Ten Angles of Vision

on Individual Differences

Nancy McWilliams, PhD

Emerita Visiting Faculty
Rutgers University Graduate School of
Applied & Professional Psychology

California Clinical Social Work Society

November 19, 2022
 Psychotherapy outcomes vary according to

• 1. Personality factors (in both client and therapist)

• 2. Relationship factors (the “fit” between the two)

www.apa.org/about/policy/resolution-psychotherapy.aspx

Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York: Oxford.
Wachtel, P. (2010). Beyond “ESTs”: Problematic assumptions in the pursuit of evidence-based practice. Psychoanalytic
Psychology, 27(3), 252-272.
Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., Horvath, A. O. (2012). Journal of Counseling Psychology, 59(1), 10-17.
 Given the extensive empirical work attesting to the
importance of personality and relationship,

• Why do we tend to study specific techniques as applied to specific DSM

diagnostic categories and conclude that this is the only relevant
evidence base for psychotherapy?
• Why do we not consider research on individual differences and the
relationships they tend to influence as equally valuable empirical
evidence, equally pertinent to decisions about psychotherapy?
• This presentation reviews 10 different, intersecting perspectives on
individual differences, all of which have been investigated empirically.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy
of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.
Orlinsky, D. E. (2009). The “Generic Model of Psychotherapy” after 25 years: Evolution of a research-based metatheory. Journal of
Psychotherapy Integration, 19(4), 319–339.
 1. Temperament
Because of the 20th century dominance of behaviorism, including
Watson’s seminal ideas about every child’s being a tabula rasa, and also
because of clinicians’ hopes that the sources of behavior are
predominantly in the realm of nurture rather than nature (and therefore
influenceable by therapy), it took decades for most psychologists to
acknowledge what observant parents of more than one child have
known for millennia.

Thomas, A., Chess, S., & Birch, H. G. (1968). Temperament and behavior disorders in children. New York: International Universities
Press.
Escalona, S. K. (1968). The roots of individuality: Normal patterns of development in infancy. Chicago: Aldine.
Kagan, J. (1994). Galen’s prophecy: Temperament in human nature. New York: Basic Books.
Halverson C. F., Jr., Kohnstamm, G. A., & Martin, R. P. (Eds.) (2014). The developing structure of temperament and personality from
infancy to adulthood. New York: Psychology Press (Taylor & Francis).
Human infants (and babies of all mammals so far studied) differ
from birth on in areas such as:
• Overall mood and mood fluctuation
• Level of energy/ activity
• Appetite for novelty
• Reactivity to stimulation
• Responsiveness to efforts to soothe
• Interest in other people/sociophilia
• Irritability
• Sleep cycles and general rhythms
• Inhibited versus uninhibited (Kagan)
• and many other areas that interact in complex ways with developmental and
environmental issues.

K. J. Saudino, & Ganiban, J. M. (Eds.) (2021). Behavior genetics of temperament and personality. New York: Springer.
 Clinical implications
• Therapists try to help their clients to understand and accept elements of their temperament
that they may consider flaws, emphasizing the positive as well as the negative elements of
their particular disposition.

• We try to help them maximize the positive aspects of their temperament and live more
comfortably with the negative ones.

• We try to help patients to understand and forgive any mismatches between their caregivers’
temperaments and their own, and to be able to explain something about their own
temperament to others who may misunderstand them based on a mismatch.

• Example: The highly sensitive child in a family of less sensitive caregivers

Aron, A. N. (2011). Therapy and the highly sensitive person: Improving outcomes for that minority of people who are the
majority of clients. New York: Routledge.
 2. Attachment style

John Bowlby (1907-1990), disparaged by many psychoanalyst colleagues

for his critique of orthodox Freudianism, argued that safety and
connection are more basic to human psychology than drive satisfaction.
His students developed creative ways of testing his ideas empirically.

Bowlby, J. (1969). Attachment and loss: Vol 1: Attachment. New York: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol 2: Separation: Anxiety and anger. New York: Basic Books.
Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28(5), 759-775.
 Attachment styles: Research-derived categories
• 1. Secure attachment
• 2. Ambivalent-insecure attachment
• 3. Avoidant-insecure attachment (dismissive)
Established by the Strange Situation research of Mary Ainsworth
• 4. Disorganized-insecure attachment (Type D)
Added by Main and Solomon once the Strange Situation research was expanded to children
who had experienced traumatic parenting, whether based on poverty, addiction, neglect,
abuse, or sociopolitical disaster.

Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M.
Yogman (Eds.), Affect development in infancy (pp. 95-124). Norwood: Ablex.
Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford.
Slade, A., & Holmes, J. (2019). Attachment and psychotherapy. Current Opinion in Psychology, 25, 152-156.
 Attachment styles are moderately stable over
time but can change

• They can be modified either by traumatic relational experiences or by

long-term positive, dependable relationships.
• A reliable, safe relationship tends to move people from more insecure
styles to more secure attachment. This can happen over many years in
a devoted connection such as a marriage, or it can happen in as little as
two years in intensive psychotherapy.
Cozzarelli, C., Karafa, J. A., Collins, N. L., & Tagler, M. J. (2003) Stability and change in adult attachment styles: associations with personal
vulnerabilities, life events. and global construals of self and others. Journal of Social & Clinical Psychology, 22(3). Published Online:1 Jun
2005 https://doi.org/10.1521/jscp.22.3.315.22888
Fraley, C. R., & Roisman, G. I. (2019). The development of adult attachment styles: Four lessons. Current Opinion in Psychiatry, 25, 26-30.
Theisen, J. C., Fraley, C. R., Hankin, B. L., Young, J. F., & Chopik, W. J. (2019). How do attachment styles change from childhood through
adolescence? Findings from an accelerated longitudinal Cohort study. Journal of Research in Personality, 74, 141-146.
Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford.
 Clinical implications
• No matter how important the therapist may think it is to move forward with particular
techniques in treatment, the primary issue one needs to monitor is whether the relationship
itself feels adequately safe and reliable to the client.
• In any ongoing therapy, a foundational concern of therapist and patient is to attend to
rupture and repair of the therapeutic relationship.
• Not only can therapists adapt their own therapeutic choices to each client’s attachment style,
they can help patients to understand their individual attachment history and take their style
into account in their choices - without the self-attack that often accompanies clients’
awareness of their relational proclivities.

Holmes, J. (2001). The search for the secure base: Attachment theory and psychotherapy. Philadelphia: Taylor & Francis.
Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford.
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519.
Levy, K. N., & Johnson, B. N. (2019). Attachment and psychotherapy: Implications from empirical research. Canadian
Psychology/Psychologie canadienne, 60(3), 178–193.
Two Recent Comprehensive Books on
Clinical Implications of Attachment
 3. Observed clinical patterns
• Much of the language that mental health professionals have used to describe differences in
overall personality and psychodynamics came from clinical observations of mental disorders
(e.g., obsessions, compulsions, hysterical conversion symptoms) and of the most maladaptive
versions of the personality styles and in which those disorders tended to be found.
• All of us have personality, and all of us have dynamics (internal conflicts and tensions), some
of which are common enough to have created a shared professional language for certain
patterns, such as obsessional, hysterical, narcissistic, schizoid, and paranoid personalities. All
these types have both positive and negative features. They are personality “disorders” only
toward the extremes of each continuum.
• The source of these terms in the observation of pathological versions of each pattern leads to
confusion between simple description and pathologization.

Freud, S. (1916). Some character types met with in psychoanalytic work. Standard Edition, 14, 311-333.
Reich, W. (1933). Character analysis. New York: Farrar, Straus, & Giroux.
Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York: Norton.
Shapiro, D. (1965). Neurotic styles. New York: Basic Books.
MacKinnon, R. A., & Michels, R. (1971). The psychiatric interview in clinical practice. Philadelphia: Saunders.
Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press.
 Clinical implications

• Understanding the personality type of any individual client, and

distinguishing it from personality styles whose observable traits are
similar, can help therapists to adapt to the person’s strengths,
vulnerabilities, and typical preoccupations, and can help them avoid
empathic failures and misunderstandings.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford.
Lingiardi, V., & McWilliams, N. (Eds.). (2017) Psychodynamic diagnostic manual, 2nd ed. (PDM-2). New York: Guilford.
Shedler, J. (2022). The personality syndromes.
In R. E. Feinstein (Ed.), (Primer on) Personality Disorders.
New York: Oxford University Press.
ISBN-13: 978-0197574393
ISBN-10: 0197574394

ISBN-1
 4. Defensive organization
• Freud, who was fond of military metaphors, used the term “defense” to describe ways in
which we keep anxiety-filled images, perceptions, and cognitions out of conscious awareness.
The earliest defenses he identified were processes that he inferred during his studies of
dreaming: repression, condensation, and displacement. His later clinical writings referred to
several other common defensive processes.
• His daughter Anna subsequently elaborated on defenses in a seminal work, which inspired
therapists to create a rich descriptive clinical literature on defenses as they appear in the
therapeutic process.
• Eventually, assessment instruments were developed, and an extensive research literature on
the topic accumulated.

Freud, A. (1936). The ego and the mechanisms of defense. New York: International Universities Press.
Laughlin, H. P. (1970). The ego and its defenses. New York: Jason Aronson.
Cramer, P. (1990). The development of defense mechanisms: Theory, research, and assessment. New York: Springer.
Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York: Guilford.
Di Giuseppe, M., Perry, J. C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, A., Fabiani, M., Maffei, S., Conversano, C. (2020). Preliminary
reliability and validity of the DMRS-SR-30, a novel self-report measure based on the Defense Mechanisms Rating Scales. Frontiers in
Psychiatry. https://doi.org/10.3389/fpsyt.2020.00870
 Clinical implications
• Identifying triggers to defensive patterns can open up ways of dealing with those situations
that are less automatic and/or self-defeating.
• Patients whose pattern of defense is inflexible, even if mature, need to be encouraged to
have a wider repertoire of response to stress.
• Patients who rely on more primitive ways of dealing with stress need to try out more mature
and adaptive ways of doing so.
• A psychoanalytic assumption deriving from a century of clinical experience: The client’s
defenses will emerge in the therapeutic relationship and are most visible and addressable in
that context, where they can be named, experienced, and modified in the here-and-now, and
the affects against which they are defending can be integrated into the person’s sense of self.

