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On the basis of clinical observations which indicate a close relationship between the ego function of reality testing and the investment of an object perceived as separate from one's self, Modell suggests that denial in the adult is the outcome of a regression or an arrest in the ego's capacity to differentiate between the self and object. He believes that the intensity of the denial is specifically related to the degree of this regression. In his opinion there is no absolute distinction between neurotic and psychotic denial; the difference is that, in the psychotic, reality is not merely disowned (denied) but object cathexes are lost and portions of the ego and superego are substituted for the lost object cathexes.
According to the author, in borderline cases separation anxiety sets in motion the defensive denial of separateness from the object in order to create the illusion that the object is part of the self and cannot be lost. A male fetishist denied certain aspects of reality; for example, he was convinced that he need not work because the therapist would do the work for him. In the transference, the therapist stood for the primal maternal object who, as a transitional object, was endowed through the processes of introjection and projection with qualities of the self. As the patient was frustrated in this expectation, his need for still more massive denial resulted in a wish for fusion with the therapist by way of incorporation. This with was manifested by a desire for sleep and by terrifying nightmares of being incorporated by an amoeboid breastlike object. On one occasion, after having overheard the therapist retch in the bathroom, the patient reacted with a most intense desire to sleep and took an overdose of medication in order to do so. According to the author this was an unconscious suicidal attempt which had as its aim a still greater dedifferentiation in the form of an oceanic fusion with the breast.