A Psychodynamic Guide for Essential Treatment Planning

Psychoanalytic Psychology Copyright 2000 by the Educational Publishing Foundation2000, Vol. 17. No. 2, 336-359 0736-9 73 5/00/$5.00 DOI: 10.1037//0736-9735.17.2.336

A Psychodynamic Guide for EssentialTreatment Planning

Frank Trimboli, PhDUniversity of Texas Southwestern Medical Center at Dallas

and Dallas, Texas

Kenneth L. Farr, PhDUniversity of Texas at Arlington and Arlington, Texas

This article presents a model for conceptualizing psychopathol-

ogy designed to assist practitioners in evaluating patients and

applying effective treatment plans. The model describes psycho-

pathology as a function of (a) level of ego organization and (b)

character style. Two adjunctive variables are discussed that

augment treatment planning through (a) evaluation of the

individual's current level of adaptive functioning and (b)

confirmation of the diagnostic conceptualization and treatment

approach by evaluation of the primary dynamic or conflict.

These 2 major dimensions and 2 adjunctive variables are

examined in relation to theoretical description of psychological

functioning and procedures for assessment and treatment

considerations, respectively. Key guidelines for the treatment

of prototypical disorders are presented.

In this era of clinical expediency induced by managed care, practitioners

are sadly encouraged (or forced) to eliminate procedures thought by

Frank Trimboli, PhD, Department of Psychiatry, Division of Psychology, University ofTexas Southwestern Medical Center at Dallas, and independent practice, Dallas, Texas;

Kenneth L. Farr, PhD, Student Health Services and Department of Psychology,

University of Texas at Arlington, and independent practice, Arlington, Texas.

Correspondence concerning this article should be addressed to Frank Trimboli,PhD, 4201 Spring Valley Road, Suite 1100, Dallas, Texas 75244.

336

PSYCHODYNAMIC GUIDE 337

business managers to be nonessential. In addition to the decline of

psychological testing that has been witnessed in recent years, there often

exist strong pressures to eliminate the entire diagnostic process and move

immediately to providing interventions, often limited by managed care

companies to a handful of psychotherapy sessions. Unfortunately, the

pressure to plunge blindly into psychotherapy dramatically undermines

therapists' abilities to choose and apply appropriate treatment. We are in

agreement with Butcher (1997) who stated, "The primary factor that the

therapist can use to prevent.. . [treatment destructive forces] or at least try

to counterbalance them is to obtain a clear assessment of the patient's

problems," (p. 332) and who has argued for the necessity of personality

assessment as a prelude to effective psychological intervention. Despite his

well-reasoned arguments, there are many situations in which formal

psychological testing is not possible or, increasingly, not permitted. Regard-

less, therapists need a coherent and comprehensive framework in order to

select and apply the best possible treatment and to predict and manage

stumbling blocks to achieving positive therapeutic outcomes. Such a

framework becomes even more essential when working within constric-

tions imposed by managed care. We hope that the guide presented herein

can complement formal psychological assessment results when they are

available and provide an effective framework for treatment planning when

they are not, regardless of whether one is working within or outside of a

managed care environment.

This article presents a treatment planning model based on conceptu-

alization of psychopathology via an integration of two broad streams in

psychoanalytic diagnosis. These streams are Id Psychology, as developed

by Freud and expounded on by numerous authors, including Abraham

(e.g., 1924) and Fenichel (e.g., 1945); and Ego Psychology, which is rooted

in Freudian structural theory (1923/1961), is most closely associated with

Hartmann (e.g., 1958,1964), and is articulated and explicated by numerous

authors, including Blanck and Blanck (e.g., 1974) and Kernberg (e.g.,

1975, 1984).

In the view of Id Psychology, all human behavior (including thought)

is in the service of drive gratification. In this view, human capacities such

as thinking and interpersonal relations develop as a compromise forced by

the demands of reality that often preclude immediate drive gratification.

Although the economic assumptions underlying Id Psychology have been

largely repudiated (Ricoeur, 1970; Schaffer, 1976; Tyson & Tyson, 1990, p.

42), the model for the stages of psychosexual development inherent within

this formulation remains useful for the conceptualization of particular

338 TRIMBOLI AND FARR

types of character styles. The stage model posits a psychosexual develop-

mental process in which the primary source of id gratification centers on

various bodily organs and the functions related to those organs in a

biologically predetermined sequence. More importantly, developmental

disturbances experienced during these periods, including trauma or exces-

sive or inadequate gratification, are thought to result in distinct types of

psychopathology (Fenichel, 1945).

Although the stage model of psychosexual development based in Id

Psychology has been useful for providing descriptive characterological

diagnoses, it has proven inadequate for the conceptualization of the

broadened array of patients that psychoanalysts and psychotherapists have

begun to treat during the last several decades. Despite attempts to extend

the psychosexual stage model to describe different levels of pathology

(e.g., Zetzel, 1968), these patients present pathologies that do not readily

conform to the diagnostic classifications derived from the Id Psychology

model (i.e., the classic neuroses). Patients whose problems are rooted in the

vicissitudes of structural development in the earliest months and years of

life have required an extension of the diagnostic system to take into

account problems based on deficiencies in self and object representations

and problems in the capacity for functional organization of the psyche in

meeting demands of reality. This is where the work of later ego theorists

has provided a bridge to extend application of psychoanalytically directed

treatment to a wider array of patients.

