Journal of Personality Assessment

ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20

Clinician-Guided Assessment of Personality Using
the Structural Interview and the Structured
Interview of Personality Organization (STIPO)

Susanne Hörz-Sagstetter, Eve Caligor, Emanuele Preti, Barry L. Stern, Chiara
De Panfilis & John F. Clarkin

To cite this article: Susanne Hörz-Sagstetter, Eve Caligor, Emanuele Preti, Barry L. Stern, Chiara
De Panfilis & John F. Clarkin (2017): Clinician-Guided Assessment of Personality Using the
Structural Interview and the Structured Interview of Personality Organization (STIPO), Journal of
Personality Assessment, DOI: 10.1080/00223891.2017.1298115

To link to this article: http://dx.doi.org/10.1080/00223891.2017.1298115

Published online: 07 Apr 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=hjpa20

Download by: [FU Berlin] Date: 09 April 2017, At: 01:05

4 Chiara De Panfilis. 4Columbia University Medical Center. For this purpose. to guide the conduct and interpretation of cial standard for PD assessment according to DSM–5. Department of Medicine and Surgery. along a con- personality disorder (e. spective in that it resembles the diagnostic decisions and pro- ality Disorder Examination [IPDE.1080/00223891.2017. New York. and also a semistructured approach. cal pathways. Stern. Milan. & Benjamin. In the unstructured clinical interview. high comorbidity.hoerz@psychologische-hochschule. likely discriminant validity. the Structured Interview of Personality Organization (STIPO. Both interviews focus on the assessment of consolidated identity versus identity disturbance.5 and John F. by stating that. Alternatively.doi. Clinicians might use relatively unstructured Personality pathology diagnosis has been going through clinical interviews. Clarkin. and intact versus loss of reality testing. approach explicitly intended to favor a clinician-centered per- Gibbon. Caligor.). University of Parma. 2004) based on this theoretical model. the Structural Interview (SI. the need for a dimensional approach to personality pathology. 6Weill Cornell Medical College.1298115 Clinician-Guided Assessment of Personality Using the Structural Interview and the Structured Interview of Personality Organization (STIPO) €rz-Sagstetter. Westen & Shedler. Loranger. Cornell University ABSTRACT ARTICLE HISTORY This article demonstrates the utility of a theory-guided psychodynamic approach to the assessment of Received 11 April 2016 personality and personality pathology based on the object relations model developed by Kernberg (1984). order criteria to make a personality disorder diagnosis. This DSM–IV Personality Disorders [SCID–II.com/hjpa. 1996]. employing their clinical experience and major changes in recent years. In the context of a more clinically oriented assessment.org/10. approaches to assessment of person. for which posits self and interpersonal functioning as key defining example. Kernberg. 5Unit of Neuroscience. theless. self-reports are frequently employed. and also takes into account transference and countertransference phenomena. Structured Clinical Interview for tinuum of severity of dysfunction in these domains. whereas the more structured approach of the STIPO incorporates clinical judgment informed by clinical theory into a well-guided interaction with the patient. 2Department of Psychiatry. University of Milano-Bicocca. Williams. Clarkin6 Susanne Ho 1 Psychologische Hochschule Berlin.2 Emanuele Preti. operationalized in the typically criterion-based.3 Barry L. structured interviews or pathology in clinical practice generally follow one of two typi. Revised 19 December 2016 We describe a clinical interview. and the clinical experience and influenced by a particular diagnostic 10 categorical and polythetic diagnoses still represent the offi- frame of reference. alternative model for personality disorder diagnosis (DSM–5 ality.g. Spitzer. Color versions of one or more of the figures in the article can be found online at www. “Patients CONTACT Susanne H€orz-Sagstetter s. Section III. and might incorporate the patient’s attracted a new wave of attention to the diagnosis of personality behavior in and response to the interview setting into the disorders (PDs). within emerging measures and models. Clinical Psycholgy and Psychotherapy. 10179 Berlin. Both interviews have good interrater reliability and are coherent with the alternative model for personality disorder diagnosis proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed. 3Department of Psychology. International Person. poor assessor organizes the material in his or her own mind. the of a categorical approach to personality pathology (e. New York.g. Germany.JOURNAL OF PERSONALITY ASSESSMENT http://dx. American Psychiatric Association. the well-documented limitations assessment process. Italy. Interviews of this kind typically rely on Diagnostic and Section III). borderline personality disorder (BPD) or narcissistic dimensions of both normal personality and PDs. 1984). Janca.. Am K€ollnischen Park 2. & Kernberg. they provide the clinician with specific implications for prognosis and treatment planning and can rationally guide clinical decision making. Approaches to the assessment of personality and personality Sartorius. Interviews of this kind typically rely heavily ders (DSM–5. & cesses typically followed by clinicians. 1997]). clinicians could use more structured. Germany. Italy.1 Eve Caligor. 2013) on clinical inference. Columbia University College of Physicians and Surgeons. the use of adaptive versus lower level defensive operations. dimensional models obtained a primary position 2000). With the alternative model. © 2017 Taylor & Francis . 1997.. Surprisingly.tandfonline. and publication of the 5th edi- theoretical background to evaluate personality functioning tion of the Diagnostic and Statistical Manual of Mental Disor- and pathology.de Psychologische Hochschule Berlin. the DSM–5 recognizes Statistical Manual of Mental Disorders (DSM) personality dis. Finally. First. Never- the clinical interview (Westen. the SI makes use of tactful confrontation of discrepancies and contradictions in the patient’s narrative. and heterogeneity) did relying on implicit or explicit prototypes developed through not lead to major changes in the DSM–5 classification. Stern.

DSM-based BPD. These relations theory internal object relations are regarded as the basic building blocks of all mental experience. BPD is con- els of internal object relations.2 € HORZ-SAGSTETTER ET AL. This model moves away from a approach to the assessment of personality functioning categorical diagnosis of PDs and differentiates personality orga- grounded in an object-relations model of personality and PD nization according to structural criteria (Kernberg.g. and poorly modulated the clinical utility of this proposed “severity indicator” of PDs.e. p. object relations and associated affect states can be integrated. what Kernberg refers to as borderline personal- Theoretical framework forming the base of the ity organization (BPO). However. the dominant affects of ogy. and affect dis- treatment of PDs (First et al. followed by neurotic personality organization structured approach to clinical interviewing. These different levels are reflected in the object rela- assessment (e. Morey. BPO cuts across the DSM-based PDs. encompassing the severe personality interview measures disorders (e. positively and negatively consistent with a clinician-guided approach to diagnosis and valenced internal object relations are integrated. These individuals are diagnosed at a borderline structs of personality pathology might find it difficult to deter. these early interactions The Structural Interview: A clinician-guided diagnostic between the child and his or her caretakers are internalized and approach to personality pathology based on object gradually organized to form internal object relations. it is inconsistent with most clinical back to this core affect. personality pathology using the Levels of Personality Function. In sum. or even five qual. The LPFS evaluates capacities and ongoing learning regarding realistic aspects of the individual’s level of functioning across the domains of iden. self and other. 1984. In the positive. the interaction between self and others under circumstances of tity and self-direction (i. Identity integration is the most important differential cri- hatred and envy that are evident in severe PDs can be traced terion between normal and NPO on the one hand. other. In the early life of the infant. For this reason. characteristics of the different levels of personality organization Kernberg posited that from birth onward. clinicians who are not familiar with these con. 1984). Kernberg & personality organization (PPO). 2005). three. and BPO on . Caligor... the core affect is primitive elation. some authors raised concerns about dened with intense. 2002). and finally at a greater level of severity. graphs might appear relatively vague and complex to less expe. The core affect of the negative sector of presence of normal identity formation versus identity pathol- affective experience is aggression. and the other series is relations theory of personality functioning and disorder. object relations. developing into sexual excitement and also evolving to organize 130). The model revolves around developmental lev. avoidant personality disorder). The SI (Kernberg. (SI). interpersonal functioning) along a continuum of is crucial for the development of psychological health. and also introduce the Struc. activated in relation to. which aims to reliably capture impairments realistic and complex affectively colored experiences of self and in both establishing a sense of self and in interpersonal func. although the LPFS provides higher level structures can be developed and more flexible affect some short descriptions for each domain level. self-functioning) and empathy and low affect activation. positions become nuanced and modulated. In fact. & Skodol. the classification of PDs is linked to the aversive behaviors. We describe the Structural Interview PDs. The main to other linked through affect states. 1981. Integration is facilitated by the development of cognitive tioning (Bender. If contradictory internal mine the specific rating of severity on each domain (e.. 2012). Clarkin & Huprich. from 0 D little or none.g.g. At the very most severe end of the spectrum is psychotic Kernberg’s object relations theory (Kernberg. 2002. to to achieve this developmental task leaves the individual bur- 4 D extreme). 2011). According to this theory.. that is consistent with the alternative model for PDs proposed Compatible with the DSM–5 Section III alternative model for by DSM–5 Section III. researchers have begun pathology reflect the degree of integration of internal object to evaluate instruments that can be used to guide such an relations. poorly integrated. DSM-based obsessive–compulsive personality dis- order. forms of aggression as well as unintegrated representations of For instance... level of personality organization. dimensions of personality functioning was regarded as more During mental development. DSM–5 Section III proposes to dimensionally evaluate tive. a more organization. have just one personality. those para. Integration of posi- Thus. designed to assess personality pathol- One series is associated with highly charged positive affect ogy within the described framework of Kernberg’s object states motivating approach behaviors. a clinician-guided interview. Over time... Zimmermann et al.g. and cognitively linked to interactions with caretakers. Failure severity and impairment (i. Rather.. gradually itatively distinct personality disorders” (First et al.e. At the healthiest end of the spectrum is normal personality tured Interview of Personality Organization (STIPO). tions theory-based model of classification of personality pathol- The goal of this article is to describe a clinically based ogy developed by Kernberg. considering PDs as adaptive failures on general dependency needs. antisocial personality disor- The approach to clinical diagnosis described here is based in der). different levels of personality rienced practitioners. loving affects and internal representations with negative. 1984) is a clinical interview of approxi- two parallel series of internal object relations are developed. aggressive affects and internal representations leads to more ing Scale (LPFS). representations of self in relation ceptualized as one of many PDs located in BPO. loving series of internal theory to suggest that a person has two. to demonstrate (NPO) encompassing personality pathology of relatively mild the clinical utility of both. inborn affects are are summarized in Table 1.e.. 1975. regulated by. 2011). The integration of internal object relations intimacy (i. severity (e. modulation will follow. Kernberg proposed a continuum of severity of pathology. mately 90 min duration. associated with highly charged negative affect states motivating Within this model.

