PERSONALITY DISORDERS INSTITUTEPERSONALITY DISORDERS INSTITUTE

Weill Medical College of Cornell UniversityWeill Medical College of Cornell University

Otto F. Kernberg, M.D., Directorg, ,John F. Clarkin, Ph.D., Co-Director

Eve Caligor, MD Kay Haran, PhDMonica Carsky, PhD Mark Lenzenweger, PhDJill Delaney, MSW Kenneth Levy, PhDy, y,Diana Diamond, PhD Armand Loranger, PhDPamela A. Foelsch, PhD Michael Stone, MD

Frank E Yeomans MDFrank E. Yeomans, MD

Axis II from a Personality Organization Point y gof View

Levels of OrganizationgA mixed Categorical and Dimensional System

1-Normal flexibility and adaptation2-Neurotic level of personality organizationp y g3-Borderline level of personality organization:

High level borderlineHigh level borderline Low level borderline

4 Psychotic level of personality organization4-Psychotic level of personality organization

Borderline Personality OrganizationBasic Characteristics

Identity Diffusion vs. integrated view of self and th (i t l f ti it )others (internal sense of continuity) No integrated concept of self

No integrated concept of significant others No integrated concept of significant others Primitive Defenses

Splitting Splitting Idealization/devaluation Projective identificationj Omnipotent control Denial

Variable Reality Testing

Reality Testing

Differentiation of self from non-self Internal from external realityy Empathy with social criteria of reality

AffectAffect Thought content Way of talkingy g

When evaluating this, look at whats inappropriate in affect, thought, behaviorpp p , g ,

Borderline Personality Organization:Borderline Personality Organization: Clinical Implications

Nonspecific ego weaknessLack of impulse control anxiety tolerance Lack of impulse control, anxiety tolerance

Disturbed object relations Difficulties with work and love Sexual pathology (Two levels: inhibition of p gy (

all sexual functioning; chaotic sexuality) Pathology of moral functioningPathology of moral functioning

Etiology of BPD A complex etiology: no single pathway Genetic Disposition, involving:Ge et c spos t o , vo v g:

Neurotransmitter Systems Abnormal Affectivity: Negative affects, aggression, and

b l t l f ff tabnormal control of affects Temperament

Object RelationsObject Relations Chronic chaotic relations and blurring of generational

boundaries Neglect Trauma/Abuse

Pathology of Attachment Pathology of Attachment

FIGURE 1

Relationship between familiar, prototypic, personality types and structural diagnosis.S f fSeverity ranges from mildest, at the top of the page, to extremely severe at the bottom.

Arrows indicate range of severity. Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of

Personality Disorders, 2nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.

Treatments for Borderline Personality Psychopharmacology

SSRIs, Low-dose Neuroleptics, Mood Stabilizers

Psychotherapyy py Cognitive Behavioral

Dialectical Behavior Therapy (Linehan)y Schema Therapy (Young) Others

Psychodynamic Supportive Psychotherapy (Rockland) Mentalization-Based Therapy (Batemen &Fonagy) Transference-Focused Psychotherapy

Theoretical Underpinnings of TFP:Theoretical Underpinnings of TFP:Object Relations Theory

Self OtherAffects

The Object Relations Dyad

Split Organization:Split Organization:Consciousness of all-good or all-bad

Normal Organization:Consciousness of

Integration/complexity

Transference

The activation of internal object relations in the relationship with the therapist.

These internalized relations with significant others are not literal representations of past relations, but

difi d b f i d d fare modified by fantasies and defenses. In borderline patients, internal object relations

have been segregated and split off from each other; include fantasied persecutory and idealized relations.

W ki ith bj t l ti th t ti t d i Working with object relations that are activated in the immediate moment creates a therapy that is experience-nearexperience near

The Relationship of Strategies, Tactics and Techniques

STRATEGIES

Long-Term Objectives

TACTICS: T kTACTICS: Tasksfor each Session that set the conditions for

TechniquesTechniques

TECHNIQUE: Consistent

interventions that address what happens fromhappens from

Moment-to-Moment

THE STRATEGIES OF TFP - ISTRATEGY 1: Defining the dominant object relationrelationStep 1: Therapist experiences and tolerates theconfusion of the patients inner world as it unfoldsin the transference

Step 2: Therapist identifies in his mind the object relation that is dominant in the moment

Step 3: Therapist names the actors as they are played out

Step 4: Therapist attends to the patients reaction

THE STRATEGIES OF TFP - IISTRATEGY 2: Observing and interpreting patient role reversals (the patient identifies with the entire relationship/dyad not just with one side of it)

STRATEGY 3: Observing and interpreting linkagesSTRATEGY 3: Observing and interpreting linkages between object relation dyads which defend against each other, with the goal of integrating the paranoid and idealized segments of experience This resolves identity diffusionsegments of experience. This resolves identity diffusion.

