PSYCHOANALYTIC PSYCHOLOGY, 1984, / (2) 113-129 Copyright 1984, Lawrence Erlbaum Associates, Inc.

Dimensions of Internalized Object Relations in Borderline and Schizophrenic Patients

Walter E. Spear, Ph.D.
Yeshiva University Yale University and the William Alanson White Institute

Alan Sugar man, Ph.D.

California School of Professional Psychology San Diego Psychoanalytic Institute and the University of California, San Diego

This paper explores two dimensions of internalized object relations in borderline and schizophrenic: patients using Rorschach scales. A thematic and a structural Rorschach measure of object relations is applied to the Rorschachs of two borderline groups (an infantile personality group and an obsessiveparanoid group) and a schizophrenic group. The findings suggest the value of both a multidimensional definition of internalized object relations and the use of such an approach to clarifying the diagnostic concept of borderline personality disorder.

Recent years have witnessed a surprising emphasis on borderline pathology in the clinical literature. In general, this outpouring of clinical descriptions, formulations, and treatment strategies is due to the increased frequency with which clinicians are confronted by patients who fail to exhibit major psychotic pathology but whose behavior is so disordered as to transgress the boundaries of neurotic character pathology and whose response to traditional psychoanalytically oriented treatment is more erratic and problemladen than would be expected of individuals with solely neurotic problems. Requests for reprints should be sent to Walter E. Spear, Ph.D., 841 Forest Road, P.O. Box 189, Northford, CT 06472.

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This discrepancy between disordered behavior of a quality and quantity more typically associated with psychotic pathology and yet a personality organization unmarred, at least manifestly, by psychotic symptoms, has been the hallmark of borderline pathology. Consequently, Kernberg (1967), the major authority in this field, has stressed the importance of projective testing (in contrast to more structured, non-projective tests like the WAIS) for an accurate diagnosis of borderline personality organization. His diagnostic prescription for testing is based on both clinical experience and the theoretical assumption that the lack of external structure or guidelines in the Rorschach and other projective instruments allows for the emergence of borderline patients' primary process thinking which is usually obscured by their ability to use external structure to counteract their own developmentally primitive psychological structures. The historical basis for this emphasis on the need for external structure to make up for disturbances in internal structures can be traced to Rapaport, Gill, and Schafer's (1945) formulations of overideational and coarcted "preschizophrenics" which were applied by Knight (1953) to the understanding and treatment of "borderline schizophrenics." Singer (1977) has developed these formulations into a near axiomatic rule for the diagnosis of borderline pathology with psychological tests--that borderline patients show a "normal" WAIS due to its structure and a thought disordered Rorschach due to its lack of structure. Kernberg's colleagues (Carr, Goldstein, Hunt, & Kernberg, 1979) have recently validated empirically this clinical formulation in a study which found that schizophrenics could be distinguished from borderlines on the basis of their differential performances on the WAIS and the Rorschach. Their findings that there was no difference in the amount of thought disorder on the Rorschach supported Singer's (1977) statement that borderlines appear dramatically schizophrenic on the Rorschach. It is our contention that Singer's (1977) and Kernberg's (Carr et al., 1979) retention of an ego psychological model, and with it an emphasis on thought disorder as the cogent personality variable, has led them to err in this conclusion (Sugarman, 1981). The recent paradigmatic shift within psychoanalytic theory to an object relations model has implicitly altered our model of psychopathology. Rather than viewing disorders along a continuum of ego disturbance, emphasis is now placed upon the qualitatively different developmental level of object relations characterizing different disorders. Such qualitative differences in developmental level of object representation should be manifested in the Rorschach responses of schizophrenic and borderline patients. Diagnostic and treatment formulations in the ego psychological "tradition deal with ego structures, cognitive style, ego weakness, capacity to delay discharge, organization of defenses into impulse/defense configurations..." (Mayman, 1976, p. 204). Mayman and Faris' (1960) suggestion, to focus instead on the individual's identity patterns and internal interpersonal

