Clinical Assessment - STIPO

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Clinician-Guided Assessment of Personality Using the Structural Interview

and the Structured Interview of Personality Organization (STIPO)
Article in Journal of Personality Assessment · April 2017

DOI: 10.1080/00223891.2017.1298115
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Clinician-guided assessment of personality using the Structural
Interview and the Structured Interview of Personality Organization
(STIPO)
Susanne Hörz-Sagstetter, Psychologische Hochschule Berlin, Germany
Eve Caligor, Columbia University College of Physicians and Surgeons,
New York, USA
Emanuele Preti, University of Milano-Bicocca, Italy
Barry L. Stern, Columbia University Medical Center, New York, USA
Chiara De Panfilis, Università degli Studi di Parma, Italy
John F. Clarkin, Cornell University, New York, USA
Contact information:
Prof. Dr. Susanne Hörz-Sagstetter
Psychologische Hochschule Berlin (PHB)
Clinical Psychology and Psychotherapy
Am Köllnischen Park 2
10179 Berlin
Germany
Phone +49-30-209166-201
Fax +49-30-209166-17
s.hoerz@psychologische-hochschule.de
PERSONALITY ASSESSMENT USING THE STRUCTURAL INTERVIEW AND THE STIPO 2
Abstract
This article demonstrates the utility of a theory-guided psychodynamic approach to the
assessment of personality and personality pathology based on the object relations-model
developed by Kernberg (1984). We describe a clinical interview, the Structural Interview (SI;
Kernberg, 1984), and also a semi-structured approach, the Structured Interview of Personality
Organization (STIPO; Clarkin et al., 2004) based on this theoretical model. Both interviews
focus on the assessment of consolidated identity vs. identity disturbance, the use of adaptive
vs. lower-level defensive operations and intact vs. loss of reality testing. In the context of a
more clinically oriented assessment, the SI makes use of tactful confrontation of discrepancies
and contradictions in the patient’s narrative, and also takes into account transference and
countertransference phenomena, while the more structured approach of the STIPO
incorporates clinical judgment informed by clinical theory into a well-guided interaction with
the patient. Both interviews have good inter-rater reliability and are coherent with the
Alternative Model for Personality Disorder Diagnosis proposed by DSM-5, Section III.
Finally, they provide the clinician with specific implications for prognosis and treatment
planning and can rationally guide clinical decision-making.
Keywords: Object Relations, Clinical Interview, Structural Interview, Personality Disorder

Clinician-guided assessment of personality using the Structural Interview
Approaches to the assessment of personality and personality pathology in clinical
practice generally follow one of two typical pathways. Clinicians may use relatively
unstructured clinical interviews, employing their clinical experience and theoretical
background to evaluate personality functioning and pathology. Interviews of this kind
typically rely heavily on clinical inference, and may incorporate the patient’s behaviour in and
response to the interview setting into the assessment process. In the unstructured clinical
interview, the assessor organizes the material in his own mind, likely relying on implicit or
explicit prototypes developed through clinical experience and influenced by a particular
diagnostic frame of reference, to guide the conduct and interpretation of the clinical interview
(Westen, 1997; Westen & Shedler, 2000). Alternatively, clinicians may use more structured,
typically criterion-based, approaches to assessment of personality. Interviews of this kind
typically rely on DSM personality disorder criteria to make a personality disorder diagnosis,
for example, borderline personality disorder or narcissistic personality disorder (e.g.
Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), First et al., 1996;
International Personality Disorder Examination (IPDE), Loranger, Janca and Sartorius, 1997).
For this purpose, structured interviews or self-reports are frequently employed.
Personality pathology diagnosis has been going through major changes in recent years,
and publication of the 5th edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Association, 2013) attracted a new wave of
attention to the diagnosis of personality disorders (PDs). Surprisingly, the well-documented
limitations of a categorical approach to personality pathology (e.g., poor discriminant validity,
high comorbidity and heterogeneity) did not lead to major changes in the DSM-5
classification, and the 10 categorical and polythetic diagnoses still represent the official
standard for personality disorder assessment according to DSM-5. Nevertheless, dimensional
models obtained a primary position within emerging measures and models, operationalized in
the Alternative Model for Personality Disorder Diagnosis (DSM-5 Section III). With the
Alternative Model, the DSM-5 recognizes the need for a dimensional approach to personality
pathology, which posits Self and Interpersonal functioning as key defining dimensions of both
normal personality and PDs, along a continuum of severity of dysfunction in these domains.
This approach explicitly intended to favour a clinician-centered perspective in that it
resembles the diagnostic decisions and processes typically followed by clinicians, by stating
that, “Patients have just one personality; it is inconsistent with most clinical theory to suggest
that a person has two, three, or even five qualitatively distinct personality disorders” (First et
al., 2002, p. 130). Rather, considering PDs as adaptive failures on general dimensions of
personality functioning was regarded as more consistent with a clinician-guided approach to
diagnosis and treatment of PDs (First et al., 2002).
Thus, DSM-5 Section III proposes to dimensionally evaluate personality pathology
using the Levels of Personality Functioning Scale (LPFS), which aims to reliably capture
impairments in both establishing a sense of Self and in Interpersonal functioning (Bender,
Morey & Skodol, 2011). The LPFS evaluates the individual’s level of functioning across the
domains of Identity and Self-Direction (i.e., Self- Functioning) and Empathy and Intimacy
(i.e., Interpersonal Functioning) along a continuum of severity/impairment (i.e., from 0= little
or none, to 4= extreme). However, some authors raised concerns about the clinical utility of
this proposed “severity indicator” of PDs. For instance, clinicians who are not familiar with
these constructs of personality pathology might find it difficult to determine the specific
rating of severity on each domain (e.g. Clarkin & Huprich, 2011). In fact, while the LPFS
provides some short descriptions for each domain-level, those paragraphs might appear
relatively vague and complex to less experienced practitioners. For this reason, researchers
have begun to evaluate instruments that can be used to guide such an assessment (e.g.
Zimmermann et al., 2012).
The goal of this article is to describe a clinically-based approach to the assessment of
personality functioning grounded in an object-relations-model of personality and personality
disorder that is consistent with the Alternative Model for PDs proposed by DSM-5 Section
III. We describe the Structural Interview (SI), a clinician-guided interview, and also introduce
the Structured Interview of Personality Organization (STIPO), a more structured approach to
clinical interviewing, to demonstrate the clinical utility of both.
Theoretical Framework Forming the Base of the Interview Measures
The approach to clinical diagnosis described here is based in Kernberg's object-
relations theory (Kernberg, 1984; Kernberg & Caligor, 2005). The model revolves around
developmental levels of internal object relations, representations of self in relation to other
linked through affect states.
Kernberg posits that from birth onward, inborn affects are activated in relation to,
regulated by, and cognitively linked to interactions with caretakers. Over time, these early
interactions between the child and his caretakers are internalized and gradually organized to
form internal object relations. These internal object relations are regarded as the basic
building blocks of all mental experience. In the early life of the infant, two parallel series of
internal object relations are developed. One series is associated with highly charged positive
affect states motivating “approach” behaviors, and the other series is associated with highly
charged negative affect states motivating aversive behaviors. The core affect of the negative
sector of affective experience is aggression; the dominant affects of hatred and envy which
are evident in severe personality disorders can be traced back to this core affect. In the
positive, loving, series of internal object relations the core affect is primitive elation,
gradually developing into sexual excitement and also evolving to organize dependency needs.
During mental development, positively and negatively valenced internal object
relations are integrated, and affect dispositions become nuanced and modulated. Integration of
positive, loving affects and internal representations with negative, aggressive affects and
internal representations leads to more realistic and complex affectively colored experiences of
self and other. Integration is facilitated by the development of cognitive capacities and
ongoing learning regarding realistic aspects of the interaction between self and others under
circumstances of low affect activation. The integration of internal object relations is crucial
for the development of psychological health. Failure to achieve this developmental task leaves
the individual burdened with intense, poorly integrated and poorly modulated forms of
aggression as well as un-integrated representations of self and other. These individuals are
diagnosed at a borderline level of personality organization. If contradictory internal object
relations and associated affect states can be integrated, higher-level structures can be
developed and more flexible affect modulation will follow.
According to this theory, different levels of personality pathology reflect the degree of
integration of internal object relations. These different levels are reflected in the object
relations theory-based model of classification of personality pathology developed by
Kernberg. This model moves away from a categorical diagnosis of personality disorders and
differentiates personality organization according to structural criteria (Kernberg, 1975; 1984).
Compatible with DSM-5 Section III Alternative Model for PDs, Kernberg proposes a
continuum of severity of pathology. At the healthiest end of the spectrum is normal
personality organization, followed by neurotic personality organization (NPO) encompassing
personality pathology of relatively mild severity (e.g., DSM-based obsessive compulsive
personality disorder, avoidant personality disorder), and finally at a greater level of severity,
what Kernberg refers to as borderline personality organization (BPO), encompassing the
severe personality disorders (e.g., DSM-based borderline personality disorder, antisocial

