1. The All-or-None Phenomenon in Borderline Personality Disorder
By Keith Hannan, Ph.D.

2. DSM-IV Criteria for BPD Must have five or more of the following:
Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or sense of self
Impulsivity in at least two areas that are potentially self damaging
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability due to marked reactivity of mood
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger
Transient, stress-related paranoid ideation or severe dissociative symptoms

3. A Three Factor Model: Impulsivity Disturbed relatedness
Lab studies find inattentiveness, a tendency toward action, disinhibition. Sensitive to rewards, insensitive to punishment.
Disturbed relatedness
Studies show more hostile representations, insecure attachment style, lower likelihood of being married, more break-ups, shorter duration of friendships, lack of romantic partner, fewer social activities.
Affective Dysregulation
Lab studies find hypervigilance for negative emotional stimuli.

4. Clarence Schulz, M.D.
Schulz, C. G. (1980a). All-or-none phenomena in the psychotherapy of severe disorders. In J. S. Straus, M. Bowers, T. W. Downey, S. Fleck, S. Jackson, & I. Levine (Eds.), The psychotherapy of schizophrenia (pp. 181–189). New York: Plenum Medical Book.
Expands on the psychoanalytic concept of splitting-seeing objects as “all good” or “all bad”
A useful construct in the treatment of patients with Borderline Personality Disorder.
A valuable construct for therapists who are Psychodynamic or Cognitive-Behavioral

5. Schulz: All Or None Attitudes All-or-none Integrated
Rigid overcontrol vs. loss of control
Attack entire problem vs. avoidance of problem
Now or never
Murderous rage or total denial of anger
Infatuation or denial of dependency
My way or your way
Optimism vs hopelessness
Impulsivity vs. failure to act
Extreme attachment vs. rejection of object
Harsh disapproval, self-injury vs. absent moral constraint
Narcissistic ideal expectation vs. despair of accomplishing anything
Instant recovery vs. no progress
Modulated expression of affect
Breakdown problem into manageable parts
Ability to tolerate delay
Partial expression of anger
Mature object dependency
Shared responsibility, cooperation
Realistic appraisal of limitations
Appropriate decision making
Stable interpersonal relationships
Fairly consistent moral regulations
Reasonable, stable goals
Improvement by small increments

6. Clinical Examples of All-or-None Thinking
Patient with addiction who vacillates between being hopeless about recovery and speaking as though sobriety will be easy.
Patient who wanted something from boss. Couldn’t handle the suspense of not knowing whether he would get it. Assumed boss would be withholding. Verbally attacked boss as being unsupportive. When confronted, berated himself for not being good enough.
Patient whose wife berates him, comes home from work saying, “I’m not going to get angry tonight,” only to explode and yell at her later.

7. Evidence-Based Treatments for BPD
Incorporate Schulz’s concept of all-or-none thinking
Dialectical Behavior Therapy-Linehan utilizes the concept of dialects to conceptualize the thinking of patients with BPD
Transference-Focused Psychotherapy-Kernberg focuses on splitting in the transference

8. Dialectics in DBT Acceptance vs. change
Unrelenting crisis vs. inhibited grieving
Emotional vulnerability vs. self-invalidation
Active passivity vs. apparent competence
Being blameless vs. totally flawed
Willingness vs. willfulness

9. Transference Focused Psychotherapy
Therapy is focused on the patients transference reactions to the therapist
Don’t interpret the past-”You are experiencing me like your mother” will be met with “you are just like her”
Here and now focus
Help patient integrate split “all good” and “all bad” images of the therapist

10. Kernberg: Treatment Model
Transference –Focused (Here and Now)
Primitive transferences are distorted, rapidly shifting, reflect part object relations
Goal=bring good and bad part objects together
Examples
“Though you began our session by mentioning that you lost your job and may have no place to live, you now sit here beaming at me as if all your troubles are over.”
“You seem to be hinting that your life is falling apart, and yet, I hesitate to bring this up fearing that you might experience it as intrusive. On the other hand, I also fear that if I don’t bring it up, you will experience me as indifferent. I’m wondering if this reflects some conflict about your dependency on me.”
“You seem to be experiencing me as cold and harsh right now.”

11. All-or-None Thinking
Researchers view emotion dysregulation as being at the root of BPD.
From a Cognitive-Behavioral perspective, all-or-none thinking leads to emotion dysregulation.
From a psychodynamic perspective, all-or-none thinking is a manifestation of splitting, where patients with BPD cannot simultaneously hold positive and negative images of self or others. Images are “all good” or “all bad.”

12. Countertransference and All-or-None Thinking
Patients who respond in extreme ways tend to provoke the strongest countertransference.
Therapists think about BPD patient outside of treatment
Staff more likely to cross boundaries with BPD patients
Projective Identification-the patient behaves in ways that provoke the therapist to feel what they are feeling. They externalize their conflict.
BPD patients cannot contain.

