The All-or-None Phenomenon in Borderline Personality Disorder - PowerPoint PPT Presentation

1 / 23
About This Presentation
Title:

The All-or-None Phenomenon in Borderline Personality Disorder

Description:

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 ... – PowerPoint PPT presentation

Number of Views:168
Avg rating:3.0/5.0
Slides: 24
Provided by: hann72
Category:

less

Transcript and Presenter's Notes

Title: The All-or-None Phenomenon in Borderline Personality Disorder


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

2
DSM-IV Criteria for BPDMust 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
  • 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. 181189). 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 AttitudesAll-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. Couldnt
    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, Im not going to get angry
    tonight, only to explode and yell at her later.

7
Evidence-Based Treatments for BPD
  • Incorporate Schulzs 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
  • Dont 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
  • Goalbring 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 dont bring it up, you will experience me as
    indifferent. Im 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 mothers
    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 pts 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 isnt 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
  • 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.

23
To Get Your CEU Certificate
  • Go to our website tzkseminars.com
  • Sign in using your email address and password
  • Complete the webinar evaluation
  • Download your certificate
Write a Comment
User Comments (0)
About PowerShow.com