Consistent with prior conceptualizations (Sandier & Rosenblatt,

1962), we use the word ego to refer to the repository of both the adaptive

functions of the psyche and internal representations of self and object.

Psychopathology characterized by deficiencies and disturbances in the ego

or its functions has been most thoroughly explicated by Kernberg (e.g.,

1975, 1984), who has addressed the need for conceptualization along a

spectrum of ego development, particularly in terms of the effective treat-

ment of patients with borderline conditions (e.g., Kernberg, 1984, p. 3).

Kernberg has demonstrated that the borderline conditions can be character-

ized (and differentiated from neurotic and psychotic conditions) according

to several well-accepted characteristic aspects of ego stucturalization

discussed below.

In this article, we present a framework that integrates Id and Ego

Psychology lines of development in the conceptualization of psychopathol-

ogy for the purpose of guiding treatment. The simultaneous incorporation

of id and ego lines of development has been addressed previously (e.g.,

Lerner, 1991; McWilliams, 1994, pp. 29-40; Smith, 1978). We propose


that diagnostic conceptualization and ultimate treatment goals should be

flexibly guided by consideration of two major dimensions: (a) level of ego

organization and (b) character style. Furthermore, the patient's current

level of adaptive functioning can augment the pursuit of these goals by

suggesting specific treatment considerations and approaches that can prove

useful in strategic treatment planning, whereas evaluation of the patient's

primary dynamic or conflict can help to validate the diagnostic conceptual-

ization and treatment approach.

Part I: Diagnostic Considerations

Level of Ego Organization

We believe the first step in the diagnostic process should be to place an

individual along the ego organization line. Although we cannot do justice

to the depth and complexity of Kernberg's (e.g., 1975, 1984) formulations

in this brief article, we hope that the following will elucidate those

elements of his formulation that bear on our discussion of treatment

planning below. For ease of presentation, three basic levels of ego organi-

zation will be delimited (neurotic, borderline, and psychotic; see Table 1).

However, the reader should bear in mind that ego organization is best

conceptualized as a continuum with lines of distinction that in reality are

less clear than these three headings may suggest. Kemberg (1984) assessed

level of ego organization according to three primary structural criteria

(level of identity integration, sophistication of defensive operations, and

adequacy of reality testing) and other nonspecific manifestations of ego

weakness (Kernberg, 1975, 1984; see Table 1).

Identity integration refers to the extent to which the individual has

integrated positive and negative self introjects and positive and negative

object introjects that are maintained in a relatively constant manner within

the psyche regardless of temporary alterations in feelings toward these

objects. In regard to self introjections, the neurotically organized indi-

vidual has an ". .. inner experience of continuity of self through time,"

(MeWilliams, 1994, p. 54) and is able to maintain and acknowledge an

understanding of positive qualities even in the face of guilt, failure, or

disappointment in oneself. An individual at the borderline or psychotic

level of organization is unable to integrate contradictory behavior in an

emotionally meaningful way (Kernberg, 1984, p. 12) and is likely to

experience pervasive feelings of worthlessness without an ability to main-

tain a sense of one's positive qualities or an ability to credit accomplish-

ments at the same time. Others are perceived in a shallow, impoverished


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manner, which makes it difficult for an interviewer or therapist to develop

empathy (Kernberg, 1984,p. 12). An example of identity integration in the

realm of object relations is the capacity to remain attached to a spouse even

when enraged, representative of the neurotically organized individual. In

contrast, an individual at the borderline or psychotic level must rely on the

defense mechanism of splitting (see below) to protect the ego from

contradictory experiences of self and others. Thus, in the case of disappoint-

ment with or rage toward a spouse, the spouse is thoroughly devalued and

affectively cathected positive aspects cannot be simultaneously main-

tained. Though borderline and psychotically organized individuals both

may be described as displaying identity diffusion, there are some differ-

ences between the two. Whereas borderline individuals' experience of self

and others are fluctuating, inconsistent, and one-dimensional, psychotic

individuals have even greater identity disturbance. They are likely to

experience (or their actions may suggest) an even deeper confusion about

themselves and others, and they may manifest an extreme fragility in the

underlying sense of self such that the psychotic often feels a breath away

from psychological obliteration. McWilliams (1994) pointed out that such

individuals may struggle with basic issues of self-definition, wondering

who they are or whether they truly exist.

Defensive operations consist of two main levels: the more sophisti-

cated version in which the individual is capable of formal repression and

the secondary defenses associated with repression, and a less sophisticated

version in which the individual's ego resources have not developed

sufficiently to permit repression. That is, the defensive operations of the

neurotic protect the ego from intrapsychic conflicts by the rejection of a

drive derivative or its ideational representation from conscious awareness.

In contrast, the mechanisms used by individuals at the borderline level of

ego organization protect the ego from conflicts by splitting, a means of

actively keeping apart contradictory experiences of the self and significant

others (Kernberg, 1984, p. 15). Unfortunately, this latter type of distortion

results in a serious weakening of ego functioning and a reduction in

adaptation and flexibility. In the psychotic individual, the same defense

mechanisms protect the individual from debilitating disintegration of

mental boundaries between self and object. As described by McWilliams,

splitting is clinically evident when a person "expresses one nonambivalent

attitude and regards its opposite (the other side of what most of us would

feel as ambivalence) as completely disconnected" (McWilliams, 1994, p.

