John F. Clarkin Cordoba, Spain 2009

PERSONALITY DISORDERS INSTITUTE O. Kernberg, Director J.F. Clarkin, Co-Director M. Lenzenweger K. Levy M. Stone M. Posner F. Yeomans

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

 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

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

 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

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

Telephone Inquires (n = 337) (294 clinical referrals, 28 non- clinical, 15 not known) Did not meet criteria from Phone Interview (n = 130) Interviewed (n = 207) Refused Randomization (n = 19) Randomized (n = 90) TFP (n = 31) DBT (n = 30) SPT (n = 29) Met Criteria Offered Randomization (n = 109) Loss of Eligibility (n = 0) Did Not Meet Criteria (n = 98) Reasonn Did not meet BPD Criteria30 Age21 Substance Dependent9 Concurrent Treatment6 IQ3 Bipolar Disorder8 Eating Disorder4 Psychotic Disorder8 Scheduling Conflict1 Dropped out8

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

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  Attempts57%  Self destructive64%  Either83 %  5

Change in 6 Domains: Effect Sizes (Clarkin et al, 2007, Amer J Psychiatry) Suicidalit y Anger Impulsivit y Anxiety Depressi on Social Adj TFP0.33(0.01)0.44(0.001)II:0.36(0.005)0.37(0.004)0.50(0.001)0.28(0.03) DBT0.34(0.01)NSNS0.50(0.001)0.38(0.003)0.44(0.001) SPTNS0.28(0.05)III:0.31(0.02)0.48(0.001)0.49(0.001)0.59(0.001)

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

 “…it is difficult to ascertain whether outcomes are attributable to the structured nature of the programs or the therapeutic orientation and models which they employ…since 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.

ORIENTATIONTHERAPISTPATIENTDBTMindfulness Behavioral targeting Chain analysis Exposure, response prevention, extinction of ineffective emotional responses; learning of new skillful responses to emotional stimuli Supportive (SPT) Focus supporting patient’s 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

Self Other Affects Object Relations Dyad

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)

Reflective Function Scale (Fonagy, Target, Steele, Steele, 1998) -1 Rejection, unintegrated, or inappropriate RF 1 Disavowal, distorted/self-serving 3 N aive simplistic or over-analytic/hyperactive 5 Ordinary or inconsistent (fairly coherent) 7 Marked 9 Exceptional (complex, elaborate)

Change in RF as a Function of Time and Treatment (Levy et al, 2006)

 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

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.

Finite Mixture Modeling: Groups of BPD Patients

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

FACTOR 2. Impulsive Antisociality Frequency T Scores > 60 Percentage Impulsive Non Conformity % Blame Externalization 1517% Care Free1719% Egocentrism Machiavellism 1517% FACTOR 1. Fearless Dominance Frequency T Scores > 60 Percentage Social Potency % Stress immunity 1011% Fearlessness1314.7%

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)

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 patient’s conception of self- therapist and related behavior is constructed to help patient reflect (not react), re-appraise

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

 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)

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

Patient’s Internal World 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. S3 O3 S1 O1 S2 O2 a3 a1 a2 Etc.

TRANSFERENCE, and the power of Internal World over External Reality Ex:RB  Experience of Self  …and of Therapist S1 S2 S3 O1 O2 S1 S2 S3 O3 a1 a2 a3

Victim Persecutor Victim (Oscillation is usually in behavior, not in consciousness) OBJECT RELATION DYAD INTERACTIONS: OSCILLATION Fear, Suspicion, Hate Self-Rep Object Rep

Victim Dependent Child Abuser Gratifying Provider Opposites OBJECT RELATION DYAD INTERACTIONS: ONE DYAD DEFENDING AGAINST ANOTHER Fear, Suspicion, Hate Longing, Love

Clinical Example of Oscillation  Observe  Engage the patient’s observation  Interpretive process  “If you see me that way, it would make sense…”  “It’s hard to see/accept that in yourself…”  “We agree on the affect, but not on its source”  “If you can acknowledge it, you’re in a position to control and master it.”

Steps of Interpretation  Understand/Identify self state in the moment  Elaborate understanding of the therapist  Consider therapist’s experience of the moment, and that it may be different from the patient’s  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

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

Internal External High Anxious | Low Anxious

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.

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

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

First Module

Second Module

Third Module

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 partner’s 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

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

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

Emotional Stroop Task (Silbersweig, Clarkin et al, 2007) POSITIVE VERBAL STIMULI GoNo-go NEUTRAL VERBAL STIMULI GoNo-go NEGATIVE VERBAL STIMULI GoNo-go

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

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

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

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

Implications 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) Persecuting Object Victimized Self Affect State: Hypervigilant Anxiety

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 patient’s conception of self-therapist and related behavior is constructed to help patient reflect (not react) and question and re-appraise

 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

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

 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 patient’s life

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

1. Defining patient and therapist responsibilities 2. Protecting therapist’s ability to think clearly 3. Providing a safe place for the patient’s 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 patient’s life

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 therapist’s involvement – (for patients with earlier experiences of challenging boundaries) Predicting Threats to the Treatment, and establishing parameters to address them

 Therapist presents a part of the contract  Patient responds to those conditions of treatment  Therapist pursues elaboration of patient’s response  Consensus -- or not

 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 therapist’s 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

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

The Initial Situation A Sense of confusion or chaos in the Session PatientTherapist 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.

 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”

Treatment Orientation ConceptionTherapist Behavior DBTTherapy interfering behavior Patient task to get therapist to continue MBTDeficit in mentalization skills Mentalizing TFPTransferenceClarification, confrontation, 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

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. -S3 -O3 -S1 -O1 +S2 +O2 -a3 -a1 +a2 Etc.

 Experience of Self  …and of therapist S1 S2 S3 O1 O2 S1 S2 S3 O3 a1 a2 a3

Victim Persecutor Victim (Oscillation is usually in behavior, not in consciousness) OBJECT RELATIONSHIP INTERACTIONS: OSCILLATION Fear, Suspicion, Hate Self-Rep Object Rep

Victim Cared-for Child Persecutor Perfect Provider Opposites OBJECT RELATIONSHIP INTERACTIONS: DEFENSE Fear, Suspicion, Hate Longing, Love

Dyad Defending Against Dyad: Example Tiger Lady Untrustworthy, but Needed Tool Desperately Needy Child Perfect Provider

ILLUSTRATIVE ROLE PAIRS FOR PATIENT AND THERAPIST Unwanted, deprived childAbsent, neglecting parent+ Defective, worthless childContemptuous parent Threatened, abused victimSadistic attacker/persecutor Controlled, enraged childControlling parent Attacking, angry childControlled, 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.

Naughty, sexually excited childSeductive parent Dependent, gratified childPerfect provider Child longing to be lovedWithholding parent Controlling, omnipotent selfImpotent parent Friendly, submissive selfDoting, admiring parent Aggressive, competitive selfPunitive, sadistic parent

 Therapeutic neutrality  Change processes: the Interpretation Process

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

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

 This technique is not a hostile challenge, but rather an honest inquiry into an apparent contradiction in the patient’s 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

 The contradiction can be within one channel of communication: “You said earlier that I was a terrific therapist, now you’re saying I’m worthless….”  Or the contradiction can be between different channels of communication: “You’re saying you’re furious, but you’re looking at me with a smile….”

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

 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 patient’s psychological structure

 Interpretation first spells out the nature of the dominant object relation and the patient’s 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

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

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

 Understand/Identify self state in the moment  Understand patient’s experience of the therapist in the moment  Consider therapist’s experience of the moment, and that it may be different from the patient’s  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