personality disorder). At the very most severe end of the spectrum is psychotic personality
organization through (PPO).
In sum, borderline personality organization cuts across the DSM-based personality
disorders; borderline personality disorder is conceptualized as one of many personality
disorders located in borderline personality organization. The main characteristics of the
different levels of personality organization are summarized in Table 1.
The Structural Interview: A Clinician-Guided Diagnostic Approach to
Personality Pathology based on Object-Relations Theory
The SI (Kernberg, 1981; 1984) is a clinical interview of approximately 90 minutes’
duration, designed to assess personality pathology within the described framework of
Kernberg's object relations theory of personality functioning and disorder. Within this model,
the classification of personality disorders is linked to the presence of normal identity
formation vs. identity pathology. Identity integration is the most important differential
criterion between normal and neurotic personality organization on the one hand, and
borderline personality organization on the other (Kernberg & Caligor, 2005). Normal identity
is characterized by an experience of self and others that is stable, complex, realistic and has
depth; in contrast, identity disturbance is characterized by a sense of self and others that is
unstable, superficial, lacking in complexity, and polarized, “all good” or “all bad.”
The SI focuses on assessment of identity formation, along with the associated domains
of defensive operations and reality testing, to characterize personality as organized at normal-
neurotic vs. borderline level of personality organization. Further refinement of the diagnosis
along the spectrum of severity is introduced with clinical assessment of quality of object
relations, moral functioning, and aggression/affect integration. In this manner, the SI
combines a categorical and dimensional approach to personality pathology, an approach that

long pre-dates the emphasis on dimensional measures of self and other functioning in DSM-5,
Section III.
The Structure of the SI
In this interview, Kernberg connects the present functioning of the patient with the
interaction of the patient with the interviewer. The interview follows a predetermined order
(initial, middle and end phase), but the interviewer has the freedom to pursue material as it
emerges in the patient’s self-presentation and responses to the interviewer. A cyclical process
in which the interviewer returns to anchoring symptoms allows an increasingly in-depth
picture of the patient’s internal and external functioning to emerge (see Figure 1).
The initial phase of the SI. The interviewer begins by inquiring in an open-ended
fashion about symptoms and difficulties that brought the patient to the interview, what he
expects from treatment, and any other difficulties the patient may have in his life. Initial
questions are relatively unstructured, and the interviewer will follow up according to the
patient’s reported symptoms. In this phase, the diagnosis of psychotic personality
organization is tested at the same time that presenting complains and symptoms are
elaborated. Behavior related to self-directed and other-directed aggression (suicide attempts,
cutting, temper outbursts, violence) typically emerges during this phase of the interview,
along with the presence of antisocial tendencies (e.g., lying, prostitution, problems with the
law).
The model identifies “anchoring symptoms" (Kernberg, 1984) along the perimeter of a
circle. The interviewer proceeds from one cardinal symptom to the next, to return eventually
to the starting point and reinitiate a new cycle of inquiry if necessary. This cyclical approach
enables the interviewer to return as often as necessary to the same issue in different contexts,
retesting preliminary findings at later stages of the interview until sufficient diagnostic clarity
emerges. The specific questions and the order of questions are not predetermined, giving the
interviewer flexibility to focus on relevant aspects and to return to important, perhaps
contradicting issues. For example, the interviewer could return to previously stated aspects in
the description of a person that contradict the present description ("I notice that you are
describing your partner in very negative words, but before you said he was the best partner
you could imagine - how does that fit together?").
The middle phase of the SI. In this phase, the interviewer acquires a comprehensive
and in-depth view of the patient’s life situation and functioning, accompanied by further
evaluation of personality organization, focusing on identity formation and defensive
functioning. Differential diagnosis of borderline versus neurotic personality organization is
made on the basis of evaluation of identity consolidation versus identity pathology, assessed
by asking the patient to provide a description of himself and a description of significant
others, complemented by the patient’s level of functioning in his work and interpersonal life
and in his utilization of free time. Descriptions of important relationships provide the
interviewer with information both about the patient’s social situation and the quality of his
object relations. In this phase, the methods of clarification and tactful confrontation provide
the interviewer with important prognostic and therapeutic information. Clarification entails
asking for specific descriptions and examples of material that is vague or confusing;
confrontation entails pointing out inconsistencies and contradictions, inquiring if the patient
can understand the interviewer’s confusion and resolve it. During this process the interviewer
simultaneously fulfills three tasks; he explores the internal world of the patient, at the same
time observing the patient’s interactions with the interviewer, while also following his own
affective reactions and countertransference. Combining these three sources of clinical data
enables the interviewer to generate hypotheses about the nature and organization of the
patient’s internal object world.

