What is reality testing in psychology. About Kernberg's structural interview in general

Reality testing

This technique is well suited for beginners. Its essence is as follows:
1. Keep some text with you or wear a digital electronic watch throughout the day. To check the degree of reality in which you are, read this text or the inscription you have, remember the time on the clock. Then look somewhere to the side and back at the inscription to check if the words or numbers have changed. Try also, by looking at them, to make them change. If the words or numbers change, or look strange, or don't make sense at all, then you're most likely dreaming. Enjoy it! If the symbols are normal, stable, and endowed with a reasonable meaning, then you are awake and should go to step 2.
2. If you are sure that you are not sleeping, say to yourself: "I may not sleep now, but if I did, what would it look like?" Try to visualize as vividly as possible that you are dreaming. Purposely imagine that everything you see, hear, touch and smell is a dream. Imagine that your surroundings are fickle, words change, objects transform, that you begin to float above the ground. Create within yourself the feeling that you are in a dream. Then, without losing it, go to step 3
3. Choose what you would like to do in your next lucid dream - flying, talking to some dream character, or simply exploring the dream world. Continuing to imagine that you are dreaming, try to fulfill what you have planned for yourself in the next dream.

This exercise should be performed regularly several times a day. In addition, it should be done whenever something unusual happens or when you somehow remember or are reminded of dreams. It is useful to choose a repetitive action for this: you look in the mirror, look at the clock, come to and from work, etc. The more often and harder you do this exercise, the better it will work.

Other Ways to Test Reality

Method of remembering the past. According to this method, when you want to do a reality test, or suspect that you may be dreaming, try to recall the sequence of your actions over the past few hours. In a dream, there are no memories of the near past or they contradict the principles of the real world (for example, you have just returned from a meeting with the Martians). In ordinary life, the past turns out to be quite meaningful, and it becomes obvious to you that you are not sleeping.

Breathing through the hand. You can test reality by trying to breathe through your palm. In the ordinary world, of course, this is not possible if you completely cover your mouth with your palm and press your nostrils with your thumb and forefinger. If you breathe freely, then you are in the arms of sleep.

Management unmanaged. This method consists in trying to change something that cannot be controlled in normal reality. Options include attempting to control the sun (try changing day to night) and voluntary cardiac arrest. Put your hand on your heart and feel it beat.

Then, by force of will, stop it. Since the heart works independently of the will, you cannot stop it in ordinary life.

Severe personality disorders [Psychotherapy strategies] Kernberg Otto F.

REALITY TESTING

Both neurotic and borderline personality organization, unlike psychotic, presuppose the ability to test reality. Therefore, while the diffuse identity syndrome and the predominance of primitive defense mechanisms make it possible to distinguish the structure of the borderline personality from the neurotic state, reality testing makes it possible to distinguish between the borderline personality organization and serious psychotic syndromes. Reality testing can be defined as the ability to distinguish between self and non-self, to distinguish between the intrapsychic and the external source of perception and stimulation, and also as the ability to evaluate one's affects, behavior and thoughts in terms of the social norms of an ordinary person. In a clinical study, the following signs tell us about the ability to test reality: (1) the absence of hallucinations and delusions; (2) the absence of manifestly inappropriate or bizarre forms of affect, thought, and behavior; (3) if others notice the inadequacy or strangeness of the patient's affects, thinking and behavior in terms of the social norms of an ordinary person, the patient is able to empathize with the experiences of others and participate in their clarification. Reality testing must be distinguished from distortions of the subjective perception of reality, which can appear in any patient during psychological difficulties, as well as from a distortion of attitude towards reality, which always occurs both in character disorders and in more regressive psychotic states. In isolation from everything else, reality testing is only in. in rare cases, it is important for diagnosis (Frosch, 1964). How does reality testing manifest itself in a situation of a structural diagnostic interview?

1. We can consider that the ability to test reality is present when we see that the patient does not and did not have hallucinations or delusions, or, if he had hallucinations or delusions in the past, he is currently fully capable be critical of them, including the ability to express concern or surprise about these phenomena.

