An Object Relations Treatment for Borderline Pathology

1
An Object Relations Treatment for Borderline
Pathology

• John F. Clarkin
• Cordoba, Spain 2009

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PERSONALITY DISORDERS INSTITUTEO. Kernberg,
DirectorJ.F. Clarkin, Co-DirectorM.
LenzenwegerK. LevyM. StoneM. PosnerF. Yeomans

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Empirical Support for Clinical Change in
Borderline Patients

• DBT vs. TAU (Linehan et al., 1991 1999)
• MBT vs. TAU (Bateman Fonagy, 1999)
• TFP compared to DBT, Supportive Treatment
  (Clarkin, et al, 2007)

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However, Many Remaining Issues

• In all trials, about 60 patients improve
  symptomatically who does not respond and why
  not?
• Existing treatments reduce symptoms, but love and
  work still defective
• Maintenance of treatment gains
• Subgroups of BPD patients suicidal (Linehan)
  other subgroups and their treatment needs?
• Randomized clinical trials do not reveal
  information about how treatments work

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Therefore, This Talk

• 1. An object relations treatment--TFP-- reduces
  symptoms
• 2. Mechanisms of change in TFP
• 3. Subgroups of BPD patients

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1. TFP Reduces Symptoms RCT

• Object relations approach to BPD pathology
• Treatment structured by a contract, consistent
  focus
• Sessions 2 times a week for a year or more
• Principle driven treatment, manualized
• Out-patient TFP combined with medication

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RANDOMIZED CONTROLLED TRIAL(Clarkin, et al., 007)

• Male and female BPD, ages 18 to 50
• Inclusion criteria Axis II BPD
• Exclusion criteria Schizophrenia, Bipolar
  Disorder, Eating Disorder and Substance
  Dependence
• Randomized to one of three treatments
• If indicated, medication by algorithm
• Assessment at four points in time during one year
  of treatment

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Patients

• 90 patients (83 Women and 7 Men)
• Mean Age 30.9 (S.D. 7.85)
• Marital status
• 7.7 Married, 12.2 Living with partner, 44.4
  Divorced, 23.3 In relationship
• Education
• 4-year college degree (any college) 32.2
  (63.3)
• Employment
• Employed (fulltime) 64.4 (33.3)
• Ethnicity/Race
• 67.8 Caucasian, 10.0 African-American, 8.9
  Hispanic, 5.6 Asian, 3.3 mixed ethnicity/race,
  4.4 other

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Sample characteristics and context

• Mean Axis II 2.5
• Par 26
• Szd 0
• Szt 3
• Asp 21
• His 24
• Nar 18
• Avd 31
• Dep 11
• O-C 14

• Mean Axis I 3.8
• MDD 48 (any mood) 78
• Anxiety 55 (PTSD) 16
• Eating d/o 34
• Substance 38
• Suicide
• Attempts 57
• Self destructive 64
• Either 83

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Change in 6 Domains Effect Sizes(Clarkin et al,
2007, Amer J Psychiatry)
Suicidality Anger Impulsivity Anxiety Depression Social Adj
TFP 0.33 (0.01) 0.44 (0.001) II 0.36 (0.005) 0.37 (0.004) 0.50 (0.001) 0.28 (0.03)
DBT 0.34 (0.01) NS NS 0.50 (0.001) 0.38 (0.003) 0.44 (0.001)
SPT NS 0.28 (0.05) III 0.31 (0.02) 0.48 (0.001) 0.49 (0.001) 0.59 (0.001)
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Summary

• Three structured treatments (TFP, DBT, SPT) are
  related to significant change in multiple domains
• TFP was predictive of significant improvement in
  6 domains DBT predictive in 4 SPT in 5.
• In direct contrast analyses, only change in
  suicidal behavior trended to favor TFP and DBT
  over SPT
• Clarkin, Levy, Lenzenweger Kernberg, 2007

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However, Little Evidence For How These Treatments
Work

• it is difficult to ascertain whether outcomes
  are attributable to the structured nature of the
  programs or the therapeutic orientation and
  models which they employsince clinicians working
  in this area are clear about the importance of
  offering structure for these patients,
  disaggregation of structure from orientation is
  clearly not an option. Bateman Fonagy.

