The Interplay Between Pathological Organizations and the Paranoid-Schizoid and Depressive Positions

In this paper I shall discuss some of the ways defences may be assembled into pathological organizations which have a profound effect on the personality and can lead to states of mind which become fixed so that the patient in analysis shows a characteristic lack of insight and resistance to change. I will emphasize the clinical importance of these organizations and try to show how they exist in an equilibrium with the paranoid-schizoid and depressive positions. I shall only briefly describe the characteristics of these positions since they are now well known, but I will emphasize transitions within them which are easy to overlook and which I believe are points at which the patient is particularly vulnerable to the influence of a pathological organization. Melanie Klein’s differentiation of two major groupings of anxieties and defences, the paranoid-schizoid and depressive, has proved to be a major conceptual tool which has made it easier to examine the way mental structures are organized at different levels of development (Klein, 1952); (Segal, 1964). This is an important technical aid since it helps us to orient ourselves to clinical material by enabling us to assess the level at which the patient is functioning. We can learn to evaluate whether his anxieties, mental mechanisms and object relations are primarily depressive or primarily paranoid-schizoid, and this will determine the way we interpret.