Transference-Focused Psychotherapy for Borderline & other Personality Disorders

1. Transference-Focused Psychotherapy for Borderline & other Personality Disorders Lietuvos Psichoanalizès Draugija Vilniaus Universitetas Medicinos Fakultetas Psichiatrijos Klinika September 2,3,4, 2016 Frank Yeomans, M.D., Ph.D. Personality Disorders Institute/Weill Cornell Medical College Columbia Center for Psychoanalysis International Society for TFP Borderline Personality Disorder Resource Center

2. Websites Personality Disorders Institute/Weill Cornell Medical College Borderlinedisrorders.com International Society for TFP www.istfp.org Borderline Personality Disorder Resource Center BPDresourcecenter.org

3. PERSONALITY DISORDERS INSTITUTE Weill Cornell Medical College Otto F. Kernberg, M.D., Director John F. Clarkin, Ph.D., Co-Director Nicole Cain, PhD Mark Lenzenwger, PhD Eve Caligor, MD Kenneth Levy, PhD Monica Carsky, PhD Kevin Meehan, PhD Jill Delaney, MSW Lina Normandin, PhD Diana Diamond, PhD Barry Stern, PhD Karen Ensink, PhD Michael Stone, MD Catherine Haran, Psy.D Alan Weiner, PhD Frank E. Yeomans, MD

4. Key TFP Manuals Yeomans FE, Clarkin JF, Kernberg OF. Transference- Focused Psychotherapy for Borderline Personality: A Clinical Guide. Washington: American Psychiatric Press (2015). Yeomans FE, Clarkin JC, Kernberg OF. A Primer on Transference-Focused Psychotherapy for Borderline Patients. Northvale, NJ: Jason Aronson; 2002. Caligor, E., Kernberg O.F. & Clarkin, J.F. (2007). Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology. Washington, DC: American Psychiatric Publishing.

5. An Early Book on Contracting Yeomans FE, Selzer MA, Clarkin JF. Treating the Borderline Patient: A Contract-Based Approach. Basic Books, New York; 1992

6. Principle TFP Manuals 2002 2015

7. Key TFP Books 1992 2007

8. Main research articles • Clarkin, J.F., Levy, K.N., Lenzenweger, M.F., & Kernberg, O.F. (2007). Evaluating three treatments for borderline personality disorder: a multiwave study. American Journal of Psychiatry, 164, 922-928. • Levy, K. N.; Meehan, K. B.; Kelly, K.M.; Reynoso, J. S., et al (2006). Change in attachment and reflective function in the treatment of borderline personality disorder with transference focused psychotherapy. J of Consulting and Clinical Psychology 74:1027-1040. • Doering, S. et al (2010). TFP vs. treatment by community therapists for BPD: RCT. British Journal of Psychiatry , 196(5)

9. Educational Objectives • Understand psychodynamic approaches to severe personality disorders: • Personality structure and identity • Phenomenology and functioning • Understand basic object relations theory • Understand basic assessment and its importance • Understand treatment contracting • Understand strategies, tactics and techniques of TFP • Identify patterns of change in treatment • Evolution of therapy: early, middle, late phases

10. What is TFP? An evidence-based manualized individual outpatient therapy for serious personality disorders It combines structure and limit-setting with an exploratory psychodynamic approach to target the split, intrapsychic structure that results in the borderline phenomenology

11. Some Key Differences with Traditional Psychodynamic Therapy - 1 • The therapist is more active • The therapist has a sense of the priorities to address (in contrast to pure free association) • The initial focus is on the here-and-now of the interaction between patient and therapist: this activates the patient’s affect systems so that affect and cognition are present together

12. Some Key Differences with Traditional Psychodynamic Therapy - 2 • Interpretations are based on the idea that “an affect is the manifestation of an underlying object relation”

13. Goals and objectives of TFP • Phase I: The containment of acting out behaviors • Phase II: Core of the treatment - the resolution of identity diffusion and the development of a coherent sense of self and others

14. The Resolution of Identity Diffusion • This is done through fostering reflection on mental states of self and other • The reflection focuses of the patient’s split internal world where representations of self and others are divided into radically opposed extremes

15. Who is TFP for and why learn it? • It is for patients with personality disorders at the borderline level of personality organization - BPO (not just BPD in narrow sense) - These include borderline personality disorder, narcissistic personality disorder, histrionic, dependent and avoidant PD • The goal goal of TFP is to go beyond symptom change and effect change in the personality that makes it possible to find satisfaction in work and love.

