16 Mar Personality Disorders – The Three Levels of Personality Organization
In this article we will explore Object Relations Theory of Personality Disorders introduced by theorist and researcher Otto Kernberg, Dr. Kernberg is an object relations theorist, a psychoanalyst and professor of psychiatry at Weill Cornell Medical College. He is most widely known for his psychoanalytic theories on borderline personality organization and narcissistic pathology. He is founder of transference focused psychotherapy He is one of the more influential voices today on the subject of severe personality disorders. In order to understand his work, it is helpful to understand the object relations theory upon which it is based.
According to object relations theory, beginning during infancy, people develop “internal representations” of themselves and of other people. Representations of the self ultimately give rise to what is popularly known as the “self-concept.” Similar representations form as a means of organizing knowledge of other people. Though these representations are of people, the psychodynamic tradition is to refer to them as “objects” thereby highlighting the distinction between two people; the person of the self who is the observer, and the person being observed, the object. Thus, a person’s internal representations of self-and-other (self-and-object) and their representation of how self-and-other get along are collectively known as internal object relations. These object relations are seen as the building blocks organizing people’s internal life, including their motivations and behavior.
The information stored within internal object relations includes the emotional tone of those relations; i.e., the emotional tone of what it is like for the self-and-other to interact with each other. Though many emotions may occur within the context of a given relationship, there is generally a dominant tone, or “affect” which reflects the way each relationship usually feels.
As infants interact with their caregivers, they begin to form internal object relations to represent these interactions. This experience is stored along with the intense emotional states that accompanied these interactions with the “object” (caregiver). It is assumed that infants do not yet experience nuanced emotions so these emotional states are generally of extreme pleasure or extreme displeasure. It is during these intense emotional states that infants develop a representation of self in relation to the other person (object). Depending on how such interactions go, these representations can take different forms. An example would be a representation of a terrified, weak self (the child) and a powerful, threatening object (the caregiver) linked together through the affect of fear.
Although object relationships are based upon actual interactions, they are not necessarily realistic and unbiased records of those interactions. Instead, they combine early impressions and memories, with fantasized interactions with others. The factual and fantasized information become blended together, all organized according to the dominant affect that is characteristic of that relationship. Once formed, these object relationship pairs (self-other dyads) function as templates through which later relationships may be understood. These internal object relation dyads are activated in future relationships and influence, or even determine, how people will experience and relate to others. Thus, they function as a sort of lens which colors people’s perceptions and expectations of their future relationships.
In very early stages of infant development, it is thought that positively-toned object relationships get built up separately from those associated with negative affect. Thus, an infant would be expected to have two separate object representations for each object; for instance, a good mommy object to store positively-toned affects and a bad mommy object used to store negatively-toned affect. Over the course of normal childhood development and maturation, these two polarized representations would normally be expected to integrate into a single, more complex object representation containing both positive and negative affects associated with mommy. In other words, it becomes understood that “good mommy” and “bad mommy” represent the same person. Thus they become integrated into a single representation. However, in some cases, this integration does not occur. This lack of integration sets up a foundation upon which a personality disorder may occur.
According to Kernberg, healthy adult personality organization requires that these early positively and negatively toned object relations become integrated and organized into a cohesive whole. This is because the world is complex and cannot be accurately represented by emotionally polarized, simplistic representations. A healthy personality must be able to accommodate this complexity and to capture the diversity and nuance of emotional reactions that may be provoked. Therefore, people with healthier personalities, based on integrated objects relations, develop this fairly realistic and accurate view of themselves and others. They are capable of representing both strengths and weaknesses (good and bad qualities) at the same time. This allows for the ambivalent and contradictory feelings that such mixed qualities may provoke.
Less healthy personalities are based on persistently polarized, and not-yet-integrated object relations. They cannot represent something that is both good and bad at the same time. Instead, good and bad representations are “split-off” from one another. The best such a personality organization can manage is to switch back and forth from one polarized “all good” or “all bad” object representation to another. In so doing, they rapidly switch from strongly negative feelings, to strongly positive ones, and then back again. This disintegrated personality organization, based on persistently polarized object relations, is characteristic of individuals who are diagnosed with severe personality disorders.
Having fragmented, extreme, and split-off, self-other representations interferes with a person’s ability to develop a consistent sense of self, and a consistent sense of other people. Frequently, people with these split-off representations of themselves do not feel like they are the same person across time and situations. They may feel very differently about themselves and their lives from one day to the next. Similarly, they perceive their relationship partners as having very different qualities at different times. It is perhaps not at all surprising that such individuals would act in ways that reflect their changeable perceptions of self and others. For instance, an inconsistent sense of self may mean frequently changing careers, relationship partners, living arrangements, and even life goals and values. Under such circumstances, genuine intimacy becomes elusive.
It may be difficult to imagine what a disintegrated personality organization would feel like if you yourself are in possession of an integrated personality organization. By way of illustration, suppose you have a friend who is very honest and forthright. You value your friend’s honesty because you know you can always count on her to “tell it like it is.” However, sometimes the blunt way she delivers this information seems a bit insensitive to you. You might reflect on this relationship and say to yourself, “I sure do like my friend’s honesty but I’m not always so fond of her bluntness.” However, disintegrated personalities would experience this friend quite differently. In one moment, they will be completely in awe of their friend’s honesty, and head-over-heels enamored with her. In the next moment, as they begin to experience their friend’s insensitive delivery of information, they will completely despise and hate her for hurting their feelings. This is because people with disintegrated personalities simply cannot experience both the good and bad qualities of a person simultaneously. At this point, it is fairly easy to imagine that such rapidly shifting experiences of self-and-others causes some very intense feelings. These intense feelings may lead to extreme behaviors that often result in conflict and disillusionment. It is also possible to imagine the hurt, anger, and confusion that are felt by the other people in relationships with these disintegrated personalities.