113). For example, a borderline individual describes a colleague as

wonderful, kind, and smart, but 1 week later the same individual is referred


to as abusive and cold, with no acknowledgment of the discrepancy. The

defense of splitting may appear in the therapeutic relationship as a patient

alternately idealizes, then devalues, his or her therapist, without an experi-

ence of concern or curiosity about the dramatic change.

The hallmark distinguishing feature of the psychotic individual is

impaired reality testing. Questions and confusion about one's basic exis-

tence may manifest as a delusion about that existence (e.g., "I am a rat in

an experiment," or "I am Jesus Christ."). The disturbances in identity can

be so profound that one may be unsure of where their own existence stops

and another's begins, leading, for example, to delusions of thought control

or insertion. These examples also suggest the presence of primitive

defensive operations reflective of psychotic ego development such as

denial of reality and withdrawal into fantasy. Note that although impaired

reality testing is often blatant, it need not be. In particular, individuals with

a degree of paranoia may be quite skilled at hiding signs of impaired reality

testing.

To the extent that an individual manifests identity integration, de-

fenses organized around repression, and intact reality testing, the indi-

vidual would be judged to have a neurotic structural organization. To the

extent that an individual manifests identity diffusion, has defenses orga-

nized around splitting, yet maintains adequate reality testing, the individual

would be judged to have a borderline structural organization. Finally, to the

extent that an individual manifests identity diffusion, has defenses orga-

nized around splitting, and has not maintained adequate reality testing, the

individual would be judged to have a psychotic structural organization.

In addition to the three primary criteria described above, Kernberg

(1984) identified deficits in the following ego functions as indications of

borderline and psychotic adaptations (see Table 1): anxiety tolerance,

referring to "the degree to which a patient can tolerate a load of tension

greater than what he habitually experiences without developing increased

symptoms or generally regressive behavior" (Kernberg, 1984, p. 19);

impulse control, referring to "the degree to which the patient can experi-

ence instinctual urges or strong emotions without having to act on them

immediately against his better judgment and interest," (Kernberg, 1984, p.

19); and developed channels of sublimation, referring to "the degree to

which the patient can invest himself in values beyond his immediate

self-interest or beyond self-preservation," (Kernberg, 1984, p. 19). Kem-

berg (1984) further indicated that although neurotic types of structural

organization manifest a well-integrated (though often severe) superego, the

superego integration of borderline and psychotically organized individuals


is typically impaired and marked by primitive superego precursors, particu-

larly primitive sadistic and idealized object representations. Taken to-

gether, neurotically organized individuals are more capable of using signal

anxiety, demonstrate greater impulse control, have a greater capacity for

sublimation, and have a more benign superego than individuals functioning

at borderline and psychotic levels of ego development. Relative to border-

line and psychotically organized individuals, neurotics furthermore have a

greater capacity to observe their own pathology, tend to develop transfer-

ences marked more by ambivalence than the strong yet fluctuating transfer-

ences marked by splitting, and spur countertransferences that can be easily

tolerated as opposed to countertransferences that are more provocative and

intense (McWilliams, 1994, p. 60).

Determination of Character Style

The consideration of issues related to the genetic and descriptive understand-

ing of character style has been a central focus of psychoanalytic theory

development from its inception (e.g., Freud, 1905/1953, 1915/1957; see

also Abraham, 1924; Fenichel, 1945; Reich, 1933/1972; Shapiro, 1965). In

his classic text, Reich (1933/1972) illustrated the extent to which neurosis

can become incorporated into the character style of the individual such that

the individual's characteristic manner of behaving and relating to the world

reflects the ongoing defenses against underlying neurotic problems and

conflicts. He and other theorists have postulated that trauma or irregulari-

ties of development in early phases of development lead to particular

predictable adaptations in the context of fixation at such early levels of

development. Freud's "Three Essays on the Theory of Sexuality" (Freud,

1905/1953) identifies the oral, anal, and phallic levels. He, his contemporar-

ies, and later theorists describe characteristics and particular types of

psychopathology resulting from difficulties at each of these levels of

development (Abraham, 1924; Fenichel, 1945). Although their original

assignment of pathology has not always held true, it does appear that there

are consistencies that exist within the individuals that are thought to have

been fixated or suffered some arrest at a particular level. Reich (1933/1972)

and Shapiro (1965) in particular have provided excellent descriptions of

several neurotic character styles. Space does not permit us to comprehen-

sively review the issue, yet we shall make some general points about the

process of determining character style and about specific characteristics of

oral, anal, and phallic character styles, respectively. In thinking about

character style, major attributes to which one should be attendant include

the nature of drives, urges, and wishes (and defenses thereagainst); styles


of cognition; affective experience; and patterns of interaction. The therapist

should attend to the quality of these factors in the patient's reported

concerns and history and in the manner of interaction with the therapist.

The manner in which the patient approaches the treatment relationship in

terms of what is wished for, needed, or feared by the patient is particularly

relevant.

Orally fixated individuals, represented by trauma or irregularities of

gratification approximately from birth through 18 months of age, have

concerns that primarily revolve around dependency and soothing and

exhibit excessive self-focus. Their struggles to obtain oral gratification

manifest in concerns about whether their needs are being met.

