The interplay between pathological organizations and the paranoid-schizoid and depressive positions.

I have presented clinical material to illustrate how a pathological organization can be considered to exist in an equilibrium with the paranoid-schizoid and depressive positions. While making use of paranoid-schizoid mechanisms such as primitive splitting and projective identification, the defensive structure is highly organized and held together by narcissistic intrapsychic relationships in which perverse gratification plays an important role. This organization of defences seems to be designed to produce a place of real or illusionary safety from the anxieties experienced in the other two positions. All individuals fluctuate in the defences they employ and hence can be thought of as moving between these organizations and the other two positions. They consequently demonstrate some evidence of paranoid-schizoid level function and also of the existence of pathological organizations even if they may function in a relatively mature way at other times and in other settings. In some patients however the pathological organization dominates the personality and leads to analyses which become fixed and stuck. It is argued that a recognition of these organizations of defences enables the analyst to orient himself more accurately to the clinical material and hence to address himself to the patient at a level he can understand.