Babl, A. M., Perry, J. C (2017). How does improving defense mechanisms in patients affect psychotherapy outcome?: A review and
meta-analysis of changes in defense mechanisms in psychotherapy studies (Unpublished). In: 48th International Annual Meeting
Society for Psychotherapy Research (SPR). Toronto, Canada. 21.06.-24.06.2017.
Euler, S., Stalujanis, E., Allenbach, G., Kolly, S., de Roten, Y., & Despland, J-N. (2019). Dialectical behavior therapy skills training
affects defense mechanisms in borderline personality disorder: An integrative approach of mechanisms in psychotherapy.
Psychotherapy Research, 29(8), 1074-1085.
Perry, J. C., & Bond, M. (2017). Addressing defenses in psychotherapy to improve adaptation. Psychoanalytic Inquiry, 37(3), 153-166.
 5. Implicit cognitions (core schemas)
• Based on our early interpersonal contexts, we all develop beliefs that explain and generalize
about our experiences, help us to assimilate them, and provide a template for future
interactions.
• These implicit, automatic convictions about the nature of life are inherently neither positive
nor negative, rational nor irrational. They arise because they are the child’s best possible
understanding of, and adaption to, a childhood situation; they may or may not deal well with
the person’s challenges as an adult.
• Individuals tend to come to therapy when their organizing cognitions, which are usually
unconscious, have recurrently failed to help them cope adequately with their contemporary
life circumstances.
Weiss, J., Sampson, H., & the Mt. Zion Psychotherapy Research Group (1986). The psychoanalytic process: Theory, clinical
observations, and empirical research. New York: Guilford.
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
Kahneman, D. (2011). Thinking fast and slow. New York: Farrar, Straus & Giroux.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s Guide. New York: Guilford Press.
 Problematic cognitive schemas (irrational cognitions,
pathogenic beliefs, emotional schemas, cognitive biases)
involve assumptions, based on prior experience, about:
• Safety and danger
• Power and weakness
• Love and hate
• Male and female
• Wealth and poverty
• Intelligence and stupidity
• Good and evil
• Insiders and outsiders
• and other major organizing concepts

Faustino, B., Vasco, A. B. (2020b). Early maladaptive schemas and cognitive fusion on the regulation of psychological needs.
Journal of Contemporary Psychotherapy, 1(50), 105-112.
 Clinical implications
• The patient’s problematic or maladaptive or self-defeating beliefs need to be
identified and brought into awareness and slowly opened to the possibility of
alternative explanations.
• The therapist needs to understand what beliefs may be “tested” in the therapeutic
relationship, and needs to pass the tests – or at least apologize and attempt repair
when a patient’s test is misunderstood and failed.
• Transference tests
• Passive-into-active transformations
The therapist needs to raise the possibility that the organizing beliefs of others
may be different from those of the patient (mentalization).

Weiss, J. (1993). How psychotherapy works: Process and technique. New York: Guilford.
Gazzillo, F., Genova, F., Fedeli, F., Curtis, J. T., Silberschatz, G., Bush, M., & Dazzi, N. (2019). Patients’ unconscious testing activity
in psychotherapy: A theoretical and empirical overview. Psychoanalytic Psychology, 36(2), 173–183.
 6. Affective patterns

• Human beings are as individual in their experiences of the

predominant and organizing emotions as they are in all other domains:
in each human brain, experience has carved particular pathways from
the amygdala to other neural areas.

• The face is the main organ of emotional expression.

Tomkins, S. S. (1995). Script theory. In E. V. Demos (Ed.), Exploring affect: The selected writings of Silvan Tomkins (pp. 312-388).
New York: Cambridge University Press.
Panksepp, J. (2004). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford.
Matsumoto, D., Keltner, D., Shiota, M. N., O'Sullivan, M., & Frank, M. (2008). Facial expressions of emotion. In M. Lewis, J. M.
Haviland-Jones, & L. F. Barrett (Eds.), Handbook of emotions (pp. 211–234). New York: Guilford.
Demos, E. V. (2019). The affect theory of Silvan Tomkins for psychoanalysis and psychotherapy. New York: Taylor & Francis.
 We all have a unique affective “fractal”
• Individuals tend to run through a limited number of affects, in a particular order.
• They are highly attuned to some affects in themselves and others, while being blind to other
emotional states.
• Some affects are not so much defended against as unformulated in the first place.
• In normal affect, the face (the primary organ of affective expression) is comparatively labile,
changing about every 8 seconds. We recognize psychopathology intuitively when a person’s
face is immobile.
• In normal affective interaction, we tend to “match” the affect that is coming at us. Part of the
stress of being a therapist is unlearning this natural matching process and containing rather
than returning the patient’s affects.

