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A. M. P.
SEMINARI 2001 - 2002
Peter Praper


Diagnostic efforts in psychotherapy coincide with introduction of medical-physiological paradigm of understanding psychological disorders. In 1977 W. Cullen coined the term Neurosis to differentiate "functional disorders of the nervous system from organic deficits". Neurotic disorders since then, drew the attention of many clinicians, although there was no acceptable explanation of neurotic phenomena and the model of diagnostics "Per Exclusionem" was the only possibility for a long time. The principle "not somatic is neurotic" was pretty loose although it had opened the door toward new terms as: digestive neuroses, cardiac neuroses... presumably important for opening the field of psychosomatics. In 19th century at least three categories have been used: Neurosis (Hysteria, Phobia), Psychosomatic Conditions (Neurasthenia, Digestive Troubles) and Neurological Affections (Epilepsy, Parkinsonism). During the last decade of 19th centrury a new science of neuroses was emerging, announcing new classifications.

Pierre Janét coined the first psychodynamic theory of neuroses introducing two mayor categories: Hysteria and Psychastenia and Sigmund Freud, elaborating libido theory, the first drive theory as an aspect of the psychic energy, offered the possibility of a positive diagnosis of neurosis as a consequence of an internalised infantile conflict. As, at the same time, he created criteria for a well grounded distinction between Psychosis and Neurosis, in the field of psychiatry the second period of diagnosis per exclusionem had followed: "Not psychotic is neurotic". The system would not allow the differentiation of neurosis from crisis or posttraumatic stress disorders, until 1915, when Freud himself introduced a new distinction among: Actual Neurosis and Psychoneuroses and divided Psychoneuroses into two categories: Transference Neurosis and Narcissistic Neurosis. From nowadays perspective narcissistic neurosis represents borderline personality organisation and adaptive disorders to be differentiated from real neuroses, including the criterion of internalised infantile conflict. Within the clinical situation, the distinction between the two categories contained the criterion of analysability.

From an other point of view another question was raising: "Is clinical psychoanalysis applicable to the patients with adaptive disorders and to psychotic patients?" There were more and more clinitians trying to find the way: Federn, leaning against the raising ego-psychology, developed "reversed psychoanalysis". Sullivan (1953) used directed questions instead of free associations. In fact, to bring the unconscious contents to consciousness was no longer the primary frame of the method.

The developmental problems of the personalities with ego modifications demanded new methods of approach. Sullivan introduced the initial, directed interview to diagnose the main characteristics of the personality structure - not only on the side of the dynamics but also on the side of control mechanisms. The initial diagnostic interview became common to all neoanalysts, supporting their shift from the Freud's drive - structure model to the relation - structure model of understanding psychopathology. 4-5 sessions of the initial interview, elaborating the questions of the motivation for seeking help, the symptomathology, trigger situation, the environmental and developmental conditions and examining the patient's personality, brought to positive dynamic and developmental interpretative diagnosis of a personality structure.

Following the development of the Theory of object relations and Self-psychology the demands of the diagnostic phase were increasing to a paradox. Are we capable to evaluate dynamic and developmental characteristics of a personality structure in 4-5 sessions? Modell (in Eagle, 1984) proposed a bifactorial approach - first: the dynamic evaluation, second: the developmental evaluation and as a third step - the integration. The first step included the dynamics and nature of impulses:
* quantitative and developmental aspects (socialisation) of the libidinal drive,
* quantitative and developmental aspects (socialisation) of the aggressive drive,
* aspects of neutralisation and integration.

The second step included the evaluation of the nature of control mechanisms:
* the nature and functions of anxiety (connected to impulses, separation, self - disintegration),
* defence mechanisms,
* superego control,
* cognitive control and organisation.

Fallowing these demands we faced some new problems:
* How to include the aggressive drive into the theory of psychosexual development, basic for a dynamic evaluation?
* The research on Ego development demands a new developmental theory.
* Crystallising of the self, achieving and maintaining the self - coherence is an important question per se.
* Diagnostic evaluation of personality structure goes for beyond the symptomathology or classifications and demands a clinical interpretative synthesis of data about the personality organisation.

The evaluation of a personality structure should include:
* the analysis of internalised conflicts,
* the antagonism between conscious and unconscious contents,
* the antagonism between id - ego - superego,
* the analysis of cognitive organisation,
* the analysis of structural derivatives of internalised object relations,
* the analysis of internalised social world and self representations.

Not only what was experienced during the period of the infantile development, but also how was it experienced, represent the imprints of processing the flow of information in later periods of the life cycle. These processes include the functions of several substructures:
* structure of motivative mechanisms from the level of drive energy and basic needs to unconscious and conscious motivation, including the content, the motor activity and emotional background components;
* structure of control mechanisms from fear and anxiety, through primitive and sophisticated defence, superego and identification with the culture, to cognitive control;
* cognitive control is the aspect of cognitive organisation, first through the characteristics of the primary process (following pleasure and avoiding displeasure) and secondary process (including reality testing), and second, the developmental characteristics of the hierarchical organization of the ego development (from the functions of primary autonomy, secondary autonomy, integrative ego functions toward synthetic and adaptive ego-functions (see Kellerman and Burry, 1981, Praper, 1999).