Throughout the interview, there is a focus on how the patient is functioning (i.e.
thinking, assessing, processing questions, organizing answers) in the here-and-now interaction
with the interviewer. For example, determining the degree of impairment of reality testing, the
interviewer might ask the patient about how he thinks the interviewer may perceive a
particular aspect of his behavior. This clarification can yield meaningful information with
regard to differential diagnosis: If a patient cannot discern that his behavior might seem odd
to the interviewer, this can be seen as an indicator for impaired reality testing. In assessing
identity pathology, the interviewer might point out frankly contradictory descriptions of
significant others or of the self, asking for the patient’s thoughts about this. A patient with
identity pathology might respond with a lack of concern or curiosity, indicating the use of
splitting and denial, as in the case of Ms. K, described below, whereas a patient organized at a
neurotic level might respond in a thoughtful way that explains the apparent contradiction, or
is perplexed or seeks to better understand it. In this phase of the interview, the interviewer
may also offer a tentative hypothesis that explains apparent contradictions (a “trial
interpretation”). The individual's reaction to a trial interpretation can provide important
diagnostic information (e.g. understanding or reflection vs. anger in response to the
intervention).
The final phase of the SI. In this phase the interviewer conducts a general exploration
of the patient’s past as it relates to current difficulties. In addition, Kernberg emphasizes
leaving enough time to find out if there are any additional issues the patient considers
important should still be discussed. Also, in this phase the necessity and the patient’s
motivation for further diagnostic or treatment steps can be evaluated, and recommendations
can be given.
Overall, the Structural Interview combines psychoanalytic thinking and psychiatric
exploration. The assessment of both clinical symptoms and level of personality organization
provides the interviewer with important information for diagnosis, prognosis and treatment
planning.
Clinical Example of the SI
The following clinical example demonstrates the use of the SI; for this purpose
material excerpted from a clinical interview are complemented by explanation of interview
techniques.
Initial phase. This phase assesses presenting symptoms and problems. The patient is
invited in an open-ended fashion to discuss her symptoms, chief reasons for coming to
treatment, any other difficulties she may be having, along with her expectations of treatment.
In listening to the patient’s response, the interviewer has an opportunity to evaluate the
patient’s awareness of her problems, whether she identifies her difficulties as residing within
herself or as coming from outside, her understanding of her need for treatment, and the
realistic or unrealistic nature of her expectations of what treatment can provide.
Ms. K, a 30-year-old, single woman was referred for treatment by her general
practitioner. She arrived to the interview with Dr. H casually but stylishly dressed, wearing
make-up and with her hair well-coiffed. The interviewer began with the standard opening to
the structural interview, comprised of a predetermined series of open-ended questions:
Dr. H: What are the problems that bring you here, are there other difficulties in your
life, and what do you hope to get out of treatment? (The complex and relatively
unstructured nature of these questions requires a clear sensorium and are a first screen
for psychotic illness)
Ms. K: I’m depressed. It’s gotten so bad, I’ve spent the past two weeks in bed. I can’t
stop crying. I feel paralyzed. Literally can’t move. I can’t go on. I wake up, can’t face
it, and go back to sleep.
Dr. H: What is it you cannot face?

Ms. K: My life, it’s a disaster. Nobody cares about me. There’s no point….I just
can’t face my life. I just lie there.
At this point Dr. H inquired about neurovegetative symptoms of depression, which
were negative. Ms. K denied suicidal ideation, but endorsed a feeling of “not wanting to go
on.” Dr. H decided to learn more about Ms. K’s present difficulties and why she was staying
in bed.
Dr. H: How long have you been depressed like this?
Ms. K: A month now. I can’t get out of it. I can’t move.
Dr. H: Has this happened to you before?
Ms. K gave a history of several similar episodes, of variable duration, over the past 10
years. She had been treated with various antidepressants, with minimal benefit, and had never
been hospitalized.
Dr. H: When you became depressed, a month ago, how were things going, were you
aware of anything that triggered the depression?
Ms. K: My boyfriend Mike broke up with me. Well, he wasn't my boyfriend, really. I
knew him through work for many years, we were best friends and then we got
involved. But he said he didn’t believe in monogamy. He never lied - honesty is really
important to me, so I’m glad he was honest. But he would never go out with me or
meet my family. It was all on his terms; he’d call me to come over at night. I was in
love with him and thought he was in love with me. He was so patient with me, so kind.
But then about a month ago out of the blue he told me he wanted to be on his own.
Dr. H: Did it bother you that he saw other women?
Ms. K: Of course it did! It drove me crazy. We fought all the time about it.
Dr. H: So is that why you two broke up?

Ms. K: No, like I said, it was out of the blue. I have no clue what happened. He said
he’d given me plenty of warning, had been suggesting I move on for a long time but
that I wouldn’t hear it. But I don’t think that’s really true. And now he won’t talk to
me, won’t answer my texts.
Dr. H was struck by Ms. K’s rather chaotic and seemingly contradictory description of
Mike and of their relationship. Dr. H planned to return to this issue, and to evaluating her
interpersonal functioning in general, in the next phase of the interview, when she evaluated
identity formation. Before doing so she decided to ask about other symptoms, inquiring about
anxiety disorders, eating disorders, symptoms of bipolar or psychotic illness, attentional
disorders, learning disabilities and substance abuse. Ms. K endorsed a lifelong history of
intermittent “panic attacks” typically lasting hours to days, treated with Clonazepam, and she
carried a diagnosis of ADD, treated with medication in the past. She denied a history of self-
destructive behavior or illegal behavior. She had never been hospitalized.
Middle phase. This phase focuses on the patient’s personality functioning and level of
personality organization. It begins by following up on aspects of the patient’s personality
functioning that have emerged in earlier parts of the interview while exploring symptoms and
presenting complaints, filling in whatever remains unclear. Evaluation of personality
functioning, focusing on work, interpersonal relations and recreation, is followed by
evaluation of identity formation and defensive style. The interviewer will pursue this line of
inquiry by asking the patient to describe herself and significant others, and by tactfully
pointing out discrepancies, contradictions, omissions or notable patterns that have emerged
during the course of the interview.
Dr. H began with systematic evaluation of Ms. K’s present life situation and
functioning. Both current functioning and symptoms and the more chronic functioning are
examined, in order to differentiate between a present disorder (e.g. depressive episode) and
more chronic impairment (e.g. long-term low functioning due to a personality disorder). This
is done by referring to different time frames and modes of functioning, as well as frequency,
pervasiveness and severity of the inquired behavior (e.g. "is this how you typically deal with
work problems?"). In the case example, Dr. H. inquired in detail about Ms. K’s vocational
functioning, her relationships, romantic life, and use of free time, and what impact, if any, her
symptoms had on her functioning in these areas. Ms. K reported that she had held several
entry-level jobs since graduating college, but lacked professional direction, skills, or interests.
She reported that she had last been working on and off as the assistant to the brother of Mike,
the man who had recently broken up with her. When her relationship with Mike ended, Ms. K
precipitously left her job with his brother. She was currently unemployed and looking into
collecting unemployment. Ms. K had a circle of women friends, several dating back to middle
school. She described these relationships as stormy and largely unsatisfactory. She had had a
series of long-term romantic relationships with men, all ending in rejection. She lived alone
and spent her days watching television, going to the gym, and meeting up with friends. She
described wanting a career, but beyond that she had no professional goals and no personal
interests. Dr. H noted to herself that Ms. K’s functioning was consistent with a borderline
level of personality organization; she lacked professional or personal goals, she described
significant pathology in her interpersonal and romantic life, she felt directionless and empty,
and had no developed interests.
To confirm or disconfirm this preliminary assessment, Dr. H moved on to assessment
of identity formation, the cornerstone of structural interview (see Table 1). To assess identity,
the interviewer asks the patient to provide an in-depth description of herself, and also of a
significant other. The standard approach in the SI is to introduce this part of the interview by
saying: “You have told me about your symptoms and your difficulties. I’d like now to hear
more about you as a person. Could you describe yourself, your personality, what you think is
important for me to know about you to get a real feeling about you as a person.”
This question is a challenging one; it requires the ability to be reflective, and asks the
patient to construct as complete and complex description of herself as she is able. In
clinically evaluating the patient’s response, the therapist attends not only to the content of
what the patient says, but also to the process of thinking and articulation the patient engages
in. For example, is she coherent and specific or vague and disorganized? Is she thoughtful or
is she glib? The extent to which the patient can engage in a lucid, detailed, and multilayered
construction of a description of herself and of her significant others is an indication of identity
integration vs. pathology, and helps to determine level of personality organization.
In response to Dr. H’s request that she provide a description of herself, Ms. K
appeared confused.
Ms. K: What do you mean? What do you want to know? I’ve been depressed, is that
what you mean?
Dr. H repeated: You’ve told me about your depression. I’d like now to hear more
about you as a person. What you’re like. For example, if you were to write a
paragraph about yourself, what would you include, so that I could get to know who
you are as a person and what your personality is like?
Ms. K: Well, I guess I’d say I’m stupid. And I can’t get anything right. And my family
always picks on me. Is that what you mean?
Dr. H: Well, are there other things about you as a person, things that would be
important to know about you?
Ms. K: Other than I’m stupid and unemployed and don’t have a boyfriend?
Dr. H: Well, are there positive things you would say about yourself?
Ms. K: Well, I think I’m a nice person. In fact I’m too nice; everyone takes advantage
of me. I always do what other people want.
Dr. H viewed the impoverished and inconsistent quality of Ms. K’s sense of herself,
along with the marked difficulty she had approaching the question, as supporting the
impression of identity pathology. Consistent with this, Dr. H noted that Ms. K’s description of
herself as “too nice” and excessively accommodating was frankly discrepant with her
behavior with Dr. H early in the interview, when she had seemed at times petulant and quietly
oppositional.
After asking the subject for a description of self, the SI next asks for a description of a
significant other. The standard approach of the structural interview is to introduce this part of
the interview by saying: “I would now like to ask you about the people who are most
important to you in your current life. For example, who is the person who is most important
to you right now?” After the patient identifies someone the interviewer then requests: “Can
you tell me more about him so that I might form a real, live impression of him? What is he
like as a person, how would you describe his personality?”
In response to Dr. H’s inquiry, Ms. K identified Mike, the man who had broken up
with her a month ago, as the person whom she was closest to and who was the most important
person in her life.
Ms. K: The most important person to me is Mike. Even though we’ve broken up I still
think about him all the time, and he is the most important person to me. Even now I
love him and cannot live without him. (Dr. H noted the self-referential quality to Ms.
K’s description of Mike, and that Ms. K had failed to provide any description of Mike
as an individual)
Dr. H: Can you tell me about Mike as a person?