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paradigms, offers the potential to clarify the developmental differences of borderline and schizophrenic patients on the basis of solely Rorschach responses. Partial identities crystallize out of the various interpersonal relationships encountered along the developmental path and become internalized as "thematic representations of prototypical dilemmas, life strategies, and role paradigms" (Mayman, 1968, p. 316). These identity patterns or internalized interpersonal paradigms shape the developing ego, channel affects and infantile wishes, and contribute to a synthesized ego identity. Thus, diagnostic formulations and distinctions should be able to be derived from the preferential sequencing of such identity patterns on the Rorschach (Sugarman, in press). Support for the usefulness of applying this object relations model to projective techniques has been demonstrated both in general (Blatt, Brenneis, Schimek, & Glick, 1976; Krohn & Mayman, 1974; Urist, 1977) and specifically, in differentiating borderline patients on the basis of solely Rorschach performance (Lerner & Lerner, 1980; Lerner, Sugarman, & Gaughran, 1981; Spear, 1980; Spear &Lapidus, 1981). This series of studies examining object relations on the Rorschach has implicitly highlighted or differentiated two separate dimensions of object relations. Those investigators at the University of Michigan (Krohn & Mayman, 1974; Urist, 1977) have based their measures primarily on psychoanalytic object relations theorists (e.g. Kernberg, 1976; Mahler, 1968). Consequently they have studied thematic content of projective test responses. Urist's (1977) scale for assessing object relations in Rorschach percepts examines each percept for the degree of mutuality of relatedness explicit in its thematic content. Construct validity for these measures has been demonstrated through the correlations of these measures with therapist/supervisor ratings of patient's overt object relations. Another dimension of object relations has been studied by Blatt and his colleagues at Yale (Blatt et al., 1976) who have been influenced theoretically by the developmental model of Werner (1948). They have applied Werner's emphasis on the individual's developmentally increasing capacity for articulation, differentiation, and integration of object concepts to assessing the structural aspects of an individual's Rorschach human percepts. Thus, their scale assesses the degree of differentiation, articulation, and four types of integration of the human percept on the Rorschach. They have validated the developmental nature of the scale and its ability to differentiate psychotic patients from normals. Influenced by the work of both groups, Lerner and Lerner (1980) developed an object relations oriented scale which drew upon both dimensions of object relations to assess the presence and degree of borderline defenses on the Rorschach. They used this scale to differentiate borderline patients from neurotic ones and more recently have used it to differentiate borderline from schizophrenic ones (Lerner et al., 1981). Spear (1980; Spear & Lapidus, 1981)

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has made a more explicit attempt to study and compare the role of each of these two object relations dimensions in psychopathology. In his earlier studies he attempted to differentiate two types of borderline personalities: an infantile personality characterized by emotional lability, intense dependency and concerns over object loss, and a proclivity for anaclitic depression (Sugarman, 1979), and the other an obsessive/paranoid type of borderline personality characterized by intellectualization, isolation of affect, and a proclivity for introjective depression. These two types of borderline patients were compared with a schizophrenic group applying both Blatt's structural measure of object representations and Krohn's thematic dream scale of object representations to both their Rorschach responses and their reports of manifest dream content. Relevant to this study, Spear (1980) found that the structural measure successfully distinguished the combined borderline group from the schizophrenic one but failed to distinguish the two types of borderline patients on the basis of their Rorschach responses. Furthermore, the thematic dream measure applied to Rorschach percepts distinguished the two types of borderlines but failed to distinguish the obsessive/paranoid borderlines from the schizophrenic patients. The present study is designed to clarify and elaborate Spear's original findings. First, we wanted to clarify the failure of the structural measure to distinguish the two groups of borderline patients. It was hypothesized that a more differential emphasis on the six developmental dimensions of the structural measure rather than the original obtaining of only one overall developmental score might better distinguish the two groups and clarify their relationship to the schizophrenic group. Second, it was thought that a thematically oriented object relations scale designed specifically for the Rorschach might yield more useful information than the thematic dream measure in understanding the "representational world" of borderline and schizophrenic patients. Thus, Urist's (1977) scale was modified and used to study the thematic dimensions of the internalized object relations of borderline patients. Through this expansion and refinement of earlier studies we hope to shed light on different dimensions of internalized object relations and their role in the psychological structure of borderline and schizophrenic patients, to clarify the nature of subtypes of borderline pathology, and to expand the utility of the Rorschach as a diagnostic instrument for assessing these personality variables and types of psychopathology. METHOD Subjects The data were collected from a final sample of 54 young adult inpatients at the Yale Psychiatric Institute. Virtually all patients in the sample came from