altruism. by attempts. flexible adaptation isolation. highly regression. the law). The specific questions and Further refinement of the diagnosis along the spectrum of the order of questions are not predetermined. The structure of the SI In this interview. For example. and aggression and affect important. along with the presence of Psychiatric Association. and any other difficulties the patient might have in his or her life. what he or she expects from treatment. All rights reserved. Phases of the Structural Interview. to return eventually to “all bad. 2005). F. denial. the inter- integration. in evaluate self and other depth. moral functioning. humor. intact reality testing depth. extremely conflict. intact reality testing realistically. lying. antisocial tendencies (e. 1984) along the perimeter of a circle. an approach tion of a person that contradict the present description (“I that long predates the emphasis on dimensional measures of notice that you are describing your partner in very negative self and other functioning in DSM–5. intellectualization. the diagnosis of PPO is tested at the same time that pre- senting complaints and symptoms are elaborated. lacking in complexity. middle. . Section III. undoing. This cyclical approach enables the interviewer to return as with the associated domains of defensive operations and reality often as necessary to the same issue in different contexts. A cyclical process in which the interviewer returns to anchoring symptoms allows an increasingly in-depth picture of the patient’s internal and exter- nal functioning to emerge (see Figure 1). Normal identity is char. Clarkin. self and delimited self and object delimited self and object contradictory aspects of self object representations are representations representations and others are poorly poorly delimited integrated and kept apart Defensive operations Mature defenses: anticipation. sharply Consolidated identity. identity disturbance is The model identifies “anchoring symptoms” (Kernberg. retest- testing. giving the inter- severity is introduced with clinical assessment of quality of viewer flexibility to focus on relevant aspects and to return to object relations. com. interpretation can lead to protect against intrapsychic devaluation. sufficient diagnostic clarity emerges. Copyright © 2015. In this manner. idealization. (2007). Kernberg connected the present functioning of the patient with the interaction of the patient with the inter- viewer. characterized by a sense of self and others that is unstable. Differentiation of personality organization. The interview follows a predetermined order (initial. and polarized. Identity pathology. identification. Yeomans. cutting. and end phase). the SI combines a categorical and viewer could return to previously stated aspects in the descrip- dimensional approach to personality pathology. Reprinted with permission from Trans- ference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. prostitution. Initial questions are relatively unstructured. to characterize personality as organized at normal-neu.” the starting point and reinitiate a new cycle of inquiry if neces- The SI focuses on assessment of identity formation. The initial phase of the SI The interviewer begins by inquiring in an open-ended fashion about symptoms and difficulties that brought the patient to the interview. temper outbursts. Structural criteria Normal Neurotic Borderline Psychotic Identity integration Consolidated identity. and O. PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 3 Table 1. defenses omnipotence. along sary. F. and has depth. sharply Identity pathology. object merging. realistic. Repression and higher level Splitting and lower level Defenses protect from suppression. Table based on Kernberg (1984) and Caligor et al. J. but the interviewer has the freedom to pursue material as it emerges in the patient’s self-presentation and responses to the interviewer. Kernberg. ing preliminary findings at later stages of the interview until rotic versus borderline level of personality organization. “all good” or from one cardinal symptom to the next. variable reality testing Note. plex. perhaps contradicting issues. and the interviewer will follow up according to the patient’s reported symptoms. words. Behavior related to self-directed and other-directed aggression (suicide Figure 1. problems with acterized by an experience of self and others that is stable. In this phase. E. but before you said he was the best partner you could imagine—how does that fit together?”). relatively adaptive maladaptive and rigid maladaptive and rigid but introduce rigidity Reality testing Capacity exists to evaluate self Capacity exists to evaluate self Impairment of capacity to Capacity to test reality is lost and others realistically. violence) typically emerges F. The interviewer proceeds superficial. the other (Kernberg & Caligor. in contrast.. defenses: reaction formation.g. defenses: projective disintegration and self– flexibility. American during this phase of the interview. in and others realistically.

assessing. determining the with her hair well-coiffed. and recommendations can be given. K: My life. prognosis. K: A month now. Ms. … I just can’t face my life. thoughts about this. For example. K denied suicidal understand it. but endorsed a feeling of “not wanting to go on. can’t face it. the inter. it’s a disaster. I can’t stop crying. might also offer a tentative hypothesis that explains appar. K. described later. complemented by an explanation of interview techniques. During this process the interviewer simultaneously fulfills difficulties he or she might be having. this can be seen as an indicator for impaired psychotic illness. In assessing identity pathology. reaction to a trial interpretation can give meaningful diag. chief reasons for coming to treatment. indicat. whereas a patient organized at a neurotic level might respond in a thoughtful way that explains the At this point Dr. quality of his or her object relations. In this phase. This clarification can yield meaningful informa. and the realistic or unrealistic nature of his object world. or her expectations of what treatment can provide. K. A patient with identity pathology Dr. comprised of a prede- might ask the patient about how he or she thinks the inter. . Initial phase ples of material that is vague or confusing. the patient’s motivation for further diagnostic or treatment accompanied by further evaluation of personality organization. and treat- self or herself and a description of significant others. Literally can’t move. Dr. the interviewer ideation. understanding or reflection vs. H: What is it you cannot face? might respond with a lack of concern or curiosity. with minimal benefit. The pointing out inconsistencies and contradictions. The individual’s why she was staying in bed. steps can be evaluated. Ms. K: I’m depressed. I feel paralyzed. or is perplexed or seeks to better toms of depression. the interviewer acquires a comprehensive and in. The middle phase of the SI are any additional issues the patient considers important that In this phase. organizing answers) in the here-and-now interac. asking for the patient’s can’t go on. thinking. and level of personality organization provides the interviewer assessed by asking the patient to provide a description of him. I can’t move. In this phase of the interview. whether the patient identifies tions and countertransference. point. In addition. comple. at the same time observing the patient’s interactions with the the interviewer has an opportunity to evaluate the patient’s interviewer. wearing makeup and tion with the interviewer.” Dr. H: Has this happened to you before? The final phase of the SI Ms. She arrived to the interview questions. In listening to the patient’s response..g. I wake up.. Throughout the interview. along with his or her three tasks: he or she explores the internal world of the patient. there is a focus on how the Ms. H: How long have you been depressed like this? nostic information (e. as in the case of Ms.4 € HORZ-SAGSTETTER ET AL. Ms. The interviewer began with the stan- degree of impairment of reality testing. focusing on identity formation and defensive functioning. I just lie there. Ms. Combining these three sources his or her difficulties as residing within himself or herself or as of clinical data enables the interviewer to generate hypotheses coming from outside. mented by the patient’s level of functioning in his or her work and interpersonal life and in his or her utilization of free time. and had never been Kernberg emphasized leaving enough time to find out if there hospitalized. difficulties in your life. any other it. She had been treated with vari- the patient’s past as it relates to current difficulties. Clarification entails asking for specific descriptions and exam. ous antidepressants. Dr. expectations of treatment. of variable In this phase the interviewer conducts a general exploration of duration. awareness of his or her problems. Overall. are there other behavior. which were negative.e. single woman was referred for treat- patient is functioning (i. and what do you hope to get out of tion with regard to differential diagnosis: If a patient cannot treatment? (The complex and relatively unstructured nature of discern that his or her behavior might seem odd to the these questions requires a clear sensorium and are a first screen for interviewer. and go back to sleep. the SI combines psychoanalytic thinking and psy- ferential diagnosis of BPO versus NPO is made on the basis of chiatric exploration. processing ment by her general practitioner. I can’t get out of it. anger in response to the intervention). termined series of open-ended questions: viewer might perceive a particular aspect of his or her Dr. with Dr. There’s no ing the use of splitting and denial. a 30-year-old. Also. over the past 10 years. with important information for diagnosis. Nobody cares about me. confrontation entails This phase assesses presenting symptoms and problems. the patient’s understanding of his or her about the nature and organization of the patient’s internal need for treatment. Clinical example of the SI Descriptions of important relationships give the interviewer information both about the patient’s social situation and the The following clinical example demonstrates the use of the SI. inquiring if the patient is invited in an open-ended fashion to discuss his or her patient can understand the interviewer’s confusion and resolve symptoms. K’s present difficulties and ent contradictions (a “trial interpretation”). H: What are the problems that bring you here. H decided to learn more about Ms. It’s gotten so bad. should still be discussed. the methods for this purpose material excerpted from a clinical interview is of clarification and tactful confrontation provide the inter. I significant others or of the self. Dif. viewer with important prognostic and therapeutic information. the interviewer dard opening to the structural interview. H casually but stylishly dressed. in this phase the necessity and depth view of the patient’s life situation and functioning. K gave a history of several similar episodes.) reality testing. ment planning. I’ve spent the past 2 weeks viewer might point out frankly contradictory descriptions of in bed. H inquired about neurovegetative symp- apparent contradiction. while also following his or her own affective reac. The assessment of both clinical symptoms evaluation of identity consolidation versus identity pathology.