Ms. K: He is the only person who has ever understood me. He was so kind and patient
with me. No one has ever treated me so well. He made me feel so safe. He was my
best friend. He was always supportive.
Dr. H was struck by the superficial, idealized description Ms. K provided, confirming
her impression of identity pathology. She decided to complete the assessment of identity
pathology by offering a tactful confrontation of Ms. K’s contradictory description of Mike, to
see if she could be reflective and possibly integrate it to some degree:
Dr. H: You are telling me now that Mike is the only person who understood you, that
he was kind and patient, he made you feel safe. I remember that earlier in the
interview you painted a different picture - you told me he was never faithful to you and
that that was very upsetting to you and cause for arguments. What do you make of
that seeming contradiction?
Ms. K: He was just wonderful, that’s what I’m telling you. The other stuff is
meaningless, and he never lied to me.
Ms. K responded to Dr. H’s confrontation by maintaining a highly idealized view of
Mike, denying the impact of the negative history she had described, and demonstrating a lack
of concern or reflectiveness in response to Dr. H’s intervention. This response to
confrontation was further evidence of a poorly integrated psychological structure, consistent
with identity disturbance and reliance on the defenses of splitting, idealization, and lower-
level denial (see Table 1, defensive operations). At this point, the diagnosis of borderline
personality organization (BPO), as opposed to neurotic personality organization is clear to the
interviewer - as manifested by identity pathology and use of primitive defenses in the context
of intact reality testing (see Table 1).
In the following phase the interviewer obtains a brief history of relevant information
from the patient’s past and her family history. Especially in the setting of identity pathology,
where descriptions of the past are typically distorted by present difficulties and contradictory,
it is best to obtain a general history including family members, important, meaningful positive
relationships growing up (a positive prognostic sign) and any history of antisocial behavior (a
negative prognostic sign).
Final phase. The final phase begins with the interviewer acknowledging that she has
completed her task and by asking the patient if there are things that have not come up that it
would be helpful for her to know about, or if she wishes to raise questions or issues that have
not been addressed. The remaining questions of the SI focus on gathering information for
questions of prognosis and treatment planning.
Psychometric Properties and Research on the SI
While the SI is a sophisticated method and a valuable clinical tool, it has significant
limitations. Because the interview does not provide a structured sequence of questions, but
rather relies on the interviewer’s clinical judgment and inference to follow the patient’s lead,
it requires of interviewers both clinical experience and familiarity with the underlying model.
In addition, even with more experienced interviewers, coverage of symptoms and domains of
functioning may be uneven across interviewers, and even the same interviewer will focus
differently interview-to-interview, depending upon a particular patient’s presentation in the
moment.
Hence, the main limitation of the structural interview is varying levels of inter-rater
reliability across settings and studies. A few studies have evaluated the agreement between
raters on the structural interview. Ingenhoven et al. (2009) examined data from 32 borderline
and psychotic inpatients from a previous study (Carr, Goldstein, Hunt, & Kernberg, 1979) and
found very good agreement (k = .90) between two well-trained experienced raters assigning
patients to the psychotic personality organization or borderline personality organization
category. Kullgren and colleagues (Armelius, Sundborn, Fransson, & Kullgren, 1990;
Kullgren, 1987) reported high correlation coefficients among raters for identity integration,
defensive structures, reality testing, and structural diagnosis, also reporting 84% inter-rater
reliability estimates for 23 psychiatric inpatients. Derksen, Hummelen, and Bouwens (1994)
reported moderate overall agreement (69%) for 37 psychiatric in- and outpatients. Finally,
Ingenhoven et al. (2009) reported satisfactory inter-rater reliability considering Kernberg’s
tripartite classification (Ksw = 0.42). Taken together, these results suggest that adequate
agreement between raters can be obtained, at least at the macro level of assigning a patient to
a specific personality organization; such agreement, nevertheless, is obtained using relatively
skilled interviewers who have an understanding of the underlying theoretical model.
In terms of concurrent validity, several studies have examined the relationship
between SI on the one hand and clinical interviews or instruments assessing personality
disorders or performance-based (projective) measures on the other hand, but a comparison
with measures of personality organization has not yet been published. Bauer, Hunt, Gould,
and Goldstein (1980) had experts rate transcribed structural interviews for a global clinical
diagnosis (borderline vs. psychotic vs. neurotic personality organization) and compared these
diagnoses to independent raters' structural assessments based on detailed analyses of the
interactions in the transcribed interviews using a newly developed manual of instructions and
scoring standards. Good agreement was found between these two perspectives on the
structural diagnoses -- the SI could differentiate well between psychotic and borderline level
of personality. Another study examined the SI in a sample of 46 psychiatric inpatients. Carr et
al. (1979) and Kernberg et al. (1981) compared the SI with Gunderson's Diagnostic Interview
for Borderlines (DIB; Gunderson, Kolb, & Austin, 1981) and a combination of the Wechsler
Adult Intelligence Scale (WAIS; Wechsler, 1955) and the Rorschach Inkblot Test (Rorschach,
1921). The SI and DIB were employed as instruments to arrive at a structural diagnosis of
borderline personality vs. psychotic personality. WAIS and Rorschach Inkblot Test were used
to test the hypothesis that borderline patients show ordinary reasoning and responses on the
WAIS, and at the same time deviant thought processes on the Rorschach Inkblot Test -
whereas psychotic individuals have difficulties on both tests. In 74% of the cases (κ=.49) the
assessment from the SI with the DIB regarding the diagnosis of borderline personality
coincided, and concordance between the structural interview diagnoses and the combined
WAIS / Rorschach Inkblot Test comparisons could be found in 78% of the cases (κ=.56).
When comparing SI assessments with clinical DSM-III diagnoses (in particular BPD) and
DIB-BPD diagnoses, several studies found low-to-moderate agreement (κ=.32 to κ=.64)
(Blumenthal, Carr, & Goldstein, 1982; Kullgren, 1987; Nelson et al., 1985). These moderate
associations can be explained by the broader conceptualization of borderline personality
organization obtained from the SI and the rather narrowly defined criteria for borderline
personality disorder according to DSM-III. According to Kernberg's model, individuals with
BPD are expected to be located on borderline personality organization (BPO), but BPO also
comprises other DSM personality disorders like narcissistic, antisocial or schizoid personality
disorders (Yeomans, Clarkin, & Kernberg, 2015). Hence, for further validation of the model,
interviews assessing BPO reliably need to be compared empirically to other instruments on
structural diagnosis.
The Structured Interview of Personality Organization (STIPO)
For clinical settings in which a more rigorously standardized approach to structural
assessment is needed, the STIPO, a semi-structured version of the SI, offers a useful
alternative to the Structural Interview (Clarkin et al., 2004). The STIPO has distinct
advantages over the SI in its accessibility to less experienced interviewers, making it ideal for
clinical training and clinic evaluation services, and its enhanced inter-rater reliability relative
to the SI, making it suitable for research settings. In addition we have found the STIPO to be
an invaluable teaching tool; experience with the STIPO greatly enhances the skill with which
trainees can provide general clinical assessment of personality functioning and pathology in
their practice.
The STIPO assesses the same domains of personality functioning as does the SI, while
providing clearly formulated questions and anchors aiding the scoring process and the
classification of personality organization. The STIPO differs from the SI in two key respects:
first, the STIPO does not specify a review of symptoms; second, the STIPO does not make
use of confrontation or trial interpretation for the purposes of clarifying the presence of
identity pathology or splitting-based defences.
The STIPO consists of 100 questions assessing seven domains: 1) identity
consolidation vs. identity pathology, 2) use of primitive defenses, 3) quality of object
relations, 4) coping strategies, 5) use of self-directed and other-directed aggression, 6) moral
values and 7) reality testing (Clarkin et al., 2004). Scores are obtained both on item-level,
following probes and using individual anchors for the item-by-item rating process (e.g. "Do
you act in contradictory ways? Do others know what to expect from you?"), and also by
giving overall, clinical ratings per domain and subdomain (e.g. sense of self, sense of others).
Finally, an overall level of personality organization is assigned clinically, ranging from
normal to neurotic to borderline personality organization.
Clinical Example of STIPO items inquiring about Identity Pathology and the Use of
Primitive Defenses
A female patient in her 20’s was interviewed with the STIPO as part of the initial
assessment for randomization in a randomized clinical trial (RCT) for the treatment of
borderline personality disorder (Doering et al., 2010). The patient expressed considerable
hostility during the interview; her presentation oscillated between distrust on the one hand,
and a childlike naïveté on the other.