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upper-middle to upper-class economic backgrounds, and had an average length of stay at the institute varying roughly from 1 to 3 years. These 54 subjects were selected from a sample of 62 chosen on the basis of the availability of their verbatim Rorschach protocols, case conference protocols, and at least three manifest dream reports, plus their initial assessment by the first author for general suitability to the diagnostic criteria of the study (e.g., patients with organic disorders, somatic character problems such as heroin addiction, etc., were excluded from consideration). Twenty-two subjects were assigned to the obsessive/paranoid borderline group, 17 to the hysterical/impulsive borderline group, and 15 to the schizophrenic group. All but one of the subjects were single and all had previously received Diagnostic and Statistical Manual-II (American Psychiatric Association, 1968) labels of either schizophrenic, borderline, or other character disorders. Data The data considered for the current study consisted of (a) extensive case conference protocols for each subject, and (b) Rorschach protocols. The case conference protocols were prepared by a variety of individuals involved with the direct assessment and treatment of the patients during their hospitalizations. These included an individual therapist, a psychological examiner, a family therapist, a ward administrator, and others. The part of the protocol used for the present study was the diagnostic formulation section (prepared by the individual psychotherapist), supplemented when necessary with descriptive behavioral information from the report on the psychological testing. In addition, certain demographic data and information about medication were drawn from other parts of the protocols. Verbatim Rorschach protocols, administered by postdoctoral clinical psychology fellows according to the standard clinical method as described by Rapaport et al. (1945), constituted the rest of the research data. All clinical data for the study were gathered between 1974 and 1975, prior to either the conceptualization or onset of the present research or development of the scales used. Procedure Diagnostic groups. The data were assembled by the first author, and all names and other identifying information were removed and encoded, both to protect the confidentiality of the subjects, and to keep the two raters blind as to which diagnostic protocol corresponded to which Rorschach. The authors secured the assistance of two independent raters (one an advanced graduate student in clinical psychology and the other a postdoctoral fellow in clinical psychology; both of whom were, at that time, blind to the theoretical

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basis and hypotheses of the current study), who then independently divided the subjects into the three diagnostic groups, according to the criteria outlined in Spear (1979), on the basis of descriptive behavioral information found in the therapist's diagnostic formulation section of the clinical case conference protocols. Briefly, these criteria outline two significant diagnostic differentiations: First, patients were divided into groups of borderline and schizophrenic disorders in accordance with the overall diagnostic impression described in the therapist's formulation, and second, specific descriptive adjectives (e.g., dramatic or clinging vs. constricted or controlled) about their characterologic/behavioral style were used to divide the borderline group into obsessive/paranoid and hysterical/infantile subgroups. This distinction was made along lines similar to the description of "neurotic character styles" outlined by Shapiro (1965) and expanded and modified for borderline disorders by Spear (1979). The schizophrenic group comprised nonparanoid/ undifferentiated disorders. For borderline subjects who were difficult to assign to a characterologic group based on this information, the same descriptive behaviorial adjectives from the report of the psychological testing were used to clarify the stylistic distinctions. This additional information was necessary in 10 of the final 54 protocols in order to determine which category of borderline should be assigned.' It also should be noted that the psychological test reports were written 2 to 5 years prior to the development of the current object relations scales and the reports were written from a predominantly ego-psychological perspective wherein the characterologic differentiation was primarily derived from the Information/Comprehension split on the WAIS. Reliability of diagnosis estimates were calculated by using the k (kappa) statistic on a matrix of agreement between the two j udges. There was exact agreement on 54 out of an original 62 protocols reviewed (86%). The observed kappa, k = .824, was significant at thep < .001 level. The eight remaining protocols involving disagreements were disregarded as inappropriate for this study due to confounding multiple diagnoses. Structural object representations. Verbatim Rorschach protocols were scored independently by two raters in accordance with the quantitative criteria outlined in Blatt et al. (1976). Each Rorschach response with human content recorded verbatim in the initial psychological assessment was scored separately on all of the appropriate subcategories in the Blatt et al. system. In
'The possibility of diagnostic overlap between this use of test report data to determine characterologic type and the subsequent analysis of specific Rorschach human figure responses was considered. Each of these 10 cases was reviewed for this possible circularity in the design. This review verified that the additional characterologic clarification in these cases was based on either specific behavioral descriptions of the subject's interpersonal test behavior or on the Information/Comprehension split on the WAIS. As such, it was concluded that the use of this test report information represented no overlap with the later Rorschach data analysis and thus could not have made a confounding difference in the current results.

