {hardcover: alk. papcr) l. Typology (Psychology} 2. Personality asscssment. 3. l'ersonality developmenr. 1. 1itlc. [DNLM: 1. Personaltty Disorders-diagnosis. 2. Personality Asscssm~nr. 3. Pcrsonality Disorders-thcrapy. 4. Ps,ychoanalytk Therapy. WM 460.S.P3) RC489.T95M38 2011 616.89'l7-dc22 2011002833 " In grateful memory Howard Gordon Riley Millicent Wood Riley Jane Ayers Riley  About the Author Nancy McWilliams, PhD, reaches in che Graduate School of Applied and Professional Psychology at Rutgers, The State University of New Jersey, and has a privare practice in Flemingron, New Jersey. She is a formcr prcsident of thc Division of Psychoanalysís {39) of the American Psychological Association and is on the editorial board of Psychoana· lytic Psychology. Dr. McWilliams's books have bccn translatcd into 14 languages, and she has lectured widcly both natíonally md íntermuíon- ally. She is a rccipient of honors including the Ro:.alee Weíss Award for contributions to practice from the Division of Indcpendcnt Practitíoners of the American Psychological Association; Honorary Membership in the American Psychoanalytic Association; and the Robert S. Wallerstein Visiring Scholar Lectureship in Psychotherapy and Psychoanalysis at the University of California, San Francisco. A graduatc of the Nacional Psychological Association far Psychoanalysis, Dr. McWílliams is also affiliated with the Center for Psychoanalysis and Psycbotherapy of New jersey and the National Training Program of the Narional lnstiture for the Psychotherapies in New York City. vil  Preface When 1 originally wrote Psychoanal1 lic Diagnosis, I knew from my expe.riencc as a reacher that studems and early-career psycho- therapists needed exposure to thc inferenrial, dimensional, contextual, biopsychosocial kind of diagnosis that had preceded the era inauguratcd by the 1980 publicarion of the third cdition of the Diagnostic and Statis- tical Manual of Mental Disorders (DSM-III) of the American Psychiat- ric Association. In particular, I wamed to keep alive the sensibility rhar represented decades of clinical cxperience and conversation, in which human beings ha.ve been seen as complex wholes rather than as collec· tions of i;omorbid symptoms. 1 also saw how i;onfusing it was, even to psychodynamically oriemcd students, to try to master the bewildi?áng diversity of language, metaphor, and theoretical emphasis that compriscs the psychoanalytic tradition. The need for a synthcsis of the sprawling and contentious history of analytic theory, as it pcrtains to understand- ing one's individual patients, was evídent. In the early 1990s 1 was also nourishíng a faint hope that the book would have sorne influence on mental heahh policy and on our culcur- ally shared conception of psychotherapy, which WC(!! beginning to be transformed in disturbing ways. No such luck: The breadth and depth of change since rhcn have been stunning. For a host of interacting reasons, psychodynamic-and even broadly humanistic (see Ca.in, 2010)-ways of understanding and treating pcople havc beconie devalued, and the líkelíhood that a patient with significant character pathology, the hall- mark of mase psycl\odynamic treatment, will find genuine, lastiog help in the mental beakb system has, in my view, plummeted. As the cognitive- behavioral movement continues to develop, sorne of irs practitioners have 111 x. Pfeface becomc as upset with these developmcnts as analytic therapists have been; my CBT-oricnted colleague Milton Spccc recel}tly complaincd (e-mail communicalion, May 28, :WlO), in reaction to this trend,.. We treat patients, noI disorders." Political and economic forces account for much of this change (see Mayes & Horwitz, 2005, for the polirical history of the paradigm shift in the arca of mental illness "from broad, etiologically deñned entities that wcre concinuous with normaliry to symptom·hased, c:acegorical dis· cases" (p. 249)). At least in che United Statcs, corporate interests-most notably those ofinsuranc:e companies and the pharmaceutical industry- have swcepingly reshaped and thus tedefined psychotherapy in line wirh their aíms! maxiroized profits. In the sccvice of short-term cost control, there has bcen a revcrsal of decadcs-long progress in heJping indíviduals with complex personality problerns-not because we lack skill in hclping chem, but because insurers, having marketed their managed-care p[ans to employers with the claim that they would provide "comprehcnsi~e" mental hcalth covcrage, latcr dedined arbirrarily to cover Axis 11 condi- tions. Meanwhile, drug companies have a substantial stake in c:onstruing psycholog\cal problems as discrete, reified illnesses so that they can mar- ket medications that treat each condition. Consequently, the emphasis is no longer on the deep healíng of pervasive personal struggles, but on the drcumsc:ribed efforr to change behaviors that incerfece with sm has lost its catastrophic ovec- tones and can frequently be heacd meaning "discomfon" or "injury." "Depression" has come to be indistinguishable from brief periods of the blues (Horowiu: & Wakefield, 2007). The term..p:mic disorder" had to be invcnted in arder to restore to our ear thc connotations of the older, perfectly useful phr:lses "anxiety neurosis" :tnd "anxiety attack" once the word "anxiety" had been applied to everything from how one feels ar a business lunch to how one would feel in front of a firíng squad. Given all this, I have strugglcd over how co present sorne of the material in this book. On a personal level, I try to observe thc current preforences of groups as to how thcy should be identified and to rcspcct the sensibiliries of pat.ients who object ro certain diagnostic /abels. Where currcnt DSM termínology has become the norm for discussíng a parcku- lar phenomenon, I use it unless it obscures older, rícher concepts. But· at a scholarly level, it secms an exercise in futility to continue to rename things racher than to use their existing na mes. Substituting "self-defeat· ing" for "rnasochistic" or "histrionic" for "hysterical" may be preferred by chose who want to avoid terms that cantain psychodynamic assump- tions, but such changes make less sense for those of us who think ana· lytically and assume the operation of unconscious processcs in character formation. My somewhat ambivalenc conclusion about che language to be used in this book has been to employ mostly traditional psychoanalytic nomendature, alternatingoccasionally, in the hope of reducing rhedank- ing weight of professional jargon, with more recent, roughly cquivalent terms. Sínce I a m trying to raise the consciousness of my nudience about che rarionale for each label that has come to denote a character attribute, I will generally rely on familiar psychoanalytí1; language and try to make ir user·friendly. To che reader without a psychodynamic background, this may lend an anachronistic oc even ínferred judgment:il tone to the text, but I can only p.sk such a person to try to suspend criticism tempo· rarily and give che analytic tradition the hendir of the doubt while trying to consi'der the possible utílity of the c,oncepts covered. 4 lntrodudlon A COMMENT ON TONE Nearly everything one can say about individual character patn:rns and meanings, even in thc comext of accepting a general psychoanalytic approach, is disputable. Many conccpts central to analyric thinking have not only not been systematically researched and validated, they are inherendy so resistant to being openuionalized and manipulated that it is difficult to imagine how they even could be empírically tested (see Fisher & Greenberg, 1985). Many scholars prefer ro place psychoanal- ysis within the hermeneutic rather than the scientific tradition, partly becausc of this resistance of much of the subícct manee ro investigation by tbe scientific method as it has come to be defined by many contempo· rary academic psychologists. I havc creed in the direction of oversimplifying rathcr rhan obfuscat- ing, of stating sorne ideas in a more swceping way than many thoughtful professionals would consider warranted. This text is aimed at begínning practirioners 1 a nd I ha ve no wish ro increase tht anxiety that inevírably suffuses che process of becoming a therapist by inrrodudng endless com- plexity. In this second edition, however, in light of recent cQm;ern in che field about essentialism and absolutistic pronouncemenc, J have rried to tame any tendencies toward universalizing. All of us learn soon cnough, from the unpredictable nuances of each thcrapy relationship into which we extend ourselves, how paleare evcn our most eleganr and satisfying formulations next ro the mystery that is human narure. Hence, 1 nust and encourage my readers to outgrow my constructions.  Part 1 CONCEPTUALISSUES INTRODUCTION TO PART 1 The following six c:hapters contain a rationalc for character diagnosis, a review of sorne major psychoanalyric theories and their respective con- trihutions to models of personality strucmrc, an exploracion of individ- ual diffcrences that have bcen widely undcrstood as ernbodying differem maturational challenges, commenrary on the therapeuric implications of such issues, and an exposition of dcfenses as they relace to character ~tructure. Together thcse chapten provide a way of lhinking about che consistencies in an individual that we think of as his or her personalicy. This section culminates in the representation of diagnostü: possi- bilicieli along a biaxial grid. Although this schcma, like any atrempt to generalize, is both arbitrary and oversimplified, 1 have found it useful in introducing 1herapists to central dynamic formulations and their clini- cal value. 1 believc that chis way of construing personali1y is implicit in mu likc anything clsc, be uscd as a dcfense ago.inst anxiery abouc thc unknown. Finally, 1 should mention that people exist for whom the existing developmental and typological categories of personalicy are at best a poor fit. When any label obscures more than it illuminates, the prac- titioner is better off discarding it and relying on common sense and human decency, like the lose sailor who throws away a useless naviga- tiona I chart and reverts to orienting by a few familiar stars. And even when a diagnosdc formulation is a good match to a particular patient, there are such wide disparities among people on dímensions other than their leve! of organization and defensive style that empathy and healing may be best pursued via attunement to sorne of these. A deeply religious pcrson of any personality rype will need Ji.rst for the rherapíst to dem- onstrate respect for bis or her depth of conviction (sec Lovínger, 1984)¡ díagnosis-influenced interventions may be of value, but only sec1mdarily. Similarly, it is sometimes more important, at least in the ear{y phascs of therapeutic engagement, to consider rhe emotionaI imp!ications of some- one's age, race, ethnicity, dass background, physical disability, political actitudes, or sexual oricntation than it is to appreciace that client's per- sonality type. Diagnosis should not be applicd bcyond its usdulness. Ongoing willíngness to reassess one's inicial diagnosis in rhc light of new informa- tíon ís part of bcing optimally therapeutic. As treacment proceeds with any individual human bcing, tbe oversimplification inherent in our diag- nosric concepcs becomes startlingly clear. People are much more com- plex than even our most thoughtful categories admít. Hcnce, even the most sophisticaced personality assessmem can become an obstacle to the therapist's perceiving critica! nuances of the patient's unique material. SUGGESTIONS FOR FURTHER READING My favorite book on interviewing, mostly becausc of its tone, remains Harry Stack Sullivan's The Psychiatric lnterview (1954). Anotl1er classic work that is ful! of uscful background and wise tcchnkal rccommenda- tíons is The Initial lrzterview in Psycbiatric Practice by Gill, Ncwman, and Rcdlich (1954). 