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

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

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.

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

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

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.

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

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

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

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.”

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.”

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.

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

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

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.

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

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

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

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

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

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

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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