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contrast to the previous research, using these data, which only examined comparisons of the structural object representations summary score of each subject on this scale, the current analysis focused on comparing each of the six separate subscales (Differentiation, Articulation, Integration, Motivation, Relationship and Nature) of the Blatt et al. system. As such, after all human responses of a given subject had been scored, individual developmental level scores were calculated on each of the six subscales. The same procedure was carried out for all subjects in the sample. Interrater reliability estimates were obtained using the alpha coefficient between the two judges. Given that the individual developmental weightings of each of the subscale scores already included a control factor for varying response productivity, a standard one-way analysis of variance was employed to examine differences among the three groups. Affective/thematic object representations. Verbatim Rorschach protocols were scored independently by the raters in accordance with the scoring criteria outlined later in our modification of the Urist (1977) mutuality scale. These scores were thus operationally defined as ranging from 10 for the lowest levels of interpersonal relations to 1 for the highest sense of emotional mutuality. After all Rorschach human responses of a given subject were scored, the data were compared in terms of the mean, best, worst, and range scores of thematic object representations level. Reliability estimates were again computed using the alpha coefficient between the two judges. An analysis of covariance procedure, controlling for differential total response productivity (R) among individual subjects, was employed to examine the thematic object representations data. Instruments

A developmental analysis of the concept of the object on the

Rorschach. Blatt et al. (1976) formulated a scoring system for studying the quality of human responses on the Rorschach in terms of their relation to the maturation of the concept of the object according to the developmental principles of differentiation, articulation, and integration. In this measure, Differentiation is defined as the level of the human content in the response; more concretely, responses are classified according to the type and completeness of the human figure the subject perceives: whole human figure, H (e.g., people, man, etc.); whole quasi-human figure, (H) (e.g., witches, dwarfs, etc.); human detail, Hd (e.g., man's hands, etc.); or quasi-human detail (Hd) (e.g., angel's face, witch's head, etc.). Weightings are H = 4, (H) = 3, Hd = 2, (Hd) = 1. Articulation is defined as the degree to which the response is elaborated, and in this subscale responses are rated on the basis of types of attributes ascribed to the figures. Seven specific attributes are scored here and are subdi-