As described in relation to the SI, assessment of identity is central to the STIPO. In a
manner adopted from the SI, initial assessment of identity integration begins with an open-
ended question in which the patient is asked to describe him or herself, briefly, for the
interviewer. In response to this question (#12), the patient answered as follows:
“Well, I am not very tolerant, uhm, curious. Hmm… stupid. Sometimes…Well, I have no
idea, I don’t know. I know these were only negative things. I also am fast in my
perception… am tidy. Sometimes I can be funny…“ Probed about a more detailed
description of what made her unique, she repeated, “No idea!” Asked if she felt that it
was difficult to describe herself, she answered “Yes, I don’t know why.”
The patient’s response reflects a meagre, superficial, and fragmented representation of
herself as a person, suggestive of showing a fair amount of identity pathology and rated with a
score of 2 on the three point scale. The anchors for this specific item are as follows: 0=
Describes self with subtlety, depth and self-awareness; easy for respondent to elaborate
multiple, diverse qualities, and to see both positive and negative aspects of the self; narrative
quality; reflection on sense of his or her personality and inner mental life; 1= Somewhat
superficial description of self; contains some self-awareness, some sense of reflection related
to inner mental life; difficulty seeing self as whole object; some poverty in descriptors of self;
tends towards list of adjectives with little elaboration, narration; 2= Superficial description
of self, little subtlety or depth; no ability to see self as whole object; poverty in descriptors of
self; list of adjectives with no elaboration; little to no narrative quality; little to no reflection
on inner mental life.
The STIPO combines responses to this relatively open-ended question with more
specific items inquiring about consistency of sense of self across time and situations, loss of
sense of self in intimate relationships, and stability of tastes and opinions values, to confirm
the assessment of identity pathology vs. integration and to characterize degree of identity
pathology across a dimension of severity. In total, the STIPO domain of "Identity" comprises
a total of 30 questions, each rated on a three point scale (with 0 indicating absence of
pathology, 1 reflecting moderate pathology and 2 severe pathology in the specific item). In
addition, a 5-point rating for the overall domain "Identity" is assigned (ranging from a score
of 1: identity consolidation, to 5: severe identity diffusion), with ratings starting at 3
indicating moderate impairment of pathology (see Figure 2).
Following the SI, the STIPO assesses the use of splitting-based defenses, but in this
case using a semi-structured format with suggested probes. One such question (STIPO #53)
asks: "Would you consider yourself someone who is cautious about what other people know
about you; would you call yourself guarded? Are you someone who is suspicious about other
people, concerned about their motives, perhaps afraid that if you let down your guard you
could be easily taken advantage of?" The patient in our example responded:
”I always think I trust someone, then something happens, and I realize it is not a
person I can trust. Then my feelings for the person change completely.”
The STIPO directs the interviewer to follow up such affirmative responses by
inquiring about the pervasiveness, severity, and frequency of the targeted behaviour or
characteristic, i.e., if this was the case in all relationships or only with specific people, all of
the time or some of the time. The patient responded:
“My friends change frequently, my family is a single disappointment, and at work I
have often seen how many faces my colleagues have”.
This question was scored to indicate an unstable view of relationships and
unpredictable shifts in view of others reflecting the impact of the splitting-based defense
idealization / devaluation.
Within the semi-structured format of the STIPO interview, the interviewer has the
freedom to follow his or her clinical inference when selecting follow-up probes, and also
when selecting among anchors for scoring, both at the item and domain-level. Thus, the
STIPO represents a semi-structured interview format that is flexible, leaving room for clinical
judgment while reducing variability across interviewers. In our example, both the clinical
presentation of the patient in the interview situation (e.g. inpatient, hostile behaviors) and the
anchor-based scores for each specific question provided the interviewer with a structural
diagnosis and clinical information necessary for treatment planning. The patient’s responses
to STIPO items are illustrated in Figure 2. The overall scores, rated on a scale of 1-5 show
particularly high levels of identity pathology (both in her sense of self and sense of others),
consistent use of splitting-based defences, and also severe self-directed aggression, while her
overall personality profile, high in most domains of pathology of personality organization, is
consistent with borderline personality organization (for a more detailed description of this
case and others on the STIPO, see Hörz, Clarkin, Stern, & Caligor, 2012). Giving clinical
weight to the domains in which the patient scored most highly with regard to pathology, the
therapist concluded that a treatment setting with a clear therapeutic frame and limit setting,
coupled with a clinical focus on self and other representations, primitive defensive operations
and self-directed aggression (cf. the peaks in Figure 2), would be helpful to this patient.
Psychometric Properties and Research on the STIPO
The English, German and Italian versions of the STIPO have demonstrated good inter-
rater reliability, concurrent validity, and differential validity (Doering et al., 2013; Preti,
Prunas, Sarno, & De Panfilis, 2012; Stern et al., 2010). Of particular interest are results
concerning inter-rater reliability. In the study examining the original English version (ICCs
ranging from .84 to .97; (Stern et al., 2010) and both in the German (ICCs ranging from .89 to
1.00; (Doering et al., 2013) and Italian versions (ICCs ranging from .82 to .97; (Preti et al.,
2012) the rating of the STIPO dimensions proved to be reliable across raters.
In terms of construct validity, Stern et al. (2010) found that STIPO domains Identity
and Primitive Defenses, collectively, were closely linked to personality disorder symptom
counts of all personality disorder clusters (assessed by the Schedule of Nonadaptive and
Adaptive Personality (SNAP; Clark, Simms, Wu, & Casillas, 2007), to measures of
aggression (Buss-Durkee Inventory; Buss & Durkee, 1957) and positive and negative affect
(PANAS-X, Watson, Clark, & Tellegen, 1988). Interestingly, semi-partial correlations
revealed unique contributions of the STIPO Identity domain to indices of personality disorder
in Cluster A, whereas the STIPO Primitive Defenses domain was uniquely associated with
multiple measures of aggression as well as personality disorders in cluster B. With the
German version of the STIPO, a good agreement on the overall level of personality
organization according to STIPO and to Operationalized Psychodynamic Diagnostics (OPD
Task Force, 2008) was found (r=.68, p<.001). At the level of the individual STIPO domains,
strong and significant correlations with external measures were found, for example, between
STIPO Primitive Defense scale and the Primitive Defenses scale (r=.493, p<.01) of the self-
report Borderline Personality Inventory (Leichsenring, 1997).
In terms of DSM PDs, the STIPO shows good construct validity: patients with
personality disorder were located on a significantly lower level of personality organization in
all domains compared to patients without PD (Bäumer, 2010; Doering et al., 2013). The
Italian STIPO study (Preti et al., 2012) provided further support to the validity of the
interview. The Identity scale showed associations with measures of the stability of self image
and the capacity of pursuing goals, measured through the Severity Indices of Personality
Problems (SIPP-118; Verheul et al., 2008). The Defenses scale was associated with an
external measure of primitive defenses, the Response Evaluation Measure 71 (REM 71;
Steiner, Araujo & Koopman, 2001), and SIPP-118 domains related to lack of self-control and
emotional instability. Finally, the Reality testing scale showed coherent associations with the
Psychosis factor of the Inventory of Personality Organization, a self-report that assesses the
three primary STIPO domains (Lenzenweger, Clarkin, Kernberg, & Foelsch, 2001; Preti et
al., 2015a). The three primary scales of the STIPO also showed the expected criterion
relations: all of the STIPO dimensions discriminated between clinical and non clinical
subjects, whereas only Identity and Defenses, and not Reality testing, discriminated between
borderline patients and non borderline patients.
A prototypical profile derived from the STIPO, consisting of high impairment in the
domains "coherent sense of self", "representation of others", "object relations" and "primitive
defenses" has been shown to differentiate neurotic and borderline personality organization
(Hörz, 2007; Hörz et al., 2009) in a mixed clinical sample. In a study with patients with
chronic pain disorder, 58% of patients were described with BPO based on the STIPO, and
63% were diagnosed with a PD according to the SCID-II, with a significant correlation
between personality organization and number of SCID-II diagnoses (r=.33, p<.05) (Fischer-
Kern et al., 2011). One-hundred percent of a sample of 50 patients with opiate addiction were
located on BPO according to the STIPO, and 90% had at least one SCID-II PD, emphasizing
the close but not complete association between structural diagnosis and DSM personality
pathology (Rentrop, Zilker, Lederle, Birkhofer, & Hörz, 2014). Similarly, in a sample of 104
individuals with borderline personality disorder, lower levels of PO on the STIPO were
associated with higher levels of axis II pathology (i.e. number of comorbid SCID-II
diagnoses, of mental health service use or self-mutilation), and individuals with two or more
DSM personality disorders showed more pathology on the STIPO than patients with one
DSM personality disorder (Hörz et al., 2010). Di Pierro, Preti, Vurro and Madeddu (2014)
compared the STIPO profile of a group of 37 dual-diagnosis inpatients, 30 psychiatric
outpatients, and 30 non clinical controls. Dual diagnosis patients where characterized by a
poorly integrated identity with difficulties in the capacity to invest, poorly integrated moral
values, and high levels of self-directed and other-directed aggression. In a sample of 47 dual
diagnosis patients, Preti et al. (2015a) investigated differences of both descriptive (i.e., DSM-
oriented) and structural (i.e., STIPO) profiles between patients that dropped out of treatment
and patients that completed the treatment program: investments and self-coherence problems
(STIPO) were higher among dropouts. Moreover, in the dropout-group a significantly higher
number of patients showed a borderline personality organization (88.9 %), whereas
descriptive characteristics (i.e., PD diagnoses) did not differentiate the two groups.
The interrelation between personality organization, assessed by the STIPO, and
reflective functioning, operationalized by the reflective functioning scale (RF; Fonagy,
Target, Steele, & Steele, 1998) was examined in a sample of 92 patients with BPD (Fischer-