1 was gready íntluenccd by the work of MacKinnon and Michcls (1971), whose basic premises are similar to che oncs inform- ing chis tcxt. They finally issued, with Buckley, a revised edition of their dassic tome in 2006 (now available in paperback). In Psychodynamic Psychiatry in CUn,ical Practice, Glen Gabbard (2005) has masterfully integrated dynamic and structural diagnosis with the DSM. For a weJl- writcen synthesis of empírkaJ work on personality, applied to the arca 20 COKCEPTUALISSUES of clínica! pracrice, I recommend Jefferson Singer's Personality and Psy- chotherapy (2005). Kernberg's Severe Personality Disorders (1984) cÓntains a short but comprehensive section on the structural interview. Most beginning. therapists find Kernberg hard to read, but his wriring here is pellucid. My own book on case formulation (McWilliams, 1999) complements this volume by systematically considering aspects of clinical assessment other than level and type of personality otganization, and my later book on psychotherapy (McWilliams, 2004) reviews the sensibifüies that underlie psychoanalytic approaches to helping people. Mary Beth Peebles-Kleiger's Beginnings (2002), similarly based on long clinical experience, is excellent. So is Tracy Eells's (2007) more research-based text on formulation. For an empírica! measure of inner capacitics of the whole person that therapists need to evaluare, consider the Shcdler- Westen Assessment Procedure (SWAP) (Shedler &: Westen, 2010; Wes- ten & Shedler, 1999a, 1999b). Finally, the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) fills in many gaps left by chis book.  2 Psychoanalytic Character Diagnosis Ciassi~al psychoanalytic theory approached personality in two different ways, cach dcriving from an early model of individual development. In the era of Freud's original drive rheory, an artempt was made to understand pcrsonality on the basís of fixatíon (At what carly maturarional phase is this person psychologically stuck?). Later, with the development of ego psychology, characrer was conceived as express- ing the operation of particular styfes of defense (\Vhat are this person's rypical ways of avoiding anxiety?J. This second way of understanding character was not in conflict with the lirst; it provided a different set of ideas and metaphors for comprehending what was mcant by a type of personallty, and it added to thc concepts of drive theory cerra in assump- tions about how we each develop our characteristic adaptive and defcn· sive patterns. These two explanacory sets are the basic elemems of my own visual- izacion of characrer possibilicies. 1 try to show also how relational mod- els in psychoanalysis (British object rclations theory, American inter- personal psychoanalysis, self psychology, and contemporary relational ideas) can illuminate aspects of charactcr organization. In addidon, my understanding of personality has been cnriched by less clinically influ- ential psychodynamic formulacions such as jung's (1954) archetypes, Henry Murray's "personology" (e.g., 1938), Silvan Tomkins's (1995)..script theory," control-mastery rheory (e.g., Silberschatz, 2005), and recent empirical work, espccially attachment research and cognitive and affcccive ncurosdem:c. 21 22 CONCEPTUAL JSSUES Readers may note that I am applying ta che diagnostic enterprise several differenc paradigms within psychoanalysís that can be sccn as mumally exclusive or essentially contradictory. Because this book is inrcnded for rherapists, and because I am cemperamentally more of a synrhesizer than a criric or distinction maker (I share chis sensibilicy with other clinical writers such as Fred Pine [1985, 19901 and Lawrcncc Josephs ), I have avoided arguing for the scientific or heuristic superiority of any one paradigm. I am not minimizing thc valuc of criti- cally evaluating competing theories. My dccision not to do so derives from the specifically dinical purposc of this book and from my obser- vation that most therapists scck to assimilate a diversity of models and metaphors, whether or not they are conceptually problemaric in sorne way. Every new devclopment in clinical thcory offers practitioncrs a fresh way of trying to communicatc to troubled people thcir wish to understand and hclp. Effective therapists-and I am assuming rhar effective therapists and brilliant theorists are overlapping but not identi· cal samples-seem to me more ofcen to draw freely from many sources chan to become ideologically wedded to onc or two favored thcoríes and techniques. Sorne analysts adhcre to dogma, but this stance has not cntichcd our clinical thcory, nor has ir contributcd to che esceem in which our field is held by those who value humility and who appreciate ambiguity and cornplexity (d. Goldberg, 1990a). Different cliems have a way of making different models relevant: One pcrson stimulatcs in thc therapist reflections on Kernberg's ideas; another sounds Jikc a personality described by Horney; still another has an unconsciou's fantasy Jifo so classically Freudian that thc rherapist starts to wonder if the patient boned up on early drive theory befare emcring treatment. Smlorow and Atwood (1979; Atwood & Stolorow, 1993) havc shcd light on the emocional processes underlying cheocies of personality by studyíng how che central themes in thc theorisr's life become the issues of focus in that pcrson's theorics of pcrsonality forma- tion, psychopathology, and psychothcrapy. Thus, it is noc surprisíng chat wc have so many alternative conccptíons. And cven if sorne af chcm are logically at odds, 1 would argue that they are not phenomenologically so; they may apply differentially to diffcrent individuals.a nd diffcrenc cha ractcr types. Having stated my own biases and predilections, I. now offer a brief, highly oversimplified summary oí diagnostically salient models within the psychoanalytic tradirion. l hope they will givc therapists wirh minimal exposure to psychoanalytic theory a basis for compre- hending the caregories that are second nature for anaJyrkally trained therapists.  Psychoanalytlc Character Diagnosis 23 CLASSICAL FREUDIAN ORIVE THEORY ANO ITS DEVELOPMENTAL TILT Freud's original theory of personality development was a biologically dedvcd model that scressed the centrality of instinccual processes and construed human beings as passing through an orderly progression of bodily preoccupations from oral to anal to phallic and genital concerns. Freud thcorizcd that in infancy and early childhood, the person's natu- ral disposirions concern basic survival issues, which are cxperienced ar firsr in a dceply sensual way via nursing and rhe morhcr's other accivities wich che infant's body and later in the child's fantasy life about birch and death and che sexual tie between his or her parents. Rabies, :md rherefore che infantile aspects of self that live on in adults, werc seen as uninhibited seekers of instinctual gratification, with some individual differenc:es in the strength of the drives. Apprupriate caregiving was construed as oscillating sensitively between, un thc onc hand. sufficient grarification to crea.te emutional securicy and pleasure and, on che other, developmentally appropriate frustration such that the child would leam in titrated doses how to replacc ch-e plea:;ure principie ("I want ali my gratificacions, including mutually contradictory ones, right now!") with the reality princíple ("Sorne gratifications are prob· lematic, and thc bese are worth waiting for"). Freud calked lictle abouc thc specific contributions of bis patients' parcnts to their psychopathol- ogy. But when he did, he saw parental faílure5 as ínvoJvíng either exc:es- sive gratification of drives, such that norhíng had ímpelled the child ta move on developmentally, or excessive deprívatíon of them, such that the child's capacity to absorb frustrating realities was overwhelmed. Parent- ing was chus a balancing act bctwcen indulgence and inhibition-an intuitiveJy resonant model for most mothers and fathers, to be sure. Orive theory postulated that if a child is either overfrustrated or overgratified at an early psychosexual stage (as per rhe interaction of the child's constitucional endowment and the parents' responsiveness), he or she would become "fixared» on the issucs of that srage. Character was seen as expressing the long-term effects of rhís fixarion; If an adult man had a depressive personaliry, it was theoríz;ed that he had been either neglected or overindulged in bis first year and a hall or so (the oral phase of development); if he was obscssíonal, ir was inferred that there had been problcms bctwcen roughly llh and 3 (the anal phase); if he was hysrerical, he had mct either rejection or overstimulating seductiveness, or both, between about 3 and 6, whcn the child's interest has turned to the genitals and sex.uality (the "phallic" phase, in Freud's male-oriented language, the latcr pare of which carne to be known as the "oedipal" phase because the 5exual competition issues and associated fantasies 24 COHCEPTUALISSUES characteristic of that srage parallel the themes in the ancient Greek story of Oedipus). It was nor uncornmon in the early days of t,he psychoana- lytic movemcnt to hear someone refcrred to as having an oral. anal, or phallic character. Lcst this oversimplified account sound endrely fanciful, I should note that the theory did not spring full-blown from Freud's fevered imaginatíon; there was an accretion of observations that inlluenced and supported it, collected not only by Freud but also by bis colleagues. In Wilhelm Reich's Character Analysis (1933), the drive theory approach to personality diagnosis reached its zenith. Although Reich's language sounds archaic to contemporary ears, tbe book is ful! of fascinating insigbts about character types, and its observations may still suike a chord in sympathetic readers. Ultimately, the effort to construe charac- tcr entirely on the basis of instinctual fixation proved disappointing; no analyst I know currently relies on a drive-based fixation model. Still, the field retains the developmental sensibility that the Freudian construcc set inmotion. One echo of the original drive model is the continuing tendency of psychodynami has a lar of  Developmental Ltvtls of Personallty Organlzatlon 45 intuitive appeal and couelates to sorne degree with t-ype of personalíty (dcpressivc people at any lcvcl of health or pathology tend to manifcsr oralíty; che preoccupations of compulsive peoplc a.re notoriously anal- see Chaprer 13-whecher or not their compulsivity causes them major problems). Yet there is substancial clinical commencary (e.g., Volkan, 1995) and incrcasing empirical research (e.g., Fonagy, Gergely, Jµrisc, & Tar- get, 2002; L. Silverman, Lachmann, &. Milich, 1982), supporting a cor- relatíon between, on the one hand, one's leve! of ego development and self-other diffecentiation, and, on che ocher, the heahh or pathology of one's persona.lity. To a certain extenc this correlation is definitional alld therefore tautological; rhat is, assessing primitive levels oí ego devclop· mene and objccr relations is like saying an intcrvicwee is.. sick," whereas seeing someone as obsessíve or schizoid is noc necessarily assigning pathology. But this way of conccpcualizing psychological wellness ver- sus discurbance according to catcgories from ego psychology and the later relational theories has profound clinical implica¡ions across differ- ent character types. A bríef hístory of psychoanalytic attempts to make diagnostic distinccions bctween people based on the extent or "depth" of their difficulties rather than their type of personaliry follows. HISTORICAL CONTEXT: OIAGNOSING LEVEL OF CHARACTER PATHOLOGY Befare the advent of descripcive psychiatry in che 19th century, certain forros of mental disturbance that occurred with any frequency in whar was considered the. '\;ivilized world" were recognized, and most observ· ers presumably made distinctíons between the sane and the insane, much as my nonpsychological friend dísringuishcs between "nuts" and "not nuts." Sane pcople agreed more or less about what constitu~es rc:ality; insane people deviaced from this consensus. Men and women with hysterical conditíons (which includcd what today would be diagnosed as posttraumatic problems), phobias, ohses- sions, compulsions, and nonpsychotic manic and depressíve symptoms were understood 10 have psychological difficu lties that fall short of com· plete insanity. Peoplc:: with hallucinations, dclusiom~, and thought disor· ders were rcgarded as insane. People we would roday call antisocial were diagnosed with "moral insaniry" {Prichard, 1835) but were i;:onsidercd menrally in touch with realicy. This rather crude taxonomy su.rvives in the catcgorfos of our legal system, which puts emphasis on whcrher the person accused of a crime was able to assess rcality at the time of its tommission. 