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vided into three perceptual attributes, (a) size or physical structure, (b) clothing or hairstyle, and (c) posture, and four functional attributes, (d) sex, (e) age, (f) role, and (g) specific identity. (In terms of articulation, responses are scored on the basis of the presence (1) or absence (0) of the particular attribute specified with perceptual attributes weighted as 1 and functional attributes weighted as 2.) The final four scoring dimensions of integration are defined by Blatt et al. as the way that the concept of the object, if engaged in human activity, is integrated into a context of action and interaction with other objects. In this section, the response is scored along four dimensions: (a) Motivation the degree of internality of the motivation of the action (unmotivated = 1; reactive = 2; intentional = 3); (b) Integration the degree of integration of the object and its action (fused = 1; incongruent = 2; nonspecific = 3; congruent = 4); (c) Relationship the integration of the interaction with another object (active/passive = 1; active/reactive = 2; active/active = 3; and (d) Nature in terms of whether the content of the interaction is malevolent ( = 1) or benevolent (= 2). The minimum response scored on the Blatt et al. scale would be a quasi-human, unarticulated part image uninvolved in any action. Such a limited response (e.g., an angel's face) would merit only a score on the differentiation subscale, with no score on either the articulation of any of the integration scales. On the other hand, a maximum score on this scale would require a carefully described full human image actively involved in congruent, intentional, and benevolent interaction. Mutuality within object relations as manifest in Rorschach imagery. As described by Urist (1977) in his report of the initial research on this measure, the scale was developed out of (a) an impressionistic survey of Rorschach human figure responses collected in a pilot study, (b) a review of the object relations literature (with special reference to Mahler's [1968] seminal work on separation/individuation) and (c) a prior scale developed for assessing object representations in dreams (Krohn & Mayman, 1974). More specifically, the scale attempts to construct a series of ordinal gradations in the degree to which relationships in Rorschach imagery are portrayed as maintaining or losing their own integrity within object relations (Urist, 1977). The original mutuality scale consisted of seven categories. However, the current authors found these differentiations to be somewhat restrictive and confusing, particularly in terms of subtle narcissistic, anaclitic, and symbiotic object relationships. As such, it has been modified to 10 scale points for the current research. Each of the differing scale points is defined as follows: 1. Figures are engaged in some relationship or activity where they are together and involved with each other in such a way that acknowledges their individual integrity. The image contains explicit or implicit reference to the fact

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that the figures are separate, and involved with each other in a way that recognizes or expresses a sense of mutuality in the relationship. (For example, on Card II, "two bears toasting each other, clinking glasses.") 2. Figures are engaged in some activity or relationship which has no particular bearing on the question of their integrity. (Card III: Two women doing their laundry.) Both figures show action but there is minimal sense of interaction. 3. Figures are seen as leaning on each other, or one figure is seen as leaning or hanging on another. The sense here is that objects do not "stand on their own two feet," or that in some way they require some external source of support or direction. Something walking on something, moving in or on something are other examples. 4. One figure is seen as the reflection, or imprint of another. The relationship between objects here conveys a sense that the definition or integrity of an object exists only insofar as it is an extension or reflection of another. Shadows, footprints, and the like would be included here. 5. Figures are seen as fused or involved in symbiotic relationships. Examples include Siamese twins, fetuses, and embryonic percepts. 6. The nature of the relationship between figures is characterized by a theme of control of one figure by another. Such themes portray a severe imbalance in the mutuality of relations between figures. As an example, some figures may be seen as powerful while others as helpless. 7. Malevolence characterizes the relationship. Figures are seen as fighting, struggling, or in the clutches of another. 8. Both malevolence and an imbalance in control characterize the relationship. In contrast to point 7, the struggle is not equal, and one figure is clearly dominant. Themes of influencing, controlling, and casting spells out of malevolent purposes are present. 9. Not only is there a severe imbalance in the mutuality of relations between figures, but here the imbalance is cast in decidedly destructive terms. Mere fighting is not "destructive" in terms of the integrity of the figures, whereas a figure being tortured or strangled by another is considered to reflect a serious attack on the integrity of the figure. Similarly, included here are relationships that are portrayed as parasitic, where a gain by one figure results by definition in the dimunition or destruction of the integrity of another. 10. Relationships here are characterized by an overpowering, enveloping force. Figures are seen as swallowed up, devoured, or generally overwhelmed by forces completely beyond their control. Both the original and the current modification of the thematic scale are designed to be used on Rorschach data by intuitive, trained clinicians. (More specific details of the Mutuality scoring procedure may be obtained from the authors.)