STRATEGY 4: Experiencing a relationship as different from the transference: working through the patients capacity to distinguish the transference from the real interpersonal relationship with the therapist and expanding e pe so e o s p w e e p s d e p d gthis to relationships outside the therapy.

Techniquesq The interpretive process:

Consists of clarifying, confronting, and interpretingy g g p g Is a means of enhancing mentalization

C d ti t f l i ( t ti Conducting transference analysis (systematic analysis of distortions in the relationship)

Managing technical neutrality (attitude of concerned objectivity; not drawn into patients problems)problems)

Utilizing countertransference awarenessg

The Techniques must be applied with attention to the

3 Channels of Communication3 Channels of Communication

1 the patients verbal communicationp2 the patients non-verbal communication3 the therapists countertransference3 the therapist s countertransference

Channels 2 and 3 are often the most important channels in the early phase of therapy with borderline patients

ClarificationClarification This technique is requesting clarification,

not offering clarificationnot offering clarification Provides material for interpretation by

clarifyingclarifying The patients perception of self in the moment The patients perception of the other/theThe patient s perception of the other/the

therapist This technique sheds light on the patients q g p

internal world and helps to elaborate distortions (i.e., enhances mentalization)

Confrontation

This technique is not a hostile challenge, but rather an honest inquiry into an apparent q y ppcontradiction in the patients verbal and non-verbal communication

It is an invitation for the patient to reflect on different aspects of the self that are split offdifferent aspects of the self that are split off from one another

Interpretation per seInterpretation per se A hypothesis about unconscious yp

determinants of present experience Interpretations address and attempt toInterpretations address and attempt to

resolve psychological conflicts Interpretations attempt to increase Interpretations attempt to increase

awareness of the impact of unconscious material on the patients thoughts affectsmaterial on the patient s thoughts, affects, and behaviors

Summary of the Interpretation Cycley p y Begins with efforts to help patient clarify his

conscious emotional experience in theconscious emotional experience in the transference, elaborating the particular representations of self and object respectively enacted and projected onto the analyst

Next, confronts the patient with his experience of this same object relation enacted in the transference at other times but with roles reversedS b l i i l li k id li d d Subsequently, interpretively links idealized and persecutory relations with the analyst that have been conscious but defensively split off by mutualbeen conscious, but defensively split off by mutual denial

TECHNICAL NEUTRALITY A therapist who intervenes from a position of

technical neutrality avoids siding with any of the forces involved in the patients conflictsp

Neutrality means maintaining the position of an observer in relation to the patient and hisan observer in relation to the patient and his difficulties

When working from a position of technical neutrality the therapist is aligned with the y p gpatients observing ego

DEVIATIONS FROM TECHNICAL NEUTRALITY:

INDICATIONSINDICATIONS

Th f f i Threat to safety of patient Threat to safety of othersy Threat to continuation of the treatment

C f i d i i f il Confrontation and interpretation fail to contain acting out

TECHNICAL NEUTRALITY

Technical neutrality is essential to therapists stance in TFP

Deviate only when patients acting out posesDeviate only when patient s acting out poses threat to patient, to others or to the treatmentR i li h li i i Reinstate neutrality when limit setting no longer needed

Unnecessary deviations from neutrality result from countertransferencefrom countertransference

DEFINING COUNTERTRANSFERENCECOUNTERTRANSFERENCE

Therapists total emotional reaction to patientp pCountertransference in the broad sense

Therapists transference to patientp pClassical view is therapist-focused

Therapists reactions to patients transferenceTherapist s reactions to patient s transferenceKleinian view is patient-focused

COUNTERTRANSFERENCE

Concordant IdentificationTherapist identifies with patients selfTherapist identifies with patient s selfexperience

Complementary IdentificationComplementary IdentificationTherapist identifies with patientsinternal and external objects

The TacticsSet Contract Set Contract To protect the survival of patient, therapist and

treatment To eliminate secondary gain of illness

Maintain the frame and boundaries of treatment to control acting outco o ac g ou

Select the focus of attention and intervention Attend to what is affectively dominant

A d h i i h f Attend to what is in the transference Attend to the general priorities of treatment

Maintain common perceptions of realityp p y Analyze both positive and negative transferences Regulate the intensity of affective involvement

Functions of the Contract1. Defining patient and therapist responsibilities 2 P t ti th i t bilit t thi k l l2. Protecting therapists ability to think clearly 3. Providing a safe place for the patients

dynamics to unfold4. Setting the stage for interpreting the meaning of

deviations from the contract 5. Providing an organizing therapeutic frame that5. Providing an organizing therapeutic frame that

permits therapy to become an anchor in the patients lifepat e t s e

Examples of Threats to the Treatmentp

Suicidal and self-destructive behaviorsH i id l i l i i l di h i h Homicidal impulses or actions, including threatening the therapist