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2. How Does TFP Work?
ORIENTATION THERAPIST PATIENT
DBT Mindfulness Behavioral targeting Chain analysis Exposure, response prevention, extinction of ineffective emotional responses learning of new skillful responses to emotional stimuli
Supportive (SPT) Focus supporting patients defenses, coping Identification with therapist utilize support and suggestions
TFP Containment of action by contracting clarification, confrontation, interpretation of here-and-now interaction Growing integration of representations of self and others
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Derivatives of Object Relations Theory
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Essential Related Concepts
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Self
Other
Affects
Object Relations Dyad
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Reflective Function (Fonagy, Target, Steele,
Steele, 1998)

• Reflective Function is defined as the capacity to
  think or mentalize in terms of mental states
  (emotions, intentions, motivations) in
  understanding self and other.
• RF rated on specific items of the Adult
  Attachment Interview (AAI)

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Reflective Function Scale (Fonagy, Target,
Steele, Steele, 1998)

• -1 Rejection, unintegrated, or inappropriate RF
• 1 Disavowal, distorted/self-serving
• 3 Naive simplistic or over-analytic/hyperactive
  
• 5 Ordinary or inconsistent (fairly coherent)
• 7 Marked
• 9 Exceptional (complex, elaborate)

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Change in RF as a Function of Time and Treatment
(Levy et al, 2006)
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3. Subgroups of BPD Patients

• Object relations theory of severity of
  personality organization posits three levels of
  severity Neurotic Organization, High Level
  Borderline Organization, Low Level Borderline
  Organization
• Each level has Internalizers and Externalizers

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Personality Organization
  Figure 1 Relationship between familiar,
prototypic, personality types and structural
diagnosis. Severity ranges from mildest, at the
top of the page, to extremely severe at the
bottom. Arrows indicate range of severity.   We
include avoidant personality disorder in
deference to the DSM. However, in our clinical
experience, patients who have been diagnosed with
avoidant personality disorder ultimately prove to
have another personality disorder that accounts
for avoidant pathology. As a result, we question
the existence of avoidant personality as a
clinical entity. This is a controversial
question deserving further study.  
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Finite Mixture Modeling Groups of BPD Patients
Antisocial Paranoia Aggression
Group I Low Low Low
Group II Moderate High Low
Group III High Moderate High
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Associated Features of the Three Groups

• Group I high Constraint, high Social Closeness,
  low Physical Abuse, low Depression and
  Somatization
• Group II low Social Closeness, high Sexual Abuse
• Group III high Negative Affect, low Constraint,
  high Depression and Somatization, high Identity
  Diffusion

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PPI Factors 1 and 2
FACTOR 2. Impulsive Antisociality Frequency T Scores gt 60 Percentage
Impulsive Non Conformity 13 14.4
Blame Externalization 15 17
Care Free 17 19
Egocentrism Machiavellism 15 17
FACTOR 1. Fearless Dominance Frequency T Scores gt 60 Percentage
Social Potency 11 12.5
Stress immunity 10 11
Fearlessness 13 14.7
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Internalizers and Externalizers (Krueger, et al.
2000) Grp 1 vs 3
Low Aggression (MPQ) High Aggression
Low Impulsiveness (MPQ) High Impulsiveness
High Constraint (MPQ) Low Constraint
Low Factor 1 (PPI) High Factor 1 (PPI)
Low Factor 2 (PPI) High Factor 2 (PPI)

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Principles of Treatment Related to Pathology

• 1. Focus the treatment on the here-and-now
• a. Present focused
• 2. The here-and-now between patient and therapist
  is a social situation
• a. Define the situation contract
• b. Responsibilities of both parties
• 3. Therapist gives space for the patient to
  reveal internalized conceptions of self and
  others
• 4. Therapist response to patients conception of
  self-therapist and related behavior is
  constructed to help patient reflect (not react),
  re-appraise

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So, How Do We Expect BPD to Relate in the
Here-and-Now?