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RESULTS Reliability of the Psychological Measures Reliability estimates of the scoring were obtained by computing the alpha coefficients between the two raters' scores for each of the object representations measures. Table 1 indicates that the magnitude of the correlations was quite high for each object representation measure and compares favorably with the reliability results previously reported in the literature (Blatt et al., 1976; Spear, 1980; Spear & Lapidus, 1981; Urist, 1977). Structural Aspects of Object Representations Table 2 presents the means, standard deviations, and analyses of variance for the six dimensions of the Blatt structural scale presented according to diagnostic category. Although significant results across the three diagnoses were found on only two of the subscales, Differentiation and Nature, previous research (Spear, 1979, 1980) using the developmentally weighted sum of the combined subscale scores suggested that the individual subscales might more effectively differentiate between the overall borderline group and the schizophrenic one. Consequently, the method of planned comparisons was then employed to compare the combined borderline group with the schizophrenics. In fact, significant differences were observed not only on Differentiation (F (1,53) = 4.67, p<. 04) and Nature (F (1,53) = 6.12, p<.02), but also on Motivationn (F (1,53) = 5.27, p<.03) and Integration (F (1,53) = 4.17, p < .05). Moreover, a strong trend in the same direction was also noted on the Relationship scale (F (1,53) = 3.05, p< .09). Only on the Articulation subscale were no significant "structural" differences observed. Finally, in an effort to examine differences between the two borderline groups, the inTABLE 1 Reliability Coefficients of the Psychological Measures Structural Scores Differentiation Articulation Motivation Integration Relationship Nature 96 82 90 94 87 93 Thematic Scores Mean Worst Best Range .94 .86 .80 .81

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TABLE 2 Means, Standard Deviations, and Univariate Analyses of Variance for the Six Structural Subscales Obsessive Paranoid (n = 22) Variable Differentiation F(2,52) = 3.36* Articulation F(2,52) = .21 n.s. Motivation F(2,52) - 2 . 6 0 n.s. Integration F(2,52) = 2.38 n.s. Relationship F (2,52)-1.52 n.s. Nature F(2,52) = 3.45* M SD Infantile (n = 17) M SD Schizophrenic (n = 15) M SD

3.07 1.41 1.12 2.80 2.63 1.66

.42 .13 .31 .68 .66 .47

3.29 1.46 1.10 3.03 2.69 1.76

.44 .11 .28 .63 .77 .53

2.84 1.43 .86 2.36 2.17 1.23

.63 .44 .48 1.31 1.36 .84

fantile group was compared with the combined schizophrenic and obsessiveparanoid borderline groups. A significant difference between the infantiles and the combined obsessive borderline and schizophrenic was then observed only on the Differentiation subscale (t = -2.33,/?<.03) though trends towards these subdiagnoses were also evident on the integration (/ = 1.73, p < .09) and Nature (t = - 1.77, p < .09) subscales. Thematic Aspects of Object Representations Table 3 presents the means, standard deviations and analyses of covariance for each group on the mean, worst, best, and range scores of the thematic object representations scale. On three of the four thematic measures, a significant difference was observed among the three groups. Further analyses of these data by means of Tukey paired comparisons (see Table 3) also revealed significant differences between the infantile and obsessive-paranoid borderline groups on the mean, worst, and range scores, thereby supporting the hypothesized distinction of these alternate borderline character types. Moreover, no significant differences were observed on any of the measures between the obsessive-paranoid borderlines and the schizophrenics, though the infantiles proved significantly more developmentally advanced than the schizophrenic group on both their mean and worst thematic scores.

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SPEAR AND SUGARMAN TABLE 3 Analyses of Covariance for the Four Thematic Measures Obsessive/Paranoid (n = 22) Infantile (n = 17) M SD Schizophrenic (n = 15) M SD

Variable Mean F(2,52) = = 3.76* Worst F(2,52) = 7.71** Best F(2,52) = 0.88 n.s. Range F(2,52) = 6.33**

SD

4.83(a) 8.22(a) 1.74 7.48(a)

1.39 1.44 1.12 1.75

3.67(a,b) 5.94(a,b) 1.85 5.06(a)

1.42 1.80 .99 1.64

4.94(b) 7.67(b) 2.27 6.40

1.31 1.77 1.51 2.32

Note: On any one line, pairs of means with a common subscript differ at the .05 level by use of Tukey tests. *p<.05 **p<.01