Anstadt, Th., Merten, J., Ullrich, B., & Krause, R. (1997). Affective dyadic behavior, core conflictual relationship themes and success
of treatment. Psychotherapy Research, 7, 397-417.
Stern, D. B. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillsdale, NJ: Analytic Press.
 Affects in the transference and countertransference
• Much communication in psychotherapy occurs on “Channel Two”
(facial affect and body language) and “Channel Three” (evocation of
affect in the other person).
• Countertransference is often the most accessible way of understanding
a patient’s deeper experience and psychological organization.
• There has been a slow revolution in psychoanalytic thinking about
countertransference, especially as therapists have increasingly worked
with more disturbed patients.
Caligor, E., Diamond, D., Yeomans, F. E., & Kernberg, O. F. (2009). The interpretive process in the psychoanalytic psychotherapy of
borderline personality pathology. Journal of the American Psychoanalytic Association, 57(2), 271-301.
Stefana, A. (2017). Psychoanalytic concepts in historical perspective: History of countertransference from Freud to the British
Object Relations School. New York: Routledge.
 Clinical implications
• In an effective psychotherapy, a patient learns a great deal at the unconscious level
through the affective, right-brain-to-right-brain communication with the therapist.
• Many clients need to learn how to name affects of which they have been completely
unaware.
• Most patients need to assimilate different ways to feel than those that come
automatically to them. For example, if situations of dependency inevitably evoke shame
in a client, a therapist needs to question why shame is the automatic outcome, since we
all depend on others.
• Experiencing intense emotions that are witnessed by the therapist, including strong
negative affective states, and being accepted in all one’s intensity, can feel powerfully
healing to patients.

Stern, D. B. (2017). The infinity of the unsaid: Unformulated experience, language, and the nonverbal. New York: Routledge.
Greenberg, L. S., & Goldman, R. N. (2019). Theory of practice of emotion-focused therapy. In L. S. Greenberg & R. N. Goldman
(Eds.), Clinical handbook of emotion-focused therapy (pp. 61–89). Washington, DC: American Psychological Association.
Schore, A. N. (2019). Right brain psychotherapy. New York: Norton.
 7. Drive (motivational systems)

• Although contemporary psychoanalysts have rejected Freud’s emphasis on

biological drives, especially when conceptualized in terms of the dual instincts of
Eros (libido, or the life drive) and Thanatos (aggression, or the death drive),
neurobiology has begun to discover biological systems that differ in their
dominance from one person to another.
• These brain systems have implications for personality: One person, for example,
may be motivated predominantly by an orientation toward care, while another
may be driven by separation and attachment issues, and yet another may be
organized around anger.
Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. New
York: Other Press.
Panksepp, J., & Davis, K. L. (2018). The emotional foundations of personality: A neurobiological and evolutionary approach. New
York: Norton.
Solms, M. (2021). The hidden spring: A journey to the source of consciousness. New York: Routledge.
 Helen Fisher’s application
of neuroscientific findings

• Depending on their dominant neurotransmitters and the brain systems

mediated by them, Fisher has classified individuals as:

• Explorers (dopamine-related)
• Builders (serotonin-related)
• Directors (testosterone-related)
• Negotiators (estrogen-related)

Fisher, H. (2009). Why him? Why her? How to find and keep lasting love. New York: Henry Holt & Co.
Fisher, H. (2016). Why we love: A natural history of mating, marriage, and why we stray. New York: Norton.
Individuals differ on what motivational systems are dominant in
their psychology
Jaak Panksepp’s empirically derived brain systems:
LUST
SEEKING
RAGE
FEAR
PANIC/GRIEF
CARE
PLAY
Panksepp, J. (2004). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford.
Panksepp, J., & Biven, L. (2012). The archaeology of mind: Neuroevolutionary origins of human emotions: New York: Norton.
Solms, M. (2021). The hidden spring: A journey to the source of consciousness. New York: Norton.
Panksepp, J., & Davis, K. L. (2018). The emotional foundations of personality: A neurobiological and evolutionary approach. New
York: Norton.
 Clinical implications
• Patients need therapists who appreciate their individual organizing motivations and who
understand how those preoccupations influence their life choices.
• Understanding that there are two anxiety systems in the brain has far-reaching clinical
implications and even pharmacological ones. Traditional psychoanalytic theorizing has
referred to the difference between separation anxiety (Panksepp’s PANIC system) and
annihilation anxiety (paranoid anxiety, psychotic anxiety – Panksepp’s FEAR system) and
other subjective experiences of anxiety. Separation anxiety can be reduced by SSRIs, but
annihilation anxiety cannot, because it is not mediated by serotonin.
• Patients may need to extend themselves into areas in which they are less likely to be
motivated (e.g., the workaholic who needs more PLAY, the competitive striver who needs to
find more capacity to CARE, the maternal accommodator who needs to learn to negotiate
(SEEKING system).

McWilliams, N. (2017). Integrative research for integrative practice: A plea for respectful collaboration across clinician and
researcher roles. Journal of Psychotherapy Integration, 27(3), 283-294.
 8. Individualistic (self-definition) vs.
communal (self-in-relationship) orientation
• Observation of a tension between autonomy and community, individualism and
collectivism, introversion and extroversion, self-care and altruism, agency and
surrender, self-efficacy and compliance with larger shared goals – and similar
polarized concepts – pervade the psychoanalytic clinical literature.
• Individuals differ in whether they tilt more toward an individualistic orientation or
toward a more collectivist sensibility.
• Cultures differ as well on this question, and individuals have to negotiate tensions
between their own inclinations and what is culturally normative.

