chapter  6
Differential Diagnosis and Treatment Selection
Pages 6

The process of elucidating disruptive defenses, as described in chapter 5, can be extraordinarily therapeutic to suffering people, but only under the following conditions:

1. They cannot be psychotic. 2. They cannot be felonious criminals (rapists, murderers, armed robbers,

grand larcenists, heinous child abusers). 3. They must possess the following capacities:

Autonomous Ego Functions

• relatively intact integrative functioning (can organize thought, stay coherent)

• relatively functional abstraction ability (can read between the lines, appreciate symbolism)

• relatively intact reality testing (can understand that fantasy is different from reality)

• some self-observation ability


• some sense of guilt or shame

Ego Strength

• some ability to keep bizarre thoughts out of consciousness (contain primary process)

• some ability to avoid intoxicating substances, and some impulse control in general

Object Relations

• fair facility to develop trust in and empathy for another human being

In other words, after assessing multiple mental operations for diagnostic purposes, it is also important to determine a person’s treatability with a psychodynamic approach. People who have psychotic and near-psychotic conditions, who have physical illnesses of the brain, or who otherwise manifest severe damage to ego functions and object relations, generally can’t be treated dynamically.