• 1. Internalized representations of self and
  others that are disturbed in some fashion
• 2. Anxious attachment either hyper or hypo
  activating
• 3. Perception influenced by negative affect

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1. Internal Representations

• CAPS model of normal personality (Mischel
  Shoda) cognitive-affective units
• Object relations theory (Kernberg) object
  relations dyads
• Attachment theory internal working model
  (Bowlby)
• Cognitive theory schemas (Beck)

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Four Aspects of Psychological Processing

• Organized pattern and sequence of activation of
  cognitive-affective mental representations
• Behavioral expressions of individuals processing
• Perceptions of self across situations
• Particular environments the individual seeks out
  and constructs
• Mischel Shoda, 1999

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Normal OrganizationConsciousness of
Integration/complexity
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Split OrganizationConsciousness of all-good or
all-bad
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Patients Internal World
.
S1
a1
O1

• S Self-Representation
• O Object - Representation
• a Affect
• Examples
• S1 Weak mistreated figure
• O1 Harsh authority figure
  
• a 1 Fear
• S2 Childish-dependent figure
• O2 Ideal, giving figure
• a2 Love
• S3 Powerful, controlling figure
  
• O3 paralyzed, controlled figure
• a3 Wrath

S2
O2
a2
O3
a3
S3
Etc.
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TRANSFERENCE,and the power of Internal World
over External Reality ExRB

• Experience of Self

• and of Therapist

S1
S1
O1
a1
S2
S2
a2
O2
S3
O3
S3
a3
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OBJECT RELATION DYAD INTERACTIONS OSCILLATION
Self-Rep
Object Rep
Fear, Suspicion, Hate
Persecutor
Victim
Fear, Suspicion, Hate
Persecutor
Victim
(Oscillation is usually in behavior, not in
consciousness)
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OBJECT RELATION DYAD INTERACTIONS ONE DYAD
DEFENDING AGAINST ANOTHER
Fear, Suspicion, Hate
Abuser
Victim
Opposites
Longing, Love
Gratifying Provider
Dependent Child
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Clinical Example of Oscillation

• Observe
• Engage the patients observation
• Interpretive process
• If you see me that way, it would make sense
• Its hard to see/accept that in yourself
• We agree on the affect, but not on its source
• If you can acknowledge it, youre in a position
  to control and master it.

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Steps of Interpretation

• Understand/Identify self state in the moment
• Elaborate understanding of the therapist
• Consider therapists experience of the moment,
  and that it may be different from the patients
• Contrast the immediate experience of self and of
  therapist with that at other times (address
  splits)
• Consider reasons for splits
• Put the above in the context of other relations

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2. Anxious (Insecure) Attachments

• Many have noted the relationship between
  features of BPD (unstable, intense relations
  feelings of emptiness affect storms, chronic
  fears of abandonment, intolerance of aloneness)
  and insecure attachment
• We have used instruments related to attachment
  theory (ECR, AAI, RF) to further our research
  questions

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High Anxious Low Anxious
Internal lt-- --gt External
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Primary Attachment Strategy

• Proximity seeking is the natural and primary
  strategy of the attachment behavioral system when
  a person needs protection or support.
• In infancy, these strategies involve crying,
  reaching out to be picked up, etc.
• In adults, these strategies can include active
  mental representations of relationship partners
  who provide care, protection. Representations of
  self include sense of security, self-soothing.

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Goal-corrected Operation of the Attachment System

• Person evaluates progress he/she is making toward
  proximity/protection then, if necessary,
  corrects his/her behavior to achieve the goal of
  proximity/protection.
• This goal-corrected operation requires the
  internalization of mental representations of self
  and the environment.
• These working models 1) allow for prediction of
  social outcomes, 2) they are provisional and can
  be changed

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Security and Secondary Strategies

• Security the world is safe attachment figures
  are helpful when called upon it is possible to
  explore the world curiously and confidently
• If there is not a sense of security, secondary
  strategies are utilized (Main 1990)
• Hyperactivating strategies get an attachment
  figure, viewed as unreliable or unresponsive, to
  pay more attention
• Deactivating strategies keep the activation
  system turned off to avoid frustration and
  disappointment by attachment figure unavailability

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First Module
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Second Module
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Third Module
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Hyperactivating Strategies Based on An Internal
Working Model