Jung, C. G., & Baynes, H. G. (1921). Psychological types or the psychology of individuation. London: Kegan Paul.
Balint, M. (1945). Friendly expanses—Horrid empty spaces. International Journal of Psycho-Analysis, 36, 225-241.
Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the
therapeutic process. Washington, DC: American Psychological Association.
 Blatt’s work on two different subjective experiences of
depressive affect
Anaclitic (self-in-relationship) Introjective (self-definition)

• Shame • Guilt
• Sense of being empty of anything • Sense of being full of badness,
valuable. evil.
• Relationship itself is therapeutic • Therapy takes longer and must
and reduces symptoms fairly include focus on cognitions about
quickly. one’s “faults.”
• Danger of losing gains at the end • Improvement may continue after
of a therapy. treatment ends.

Blatt, S. J. (2004). Experiences of depression: Theoretical, clinical, and research perspectives. Washington, DC: American Psychological Association.
 Broader implications
• In Western psychiatry, some psychologies are considered pathological because they are at the
extreme end of the self-in-relation versus self-definition continuum.
• For example, antisocial personality disorder represents a psychology in which everything is
about oneself and one’s power, with indifference to one’s effects on others; dependent
personality disorder represents an over-enmeshment in one’s family or interpersonal system
and an inability to advocate for the self.
• In many psychologies, not simply depressive experience, there are self-in-relation and self-
definition versions of a particular dynamic (e.g., narcissistic, self-defeating, and histrionic
patterns).
• Blatt found that mental health is associated not with being at a kind of mid-point between
poles, but with being strong on both ends of the polarity.

Lingiardi, V., McWilliams, N., & Muzi, L. (2017). The contributions of Sidney Blatt’s two-polarities model to the Psychodynamic
Diagnostic Manual. Research in Psychotherapy: Process and Outcome, 20, 12-18.
 Cultures and subcultures differ on their normative balance
between individualistic and communal concerns and orientations

• The main implication for therapists is to avoid pathologizing these differences. In

Western cultures, we tend to tilt strongly toward individual rights rather than
communal responsibility; this inclines us to misunderstand the meaning of many
behaviors that are normative in other cultures. For example, in many traditional
societies, separation from one’s family of origin is not as highly valued as in
mainstream North American cultures.

Roland, A. (1988). In search of self in India and Japan: Toward a cross-cultural psychology. Princeton, NJ: Princeton University Press.
McGoldrick, M., Giordano, J., & Garcia-Preto (Eds.) ( (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford.
Akhtar, S. (Ed.) (2010). Freud and the Far East: Psychoanalytic perspectives on the people and culture of China, Japan, and Korea .
Northvale, NJ: Jason Aronson.
Boyd-Franklin, N. (2006). Black families in therapy: Understanding the African-American experience., 2nd ed. New York: Guilford.
Tummala-Narra, P. (2016). Psychoanalytic theory and cultural competence in psychotherapy. Washington, DC: American Psychological
Association.
 Clinical implications

• Treatment should vary depending on the patient’s position on the self-

in-relationship versus self-definition polarity.
• Patients need to be selectively helped to develop strengths on both
ends of the continuum.
• The therapist’s humility, respect for difference, and willingness to learn
from patients of different backgrounds is critical to therapy outcome.

Auerbach, J. S. (2019). Relatedness, self-definition, mental representation, and internalization in the work of Sidney J. Blatt:
Scientific and clinical contributions. Psychoanalytic Psychology, 36(4), 291-302.
Luyten, P., Campbell, C., & Fonagy, P. (2019). The dialectical needs for autonomy, relatedness, and the emergence of epistemic
trust. Psychoanalytic Psychology, 36(4), 328-334.
 9. Internalized object relations/
inner working models/ schemas
• The term “psychodynamic” comes originally from Freud’s observation of tensions or
“dynamisms” underlying human behavior and experience.
• W. R. D. Fairbairn, a student of Melanie Klein, was the first psychoanalyst to describe how
psychopathology and recurrent psychological patterns involve not simply ambivalent feelings
(such as simultaneously fearing and wishing a given outcome) but the internalization of an
interpersonal dynamic. Relations with early love objects (“object relations”) remain alive in
the self and are reenacted both internally and on the stage of the outer world. These
“internalized object relations” involve strong affects and contrasting positions such as both
love and hatred toward self and others.
• Over many decades, various theorists and researchers have tried to articulate the internal
conflict, tension, or polarized preoccupation of various kinds of clients.

