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. 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 AttitudesAll-or-noneIntegrated • 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. 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 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 • 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

10. Kernberg: Treatment Model • Transference –Focused (Here and Now) • Primitive transferences are distorted, rapidly shifting, reflect part object relations • Goal=bring 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 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 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 mother’s behavior and I feel angry with mother. Patient denies being angry with mother.

16. Schulz: Countertransference Symptom Overidentification Observation Rejection

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 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

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

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