2. In patients who have not had hallucinations or delusions, the ability to test reality can be assessed on the basis of a close examination of inappropriate forms of affect, thinking or behavior. Reality testing expresses itself in the patient's ability to experience empathy for how the therapist perceives these inappropriate phenomena, and more subtly, in the patient's ability to experience empathy for how the therapist perceives the interaction with the patient as a whole. The structural interview, as I have already mentioned, provides an ideal opportunity to explore reality testing and thus help to distinguish borderline versus psychotic personality organization.

3. For the reasons discussed above, the capacity for reality testing can be assessed by interpreting the primitive defense mechanisms operating during the diagnostic interview between patient and therapist. The improvement in the patient's functioning as a result of this interpretation reflects the presence of the ability to test reality, and the instant deterioration after it makes one think of the loss of this ability.

Table 1 summarizes the differences between different personality organizations in three structural dimensions: the degree of identity integration, the prevalence of defense mechanisms, and the ability to test reality.

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For the psychologist, the role of the first meeting with the client is as important an event as it is for the client. At this meeting, as a psychologist, I must definitely carry out one or another diagnostic option in order to understand a) could I help a person in the problem with which he turned to me? b) what methods and techniques can I afford to use in my work? The answers to these two questions are given by a structured interview, which was proposed by Otto Kernberg.

Determination of the type of psyche
My first task is to determine the type of psyche of the client. It depends on what techniques I can afford to use in working with a person. Let's talk more about the three types of psyche.

One of the features of growing up is that a person gradually begins to live not only in the imaginary world, but also in the real one. The world of the baby is completely imaginary, and the task of the mother is precisely to help him perceive reality, to take it into account. The mother achieves this by giving her baby this world in small portions and only when he is ready for it (for more details, read the works of D. Winnicott).

But sometimes things can go wrong. Sometimes a person, due to some reasons, can still live in an imaginary world. This can happen if the mother has not learned to separate the real from the imaginary or the child is faced with some kind of insurmountable difficulty for himself: the reality suddenly became too much. In this case, we are talking about the psychotic type of the psyche, that is, about the case when the imaginary replaces reality (this refers, for example, schizophrenia). And then we say that man lacks reality testing.

Other people are quite good at “testing reality”, that is, they are able to separate the imaginary from the real, they are able to evaluate their actions from the point of view of the rules and norms of society, from the point of view of others. This is already better for the individual. But there may be problems with the ability to cope with their aggression and anxiety. Depending on the extent to which a person successfully defends himself from these states, we are talking about either a borderline type of psyche or a neurotic one.

Definition of methods and techniques
For me, as a psychologist, it is very important to understand a person with what type of psyche turned to me for help. It depends on what techniques I can afford to use in my work. Basically, as a specialist in psychoanalytic orientation, I have the following techniques in my arsenal: expressive and interpretive.

With interpretative techniques, my task is to show the client the connection of his current reactions and states with what happened in his life in the past. For example, if the client is angry, I can notice for him that maybe his anger towards me reminds me of the anger towards his father in childhood. This will be an interpretation of the client's anger. Next, we can explore the origins of anger in childhood. This technique is the main one when working with people who are in neurotic states. The technique is also suitable for working with people of the border organization.

When working with a person who has a borderline personality organization, one should focus not only on interpretive techniques, but also on expressive ones. For many people, it will be a great help to give them the opportunity to express themselves, their very intense feelings. As a rule, these are feelings of despair, resentment, anger, jealousy and resentment. The task of the therapist is to “survive”. Seeing that the therapist is able to withstand all these feelings of the client, the latter begins to transform. Positive irreversible changes begin to occur in the human psyche.

With people of a psychic organization, you need to work with supportive techniques and be very gentle. I note that for working with people who have “psychotic” difficulties, I am not ready to take on the strength of not such good technical training.

In order to understand what the mental organization of the client is, I use a structured interview. If you are interested, then you can get acquainted with what I will ask

NON-SPECIFIC MANIFESTATIONS OF EGO WEAKNESS

Non-specific manifestations of ego weakness include an inability to bear anxiety, a lack of impulse control, and a lack of mature ways of sublimating.