Anally fixated individuals, represented by trauma or irregularities of

gratification approximately between the ages of 18 months to 3 years, show

concerns or conflicts primarily revolving around issues of control and

manipulation in the context of a dyadic dynamic in which a wish to control,

dominate, or defeat others is prominent. Feelings of envy and control or

containment of aggression are characteristic problems. Competition, when

observed, is in the service of domination (dyadic) as opposed to winning a

prize (triadic). Defensive operations involving isolation and undoing are

enlisted in attempts to avoid the threat of impulses, wishes, and urges.

Shapiro (1965) described individuals with anal character styles (in the

neurotically organized ego range) as "automatons" because of their

rigidity and loss of autonomy or free will in attempts to eliminate id-driven

wishes or impulses that are experienced as threatening. Individuals with

anal character styles have often been described in the literature with terms

such as compulsive or obsessive-compulsive (e.g., Reich, 1933/1972;

Shapiro, 1965).

Individuals with phallic character styles, represented by trauma or

irregularities of gratification approximately between the ages of 3 to 6

years, struggle with issues of competition, jealousy, guilt, and shame

seeded in Oedipal conflict. Of the neurotic conditions, none has more

definitively or clearly been associated with specific defensive operations

than has hysteria with repression (Shapiro, 1965, p. 108). Individuals with

hysterical character styles tend to manifest high affectivity and high

interpersonal intensity (McWilliams, 1994, p. 302). The nature of the

primary conflicts in these individuals is triadic and marked not only by

feelings of jealousy ("I want who [or what] you have") but also by strong

superego-based guilt that may result in intrapsychic anxiety and behavioral

conformity or restraint. Repression of the conflict results in heightened

anxiety as the individual struggles to contain competitive impulses, and


anxiety may be rooted in unconscious fears characteristic of this character

style. Selected self-representations in such individuals may be marked by

weakness, insignificance, and inadequacy. Defensive operations may lead

to outwardly sexual, seductive, or self-aggrandizing presentations as coun-

terreactions to such self-representations.

Level of Adaptive Functioning

In the process of conceptualization, it is important to consider not only

issues of ego organization and character style but, secondarily, the level of

adaptive functioning at which a patient presents. In our view, level of

adaptive functioning is reflective of the degree to which the individual is

able to maintain adaptive functioning or has become debilitated in light of

underlying structural deficits, character pathology, or both. Level of

adaptive functioning is reflected in the intensification and development of

problems representative of the breakdown in the individual's ability to

cope internally with intrapsychic conflict, thus resulting in compromises or

defensive operations that are associated with maladaptive behaviors, over-

whelming affects, symptom formation, or all three.

Level of adaptive functioning should be thought of as a continuum

from adaptively functioning (characteristically adaptive and relatively

symptom-free) to fully impaired (exhibiting maladaptive debilitated func-

tioning and full symptom formation), similar to the manner in which ego

organization is represented as a continuum from neurotic to psychotic

organization. However, for ease of presentation, three basic levels or

degrees are differentiated. These degrees are (a) adaptively functioning, (b)

partially impaired, and (c) fully impaired (see Figures 1,2, and 3).

Individuals who are functioning adaptively will rarely seek treatment

and will be free of disruptive and debilitating symptoms (Figure 1).

Adaptively functioning neurotically organized individuals tend to be

flexibly assertive and asymptomatic. When unburdened by any conspicu-

ous fixations in character style, they represent the most healthy type of

individuals. They display a healthy balance between concerns for self and

concerns for others. Adaptively functioning individuals at the borderline

level of ego development tend to be self-absorbed and exploitative of

others, with these attitudes being completely ego-syntonic. They do not

experience clinically significant depression, anxiety, or other psychiatric

symptoms. Likewise, the functioning of psychotically organized individu-

als who are adaptively functioning is ego-syntonic. These individuals tend

to be avoidant and guarded. They tend to be isolated individuals who keep


Ego Development Level

Neurotic Borderline Psychotic

Oral

Anal

Flexibly

Assertive

And

Asymptomatic

Self-Absorbed

-

And

Exploitative

Avoidant

-

And

Guarded

Figure 1. Characteristics of adoptively functioning individuals. (Note:These individuals rarely seek treatment).

interpersonal interactions to a minimum. They give little to others interper-

sonally, but neither do they make demands.

Although adaptively functioning individuals display minimal overt

symptom development, those who are partially impaired or fully impaired

show symptom development and compromised functioning. Figure 2



U

Oral

Anal

Phallic

Intensification ofAnxiety/

"Actual Neurosis"/

DepressivePersonality

Intensification of

Anxiety/"Actual Neurosis"/

ObsessivePersonality

Intensification ofAnxiety/

"Actual Neurosis"/HystericalPersonality

Intensificationof

" Self-ProtectiveBehavior

And

Ruthlessness

Intensificationof

ParanoidGuardedness

And

Suspiciousness

Figure 2. Characteristics of partially impaired individuals.


