Presentation on theme: "The All-or-None Phenomenon in Borderline Personality Disorder"— Presentation transcript:
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 abandonmentA pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluationIdentity disturbance: markedly and persistently unstable self-image or sense of selfImpulsivity in at least two areas that are potentially self damagingRecurrent suicidal behavior, gestures, or threats, or self-mutilating behaviorAffective instability due to marked reactivity of moodChronic feelings of emptinessInappropriate, intense anger or difficulty controlling angerTransient, 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 relatednessStudies 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 DysregulationLab 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 controlAttack entire problem vs. avoidance of problemNow or neverMurderous rage or total denial of angerInfatuation or denial of dependencyMy way or your wayOptimism vs hopelessnessImpulsivity vs. failure to actExtreme attachment vs. rejection of objectHarsh disapproval, self-injury vs. absent moral constraintNarcissistic ideal expectation vs. despair of accomplishing anythingInstant recovery vs. no progressModulated expression of affectBreakdown problem into manageable partsAbility to tolerate delayPartial expression of angerMature object dependencyShared responsibility, cooperationRealistic appraisal of limitationsAppropriate decision makingStable interpersonal relationshipsFairly consistent moral regulationsReasonable, stable goalsImprovement 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 thinkingDialectical Behavior Therapy-Linehan utilizes the concept of dialects to conceptualize the thinking of patients with BPDTransference-Focused Psychotherapy-Kernberg focuses on splitting in the transference
8 Dialectics in DBT Acceptance vs. change Unrelenting crisis vs. inhibited grievingEmotional vulnerability vs. self-invalidationActive passivity vs. apparent competenceBeing blameless vs. totally flawedWillingness vs. willfulness
9 Transference Focused Psychotherapy Therapy is focused on the patients transference reactions to the therapistDon’t interpret the past-”You are experiencing me like your mother” will be met with “you are just like her”Here and now focusHelp 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 relationsGoal=bring good and bad part objects togetherExamples“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 ThinkingResearchers 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 treatmentStaff more likely to cross boundaries with BPD patientsProjective 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 levelPt views and treats staff differentlyStaff react to pt as though they were the projected aspectStaff assume highly polarized views of pt
14 Projective Identification Function of projective identification (Gabbard)Active mastery of passively experienced traumaMaintenance of attachmentsA cry for helpA wish for transformationGoals in dealing with projective identificationEngage and reactPolarized staff communicate-process the projectionsProjections 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 relationshipsSides with split aspect, accepts as realityKeeps split parts communicatingsees pt as pitting staff against each otherImpulsivity, substance abuse, acting outVicariously enjoys the behaviorcurbs acting out, sees it as a communicationPunishes acting out, removes from therapyAffective instabilityBecomes frantic with pt, insists on medsEmpathy, confident of resolutionRidicules pts feelings, premature use of medsIntense anger, rageSeeks justification in pts anger, sides with ptSensitive to precipitantsRetaliates or untouched by angerRecurrent suicidal threats, self-mutilationAnxious response, assume responsibilityResponds with support and explore behaviorIgnores threats or terminates treatmentIdentity diffusion, negativismFeels rejected by pt, decides things for ptOptimal distance with engagementRejects or opposes ptEmptiness, boredomTries to entertain ptDefense against affects of achievementSees it as pt’s problemAvoidance of abandonmentDependent gratificationFosters mature dependencyInsists on autonomous functioning
17 Helping Patients with All-or-None Thinking Tension between:Empathy and interpreting distortionEngagement and non-reactivityAcceptance and desire for changeBeing supportive and fostering independenceThe environment should:Tolerate intense affectNon-judgmental, but with a healthy respect for the potential damage caused by acting outIntegrate splitsCommunicate wellEncourage 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 affectBe engaged enough to get “sucked in,” then reflect on itTreatment team understands projective identification and continues to communicateProgress-two steps forward and one backDefense against the affects associated with achievement, fear of destructive sideCountertransference-self-protective cynicism vs. naïve optimism
19 Treatment Techniques Idealization Point it out-predict disappointment Positive and negative sides to itAvoid being saintly, recognize the splitting processOpen to the perspective of those being devaluedIf you overindulge pt, acknowledge this, and process itDevaluationNon-defensive without being defenselessRemain in communicationConfident in problem resolutionAware of pts disorder, real sufferingIf you respond angrily or become avoidant, acknowledge this, and process it
20 Negative Transference Negativism-the search for a bad object“Warmth through friction”-SchulzSeeks negative response-pt isn’t the only angry person in the roomStaff acknowledge feelings or pt will escalate, acknowledging anger makes anger acceptableExplore why pt wants to elicit such feelingsRequires 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 treatmentPatients find it easy concept to grasp
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