Table 1. Features of personal organization

These signs must be distinguished from the "specific" aspects of ego weakness - from those that are the result of the predominance of primitive defense mechanisms. Anxiety tolerance is characterized by the degree to which a patient can tolerate emotional stress beyond their usual level without suffering an increase in symptoms or general regressive behavior. Impulse control is characterized by the degree to which the patient can experience instinctive desire or strong emotions and yet not act impulsively against his decisions and interests. The effectiveness of sublimation is determined by the extent to which the patient can "invest" himself in his values that go beyond immediate benefit or self-preservation, in particular, by the extent to which he is able to develop creative abilities in areas not related to his upbringing, education or acquired skills.

These characteristics, reflecting personality structures, are directly manifested in behavior, which can be learned from examining the patient's history. Non-specific manifestations of ego weakness help to distinguish borderline personality organization and psychosis from a neurotic structure. But in the case when it is necessary to separate the borderline from the neurotic structure, these signs do not provide as valuable and clear criteria as the integration of identity and the levels of organization of defenses. For example, many narcissistic personalities show far fewer non-specific symptoms of ego weakness than might be expected.

TOTAL OR PARTIAL LACK OF SUPER-EGO INTEGRATION

A relatively well-integrated but very rigid Super-Ego is characteristic of the neurotic type of personality organization. The borderline and psychotic personality organizations are characterized by violations of the integration of the Super-Ego, as well as the presence of non-integrated predecessors of the Super-Ego, in particular, primitive sadistic and idealized object representations. Superego integration can be judged by the extent to which the patient identifies with ethical values and by whether normal guilt is a significant regulator for him. Regulation of self-esteem through extreme guilt or depressive mood swings suggests a pathological integration of the superego (which is typical of a neurotic organization), in contrast to the normal person's more calm, concretely oriented, self-critical functioning in the realm of ethical values. Signs of Super-Ego integration are: the extent to which a person can regulate his actions on the basis of ethical principles; how much he refrains from exploitation, manipulation and cruelty towards another person; how honest and morally whole he remains in the absence of external coercion. For diagnosis, this criterion is of less value than those described above. Even in patients with predominantly primitive defense mechanisms, the Super-Ego can be integrated, although it may be of a sadistic nature - there are patients with borderline personal organization who have a fairly high degree of integration of the Super-Ego, despite a serious pathology in the areas of integration of identity, object relations and organization. protection In addition, information about Super-Ego integration is easier to obtain by studying the patient's history or observing the patient for a long time than during a diagnostic interview. Nevertheless, the degree of integration of the Super-Ego is of great prognostic value, which is why it is the most important structural criterion in the question of indications or contraindications for long-term intensive psychotherapy. In fact, the quality of object relations and the quality of superego functioning are the two most important predictive criteria in structural analysis.

GENETIC AND DYNAMIC CHARACTERISTICS OF CONFLICTS

Conflicts of instincts characteristic of the borderline personality organization appear only in the course of a long therapeutic contact, and they are difficult to determine during a diagnostic interview, nevertheless, for the sake of completeness, they are described here.

The borderline personality organization is a pathological mixture of genital and pregenital instinctive drives, with a predominance of pregenital aggression (Kernberg, 1975). This explains the bizarre or inappropriate mix of sexual, addictive, and aggressive impulses that we see in borderline (and also psychotic) personality organization. What appears to be the chaotic constancy of primitive drives and fears, the pansexualism of the borderline patient, is a combination of various pathological solutions to these conflicts.

It must also be emphasized that there is a huge discrepancy between the patient's life history and his internal fixed experiences. In the psychoanalytic study of such patients, we discover not what happened in their external world, but how the patient experienced significant object relations in the past. In addition, we should not take as pure truth the patient's life story, which he tells at the first meetings: the more severe the character disorder, the less trust this information should be. In severe narcissistic disorders, as in borderline personality organization in general, the account of the early years of life is often empty, chaotic, or unreliable. Only after several years of therapy is it possible to reconstruct the internal genetic sequence of events (intrapsychic causes) and find a connection between it and how the patient himself now experiences his past.