Kern et al., 2010). Significant associations between STIPO level of PO and SCID-I and -II
diagnoses were found, but not between severity of axis I and II pathology and RF. Only
moderate associations between RF and personality organization were observed (r =.207, p <
.048) suggesting that the nosological diagnoses based on SCID are more closely related to
personality pathology on the STIPO than RF.
The STIPO has been used to document personality organization changes in a RCT for
the treatment of borderline personality disorder. One-hundred four patients with BPD were
randomized to either transference-focused psychotherapy or psychotherapy by experienced
community therapists. The overall level of personality organization was examined as outcome
variable. After one year of treatment, a significant improvement of PO could be found in both
in the TFP group, and in the comparison group, with a significant superiority for the TFP
group (Doering et al., 2010).
Finally, a revised and shortened version of the interview (STIPO-R) has recently been
developed based on a large dataset comprising English, German, and Italian interviews, and
the psychometric properties of the 55-item STIPO-R are currently under examination.
Discussion
Comparison of SI, STIPO and Other Instruments of Personality Pathology
So far, no study has been published that empirically examines the relationship between
SI and STIPO (as the STIPO is a rather new instrument). While both instruments assess the
same construct (i.e. level of personality organization) and dimensions grounded in the same
theoretical framework, important differences in the diagnostic procedure can be found (Table
2). One of the main differences is that the more structured STIPO provides higher inter-rater
reliability while losing a more clinically oriented approach as provided by the SI, namely, the
ability to use clinical inferences to frame confrontations, i.e., between contradictory pieces of
information.
Another line of research is the comparison between SI and STIPO to other instruments
assessing personality structure. The aforementioned validity studies on the SI compared the
structural diagnosis of the SI to instruments of personality disorder diagnosis (e.g. the
Diagnostic Interview for borderline patients DIB; Gunderson, Kolb, & Austin, 1981), though
only moderate relationships were found. This can be explained by the broader construct of
structural diagnosis (i.e. personality organization in Kernberg's framework) that cuts across
several personality disorders (e.g. borderline, narcissistic, schizoid PDs) within the DSM
framework (cf. Yeomans, Clarkin, & Kernberg, 2015). Along these lines, severity of
personality pathology was examined using STIPO domains and DSM PDs (Hörz et al., 2010),
linking a lower level of personality organization and more pathology on the STIPO domains
to more than one DSM-IV personality disorders assessed by the SCID-II (First et al., 1996).
Doering and colleagues (2013) found a significant correlation (r=.68, p<.001) between STIPO
level of personality organization and level of structural integration based on the
Operationalized Psychodynamic Diagnostics (OPD Task Force, 2008). The comparison
between the individual STIPO domains and OPD domains has not yet been published (Hörz-
Sagstetter, Träger, Lederle, & Rentrop, 2014), while OPD level of personality organization
has been compared to the Levels of Personality Functioning Scale (Zimmermann et al., 2012).
It would be fruitful to examine how SI, STIPO and other instruments of personality structure
like the Shedler-Westen Assessment of Personality (Westen & Shedler, 1999a; Westen &
Shedler, 1999b) relate to each other.
Usefulness of these Theory-Based Interviews for Routine Clinical Assessment, Training
and Research
In our collective experience, instruction in the SI procedure and STIPO provide
significant benefits to practitioners working with patients across the whole range of severity
of pathology. These procedures provide a practical approach to assessment that
operationalizes theoretical concepts, grounded in object-relations theory, central to our
understanding of personality health and pathology, making these concepts accessible to
clinicians as they evaluate patients in daily practice. It is one thing to understand identity
pathology and the operation of primitive defenses in theory; it is far more challenging to
assess them in a clinical setting. This requires familiarity with specific, effective lines of
inquiry that will be predictably accessible to patients, as well as a set of implicit or explicit
guidelines by which to gauge patient responses along a spectrum of severity. Both are
provided by training in and experience with Structural Interviewing and/or STIPO
interviewing. Training in SI and STIPO is part of specific curricula in Transference Focused
Psychotherapy provided by the associated institutes (see ISTFP.org). Also, additional STIPO
trainings take place for research projects involving the STIPO. Typically, several STIPO
training tapes are scored and ratings are compared to master ratings along with a detailed
discussion of both underlying model as and ratings. Training in the STIPO carries the
additional advantage of providing specific language for inquiring about different domains of
personality functioning, along with more systematic coverage of content areas, a task often
complicated by the confusion and / or intensity involved in the back and forth of the initial
clinical interview. Particularly, questions about sexuality or aggression, often neglected in a
clinical interview, are well operationalized in the STIPO and provide the clinician with a
theory-based guide through the assessment procedure.
Clinical assessment of identity, defenses, and reality testing, complemented by
evaluation of quality of relationships, moral functioning, and self and other aggression, as
covered in both the SI and the STIPO, offer the clinician essential information regarding
severity of pathology, prognosis, and differential treatment planning. Initial empirical work
suggests that the STIPO can be administered reliably in both sexes and several cultural
contexts (Doering et al., 2013; Preti et al, 2012; Stern et al., 2010). These approaches can be
employed in a variety of settings including out-patient clinic and private practice settings, as
well as on in-patient units, emergency rooms, and community-based psychiatric services. The
outcome is a clinically meaningful assessment of personality pathology, focusing on severity.
As reviewed above, the STIPO has proven its clinical usefulness in different domains, e.g.
characterizing patients at risk for drop-out (Preti et al., 2015b), assessing domains of specific
impairment for dual diagnosis patients (Di Pierro et al., 2014), assessing severity of
personality pathology (Hörz et al., 2010), tracking personality organization following
treatment (Doering et al., 2010).
An example for a STIPO-based treatment recommendation relates to the STIPO
profile depicted in Figure 2. It suggests the value of identifying a treatment approach that
targets identity pathology, focusing on splitting-based defensive operations, instability in the
sense of self and others, and self-directed aggression. The high level of severity reflected in
Figure 2 supports the clinical benefits of a clearly established treatment frame in conjunction
with limit-setting.
Personality pathology organized at a neurotic level of personality organization calls
for a very different therapeutic approach and follows a very different course (e.g. Caligor,
Kernberg & Clarkin, 2007) than does personality pathology organized at a borderline level of
personality organization (e.g. Yeomans, Clarkin, & Kernberg, 2015). For example, in the
treatment of individuals with borderline pathology, the use of a treatment contract is a key
constituent of the therapeutic frame to which the therapist will refer regularly to provide the
patient with a clear and stable structure, while in the treatment of individuals with neurotic
level of personality organization this contract and frequent discussion of it are not as
necessary. Table 3 shows key elements relating levels of personality organization with
implications for treatment.
In sum, training in structural interviewing provides clinicians with an integrated,
psychodynamically-based model of personality disorder linked to an organized and specific
approach to assessment. Training can be enhanced by exposure to the STIPO (Clarkin et al.,
2004), the semi-structured version of the SI. The STIPO provides the interviewer with clearly
formulated questions and anchors that systematize the interview, and familiarity with the
scoring narratives of the STIPO can help the clinician to evaluate patients’ responses to the
SI. For research purposes, the STIPO can serve as a proxy for the SI. The semi-structured
approach of the STIPO interview leads to improved inter-rater reliability (see above) when
compared with the clinical SI (Doering et al., 2013; Stern et al., 2010). The recent
development of a revised, shorter version of the interview (the STIPO-R), which can be
administered in one single session (45-60 minutes) makes this assessment procedure even
more adequate for research purposes. The process of the STIPO-R development combined
theoretical and clinical considerations with the analysis of the STIPO-100 items reliability and
factor loadings in a large dataset comprising English, German and Italian interviews. The
final result is a 55-item interview and the main modifications to the original structure are the
elimination of the Reality Testing domain and the addition of a new narcissism domain. The
psychometric properties of the STIPO-R are currently under examination.
Closeness of these Theory-Based Interviews to the DSM-5 Alternative Model of
Personality Disorders
The theoretical background of the SI and the STIPO - Kernberg’s object-relations
model of personality pathology (Kernberg, 1984; Kernberg & Caligor, 2005) - is quite
consistent (if not integral) to the Alternative Model of personality disorders proposed by
DSM-5, Section III. In fact, the areas of inquiry of the presented clinical interviews based on
an object relations model cover several domains of Self and Interpersonal functioning that are
included the DSM-5 LPFS (Bender, Morey, & Skodol, 2011). Overlapping aspects with the
LPFS include difficulties in the sense of continuity and uniqueness of self (Identity);
problems relating to the ability to set reasonable goals based on a realistic assessment of one’s
own capacities (Self-Direction); difficulties in understanding others’ experiences and
motivations as well as the effects of one’s own behaviors on others (Empathy); limitations in
establishing and maintaining close and mutual relationships with others (Intimacy). The
parallel between a psychodynamic structural approach to personality pathology and the DSM-
5 alternative model of personality diagnosis has been demonstrated in recent studies
(Zimmermann et al., 2012; Zimmermann et al., 2014) that used the OPD system (OPD Task
Force, 2008) to obtain clinical interviews that were then used to successfully rate the DSM-5
LPFS. In the same vein, we propose that familiarity with the tactful and comprehensive
evaluation of identity and object relations pathology assessed by the SI as well as with the
fine-grained, articulated descriptions of the various domains of personality provided by the
STIPO could help clinicians to assess personality pathology according to the DSM-5
alternative model.
Conclusions and Clinical Implications