• Vigilance about possible threats
• Exaggerated appraisals of threats
• Rumination about previous and merely possible
  threatening experiences
• Emphasis on the urgency of gaining a partners
  attention, care, support
• Overdependence on other for comfort
• Excessive demands for attention and care
• Strong desire for enmeshment or merger
• Attempts to minimize cognitive, emotional, and
  physical distance from other
• Clinging or controlling behavior designed to
  guarantee others attention and support

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Deactivating Strategies Based on An Internal
Working Model

• Diversion of attention away from threats
• Denial of attachment needs
• Suppression of threat-related thoughts
• Compulsive self-reliance
• Control and maximize psychological distance from
  the other
• Avoid interactions that involve emotional
  involvement, intimacy, self-disclosure,
  interdependence
• Reluctance to think about or express personal
  weakness and relational conflicts
• Suppression of fears related to rejection,
  separation, abandonment

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3. Perceptions Influenced With Negative Affect

• Borderlines experience more negative affect than
  positive affect
• This tendency to infuse perceptions with negative
  affect can be examined in experimental designs

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Emotional Stroop Task (Silbersweig, Clarkin et
al, 2007)
POSITIVE VERBAL STIMULI Go No-go
NEUTRAL VERBAL STIMULI Go No-go
NEGATIVE VERBAL STIMULI Go No-go
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Behavioral Results

• Patients rated negative words more negative
• Longer reaction times for patients during no-go
  blocks
• Greater errors of omission for patients during
  no-go and negative no-go
• Greater errors of commission for patients under
  negative no-go condition

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Neuroimaging Results

• Behavioral inhibition and negative emotion
  Patients manifested decreased ventromedial
  prefrontal (medial orbitofrontal, subgenal
  anterior cingulate) activity
• Behavioral inhibition and negative emotion
• Patients manifested decreasing vetromedial
  prefrontal increasing extended amygdalar-venral
  striatal activities
• These activites signficantly correlated with
  trait measures (MPQ) of decreased constraint and
  increased negative emotion

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Discussion

• OFC lesions/dysfunction associated clinically
  with socio-emotional dyscontrol
• In BPD, a bias toward intense negative feelings
  may dominate the process coupled with failure of
  top-down control
• Negative affective memories/states may propel
  behavior, unchecked by evolving socioemotional
  contexts

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Rupture Repair of Cooperation in BPD
(King-Casas et al, 2008)

• Investment task healthy investor and healthy
  trustee vs. healthy investor and BPD trustee
• E.g., if investor sends 20 to trustee, and
  trustee splits the tripled investment (60) with
  investor, both profit.
• As game went on, BPD trustees broke cooperation
  by keeping large portion of the investment
• Neural correlates of the failure in cooperation
  bilateral anterior insula in BPD insensitivity
  to offer level size low offers from partners do
  not violate the social expectations of the BPD
  subjects

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Implications
Persecuting Object
Victimized Self
Affect State
Hypervigilant Anxiety

• The affect state of anxiety and hypervigilance
  associated with HPA hyperreactivity is linked to
  a specific internal object relationship involving
  a persecuting object and a victimized self.
• (Gabbard,2005)

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Principles of Intervention that Arise from the
Pathology

• 1. Focus the treatment on the here-and-now
• 2. The here-and-now between patient and therapist
  is a social situation
• 3. Therapist gives space for the patient to
  reveal internalized conceptions of self and
  others, and current life reality
• 4. Therapist response to patients conception of
  self-therapist and related behavior is
  constructed to help patient reflect (not react)
  and question and re-appraise

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Borderline Functioning That Influences Focus of
Intervention

• Meager, conflicted representation of self
• Incomplete, inadequate understanding of others
• Anxious attachment to others
• Primitive defenses leading to splitting, rapid
  shifts in views of others
• Intense affect with affective shifts
• Varying degrees of externalizing symptoms, e.g.,
  ETOH and drug abuse, aggressive behaviors,
  antisocial behaviors

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1. Focus the Treatment on the Here-and-Now

• Patient instructed in contract setting to talk
  freely about problems, concerns, what on
  patients mind
• Patient may talk of past, therapist listens,
  brings the reference back to present

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2. The Here-and-Now of Patient-Therapist is a
Social Situation