Consistent with this theory, Kernberg would view someone with Borderline Personality Disorder as having persistently primitive (e.g., developmentally early) internal object relations split-off into “all good” and “all bad” representations. At any given moment, this person will operate from one of these polarized representations or the other, but not from both at the same time. Mixtures of contradictory feelings (e.g., like and dislike) occurring at the same time are experienced as intensely disorienting and anxiety provoking. This anxiety and discomfort prompts the person to keep such feelings “split-off” from each other, and separate. While temporarily reducing anxiety, this splitting prevents the person from experiencing affectionate feelings and aggressive feelings at the same time. Because the person cannot experience conflicting feelings simultaneously, it prevents them from integrating representations into a cohesive whole. This, then, leads to intense feelings and behaviors that interfere with their functioning.
The Three Levels of Personality Organization
The neurotic level:
In Kernberg’s view, the healthiest level of personality organization is called the neurotic level of organization. People whose personalities are organized at the neurotic level have:
1) intact reality testing
2) a consistent sense of self and of other people
3) generally rely on mature defense mechanisms when stressed.
People with a neurotic level of personality organization have a good sense of reality, so they can distinguish between what is real from what is not. For instance, they don’t hear voices that are not there or believe other people are trying to harm them when this is not the case. They have a good sense of their own strengths and weaknesses. They know what their values are. They have a pretty consistent sense of purpose, direction, and life goals. They are able to deeply commit to, and care about, other people and view other people accurately, taking into account both their strengths and weaknesses. They successfully cope with stress in an effective and adaptive manner.
The psychotic level:
At the opposite end of the personality organization dimension are severely disorganized personalities. People with this level of personality organization have:
1) severely compromised reality testing,
2) an inconsistent sense of self and others
3) utilize immature defenses.
Because their reality testing is compromised these people might hear or see things that are not really there, or have delusions, such as being convinced that they have special powers (for instance, the ability to read other people’s minds or to fly). They may believe they receive special messages through the television (a phenomenon known as “Ideas of Reference” or “Delusions of Reference”). They don’t have a clear sense of themselves and the boundary between themselves and other people is often blurred. As such, they have great difficulty distinguishing between experiences and perceptions that originate within their own mind, from those that originate in the real world. Their ability to cope with stress is extremely poor and they do not function well in society.
The borderline level:
Along the middle of this dimension are personalities organized at the borderline level. At this level, reality testing is generally intact (unlike the more severe psychotic level). However, people with a borderline level of personality organization have a fragmented sense of self and others (unlike the less severe neurotic organization with an integrated self). Because they possess a fragmented sense of self they don’t have a consistent view of themselves or others, over time and across situations. This fragmented sense of self is the most significant and defining feature of the borderline level and results in severe and repetitive problems with interpersonal relationships.
In addition, people with a borderline level of personality organization tend to rely on primitive defense mechanisms. Therefore, they don’t manage stressful situations very well. One of the main primitive defense mechanisms used by people with borderline personality organization is called “splitting.” This defense mechanism is characterized by a tendency to view the world and other people in a polarized manner, as “all good” or “all bad,” flipping back and forth between these two extremes based on moment-to-moment perceptions.
It is important to bear in mind that in Kernberg’s model the term “borderline” is used in its original psychodynamic sense to describe the middle ground (or the borderline) between neurotic and psychotic personality organization. It should not be confused with our modern use of the word “borderline” that references the DSM diagnosis of Borderline Personality Disorder. In Kernberg’s model, the term “borderline disorder” is a much broader term that includes any severe personality disorder, such as Borderline, Narcissistic, Antisocial, Schizoid, and Schizotypal Personality Disorders.
Healthy people might have trouble visualizing what it is like to live with this “borderline” level of personality organization. Healthy people understand that who they are is not determined by a particular action, in a particular moment in time. They know that if they behave poorly one minute, this one bad behavior, in this one moment of time, does not define who they are. They are still able to recall all the wonderful things they have done in the past, and plan to do in the future. People with a fragmented sense of self are not so fortunate. If they just did something “bad,” they literally become a bad person (i.e., they start representing themselves as an entirely bad person with no redeeming qualities). When this occurs, they can no longer access any of their good qualities. This is a terribly painful state to endure.
The same pattern of polarization holds true of their experience of other people. Based on whatever their current emotional state is at the time, they can switch from idealizing someone and treating them with tremendous admiration and affection, to devaluing the same person and treating them with contempt and hostility in the next moment. For example, if a loved one just behaved insensitively, that person suddenly becomes “all bad,” as though all their loving acts before this one insensitive moment in time did not exist. Obviously, this degree of polarization makes it quite difficult for such a person to realistically assess other people’s true qualities and to select and retain friends and romantic partners. It is also responsible for their tendency to act inconsistently and impulsively, resulting in frequent and rapid changes of career, partners, and life goals.
By Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.
Treatment of Personality Disorders at Trauma Recovery Institute
Trauma Recovery Institute offers unparalleled services and treatment approach. Trauma Recovery Institute offers unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP).
Dynamic Psychosocialsomatic Psychotherapy (DPP) at Trauma Recovery Institute Dublin
Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.
Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.
“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking and behaviour.”