Iu

Oral

Anal

Phallic



"Neurotic"

Depression

Obsessions and

Compulsions

Hysterical

Conversion/Phobia

BorderlinePersonality

Disorder

Sadistic/

Masochistic/

Antisocial

Personalities

Narcissistic and

Histrionic

Personality

Disorders

Schizophrenia/Psychotic

Depression

Paranoia

(Delusional

Disorder)

Manic- Depression/

"Hysterical

Psychosis"

Figure 3. Prototypical disorders characteristic of fully impaired individu-

als. We wish to express our gratitude to Rycke L. Marshall for her assistance

in delineating the placement of the prototypical disorders.

displays characteristics of partially impaired individuals. In neurotically

organized individuals, partial impairment is manifested by intensification

of general (particularly somaticized) anxiety, feelings of listlessness and

fatigue, or both. In the past these two syndromes were grouped under the

heading of the actual neuroses and were referred to as anxiety neurosis and

neurasthenia, respectively (Freud, 1895/]962a, 1898/1962b). Despite the

fact that Freud's ideas about the pathogenesis of these two conditions have

been revised (e.g., Giovacchini, 1987, p. 183), they remain descriptively

useful. Fenichel (1945, pp. 185-192) also used the phrase "actual neuro-

sis" to describe the beginning stages of a symptom disorder in neurotically

organized individuals. With partial impairment, individuals whose function-

ing is at the neurotic level of ego organization will manifest an intensifica-

tion of their depressive, obsessive, or hysterical personality traits on the

basis of their basic character style (oral, anal, and phallic, respectively).

Partial impairment in the face of stress for those individuals at the

borderline level of ego development will result in (compared with adap-

tively functioning borderlines) an intensification of their self-protective

behavior and ruthlessness, whereas those at the psychotic level of ego

organization will manifest (compared with adaptively functioning psychot-

ics) increased paranoid guardedness and suspiciousness.

Figure 3 presents the major diagnostic classifications associated with


full impairments. We believe the disorders listed to be consistent with the

bulk of psychopathology literature and only prototypical of the particular

categories we have delimited, not exhaustive of all diagnostic classifica-

tions. Other disorders (e.g., addictions, eating disorders), may span the

boundaries of our categories. That is, in some cases an individual with

these other disorders will most accurately be classified in one category,

whereas other individuals will fit best into another.

Full impairment in neurotically organized individuals is associated

with the development of the classic neurotic symptoms. Fully impaired

neurotics with oral character styles will present with serious depression,

characteristics of extremely dependent personality disorder, or both; fully

impaired neurotics with anal character styles will often present with

distinct and ego dystonic obsessive symptoms, compulsive symptoms, or

both; and fully impaired neurotics with phallic character styles often

display hysterical conversion symptoms or phobias (see Figure 3).

In individuals organized at the borderline level, full impairment

results in the manifestation of the more severe personality disorders. Fully

impaired individuals with borderline organization and an oral character

style will present with an exaggeration of those symptoms classically

associated with borderline personality disorder (i.e., intense, unstable, and

reactive affect; intense and unstable interpersonal relationships; intense

and unstable self and object representations; impulsivity; rage; and intense

abandonment fears); fully impaired individuals with borderline organiza-

tion and an anal character style will manifest more overt masochistic and

sadistic disorders, and when further combined with serious superego

deficits, antisocial patterns are exhibited; fully impaired individuals with

borderline organization and a phallic character style struggle with the

combination of Oedipal conflict associated with phallic character issues

and deficiencies in self and object representations resulting from ego

development deficits. They may well manifest severe narcissistic personali-

ties (as described by Kernberg, 1975,1984) or the more regressive forms of

the hysterical-variety personality disorders referred to in the psychoana-

lytic literature as hysteroid (Easser & Lesser, 1965), Zetzel type 3 and 4

(Zetzel, 1968), or infantile (Kernberg, 1975) personalities.

Psychotically organized individuals, when fully impaired, exhibit

overt psychotic symptoms reflected, for example, in the presence of

schizophrenia, delusional disorders, and manic-depressive psychosis. Fully

impaired psychotics with oral character styles will typically exhibit psy-

chotic depression or schizophrenia; fully impaired psychotics with anal

character styles tend to have paranoid or delusional disorders; and fully


impaired psychotics with phallic character styles we believe present with

manic-depressive psychosis or what has been referred to in the literature as

hysterical psychosis (Hollender & Hirsch, 1964; see Figure 3).

Verification of Conceptualization Through Assessment of Primary

Dynamics/Major Conflicts

Once one has a reasonably comprehensive conceptual understanding of the

pathology of the patient, it is wise to seek verification of one's diagnostic

hypotheses by attending to primary dynamics reflected in the therapeutic

relationship and in the content of the patient's descriptions of self,

relationships, and problems. Table 2 summarizes the major points. Lest the

reader be confused, we want to clarify that in our presentation of Table 2

and elsewhere (e.g., Figure 3), we discuss dynamics, conflicts, and de-

fenses that we consider prototypical of one form of psychopathology or

another, such as a particular level of ego development or a particular

character style. We contend that these dynamics, conflicts, and defenses are

primary to these forms of psychopathology because of their prevalence, not

their exclusivity. It is common, in fact, to observe a variety of conflicts and

concerns in any individual. Our formulations reflect our view that particu-

lar conflicts or concerns are more frequently associated (not exclusively

associated) with particular forms of psychopathology.