46 COKCEPTUALlSSUES Kraepellnlan Diagnosis: Neurosis versus Psychosls Emil Kraepelin (1856-1926) is usually cired as thc fathcr of contempo- rary diagnostic classification. Kraepelin observed mental patients care- fully, wich thc aim of identifying general syndromes that share common characterinics. In addition, he developed rheories about the eciologics of those condífions, ar lcast ro the exrent of rcgarding rheir origins as eichcr cxogenous and treacable or cndogcnous and incurable (Krncpclin, 1913). (Inrerestíngly, he put scvcrc bipolar illncss ["manic-depressivc psycho- sis"] il'l the former category and schizophrenia ["demcntia praecox"- believed to be an organic deterioracion of the brain] in rhe lam:r.) The "lunatic" began to be understood as a person afflicted with ene of sev- era[ possible documenced illnesses. Freud wcnt beyond description and simple levels of deduction into more infcrential formulations¡ bis dcveloping theory posíted complex epigenetic explanations as preferable to Kraepclin's basic:: internal-exter- nal versio11s of causality. Still, Freud tended to view psychopathology by thc Kracpelinilln categorics then available. He would describe a man troubled by obsessions (e.g., his patient the "Wolf Man" [Freud, 1918; Gardiner, 1971]), as having an obsessive-compulsive neurosis. By che end of his carccr, Frcud bcgan to discriminate between an obsessional neurosis in an orherwise nonobsessive person andan obsession that was part of an obsessive-compulsivc character. But ir was Jacer analysts (c.g., Eisslcr, 1953; Horner, 1990) who made che distincrions that are thc sub- ject of this chapter, among (1) thc obsessivc person who is virtually dclu- sional, who uses ruminative thoughts to ward off psychotic decompensa- tion; (2) thc person whosc obscssing is part of a bordedine personality struccure (as in the uWol( Man"); and {3) the obsessive person with a neurotic-to-normal pcrsonality organization. Befare the catcgory of.. borderline" emerged in the middle of the 20th cencury, anaJytically influenced thcrapists followed Freud in dif- ferentiating only between neurotic and psychotic levels of pathology, the former being distinguishcd b)' a general appreciarion cif realíty and the lattcr by a loss of contact with ic. A neurotic woman knew at some level that her problem was in her own head; che psychotic one bdicvcd it was the world that was out of kilter. When Freud developed thc strucrural model ofche mind, this distinction took on the quality of a comment on a pcrson's psychological infrastructure; Neurocic people were viewed as sufforing becausc their ego defenses were too automatic and inflexible, ClJttíng them off from id energics that could be put to creative use; psychotic enes suffered bccause their ego defenses were too weak, leaving them helplessly overwhelmed by primidve material from the id.  Developmental Levels of Personallty Organlzatlon 47 The neurotic·vcrsus-psychotic disrinctíon had important clinical implications. Thc gist of these, considered ín light of Freud's structural model, was that rherapy with a neurotic person should involve weakening the defenses and gettíng access ca the id so chat its energies may be released for more constructive activicy. In connast, therapy with a psychotic person should aim at strengtheníng defenscs, covering over primitive preoccupa- tions, influencing realistically srressful circumstanccs so thar they are less upscccing, encouraging reality resting, and pushlng the bubbling id back into unconsciousness. It was as if the neurotic penon wete like a pot on che stove with che lid on too tight, making the therapi$t's job to !et sorne steam escape, while the psychotic pot was boiling over, necessitating that the therapist get the lid back on and turn down the heat. lt became common for supervisors to recommend that with health- ier patients, one should attack che defenses, whereas with people suffer- ing from schizophrenia and othcr psychoses, onc should supporr them. Wirh che advcnt of antipsychotic drugs, chis formulation lent itself to a widespread tendency not only ro medicate-often the compassionate response co psychotic levels of anxiety-but also to assume that medica- tion would do the covering over and would be needed on a lifetirne basis. Therapists were advised not to do any "uncovering" with a pOtentially psychotic person: That míght disturb the fragile defcnses and send the clíent over the edgc again. This way of conceptualizing degree of pathol- ogy is not withour usefulness; it has opened the door to che development of different therapcutic approaches for difforent kinds of difficulties. But it falls short of a comprehensive and dinically nuanced ideal. Any the· ory oversimplifies, but this neurotic-versus-psychocic division, even with Freud's elegant strui;tural underpinnings and theír therapeutic impliQl· tions, offered only a start ata useful inferencia! diagnosis. Ego Psycbology Diagnosis: Sy111ptom Neurosis, NeurotJc Character, Psychosls In thc psychoanalytic community, in addition to a distim;:tion bccween neurosis and psychosis, diffccenciations of extent of maladaptation, not simply type of psychopathology, gradually began to appear within che neurotic category. The firsr dini¡;alJy important one was Wilhelm Rcich's (1933) discrimínation betwcen "symptom neuroses" and "char- acter neuroses." Therapists were learning that it was useful to distin- guish betwecn a person with a discrere neurosis and one with a character permeated by neurotic panerns. This distinction lives on in che DSM, in which conditions Iab.eled "disorder" tend to be chose that analysts have called neuroses, and conditions labeled ªpersonality disorder" resemble the old analyríc concept of neurotic character. 48 CONCEPTUALISSUES To assess whether they were dealing with a symptom neurosis or a characrer problem, therapists were trained to pursue the following kinds of ínformation when interviewing a person wirh neurotic' complaints: 1. Is rhcre an idencifiable precipitant of che difficulty, or has ir existcd to sorne degree as long as the paticnc can remember? 2. Has there been a dramatic increasc in the patient's anxiety, espe- cially perraíning to thc neurotic symptoms, or has thcre becn only an iacremental worsening of the person's ovcrall state of íeelíng? 3. Is the patient self·referrcd, or did others (relatives, fríends, the legal system} send him or he1 for creatment? 4. Are the person's symptoms ego alien (scen by him or her as prob· Jematic and irrational) or are they ego syntonic (regarded as the only and obvious way the patient can imagine reacring to cur· rent life circumstances)? 5. Is the person's capacity to gct sorne perspective on his or her problems (the "observing ego") adequate to develop an alliance wirh the therapist against the problematic symptom. or does the patient seem to regard the interviewer as either a potential attacker or a magic rescuer? Thc former alternative in eac:h of thr: above possibilities was pre· sumptive evidence of a symptom problem, thc latter of a character probJem (Nunbetg, 1955). The signific:anc:e of this distinctíon lay in its implications for treatment and prognosis. lf it was a symptom neurosis that rhe dient suffered (equivalent to "Axis I disorder wirhout comorbid personality disorder"), then one suspected rhat somcthing in the person's c:urrent life had activated an unconscious conflict and that thc: patient was now using maladaptive mechanisms to cope with it-merbods that may have been the best available solution in childhood bue that werc now creadng more problems than they were solving. The rherapist's task would be to determine the co11flicc, help the patient understand and pro· cess the emorions connected to it, and develop new resolutions of it. The prognosis was favorable, and treatment might be relatively short (cf. Menninger, 1963). One could e.xpcct a climatc of mutualicy during therapy, in which strong transfcrence (and countcrtransfercnce) reac- tions might appear, but usually in the context cf an even srronger degree of cooperation. If the patient.ls difficulties amounted ro a characrer neurosis or per· sonality problem, then thc therapeutic task would be more c:omplicated, dcmandíng, and time consuming, and the prognosis more guarded. This is only common sense, of course, in that trying to foster personality  Devtlopmental Levels of PerSonallty Organlrat!on 49 change obviously poses more challenges. chan helping sorneone get rid of a maladaptive response to a specific stress. But analytic theory went beyond common sense in specifying ways in which work on a person's basic characler would díffer from work with a symptom not embedded in pers~nality.. First, one couJd not take for granted that what the pacient wanted (immediate relief from suffering) and what the therapísr saw as neces- sary for the pacien~·s c;:ventual recovery and resistance ro future difficul- ties (modification of personality) could be seen by the patient as compat- ible. In insrances when the patient's aims and the analyst's conception of what was ultimately needed were ar variance1 the analyst's educative role became cridcal. One had to start by trying to convey to rhe patient how the therapist saw che problem; that is, "making ego alien what has been ego syntonic." For example, a 30·ycar-old accountant once carne to me looking to "achieve more balance" in his life. Raised to be the hope of his family, wirh a missíon ro compensate for his fathcr's failcd ambitions, he was hardworking ro the point of drivenness. He leared chat he was missing precious ycars with his young childrcn, whom he might enjoy if only he could stop pushing hirnself relentlessly to produce at work. He wanted me to develop a..program" with him in which he agreed to spend a certain amount of time per day exercising, a cenain amount playing wirh his kids, a certain amount. working on a hobby, and so forth. The proposcd program included designared space for voluntccr work, wacching television, cooking, doing housework, and making love to bis wife. In the meeting that followed our initial interview, he broughc in a sample schedule detailing such changes. He felt thac if l could get him to put this program inco effect, his problems would be solved. My first task was co try to suggest that thís solution was part of the problem: He approachcd therapy wírh the same drivcnness he was complaining about and pursucd. the serenity he knew he needed as if it were another job to do. 1 told him he was very good at doing, bue he evidently had had litcle experienc;e with just being. While he grasped this notion intel· lectually, he had no emationally salient memory of a less compulsive approach to life, and he regarded me with a mixture of hope and skepci- cism. Although simply telling his scory had provided somc short-term relief of his