I had to seriously redo the first part of my introduction, but now I just cant see if it still makes sense or not. Going over the same text over and over makes you blind to stuff.
Is this piece of text still logical and understandable? (esp first two paragraphs?)
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Mental health care patients with one and the same DSM-IV (Diagnostic and Statistical Manual of Mental Disorders – 4th ed.; American Psychiatric Association, 1994) classification may differ considerably concerning underlying dynamics, etiopathogenic characteristics (Luyten & Blatt, 2007; Westen, Sheldler, & Bradley, 2006) and trait profiles. Therefore no psychological or psychopharmacological treatment has an efficacy of 100% for any single disorder and consequently one particular treatment protocol might not work for every patient (van Kalmthout, 2008). One can imagine that when a patient does not match the profile on which the treatment protocol was based, this may result in an unsuccessful treatment or a treatment that lasts longer than expected and thus in a more costly treatment and prolonged suffering for the patient.
The (false) assumption of homogeneity was already recognized almost 50 years ago as the ‘assumption of uniformity’ or the idea that “patients at the start of treatment are more alike than they are different” (Colby, 1964, p. 359) while in fact patients are “much more different than they are alike” (Kiesler, 1966, p. 111)). In other words: Using only manifest phenomena, such as in the descriptive/categorical diagnosis of the DSM-IV, which underscores high reliability at the cost of validity (Gray, 2007), does not result in homogeneous groups. Because of the differences between patients with one and the same classification clinicians should not solely rely on the descriptive/categorical assessment of the DSM-IV, but also on the structural/dynamic assessment (Kernberg & Caligor, 2005) as is currently acknowledged in the new proposals for the assessment of personality pathology for DSM-5 (see
www.DSM5.org; Skodol et al. 2011).
Structural/dynamic assessment is largely based on psychodynamic theory and assumes personality has an organization (Westen, 2000). This concept of personality organization describes the interdependency of affects, motives, cognition and behavior (Westen, 2000) and finds it’s origin in infancy when the perception of self and others develops by (partially) completing two tasks: In the earliest stages of a child’s development the child does not yet see a distinction between itself and the world around it: the whole world is an extension of itself, fulfilling all of its needs. The first task in the formation of identity is learning to make the distinction between self and objects - significant others, such as parents and/or caregivers, who appear to have their own needs and goals. The second task in the development is the integration of good and bad aspects of objects and of the self: the contradictory positive and negative affects which are at first seen as two different objects (‘splitting’) are integrated in whole entities that have both good and bad qualities (Mitchel & Black, 1995; Eurelings-Bontekoe, Onnink, Williams, & Snellen, 2008). According to Kernberg (1994) the strength of the personality structure depends on how well these developmental tasks have been accomplished. The outcome of these developmental tasks can be measured using three dimensions: identity integration vs. identity diffusion, defense mechanisms (predominantly mature/neurotic vs. predominantly primitive) and reality testing (absent, frail or good) (Kernberg & Caligor, 2005; Eurelings-Bontekoe, et al., 2008). These dimensions can be used to distinguish three personality organizations: neurotic (NPO), borderline (BPO) and psychotic (PPO; Kernberg, 1975), where the NPO represents the strongest and the PPO the weakest personality structure.
