By employing primitive defense mechanisms such as denial, splitting, projection, projective identification, omnipotence, Barbara split off the bad mother image and was thereby able to continue her relationship to mother. However, her conduct vis a vis mother was one of complete helplessness and masochistic submission: always explaining away, or denying, mother's bad behavior and justifying mother's aggression towards her. Barbara's internal self representation was also split into two elements, reflecting a good and a bad self. The bad self was equated with her femaleness and needed to be denied, split off, and projected outwards. The good self, that is, her male element, developed independently, shielding Barbara from the destructive potential of her female self (which threatened to engulf and destroy her).

By employing primitive and rigid defense mechanisms Barbara could appear confident, headstrong, cocky, and self assured. Indeed, her girlfriends responded to these aspects of Barbara's personality as if she were a strong masculine figure. While these defenses had an adaptive function, they also severely impaired her ability to reality test (especially when she was under stress). Indeed, Barbara had difficulty organizing and synthesizing percepts (for which she substituted a rigid, dogmatic adherence to a false belief which, conveyed with conviction, could easily disarm her adversary into believing that she was correct).

Barbara's ultimate defense against her inner anxiety was either to employ splitting or to use projection and externalize her inner conflicts. It was her use of projective identification, and its integration into her character structure, which made it all but impossible for Barbara to make effective use of psychotherapy leading to personality changes.

Barbara's good object, that is, her father image, was over idealized and invested with a kind of magical quality, protecting Barbara from being engulfed by her abandonment depression and feared homosexual involvement with mother. Maleness was associated with elation, euphoria, mania (a denial of inner reality), and optimism (a will to stay alive). Barbara enjoyed the kinesthetic sense of maleness, that is, feeling alive through the exercise of her muscles. Maleness became associated with control, power, hope, and life; femaleness was equated with hopelessness, powerlessness, and vulnerability to harm.

Barbara's exposure to chaotic, often overwhelming sexual and aggressive stimuli disorganized her perceptions and left her vulnerable to severe ego impairment and a subtle, but pervasive, thought disorder. Barbara was especially deficient in those ego functions related to judgment. While she was always making snap decisions (with an air of authority and confidence), her judgment was usually poor. She vacillated between making rigid moral judgments which seemed like categorical imperatives, and an apparent lack of any moral consideration, in which every possible behavior was acceptable. Indeed, her decision making processes were markedly impaired and her superego poorly developed. Barbara was not able to internalize moral norms and standards because of the instability of her object world. She viewed all behaviors as equally viable and judged things in terms of the pleasure they afforded her. Her integrative skills were also impaired. Further, there was evidence of serious ego defects concerning stimulus barrier, frustration tolerance, delay of gratification, and impulse control. Barbara externalized all of her conflicts and experienced little anxiety about her life style. Because of her defensive use of projection and externalization, she rarely experienced anxiety about her life situation. However, when she was stressed through a separation, death, or abandonment, her anxiety emerged full force. At those times she became panicky, agitated, confused, disorganized, clinging, frightened, whiny, and symptomatic. (see THE FORMULATION OF BARBARA'S DIAGNOSIS OF TRANSSEXUALISM PART IV)