The Three Levels of Personality Organization

The model of personality organization was first theorized by Otto F. Kernberg; his model is still used today. This theory states that there are three levels of personality: neurotic, borderline, and psychotic. These different personality levels can provide insight into human behaviors.^[1]

What Is Personality Organization?

Kernberg’s model of personality organization can assist with the evaluation of personality disorders by providing a method for differentiating typical from atypical personality development. This model has origins in psychoanalytic theory, and more specifically, object relations theory. Object relations theory assesses the way that infants and young children develop internal mental images of themselves in relation to other people, primarily attachment figures.^[2]

According to Kernberg, from infancy onward, individuals develop internalized object relations that reflect emotions associated with interactions between oneself and an attachment figure. For instance, a child who receives warmth and nurturing from a mother will develop an internal image of the self as being loved and the mother as being caring. Alternatively, a child with a cold, distant parent may develop a sense of shame. These internal representations ultimately become the building blocks of personality and determine whether a person develops realistic views of self and others.^[2]

In individuals with realistic views of self and others, there is an ability to integrate positive and negative interactions with caretakers, as these individuals understand that people have both good and bad traits. Furthermore, children who have mostly positive interactions with their caretakers can more easily tolerate negative experiences and include such experiences within a realistic framework of viewing themselves and others.^[2]

When children are exposed to negative experiences, such as trauma or neglect, object relations theory states that they will struggle with identity development and therefore are at increased risk of mental health conditions.^[2] According to this theory, when a person develops a mental health disorder, the disorder occurs at one of the three levels of personality organization: borderline, psychotic, or neurotic.^[3]

Normal Personality Organization

Before learning about the three levels of personality, it’s helpful to have an understanding of normal personality organization. The normal or mature personality organization involves the use of mature defense mechanisms, such as the use of humor or healthy coping skills, to manage distress. Individuals with normal personality organization remain in touch with reality, and they have well-integrated object relations, meaning they can view others and themselves holistically, recognizing that people have both positive and negative traits.^[3]

Normal personality organization is linked with psychological well-being for several reasons. First, this type of personality organization is associated with mature defense mechanisms rather than those that are immature or maladaptive. Furthermore, people with normal personality organization can adapt to situations that occur at work and in relationships.^[2]

Neurotic Personality Organization

Individuals with neurotic personality organization generally remain in touch with reality. They have a stable sense of self and healthy object relations, meaning they can integrate the positive and negative features of themselves and other people. These traits fall in line with normal personality organization.

However, those with neurotic personality organization use neurotic defense mechanisms, such as repressing upsetting emotions. They may also engage in a defense called reaction formation, in which they act in opposition to how they really feel to cover up uncomfortable thoughts or emotions.^[3]

While the neurotic personality has some features of normal personality organization, it can be rigid and inflexible. Because of the use of neurotic defenses, which may not always be useful, a person with a neurotic personality may struggle to adapt to the demands of life, despite having healthy object relations. Given the rigid tendencies of the neurotic personality level, those with these features tend to be overly critical of themselves and avoid confrontation. They are at risk of depression, anxiety, and obsessive tendencies.^[4]

Borderline Personality Organization

The borderline organization of personality is considered more severe or maladaptive than the neurotic organization. Unlike those with normal personality organization, those at the borderline level have immature defense mechanisms. They struggle to control their impulses and have an unstable sense of self due to poor object relations. The typical defense mechanisms associated with borderline organization include splitting, which involves viewing people as all good or all bad. Those at the borderline level also use a defense mechanism called projective identification, in which they displace their own insecurities or uncomfortable emotions onto others.^[3][4]

As one might imagine, the borderline level of personality organization includes borderline personality disorder, but it is not synonymous with this disorder. Those at the borderline level may have significant difficulties with daily functioning, because of outbursts of anger and difficulty regulating emotions and impulses. During times of distress, they may have brief psychotic episodes, during which reality is distorted.^[4]

Psychotic Personality Organization

The psychotic level of personality organization is the most severe of the personality levels. Individuals with psychotic organization do not remain in touch with reality. They show delusional thinking and distortion of reality. Individuals at this level of personality organization may present with schizotypal, schizoid, or paranoid personality disorders.^[3][5]

In addition, those with paranoid personality organization tend to have poor object relations, characterized by a lack of boundaries. They lack a core sense of self and do not maintain boundaries between themselves and others.^[3]

Diagnosing Personality Organization Levels

Mental health clinicians may diagnose different levels of personality organization to assist with treatment planning. Clinicians can use a tool called the Psychodiagnostic Chart (PDC) to assess a person’s personality organization level. This tool can assess whether a person presents with healthy, neurotic, borderline, or psychotic personality organization. It can also assess for the presence of personality disorders, such as narcissistic or psychotic.^[3]

To assess personality level, the PDC evaluates a person’s identity, object relations, defense mechanisms, and reality testing. A person is ranked on a scale of 1 to 10 for each dimension. A score of 1-2 represents the psychotic level, whereas 9-10 falls at the healthy or normal level of personality organization. The borderline level is ranked at 3-5, whereas the neurotic level ranks at 6-8.^[3]

According to the PDC, a person with a healthy personality organization can view themselves in a stable, realistic way. They have healthy object relations and mature defenses, such as using humor and asserting themselves. Finally, they can maintain a realistic view of reality.

On the other hand, a person who has a psychotic personality organization will be assessed as having delusional or distorted defenses. Those with borderline organization will show splitting, denial, and projective identification. Finally, those at the neurotic level will engage in repression, reaction formation, and displacement.^[3]

What Does This Mean for Mental Health Treatment?

A person’s level of personality organization can determine what interventions will be most beneficial for them. For example, those with a healthier personality organization generally do better with treatment, suggesting that those with more maladaptive personality organization may need more intensive treatment approaches. Those who have borderline or psychotic personality organization may require greater clarification due to disconnection from reality. Clarification can help patients at the borderline or psychotic level to consider more realistic views of reality.^[3]

In addition, those at the psychotic or borderline levels of personality organization may need more supportive interventions from their therapists. Supportive interventions can include intensive education, emphasizing patient strengths, offering encouragement and praise, setting limits, modifying the environment, and putting extra effort into developing a strong therapeutic relationship with patients.^[3]

Lower levels of personality organization may require psychodynamic approaches, which evaluate the effects of unconscious motives and unresolved conflict, in combination with supportive techniques.^[3]

Personality Organization and Therapist Behavior

Another consideration when treating patients with psychotic or borderline personality organization is the occurrence of countertransference. Countertransference occurs when the therapist has a strong reaction to the patient. Because those with lower levels of personality organization can be difficult to treat, therapists may have stronger reactions to their behaviors.

Therapists may become angry or irritated toward patients with lower levels of personality organization, making it more difficult for them to show empathy and care toward these patients. Therapists therefore must learn to manage countertransference reactions to be effective with patients at the psychotic or borderline levels.^[3]

Finally, because those with lower levels of personality organization tend to have poor boundaries and difficulty with object relations, therapists are likely to find themselves spending more time clarifying the nature of the therapeutic process with these patients. This involves talking about the specific techniques the therapist will use, as well as discussing the role of both the therapist and patient in treatment. Patients at lower levels of personality organization will also likely spend more time talking with their therapists about boundaries and receiving reminders of the ground rules of therapy.^[3]

Patients who have borderline or psychotic personalities fall at lower levels of personality organization. Because of their difficulties with object relations and perception of reality, they are likely to be more challenging for therapists to treat. However, with the use of supportive techniques and clarification, therapists can effectively treat these patients.^[3]