Psychoanalytic Psychology
2000, Vol. 17. No. 2, 336-359
Copyright 2000 by the Educational Publishing Foundation
0736-9 73 5/00/$5.00 DOI: 10.1037//0736-9735.17.2.336
A Psychodynamic Guide for Essential
Treatment Planning
Frank Trimboli, PhD
University of Texas Southwestern Medical Center at Dallas
and Dallas, Texas
Kenneth L. Farr, PhD
University of Texas at Arlington and Arlington, Texas
This article presents a model for conceptualizing psychopathology designed to assist practitioners in evaluating patients and
applying effective treatment plans. The model describes psychopathology 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 of
Texas 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.
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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. Regardless, 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 constrictions 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 conceptualization 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
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TRIMBOLI AND FARR
types of character styles. The stage model posits a psychosexual developmental 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 excessive 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 treatment of patients with borderline conditions (e.g., Kernberg, 1984, p. 3).
Kernberg has demonstrated that the borderline conditions can be characterized (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 psychopathology 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
PSYCHODYNAMIC GUIDE
339
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 conceptualization 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 organization 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 individual 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 maintain a sense of one's positive qualities or an ability to credit accomplishments at the same time. Others are perceived in a shallow, impoverished
TRIMBOLI AND FARR
340
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Impulse control
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Table 1
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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 disappointment with or rage toward a spouse, the spouse is thoroughly devalued and
affectively cathected positive aspects cannot be simultaneously maintained. Though borderline and psychotically organized individuals both
may be described as displaying identity diffusion, there are some differences 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 sophisticated 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
342
TRIMBOLI AND FARR
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 experience 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 existence 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, defenses organized around repression, and intact reality testing, the individual would be judged to have a neurotic structural organization. To the
extent that an individual manifests identity diffusion, has defenses organized 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 organized 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 experience 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). Kemberg (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
PSYCHODYNAMIC GUIDE
343
is typically impaired and marked by primitive superego precursors, particularly primitive sadistic and idealized object representations. Taken together, 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 borderline and psychotically organized individuals, neurotics furthermore have a
greater capacity to observe their own pathology, tend to develop transferences marked more by ambivalence than the strong yet fluctuating transferences 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 understanding 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 irregularities 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 contemporaries, 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 comprehensively 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
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TRIMBOLI AND FARR
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
PSYCHODYNAMIC GUIDE
345
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 counterreactions 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, overwhelming 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 functioning 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 conspicuous 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 individuals who are adaptively functioning is ego-syntonic. These individuals tend
to be avoidant and guarded. They tend to be isolated individuals who keep
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TRIMBOLI AND FARR
Ego Development Level
Neurotic
Borderline
Psychotic
Self-Absorbed
Avoidant
Flexibly
Oral
-
Assertive
-
And
And
Exploitative
Guarded
Anal
And
Asymptomatic
Figure 1. Characteristics of adoptively functioning individuals. (Note:
These individuals rarely seek treatment).
interpersonal interactions to a minimum. They give little to others interpersonally, 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
Ego Development Level
Neurotic
Oral
Anal
U
Phallic
Intensification of
Anxiety/
"Actual Neurosis"/
Depressive
Personality
Intensification of
Anxiety/
"Actual Neurosis"/
Obsessive
Personality
Intensification of
Anxiety/
"Actual Neurosis"/
Hysterical
Personality
Figure 2.
"
Borderline
Psychotic
Intensification
of
Intensification
of
Self-Protective
Behavior
Paranoid
Guardedness
And
And
Ruthlessness
Suspiciousness
Characteristics of partially impaired individuals.
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PSYCHODYNAMIC GUIDE
Ego Development Level
Neurotic
Borderline
Oral
"Neurotic"
Depression
Borderline
Personality
Disorder
Schizophrenia/
Psychotic
Depression
Anal
Obsessions and
Compulsions
Sadistic/
Masochistic/
Antisocial
Personalities
Paranoia
(Delusional
Disorder)
Narcissistic and
Histrionic
Personality
Disorders
Manic- Depression/
"Hysterical
Psychosis"
I
u
Phallic
Figure 3.