were you aware of anything that triggered the depression? time. attentional disorders. into collecting unemployment. or interests. example. Ms. he’d call me to come Mike. H. H: When you became depressed. And I can’t get anything siveness. K precipitously left her job with me. Dr. so I’m glad he was honest. She lived alone and spent her days watching television. H: Well. is followed by construction of a description of himself or herself and of his or evaluation of identity formation and defensive style. and meeting up with Ms. I’d like now to hear more about you as a person. borderline level of personality organization. several dating back to middle school. organization. For emerged in earlier parts of the interview while exploring symp. K: What do you mean? What do you want to know? I’ve been Dr. if any. H began with a systematic evaluation of Ms. when she evaluated identity formation.” never been hospitalized.. symptoms of bipolar or psy. saying: “You have told me about your symptoms and your diffi- tent “panic attacks” typically lasting hours to days. if you differentiate between a present disorder (e. I guess I’d say I’m stupid. Ms. but lacked profes- were best friends and then we got involved. contradictions. This question is a challenging one. learning disabilities. H moved on to assessment of identity formation. going to the gym. This is done by referring to different time personality is like? frames and modes of functioning. It begins by following up on not only to the content of what the patient says. or In response to Dr. K: My boyfriend Mike broke up with me. H think that’s really true. depressive epi. are there other things about you as a person. Well. interpersonal relations and recreation.. sode) and more chronic impairment (e. or herself. as well as frequency. She was currently unemployed and looking month ago out of the blue he told me he wanted to be on his own. and also of a significant other. detailed. To confirm or disconfirm this preliminary assessment. He was so patient with me. She denied a his. her significant others is an indication of identity integration viewer will pursue this line of inquiry by asking the patient to versus pathology.g. had had a series of long-term romantic relationships with men. and severity of the inquired behavior (e. He never lied—honesty is really important to last been working on and off as the assistant to the brother of me. had been suggest- ing I move on for a long time but that I wouldn’t hear it. She about it. so kind. K: Well. And now he won’t talk to me. K appeared confused. But he said he didn’t sional direction. and by tact. your personality. what would you include. What you’re like. a month ago. and she carried a diagnosis of attention deficit you describe yourself. treated with culties. how were things functioning. she felt directionless and contradictory description of Mike and of their relationship. The inter. Ms. PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 5 Dr. Before doing so stone of the SI (see Table 1). It was all on his terms. She described Ms. She had you as a person. K’s rather chaotic and seemingly her interpersonal and romantic life. were to write a paragraph about yourself. K endorsed a lifelong history of intermit. and had no developed interests. Could Clonazepam. She reported that she had believe in monogamy. perva. eating disorders.g. important for me to know about you to get a real feeling about tory of self-destructive behavior or illegal behavior. filling in whatever remains organized? Is he or she thoughtful or glib? The extent to which unclear. so that I could get to know who you are as a person and what your tioning due to a PD). H planned to return to this issue. really. long-term low func. and helps to determine level of personality describe himself or herself and significant others. K’s vocational would be important to know about you? . Evaluation of personality functioning. Dr. But then about a with his brother. Dr. And my family always picks on me. H was struck by Ms. and approach in the SI is to introduce this part of the interview by substance abuse. and to evaluating her inter. In the case Dr. H: Did it bother you that he saw other women? friends. focusing on the patient can engage in a lucid. K’s present depressed. in the next phase of the inter. K’s functioning was consistent with a my texts. But he would never go out with me or meet my family. like I said. is the patient coherent and specific or vague and dis- toms and presenting complaints. empty. asks the patient to provide an in-depth description of himself iety disorders.. her relationships. She described wanting a career. Dr. Dr. omissions. The standard chotic illness. skills. but beyond that she pened. the interviewer she decided to ask about other symptoms. Both current functioning and Dr. Ms. personal functioning in general. “Is this right. and asks the patient to construct as complete and Middle phase complex description of himself or herself as he or she is able. To assess identity. the corner- view. the man who had recently broken up with her. I have no clue what hap- friends. I was in love with him and thought he was in love relationship with Mike ended. When her over at night. interview. what you think is disorder. H’s request that she provide a description notable patterns that have emerged during the course of the of herself. inquired in detail about Ms. H: You’ve told me about your depression. Ms. it requires the ability to be reflective. treated with medication in the past. things that example. Ms. he wasn’t my tioning in these areas. I’d like now to hear symptoms and the more chronic functioning are examined to more about you as a person. she described significant pathology in Dr. we entry-level jobs since graduating college. Ms. she lacked profes- sional or personal goals. K: No. is that what you mean? life situation and functioning. but also to the aspects of the patient’s personality functioning that have process of thinking and articulation the patient engages in. K reported that she had held several boyfriend. fully pointing out discrepancies. her symptoms had on her func- Ms. romantic life. and what impact. H: So is that why you two broke up? all ending in rejection. Is that what you mean? how you typically deal with work problems?”). But I don’t had no professional goals and no personal interests. and multilayered work. We fought all the time these relationships as stormy and largely unsatisfactory.g. I knew him through work for many years. and use of free going. won’t answer noted to herself that Ms. K had a circle of women Dr. He said he’d given me plenty of warning. the therapist attends level of personality organization. it was out of the blue. K: Of course it did! It drove me crazy. In This phase focuses on the patient’s personality functioning and clinically evaluating the patient’s response. inquiring about anx. For example.