• Two people meeting
• Similar to and different from a usual social
  situation
• Contract between the two defines the situation
• Session frequency (2 times a week) set to
  increase salience of therapist in patients life

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BEGINNING TREATMENT
History Sessions
Contracting Sessions
Family Session
Therapy
Pre-Therapy
Therapy Begins (or not)
N.B. 1 Often a Sense of Urgency 2 Avoid
interpretations, unless absolutely necessary
Goal To move from Acting Out to Transference
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Contract Setting Functions of Contract

• 1. Defining patient and therapist
  responsibilities
• 2. Protecting therapists ability to think
  clearly
• 3. Providing a safe place for the patients
  dynamics to unfold
• 4. Setting the stage for interpreting the meaning
  of deviations from the contract
• 5. Providing an organizing therapeutic frame that
  permits therapy to become an anchor in the
  patients life

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Contract Standard Content

• Patient Responsibilities
• Attendance and participation
• Paying fee
• Reporting thoughts and feelings without censoring
• Therapist Responsibilities
• Attending to the schedule
• Making every effort to understand and, when
  useful, to comment
• Clarifying the limits of the therapists
  involvement (for patients with earlier
  experiences of challenging boundaries)
• Predicting Threats to the Treatment, and
  establishing parameters to address them

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Treatment Contracting Process

• Therapist presents a part of the contract
• Patient responds to those conditions of treatment
• Therapist pursues elaboration of patients
  response
• Consensus -- or not

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Examples of Threats to the Treatment

• Suicidal and self-destructive behaviors
• Homicidal impulses or actions, including
  threatening the therapist
• Lying or withholding of information
• Substance abuse
• Eating disorder - uncontrolled
• 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 therapy
• A chronically passive lifestyle, favoring
  secondary gain of illness

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3. Therapist Creates Space, Patient Reveal
Representations of Self/Others

• Three avenues of communication
• Patients communication can be confusing
  therapist uses object relations theory to
  understand what is going on
• Therapist looks for implicit and explicit
  references to patients reaction/conception of
  therapist
• Extensive use of clarification and confrontation
  to encourage patient to reveal conceptions

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The Initial Situation
A Sense of confusion or chaos in the Session
Patient
Therapist as Perceived by the Patient
Fragmented part self and object representations
are activated in rapid succession. The tactics
and techniques of TFP help the therapist make
sense of the chaos and use it interpretively.
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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 are 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.
• Working with object relations that are activated
  in the immediate moment creates a therapy that is
  experience-near

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How Do Treatments Address Patient/Therapist
Interaction?
Treatment Orientation Conception Therapist Behavior
DBT Therapy interfering behavior Patient task to get therapist to continue
MBT Deficit in mentalization skills Mentalizing
TFP Transference Clarification, confrontation, interpretation
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Transference Interpretation

• Transference is the activation of internal
  object relations leads to the activation of
  affects and conflicts
• Basic technique
• to tease out these internal relationships,
• to help the patient
• Tolerate awareness of these internal relations,
• Integrate them into a coherent whole, and
• Generalize the experience in therapy to other
  relations

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Patients Internal World
.
-S1
-a1
-O1

• S Self-Representation
• O Object - Representation
• a Affect
• Examples
• S1 Meek, abused figure
• O1 Harsh authority figure
  
• a 1 Fear
• S2 Childish-dependent figure
• O2 Ideal, giving figure
• a2 Love
• S3 Powerful, controlling figure
  
• O3 Weak, Slave-like figure
• a3 Wrath

S2
O2
a2
-O3
-a3
-S3
Etc.
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TRANSFERENCE the immediate experience of self
and other