17. What do we mean by a manual? • A book: derived from discussing videotapes of analysts’/therapists’ • Viewing videos • Peer supervision, with an emphasis on countertransference and projective identification • Overarching concept: principle-driven • Rating adherence and competence

18. What are the elements of our manualized therapy? • Diagnosis-specific • Articulate specific treatment goals [how specific?] • Set the Contract (v. “meet the patient”) • Look for activated dyads in the here-and-now • Conceptualize drives and defenses as embodied in dyads

19. Elements of manualization – cont’d • Respect priorities of intervention (v. free association, which can be in the service of defense and omnipotent control) • Increased level of therapist activity • use interpretations, starting with “experience-near” • On-going attention to the patient’s “external life”

20. Manualization in the context of a research study • one impact: staying with the case • on and off- camera: the drift to be supportive • drift as developing one’s individual style of therapy • drift as colluding with resistance to deep exploration. The ucs never loses its potential to make us uneasy

21. TFP – Focus on the intrapsychic • Why bother working at this level? • Symptom Change • Change in sense of self and experience of the world • Change in underlying psychological functions • Satisfaction in love and work • a ”full” life

22. How do we consider personality?

23. Two Dominant Approaches to PERSONALITY • Dispositional or trait theory approach: goal is to characterize people in terms of a comprehensive but small set of stable behavioral dispositions • Processing approach: personality as a system of mediating units (expectancies, goals, motives) and psychological processes (cognitive-affective units) that interact with the situation Mischel & Shoda, 1999

24. Four Aspects of Psychological Processing • Organized pattern and sequence of activation of cognitive-affective mental representations • Behavioral expressions of individual’s processing • Perceptions of self across situations • Particular environments the individual seeks out and constructs Mischel & Shoda, 1999

25. Personality - 1 • It is an umbrella concept: the total psychological structure and functioning of the individual • It is a permanent organization of how one perceives and reacts to stimuli – it involves how one perceive self and other • Assessment of and adaptation to the environment Ref: Kernberg & Caligor (2005). A psychoanalytic theory of personality disorders. In: Major Theories of Personality Disorders, 2nd Ed. Eds: Clarkin & Lenzenweger. NY, Guilford, 115-156.

26. Personality - 2 • To understand personality organization, we describe the major personality structures (combinations of functions that group together at the biological or psychological level): • Temperament • Character • Identity • Ethical values • Intelligence/Cognition

27. Using Structural Features of Personality to Develop a Diagnostic System for Personality Disorders • The focus is on key psychological processes (“structures”) that process information and affects, thus influencing behavior • This focus leads to the concepts of “Structural diagnosis” and “level of personality organization”

28. Component Structures of Personality: Temperament • Temperament arises from genetic endowment and comprised of four motivational systems: appetitive, defensive, aggressive, nuturant • Temperament involves individual differences in both motor and emotional reactivity and self-regulation • Effortful control is the self regulation dimension of temperament; ability to inhibit a dominant response in order to perform a subdominant response

29. Temperament and Interaction with Caregivers • The combination of temperament and interactions with caregivers leads to the internalization of perceived interactions. These determine habitual ways of perceiving, reacting/behaving, orcharacter traits. • Affects guide the infant to pleasurable stimuli, experiences and away from painful ones. • In interacting with mother, mother may do “right” thing which leads to pleasure, or “wrong” to pain • These experiences internalized as guiding system for future behavior

30. Component Structures of Personality: Character Character: the integration of habitual behavioral patterns into a structure. It is the psychological organization developed from interactions that are internalized and repeated in habitual ways Character structure determines one’s reaction to the environment Character is observable by behavior, affective responses Character is the behavioral manifestation of Identity: ways of thinking, feeling, and relating to the world.

31. Component Structures of Personality: Identity • Identity is the structural correlate of both the subjective sense of self and the experience of significant others • Normal identity is manifested subjectively in experiences of self and others that are complex, well differentiated, characterized by subtlety and depth, continuous over time and across situations, flexible and realistic • Normal identity is associated with the ability to accurately appreciate the internal experience of others

32. Component Structures of Personality: Moral Values • Commitment to values and ideals that is consistent, flexible, and fully integrated • A dynamic integration of developmental influences

33. Component Structures of Personality: Intelligence • Intelligence: the capacity for cognitive assessment • The cognitive ability of establishing the context in which affect emerges • Analyze reality in more and more complex ways • Helps develop symbolic ways of relating to reality • Avoids distortions of reality under extreme affects • Plays an important role in impulse control • Affects become cognitively framed by the action of the cortex

34. Descriptive Features of Personality Disorder PD’s are distortions of normal personality characterized by: • Rigidity or loss of flexibility of behavior patterns, resulting in poor adaptation • Inhibition of normal behaviors • Exaggeration of certain behaviors • Chaotic alternation between inhibitory and impulsive behavior patterns • Vicious circles develop: abnormal behaviors elicit abnormal responses

35. Consequences of Personality Disorders: - A reduction in the capacity to adapt to the psychosocial environment and to satisfy internal psychological needs (e.g., self-affirmation, sexuality, and dependency). - In turn, personality disorders tend to be re-enforced by the pathological responses that patients elicit in their environment.