including family members. H was struck by the superficial. Even now I love him and cannot live follow the patient’s lead. The then requests: “Can you tell me more about him so that I might remaining questions of the SI focus on gathering information form a real. the diagnosis of BPO. never- response to confrontation was further evidence of a poorly inte. and he never lied to me. K identified Mike. that’s what I’m telling you. K had failed to provide any experience and familiarity with the underlying model. it has significant limitations. H tory. Sundborn. the man who had broken up with her a month ago. K: He is the only person who has ever understood me. the interviewer to raise questions or issues that have not been addressed. K’s description of Mike. when she had seemed at times petulant tive relationships growing up (a positive prognostic sign). and he is the relies on the interviewer’s clinical judgment and inference to most important person to me. where descriptions of the past are typically distorted by present K’s description of herself as “too nice” and excessively accom. the SI next asks for a description of a significant other. as supporting the impression of family history. hoven et al. important. Dr. H noted that Ms. Taken together. H noted the self-referential quality to Ms. . Kullgren. who is the person who is most important to you right be helpful for him or her to know about. No one has ever treated me so well. and even the same interviewer will focus differ- Ms. Fransson. idealiza- boyfriend? tion. between two well-trained. Because the interview Ms. The standard Final phase approach of the structural interview is to introduce this part of The final phase begins with the interviewer acknowledging that the interview by saying: “I would now like to ask you about the he or she has completed his or her task and by asking the people who are most important to you in your current life. or if the patient wishes now?” After the patient identifies someone. He was always supportive. he made you feel reported high correlation coefficients among raters for identity safe. H: Can you tell me about Mike as a person? interviewers. H viewed the impoverished and inconsistent quality of In the following phase the interviewer obtains a brief history Ms. Ms. I remember that earlier in the interview you painted a different integration. K: He was just wonderful. it is best to obtain a general his- modating was frankly discrepant with her behavior with Dr. What do you make of that seeming contradiction? 23 psychiatric inpatients. confirming her impression of identity pathology. (2009) stuff is meaningless. and Bouwens (1994) reported moderate overall agreement (69%) for 37 psy- Ms. theless. at least at the macrolevel of assigning a patient cern or reflectiveness in response to Dr. posi- early in the interview. and structural picture—you told me he was never faithful to you and that that was diagnosis.and outpatients. as opposed to NPO is clear Ms. H’s inquiry. K responded to Dr. but rather we’ve broken up I still think about him all the time. coverage of symptoms and domains of functioning might be uneven across Dr. H’s intervention. I always do what other people want. everyone to the interviewer—as manifested by identity pathology and takes advantage of me. defensive operations). cal tool. difficulties and contradictory. & Kullgren. K: Other than I’m stupid and unemployed and don’t have a disturbance and reliance on the defenses of splitting. H: Well. K’s contradictory & Kernberg. He was my best friend. can be obtained. In addi- description of Mike as an individual. Goldstein. He was ently interview to interview. live impression of him? What is he like as a person. such agreement. for questions of prognosis and treatment planning. and demonstrating a lack of con. use of primitive defenses in the context of intact reality testing (see Table 1). idealized description Ms. and and quietly oppositional. K: Well. Derksen. it requires of interviewers both clinical without him. In fact I’m too nice. identity pathology. 1979) and found very good agreement (k D . 1990. reality testing. Hence. as the person Psychometric properties and research on the SI to whom she was closest and who was the most important per.) tion. depending on a particular patient’s so kind and patient with me. Hunt. and that Ms. Even though does not provide a structured sequence of questions. 1987) understood you. K’s sense of herself. Dr.6 € HORZ-SAGSTETTER ET AL. Ingenhoven et al. denying the impact of the nega. meaningful. H: You are telling me now that Mike is the only person who lius.42). is obtained using relatively skilled interviewers who grated psychological structure. Kullgren and colleagues (Arme- Dr. that he was kind and patient. reported satisfactory interrater reliability considering Kern- Ms. Dr. presentation in the moment. The other chiatric in. along with the marked difficulty she of relevant information from the patient’s past and his or her had approaching the question. the main limitation of the SI is varying levels of interrater reliability across settings and studies. these results suggest that adequate agreement between raters tive history she had described. experienced raters assigning patients bly integrate it to some degree: to the PPO or BPO category. are there positive things you would say about yourself? At this point. to see if she could be reflective and possi. even with more experienced interviewers. Ingen- K provided. Hummelen. I think I’m a nice person. how would you describe his personality?” In response to Dr.90) description of Mike. Consistent with this. After asking the subject for a description of self. also reporting 84% interrater reliability estimates for very upsetting to you and cause for arguments. A few studies Dr. Although the SI is a sophisticated method and a valuable clini- son in her life. any history of antisocial behavior (a negative prognostic sign). This to a specific personality organization. Ms. Especially in the setting of identity pathology. highly idealized view of Mike. H’s confrontation by maintaining a berg’s tripartite classification (Ksw D 0. (2009) examined data from 32 borderline and psy- She decided to complete the assessment of identity pathology chotic inpatients from a previous study (Carr. He made me feel so safe. have evaluated the agreement between raters on the SI. (Dr. by offering a tactful confrontation of Ms. Finally. K: The most important person to me is Mike. and lower level denial (see Table 1. defensive structures. For patient if there are things that have not come up that it would example. consistent with identity have an understanding of the underlying theoretical model.

1921). Well. but a comparison pathology in their practice. and to see both positive and negative aspects of the self. Hunt. and at the same time deviant NPO to BPO. curious. (f) moral values. uhm. Scores are obtained both on the item level. Clarkin. the showing a fair amount of identity pathology and rated with a STIPO. & Austin. aggression. assessment of identity integration begins with an open-ended teria for BPD according to DSM–III. or schizoid personality disorders (Yeomans. antisocial. offers a useful score of 2 on a 3-point scale.. clinical ratings per domain and subdomain (e. reflection on sense of his or her personality rater reliability relative to the SI. ing and clinic evaluation services. (1981) compared the SI with coping strategies. diverse experienced interviewers. The STIPO has are as follows: 0 D describes self with subtlety. In addition we have found the STIPO to self. I also am fast in my perception … am tidy. qualities. the STIPO does not specify a review of the interactions in the transcribed interviews using a newly symptoms. According to Kernberg’s question in which the patient is asked to describe himself or model. narrative quality. Blumenthal. Wechsler. she answered “Yes. and (g) reality testing (Clarkin derson. making it ideal for clinical train. several studies found low to moderate agree. for the interviewer. but BPO also comprises other DSM personality disorders (Question 12). ranging from normal to and responses on the WAIS. 2004). experience with the STIPO ined the relationship between SI on the one hand and clinical greatly enhances the skill with which trainees can provide interviews or instruments assessing PDs or performance-based general clinical assessment of personality functioning and (projective) measures on the other hand. Another study domains: (a) identity consolidation versus identity pathology.” (STIPO) The patient’s response reflects a meager. The STIPO differs from the SI in two dent raters’ structural assessments based on detailed analyses of key respects: First. (1979) and Kernberg et al. and For clinical settings in which a more rigorously standard. sense WAIS and Rorschach Inkblot Test were used to test the of self. and a childlike naivete on the other. second. Hence. Bauer. the STIPO does not make use of confronta- developed manual of instructions and scoring standards. The SI and DIB rating process (e. briefly. These moderate associa. I don’t know why. & Goldstein. follow- Wechsler Adult Intelligence Scale (WAIS. and also by giving of borderline personality versus psychotic personality. Gould. her presentation oscillated between distrust on ment (k D . personality organization. The overall. providing clearly formulated questions experts rate transcribed SIs for a global clinical diagnosis (BPO and anchors aiding the scoring process and the classification of vs. Carr. easy for respondent to elaborate multiple. Some- be compared empirically to other instruments on structural times I can be funny. Some- times … Well. Kolb.. In response to this question BPO. with measures of personality organization has not yet been The STIPO assesses the same domains of personality func- published. 1 D somewhat superficial description of research settings. As described in relation to the SI. 1985). I know these were only dation of the model. (c) quality of object relations. & Kernberg. some sense of reflection . Carr (b) use of primitive defenses. individuals with BPD are expected to be located on herself. Hmm … stupid. depth and self- distinct advantages over the SI in its accessibility to less awareness.. NPO) and compared these diagnoses to indepen. The patient expressed considerable hostility during BPD diagnoses. Good tion or trial interpretation for the purposes of clarifying the agreement was found between these two perspectives on the presence of identity pathology or splitting-based defenses. the interview. In 74% of the cases (k D . superficial. sense of others). and Goldstein (1980) had tioning as does the SI. I have no idea. Gun. thought processes on the Rorschach Inkblot Test—whereas psychotic individuals have difficulties on both tests. several studies have exam. (e) use of self-directed and other-directed Gunderson’s Diagnostic Interview for Borderlines (DIB. diagnosis. the one hand. I don’t know.g. When comparing SI assessments ized clinical trial (RCT) for the treatment of BPD (Doering with clinical DSM–III diagnoses (in particular BPD) and DIB et al. Finally. the patient answered as follows: like narcissistic. Kullgren. structural diagnoses—the SI could differentiate well between The STIPO consists of 100 questions assessing seven psychotic and borderline level of personality. for further vali. an overall level of personality hypothesis that borderline patients show ordinary reasoning organization is assigned clinically.g. fragmented representation of herself as a person. In a manner adopted from the SI. 2004). Nelson et al. 2010). PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 7 In terms of concurrent validity.. “Do you act in contradictory ways? Do were employed as instruments to arrive at a structural diagnosis others know what to expect from you?”). interviews assessing BPO reliably need to negative things. 1981) and a combination of the et al. a semistructured version of the SI. suggestive of ized approach to structural assessment is needed.32 to k D . “No idea!” Asked if she felt that it was dif- The Structured Interview of Personality Organization ficult to describe herself. (d) et al. 1982.64... 2015). pathology and the use of primitive defenses and concordance between the SI diagnoses and the combined A female patient in her 20s was interviewed with the STIPO as WAIS and Rorschach Inkblot Test comparisons could be found part of the initial assessment for randomization in a random- in 78% of the cases (k D . Probed about a more detailed description of what made her unique. initial BPO obtained from the SI and the rather narrowly defined cri.56). 1987. The anchors for this specific item alternative to the SI (Clarkin et al.49) the assessment from the SI with the DIB Clinical example of STIPO items inquiring about identity regarding the diagnosis of borderline personality coincided. be an invaluable teaching tool. making it suitable for and inner mental life. assessment of identity is tions can be explained by the broader conceptualization of central to the STIPO. PPO vs. she repeated. 1955) and ing probes and using individual anchors for the item-by-item the Rorschach Inkblot Test (Rorschach. I am not very tolerant. contains some self-awareness. examined the SI in a sample of 46 psychiatric inpatients. and its enhanced inter.