With regard to issues of level of ego organization, one should find in

neurotically organized individuals feelings of guilt or shame as the primary

dynamic; in borderline organized individuals themes of separation, aban-

donment, and betrayal should appear; and in psychotically organized

individuals fears of annihilation and loss of self should be evident. With

regard to character style, in orally fixated individuals, one should find

themes of self-focus and wishes to be gratified, soothed, or taken care of. In

anally fixated individuals, one should find dyadic conflicts marked by

Table 2

Prototypical Primary Dynamics and Major Conflicts

Dimension Dynamic/conflict

Ego development levelNeurotic Guilt or shameBorderline Separation, abandonment, betrayalPsychotic Annihilation, engulfment, loss of self

Character styleOral Self-focus: "What about my needs?"Anal Dyadic: "I want to control/dominate you"Phallic Triadic: "T want what/who you have"


wishes to control or dominate others and defenses against aggressive

wishes. Lastly, in phallically fixated individuals, one should find triangular

conflicts marked by wishes for and defenses against competitive strivings.

Part II: Treatment Considerations

When approximations of the primary dimensions and augmentative vari-

ables discussed above have been established, the following guidelines

regarding treatment planning should be observed: (a) issues of ego organi-

zation and character style take precedence in treatment planning in that

these issues dictate basic goals and approaches to treatment; (b) in most

individuals, symptoms of full impairment must be addressed in the early

treatment phases in order to involve them in the treatment process; and (c)

character style considerations are most salient in dictating treatment

approaches when an individual has been assessed to be functioning at the

neurotic level of ego development. It should be noted that individuals with

disorders thought to have a significant biological component (e.g., schizo-

phrenia, and some forms of depression and manic-depression) will rarely

seek or require treatment when symptom-free or in medication remission.

Tables 3, 4, and 5 summarize the focal treatment issues. Note that this

section on treatment is not intended to be a comprehensive treatise on

psychoanalytically oriented therapeutic techniques but rather is intended to

supplement and complement such writings by emphasizing fundamental

ideas about the treatment of various forms of psy chopathology. There are a

Table 3

Treatment Planning for Individuals at the Neurotic Level of Ego Development

Character style Treatment considerations

All styles Resolution of neurotic conflict (primary goal)Neutralization of neurotic defensesEasing of prohibitive superegoDevelopment of understanding into how symptoms are maintainedDevelopment of understanding into how symptoms create interpersonal distance

Oral Treatment goals listed for all stylesEncourage empathy

Anal Treatment goals listed for all stylesConfront contentExplore affect

Phallic Treatment goals listed for all stylesConfront affectExplore content

Note. These individuals rarely seek treatment when functioning adaptively; may need to assist instabilization if severely fully impaired.


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Table 5

Treatment Planning for Individuals at the Psychotic Level of Ego Development

Level of adaptive functioning Treatment considerations

All styles PacifyStabilizeSupport

Functioning adaptively Treatment goals for all stylesRemain at supportive levelGuard against tendency to uncover and explore

Partially impaired Treatment goals for all stylesReinstate and reinforce defensive functioningConsider environmental manipulationConsider medication to promote stabilization

Fully impaired Treatment goals for all stylesMedication and hospitalization frequently required to achieve

superordinate treatment goalsOnce stabilized, follow prescription for partially impaired

psychotically organized individual

Note. These individuals rarely seek treatment when functioning adaptively. Character style issuesare minimally important at the psychotic level of ego organization; ego development concerns takeprecedence.

number of guides to the practice of psychoanalytically based psycho-

therapy one may wish to consult. These include the works of Friedman

(1988), Greenson (1967), Kernberg (1975, 1976, 1980, 1984), Langs

(1978, 1979, 1980, 1981a, 1981b), and Paul (1973, 1997), as well as

numerous others. We also hasten to mention that our treatment guidelines

cannot and must not be applied mechanically. Instead, they must be

implemented within the context of a relationship between patient and

therapist characterized by features such as empathy, respect, and collabora-

tion. A sound therapeutic alliance/relationship is considered the essential

prerequisite to treatment.

If an individual is thought to be neurotically organized, the superordi-

nate treatment goal is the resolution of the neurotic conflict. At times,

however, severe impairments in adaptive functioning in neurotics must

first be addressed in order to ensure an opportunity to conduct treatment.

For example, life-threatening suicidal ideation may need to be dealt with

directly, or serious symptoms (e.g., lethargy, compulsive rituals, agorapho-

bia) that interfere with the individual's attendance in therapy must be

addressed. A variety of techniques may be used in helping the fully

impaired neurotically organized individual reestablish a higher degree of

functionality. These techniques include providing opportunities for cathar-

sis, supportive interventions, drawing family members into treatment,


providing behavioral recommendations, prescription of medication, and

hospitalization. Space does not permit a complete coverage of techniques

available to address these treatment limiting factors, but the reader is

encouraged to consult other sources (e.g., Bellak, 1992; Puryear, 1979).

Most neurotically organized individuals have the capacity and stabil-

ity to tolerate intensive exploratory treatment without inducing further

functional impairment. Thus, to the extent that the patient's symptomatol-

ogy is not so severe as to put life in danger or disturb functioning to the

point of interfering with the patient's ability to attend therapy, it becomes

necessary to focus on the accomplishment of the superordinate goal (i.e.,

resolution of the neurotic conflict). To achieve the superordinate goal, one

must help the individual to neutralize neurotic defenses, address superego

prohibitions, assist in the development of understanding into how the

expression of symptoms is maintained, and promote understanding into

how symptoms create or maintain interpersonal distance. Each character

style is associated with particular types of defenses, styles of superego

functioning, symptoms, and self-defeating patterns by which these symp-

toms maintain interpersonal distance. Table 3 summarizes the major points.

