8 Psychotherapy8.7 Psychotherapeutic psychiatry
8.7.3 Personality organisation and therapeutic care
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
How personality develops and changes
Personality does not come from a single childhood event. It develops as temperament, learning, attachment, relationships and social experience interact.
Personality can change. A person may regulate their emotions better, build a more coherent identity and relate to others more flexibly, even when some vulnerabilities remain.
A personality formulation describes the person's strengths, their recurring difficulties and the context of these. It does not reduce the person's whole identity to a diagnosis.
Kernberg's levels of personality organisation
Kernberg's three levels describe a psychodynamic model. They are not three diagnoses.
Level | Identity | Defences and reality testing |
|---|---|---|
Neurotic | Fairly well integrated | More mature defences. Reality testing is kept. |
Borderline | Identity diffusion (a poorly integrated sense of self and others) | Primitive defences, including splitting (seeing self and others as all good or all bad). Reality testing is generally kept. |
Psychotic | Marked difficulty integrating the self and others | Reality testing is substantially impaired |
Borderline organisation is broader than borderline personality disorder. The two terms do not mean the same thing.
Arousal and context can change how a person functions. Before treating a pattern as enduring, consider current illness and stress in their environment.
Treatment approaches
Approach | Main focus |
|---|---|
Mentalisation-based treatment | Regaining the ability to reflect on mental states under attachment stress |
Dialectical behaviour therapy | Building skills and changing behaviour, alongside acceptance |
Transference-focused psychotherapy | Integrating split views of self and others as they appear in the therapeutic relationship |
Structured clinical management | A coherent shared plan, problem-solving and coordinated support |
Delivering care
Treatment needs a clear structure: agreed aims, boundaries, supervision and coordination between clinicians. This reduces conflicting responses and repeated crises.
Treat comorbid disorders as indicated. Do not prescribe medication simply to treat borderline personality disorder as a whole.
Judge progress by safety, day-to-day functioning, relationships and the person's own goals, as well as by symptom change.
Do not refuse someone access to care solely because they have a personality disorder diagnosis or a history of self-harm.