g. related to inner mental life. Clarkin. if this was the case in all relationships or with little elaboration. and stability of tastes and opin- Within the semistructured format of the STIPO interview. tion. the ions. little to no narrative quality. time. would be affirmative responses by inquiring about the pervasiveness. loss of sense impact of the splitting-based defense idealization or devaluation. Severity of Pathology: 5= very severe pathology STIPO Patient Profile 4= severe pathology 3= moderate pathology Pre-Assessment (Clinical Ratings) 2= slight pathology 1= absence of pathology 5 4 Severity of pathology 3 2 1 y S ps S S n on ES rs Y f N n TY ts s l lit se io ip tio N N SE IT O en he hi si ua TI O ss LU sh O SI ID ua ns es of m ot EN TI I EN ex re n AT ES IG VA st al tio gr io se R of gg /S EF ve v ID /R EL TO at Ag R la en lf- n AL ps A G el In G D io re Se R IS ts ed ed AG R hi N R at E al T D PI ns O en IV nt of ct ct EC on M AL O se re ire tio IT er s rs C BJ el di IM oh re la TU -d e od lf- re O ep er rp PR C EP Se M te th e R at O In g C n tim ER ki or In /P lW G IN a rn ST te TE In TY LI Dimensions and Subdimensions of the STIPO EA R Figure 2. The patient in our example responded: Stern. One such question (Question 53) asks. The STIPO directs the interviewer to follow up such and self-directed aggression (cf. the peaks in Figure 2). & Caligor. with ratings starting at 3 indicating moderate question provided the interviewer with a structural diagnosis and impairment of pathology (see Figure 2). Giving clinical weight to the domains in I always think I trust someone. 2012).8 € HORZ-SAGSTETTER ET AL. helpful to this patient. each rated on a 3-point the STIPO represents a semistructured interview format that is scale (with 0 D absence of pathology. narration. The patient responded: poverty in descriptors of self. primitive defensive operations. that is. and also when selecting among across a dimension of severity. to confirm the assessment of identity pathology versus interviewer has the freedom to follow his or her clinical inference integration and to characterize degree of identity pathology when selecting follow-up probes. show particularly with suggested probes. concerned about their motives. based defenses.. coupled with a clinical focus on self and other representations. the STIPO domain of anchors for scoring. all of the time or some of the self. rated on a scale of 1 to 5. a 5- ability across interviewers. then something happens. 2 D superficial description of only with specific people. the STIPO assesses the use of splitting- patient’s responses to STIPO items are illustrated in Figure 2. both the clinical pre- point rating for the overall domain identity is assigned. ize it is not a person I can trust. The Following the SI. high levels of identity pathology (both in her sense of self and “Would you consider yourself someone who is cautious about sense of others). flexible. my family is a single disappointment. but in this case using a semistructured format The overall scores. impatient. In addition. Clinical personality profile based on the Structured Interview of Personality Organization (STIPO) interview. from a score of 1 (identity consolidation) to 5 (severe identity hostile behaviors) and the anchor-based scores for each specific diffusion). see H€ orz. severity. is consistent with BPO (for a more detailed descrip- let down your guard you could be easily taken advantage of?” tion of this case and others on the STIPO. apeutic frame and limit setting. Thus. list of adjectives with no elabora- My friends change frequently. high in most domains of pathology of personality ple. little to no reflection on inner and at work I have often seen how many faces my colleagues have. and frequency of the targeted behavior or charac- some poverty in descriptors of self. which the patient scored most highly with regard to pathology. leaving room for clinical judgment while reducing vari- and 2 D severe pathology in the specific item). of self in intimate relationships. Then my feelings for the person the therapist concluded that a treatment setting with a clear ther- change completely. difficulty seeing self as whole object. clinical information necessary for treatment planning. consistent use of splitting-based defenses. and what other people know about you. identity includes a total of 30 questions. perhaps afraid that if you organization. tends toward list of adjectives teristic. no ability to see self as whole object. In total. The STIPO combines responses to this relatively open- This question was scored to indicate an unstable view of rela- ended question with more specific items inquiring about con- tionships and unpredictable shifts in view of others reflecting the sistency of sense of self across time and situations. mental life. ranging sentation of the patient in the interview situation (e. would you call yourself also severe self-directed aggression. little subtlety or depth. both at the item and domain levels. 1 D moderate pathology. . and I real. In our example. whereas her overall personal- guarded? Are you someone who is suspicious about other peo- ity profile.

At the level of the individual STIPO domains. suggesting that the nosological diagnoses based related to lack of self-control and emotional instability. 2011). of high impairment in the domains coherent sense of self. 2001). Di Pierro. and primitive 2010). Preti. With the German version of the STIPO. 2015). for ment and patients who completed the treatment program: example. between the STIPO primitive defense scale and the Investments and self-coherence problems (STIPO) were primitive defenses scale (r D . and 90% had at least one SCID–II ranging from . psychosis factor of the Inventory of Personality Organization.89–1. & Tellegen. dred and four patients with BPD were randomized to either et al.e. Stern et al. Sarno. PD diagno- validity: Patients with PD were located on a significantly lower ses) did not differentiate between the two groups. & Foelsch. and Madeddu (2014) compared the STIPO profile of correlations revealed unique contributions of the STIPO iden. a significant improvement of personality between borderline patients and nonborderline patients. Wat. 2013). 2012) the rating between structural diagnosis and DSM personality pathology of the STIPO dimensions proved to be reliable across raters. In the study tion and number of SCID–II diagnoses (r D . One hundred percent of a sample coefficients [ICC] ranging from . and Italian versions of the STIPO have In a study with patients with chronic pain disorder. significantly higher number of patients showed a BPO In terms of DSM PDs.001). et al. & Casillas.. object relations.97. & Koopman. Personality [SNAP.. zation changes in an RCT for the treatment of BPD. Doering et al. p < . examining the original English version (intraclass correlation Fischer-Kern et al. Stern et al. Wu. Only moderate associations tive defenses. 1998) was examined in a sample of 92 patients with ations with measures of the stability of self-image and the capac. Clark.84–. organization could be found both in the Transference Focused A prototypical profile derived from the STIPO. 2007.68. 2012) provided further support the Reflective Functioning Scale (RF.. and SIPP–118 domains . 2014). emphasizing the close but not complete association sions (ICCs ranging from . Of particular with a significant correlation between personality organiza- interest are results concerning interrater reliability.. the STIPO shows good construct (88. 2008) was found (r D . Preti et al.82–. (2015) investigated differences Diagnostics (OPD Task Force. The identity scale showed associ. Buss & Dur. (Rentrop. Interestingly. 2007]).. 2012.. & H€orz.e. 1988). lower levels the STIPO domains identity and primitive defenses. patients. p < . patients were described with BPO based on the STIPO. Significant associations ity of pursuing goals. a group of 37 dual-diagnosis inpatients. Prunas. The three primary scales of the STIPO also showed transference-focused psychotherapy or psychotherapy by expe- the expected criterion relations: All of the STIPO dimensions rienced community therapists. Fonagy. 2009) in a mixed clinical sample. good moral values. p < of both descriptive (i.e. and individuals with two or more DSM measures of aggression (Buss–Durkee Inventory. measured through the Severity Indices of between STIPO level of personality organization and SCID–I Personality Problems (SIPP–118. a The STIPO has been used to document personality organi- self-report that assesses the three primary STIPO domains (Len. 2010). whereas organization was examined as an outcome variable. . semipartial Vurro. number of clusters (assessed by the Schedule of Nonadaptive and Adaptive comorbid SCID–II diagnoses. whereas descriptive characteristics (i. Dual-diagnosis whereas the STIPO primitive defenses domain was uniquely patients were characterized by a poorly integrated identity associated with multiple measures of aggression as well as PDs with difficulties in the capacity to invest.. H€orz et al. Verheul et al. 63% were diagnosed with a PD according to the SCID–II. German. Simi- In terms of construct validity. & to the validity of the interview. In a sample of 47 dual-diagnosis according to STIPO and to Operationalized Psychodynamic patients. The by the STIPO. Clarkin. representation of others. 58% of demonstrated good interrater reliability. Kernberg.. in a sample of 104 individuals with BPD.. . PDs showed more pathology on the STIPO than patients kee. Moreover.. and 30 nonclinical controls... Prunas. Axis I and II pathology and RF. 2013. 2008).207. with a significant superiority for the TFP group (Doering et al. strong and STIPO) profiles between patients who dropped out of treat- significant correlations with external measures were found. Preti. collec- of personality organization on the STIPO were associated tively. Finally. operationalized by Italian STIPO study (Preti et al. and reflective functioning. 2001. Preti.05. and high levels of self-directed and other- agreement on the overall level of personality organization directed aggression. and in the comparison group. 1957). The overall level of personality discriminated between clinical and nonclinical subjects. son.. 2010.33.. 2013) and Italian ver- PD. Steele. Clark. Doering et al. PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 9 Psychometric properties and research on the STIPO defenses has been shown to differentiate NPO and BPO (H€orz. and and differential validity (Doering et al. level of personality organization in all domains compared to The interrelation between personality organization. & De Panfilis. DSM-oriented) and structural (i. were closely linked to PD symptom counts of all PD with higher levels of Axis II pathology (i. 30 psychiatric out- tity domain to indices of personality disorder in Cluster A. Stern et al. Simms. 2010) and of 50 patients with opiate addiction were located on BPO both in the German (intraclass correlation coefficients [ICC] according to the STIPO. concurrent validity. 2010).048). Preti. to or self-mutilation). assessed patients without PD (B€aumer. 1997). consisting Psychotherapy (TFP) group. between RF and personality organization were observed (r D Steiner. 2010).97. discriminated year of treatment.. on SCID are more closely related to personality pathology on the reality testing scale showed coherent associations with the the STIPO than RF. BPD (Fischer-Kern et al.. but not between severity of defenses scale was associated with an external measure of primi. Steele. p < . Zilker.e. and positive and negative affect (PANAS-X. the Response Evaluation Measure 71 (REM 71.. and not reality testing. Araujo.00. poorly integrated in Cluster B. Birkhofer. (2010) found that larly.493. One hun- zenweger. of mental health service use. a Borderline Personality Inventory (Leichsenring. in the dropout group.9%). The and SCID–II diagnoses were found.01) of the self-report higher among dropouts. Lederle. with one DSM PD (H€orz et al. After 1 only identity and defenses. The English. Prunas.. Target.