13. Projective Identification
Projective identification on the inpatient unit (Gabbard)
Occurs at unconscious level
Pt views and treats staff differently
Staff react to pt as though they were the projected aspect
Staff assume highly polarized views of pt

14. Projective Identification
Function of projective identification (Gabbard)
Active mastery of passively experienced trauma
Maintenance of attachments
A cry for help
A wish for transformation
Goals in dealing with projective identification
Engage and react
Polarized staff communicate-process the projections
Projections are given back to pt in modified form

15. Examples of Projective Identification
Patient afraid at the time of discharge behaved in ways that left me conflicted about whether to re-hospitalize her.
Patient angry with mother reports mother’s behavior and I feel angry with mother. Patient denies being angry with mother.

16. Schulz: Countertransference Symptom Overidentification Observation Rejection
Unstable intense relationships
Sides with split aspect, accepts as reality
Keeps split parts communicating
sees pt as pitting staff against each other
Impulsivity, substance abuse, acting out
Vicariously enjoys the behavior
curbs acting out, sees it as a communication
Punishes acting out, removes from therapy
Affective instability
Becomes frantic with pt, insists on meds
Empathy, confident of resolution
Ridicules pts feelings, premature use of meds
Intense anger, rage
Seeks justification in pts anger, sides with pt
Sensitive to precipitants
Retaliates or untouched by anger
Recurrent suicidal threats, self-mutilation
Anxious response, assume responsibility
Responds with support and explore behavior
Ignores threats or terminates treatment
Identity diffusion, negativism
Feels rejected by pt, decides things for pt
Optimal distance with engagement
Rejects or opposes pt
Emptiness, boredom
Tries to entertain pt
Defense against affects of achievement
Sees it as pt’s problem
Avoidance of abandonment
Dependent gratification
Fosters mature dependency
Insists on autonomous functioning

17. Helping Patients with All-or-None Thinking
Tension between:
Empathy and interpreting distortion
Engagement and non-reactivity
Acceptance and desire for change
Being supportive and fostering independence
The environment should:
Tolerate intense affect
Non-judgmental, but with a healthy respect for the potential damage caused by acting out
Integrate splits
Communicate well
Encourage modulated verbal expression of feelings

18. Treatment Techniques The Basics “Put your feelings into words”
Challenge all or none thinking-help them integrate splits, modulate affect
Be engaged enough to get “sucked in,” then reflect on it
Treatment team understands projective identification and continues to communicate
Progress-two steps forward and one back
Defense against the affects associated with achievement, fear of destructive side
Countertransference-self-protective cynicism vs. naïve optimism

19. Treatment Techniques Idealization Point it out-predict disappointment
Positive and negative sides to it
Avoid being saintly, recognize the splitting process
Open to the perspective of those being devalued
If you overindulge pt, acknowledge this, and process it
Devaluation
Non-defensive without being defenseless
Remain in communication
Confident in problem resolution
Aware of pts disorder, real suffering
If you respond angrily or become avoidant, acknowledge this, and process it

20. Negative Transference
Negativism-the search for a bad object
“Warmth through friction”-Schulz
Seeks negative response-pt isn’t the only angry person in the room
Staff acknowledge feelings or pt will escalate, acknowledging anger makes anger acceptable
Explore why pt wants to elicit such feelings
Requires staff to feel, then reflect

21. All-or-None Thinking Useful focus of treatment for patients with BPD
Fits nicely into a psychodynamic or cognitive-behavioral treatment
Patients find it easy concept to grasp

22. Our Webinars Jared Keeley, Ph.D. on DSM-5-July 11th
Keith Hannan, Ph.D., consultant to juvenile facilities on “What We Know About Acting Out Teens.”
David Shapiro, Ph.D., the father of clinical forensic psychology on the “Fundamentals of Forensic Assessment.” Learn forensic assessment from the best. He also does “New Developments in Ethics and Law”
David McDuff, M.D., consultant to the Baltimore Orioles and Ravens on “Sports Psychiatry.” This webinar is appropriate for all mental health clinicians interested in working with athletes. He also does “The treatment of Complex Alcohol, Tobacco, and Drug Dependence.”
Heather Hartman-Hall, Ph.D., internship training director and talented clinician on “Making Sense of the Complexities of Trauma.”
Scott Hannan, Ph.D., seen on the show “Hoarders,” on “Cognitive Behavioral Therapy for School Refusal” and “The Treatment of Hoarding.”
Monnica Williams, Ph.D. on “Psychotherapy with African Americans
Phil Rich, Ed.D, “Working With Sexually Abusive Youth: Current Perspectives and Approaches”
Emerson Wickwire, Ph.D on “Assessment and Treatment of Sleep Disorders.”
Jared Keeley, Ph.D. on DSM-5-July 11th
Home Study versions of all of our webinars.

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