Elements of Psychotherapeutic Assessment and Treatment with Structured and Under-Structured Personalities

This paper explores some aspects of psychotherapeutic technique in work with a range of presenting individuals who appeared to evidence various levels of personality integration. Consideration is given to a continuum of personality organization, based on psychotic, borderline and neurotic self-structures. The central contention advanced in the paper is that a very careful and detailed analysis of the presenting patient's level of structuralization is required before a decision on the suitability of psychotherapeutic intervention can be made. I have suggested that prospective diagnosis, by recourse to symptomatology or subset symptomatology, is an inadequate means by which to gain an accurate understanding of an individual's particular needs. Recognition of the predominant mode of personality structure, whether this is psychotic, borderline/narcissistic or neurotic, is of the utmost importance. Experience shows that the ability of individuals to ‘adjust’ to the parameters of the therapeutic frame will be contingent upon the level of personality structure that has been attained. In turn, the particular forms of psychotherapy appropriate to the developmental level of individuals should be carefully considered. Generally, under-structured patients require a greater degree of supportive work, before movement towards a psychodynamically interpretative approach can be utilized.