prognosis. clinical interview. and research predefined scales Uses clarification. This requires familiarity with specific. 1981).e. underlying model well and ask clearly operationalize each appropriate questions dimension of the theoretical model Interviewer can make use of Interviewer uses clearly formulated Usefulness of these theory-based interviews for routine clinical inference anchors for giving ratings on clinical assessment. inquiry that will be predictably accessible to patients. Commonalities and differences between Structural Interview (SI) and of personality organization and level of structural integration Structured Interview of Personality Organization (STIPO). Although both instruments assess the along with a detailed discussion of both the underlying model same construct (i. characterizing .68. and self and other aggression. and other instruments of psychotherapy provided by the associated institutes (see ISTFP. 2015). personality organization treatment planning. for example. central to our understanding of personality health and pathology. tionalized in the STIPO and provide the clinician with a theory- Another line of research is the comparison between SI and based guide through the assessment procedure. narcissistic. These approaches can be employed in a variety of of personality pathology was examined using STIPO domains settings including outpatient clinic and private practice settings. German. STIPO with other instruments assessing personality structure. & Examines personality pathology based on same theoretical model Assesses identity pathology. or both. defenses. and commu- sonality organization and more pathology on the STIPO nity-based psychiatric services. grounded in object relations the- ory. confrontation.. 2012). although only moderate the SI and the STIPO. based on the OPD (OPD Task Force.. 1996). 2010). These with strengths and deficits personality organization procedures provide a practical approach to assessment that oper- evolving from the interview) ationalizes theoretical concepts. Stern framework (cf. personality pathology org). The comparison SI STIPO between the individual STIPO domains and OPD domains has not yet been published (H€orz-Sagstetter. The aforementioned validity studies on the SI compared the complemented by evaluation of quality of relationships. as well as a set of implicit or explicit guidelines by which to gauge patient responses along a spectrum of severity.. as well as on inpatient units.... moral structural diagnosis of the SI to instruments of PD diagnosis functioning. No clinical interventions apart from In our collective experience. Typically. p < . the STIPO has proven its clinical significant correlation (r D . Particularly.. Rentrop. (Zimmermann et al. and theory. along with more systematic (Table 2). 2014).. the ability to use clinical inferences to frame confronta.g. linking a lower level of per. STIPO. It would be fruitful to examine following circular model no changes in order of questions Covers present and chronic (dys) Covers the last 5 years how SI. Also. It is one thing to understand (STIPO–R) has recently been developed based on a large data identity pathology and the operation of primitive defenses in set comprising English. 2008). additional STIPO trainings take place for research So far. Follows 100 questions consecutively. coverage of content areas. This can be explained by the broader regarding severity of pathology.001) between STIPO level usefulness in different domains.g. and Italian interviews. offer the clinician essential information relationships were found. 1999a. The outcome is a clinically domains to more than one DSM–IV PD assessed by the SCID– meaningful assessment of personality pathology. Clinical assessment of identity. 2012. between contradictory pieces of information. no study has been published that empirically examines projects involving the STIPO. often neglected in a clinical interview. STIPO can be administered reliably in both sexes and several borderline. tage of providing specific language for inquiring about different important differences in the diagnostic procedure can be found domains of personality functioning. One of the main differences is that the more struc. several STIPO training the relationship between SI and STIPO (as the STIPO is a tapes are scored and ratings are compared to master ratings rather new instrument). STIPO.e. severity et al. 1999b) relate to each other.. use of defensive operations. Table 2. Along these lines.10 € HORZ-SAGSTETTER ET AL. As reviewed earlier. Yeomans et al. Tr€ager. moral values and reality testing been compared to the Levels of Personality Functioning Scale Dynamic order of questions. effective lines of rently under examination. are well opera- tions. it is far more challenging to assess them in a clinical set- the psychometric properties of the 55-item STIPO–R are cur. Training in SI and STIPO is part of specific curricula in transference focused Comparison of SI.. ting. 2010). and schizoid PDs) within the DSM cultural contexts (Doering et al. Training in the STIPO carries the additional advan- dimensions grounded in the same theoretical framework. a task often complicated by the confu- tured STIPO provides higher interrater reliability while losing a sion or intensity involved in the back and forth of the initial more clinically oriented approach as provided by the SI. and other instruments of personality structure functioning like the Shedler–Westen Assessment of Personality (Westen & Interviewer needs to know the Interviewer can use questions that Shedler. Lederle. emergency rooms. the DIB. 2013. Gunderson et al.. that is. but OPD level of personality organization has aggression. a revised and shortened version of the interview evaluate patients in daily practice. making these concepts accessible to clinicians as they Finally. aggression. Both are provided by Discussion training in and experience with SI. instruction in the SI procedure and and interpretation clarifying and asking for examples STIPO provide significant benefits to practitioners working with Provides clinical diagnosis of Yields scores on seven domains and personality organization (along subdomains as well as level of patients across the whole range of severity of pathology. and DSM PDs (H€ orz et al.. level of personality organization) and and ratings. and differential construct of structural diagnosis (i. training. and reality testing. STIPO. object relations. Doering and colleagues (2013) found a severity. questions about sexuality or namely. Preti et al. as covered in both (e. Initial empirical work suggests that the in Kernberg’s framework) that cuts across several PDs (e. focusing on II (First et al.

