Implications of Developmental Levels of Organization

Implications of Developmental Levels of Organization

Like politics, psychotherapy is the art of the possible. One advantage of conceptualizing each client developmentally is that one can derive a sense of what is reasonably expectable, with optimal treatment, for each one. Just as a physician expects a healthy person to recover faster and more completely from an illness than a sickly one, or as a teacher assumes that an intelligent student will master more material than a slow one, a therapist should have different expectations for people with different levels of character development. Realistic goals protect patients from demoralization and therapists from burnout.

It was easier to write the first edition of this chapter; in the early nineteen nineties there was something closer to a psychoanalytic consensus about what approach is appropriate for each level of personality organization. Since that time, several things have occurred. Analysts in the relational movement have challenged many aspects of traditional technique-especially its assumptions about the analyst's capacity for objectivity and neutrality. They have also questioned the value of any generalizations about character structure and have revised our understandings of the patient-therapist dyad to put the emphasis on what the two parties construct together rather than on what the therapist does for or to the patient. The two-person model of the therapeutic process has gone mainstream and has influenced even those who think more traditionally. It will probably be evident, even in this book with its one-person focus on patients' individual psychologies, that relational analysts have greatly influenced my thinking.

At the same time, several specific therapies for borderline personality organization have been developed, and psychoanalytic theorists no longer dominate professional conversations about how to understand borderline phenomena. Marsha Linehan, the architect of dialectical behavior therapy, has frequently acknowledged her debt to Otto Kernberg, but the treatment she created reflects both cognitive-behavioral concepts and some Zen Buddhist ideas, not assumptions about a dynamic unconscious. Jeffrey Young's schema therapy, which also derives from cognitive-behavioral psychology with some psychodynamic influences, has been applied to borderline-level personality disorders. In the specifically psychoanalytic realm, where Kernberg's original notion of expressive therapy once predominated, we have seen the development of several specific, research-tested treatments: Kernberg's transference-focused psychotherapy and Fonagy's mentalization-based therapy being the best known.

Finally, the International Society for the Psychological Treatments of Schizophrenia has brought together therapists interested in psychotherapy with psychotic patients, and their synergy has added new elements to what we know about treating severely troubled people. Even more than in nineteen ninety-four, our mental health culture tends to overstate the pharmaceutical needs of people with psychoses and to understate their need for therapy. I think there is greater urgency now than in earlier decades to pass on our knowledge about effective talk therapy for those who suffer the most.

I start, as before, with considerations about treating neurotic-level clients, then those in the psychotic range, and finally those in the borderline spectrum. Even though the story has become more complicated, I think it is still useful to note clinical implications of levels of severity. I cannot do justice to the subtleties of specific approaches, but I try to present enough of a feel for how to work, depending on a person's inferred developmental challenges, that I demonstrate the value of assessing these levels. The goal of any dynamic therapy is to help each client with the maturational task that is most compelling for that person-whether that is the full flowering of one's creativity or the attainment of some minimal awareness that one exists and deserves to stay alive.

Therapy with Neurotic-Level Patients

It used to be commonly claimed that psychoanalytic therapy is unsuited to anyone but the "worried well." The kernel of truth in this view is that psychoanalysis as a specific treatment works best with articulate neurotic-level clients who have the ambitious goal of character change and/or deep self-knowledge. The arrangements that define classical Freudian analysis (frequent sessions, free association, use of the couch, attention to transference and resistance, open-ended contract) work less well for other patients-although early in the psychoanalytic movement, before modified approaches were developed, analysis was attempted with a wide array of clients. Also, the session frequency that Freud had recommended (originally six, then five times a week; later four or even three) made traditional analysis affordable only by people of some means.

That psychoanalytic therapy works faster and goes further with already advantaged people can be compared to the responses of healthy people to medical care or bright people to education. There are many reasons why it is easier to do analytic therapy with healthier patients than with borderline or psychotic individuals. In Eriksonian terms, one can assume basic trust, considerable autonomy, and a reliable sense of identity. Treatment goals may include removing unconscious obstacles to full gratification in the areas of love, work, and play. Freud equated psychoanalytic "cure" with freedom, and in the Platonic tradition, he believed it is truth that ultimately makes us free. A search for difficult truths about the self is possible for neurotic-level people because their self-esteem is resilient enough to tolerate some unpleasant discoveries. Accordingly, Theodor Reik used to say that the primary requisite to conduct or undergo analysis is moral courage.