PERSONALITY DISORDERS INSTITUTE

Weill Medical College of Cornell University

Otto F. Kernberg,
g, M.D.,, Director
John F. Clarkin, Ph.D., Co-Director
Eve Caligor, MD
Kay Haran, PhD
Monica Carsky, PhD
Mark Lenzenweger, PhD
Jill Delaney,
y, MSW
Kenneth Levy,
y, PhD
Diana Diamond, PhD
Armand Loranger, PhD
Pamela A. Foelsch, PhD
Michael Stone, MD
Frank E
E. Yeomans
Yeomans, MD

Axis II from a Personality

y Organization
g
Point
of View
g
Levels of Organization
A mixed Categorical and Dimensional System

1-Normal flexibility and adaptation

2-Neurotic level of p
personalityy organization
g
3-Borderline level of personality organization:
High level borderline
Low level borderline

4 Psychotic level of personality organization

4-Psychotic

Borderline Personality Organization

Basic Characteristics
Identity Diffusion vs. integrated view of self and
others
th (internal
(i t
l sense off continuity)
ti it )
No integrated concept of self
No integrated concept of significant others

Primitive Defenses

Splitting
Idealization/devaluation
Projective
j
identification
Omnipotent control
Denial

Variable Reality Testing

Reality Testing
Differentiation of self from non-self
Internal from external reality
y
Empathy with social criteria of reality
Affect
Thought content
Wayy of talkingg

When evaluating this, look at whats

pp p
in affect,, thought,
g , behavior
inappropriate

Borderline Personality Organization:

Clinical Implications
Nonspecific ego weakness
Lack of impulse control,
control anxiety tolerance

Disturbed object relations

Difficulties with work and love
Sexual ppathology
gy (Two
(
levels: inhibition of
all sexual functioning; chaotic sexuality)
Pathology of moral functioning

Etiology of BPD
A complex etiology: no single pathway
Genetic
et c Disposition,
spos t o , involving:
vo v g:
Ge
Neurotransmitter Systems
Abnormal Affectivity: Negative affects, aggression, and
abnormal
b
l control
t l off affects
ff t
Temperament

Object Relations
Chronic chaotic relations and blurring of generational
boundaries
Neglect
Trauma/Abuse

Pathology of Attachment

FIGURE 1

Relationship between familiar, prototypic, personality types and structural diagnosis.

S
Severity
ranges from
f
mildest, at the top off the page, to extremely severe at the bottom.
Arrows indicate range of severity.
Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of
Personality Disorders, 2nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.

Treatments for Borderline Personality

Psychopharmacology
SSRIs, Low-dose Neuroleptics, Mood
Stabilizers

Psychotherapy
y
py
Cognitive Behavioral
Dialectical Behavior Therapyy (Linehan)
Schema Therapy (Young)
Others

Psychodynamic
Supportive Psychotherapy (Rockland)
Mentalization-Based Therapy (Batemen &Fonagy)
Transference-Focused Psychotherapy

Theoretical Underpinnings of TFP:

Object Relations Theory

Self
Affects

Other

The Object Relations Dyad

Split Organization:
Consciousness of all-good or all-bad

Normal Organization:
Consciousness of
Integration/complexity

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
difi d by
b fantasies
f
i andd defenses.
d f
In borderline patients, internal object relations
have been segregated and split off from each other;
include fantasied persecutory and idealized relations.

W
Working
ki with
ith object
bj t relations
l ti
that
th t are activated
ti t d in
i
the immediate moment creates a therapy that is
experience-near
experience near

The Relationship of Strategies, Tactics and Techniques

STRATEGIES
Long-Term Objectives
TACTICS: Tasks
T k
for each Session that
set the conditions for
Techniques

TECHNIQUE:
Consistent
interventions that
address what
happens from
Moment-to-Moment

THE STRATEGIES OF TFP - I

STRATEGY 1: Defining the dominant object
relation
Step 1: Therapist experiences and tolerates the
confusion of the patients inner world as it unfolds
in the transference
Step 2: Therapist identifies in his mind the object relation
that is dominant in the moment
Step 3: Therapist names the actors as they are played out
Step 4: Therapist attends to the patients reaction

THE STRATEGIES OF TFP - II

STRATEGY 2: Observing and interpreting patient role
reversals (the patient identifies with the entire
relationship/dyad not just with one side of it)
STRATEGY 3: Observing and interpreting linkages
between object relation dyads which defend against each
other, with the goal of integrating the paranoid and idealized
segments of experience
experience. This resolves identity diffusion.
diffusion
STRATEGY 4: Experiencing a relationship as different
from the transference: working through the patients
capacity to distinguish the transference from the real
interpersonal
e pe so relationship
e o s p with
w thee therapist
e p s andd expanding
e p d g
this to relationships outside the therapy.