Neurotically organized individuals with an oral character style can

benefit most from a treatment approach that encourages the development of

empathy because these individuals are excessively self-focused. Their

neediness and dependency interferes with their ability to form mutually

satisfying interpersonal relationships. In other words, individuals with this

character style have an insatiable hunger that leads to an excessive focus on

one's own needs and excludes a reasonable consideration of others' needs.

Passivity may need to be addressed in the oral neurotic, who may become

passive secondary to a fear that expression of aggression will result in the

loss of a needed source of gratification.

Treatment of neurotically organized individuals with an anal charac-

ter style must take an approach that confronts the defensive use of

cognition (the more common defense mechanisms being intellectualiza-

tion, obsessive doubting, compulsivity, etc.) and encourages the explora-

tion of emotion. Intellectualization must be curtailed, and doubting and

procrastination must be addressed. This sometimes begins with a basic

labeling process whereby bodily sensations experienced by the individual

are labeled by the therapist with affectively descriptive terms. Superego

prohibitions of aggression are common and defended against through the

mobilization of attempts to isolate id urges and channel them into rigidly

controlled intellectualized pursuits. Passivity may also be a problem; the

individual unconsciously experiences danger in the destructive force of his

354 TRMBOLI AND FARR

or her own aggression and overcompensates for or suppresses it. Thus, as

in the treatment of an oral neurotic, passivity may need to be addressed,

though the underlying dynamics differ: Passivity in the anal character style

occurs out of fear of the sheer destructive force of one's aggression,

whereas passivity in the oral character style is more need-driven in that the

experienced threat is related to the fear that expression of aggression will

result in the loss of a needed source of gratification. Treatment of the anal

neurotic must involve the gradual development of insight into underlying

threatening emotions. Neutralization of cognitive defenses helps this to

take place. Successful treatment will also address the interpersonal dis-

tance (rigidity and lack of emotional involvement) that results from the

anal dynamism.

In contrast to the treatment approach discussed immediately above,

treatment of neurotically organized individuals with a phallic character

style must involve confrontation of the defensive use of affect in order to

neutralize the defenses, thereby allowing for an exploration of the content

of one's wishes and thoughts, which will encourage the development of

logical thought and causal thinking. In these individuals, superego prohibi-

tions of sexualized and competitive wishes often lead to the repression of

such wishes, which are often masked with excessive emotionality, confron-

tation of which will help neutralize such defenses, providing an opportu-

nity for increased self-understanding.

Table 4 displays the focal issues in the treatment of individuals

functioning at the borderline level of ego development. In the treatment of

such individuals, promotion of object constancy always should be the

overriding goal. To achieve this, the maintenance of consistent and clear

therapeutic boundaries is essential when performing psychotherapy. Unfor-

tunately, borderline organized individuals suffer from significant func-

tional impairments more frequently than those with neurotic ego organiza-

tions, and the impairments are often associated with life threatening

symptoms that demand urgent attention. One may find oneself forced into a

crisis intervention mode of treatment as opposed to psychotherapy. Medi-

cation may provide a modicum of stability through which treatment can be

enhanced.

Adaptively functioning individuals organized at the borderline level

rarely present for treatment because their problems tend to be ego syntonic.

When they are distressed, they typically see their upset as a legitimate

reaction to their circumstances, or they perceive they have been provoked

by others. Therefore, when they do present for treatment, it is often a

mandated participation, perhaps ordered by a court of law, or occasionally


at the urging of a spouse or family member. It is typically very difficult to

engage such individuals in the treatment process (i.e., they are not open to

the formation of a working alliance). The general guidelines provided

below for the treatment of partially impaired borderline individuals should

be borne in mind, though in cases of highly resistant individuals the heavy

use of didactic approaches may be of benefit; at least the individual may

learn something that they may make use of at a later time when they are

more open to alternative modes of thinking or behavior.

Partially impaired and fully impaired borderline organized individu-

als present some of the greatest challenges to psychotherapists and are

often considered to be "difficult" patients. They may be experienced as

demanding, unstable, ruthless, manipulative, exploitative, seductive, dan-

gerous, etc. Treatment of borderline organized individuals when they are

partially impaired must address and confront the use of splitting (a direct

consequence of the lack of object constancy) as the primary defense

mechanism along with nurturing and supporting higher level defensive

operations when any evidence of them is observed. Moreover, an examina-

tion of acting out behavior will often help the individual to understand

triggers and self-defeating consequences to these behaviors. Lacking in

skills, these individuals may need to be taught alternatives to acting out.

When fully impaired, ego functioning in borderline individuals may be so

seriously impaired that the individual is functioning much as a psychotic

individual might. In these cases, it becomes necessary to treat the indi-

vidual as if he or she were indeed psychotic (see below). When the

individual regains a modicum of stability, one can transition to treating the

individual according to the guidelines for partially impaired individuals at

the borderline level of ego organization.