Rottoli. mental representations of self and others and quality of pat- cal considerations with the analysis of the STIPO–100 terns of relatedness.. The process of including assessment of (a) symptoms and mental status. this contract and fre- approach to personality pathology and the DSM–5 alternative quent discussion of it are not as necessary. 2010). and not as embodied generalized traits. the areas of inquiry of the presented clinical frame in conjunction with limit setting. For example.. Neurotic personality Use of treatment frame Therapist operates from a Therapeutic techniques of Focus on present. 2014. ogy (H€ orz et al. The final this theory-based assessment has the potential to spread the use result is a 55-item interview and the main modifications to of the proposed severity indicator of the DSM–5 alternative the original structure are the elimination of the reality model for PDs... and the- The recent development of a revised. relations pathology assessed by the SI as well as with the fine- 2004).g. assess. we propose that familiarity with organized and specific approach to assessment. psychodynamically based model of PD linked to an DSM–5 LPFS. whereas in the treatment of individuals with a neu- macy). past neutrality confrontation. The STIPO pro- grained. related to organization stance of therapeutic clarification... German. Training the tactful and comprehensive evaluation of identity and object can be enhanced by exposure to the STIPO (Clarkin et al. The parallel between a psychodynamic structural rotic level of personality organization. It offers single session (45–60 min) makes this assessment procedure a comprehensive evaluation of personality (dys)function even more adequate for research purposes. Kernberg.g.. difficulties in understanding others’ borderline pathology. The semi- Conclusions and clinical implications structured approach of the STIPO interview leads to improved interrater reliability (see earlier) when compared In conclusion. problems relating to the ability to a borderline level of personality organization (e. Stern et al.. 2010). PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 11 Table 3. focusing on splitting-based defensive operations. 2015). Kernberg & Caligor. Familiarity with including English. the semistructured version of the SI. in the treatment of individuals with capacities (self-direction). Yeomans set reasonable goals based on a realistic assessment of one’s own et al. and Italian interviews. and interpretation Borderline personality Treatment frame includes a Therapist deviations from More extensive use of Focus on the present organization carefully articulated therapeutic neutrality clarification to set the treatment contract are used in certain stage for crises interpretation patients at risk for dropout (Preti. assessing severity of personality pathol. the object-relations-based model of clinical with the clinical SI (Doering et al. and tracking personality organization following treatment (Doering et al. training in SI provides clinicians with an inte- clinical interviews that were then used to successfully rate the grated. interviews based on an object relations model cover several Personality pathology organized at a neurotic level of per- domains of self and interpersonal functioning that are included sonality organization calls for a very different therapeutic in the DSM–5 LPFS (Bender et al. clinician-friendly.. interviewing provides an organized. ports the clinical benefits of a clearly established treatment Section III. In fact. In the same vein. testing domain and the addition of a new narcissism ing domains of specific impairment for dual-diagnosis patients domain. Zimmermann et al. 2010). Caligor. 2008) to obtain In sum. berg’s object relations model of personality pathology (Kernberg. 2011). that used the OPD system (OPD Task Force. shorter version of the ory-driven assessment of patients as individuals living in a interview (the STIPO–R). An example for a STIPO-based treatment recommendation Closeness of these theory-based interviews to the DSM–5 relates to the STIPO profile depicted in Figure 2. It suggests the alternative model of personality disorders value of identifying a treatment approach that targets identity The theoretical background of the SI and the STIPO—Kern- pathology. 2005)—is quite consistent (if not inte- aggression. the scoring narratives of the STIPO can help the clinician to evaluate patients’ responses to the SI. and familiarity with personality pathology according to the DSM–5 alternative model. Level of personality organization and implications for treatment. the use of a treatment contract is a key experiences and motivations as well as the effects of one’s own constituent of the therapeutic frame to which the therapist will behaviors on others (empathy). and self-directed 1984. et al. and (c) professional and work functioning items’ reliability and factor loadings in a large data set and depth of friendship and intimate relations. 2012) cations for treatment. which can be administered in one unique context. articulated descriptions of the various domains of per- vides the interviewer with clearly formulated questions and sonality provided by the STIPO could help clinicians to assess anchors that systematize the interview. 2007) than does personality pathology organized at uniqueness of self (identity). instability in the sense of self and others. the STIPO can serve as a proxy for the SI. (b) the STIPO–R development combined theoretical and clini. 2014). The high level of severity reflected in Figure 2 sup- gral) to the alternative model of PDs proposed by DSM–5. with the LPFS include difficulties in the sense of continuity and & Clarkin.. and to increase clinicians’ confidence in their . For research pur- poses. 2013... and limitations in establishing refer regularly to provide the patient with a clear and stable and maintaining close and mutual relationships with others (inti- structure. 2015).. currently under examination. Overlapping aspects approach and follows a different course (e. Table 3 shows key model of personality diagnosis has been demonstrated in recent elements relating levels of personality organization with impli- studies (Zimmermann et al. The psychometric properties of the STIPO–R are (Di Pierro et al.

R. version 2. 896–903.. S. & Huprich... 21. NY. 43. relational disorders: A research agenda for addressing crucial gaps Lenzenweger. sample. Interrater reliability for Kernberg’s University. NY: Doering. (2011). G. D. & Caligor. J.. K. Fischer-Kern. Journal of Clarkin. 169. F. H. H. A. P. S. F. E. ing manual for application to adult attachment interviews (Version 5.. G. severity and change of personality pathology. S.. Fischer-Kern. Kernberg. F. (1979). D.). Clarkin. F. by the Structured Interview of Personality Organization (STIPO). G. Lubking. Reflective-Function- ality organization defined by DMT and the Structural Interview. In M. Stern. B. Handbook of dynamic chosomatische Medizin und Psychotherapie. S. Rentrop. A.. Minneapolis: University of Minnesota Press.). … Buchheim. Unpublished manu. The relationship between person- ality organization. and psychiatric classification in chronic pain patients. clinical severity of borderline personality disorder]. Rentrop. M.. 44. Clarkin. Washington.. L. 224–233. M. psychotherapy for higher level personality pathology. Journal of Personality Assessment. Zeitschrift f€ ur Psy- Caligor. Tr€ager. Simms. 27. 192–205. & Sartorius. part I: A review of based practice and practice-based evidence (pp. Parma. New York. F. B. L.. O. & Passchier. DC: H€orz. C. (1994). N. J. 131–139. (2007). Preti.. M€ unster. NY: Humana Press. Schedule for Nonadaptive and Adaptive Personality. 332–346. & Skodol. F. R. S.. Manual First.. D. Blumenthal. Washington. (1984). ability to evaluate their patients’ difficulties in self and interper. B. O. L.. T. 114–156). & Casillas. (2004). Strukturniveau und klinischer Schwere- Buss. (2010). Kapusta. J.. F.. for borderline patients. (2011). Stern. L... CT: Yale University Press. A. H€ orz.. Kernberg. N. Hummelen.. Borderline Gunderson. 196. P. J. Ablon. Borderline-Pers€onlichkeits-Inventar (BPI). B. (2010). F. First. K.. & Madeddu.. A.. Levy. 210.. F.. (2013). & Steele. pp. The relationship between personality organization American Psychiatric Association. Structural interviewing. P. S. Fransson. S. & Durkee. J. & Aigner.. F. Germany. J. 56. Steele. Kernberg. Diagnostic and statistical man. Psychiatric Hospital. 582–590. Gibbon. F. F. D. (1980). E. E. References Fischer-Kern. (2010). Washington. NY: Aronson. ual of mental disorders (5th ed. 577–591... concepts.. 81–88. 225–231. F. Janca. Fischer-Kern. Leichsenring.. F. Sundborn.. Person. Italy. B.. Version of the Structured Interview of Personality Organization H€orz. H€ orz. J. K. (2014).. Wu.. 93. proposals meet criteria for clinical utility? Journal of Personality Disor. 8. Das Strukturierte Interview zur Pers€onlichkeitsorganisa.. ity disorders. M. Germany: Offord. A The Inventory of Personality Organization: Psychometric properties. P. B. P. F. Second Edition Personality structure of (subjectively) healthy individuals. M. F. R. 528–534. Diagnosing borderline personality: A pilot study Psychiatry. Psychiatric Clinics of North ability of the structural interview. Lederle. M. & Foelsch. (2011). Borderline conditions and pathological narcissism. 4. Journal of Nervous and Mental Dis- Doering. Bender. 43. H€orz. personality structure among patients with substance use disorders and Kernberg. J. treatment Kullgren. Brogtrop. Caligor. E. N. F. A. A. Bell. 55. Gould. C. H... New York. (1997). P. B.. J. O. C. 1398–1404. G. (2010). P. 25. Morey.. Vurro. M.. S. R. G. America.. Ingenhoven. H... (2001).. 31. G.. Structured Clinical Interview for DSM–IV Axis II Personality Loranger. 169–195. 389–395. Mikutta. & Caligor. New York. S. ries of personality disorder (2nd ed. 13. & Benjamin. S. A.. E. (2002). S.. ease. October).. S. Williams. D. Clark.. Kernberg. J. O. Doering. tion (STIPO). view: A pilot study of interview analysis.. & Austin. omised controlled trial. E. Scan. heim. Bauer.. Westf€alische Wilhelms-Universit€at. S. A.. & Kernberg. [Borderline Personality Inventory (BPI). Kapusta. G. psychosis proneness. A. Lenzenweger & J. In D.. Stern. ment. Fonagy.. and criterion relations with affect. F. A. Psychoanalytic Psychology. & Clarkin. (2009). The Structured Inter- (STIPO-D)—a study on the convergent validity] (Unpublished doctoral view of Personality Organization (STIPO): An instrument to assess dissertation). H€orz. reflective functioning. F.. (1996). in DSM.. B. (1998). H. [The German burg. P. Kolb.. O. J. & Goldstein. E. Acta Psychiatrica Scandinavica.. Kupfer. P. 123–199). UK: University College London. G€ ottingen.. Hunt. Clarkin (Eds. 246–255. 395– 409. 76. W.. C. (1981). A.). E. & Doering. 13. Journal of Personality Assess.. Interview of Personality Organization (STIPO). & Clarkin. Reliability and validity of the German version Kernberg. M. & Kernberg. A prototype of borderline personality organization assessed B€aumer. O. S. & Bouwens. 136–149. V. . Psychopathology. C.. D. aggressive American Psychiatric Association. 23. F. der Examination (IPDE). J. M. & Rentrop. Hunt.. Guilford Press. … Wisner. Schuster. using multiple diagnostic methods. Toward a model for & H. Psychiatry. (1975). (2009). A. Carr. Personality disorders and Hogrefe. Lindenborn. Target. M. R. Ham- tion (STIPO-D)—eine Studie zur konvergenten Validit€ at. Dimensions of strategies. (1997).. British Journal of Psychiatry. C. (2005). W. Schuster. B. L.0). American Psychiatric Publishing. organization using the Structured Interview of Personality Organiza- chological tests and borderline patients. G. Kapusta. Menke.. dyscontrol.. Malison. Heuft. Transference-focused psychotherapy v. Major theo- patients and healthy controls. Manual for the H€orz-Sagstetter. B. M. M. and self-domains in a nonclinical First. G. Structured Transference Focused Psychotherapy (ISTFP)... Caligor. New York.0). B.. & Kullgren. Bauer. (2013). O. Carr. structural diagnosis and the structural inter.. A. 142–148. Do DSM–5 personality disorder Personality Disorders. (1981). M. The diagnostic interview personality organization. Derksen. J. M. 13. K. (1987). An inventory for assessing different grad der Borderline Pers€ onlichkeitsst€orung [Personality structure and kinds of hostility. K€achele (Eds. A.. H. New York State Psychiatric Institute.. Regier (Eds. F. (2007). O. (1957). Armelius. J. and psychiatric classification in borderline personality disorder.. Journal of the American Psychoanalytic Association. J. W. A. Benecke. M.. Goldstein. S. A. 138. Van script. J. Manual]. O. L. J. C. B.. In R.. Spitzer. S.. & of the Structured Interview of Personality Organization (STIPO). F. DSM–III and struc. dinavian Journal of Psychology. J. New York. Baumer.. (1981). E. Cuthbert. Psy.. E. & Goldstein. P. DC: factorial composition.. Germany: Verlag Dr. E. A psychoanalytic theory of personal- co-occurring personality disorders: A comparison with psychiatric out. 343–349. (2007).. Kernberg. Journal of Personality Disorders.. Journal of Consulting Psychology. An empirical comparison of three different borderline by community psychotherapists for borderline personality disorder: Rand. W. structural interview for assessing personality organization. B.. Goldstein. M. R. 1464–1468. (1982). UK: Cambridge University Press. Buchheim.. W. J. Comprehensive Psychiatry. Kovac. Mertens. S. Psychological Assessment. Assessment and diagno- Disorders (SCID–II. Interrater reli. M.12 € HORZ-SAGSTETTER ET AL. F. at the 3rd International Conference of the International Society for Clarkin. BMC Blumenthal. Schuster. J. (2012).. C.. N. M. H€orz.. E. Personality Disorders Institute. M.. L. J.. … Schneider. Kernberg. Weill Medical College of Cornell Den. O. A prototypical profile of borderline personality Carr. & D. London. research agenda for DSM–V (pp.. 21–26.. … Fonagy. Doering. (1990). (2014.. Krystal. ders. Psychodynamic psychotherapy research: Evidence- assessing level of personality functioning in DSM–5. H. A. Duivenvoorden. Hunt. Presentation (SNAP–2). F. Burgmer. Severe personality disorders: Psychotherapeutic Di Pierro. American Journal of Psychiatry... E.. 57. Buch- tural diagnosis of borderline patients. N.). Cambridge... M. NY: Biometrics Research sis of personality disorders: The ICD-10 International Personality Disor- Department. 571–592). Critchfield. New Haven.. sonal functioning.. theory and methods. L.. F.. DC: Author. S.