DISCUSSION The results of this study provide strong support for a multi-dimensional approach to the study of internalized object relations with the Rorschach and presumably other clinical techniques. It is clear from our findings that the use of either a solely structural or a solely thematic approach would provide an incomplete understanding of the representational worlds of both of the borderline groups and the schizophrenic one. In fact, as will be discussed below, attention to only one or the other dimension of internalized object relations would only continue the present diagnostic confusion surrounding the borderline concept and its relation to schizophrenia. Furthermore, our findings add to the growing body of literature (Lerner et al., in press; Spear, 1980; Spear & Lapidus, 1981; Sugarman, 1981) which contradicts Singer's (1977) and Kernberg's (Carr et al., 1979) contention that borderline patients cannot be distinguished from schizophrenic ones solely on the basis of Rorschach performance. There is no doubt that borderline patients use external structure to compensate for their proclivity toward primary process thinking. But it appears that a shift of theoretical models, with an attendant shift of emphasis to vicissitudes of internalized object relations, allows for the diagnostic distinction of borderlines from schizophrenics regardless of the degree of external structure present in the environment. Our findings also support Kernberg's emphasis on borderline pathology as a structural diagnosis which cuts across a number of character styles. Thus, our findings that on four of the structural dimensions (Differentiation, Motivation, Integration, and Nature) the combined borderline group was signif-

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icantly different than the schizophrenic one and that on another structural dimension (Relationship) there was a statistical trend in that direction, provides overwhelming support for the structural distinctiveness of the borderline group from the schizophrenic one. Furthermore, the failure of five of the structural dimensions (Articulation, Motivation, Integration, Relationship, and Nature) to distinguish the infantile borderline group from the obsessive-paranoid one provides support for the relative structural homogeneity of the overall borderline group. This issue is more complex, however. Because the findings on the thematic scale indicate that a solely structural focus obscures important differences between the two borderline groups, the overall borderline diagnostic category may appear more homogeneous than it really is. The thematic measures demonstrate that the obsessive-paranoid borderlines are much more similar to the schizophrenic patients than they are to the infantile personalities. Thus, the thematic mean of the infantile patient's object relations is significantly better than that of the schizophrenics or the obsessive borderlines whose means are not significantly different. Even at their worst level of object relational functioning the infantile personalities maintain a healthier level than either the schizophrenics or the obsessive-paranoid borderlines who again appear more similar than different with regard to their capacity for regressed patterns. In this context, the failure of the best thematic level of object relations to distinguish among the three groups would suggest that the similarity between the obsessiveparanoid group and the schizophrenic group appears due to the fact that the obsessive-paranoid group shows the greatest range of thematic object relational functioning. As such, the interpersonal styles of the obsessiveparanoid ranges from the healthier, more object seeking patterns of the infantile group to a more dominant vulnerability to regress to the passive withdrawal and malevolence of the schizophrenic levels. Moreover, the failure of the best thematic measures to distinguish among the groups also speaks to the ability of schizophrenic patients not to function always at a schizophrenic level, an ability which probably contributes to the frequent difficulty in making a differential diagnosis between borderline and schizophrenic pathology. These differential thematic and structural findings may help consequently to illuminate the continued confusion in the literature surrounding the relationship of borderline pathology to schizophrenia. Despite Kernberg's (1967) formulation of borderline personality disorder as distinct from the psychoses, the clinical literature has continued to confuse this distinction both implicitly and explicitly (Sugarman & Lerner, 1980). Our findings suggest that the basis for this continued confusion lies not so much in the conceptual realm as in the phenomenological one. That is, there are important differences in types of borderline personalities and although the infantile personalities are clearly distinct from schizophrenics along both thematic and structural lines, the obsessive-paranoid borderlines are so similar to schizophren-