depression, 1 saw him as having to get used to the fact that to avoid this kind of misery in rhe future, he would nccd to bring into conscious awareness and to rethink sorne of the major assurnptions that had goveroed his life. Second, in working wich someone whose character was fundamen- rally ncurotic, one could not take for granted an immcdiate "workíng allianccn (Greenson, 1967). Instead., one would have to i;reate the condi· 50 CONCEPTUALISSUES tions undcr which it could develop. The concept of the working or thcta· peutic allíance refers to the collaborative dimension of thc work between cherapist and client, the cooperation that endures in spite of the strong and often negative emotions that may surface during treatment. Empiri- cally1 a solid working alliance is assodated with good outcome (Safran & Muran, 2000), and its establishment (or restoration after a rupture) takes precedence over orhcr aims. Padents with symprom neuroses íeel on the side of the therapist in opposing a problematic part o{ tht sel f. They rarely require a long period to devclop a shared perspective. In contrast, those whose problc:rns are complexly interwoven wich cheir personality may casily feel alone and under attack. When che therapist raises qucstions about lífelong, ego· syntonic panerns, their wholc identity may feel assaulred. Distrust is inevitable and must be paciencly endurcd by both partics until the thera· pise has earned thc client's confidence. With sorne patients, this process of building an alliance can cake more than a year. Trying too quickly to take on what the therapist sees as obvious pcoblems may damage the alliance and impede che process of change. Third, therapy sessions with someone wich a characcer rather than a sympcom problem could be expected to be less exciting, less sur- pdsing, Jcss dramatic. Whatcver the therapist's and patient's fantasics about unearthing vivid repressed memories or unconscious conflicts, they would have to content themselves with a more prosaic process, che paínstaking unravcling of ali the threads that had created the emotion ll knot that che patient had until now believed was just the way things had ro be, and the slow working out of new ways of thinking and handling feclings. In che development of personality disorders, as opposed to che appearance of neurotic reactions to particular current stresses, there are long patterns of idcmiñcation, leaming, and reinforcemcnt. Whcre the etiology is traumaric, "strain trauma.. (Kris, 1956) is implicated, rather than the "shock trauma" (one unassímilatcd, unmourned injury) cclebrated in Hollywood's eady, enchusiascic portrayals oí psychoana· lytic treacrnent (see, e.g., Hitchcock's Spellboimd). As a conscqucnce; one could expccr chat in the therapy of character neuroses, both par- ties would have to deal with occasional borcdom, impatience, irritabil- iry, and demoralization-the patient by expressíng rhem without foar of criticism and the therapist by mining such feelings for emp~thy wich the patient's struggle with a difficuJt, protracted task. This discinclion betwccn neurotk symptoms and neurotic personal- ity remains important, even in instances where one cannot do the long- terr:n work (e.g., D. Shapiro, 1989) thac character change requi.res. If one u11derstands one's patient's inflexible personality issues, one can often  Developmental Levels of Personality Org;inlzatlon Sl find sorne way of making a shon-rerm impact thac avoids thc person's fecling misundcrsrood or atrackcd. For example, knowing thac a woman has a central psychopathic streak alerts thc therapist that in trying to interfere with some damaging pattcrnt it is better to appeal to her pride than to her assumed concern for others. For a lorig time, the categories of symptom neurosis1 character neu- rosis, and psychosis constituted the main constructs by which we under- stood personaliry differences on the dimension oí severity of disorder. A neurosis was che lcast serious condition, a pcrsonality disorder more serious, and a psychotic disturbance quite grave. These formulations maintained the old distinction becween sane and insane, with the sane category including two possibiHtics: neurotic reactions and neurotically structured personalities. Over time, however, it became apparenr that such an ovcrall scheme Qf classiñcadon was both incomplete and mis· leading. One drawback of this taxonomy is its implication that ali character problems are more pathological than ali neuroses. Onc can stilt discern such an assumption in the DSM, in which the criteria for diagnosing mast personality disorders indude signifi.cant impairmerits in fonction- ing. And yet sorne stress-related neurotic reaccions are more críppling to a person's capadty co cope than, say, sorne hysrerical and obsessional personalíty disorders. A man I know suffers from agoraphobia, ego alíen but severc. He has warm relations with friends, enjoys bis family, and works producrively at home, but he never leaves his house. 1 see bis lile as more consrricted and deadened than that of many people with personal· icy disorders and even psychoSi:s. To complicate the issue scill further, there is also a problem in the other dírection: Sorne character disturbances seem to be mucb more severc and primitive in quality than anythíng rhat could reasonably be callcd "neurotic." One can see thar therc is no way in such a linear, ehree-part classificarion to differentiate between distonions of char- acrer that are mildly incapacitaríng and those that involve fairly dire consequences. A problem can be charactcrological and of any lcvel of sevcricy. The line between benign personality.. traits" or styles" and 14 mild personality "disordcrs" is quite blurry. On the other cnd of thc continuum, sorne cha racter disorders have been understood for a long time as involving such substa.ntial deformíties of thc ego that they are closer to psychosis than neurosis. Psychopatby and rnalignant forms of narcissistic personality'organh.ation, for example, have long been recog- nized as variants of human individualicy, but uncil fairly recently, they have tended to be cQnsidered as somewhat outsidc the scope of possible therapeutic intervention and not easily placed on a neurotic-character disordered-psychotic continuum. S2 COHCEPTUALISSUES Objed Relatlons Dlagnosls: The Dellneatlon of Borderllne Condltlons Even in the late l 9th century, sorne psychiatrists were identifying patienu who seemed to inhabit a psychological "borderland" (Rosse, 1890) between sanity and insanity. By the middle of the 20th century, othcr ideas about personality organization suggesting a middle ground between neurosis and psychosis began to appear. Adotph Stein {1938) noted that people with qualities he called "bordedine" got worse rather than better in standard psychoanalytic tteatment. Helene Deutsch (1942) proposed the concept of the "as-if personality" for a subgroup of people we would now see as narcissistic or bordedine, and Hoch and Polatin (1949} rnade a case for the category of "pseudoneurotic schizo- phrenia." By the middle 1950s, the menea! health communicy had followed these inrtovators in notíi:ig the limitations of the neurosis-versus-psychosis model. Numerous analysts began complaining about clients who seemed character disordered, but in a peculiarly chaotic way. Because they rareJy ornever reported nallucinations or delusions, they could nor be considered psychotic, bue they also lacked che consistency of neurocic·level patients, and they seemed to be miserable on a much grandcr and less comprehcn· sible scale than ncurotics. In creatmenr. they could bccome ternporarily psychotic-convinced, for cxample, that their therapist was exactly likc thcir mother, yet oucsidc the consulting room there was an odd stabilicy ca their instability. In other words, they were too sane co be considered crazy, and too crazy to be considered sane. Therapists began suggesting new diagnostic labcls that captured the quality of these people who lived on the border berween neurosis and psychosis. In 1953, Knighc published a thoughtful essay about "borderline staces." In the same decade, T. F. Main (1957) was ceferríng to similar pathology in hospítalized patients as "The Ailment." In 1964, Frosch suggested the diagnostic category of "psychotic character."' In 1968, Roy Grinker aod his colleagues (Grinker, Werble, & Drye, 1968) did a seminal study documenting a "borderline syndrome" inher- ing in personality, with a range of severity from che border with the neu- roses to tbe bordee with the psychoses. Gunderson and Singer (e.g., 1975} continued to subject the concept to empirkal scrutiny, and eventually, via both research and clinical findings, and thanks to the elucidation of writ- ers such as Kernberg (1975, 1976), Mascerson (1976), and M. H. Stone (1980, 1986), th5i concept of a borderline leve! of personality organita- tion attained widespread acceptance in the psychoanalytic communíty. By 1~80, the term had been sufficienrly rcsearched to appear in the DSM (DSM-111; American Psychiatdc Associarion, 1980) as a personal-  Developmental Levels ol Personallty Organlzatlon 53 ity disorder. This development has had mixed effects: lt has legitimated a valuable psychoanalytic com:epr but at tbe price of losing ics original meaning as a level of fimctioning. The concept of borderline psychol- ogy rcpresented in the DSM drew heavily on the work of Gunderson (e.g., 1984), who. had studied a group chac most analysts would have diagnosed as having a hysterical or histrionic psychology ac the border- line level. Kernberg (1984), one of the origínators of the concept, began having to differentiate betwccn "borderline personality organizacion" (BPO) and the DSM's "borderline personality disorder'' (BPD). 1 am probably fighting a losing batrle in trying to preserve the origi· na! meaning of the terrn "borderline" (as 1 did, for example, in the Per· sonality section of the Psychody,umiic Diagnostic Man11a/ [PDM Task Force, 2006]), but 1 think a loe has been sacrificed in equating the 1erm wlth a particular character typc. The conccpt of "borderline" as a Ievel of psychological functioning had evolved over decades of clinical experi· ence, coming to be generally viewcd as a stable instability on thc bor- der between rhe neurotic and psychotic ranges, charactcrized by Jade of identity intcgration and reliance on primitive defenses without ovcrall loss of reality testing (Kernberg, 1975). I worry that with the DSM defi- nition having become accepted, we are losing a way of talkíng about, say, obsessional or schizoid people at thc borderlíne level (e.g., the "quict borderline" parient of Sherwood & Cohen, 1994). If a\I our emplrical research on borderline phenomena applies narrowly to thc more self- dramatizing, histrionic version of borderline-lcvcl personality organiza- tion, we are lcfc in thc dark about thc eriology and rceatmenr of other persooality disorders at thc bordcrline levcl. By the sec:ond half of the 20th century, rna11y therapis1s struggling to hclp clients rhat we now see as borderline found themselves drawing inspiration and validaríon from writings of analysts in the British object relations movement and che American interpersonal group, who looked at patients' experienccs with key figures in childhood. Thcse theoriscs emphasized the pa.tient's experience of relationship: Was the person preoccupied with symbiotic issues, separa.tion-individuation themes, or highly individuated comperitive and identificatory molifs? Erikson's {1950} reworking of Freud's three infantile stages in terms of the child's intcrpeuonal task made a significant clínica! impact, in that patients could be conccptualized as fixated at either primary dependency issucs {trust vs. mistrust), secondary separation-individuation issues (auton· omy vs. shame and doubt), or more advanced levels of identification (íni- tiative