Structural Diagnosis – Seeing Beneath the Surface

Descriptive diagnosis tells us what a person has. Structural diagnosis tells us who a person is trying to be.

—Adapted from Otto Kernberg

Imagine two clients. Both meet criteria for Borderline Personality Disorder (BPD). Both have histories of trauma, engage in self-harming behavior, and describe chaotic relationships. But when you sit across from them, you notice something different. One feels deeply confused about who they are. The other is intensely controlling, rigid, even perfectionistic.

Both may carry the same DSM label, but they are not the same person, and they are not to receive the same treatment.

This is the problem with descriptive diagnosis: it categorizes, but it doesn’t clarify.

Transference-Focused Psychotherapy (TFP)[1] was designed to address this gap, using what’s known as structural diagnosis, a powerful tool that changes how we see, conceptualize, and ultimately treat the people in front of us.

What Is Structural Diagnosis?
Structural diagnosis doesn’t ask what symptoms a person has.[2] It asks:

• What is their capacity for identity integration?
• How well do they tolerate and regulate affect?
• What is their defensive structure?

Instead of starting with the DSM, TFP starts with psychic structure, specifically, the organization of internal representations of self and others.[3]

Kernberg’s tripartite model outlines three levels of personality organization:

1. Neurotic (integrated identity, mature defenses)
2. Borderline (identity diffusion, primitive defenses)
3. Psychotic (fragmented identity, reality testing impaired)

This framework is not about labeling, it’s about tailoring treatment to the person’s internal world. It tells us not only how deeply someone is suffering, but how they make sense of that suffering, and what kinds of interventions they’re developmentally equipped to tolerate.

Why It Matters
A descriptive diagnosis may tell you your client has “borderline personality disorder.”[4] But structural diagnosis helps you understand:

• Why they react so intensely to perceived rejection
• Why they split you into “good” or “bad” from week to week
• Why empathy alone may not be enough

More importantly, it helps you anticipate what will happen in the therapeutic relationship; because the way your client organizes their inner world will shape how they relate to you.[5] Without structural diagnosis, you may misread “resistance”, rush interpretation, or miss opportunities for deeper integration.

With it, you gain a compass.

The Clinician’s Eye: Signs of Identity Diffusion
How do we assess structural diagnosis in real time?

Here are a few signs of identity diffusion[6], the hallmark of borderline personality organization:

• The client shifts dramatically in how they view themselves and others
• They speak in global, contradictory terms (“I’m either a genius or a complete failure”)
• They idealize then devalue the therapist or people in their lives
• They have limited capacity to describe nuanced emotions or motivations
• Their internal world is full of “good” and “bad” parts, with little gray area

In TFP, we listen for representational themes. Is there a sense of continuity in their narrative? Are internal conflicts tolerated, or projected? Do they speak as a whole person, or as fragmented parts?

You don’t need a formal test. The story tells you everything.

From Understanding to Action: What Structural Diagnosis Guides Us To Do
Once you assess a client’s structural level, TFP helps you choose appropriate techniques and interventions:

• Neurotic level: Use interpretation and insight-building early on.[7]
• Borderline level: Focus on containment, transference analysis, and integration of split representations.[8]
• Psychotic level: Use simpler language, prioritize reality testing, and consider adjunctive supports.[9]

This is the brilliance of TFP: it helps us meet the client where they are, without pathologizing or infantilizing.

And it reminds us that real diagnosis is not about naming a disorder. It’s about understanding a person’s internal structure well enough to help them rebuild it, piece by piece, moment by moment, in the safety of the therapeutic relationship.

A Call to Depth: Join the Weekly Series
If this reframing resonates with you—if you’ve ever felt that labels alone don’t tell the full story—come learn how to use structural diagnosis in real time with your clients.

Watch out for the upcoming registration opportunities to join our 8-week, 1-hour series on Transference-Focused Psychotherapy, held live every Thursday.

Together, we’re not just treating diagnoses. We’re transforming internal worlds.

[1] Blüml, Victor. “Transference-Focused Psychotherapy.” 307.

[2] Levy, Kenneth N., Yogev Kivity, and Frank E. Yeomans. “Transference-focused psychotherapy: Structural diagnosis as the basis for case formulation.” Case formulation for personality disorders. Academic Press, 2019. 19-40.

[3] Clarkin, John F., Nicole M. Cain, and Mark F. Lenzenweger. “Advances in transference-focused psychotherapy derived from the study of borderline personality disorder: clinical insights with a focus on mechanism.” Current opinion in psychology 21 (2018): 80-85.

[4] Tardivo, Leila SP Cury. “The borderline personality structure in adolescents-a clinical case report.”

[5] Bauer, Stephen F., et al. “Borderline personality organization, structural diagnosis and the structural interview: A pilot study of interview analysis.” Psychiatry 43.3 (1980): 224-233.

[6] Sollberger, Daniel, et al. “Change in identity diffusion and psychopathology in a specialized inpatient treatment for borderline personality disorder.” Clinical psychology & psychotherapy 22.6 (2015): 559-569.

[7] Hersh, Richard G., Eve Caligor, and Frank E. Yeomans. “Fundamentals of Transference-Focused Psychotherapy.” Cham, Switzerland: Springer (2016).

[8] Yeomans, Frank E., John F. Clarkin, and Otto F. Kernberg. A primer of transference-focused psychotherapy for the borderline patient. Jason Aronson, Incorporated, 2002.

[9] Levy, Kenneth N., Frank E. Yeomans, and Daniel S. Spina. “Transference-focused psychotherapy.” (2022).