In conclusion, the object-relations based model of clinical interviewing provides an
organized, clinician-friendly and theory driven assessment of patients as individuals living in
a unique context, and not as embodied generalized traits. It offers a comprehensive evaluation
of personality (dys)function including assessment of: 1) symptoms and mental status; 2)
mental representations of self and others and quality of patterns of relatedness; and 3)
professional/work functioning and depth of friendship and intimate relations. Familiarity with
this theory-based assessment has the potential to spread the use of the proposed severity
indicator of DSM-5 Alternative Model for PDs, and to increase clinicians’ confidence in their
ability to evaluate their patients’ difficulties in Self and Interpersonal functioning.

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Table 1. Differentiation of Personality Organization (based on Kernberg, 1984; Caligor et al. 2007)
Structural Criteria Normal Neurotic Borderline Psychotic
Identity pathology.
Identity integration Consolidated identity. Consolidated identity. Identity pathology. Self and object
Sharply delimited self Sharply delimited self and Contradictory aspects of self representations are poorly
and object object representations and others are poorly delimited.
representations integrated and kept apart.
Defensive Operations Mature Defenses: Repression and higher level Splitting and lower level Defenses protect from
anticipation, defenses: reaction formation, defenses: disintegration and
suppression, altruism, isolation, undoing, Projective identification, self/object merging.
humor; Flexibility. intellectualization. idealization, omnipotence, Interpretation can lead to
Flexible adaptation Defenses protect against denial, devaluation regression
intrapsychic conflict Highly maladaptive and Extremely maladaptive and
Relatively adaptive but rigid rigid
introduce rigidity.
Reality Testing Capacity exists to Capacity exists to evaluate self Impairment of capacity to Capacity to test reality is
evaluate self and others and others realistically, in depth. evaluation self and other lost.
realistically, in depth Intact Reality Testing. realistically. Variable reality
Intact Reality Testing. testing
Table 2. Commonalities and Differences between Structural Interview and STIPO
SI STIPO
Examines personality pathology based on same theoretical model