Character style influences can often be observed in partially impaired

and fully impaired borderline organized individuals, and although issues

related to character style are secondary in importance to those related to

ego deficits in the conceptualization and treatment of these individuals,

they are nonetheless important. In an orally fixated, partially impaired

borderline organized individual, for instance, one must be alert to intense

engulfing transferences and to the possibility that such individuals may

engage in self-destructive (e.g., self-mutilating) acts. The danger of self-

destructiveness becomes particularly acute when the individual is judged

to be fully impaired, at which point it is highly likely that steps may need to

be taken to ensure the safety of the individual (e.g., hospitalization).

Individuals in this category at times may also pose a threat to the physical

safety of others, against whom unmodulated rage may be directed. (Note

356 TRIMBOLI AND PARR

that risk of self-destructiveness in these individuals is greater than risk to

others, though the reverse is true for fully impaired anally fixated border-

line individuals; see below). In tandem with addressing risk of harm to the

patient and others, one should look for opportunities to confront appetitive

instability in order to help the individual develop some degree of ego

awareness and, thus, hopefully, affective modulation.

In partially impaired and fully impaired borderline-organized individu-

als who are anally fixated, one must be alert to aggression in the transfer-

ence, which can threaten the treatment. And in some cases of partially

impaired and many cases of fully impaired borderline individuals with an

anal character style there may be a danger that serious and/or poorly

modulated aggression may present a danger to others, and the therapist will

need to consider the appropriateness of taking steps to protect potential

victims. One should look for opportunities to confront and neutralize

aggression in these individuals.

A primary concern in the treatment of partially impaired and fully

impaired borderline individuals with a phallic character style is likely to be

the management of idealization in the transference. Recall that these

individuals typically present with narcissistic disorders. Though there is

some debate in the literature (with Kernbergians on the one side [e.g.,

Kernberg, 1975, 1976, 1984] and Kohutians on the other [e.g., Kohut,

1971, 1977; Kohut & Wolf, 1978]) about the most effective treatment

techniques for dealing with the idealizing transferences of narcissistic

individuals, there is little argument that it must be addressed.

Table 5 indicates that character style issues are of only minor

importance in the treatment approach of individuals assessed to be function-

ing at a psychotic level of ego development. Because of the severity of ego

deficits in these individuals, which leaves them susceptible to disorganized

and fully impaired functioning, treatment considerations must focus fore-

most on dealing with the weak ego, along with a consideration of the level

of adaptive functioning. The superordinate treatment goals for individuals

who are psychotically organized should emphasize pacification, stabiliza-

tion, and support because of the fragility in the ego and the tendency for

these individuals to decompensatc along the ego line of development.

Medication is commonly necessary.

Psychotically organized individuals who are adaptively functioning

rarely seek treatment. When they do, it is important to remain at the

supportive level therapeutically. There may be a temptation to explore and

uncover and to establish a treatment environment (e.g., including neutrality

and transference interpretation) more appropriately suited for neurotically


organized individuals because the individual may outwardly seem stable

and may exhibit only very subtle signs of reality impairment that can be

easily overlooked. Perhaps the individual appears slightly odd or eccentric

but seems otherwise lucid and organized. Nevertheless, one must resist the

temptation to treat the individual as one would someone functioning at a

higher level of ego development or run the risk of precipitating a decompen-

sation in the individual's level of adaptive functioning.'

In psychotically organized individuals who are more obviously fully

impaired, treatment often requires more active and invasive procedures,

along with a level of case management. Those who are partially impaired

require a focus on reinstating and reinforcing defensive functioning, lest

they become overwhelmed by primary process material and further disor-

ganized. It may be necessary to instigate environmental manipulation, such

as encouraging changes in work or home environment. The therapist must

take an active role in decision making and problem solving and must be

willing to be disclosing of one's own thoughts or feelings so as to preclude

the development of a transference heavily based in the patient's fantasy

life. Medication is often indicated to promote stabilization.

Finally, for individuals who are psychotically organized and fully

impaired, the initial treatment approach will require a high degree of

pacification in regards to primary process material and assistance in

stabilization. This approach frequently requires the use of medication and

hospitalization, with pacification and support being provided through the

hospital milieu, which in addition provides a measure of safety. Once the

individual has stabilized, treatment should follow the approach used for

treating partially impaired psychotically organized individuals.

The above has been an endeavor to articulate a strategy for conceptu-

alizing psychopathology to ensure appropriate treatment interventions. We

attempted to describe psychopathology as a function of two primary

dimensions and two augmentative variables designed to assist the practi-

tioner in using the appropriate treatment for various individual psychopa-

thologies. This is not intended to provide an exhaustive method for use

with all patients. We acknowledge that this is but an example of how

psychopathology may be conceptualized from within one particular para-

digm, and comparable models can be used by individuals practicing from

other comprehensive frameworks of psychopathology. Particularly in this

1 In years past, when clinical decisions were not dictated by business practices,one would likely have sought psychological testing to help in the differential diagnosisof individuals who were suspected of having severely compromised ego developmentdespite showing no obvious signs of psychotic symptomatology.


era when clinicians are faced with encumbrances of arbitrary limitations

imposed by cost containment plans and thus are not free to practice in such

a way that allows for a thorough evaluation of their patients, conceptualiza-

tions such as these will hopefully ensure more efficient treatment practices

by guiding appropriate clinical interventions.

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