• Experience of Self

• and of therapist

S1
S1
O1
a1
S2
S2
a2
O2
S3
O3
S3
a3
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OBJECT RELATIONSHIP INTERACTIONS OSCILLATION
Object Rep
Self-Rep
Fear, Suspicion, Hate
Persecutor
Victim
Fear, Suspicion, Hate
Persecutor
Victim
(Oscillation is usually in behavior, not in
consciousness)
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OBJECT RELATIONSHIP INTERACTIONS DEFENSE
Fear, Suspicion, Hate
Persecutor
Victim
Opposites
Longing, Love
Perfect Provider
Cared-for Child
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Dyad Defending Against DyadExample
Untrustworthy, but Needed Tool
Tiger Lady
Desperately Needy Child
Perfect Provider
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ILLUSTRATIVE ROLE PAIRS FOR PATIENT AND
THERAPIST
Unwanted, deprived child Absent, neglecting
parent Defective, worthless child Contemptuous
parent Threatened, abused victim Sadistic
attacker/persecutor Controlled, enraged
child Controlling parent Attacking, angry
child Controlled, submissive parent -------------
-------------------------------------------------
It must be remembered that the role pairs
alternate. The therapist and the patient
become, in turns, the depositories of part self
and object representations. Often the parents
are not clearly differentiated as a mother and
father, but are merged as a single parent
fragment.
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Illustrative role pairs. Contd

• Naughty, sexually excited child Seductive parent
• Dependent, gratified child Perfect provider
• Child longing to be loved Withholding parent
• Controlling, omnipotent self Impotent parent
• Friendly, submissive self Doting, admiring
  parent
• Aggressive, competitive self Punitive, sadistic
  parent

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4. Therapist Response to Patients Revelation of
Internal World

• Therapeutic neutrality
• Change processes the Interpretation Process

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Transference Interpretation Process

• Conceptualized as a series of interventions that
  build on one another
• May take many sessions to complete a single cycle
  of interpretation, or
• May have many completed cycles in one session

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Clarification

• This technique is requesting clarification, not
  offering clarification
• Provides material for interpretation by
  clarifying
• The patients perception of self in the moment
• The patients perception of the other/the
  therapist
• This technique sheds light on the patients
  internal world and helps to elaborate
  distortions

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Confrontation

• This technique is not a hostile challenge, but
  rather an honest inquiry into an apparent
  contradiction in the patients communication
• It is an invitation for the patient to reflect
• It is assumed that the different elements of the
  contradiction represent aspects of the self that
  are split off from one another

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Confrontation

• The contradiction can be within one channel of
  communication You said earlier that I was a
  terrific therapist, now youre saying Im
  worthless.
• Or the contradiction can be between different
  channels of communication Youre saying youre
  furious, but youre looking at me with a smile.

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Interpretation

• A hypothesis about unconscious determinants of
  present experience
• It attempts to increase awareness of the impact
  of unconscious material on the patients
  thoughts, affects, and behaviors
• Interpretations address and attempt to resolve
  psychological conflicts

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Interpretation with Borderline Patients

• In borderline patients, conflicts are based on
  the lack of identity integration and are
  manifested in the diverse dyads that emerge in
  the transference
• Interpretations attempt to explain the
  motivations for maintaining splitting defenses as
  the basis of the patients psychological structure

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Interpretation with Borderline Patients

• Interpretation first spells out the nature of the
  dominant object relation and the patients
  difficulty recognizing it (interpreting defenses)
• Interpretation then addresses defensive object
  relations that are closer to awareness before
  addressing those that are defended against and
  dissociated or projected

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Focus of Interpretation

• Because of the predominance of splitting-based
  defensive operations (rather then
  repression-based defenses)
• Interpretation focuses on mutually dissociated
  aspects of experience that are fully accessible
  to consciousness, though at different times
  (rather than repressed material)
• As treatment progresses, dissociative defenses
  give way to repressive defenses, when
  interpretations can shift to focus on repressed
  mental contents

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Interpretation Cycle

• Begins with efforts to help patient clarify his
  conscious emotional experience in the
  transference, elaborating the particular
  representations of self and object respectively
  enacted and projected onto the analyst
• Next, confront the patient with his experience of
  this same object relation enacted in the
  transference at other times but with roles
  reversed
• Subsequently, interpretively link idealized and
  persecutory relations with the analyst that have
  been conscious, but defensively split off by
  mutual denial

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Steps of Interpretation

• Understand/Identify self state in the moment
• Understand patients experience of the therapist
  in the moment
• Consider therapists experience of the moment,
  and that it may be different from the patients
• Contrast the immediate experience of self and of
  therapist with that at other times (address
  splits)
• Consider reasons for splits
• Put the above in the context of other relations