Fairbairn, W. R. D. (1952). An object-relations theory of the personality. New York: Basic Books.
 Some versions of this idea, organized historically, from both
clinical theorists and empirical researchers
• French, T. (1958). The integration of behavior, vol. 3. The reintegrative process in a psychoanalytic treatment. Chicago: University of
Chicago Press. “repetitive structures”
• Bowlby, J. (1969. Attachment and loss: Vol. 1: Attachment. London: Hogarth. “inner working models”
• Malan, D. H. (1976). The frontier of brief psychotherapy. New York: Plenum. “nuclear conflicts”
• Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic
Books. “representations of internalizations that have been generalized (RIGs)”
• Dahl, H. (1988). Frames of mind. In H. Dahl, H. Kachele, & H. Thomae (Eds.). Psychoanalytic process research strategies (pp. 51-66).
New York: Springer-Verlag. “fundamental and repetitive emotional structures (FRAMES)”
• Aron, L. (1991). Working through the past—working toward the future. Contemporary Psychoanalysis, 27, 81-108. “internal relational
models”
• Tomkins, S. S. (1995). Script theory In E. V. Demos (Ed.), Exploring affect: The selected writings of Silvan Tomkins (pp. 312-388). New
York: Cambridge University Press. “nuclear scenes”
• Bucci, W. (1997). Psychoanalysis and cognitive science. New York: Guilford. “emotion schemas”
• Luborsky, L., & Crits-Cristoph, P. (1996). Understanding transference (2nd ed.). Washington, DC: American Psychological Association.
“core conflictual relationship theme”
• Lyons-Ruth, K. (1999). The two-person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence
of new forms of relational organization. Psychoanalytic Inquiry, 19, 576-617. “implicit relational knowing”
• Horowitz, M. (1998). Cognitive psychodynamics. New York: Wiley. “personal schemas”
• Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner’s guide. New York: Guilford. “individual schemas”
 Clinical implications
• A patient’s “story” needs to be inferred from the all sources of data that the therapist has
available. It will tend to have a central theme and a small number of possible roles within
that theme (e.g., for the organizing theme of threat and oppression, the roles might be
victim, persecutor, rescuer, and negligent bystander). Slowly understanding the far-reaching
implications of their core relational assumptions will help clients to extend themselves in new
directions.
• Patients who are aware in the moment of only one side of an unconscious conflict or tension
will be helped by a therapist’s empathic attunement to, and tactful exposure of, the other
side.
• Clinicians can expect to be cast into these roles, and to have the strong feelings associated
with them. Patients will unconsciously note ways in which their therapists extricate
themselves, and eventually them, from such expectations and expand their view of what is
possible.
Caligor, E., Kernberg, O. F., Clarkin, J. F., & Yeomans, F. E. (2018). Psychodynamic therapy for personality pathology: Treating self and
interpersonal functioning. Washington, DC: American Psychiatric Publishing.
Caligor, E., Kernbereg, O. F., & Clarkin, J. F. 2007). Handbook of dynamic psychotherapy for higher level personality pathology. Washington,
DC: American Psychiatric Publishing.
 10. Organizing developmental issue/
levels of severity
• The earliest formulation psychoanalysts made to account for whether disturbances in
personality and psychopathology are more or less severe was framed in terms of Freud’s idea
of fixation.

• The idea that we all go through predictable phases of psychological development in a

particular order, and can get stuck psychologically in any phase when we have not adequately
addressed its challenges, has had enormous staying power over the history of psychotherapy.
It has offered an alternative to the idea that some people are simply qualitatively different
from others – crazy in an incomprehensible way. It supports the more humane view that any
of us could get developmentally arrested if our lives were either too frustrating to master the
tasks of a particular phase or if we were chronically reinforced for the satisfactions of that
developmental stage at the expense of more mature gratifications.

Freud, S. (1905). Three essays on the theory of sexuality. Standard Edition, 7, 135-243.
 Empirical evidence for a severity dimension
• The idea that specific psychopathologies (such as disorders of mood or behavior),
as well as personality types or styles, exist on a continuum of severity has emerged
from decades of clinical experience and theorizing. It reflects ancient wisdom to
the effect that psychopathology and suffering are matters of degree and do not
differ qualitatively among individuals. The Roman playwright Terence remarked, for
example, in the 2nd century BCE, that “nothing human is alien to me.”
• Recently, the research of Carla Sharp and her colleagues has supported the clinical
value of appreciating a general factor in psychopathology that resembles
Kernberg’s long emphasis on evaluating level of severity.

Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., & Clark, L. A. (2015). The structure of personality
pathology: Both general (‘g’) and specific (‘s’) factors? Journal of Abnormal Psychology, 124(2), 387-398.
Sharp, C., & Wall, K. (2021). DSM-5 level of personality functioning: Refocusing personality disorder on what it means to be human.
Annual Review of Clinical Psychology, 17, 313-337.
 Over decades, theorists and researchers have devised
many models of developmental phases
These paradigms have emphasized angles of vision as diverse as:

• How body-based drive issues evolve (Sigmund Freud)

• How cognitive processes evolve (Jean Piaget)
• How attributions of psychological causality evolve (Melanie Klein)
• How modes of experience evolve (Harry Stack Sullivan)
• How social-relational challenges evolve (Erik Erikson);
• How the separation-individuation process evolves (Margaret Mahler);
• How moral sensibilities evolve (Lawrence Kohlberg)
• How capacities for self-reflection and mentalization evolve (Peter Fonagy)

All involve some association between earlier levels and more severe psychopathology.
 Sigmund Freud’s ideas about fixation
• Oral phase: birth to about 18 months. Child is organized around eating/survival; exploration
by mouth; development of talking.

• Anal phase: 18 months to about 3 years. Child faces original socialization into demands of
community. Toilet training and attendant issues of cooperation vs. resistance, submission vs.
rebellion, cleanliness vs. dirtiness, promptness vs. lateness.

• Oedipal phase: 3 to about 6 years. Child perceives others as in relationship with each other,
with attendant issues of envy and competition. Growing awareness of the fact of death and
of the possibilities of bodily injury influences the child’s fantasies.

