Transcript All-or-None Thinking in the Treatment of Borderline

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:
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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 selfimage or sense of self
Impulsivity in at least two areas that are potentially self
damaging
Recurrent suicidal behavior, gestures, or threats, or selfmutilating 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:
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Impulsivity
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Disturbed relatedness
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Lab studies find inattentiveness, a tendency
toward action, disinhibition. Sensitive to rewards,
insensitive to punishment.
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
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Lab studies find hypervigilance for negative
emotional stimuli.
Clarence Schulz, M.D.
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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 splittingseeing 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
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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
Integrated
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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
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Stable interpersonal relationships
Fairly consistent moral regulations
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Reasonable, stable goals
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Improvement by small increments
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Clinical Examples of All-or-None Thinking
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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
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Incorporate Schulz’s concept of all-ornone thinking
Dialectical Behavior Therapy-Linehan
utilizes the concept of dialects to
conceptualize the thinking of patients with
BPD
Transference-Focused PsychotherapyKernberg focuses on splitting in the
transference
Dialectics in DBT
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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
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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
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Transference –Focused (Here and Now)
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Primitive transferences are distorted, rapidly
shifting, reflect part object relations
Goal=bring good and bad part objects together
Examples
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“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
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Researchers view emotion dysregulation as
being at the root of BPD.
From a Cognitive-Behavioral perspective, all-ornone 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
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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
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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
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Projective Identification
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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
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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-orNone Thinking
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Tension between:
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Empathy and interpreting distortion
Engagement and non-reactivity
Acceptance and desire for change
Being supportive and fostering independence
The environment should:
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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
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The Basics
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“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
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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
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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
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All-or-None Thinking
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Useful focus of treatment for patients with
BPD
Fits nicely into a psychodynamic or
cognitive-behavioral treatment
Patients find it easy concept to grasp
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