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ics along thematic lines that they may be the type of borderline patients who continue to be called borderline schizophrenic or borderline psychotic. Our findings demonstrate that the infantile personality is consistently healthier along both thematic and structural lines and so provide support for Sugarman's (1979) contention that they should be conceptualized as a separate diagnostic group with its own treatment needs and paradigms. Even the structural measures provide some support for this conclusion. Our more detailed use of the structural scale shows that the infantile group is significantly different in terms of the degree of Differentiation of their internalized object relations and that there are strong trends along two other dimensions (Integration and Nature). These findings, in conjunction with an almost ubiquitous trend for the infantile group to have the best scores on both the thematic and structural measures, support the conclusion that infantile personalities function consistently at a higher interpersonal level than either obsessiveparanoid borderlines or schizophrenics. Consequently, they are more likely to form a benign therapeutic alliance and to have subsequently better therapeutic prognoses than either of the two other groups. Their higher developmental level of object relations should allow them to better utilize the expressive psychotherapeutic techniques outlined by Kernberg (1975) for the treatment of borderline personalities. In contrast, the obsessive-paranoid borderlines presumably have a worse therapeutic prognosis because of their vulnerability to schizophrenic levels of internalized object relationships. Their wide range of object relationships (the greatest range of the three groups) adds to the difficulty of treating them. Because obsessive-paranoid borderlines are capable of relatively good levels of relating when functioning at their best, treaters are more likely to overestimate their potential and hence to be surprised and dismayed at how regressively they can relate under stress. Thus, treatment strategies for these patients might better be guided by Knight's (1953) and Zetzel's (1971) prescriptions for a supportive treatment approach with minimal focus on the transference so as not to precipitate an untoward regression. The wide range of functioning of the obsessive-paranoid borderline group is probably one of the factors entering into the common but according to our data incorrect clinical wisdom that such patients are more advanced developmentally and hence better treatment cases than infantile personalities. Another factor contributing to this common but apparently incorrect clinical assumption is implicit in the one structural dimension in which they are superior to the infantile personalities Motivation. Obsessive-paranoid borderlines are more likely (although not to a statistically significant degree) to integrate purposeful intention into their action. Consequently, their instrumental behavior is more likely to have a planned and organized quality to it than that of the infantile personalities whose dependency and neediness makes their behavior erratic and impulse ridden (Sugarman, 1979). This interpretation is consist-

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ent with that of Blatt and Wild (1976) about the organizing impact of the ego of paranoid defenses. They suggest that paranoid defenses serve to provide greater ego boundary collapse. Our data suggests the subsequent higher level of ego functioning may be at the expense of object relatedness. However, the superior ego functioning of obsessive-paranoid borderlines may obscure their more primitive interpersonal paradigms which are more likely to interfere with successful psychotherapy. Thus, our findings lend some speculative support to the idea of differential levels of ego and object relations functioning in different types of borderline patients in a fashion that may parallel Sugarman's (1979) distinction between object relations versus ego functions as seen in infantile personalities and narcissistic ones. Sugarman has suggested that narcissistic personalities (like perhaps, our obsessive-paranoid borderlines) have a better organized ego due to their grandiose self structure defending against their underlying low self esteem and dependency. Thus, their ego functioning is better than that of the infantile personalities despite having a more primitive level of object relatedness. Finally, our research suggests that schizophrenic patients are not as uniformly and consistently impaired in their object relations as is commonly assumed. In fact, their worst level of object relations is not as bad as that of obsessive-paranoid borderlines at their worst while the schizophrenics' object representations show greater (although not statistically significant) articulation than those of obsessive-paranoid borderlines. One interpretation of this finding is that obsessive-paranoid borderlines are capable of regression to a more primitive level of object relatedness than schizophrenics. A more likely alternative explanation might be that the schizophrenics' chronic blandness may restrict their relationships to a narrower band of functioning. In contrast, the obsessive-paranoid borderlines are still engaged in an active internal struggle and so are capable of more extreme functioning at both ends of the developmental spectrum. Such findings lend empirical support to the often overlooked fact that schizophrenics are not schizophrenic 100% of the time. At their best, they are capable of functioning roughly at the same level as the two borderline groups when each is functioning respectively at its best. Hence, it does not appear logical to rule out the use of psychotherapy to treat schizophrenic patients as the current biological vogue within psychiatry would espouse. Rather, a supportive psychotherapeutic approach, similar to that suggested for the obsessive-paranoid borderlines, which focuses on these higher-level capacities and avoids potentially regressive material should be of help. In conclusion, it appears that the object relations model offers insight into more serious types of pathology that is complementary to that of the more traditional ego psychological approach. Furthermore, the Rorschach appears to have genuine potential both as a diagnostic instrument for such conditions and even more importantly as a unique research instrument capable

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of shedding light on certain personality variables which are both clinically relevant and of conceptual importance.

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