Disclaimer: Nothing in this document should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. It contains the current condition of my thinking related to typologies of SUDs and sorting among them.
Three Levels of Organization
Traditional psychodynamic approaches to abnormal psychology examine three levels of general organization/disorganization of any person with any mental disorder. These three levels are not of the disorder only, or of the person independent of their disorder. Rather, they are with regard to the totality of the whole person.1
Originally, Freud thought there were two levels: “neurotic” and “psychotic”. After many years the clinical community came to a general consensus that a third level seemed to exist. That third level was between the more severe “psychotic” level and the far less disturbed “neurotic” level. The proposed in-between level was named the “borderline” level, because it was on the border between the two levels first proposed.1,2
Consider the following descriptive range of the three levels.
| Psychotic | Borderline | Neurotic |
| broken reality testing | inconsistent reality testing | intact reality testing |
| extreme dissociation | emotional lability | rigid defenses (repression, guilt) |
| primitive defenses | splitting (all-good/ all-bad thinking) | stable identity |
Application to SUDs
How can the determination of a recommended level and kind of SUD care be made that includes such information? And done so in a way that adds to what is found in the DSM-5-TR diagnosis of the individual?3 A proposed pathway is outlined below.
First, listen to their life story. Then determine which level of organization their disorder takes.
- “Neurotic” is the “hard-drinker” (AA)4 or the “non-disease form” (Jellinek).5.6
- “Borderline” and/or “Psychotic” is the “true alcoholic” (AA)4 or the “disease form” (Jellinek).5,6
Next, consider both the DSM-5-TR SUD severity and level of organization determination. This provides a more wholistic view of the person than the DSM alone.
Finally, what level of challenge does the person present?
- Generally, the “neurotic” range would indicate appropriate options could include one, some, or all of the following: Moderation management. Stopping use, plus nothing – and that strategy actually works. SUD education. CBT, MI, or a combination.
- Generally, the “borderline/psychotic” range would indicate appropriate options include all of the following: Primary addiction treatment such as in a residential program or IOP.. Finding, choosing and joining a mutual-aid fellowship. “Identifying” relative to the diagnosis and the fellowship. Abstinence and a personal program to sustain full-person recovery
Examples for SUDs
Below are SUD examples that could serve as indicators across the three levels.
| Personality Organization | SUD Example |
| Neurotic | |
| Intact reality testing | Presents the consequences of using behavior as chief compliant |
| Rigid defenses | Consistently intellectualizes to support moderation goal |
| Stable identity | Seeks to preserve self and life situation as goal of therapy |
| Borderline | |
| Inconsistent reality testing | Assigns cause for some consequences of using to other people while unable to acknowledge others |
| Emotional lability | Intermittently hostile and volatile |
| Splitting | Divides others to friend or enemy status |
| Psychotic | |
| Broken reality testing | Drinking while jaundiced and voicing contentment with sleep hygiene and pattern of eating. |
| Extreme dissociation | Holds all facts, thoughts, judgments and values as speculative and at best, preliminary. |
| Primitive defenses | Denial and delusion about problem identification, while externalizing focus of discomfort. |
References
1Kernberg, O. F. (2016). What Is Personality? Journal of Personality Disorders. 30(2): 145-156. 10.1521/pedi.2106.30.2.145
2Labbé-Arocca, N., Castillo-Tamayo, R., Steiner-Segal, V., & Careaga-Diaz, C. (2021). Diagnosis of Personality Organization: A theoretical-empirical update of Otto F. Kernberg’s proposal. Journal of Neuropsychiatry. 57(4). journalofneuropsychiatry.cl/articulo.php?id=40
3Galanter, M. (2014). Alcoholics Anonymous and Twelve-Step Recovery: A model based on social and cognitive neuroscience. The American Journal on Addictions. 23: 300-307.
4Alcoholics Anonymous. (2001). There Is a Solution. Alcoholics anonymous: The story of how many thousands of men and women have recovered from alcoholism (4th ed.). A.A. World Services
5Jellink EM. (1946). Phases in the drinking history of alcoholics. Quarterly Journal of Studies on Alcohol. 7: 1-88.
6Jellinek EM. (1960). Alcoholism, a genus and some of its species. Can Med Assoc J. 24; 83(26):1341-5.
Suggested Reading
Johnson, S. M. (1994). Character Styles. W. W. Norton.
A colleague texted me the following question: “Thanks, Brian. If the original Freud perspective was split in two, neurotic and psychotic, and the application to levels of care layed out is group by neurotic and or borderline/psychotic (still grouped in two), where does the differentiation of 3 separate groups help apply to SUD levels of care?”
Here was my reply: “Perhaps only insofar as the people presenting the signs and symptoms of the middle group can or should be recognized as needing generally as much of a change and kind of help as the sickest seem to need. That is to say, to not under-treat but appreciating the kind of challenge they face, while still having room for their illness to yet progress. Guiding the clinician to not under-treat.”