Lying or withholding of informationy g g Substance abuse Eating disorder - uncontrolled

P tt d Poor attendance Excessive phone calls or other intrusions into the

therapists life Not paying the fee or arranging not to be able to pay Problems created external to the sessions that interfere

with therapywith therapy A chronically passive lifestyle, favoring secondary gain of

illness

HIERARCHY OF THEMATIC PRIORITY - I Obstacles to Transference Exploration Resistances to

explore suicide or homicide threats Threats to treatment continuity (inc. financial probs,

plans to move, requests to meet less often)di h t d lib t ithh ldi i i ( dishonesty or deliberate withholding in sessions (e.g., lying to the therapist, refusing to discuss certain subjects, silences occupying most of the sessions)

contract breaches (e.g., failure to act on other parts of treatment such as AA, failure to take prescribed meds)

in-session acting out (e.g., abusing office furnishings, g ( g , g g ,refusing to leave at the end of the session, shouting)

narcissistic resistancesnon lethal between session acting out non-lethal between-session acting out

non-affective or trivial themes

Dynamics of Separation and Termination

Narcissistic dynamics denial of the importance of the other; devaluing.

Paranoid dynamics separation as an y pattack/rejection: Im being thrown out and/or Im getting away from the enemy.g g y y

Depressive dynamics guilt: Ive depleted the supplies this person can offer me;the supplies this person can offer me ; Im not worthy.

Psychopharmacology

Overall approach Reduce unnecessary medication use Medicate target symptoms Understand the dynamics of medicating

Algorithms: Three Paranoid/suspiciousness, mild thought disorder,

hallucinations dissociationhallucinations, dissociation Depressed/angry/anxious/labile mood Impulsive aggression, self-injurious behavior, bingesImpulsive aggression, self injurious behavior, binges

A ti t l i i l fi t i t t th t li it

TREATMENT COMPLICATIONS Acting out--general principle: first interpret, then set limits

----------------------------------------------------- Suicide and parasuicidep Eating disorders, substance abuse, antisocial

behavior/psychopathic transference all need containment, extra frameextra frame

---------------------------------------------------- The threat of drop-out Affect storms overt and silent Paranoid regression/micro-psychotic episodes Dissociative reactions a form of splitting Dissociative reactions a form of splitting Erotization Severe hatred in the transference: syndrome of arrogancey g Hospitalizations

Conceptualization of the pathology Conceptualization of the treatment and clinical

testing Manualization of treatment Therapist training to adherence and competence Preliminary data with effect sizes

R d i d ll d i l Randomized controlled trial Investigation of moderators and mediators

G li bilit f t t t ( ti t t Generalizability of treatment (patients not excluded; treatment in community; transport to another setting)

Three structured treatments (TFP, DBT, SPT) are related to significant change in multiple domains

di i f i ifi i i TFP was predictive of significant improvement in 6 domains; DBT predictive in 4; SPT in 5.I di t t t l l h i i id l In direct contrast analyses, only change in suicidal behavior trended to favor TFP and DBT over SPT

Clarkin Levy Lenzenweger & Kernberg 2007Clarkin, Levy, Lenzenweger & Kernberg, 2007

DBT: borderline patients change by learning affect regulation skills in the g gcontext of validation (Linehan)

MBT: borderline patients change by p g yincreasing mentalization (Bateman & Fonagy)

TFP: borderline patients change by integrating representations of self and

h d l d ff (K b )others and related affects (Kernberg)

Reflective Function is defined as the capacity to think or mentalize in terms ofcapacity to think or mentalize in terms of mental states (emotions, intentions, motivations) in understanding self andmotivations) in understanding self and other.

-1 Rejection, unintegrated, or inappropriate RF1 Disavowal distorted/self serving1 Disavowal, distorted/self-serving3 Naive simplistic or over-analytic/hyperactive5 Ordinary or inconsistent (fairly coherent)7 Marked 9 Exceptional (complex, elaborate)

4 14.34.5

3.73.94.1

TFP

3 13.33.5 DBT

SPT

2.72.93.1

2.5RF Time 1 RF Time 2

TFP vs Treatment in CommunityTFP vs. Treatment in Community (Doering, et al, 2009)

Study sites: Munich, Germany and Vienna, Austria

104 female BPD outpatients randomized to TFP or experienced communityTFP or experienced community psychotherapists (ECP)

Treated for one year Treated for one year

Results

TFP had significantly fewer dropouts (38.5% vs. 67.3%)

TFP superior in reducing BPD symptoms, improving psychosocial functioning, improving personality organization, and reducing inpatient admissions

Both groups improved significantly in depression and anxiety