The problem how to fulfil the diagnostic demands in few sessions of the diagnostic phase in psychotherapy may be resolved on different levels:

Anna Freud (in Praper, 1999) considered the initial diagnostic phase as the first evaluation, giving the basic picture of a personality structure, offering the data for indication, prognostic estimation and the starting points for psychotherapy process. The complete evaluation of a personality structure is feasible not before the completion of the process.

The second possibility lies in an extended team diagnostic approach, including a psychiatric diagnostics, psychodiagnostic procedure of a clinical psychologist, social worker's evaluation and a flexible combination of other disciplines involved. Such an extended team diagnostics should follow the first visit of a patient, his complaints and the exploration of the basic problem.

The possibilities of an extended psychological evaluation were proved as very useful since Rapaport started to build the ego-psychological evaluation, organising semi projective and projective psychodiagnostic tests, especially Rorschach inkblots test. He elaborated the Rorschach response process as "cog wheeling of the process of perceptual organisation with the associative process". (1957). The model is following the continuum from the primary process thinking to secondary process modes (observed from the developmental view or in the opposite direction when following the idea of regression to delineate normal, healthy forms of thought organisation from pathological modes, stemming from primary process unconscious material.

Johnston and Holzman (1976), concerning implications of object representation for normal thought organisation, built a "Thought Disorder Index", a system of scoring primary process thinking. Modes of pathological thought organization reflect a disturbance in the normal articulation and integration of subjective experience with object reality.

"The creative synthesis of the divergent fantasy and reality context demand some adaptive regression (regression in the service of the ego). Without it we may loose the creativity to preserve the reality control. On the other hand, what begins as adaptive regression may become pathological if the person's representational processes are insufficiently autonomous and/or his or her unconscious repressed conflicts are too strong for a person to maintain an optimal distance and closeness from perceptual reality. The situation is followed by the loss of reality control to a certain degree" (Athey G. in Kissen M., 1986, p. 27).

Rigid position on extreme distance (followed by the loss of contact) or extreme closeness (fallowed by the loss of the boundary) or shifting from one extreme to the other, are the capital signs of a pathological thought organisation.

Blatt and his colleagues (1976) were among the first to offer the understanding of the relationship between object relations and thought organisation seen through Rorschach.

Rorschach scores, such as fabulised combination, confabulation, contamination, were viewed as reflecting different intensities of "loss of boundary" between separate ideas. More than this. Such loss of conceptual boundaries was seen as "a process that runs parallel, within the domain of thinking, to the progressive loss of boundary between self and other.

Thought organisation and object relations are the different sides of the same coin although not always at the same level of regression or fixation. Problems with the differentiation between self and the other may appear without a parallel regression in a field of thought organisation, while pathological thought organisation seem to be involving loss of boundary between self and the other at the same time.

Primitive object-relation organisation and boundary deficit between self and the other is not only parallel to boundary loss in the field of cognition. Both interact in an active relation. Healthy or pathological modes of thought organisation are in the same time healthy or pathological organiser of relation:
* between self and the other and
* between subjective and objective reality.

The fact is, that psychotherapist can carry out the diagnostic phase by means of the initial interview and maybe better detect starting points of therapeutic process. On the other hand, when there is a question of selection, we may not want to engage these starting points. The advantages of using psychodiagnostic procedures within the diagnostic phase in psychotherapy are clinical and scientific. Clinical experience shows that the patient acts much les dependent on interaction details of the patient - examiner relationship. His transferrential contents are exposed in the relation to the test (not the examiner) while, at the same time, the patient s potential to restore the therapeutic working alliance may be revealed as well. On the other hand, the referral to another therapist after the diagnostic phase, based on psychodiagnostic evaluation, may be much less painful for the client.

The possibilities to involve the research work is by the use of psychological tests perceptibly expanded - not only because of introducing more objective data, but also by opening new fields of research such as revealing the including or excluding criteria or testing the depth of the therapeutic results - the effect on the level of a personality structure.


Athey, G., (1986): Trasference Enactment and the Rorschach. In: Kissen, M.: Assessing Object Relations Phenomena. International Universities Press Inc. Madison, Connecticut.

Blat, Wild, C. (1976):Shizophrenia: A developmental Analysis. Academic Press, New York.

Eagle, M. (1984): Recent Developments in Psychoanalysis: A Critical Evaluation. McGrow-Hil Book Comp: New York.

Kellerman, H., Burry A. (1981): Handbook of Psychodiagnostic Testing: Personality Analysis and Report Writing. Grune & Stratton, New York, London.

Johnston, M., Holzman P. (1976): The Thought Disorder Index. In: Kissen, M.: Assessing Object Relations Phenomena. International Universities Press Inc. Madison, Connecticut.

Praper, P. (1999): Razvojna analiti_na psihoterapija (Developmental Analytic Psychotherapy). In_t. za klin. psihologijo, Ljubljana.

Rapaport, D. (1957): Cognitive Structures. In: Bruner et al.: Contemporary Approaches to Cognition. Harvard University Press, Cambridge.

Sullivan (1953) The Interpersonal Therapy of Psychiatry. Norton, New York.

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