Hysterical
Conversion/
Phobia
Psychotic
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 neurosis" to describe the beginning stages of a symptom disorder in neurotically
organized individuals. With partial impairment, individuals whose functioning is at the neurotic level of ego organization will manifest an intensification 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 adaptively 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 psychotics) increased paranoid guardedness and suspiciousness.
Figure 3 presents the major diagnostic classifications associated with
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TRIMBOLI AND FARR
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 classifications. 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 organization 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 personalities (as described by Kernberg, 1975,1984) or the more regressive forms of
the hysterical-variety personality disorders referred to in the psychoanalytic 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 psychotic depression or schizophrenia; fully impaired psychotics with anal
character styles tend to have paranoid or delusional disorders; and fully
PSYCHODYNAMIC GUIDE
349
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 defenses 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 particular 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, abandonment, 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
Ego development level
Neurotic
Borderline
Psychotic
Character style
Oral
Anal
Phallic
Dynamic/conflict
Guilt or shame
Separation, abandonment, betrayal
Annihilation, engulfment, loss of self
Self-focus: "What about my needs?"
Dyadic: "I want to control/dominate you"
Triadic: "T want what/who you have"
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TRIMBOLI AND FARR
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 variables discussed above have been established, the following guidelines
regarding treatment planning should be observed: (a) issues of ego organization 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., schizophrenia, 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 defenses
Easing of prohibitive superego
Development of understanding into how symptoms are maintained
Development of understanding into how symptoms create interpersonal distance
Oral
Treatment goals listed for all styles
Encourage empathy
Anal
Treatment goals listed for all styles
Confront content
Explore affect
Phallic
Treatment goals listed for all styles
Confront affect
Explore content
Note. These individuals rarely seek treatment when functioning adaptively; may need to assist in
stabilization if severely fully impaired.
PSYCHODYNAMIC GUIDE
351
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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
Pacify
Stabilize
Support
Functioning adaptively
Treatment goals for all styles
Remain at supportive level
Guard against tendency to uncover and explore
Partially impaired
Treatment goals for all styles
Reinstate and reinforce defensive functioning
Consider environmental manipulation
Consider medication to promote stabilization
Fully impaired
Treatment goals for all styles
Medication and hospitalization frequently required to achieve
superordinate treatment goals
Once stabilized, follow prescription for partially impaired
psychotically organized individual
Note. These individuals rarely seek treatment when functioning adaptively. Character style issues
are minimally important at the psychotic level of ego organization; ego development concerns take
precedence.
number of guides to the practice of psychoanalytically based psychotherapy 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 collaboration. A sound therapeutic alliance/relationship is considered the essential
prerequisite to treatment.
If an individual is thought to be neurotically organized, the superordinate 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, agoraphobia) 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 catharsis, supportive interventions, drawing family members into treatment,
PSYCHODYNAMIC GUIDE
353
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 stability to tolerate intensive exploratory treatment without inducing further
functional impairment. Thus, to the extent that the patient's symptomatology 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 symptoms 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 character style must take an approach that confronts the defensive use of
cognition (the more common defense mechanisms being intellectualization, obsessive doubting, compulsivity, etc.) and encourages the exploration 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 distance (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 prohibitions of sexualized and competitive wishes often lead to the repression of
such wishes, which are often masked with excessive emotionality, confrontation of which will help neutralize such defenses, providing an opportunity 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. Unfortunately, borderline organized individuals suffer from significant functional impairments more frequently than those with neurotic ego organizations, 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. Medication 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
PSYCHODYNAMIC GUIDE
355
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 individuals 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, dangerous, 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 examination 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 individual 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 selfdestructiveness 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 borderline 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 individuals who are anally fixated, one must be alert to aggression in the transference, 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 functioning 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 foremost 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, stabilization, 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
PSYCHODYNAMIC GUIDE
357
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 decompensation 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 disorganized. 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 conceptualizing 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 practitioner in using the appropriate treatment for various individual psychopathologies. 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 paradigm, 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 diagnosis
of individuals who were suspected of having severely compromised ego development
despite showing no obvious signs of psychotic symptomatology.
358
TRIMBOLI AND FARR
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, conceptualizations such as these will hopefully ensure more efficient treatment practices
by guiding appropriate clinical interventions.
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