Freud, S. (1905). Three essays on the theory of sexuality. Standard Edition, 7, 135-243.
Freud, S. (1938). An outline of psycho-analysis. Standard Edition, 23, 144-207.
 Jean Piaget’s stages of cognitive development

• Sensorimotor: birth to 18-24 months. Development of the concept of

object permanence.
• Preoperational: 2 to 7 years. Development of symbolic thought.
• Concrete operational: 7 to 11 years. Development of operational
thought.
• Formal operational: Adolescence through adulthood. Development of
abstract thought.

Piaget, J., & Inhelder, B. (1958). The growth of logical thinking from childhood to adolescence.New York: Basic Books.
 Melanie Klein’s “positions”

• Paranoid-schizoid position: Self-centric. Splits between all-good and all-bad

percepts. Effort to preserve the sense of good inside and project the bad outside.
• Depressive position: Appreciation of separateness of others leads to realization
that caregivers and the self are combinations of good and bad, gratification and
frustration.
Although the paranoid-schizoid position precedes the depressive position in an
infant’s earliest experience, Klein’s theory is not strictly one of developmental phases
subject to fixation and regression, in that everyone continues to alternate between
these positions throughout life.

Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. In Love, guilt and reparation and other works 1921-
1945 (pp. 262-289). New York: Free Press.
 Harry Stack Sullivan’s modes of experience
• Prototaxic mode: All the infant "knows" are momentary states, the distinction of
before and after being a later acquirement. The infant vaguely “prehends” earlier
and later states without realizing any serial connection between them. There is no
awareness of self as an entity separate from the rest of the world.
• Parataxic mode: Experiences are felt as concomitant, not recognized as connected
in an orderly way. The child cannot yet relate them to one another or make logical
distinctions among them. What is experienced is assumed to be the “natural” way
of such occurrences, without reflection and comparison. Experience is undergone
as momentary, unconnected states of being.
• Syntaxic mode: The child gradually learns the “consensually validated” meaning of
language – in the widest sense of language – acquired from group activities,
interpersonal activities, and general social experience. Involves an appeal to
principles that are accepted as true by the hearer.

Mullahy, P. (1973). The beginnings of American psychiatry: The ideas of Harry Stack Sullivan. New York: Houghton Mifflin.
 Erik Erikson’s developmental phases

• Basic Trust vs. Mistrust: birth to about 18 months. Hope.

• Autonomy vs. Shame and Doubt: 18 months to 3 years. Will.
• Initiative vs. Guilt: 3 to 6 years. Purpose.
• Industry vs. Inferiority: 6 to 12 years. Competence.
• Identity vs. Confusion: 12 to 19 years. Fidelity.
• Intimacy vs. Isolation: 20 to 25 years. Love.
• Generativity vs. Stagnation: 25 to 64 years. Care.
• Integrity vs. Despair: 65 and older. Wisdom.
Erikson, E. H. (1950). Childhood and society. New York: Norton.
 Margaret Mahler’s research-based
model of separation and individuation
• (Autistic phase: First month)
• Symbiotic phase: 2 months to 5 months
• Separation-Individuation phase: 5 months to 3 years:
• Hatching (differentiation): 5-10 months
• Practicing: 10-16 months
• Rapprochement: 16-24 months
• “On the way to object constancy”: 24-36 months
• Object Constancy: 3 years and upward.

Mahler, M. S., Pine, F., & Bergmann, A. (1985). The psychological birth of the human infant. New York: Basic Books.
Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel.
Lawrence Kohlberg’s stages of moral development
• Preconventional level: Childhood
Stage one: Actions judged by consequences
Stage two: Actions driven by obedience/punishment and self-interest
• Conventional level: Adolescents and adults
Stage three: Actions judged by good intentions
Stage four: Actions driven by authority and social order
• Post-conventional (principled) level:
Stage five: Actions driven by social contracts
Stage six: Actions driven by universal ethical principles
• (Transcendent level)

Kohlberg, Lawrence (1976). "Moral stages and moralization: The cognitive-developmental approach." In Lickona, T. (Ed.). Moral
development and behavior: Theory, research and social issues. New York: Holt, Rinehart & Winston.
 Peter Fonagy’s developmental phases

• Psychic equivalence phase: birth to 18 months. The external world is

isomorphic with the internal world.
• Pretend phase: 18 months to 3 years. Internal state is decoupled from
external reality, allowing the exercise of imagination that has no
immediate impact on outside reality.
• Mentalization phase: 3 years and upward. Capacity for plausible
interpretation of one’s own and others’ behavior in terms of underlying
mental states: Reflective function develops toward self.

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York:
Other Press.
Bateman, A., & Fonagy, P. (2004). Mentalization-based treatment for borderline personality disorder. New York: Oxford.
 Structural concepts of level of severity
• In the mid-1980s, Otto Kernberg urged therapists to evaluate whether the personality of their
client was organized at a healthy, neurotic, borderline, or psychotic level. His view, a welcome
counteractive to the DSM’s effort to classify personality disorders categorically but not
dimensionally, reflected the longstanding assumption of clinicians that personality disorders
and psychopathology are best understood not simply as matters of kind but as matters of
degree.
• His Personality Disorders Institute developed and validated the Structured Interview of
Personality Organization for clinical use.
• This explicitly dimensional perspective encouraged the development of different therapeutic
approaches based on the level of severity at which each client’s personality is organized.

Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press.
Steiner, J. (1993). Psychic retreats: Pathological organization in psychotic, neurotic, and borderline conditions. London:
Routledge.
Clarkin, J. F., Caligor, E., Stern, B., & Kernberg, O. F. (2019). Manual for the Structured Interview of Personality Organization –
Revised. https://www.borderlinedisorders.com/assets/STIPORmanual.July2019FINALMod.pdf
 Prior dimensional conceptions of specific personality
types and psychopathologies
• Elizabeth Zetzel on hysterical (histrionic) conditions
• Edith Jacobson on depressive conditions
• Otto Kernberg on masochistic conditions
• Otto Kernberg on aggressivity and narcissism
• J. Reid Meloy on psychopathy (antisocial personality disorder)
Zetzel, E. (1968). The so-called good hysteric. International Journal of Psycho-Analysis, 49, 256-260.
Jacobson, E. (1971). Depression: Comparative studies of normal, neurotic, and psychotic conditions. New York: International
Universities Press.
Kernberg, O. F. (1988). Clinical dimensions of masochism. Journal of the American Psychoanalytic Association, 36, 1005-1029.
Kernberg, O. F. (1984). Aggressivity, narcissism and self-destructiveness in the psychotherapeutic relationship: New
developments in the psychology and psychotherapy of the severe personality disorders. New Haven, CT: Yale University Press.
Meloy, J. R. (Ed). (2001). The mark of Cain: Psychoanalytic insight and the psychopath. Hillsdale, NJ: Analytic Press.
 Clinical implications for individuals in the healthy
through neurotic ranges of personality structure

• A positive therapeutic alliance can usually be established relatively easily.

• The patient will tend to appreciate that the therapist is trying to help, even when the content of a
communication is painful.
• The patient will typically try to cooperate with the treatment plan and may be interested in looking
at the part of the self that wants not to cooperate, whether the technique of treatment involves
free association, dream interpretation, empathic reflection, emotional re-experiencing, cognitive
reframing, exposure, homework, or other modes of collaborative work.
• Regressive and emotionally intense ways of working therapeutically may be useful because of the
client’s capacity to re-equilibrate afterward.
• The therapist can expect relatively mild countertransference reactions.
• The patient will generally not need explicit directives, limits, and contracts.
• Ruptures of the therapeutic alliance will usually be readily repaired.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process, 2 nd ed. New York: Guilford.
 Clinical implications for the psychotic level
• Therapy requires a tone that is both realistically authoritative and deeply egalitarian.
• Issues of safety are paramount in making a therapeutic alliance; the patient’s level of terror of
annihilation needs to be appreciated.
• Therapists need to avoid the patient’s profound vulnerability to humiliation.
• Normalizing is usually important for patients with psychotic tendencies.
• Education is often necessary for patients dealing with psychotic confusions.
• Therapists of patients with psychotic tendencies need to be especially appreciative of health-
seeking aspects of their symptoms.
• Therapy should be conversational and active.
Arieti, S. (1974). Interpretation of schizophrenia (2nd ed.). New York: Basic Books.
Atwood, G. E. (2011). The abyss of madness. New York: Routledge.
Cosgro, M., & Widener, A. (Eds.) (2018). The widening scope of psychoanalysis: Collected essays of Bertram Karon. Queens, NY: International
Psychoanalytic Books.
Garrett, M. (2019). Psychotherapy for psychosis: Integrating cognitive-behavioral and psychodynamic treatment. New York: Guilford.
Marcus, E. R. (2017). Psychosis and near psychosis: Ego functions, symbol structure, treatment (3rd ed.). New York: Routledge.
Werman, D. S. (2015). The practice of supportive psychotherapy. New York: Routledge.
 Clinical implications for the borderline level
• The therapeutic relationship may be hard to establish and may feel fragile.
• Explicit boundaries, limits, and contracts may be necessary.
• Therapists should avoid using regressive techniques, at least early in treatment.
• Emphasis should be on the here and now.
• The therapist should expect to experience intense countertransferences.
• In the therapy process, binary dilemmas will recurrently appear.
• Ruptures of the alliance may happen abruptly and take a long time to repair.
• The therapist needs to be somewhat emotionally expressive.
• Consultation and supervision may be critical to the success of the therapy.
Caligor, E., Kernberg, O. F., Clarkin, J. F., and Yeomans, F. (2018). Psychodynamic therapy for personality pathology: Treating self and interpersonal functioning.
Washington, DC: American Psychiatric Association.
Liotti, G., Cortina, M., & Farina, B. (2008). Attachment theory and multiple integrated treatments of borderline patients. Journal of the American Academy of
Psychoanalysis and Dynamic Psychiatry, 36, 295-315.
Bateman, A., & Fonagy, P. (2016). Mentalization based treatment for personality disorders: A practical guide. London: Oxford.
Meares, R. (2012). Borderline personality disorder and the conversational model. New York: Norton.
Mucci, C. (2018). Borderline bodies: Affect regulation therapy for personality disorders. New York: Norton.
Gregory, R. J., & Remen, A. L. (2008). A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder. Psychotherapy: Theory,
Research, Practice, Training, 45, 15-27.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner’s guide. New York: Guilford.
 Thank you!

nancymcw@aol.com