vs. guilt). Thcse developmcncal-stage concepts made scnse of the differcnces therapists were noticing among psychotic-, borderline-, and neurotíc- lcvcl patients: Pcople in a psychotic state sccm~d fixated at an unindi-  54 CONCEPTUALISSUES viduated leve! in which they could not differentia(e betw~en what was inside :.rnd what was outsidc thcmselves¡ people in a bordedine condi- tion were construed as ñxared in dyadic struggles between total enmcsh- ment, which they foared would obliterate chcir identity, and toral isola- tion, whkh they equated with traumatic abandonmcnt; and people with ncurotic difficulties were understood as having accomplished separation and individuiltion but as having run imo conflicts bctween 1 fot cxample, things they wished for and things they feared, thc prototype for which was the oedipal drama. This way of thinking made sensc of numerous puzzling and demoralízing dinical challenges. It accounted far why one woman with phobias scemed ro be clinging to sanity by a thread, while anothcr was oddly stable in her phobic: instability, and yet a third woman was, despite having a phobia, otherwise a paragon of mental health. By the late 20th century there was, both within the psychoanalytic tradition and outside it, a vast literature on borderline psychopathol- ogy, showing a bcwildering dívergence of conclusíons about.its ctiology. Sorne investigators (1?.g. 1 M. H. Stone, 1977) cmphasized consticudonal and neurologica[ predispositions; sorne (e.g., G. Adler, 1985; Master- son, 1972, 1976) focused on developmental failures, cspecially in the separation-individuation phase described by Mahler (1971); sorne (e.g., Kernberg, 197S) conjecturcd about abcrrant parcnt-chíld interaction at an earlier phase of infantile developmcnt; sorne (e.g., Mandclbaum, 1977; Rinsley, 1982) pointed to poor boundaries becwcen ~embers in dysfunctional family systems¡ and sorne (e.g., McWilliams, 1979; Wes- ten, 1993) madc socíological speculations. Others (e.g.. Meissner, 1984, 1988) were integrativc of ma.ny of these perspcctives. Wíth advam:es in attachment research (e.g., Ainsworth, Blehar, Waters, & Wall, 1978), sorne wrirers began to conjecrurc about the infantile auachment styles that conelated latcr with borderline psychology. By the 1990s, more and more people were writing about how trauma, especially incest, plays a bigger role in rhe development of borderlinc dynamics than had previ· ously bcen suspectcd (e.g., Wolf & Alpert, 1991). Recent empirical studies of borderline personaíity, most of tbem using the DSM definition, havc looked ar all these aspects. Therc is sorne cvidence for constitutional predispositions (Gunderson & Lyons· Ruth, 2008; Siever & Weinstein, 2009); sorne for misattuned parenc- ing around attachment and separation issues (Fonagy, Target, Gergdey, Allen, & Bateman, 2003; Nickell, Waudby, & Trull, 2002); and sorne for the role of trauma, espccially relarional trauma in early attachment ($chore, 2002) bYt also later experiences of sexual abus~ (Herman, 1992). lt is probable that ali these facrors play a tole, thac borderline psyc:hology is not a single entity and ís multidetermined, lik~ most other c:omplex psyc:hological- phenomcna. Current psychoanalytic writing,  Development;il levelul Pemmallty Organlzatlon 55 especially abour bordcrlinc dynamics, has drawn neavily on empirical fiudings in the arcas of infont development, attachmcnt, and trauma. One consequence has been a significant paradigm shift, as unquestioned notions of fixation at a normative developmental phase have bccn chal- lenged by evidence for different experiences of attachment and for che destructive effects of recurrent trauma cven long after the preschool years. Whatcvcr thc etiology of borderline pcrsonality organization, and it probably diffcrs from person co person, clinicians of diverse perspec- cives have attained a surprisingly reliable consensus on the clinical manifcscations of probh:ms in che borderlinc range. Especially when an intcrvicwer is trained in what information, subjective as well as objec- tive, should be observed and pursued, thc diagnosis of bordcrline lcvel of charactcr structurc: may be readily confirmed or disconfümed (e.g., chrough Kernberg's structural interview or the later. more care- fully empirically validated instrumenr of his collcagues, che Structured Incerview for Pcrsonality Organization [STIPO; Stem, Caligor, Roose, & Clarkin, 2004]). Despite the complexity of thc eriologies of borderlínc conditions, I think it can still be useful to view people with a vulnerability to psycho- sis as unconsciously preoccupied with the issues of the eariy symbiocic phas11 (especially trust), peoplc with bordcrline pcrsonality organítation as focuscd on separaticm-individuarion thcmcs, and those with ne'1roric structure as more "oedipal" or capable of experiencing confliccs that foel more interna! to them. The most prevalent kind of anxiety for people in rhe psychmic range is foa.r of annihilation (Hurvich, 2003), evidendy an activation of the brain's FEAR system {Panksepp, 1998) that evolved to procect against predacion; the central anxiety for peopJe in the border- linc range is scparation anxiety or thc activation of Pankscpp's PANIC system that deals wich early attachment needs; anxiety in neurotic peo- ple tends to ínvoive more unconscious conflict, especially fear of enacr- ing guílty wishes. OVERVIEW OF THE NEUROTIC-BORDERLINE-PSYCHOTIC SPECTRUM In the following sections, 1 discuss neurotic, borderline, and psychocic levels of character structure in terms of favored delenses, level of iden- tity integration, adequacy of reality testing, capacity to observe one's pachology, nature of.one's primary conflict, and tranderence and coun- tertransference. 1 focus en how these abstractions mani(est themselves as discernible behaviors and communications in an initial interview or 56 CONCEPTUALISSUES in an ongoing treatment. 1n Chapter 4 1 explore implications of these discriminations for the conduct and prognosis of therapy. Again, l want to emphasize that these levels of organization are somewhat artificial, that wc can all 6.nd in ourselves issues from every leve[, and that viewing one's clicnt as organized ar one or anorher of the levels should nor dis- tract a therapist from the person's individualíty and arcas of strength. CharacterJstlc.s of Neurotlc-Level Personallty Structure It is an irony that the term "neurotic., is now reserved by most ana- lysts for people so emotionally healthy chat they are considered rare and unusually gratifying c\ients. In Freud's time, the word was applíed to most nonorganic, nonschizophrenic, nonpsychopathic, and non- manic-depressive patienrs-that is, to a large class of individuals wíth emotional distress short of psychosis. Wc now see many of the people Freud called neurotic as having borderline or even psychotic features ("hysteria" was understood to includc halluc:inatory experiencc:s that dcarly cross the border into unreality). The more we have learned about rhe depth of certain problcms, and their stubborn enrneshmcnt within the matrix of a person's character, the more we currendy reserve thc term "neurotic" to denote a high leve! of capacity to funi::tion despite emocional suffering. People whose personalities would be described by many contcmpo- rary analysrs as organizc.d at an essentially neurotic leve! rely primarily on the more mature or second-order defenses. While they also use primi- tive defenses 1 thcse are not nearly so prominent in their overall function- ing and are evident mostly in times of unusual stress. While the presence of primitive defenses does not rule out the diagnosis of neucotic level of charactcr structure, the absence of mature defenses does. Traditionally, thc psychoanalytic literature noted that healthier peoplc use repression as their basic defense, in preference ro more indiscriminate solucions ro conflict such as denial, splitting, projective identification, and ocher more archaic mechanisms. Myerson {1991) has described how empathic parenting allows a young child to expcriencc intense affects without having to hang on to infanrile ways of dealing wirh them. As rhe child grows up, these pe'.>wer- ful and often painful statcs of mind are put away and forgotten rarher rhan continually reexperienced ancl then denied, split off, or projected. They may reemerge in long-term, intensive analysis, when analyst and client together, untler the conditions of safety that evoke a "transference neurosis," peel back layers of repression; bue ordinarily, overwhelming affects and primitive ways of handling tbem are not characteristic of persons in the neurotic range. And even ín deep psychoanalytic treat-  Deve1opmental L~ls ot Personallty Organlzatlon 57 ment, the neurotic-Ievel dient maintains sorne more rational, objective capacities in the middle of whatever emotional storms and associated discortions occur. 1 People with healthier character structure strike the interviewct as having a somewhat integrated sense of idemity (Erikson, 1968). Their behavior shows sorne consistcncy, and their inner ex:perience is of conti- nuity of self through time. When askcd to describe themselves, they are not ata loss for words, nor do they respond one-dimcnsíonally; they can usually delineate thelr overall temperament, values, tastes, habiu, con- victians, virtues, and shorrcamings with a sense of theír long·range sta· bility. They feel a sense of continuity with the child they used to be and can project themselves into che foture as well. When asked to describe important others, such as their parents or Joven, rhcir characterizations tend to be multifaceted and appreciative of the complex yet coherent set of qualities that conscitutes anyone's personality. Neurotic-level people are ordinarily in solid touch with what most of the world calls "rcalicy." Not only are they srrangers to hallucinatory or dc:lusional misiilterprecations of experience (except under conditions of chemical or organic influence, or po&ttraumatic flashback), chey also strike tbe interviewer or therapist as having comparatively líttle necd to misunderstand things in order to assimilate them. Patient and therapist live subjectivcly in more or lcss the same world. Typically, the thera- pist feels no compelling emocional pressure to be complicit in seeing life through a lens that feels distorting. Some portian of what has brought a neurotic patient for help is seen by him or her as odd; in other words, much of the psychopathology of neucotically organized people is ego alíen or capable of beíng addressed so that it becomcs so. People in the neurotic range show early in therapy a capacity for what Stcrba (1934) callcd the "therapeutic split" between the observing and the expericncing parts of the self. Even when thcir difficulries are somewhat ego synranic, m:urotic-level peoplc do not seem co demand the interviewer's implicit validation of their ways of perceiving. For example, a paranoid man who is organized neurotically wmbe willing to considcr tbe possibifüy that his suspicions derive from an interna! disposition to emphasiz.c che dcstructivc intcnt of others. Contrastingly, paranoid patients at thc borderlinc or psychotic level will put intense pressure on the thcrapist to join thcir conviccion thac cheir dif6culties are externa! in ocigin; for example, to agree that others may be out to get them. Withour such validation, they worry that they are not safe with the therapist. Similarly, compulsive peoplc in the neurotic range may say that their repetitive rituals are crazy but that they feel anxiety if they neglecc tbcm. Compulsive bordedine and psychoric people sincercly belicve thcmselves to be protected in sorne elemental way by acting on their compulsions 58 CONCEPTUAL JSSUES and have often developed elaborare ratíonalizations for them. A neu- rotic-level patient will share a therapist's