E. (2010). 536–547. for DSM–5. Rancati.. focused psychotherapy for borderline personality disorder: A clinical lent addiction. J. Maccornack. A. C. E.. H€ orz. (1955).. A.. (2014).. Berghout. Dolan. & Stone. C. & Shedler. F. H. 13. . F. H. … Fonagy. assessing personality disorders: Implications for research and the evo- triche della STIPO [Psychometric properties of the STIPO].. Assessing the level of structural integration Personality Organization (STIPO): Preliminary psychometrics in a clinical using operationalized psychodynamic diagnosis (OPD): Implications sample.. J. & Shedler.. Oxford. & Kernberg. Prunas. O. & Kernberg. 92. Problems (SIPP–118): Development. van M. Kernberg’s model. E. D. 35–44. factor structure. part the Structured Interview of Personality Organization] (pp. J.F. Araujo.. Andrea. P.. (1999a). Madeddu. B. Journal of Personality and Social Psychology. 285. 156. C. Doering.. D. 14... Busschbach. Manual for the Wechsler Adult Intelligence Scale.. Washington. Switzerland: Bricher. reliability. part I: secondo il modello di O. F. 133–140. American Journal of Psychiatry... Yeomans.. R. American Journal of Psychiatry. 158. Clark.. (1997). J. L.. Journal of Personality orders. Disorders. Schauenburg. L. 154. Research. through the Inventory of Personality Organization. Revising and assessing Axis II. C. UK: Psychological Corporation.). A. 855–858... 467–473. A. (2014).. S. J. (1999b).. J. Clarkin. Benecke. of personality disorders... & Benecke. B. (2012). F. PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW 13 Nelson. DC: American Psychiatric Publishing.. Rottoli. Cierpka. & Koopman. Ehrenthal. International Journal of Mental Health & Addiction. La diagnosi strutturale di personalita Westen. D. Kubeck. (OPD): Manual of diagnosis and treatment planning.. 258–272. C. Birkhofer. Severity Indices of Personality sonality disorder.. J. Marchesi. F. The Response Evaluation functioning from videotaped clinical interviews: A pilot study with Measure (REM-71): A new instrument for the measurement of defenses untrained and clinically inexperienced students. and OPD Task Force. 20. M. Psychological Assessment. 109–126. 129–140. & Madeddu. J. A. F. 54. tured Interview of Personality Organization [Structural diagnosis of American Journal of Psychiatry. H. 94. Bender. Journal of Personality in adults and adolescents. C. personality according to O. 142. A. 6. Psychodiagnostics: A diagnostic test based on percep. Sarno. J... Divergences between clinical and research methods for Preti. E. J. L. Madeddu & E. tion. J. Bern. D. Transference- chiatric comorbidity and personality structure in patients with polyva. La versione italiana della Struc.. I. & Shedler. R. 895–903. Development and valida- Hogrefe & Huber. A prototype matching approach to diag- patients with substance-related disorders and comorbid personality dis. (1985). Westen. nosing personality disorders: Toward DSM–V. Assessment.. (2000). M. F. (1988).. guide. D. F.. S. & Clarkin. 23–34. The facets of identity: Personality pathology assessment Wechsler. D. T. & Tellegen. M. Cierpka. Developing a clinically and empirically valid assessment method. Lederle.. Operationalized Psychodynamic Diagnostics validity. F. Journal of Personality Assessment. Preti (Eds. tion of brief measures of positive and negative affect: The PANAS Preti. (2015). Tasman. O. Zilker.F.. E. (1921). H. M. C. D. Comparison of three systems for diagnosing borderline per.. Rorschach. 522–532. The Italian version of Westen. Verheul. J. Proprieta psicome.... H. C. Zimmermann. F.. ders: Theory. 96.. (2015). Borton. Structured Interview of S.. Scales. American Journal of Psychiatry.. Prunas. S. (2012). A. Lenzenweger. Cambridge... A. Journal of Personality Assessment. Zimmermann. Caligor. Personality structure features associated with early dropout in Westen. Schauenburg.. 397–409. 59–84). Clarkin. M.. & Leising. C.. Italy: Raffaello Cortina. C. (2001). In lution of Axis II. 156.. F. Di Pierro. Critchfield. (2008). Kernberg. MA: Watson... F. & De Panfilis. C. P. De Panfilis. Stern.. Rentrop. M. (2008). K. Dainese. (2015).. Skodol. Assessing DSM–5 level of personality Steiner. E. 47. K. & H€ orz. II: Toward an empirically based and clinically useful classification Milano. and Treatment. 1063–1070. Revising and assessing Axis II.. H. D. Personality Disor. V. Psychopathology. 273– Preti. American Journal of Psychiatry. H. Psy. der Kroft. Tennen.