Assesses identity pathology, use of defensive operations, object relations, aggression, moral
values and reality testing
Dynamic order of questions, following Follows 100 questions consecutively, no
circular model changes in order of questions
Covers present and chronic (dys)functioning Covers the last 5 years
Interviewer needs to know the underlying Interviewer can use questions that clearly
model well and ask appropriate questions operationalize each dimension of the
theoretical model
Interviewer can make use of clinical Interviewer uses clearly formulated anchors
inference for giving ratings on pre-defined scales
Uses clarification, confrontation, No clinical interventions apart from
interpretation clarifying and asking for examples
Provides clinical diagnosis of personality Yields scores on 7 domains and subdomains
organization (along with strengths and as well as level of personality organization
deficits evolving from the interview)
Note: SI= Structural Interview; STIPO= Structured Interview of Personality Organization.
Commonalities between the SI and the STIPO are italicized in the table.
Table 3. Level of Personality Organization and implications for treatment
Neurotic Use of treatmentTherapist Therapeutic Focus on

Personality frame operates from a techniques of present, related
Organization stance of clarification, to past
therapeutic confrontation,
neutrality interpretation
Borderline Treatment frame Therapist More extensive Focus on the
Personality includes a deviations from use of present
Organization carefully therapeutic clarification to
articulated neutrality are set the stage for
treatment used in certain interpretation
contract crises
Figure 1. Phases of the Structural Interview (from: Yeomans, Clarkin, & Kernberg, 2015)
Figure 2. Clinical personality profile based on STIPO Interview

Severity of Pathology:
STIPO Patient Profile 5= very severe pathology
4= severe pathology
Pre-Assessment (Clinical Ratings) 3= moderate pathology
2= slight pathology
1= absence of pathology
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Clinician-Guided Assessment of Personality Using the Structural Interview

Article in Journal of Personality Assessment · April 2017

Eve Caligor Emanuele Preti

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Clinician-guided assessment of personality using the Structural

Interview and the Structured Interview of Personality Organization

Susanne Hörz-Sagstetter, Psychologische Hochschule Berlin, Germany

Eve Caligor, Columbia University College of Physicians and Surgeons,

New York, USA

Emanuele Preti, University of Milano-Bicocca, Italy

Barry L. Stern, Columbia University Medical Center, New York, USA

Chiara De Panfilis, Università degli Studi di Parma, Italy

John F. Clarkin, Cornell University, New York, USA

This article demonstrates the utility of a theory-guided psychodynamic approach to the

assessment of personality and personality pathology based on the object relations-model

countertransference phenomena, while the more structured approach of the STIPO

planning and can rationally guide clinical decision-making.

Keywords: Object Relations, Clinical Interview, Structural Interview, Personality Disorder

Clinician-guided assessment of personality using the Structural Interview

Approaches to the assessment of personality and personality pathology in clinical

unstructured clinical interviews, employing their clinical experience and theoretical

background to evaluate personality functioning and pathology. Interviews of this kind

explicit prototypes developed through clinical experience and influenced by a particular

typically criterion-based, approaches to assessment of personality. Interviews of this kind

for example, borderline personality disorder or narcissistic personality disorder (e.g.

For this purpose, structured interviews or self-reports are frequently employed.

Disorders (DSM-5; American Psychiatric Association, 2013) attracted a new wave of

attention to the diagnosis of personality disorders (PDs). Surprisingly, the well-documented

limitations of a categorical approach to personality pathology (e.g., poor discriminant validity,

standard for personality disorder assessment according to DSM-5. Nevertheless, dimensional

This approach explicitly intended to favour a clinician-centered perspective in that it

personality functioning was regarded as more consistent with a clinician-guided approach to

diagnosis and treatment of PDs (First et al., 2002).

Thus, DSM-5 Section III proposes to dimensionally evaluate personality pathology

impairments in both establishing a sense of Self and in Interpersonal functioning (Bender,

(i.e., Interpersonal Functioning) along a continuum of severity/impairment (i.e., from 0= little

Zimmermann et al., 2012).

The goal of this article is to describe a clinically-based approach to the assessment of

personality functioning grounded in an object-relations-model of personality and personality

the Structured Interview of Personality Organization (STIPO), a more structured approach to

clinical interviewing, to demonstrate the clinical utility of both.

Theoretical Framework Forming the Base of the Interview Measures

The approach to clinical diagnosis described here is based in Kernberg's object-

developmental levels of internal object relations, representations of self in relation to other

linked through affect states.

During mental development, positively and negatively valenced internal object

diagnosed at a borderline level of personality organization. If contradictory internal object

developed and more flexible affect modulation will follow.

relations theory-based model of classification of personality pathology developed by

differentiates personality organization according to structural criteria (Kernberg, 1975; 1984).

continuum of severity of pathology. At the healthiest end of the spectrum is normal

personality organization, followed by neurotic personality organization (NPO) encompassing

personality pathology of relatively mild severity (e.g., DSM-based obsessive compulsive

what Kernberg refers to as borderline personality organization (BPO), encompassing the

severe personality disorders (e.g., DSM-based borderline personality disorder, antisocial

organization through (PPO).

In sum, borderline personality organization cuts across the DSM-based personality

disorders; borderline personality disorder is conceptualized as one of many personality