assumption that thc compulsive behaviors are in sorne realistic sense unnecessary, but a bordedine or psychotk patient may privatcly worry that the practitioner who ques- tions rhe ritual5 is deficient in eicher common sense or moral dec:ency. A neurotíc woman with a de.aning compulsion will be embarrassed to admít how írequcntly shc launders the sheets, while a bordcrline or psy- chotic one will fee\ thar anyonc who washes the bedding less rcgularly is unclean. Sometimes years cango by in rreatment befare a borderline or psy- chotic person will even mention a cornpulsion ar phobia or obsession-in the patient's view there is nothing unusual about it. I worked with one borderlinc client for more rhan 10 years befare she casually mentioned an elaborate, time-consuming morning ritual to "dear her sinus·es" that she considen:d part of ordinary good hygienc. Another borderline woman, who had never mentioned bulimia in her abundance of even more dis- tressíng symptoms, dropped the comment, after 5 years in therapy, "By che way, 1 notice I'm not puking anymore.'' She had not previously thought to regard that part of her behavioral repertoire as consequen- tial. Their histories and their bchavior in the interview situation givc cvidence that neurotic-level peoplc have more or less succcssfolly rra- versed Erikson's first two stages, basic trust and basic autonomy, and chac they have made at least sorne progress toward idenciry integrarion anda sense of initíative. They tend to seek therapy noc because of prob- lems in essencial security or agency, but because rhey keep running into conflicts between what they want and obstades 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; sorne neurotic-level people are also looking to expand their capacity for solitude and play. Being in the presencc of someone ac che healthier end of the contin- uum of character pathology focls generally benign. The counterparc of che patienr's possessíon of a sound observing ego is the therapist's expe- rience oí a sound working alliancc. Often irom the very first session, the therapist of a ncurotic client fecls that he or she and the patient are on the same side and that their mutual antagonist is a problematic part of the patient. The sociologist Edgar Z. Friedcnberg (1959} compared chis alliance to the experience of two young men tinkering with a car: one che expert, the orher ln interested learner. In addition, whatever the valence of che therapist's countertransference, positive oc negative, it tends not to feel overwhelming. The neuroric-Jevel client engenders in the fütener neither thc wish to kili nor the compulsion to save.  Developmental levets of Personallty Org¡rllzatlon 59 Characterfstfcs of PsydtoUc-Level Personallty StTacture At the psych.otic end of the spectrum, people are much more internally desperatc and disorganized. lnterviewing a decply disturbed patient can range from being a participant in a pleasant, low-key díscussion ro being che recipíem of a homicida! attack. Especially befare thc advent of anti- psychotic drugs in the 1950s, fow therapists had the natural inruitivc talent :md emotional stamina to be significantly therapeutíc to those in psychotic states. One of the finest achievements of the psychoanalytic tradition has been its inference of sorne arder in the apparent chaos of people who are easy to dismiss as hopelessly and incomprehensibly crazy, and its consequcnt offer of ways to understand and mitigare severe men- tal suffering (Aricti, 1974; Bucklcy, 1988; De Waclhcns & Ver Eccke, 2000; Eigen, 1986¡ Ogdcn, 1989; Robbins, 1993¡ Searles, 1965; Silver, 1989; Silver & Cantor, 1990; Spotnit~, 1985; Valkan, 1995). It is nat dif6cult to diagnose patients who are in an ovcrt state of psychosis: they express hallucinacions, delusions, and ideas of reference, and their thinking strikes the listener as illogical. There are many people walking around, however, whose basíc psychoric-level internal confu- sion does not surface conspicuously unlcss chey are undcr considerable stress. The knowledge that one is dealing wíth a "compensated" schizo- phrenic, or a cuuently nonsuicidal depn:ssivc who may be subject to periodic delusional yearnings to die, can make the diffcrence bctwecn prcventing and precipícating disasrer. Having carricd out or supcrvised che long-term ueacment of many extremely difficulr, sometimes puta- rively "untreatable" cases, 1 am convinced thar devoted therapists do significant prc:vcncion. Wc precmpt psychocic breaks, prcvent suicides and homicides, and keep peoplc out of hospitals. (These critica! cffocts of thcrapy go mostly undocumentcd; no one can prove that he or shc prcvcntcd a calamity, and critics tend to argue that if one claims to ha ve forestalled a psychotic break, the paticnt was not really at risk of pi;y- chosis in thc ñrst place.) 1share with many analysts the view that it is also useful to conceive of sorne pcoplc who may never bccome diagnosably psychoric as never- thelcss living in a symbiotic-psychotic incemal world or, in Klein's {e.g. 1946) tcrms, in a consistently "paranoid-schizoid" state. They function, somerimes quite effecrively, but thcy strike one as confuscd and deeply terrified, and thcir thinking feels disorganized or paranoid. One man 1 worked with, for cxamplc, told me with palpable drcad that he would never return co a particular gym to cxcrcise: "Tl1ree times s~meone has moved my thíngs, so ir's obvious chat l'm noc wanted there." Another uscd to switch topics abruptly whenever he was becoming very sad. I commented on rhis, and he 5aid, "Oh ycah, I know 1 do that." 1 asked 60 CONCEPTUALISSUES him what his undersrandjng of rhe pattetn was, expecting him to say something like "l'm not ready to go thcre," or..lt hurts too much," or "I don't want ro srart crying." But wltat he said, in a tone suggcsting ir was self-evident, was "Welt, 1 can see I'm hurting you!" He saw sympathetic sadness on my face and could not imagine he was not damaging me. To understand the subjcctive wodd of psychotic-leve\ dients, one must first apprec:iate the defenses they tend to use. I wiU expand on thesc in Chapcer S; ac this point 1 am simply listing them: withdrawal, denial, omnipotcnt control, primitive idealization and devaluatíon, prímitivc forms n:, immobilizing dread of their fantasied superhuman potencial for desrrucriveness. Second, people whose personaliries are organized at an essentially psychotic leve! have grave difficulties with identity-so much so rhat they may not be fully su re that they exist, much less whether their exis- tence is sarisfying. Thcy are deeply confused about who they are, and thcy usually struggle with such basic issues of self-definition as body conccpt, age, gender, and sexual oriencation. "How do l know who 1 am?" or even "How do 1 know that I exíst?" are not uncommon ques- tions for psychorícally organízed pcople co ask in earnesr. They cannot depend on a sense of continuify of idenriry in thcmselves and do not experiencc others as having c1>ntinuity of self either: They live in fear of "malevolent transformatícms" {Sullivan, 195)) that wiU turn a trusted person abruptly into a sadistic persecutor. When asked to describe thcm- selves or othcr important people in thcir lives, they tend to be vague, tangential, concrete, or observably distorting. Often in rather subtle ways, one feels that a patient wíth an esscn- tially psychotic personality is not anchored in realiry. Although most of us have vestiges oí magícal beliefs (e.g., the idea that saying somethíng positivc will ji.nx a situation), careful ínvestigation wiU revcal that such attitudes are not ego alien to psychotic-level individuals. Thcy are often confused by and esccanged from the assumptions abour "rcality" that are conventional within their cuJture. Although they may be pretematu· rally attuned to the underlying affect in any situation, they ofren do not know how to inter~ret its meaning and may assign highly self-referential significance to it. - For example, a very paranoid patient I worked with for a long time, whose sanity was olten at risk, had an uncanny feel for my emotional  Developmental Levels ot Perst>nallty Organlzatlon 61 state. She would read it accurately but then attach to her perceptíon of ir the primitive preoccupations she had about her own essential good- ness or badness, as in "You look irritated. le must be becausc you think I'm a bad mother." Or "You Jook bored. 1 must have offended you last week by leaving t~e session 5 minutes early." It took her yc:?ars w feel safe enough to tell me that was how shc was intcrpreting my exprcssions, and severa! more years to transform the conviction "Evil people are going to kili me because they bate my lífestyle" into '"I feel guilty about sorne aspects of my life." People with psychotic tendencies have trouble getting perspective on their psychological problems. They lack rhc "reflective functioning" that Fonagy and Target (1996) have identificd as critica] to cognitive macu- ration. This defidt may be related to thc well-documcnted difficulties that schizophrenic people have with abstraction (Kasanin, 1944). Those whose menea! health history has given them enough jargon to so1md like good self-observers (e.g., "1 know I tend to overreact" or even "My sc:hizophrenia interferes wich my judgment") may revea! to a sensítíve interviewer that in an effort to redut:e anxiety they are compliantly par- roting what they have been told about themselves. One patient of mine had had so many intakes at psychiatric hospitals during which she had bccn askcd {in a mental scarus cvaluation that helps decerminc whether the paríent is capable of abstract thought) to give the meaning of the proverb..A bird in the hand is worch two in the bush" that she had asked an ai;quaintance whac it meant and memoriz;ed the answer (she proudly offered this explanárion when 1 commented in an incerested way on the automatic quality of her response). Early psychoanalytic formulations about the difliculties that psy- chotic 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 serv.ice of coping with reality. Ego psychology models emphasizcd the psychoric person's lack of interna! differentiation between id, ego, and superego, and between observing and expericndng aspeccs of the ego. Students of psychosis influcnccd by ínrerpersona.1, object relations, and self psychology theories (e.g., Atwood, Ocange, & Stolorow, 2002) have referred to boundary confusion bctween inside and outsidc experi- ence, and to deñcits in attachment thar make ír subjecrively too danger~ ous for the psychotic person to enter the same assumprive world as thc interviewer. Recently, in light of fMRI studies showing similarities becween effects of trauma on the developing brain and the biological abnormali- ties found in the brains of individuals diagnosed with schizophrenia, John Read and his colleagues (Read, Perry, Moskowitz, & Connolly, 62 CONCEPTUALJSSUES 2001) havc argued for a traumaric eriology of schizophrenia. A full accounc of the lack of.. observing ego" in psychotic·lcvel cliems prob· ably includes ali these perspectives as well as generic, biochemical, and situational contributants. Thc critic:al thing for thcrapists to appreciate is that dose to the surface in people with psychotic-level psychologies, one finds both mortal fear and dire confusion. The nature of the primary conflict in peoplc with a potential for psychosis is literally cxistential: lifc versus dcath, existence versus oblit- eration, safety versus terror. Their dreams are foil of stark imagcs of death and desrruction. "To be or not to be" is their recurrent rheme. Laing (1965) eloquently depicted them as suffering "ontological inse- curity." Psychoanalytically iníluenced studies of rhe families of schizo· phrenic pcople in the l 950s and 1960s consisrently reported patterns of emotional communication in which the psychotic