Techniques
q
The interpretive process:
Consists of clarifying,
y g confronting,
g and interpreting
p
g
Is a means of enhancing mentalization

C
Conducting
d ti transference
t
f
analysis
l i (systematic
( t
ti
analysis of distortions in the relationship)
Managing technical neutrality (attitude of
concerned objectivity; not drawn into patients
problems)
Utilizingg countertransference awareness

The Techniques must be applied

with attention to the
3 Channels of Communication
1 the p
patients verbal communication
2 the patients non-verbal communication
3 the therapists
therapist s countertransference
Channels 2 and 3 are often the most important
channels in the early phase of therapy with
borderline patients

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
patient s perception of the other/the
therapist

This technique
q sheds light
g on the ppatients
internal world and helps to elaborate
distortions (i.e., enhances mentalization)

Confrontation
This technique is not a hostile challenge,
but rather an honest inquiry
q y into an apparent
pp
contradiction in the patients verbal and
non-verbal communication
It is an invitation for the patient to reflect on
different aspects of the self that are split off
from one another

Interpretation per se
A hypothesis
yp
about unconscious
determinants of present experience
Interpretations address and attempt to
resolve psychological conflicts
Interpretations attempt to increase
awareness of the impact of unconscious
material on the patient
patientss thoughts
thoughts, affects
affects,
and behaviors

Summaryy of the Interpretation

p
Cycle
y
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, confronts the patient with his experience of
this same object relation enacted in the
transference at other times but with roles reversed
Subsequently,
S b
l interpretively
i
i l links
li k idealized
id li d andd
persecutory relations with the analyst that have
been conscious,
conscious but defensively split off by mutual
denial

TECHNICAL NEUTRALITY
A therapist who intervenes from a position of
technical neutrality avoids siding with any of
the forces involved in the ppatients conflicts
Neutrality means maintaining the position of
an observer in relation to the patient and his
difficulties
When working from a position of technical
neutralityy the therapist
p is aligned
g
with the
patients observing ego

DEVIATIONS FROM
TECHNICAL NEUTRALITY:
INDICATIONS

Threat to safety
Th
f off patient
i
Threat to safetyy of others
Threat to continuation of the treatment
C f
Confrontation
i andd interpretation
i
i fail
f il to
contain acting out

TECHNICAL NEUTRALITY
Technical neutrality is essential to therapists
stance in TFP
Deviate only when patient
patientss acting out poses
threat to patient, to others or to the treatment
Reinstate
R i
neutrality
li when
h limit
li i setting
i no
longer needed
Unnecessary deviations from neutrality result
from countertransference

DEFINING
COUNTERTRANSFERENCE
Therapists
p
total emotional reaction to ppatient
Countertransference in the broad sense
Therapists
p
transference to ppatient
Classical view is therapist-focused
Therapists
Therapist s reactions to patient
patientss transference
Kleinian view is patient-focused

COUNTERTRANSFERENCE
Concordant Identification
Therapist identifies with patient
patientss self
experience
Complementary Identification
Therapist identifies with patients
internal and external objects

The Tactics
Set Contract
To protect the survival of patient, therapist and
treatment
To eliminate secondary gain of illness

Maintain the frame and boundaries of treatment to

control
co
o acting
ac g out
ou
Select the focus of attention and intervention
Attend to what is affectively dominant
Attend
A
d to what
h iis iin the
h transference
f
Attend to the general priorities of treatment

Maintain common pperceptions

p
of realityy
Analyze both positive and negative transferences
Regulate the intensity of affective involvement

Functions of the Contract

1. Defining patient and therapist responsibilities
2 Protecting
2.
P t ti therapists
th
i t ability
bilit to
t think
thi k clearly
l l
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
pat
e t s lifee