36. Structural Features/Variables at the Center of the Diagnostic Sysgtem • Identity - Sense of self and sense of others • Defensive Operations - Customary ways of coping with external stress and internal conflict • Reality Testing - Appreciation of conventional notions of reality • Quality of Object Relations - Understanding of the nature of interpersonal relations • Moral Functioning - ideals and values, expressed in ethical, or unethical behavior

37. Structural Diagnosis andLevels of Personality Organization • These structural features of personality determine: • Severity of pathology / level of functioning: • Ability to deal with life tasks and with related instinctual impulses (aggression, love, sexuality, and interdependence) • Treatments that effect change at the level of psychological structures result in change at the symptom level and quality of life

38. Structural Change The overarching goals of TFP are defined in structural terms: • To integrate the identity • To develop more adaptive defenses (to move beyond splitting) and thus enhance coping and adaptation to life

39. Clinical Manifestations of Structural Change Change at the level of psychological structures will lead to: • Reduction of symptoms and maladaptive behaviors • Better functioning • Change in the patient’s sense of self and experience of the world • Ability to cope with stress and adversity • Enhanced satisfaction and effectiveness in love and sex, work and social life: living a “full” life

40. The Structural Classification of Personality Disorders by Levels of Severity Normal personality: Consolidated identity, adaptive defenses, stable RT, flexible moral functioning, full object relations including capacity for intimacy and healthy dependency Neurotic level of personality organization : Rigidity of defenses, inflexible morality, +/- problems with intimacy Borderline level of personality organization : More fully described below • High level borderline: dependent, needy, depressive • Low level borderline: hostile, aggressive Psychotic level of functioning (loss of reality testing)

41. Borderline Personality Organization Basic Characteristics • Identity Diffusion vs. integrated view of self and others (internal sense of continuity) • Primitive Defenses • Splitting • Idealization/devaluation • Projective identification • Omnipotent control • Denial • Variable Reality Testing

42. Prognostic Factors • Pervasive aggression • Antisocial features • Secondary gain (chronic support system) • Severely restricted object relations • No love life; low attractiveness • Low intelligence • No work or shifting lifestyle • Negative therapeutic reaction

43. Borderline Level of Personality Organization: The Defining Psychological Characteristics and their Clinical Correlates I. Identity pathology • Sense of self and others is fragmented, distorted and superficial • Difficulty “reading” others… and self • Lack of continuity in time • Feelings of emptiness

44. Borderline Personality Organization:Clinical Correlates of Structural Features II. Splitting- based/Lower level defenses - These dissociative defenses based on splitting involve projecting negative aspects of the self to attempt to avoid anxiety • They lead to unstable, black and white experiences of the world (of self and of others) • They also lead to difficulty modulating affects

45. Borderline Personality Organization:Clinical Correlates of Structural Features III. Variable Reality Testing • Difficulty distinguish internal and external sources of affect • Deficits in social reality testing • Possible gross distortion under stress with micro-psychotic phenomena

46. Borderline Personality Organization:Clinical Correlates of Structural Features IV. Pathology of Object relations • Difficulty appreciating the needs of the other independent of the self, difficulty with healthy dependency, difficulty with intimacy V. Pathology of Moral Functioning • Inconsistent or lacking values and ideals • Unethical behavior

47. Personality Disorders from a Personality Organization Point of View – Levels of OrganizationA mixed Categorical and Dimensional System 1-Normal flexibility and adaptation 2-Neurotic level of personality organization 3-Borderline level of personality organization: • High level borderline • Low level borderline 4-Psychotic level of personality organization

48. The following slide shows:The relationship between familiar, prototypic, personality types and structural diagnosis.Severity of illness ranges from mildest, at the top of 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.

49. Relationship Between DSM-5 Personality Disorders and Structural Diagnosis

50. Comparison with DSM 5 –PD Diagnostic Criteria: Section 3 A. Degree of Impairment in Personality Functioning 1. Identity: frail or distorted experience of self 2. Self-direction: unrealistic standards and goals 3. Empathy: limited capacity to understand feeling and behaviors of others, and one’s own impact on them 4. Intimacy: limited capacity to establish enduring and mutually satisfactory relations with others B. Abnormal Personality Traits Negative affectivity Detachment Antagonism Disinhibition Psychoticism