child reccived subtle messages to the effect that he or she was not a separatc pcrson but an extension of someone else (Bateson, jackson, Haley, & Weakland, 1956¡ Lid:z., 1973; Mischler & Waxier, 1968; Singer & Wynne, 1965a, 1965b). Although the discovery of the major tranquili:z.ers has divcrted attention from more stricdy psychological invesrigations of psychoric proccsses, no one has yet presentcd evidence controverting the observa- tion rhat the psychotic person is decply unconvinced of his or her righr to a separare existence, ar may even be unfamiliar with the sense of existing at all. Despite their unusual and even frightening aspects, patients in thc psychotic range may induce a positive counterrransference. This reaction differs a bit from warm countertransfcrence reactions to neurotic-level clients: One may feel more subjective omnipotcnce, parental protective- ness, and decp soul-level empathy toward psychotic people than toward neurotic ones. The phrase.. the lovablc schizophrenic" was for a long time in vague as an ex:pression of the solicitous attitude that mental health personnel often feel toward rheir most severely troubled patients. (The implicit contrast group here, as I discuss below, is the borderline population.) Psychotic pcople are so desperate for respect and hope that they may be deferential and grateful to any therapist who docs more than classify and medicate them. Their gratitude is naturally touching. People with psychotic tendencies are particularly appreciative of sincerity. A recovered schizophrenic woman once told me she could for- give even scrious failings in a therapist if she saw them as "honest mis- takes." Psychotic-level clients may also apprcciate educative efforts and may respond with telief to the normali:z.ation or reframing of their pre- occupations. These dispositions, along with their propensity for fusion and idealízation, can make the therapist fcel srrong and benevolenr. The downside of thcse patients' poignant dependcnce on our care is the bur-  Developmental Levels of Personallty Organlzatlon 63 den of psychological responsibility they inevitably impose. In fact, the countertransference with psychotic-lcvcl pcople is remarkably like nor- mal maternal feelings toward infants under a year and a half: They are wonderful in their attachmenr and terrifying in their needs. They are not yet oppositional and irritating, bue they also tax one's resources to the limit. I should not work with a schizophrenic, a supervisor once told me, unless I was prepared m be caten alive. This "consuming" feature of their psychology is one rcason thar many thcrapists prefer not to work with individuals with schizophre- nia and othcr psychoses. In addition, as Karon (1992) has noted, the access of psychotic parients to deeply upsetting rcalities that the rest of us would prefer to ignore is oftcn too much for us. In particular, they see our flaws and limitacions with stunning darity. Orher reasons for their relative unpopularity as patients despite their appealing qualities prob- ably indude therapists' lack of adequate rraining in psychotherapy wich psychotics (Karon, 2003; Silver, 2003), economic pressures that breed rationalizations about limited approaches or "management" instead of thcrapy (Whitaker, 2002), and personal dispositions not to work roward relatively modest treatment goals in contrast to what can be achieved with a neurotic-levcl person. But as I stress in the next chaptcr, ic can be effcctive and rewarding to work with dients in thc psychotic range if one is realistic about the nature of their psychological difficulties. Charaderlstlcs of Bordertlne Personallty Organlzatlon One of the most striking features of people with borderline personality organization is thcir use of primitive defenses. Because they rely on such archaic and global operations as denial, projective identification, and splitcing, when rhey are regressed they can be hard to discinguish from psychoric patients. An important difference becween borderline and psy- chocic people, though, is that when a therapist confronts a borderline patient on using a primitive mode of experiencing, the patient will show ar leasr a temporary responsiveness. When the therapist makes a simi- lar commenr to a psychotically organiz.ed person, he or she will likely become further agitated. As an illusrration, consider the defense of primitive devaluation. Being devalued is a familiar and painful experience to any therapist. Devaluation is an unconscious straregy that is often incended to pre- serve self-esteem, bue which does so ar the expense of learning. An effort to address that defense might go something like "You certainly love to cherish ali my defr.:cts. Maybe that protects you from admitting that you might nced my help. Perhaps you would be feeling 'one down' or ashamed if you weren't always putting me down, and you're trying to 64 CONCEPTUAL ISSUES avoid that feeling." A borderline patient might scorn such an intcrpreta- rion, or grudgingJy admit it, or receive it silently, but in any event, he or she would give sorne indicacions of rcduced anxicty. A psycbotic person would reacc with increased anxicty, since to someone in existencial ter- ror, devaluation of the power of che therapisc may be the only psycho- logical mea ns by which he or she fecls protecced from obliteration. Thc thcrapist's discussing itas if it were optional would be exuemely fright· ening. Borderline patients are in sorne ways similar to and in others differ- ent from psychotic people on the dimcnsion of idcntíty integration. Their expericnce of self is likely to be full of inconsisrcncy and disconrinuity. When asked to describe their personalities, chcy may, lilce psychotic· leve! patients, be ar a loss. And when askcd to describe important people in their lives, they may respond with anything but three-dimensional, evocative desc:riptions of recognizable human beings. "My mother? She's just a regular mother, 1 guess" is a typical response. They often give global, dismissive descriptions such as "'An alcoholic. That's all." Unlike patients with psychosis, chcy rarely sound concrete or tangential ro the point of being bizarre, but they do tend to dismiss che therapisr's inter- est in the complexities of themselves and others. Fonagy (2000} wri[es that borderline dients are insecurely attached and lack the "reflec:tive function" that finds mr:!aning in tbeir own behavior and that of other&. Thcy cannot "mcntalize"; that is, they cannor appreciatc the separacc subjectivities of other people. In philosophical terms, they lack a rheory of mind. Ctients in che borderline range may become hostik whcn con- fronted with the limited continuiry of their identity. One of my patients flew into a full-blown fury at a questionnaire she was given as a stan- dard intakc procedure in a dinic. lt had a sentcnce-completion scction in which che client was asked to fill in blanks like "I am the kind of person who." "How can anybody know what to do with this shit?" she ragcd. (Some years and countless sessions later she mused, "Now I could fill in rhat form. 1 wonder why 1 went ballíscic about it.") In general, borderlioe paticnts have trouble wirh affect tolerance and reguJation, and quickly go to angeC" in situations where others might !ed shame o.r envy or sadness or sorne other more nuanced affecc. In two ways, the relation of borderlinc patients to their own identity is different from that of psychotic people. First, the sense of incoosistency and disconrínuity that people with borderline organization suffer lacks the degrce of exis1ential terror of the schizophreníc. Borderline patients may have identity confusion, but they know they exist. Second, peoplc with psychotic tendencies are much less likely than borderline patients to ccact with hostility to questions about identity of sclf and others. They  Developm enlaf Le\'els of Personallty Organlzatlon 65 are too worried about losing their sense of ongoing being, consístent or oot, to resenc the iote[viewer's focus on that problem. Despite these distinctions, both borderline and psychotic people, unlikc neurotks, rely hcavily on primitive defenses and suffer a basic defect in the sen~e of sell. The dimension of experience on which the two groups differ substamially is reality testing. Borderline dients, when interviewed thoughtfully, demomtrate an appn:ciation of reality no mat· ter how cr.azy or florid their symptoms look. lt used to be standard psy- chiauic practice to assess che degree of che paticnc's "insight into illncss" in order to discdminate between psychotic and nonpsychotic states. Bcc:iuse a bordcrllne patient may rclendcssly deny psychopathology yet still show a level of discrimination about what is real or conventional that disringuishes him or her from a psychotic peer, Kernberg (1975) proposcd chat "adequacy of reality testing" be substituted for that ccj- terion. To make a dífferential diagnosis between borde.rline and psychotic lcvcls of organization, Kernbcrg (1984) adviscs invcstigating the per- son's appreciation of convencional notions of reality by picking out sorne unusual fcature of his or her sclf-prcsentation, commenting on it and asking if (he patient is awarc chat others might find th.ac fcature peculiar (e.g., "I notice that you have a tattoo on your check that says 'Deathl' Can you undersrand how thac might seem unusual to me or ochers?"). The borderlinc person will acknowledge that che feature is um:onventional and that outsiders might not underscand its significancc. The psychotic pcrson is likely to becomc frigfmmcd and confused because rhe scnse that he or she is not undcrscood is deeply disturbing. These diffcring reaccions, which Kemberg and bis coworkers {e.g., Kernberg, Yeomans, Clarkin, & Levy, 2008) have explored both clinically and vía empiri- cal research, may be vicwed as suppott for psychoanalytic assumptions abouc the centrality of separa1ion-individuation issues far people with borderline pathology as contrasted with unconscious deficits in self- other difforentiation in psychosís. The capacity of someone at the borderline leve! to observe his or hcc own pathology-at least the aspects of it that impress an exrernal observer-is quite limited. Peoplc with borderline psychologies come to therapy for complaints such as panic attacks or depression or íllnesses that a physician has insisred are rclatcd to "stress," or thcy arrive at the therapisc'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 advancageous. Even in recent years, when they are apt to know rhey "have BPD" and can endorse the DSM criteria for diagnosing it, thcy still lack a sensc of what it would be like to be different. Having never had any other kind of character, thcy 66 CONCEPTUAL ISSUES have lirtle emorional basis fof" knowing how it would feel to have identity integration, mature deíenses, the capacity to defcr gratification, a toler- ance for ambivalencc and ambiguicy, or an ability to regulatc affects. They just want to stop hurting orto get sorne critic off their back. In nonrcgrcsscd statcs, because their reality testing is fine and because they may present themselves in ways that campe! our empathy, rhey do not look particularly sick." Sometimes it is only afcer therapy has proc:eeded for a whíle that one realizes that a given parient has a borderline srruccure. Usually the first due is that interventions that the rherapíst íntends to be helpful are received as attacks. In ocher words, the therapist keeps assuming a capacity for reflective functioning rhat che patient mosdy lacks. (In older language, che therapist is trying to talk wíth an obscrving ego, something the client cannot access, especially when upset.) The paticnt knows only that sorne aspect of thc self is being critidzed. The thcrapist keeps trying to forgc thc kind of alnance that is possible with neurotic-level parients and keeps