Examples
p of Threats to the Treatment
Suicidal and self-destructive behaviors
Homicidal
H i id l impulses
i
l or actions,
i
including
i l di threatening
h
i the
h
therapist
Lying
y g or withholdingg of information
Substance abuse
Eating disorder - uncontrolled
Poor
P
attendance
tt d
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

HIERARCHY OF THEMATIC PRIORITY - I

Obstacles to Transference Exploration Resistances to
explore
suicide or homicide threats
Threats to treatment continuity (inc. financial probs,
plans to move, requests to meet less often)
dishonesty
di h
t or deliberate
d lib t withholding
ithh ldi in
i sessions
i
(e.g.,
(
lying to the therapist, refusing to discuss certain
subjects, silences occupying most of the sessions)
contract breaches (e.g., failure to act on other parts of
treatment such as AA, failure to take prescribed meds)
in-session actingg out ((e.g.,
g , abusingg office furnishings,
g,
refusing to leave at the end of the session, shouting)
narcissistic resistances
non-lethal
non lethal between-session
between session acting out
non-affective or trivial themes

Dynamics of Separation and Termination

Narcissistic dynamics denial of the
importance of the other; devaluing.
Paranoid dynamics
y
separation
p
as an
attack/rejection: Im being thrown out
getting
g away
y from the enemy.
y
and/or Im g
Depressive dynamics guilt: Ive depleted
the supplies this person can offer me
me;;
Im not worthy.

Psychopharmacology
Overall approach
Reduce unnecessary medication use
Medicate target symptoms
Understand the dynamics of medicating

Algorithms: Three
Paranoid/suspiciousness, mild thought disorder,
hallucinations dissociation
hallucinations,
Depressed/angry/anxious/labile mood
Impulsive aggression, self
self-injurious
injurious behavior, binges

TREATMENT COMPLICATIONS
A
Acting
ti out--general
t
l principle:
i i l first
fi t interpret,
i t
t then
th sett limits
li it
----------------------------------------------------p
Suicide and parasuicide
Eating disorders, substance abuse, antisocial
behavior/psychopathic transference all need containment,
extra
extra frame
--------------------------------------------------- The threat of drop-out
Affect storms overt and silent
Paranoid regression/micro-psychotic episodes
Dissociative reactions a form of splitting
Erotization
y
of arrogance
g
Severe hatred in the transference: syndrome
Hospitalizations

 Conceptualization of the pathology

Conceptualization of the treatment and clinical
testing
Manualization of treatment
Therapist training to adherence and competence
Preliminary data with effect sizes
Randomized
R d i d controlled
ll d trial
i l
Investigation of moderators and mediators
Generalizability
G
li bilit off treatment
t t
t (patients
( ti t nott
excluded; treatment in community; transport to
another setting)

 Three structured treatments (TFP, DBT, SPT) are

related to significant change in multiple domains
TFP was predictive
di i off significant
i ifi
improvement
i
in
i 6
domains; DBT predictive in 4; SPT in 5.
In
I direct
di t contrast
t t analyses,
l
only
l change
h
in
i suicidal
i id l
behavior trended to favor TFP and DBT over SPT
Clarkin,
Clarkin Levy,
Levy Lenzenweger & Kernberg,
Kernberg 2007

 DBT: borderline patients change by

g affect regulation
g
skills in the
learning
context of validation (Linehan)
MBT: borderline p
patients change
g byy
increasing mentalization (Bateman &
Fonagy)
TFP: borderline patients change by
integrating representations of self and
others
h and
d related
l d affects
ff
(Kernberg)
(K b )

 Reflective Function is defined as the

capacity to think or mentalize
mentalize in terms of
mental states (emotions, intentions,
motivations) in understanding self and
other.

-1 Rejection, unintegrated, or inappropriate RF

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

4.5
4.3
41
4.1
3.9
3.7
3.5
3.3
31
3.1
2.9
2.7
2.5

TFP
DBT
SPT

RF Time 1

RF Time 2

TFP vs.
vs Treatment in Community
(Doering, et al, 2009)
Study sites: Munich, Germany and Vienna,
Austria
104 female BPD outpatients randomized to
TFP or experienced community
psychotherapists (ECP)
Treated for one year

Results
TFP had significantly fewer dropouts
(38.5% vs. 67.3%)
TFP superior in reducing BPD symptoms,
improving psychosocial functioning,
improving personality organization, and
reducing inpatient admissions
Both groups improved significantly in
depression and anxiety