coming to grief in the effort. Eventually, one learns that one must füst just weacher the affective storms that sccm to keep raging, while rryin~ to behave in ways that the patient will expericnce as different from whatever influences have shaped such a troubled and hclp-resistant person. Only a{te.r therapy has brought about sorne structural change will the patient be different enough to begin to undcrstand what the therapist is trying to work roward. This may cake a long time-sometimes 2 years in my experience-but ít is of comfort that in the meantime, the most disabling borderline behaviors may disappear. Clarkin and Levy (2003) describe significant symptom reduction after 1 year of transference-focused therapy. Still, the work will cypically have been tumultuous and frustrating to both parties. Mastcrson (1976) has vividly depicted, and others with different viewpoints report similar obscrvations, how borderline clients seem caught in a dilemma: When rhcy feel clase to another person, they panic becausc thcy foar cngulfmcnc and total control; when they are alone, they feel traumatically abandoned. This central conflicc of their cmo- tional cxperience resulrs in their going back and forth in relationships, including the therapy relationship, in which neither doseness nor dis· tancc is comfortable. Living with such a basic conflicr, one that does not respond immcdiarely ro interpretive efforts, is exhausting for bor- derline patients, their friends, their families, and their therapists. They- are famous among emergency psychiatric ser vice wgy. SUGGESTIONS FOR FURTHER READING Therc has been a voluminous psychoanalytic literature on narcissislll since the 1970s, when Kohut published Tbe Analysis o{ the Sel{ (1971) and Kernberg offercd an alternativc conception in Borderfine Condi- tions a11d Pathological Narcissism (1975). Both thcsc books contain so much iargon thar chey are almosc imposslble for somcone new to psy- choanalysis to read. More manageablc alternatives include Alice Miller's Prisoners of Chi/dbood (1975) (known in anothet edition as The Drama of the Gifted Child), Bach's Narcissistic States and the Therapei1tic Process (1985}, and Morrison's Sba.me: The Undersíde o{ Narcissism (1989). Morrison also edíced a callcction, availahle in paperback, titled Essential Papers on Narcissism (1986), which contains majoi psyc:ho- analytk: essays on the topic,.most of which are cxcellent. For a scholarly analysis of the cultural trcnds behind thc "empty self" that is central to nardssistic personaliry. see Phíiip Cushman's Constructi11g the Sel{, Con!.tructing ArM1'ica (1995;. Newer works Qn narcissism tend to be ha.sed on the dcscription in DSM-IV. and chus strike me as more superficial, trait based, and one- dimcnsional thart thcsc analytic wrkings. Bue the oversimpli.ficarion and popularizarion of a ~oncept can have its advantages: Thert are now many helpful popular books for indiv.iduals coping wirh narcissiscic parents, lovers, colleagues, employcr:s, and other difficult people.  9 Schizoid Personalities The person whose character is essentially schizoid is subject to widespread misunderstanding, based on the common misconcep- tion that schizoid dynamics are always suggestive of grave primitivity. Be(.:ause thc inconcrovcrribly psychotic diagnosis of schizophrenia fits people at the discurbed cnd of the schizoid continuum, and because the behavior of schizoid people can be unconventional, eccentric, or even bizarre, nonschizoid ochers tend to pathologize those with schizoid dynamics-whethet or not they are comperent and autonomous, with significanr areas of ego strength. In facc, schizoid people run the gamut from che hospitalized catatonic patiem to rhc creative genius. As with the other rypological catcgories, a person may be schizoid ac any leve!, from psychologically incapacíta.tcd to sancr than average. Because the defense that defines the schizoid character is a primitive one (withdrawal into fantasy), it may be that healthy schizoid peoplc are rarer chan sicker ones, bue 1 do not know of any research findings ar chizoid peoplc will opt for the latter, despite its \onelincss, because closeness is associatcd with unbearable overstimulacion and with having the self taken over in nox- ious ways. Possible constitutional sources of schizoid tendencies indude hypersensitivity and hyperpermeabílity of the self. In addition to the use of autistic-like withdrawal into fantasy, the schizoid person employs ·other "primitive" defenses but also shows enviable capacities for authen- ticity and creativity.  Schlzold Person¡lltles 213 I discussed the impact of chese tendcncies on relatíons with orh- ers, with attenrion, to the pauerns of family imeraction that may have fostered the schizoid person's approach-avoidance conflict, namely the coexistence of deprivation and intrusion. l framed relevant transference and countertransferem:e issues as including difficulties in the therapist s initial admission inro the dient's world, a tendency for the therapisc to share the dient's feelings of cither helpless vulnerabilicy or grandíose superiórity, and temptations ro be complicit wirh the patient's reluc- tance to move toward others. 1 recommended maximal self-awareness in the therapist, as well as patience, authenticíty, normalization, and a willingness to show one's.. realn pcrsonality. Finally, I emphasized the importance of assessing accurately a person's loi:aríon on the schizoid continuum, and 1 differentiated the schizoid character írom obsessive and compul:iive personalities. SUGGESTIONS FOR FURTHER READING Much commentary on schizoid conditions is buried in writing on schízo- phrcnia. An eloquent and absorbing exception is Guntrip's ScMzoid Pl1e· nomtma, Object Relatio11s a11d the Se/f (1969}. Seinfeld's Tbe Empty Core (1991) is al so an excellcnt represenrative of object-relaríonal think- ing abouc schizoid psychology. More recently, Ralph Klein's chapters about the "self-in-exile" in a book he coediced on disordcrs of the self (Mastcrson & Klein, 1995) are very helpful to che dinician. Arnold Mod- ell's The Private Seff (1996) is an important contribution. For more of my own thinking on this topic, readers can consult my essay on the mute schizoíd woman 1 mentioned earlier (McWílliams, 2006a) or a recent arride in the journal Psychoanalytic Review (McWilliams, 2006b). The American Psychological Association incends co put out two vid- eos in August 2011, ro be markctcd as Three Approaches to Psychother- apy: The Next Ge11eratíon (Bei;k, Grecnbcrg, & McWilliams, in press-a, in press·b} modeled afrer the famous "Gloria" rapes (Shostrum, 1965), in which a woman wíth that pseudonym was filmed in single-session interaction with Carl Rogers, Frirz Peris, and Albecc Ellis, respcctively. This time, thc therapists wíll be Judith Beck, Leslie Greenbcrg, and me, and there will be one DVD of our work with a male patient and one with a female parienr. Readers who would like to see me doing shorr-term, analytically oriented work wirh a patient I saw as having a basically schizoid personalicy structure (at the healthy end of the spcctrum) can watch the DVD of my interview (and those of Beck and Greenberg) with a man namcd Kevin (Beck, Greenberg, & McWiJliams, in press-b).  10 Paranoid Personalities Most of us have a clear mental image of a paranoid person and rccogni:i:c the type when it is portrayed fictíonally. Peter Sellers's bril- lianr performance in the dassic movíe Doctor Stra,,gelove, for exnmple, captures the suspiciousncu, humorlessness, and grandiosity du1t strike familiar chords in any of us who have paranoid acquaintam;es, ar who recognize the comic elaboration of rhe patanoid streak we c:m all lind in ourselves. ldenrifying less flagranr paranoid presenrations requires a more disciplined sensibility. The esscnce of paranoid personality orga· nization is the habit of dealing wich one's felt negative qualities by dís· avowing and projccting them; the disowned anributcs then feel like externa! threats. The projective proccss mayor may not be accompanied by a consciously megalomanic sense of sclf. The diagnosis of paranoid personality scructure implíes co many peple a serious dísturbance in mental health, yet as with othet dynamics that infuse personality, this typc of organization exists on a continuum of severity from psychoüc to normal (Freud, 1911; Meissner, 1978; D. Shapiro, 1965). As wich the pcrsonality types in the preceding chapters, the defcnse chac defines paranoia may derive from a time before thc chlld had clarity about interna! versus external cvents, where self and object were chus confused. Paranoia intrinsically involves experiencing whac is inside as if it weré outside the self. lt may be thac "healrhier" paranoid pcople are carer than..sicker" ones, bur someone can havc a paranoid characcer at any leve! oí ego strength, identity integration, reality test- ing, and objecr relations. 214  Paranold Per.soRalltles 215 Thc trait-bascd dcscriptions of p:uanoid pcrsonaliry disordcr in DSM-JV are from a clínician's perspecrivc rarhec superficial, but the manual is accurare in noting that our knowledge of this personality type may be limited. A paranoid pcrson has to be in fairly deep trouble beforc he or she seeks (or is brought for) psychological help. In contrast co depressiv~, hystcrical, or masochiscic people, for examplc, highcr-func- tioning paranoid individuals tend to avoid psychotherapy unlcss they are in severc emotional pain orare causing significant upscr ro others. Because they are not disposed to trust strangers, paranoid people are also unlikcly to \'oJunteer to be research subjects. People with normal-level paranoid characters oftcn seek out politi- cal roles, where their disposition to oppose thcmselves co forces they sec as evil or thrcaccning can.find ready expression. Reportcrs and saririsrs have ofren portrayed Dick Cheney as paranoid> but even íf they h:ne his politics, thcy have seldom questioncd his capacity to cope efficaciously in the world. At the othcr cnd of the continuum, sorne serial murdcrcrs wbo killed their victims out of the conviction that ch.e victims were trying to murder them exemplífy che destructivencss of projection gone mad; that is, paranoia operating without thc moderating effccts of more maturc ego processcs and without a solid grouriding in reality. Severa! recent notorious murders seern to have had a paranoid basis. 1 wanr ro emphasízc again :JS I did in Chapcer 5 that amibutions of paranoia should not be made on the basis of an interviewer's belicf that a person seeking help i5 wrong about thc danger he or she is in. Somc people who look paranoid are actually being sralkcd or perse~uted­ by mcmbers of a cult they have left, for cxample, or by a rejected lovcr or a disaffected relative. (Sorne peoplc who are diagnosably pnranoid are also realistkally imperiled; in fact, che off-putting qualities of many paranoid pcoplc make them natural ma.gnets for mistn:armenr.) Somc pcoplc who are nm characterologically paranoid becomc temporarily so in paranoiagenic situations that are humiliating and entrapping. When incervicwing for diagnostic purposes, one should not reject out of hand the possibility that the intcrviewee is legicimately fríghtened, or that those who are urging him or her to seek therapy have a personal scake in makíng thc client look crazy. Contrastingly, sorne índividuals who are in fact paranoid do not appear to be. Nonparanoid associates in their social group-and thc interviewer for that matter-may share their beliefs about the dangcrs of certain people, forces, or institutions (terrorísts, capitalists, relígious authoritics, pornographers, che media, che govcrnment, patriarchy, racists-wharcver is seen as thc obstacle to che rriumph of good) and may therefote fail to discern thac therc is something internally genecaced and driven about thcir preoccuparions (