REDISCOVERING PSYCHOTHERAPY

Eve Caligor, MD

RANZCP Faculty of Psychotherapy Conference

Saturday August 25

Adelaide, Australia

Transference-Focused Psychotherapy—Extended

Treating Self and Interpersonal Functioning within the Framework of Object Relations Theory

Transference-Focused Psychotherapy Extended

Caligor RANZCP 2018

PERSONALITY DISORDERS INSTITUTEWeill Cornell Medical College

Otto F Kernberg, MD, DirectorJohn F Clarkin, PhD, Co-Director

Nicole Cain, PhDEve Caligor, MDMonica Carsky, PhDJill Delaney, MSW Diana Diamond,Karen Ensink, PhDCatherine Haran, PsyD

Mark Lenzenweger, PhDKenneth Levy, PhDKevin Meehan, PhDLina Normandin, PhD Barry Stern, PhDMichael Stone, MDAlan Weiner, PhDFrank E. Yeomans, MD

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Conceptualization of a Disorder Organizes and Informs Treatment Development and Clinical Technique

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Traditional Approach to Personality Disorders: DSM III -DSM 5

§ Categorical diagnosis determined by counting criteria - traits and symptoms

§ Rampant comorbidity

§ Poor coverage of spectrum of presentations of PDs

§ Heterogeneity among those who met the criteria for one personality disorder

§ Failure to define what is essential to and shared by all PDs

§ Resulting failure to provide a framework that could organize coherent approaches to treatment

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Personality Disorders –Emerging Consensus

§ PD best described dimensionally rather than categorically

§ Dimension of severity most robust predictor of prognosis and course (Hopwood et al 2011)

§ Core defining features of PD lie in domains of self and interpersonal functioning (Sharp et al 2015; Wright et al 2016)

§ “General factor” for PD pathology

§ Conceptualized as expression of underlying systems / processes / structures

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General and Specific Factors(Sharp et al 2015)

§ “General factor” for PD pathology captures common variance shared by diverse presentation of PD pathology

§ Lies in domain of self and interpersonal functioning

§ Specific factors differentiate among PDs Relate to personality traits – e.g., detachment, impulsivity, agreeableness

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Revised Approach to Classification of PD pathology

§ Classify PDs according to severity of impairment of self and interpersonal functioning

§ First level classification = “General factor”

§ Complemented by description of dominant traits

§ Second level classification = “Specific factors”

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General and Specific Factors:Stability and Impact on Functioning(Wright et al 2016)

§ Specific factors have relatively circumscribed relationship to level of functioning compared with general factor

§ Specific factors tend to be relative stable across time

§ General factor scores tend to shift – with time, maturation, treatment

§ General factor scores relate (inversely) to markers of psychosocial functioning

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Implicationsfor treatment of personality disorders: shifting our conceptual and clinical focus

Conventional model 1: § Direct treatment to symptoms or

maladaptive behaviors (self-destructiveness, affective dysregulation, lack of goal directedness)

Conventional model 2: § Direct treatment to psychodynamics

Emerging model: § Focus on self and interpersonal

functioning§ Direct treatment to processes that

organize self and interpersonal functioning across personality disorders

§ Tailor treatment to severity of pathology

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DSM Personality Disorders Redux: DSM5 Section III

Alternative Model for Personality Disorders (AMPD) DSM5

• Identity and goal directedness

• Empathy and intimacy

Criterion A:Moderate or greater Impairment in Self

functioning and Interpersonal functioning

• Negative affectivity, detachment, antagonism, disinhibition, psychoticism

Criterion B: One ore more pathological

personality traits

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Prototypes for five levels of severity of self and

interpersonal functioning

0 = NORMAL

1 = MILD IMPAIRMENT SUBSYNDROMAL PD

2 = MODERATE IMPAIRMENTTHRESHOLD FOR PD

3 = SEVERE IMPAIRMENT

4= EXTREME IMPAIRMENT

DSM5-AMPD Level of Personality Functioning Scale (LPFS) - Criterion A DSM-5 AMPD

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DSM-5 AMPDa big step forward for clinicians–but only takes us so far

§ Dimensional orientation, privileges severity, provides information about prognosis

§ Corresponds with clinical reality

§ Supported by empirical findings

BUT

§ AMPD model lacks explicit theoretical framework

§ No organizing underlying model of pathology

§ No direct link between diagnosis and treatment development

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AMPD Meets Object Relations Theory

§ Recent empirical developments focus on general and specific factors in PDs

§ AMPD model of classification of personality disorders

§ Dimensional classification by severity of general factor complemented by description of traits

§ Consistent with object relations theory based approach to personality disorders (Kernberg1984)

§ Object relations model is theory-based

§ Allows clinicians to understand the “whys” of personality disorder and diagnostic classification

§ Helps clinicians appreciate the subjective experience of individual patient with personality pathology

§ Underlying explanatory model provides a link between diagnosis and treatment development

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Object Relations Theory

Linking Diagnosis and Treatment

§ Clinically-based psychodynamic model for conceptualizing and classifying personality pathology

§ Descriptive focus on self and interpersonal functioning

§ Conceptual focus on key psychological processes or “structures” organizing self and interpersonal functioning

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Psychological Structure Defined

§ Stable and enduring pattern of psychological functioning

§ Can be seen to underlie and to organize descriptive features of personality functioning

§ Repetitively activated in particular circumstances

§ Organize an individual’s perceptions, attributions, subjective experience, and behavior

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Centralityof Internal Object Relations

Most basic psychological structure

Internalized relationship pattern

Organize subjective experience of self and other

Building blocks of higher order structures - Identity

Self OtherAffect

Internal object relation

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Neglected Self

Self

OtherSelf

OtherSelf

Other

Unavailable other

Dominant self experience in the moment

Experience of other (therapist) in the moment

FRUSTRATIONNeedy, childlike self

Internal Object Relations Organize Subjective Experience

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Normal Identity Formation

Self

OtherComplex affect states

§ Individual IOR coalesce to form coherent, central sense of self § Complex, continuous sense of others§ Complex and well modulated affect states, predominantly positive§ Contextualization of moment-to-moment sense of self and others§ Mature, adaptive defenses§ Flexible and adaptive self and interpersonal functioning

Other Other

Other

Complex affect states

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S -

O -O+

- affect

- affect

+affect

S++affect

`

S - - affect

Positive affect“Idealized”

Negative affect“Paranoid”

§ Individual IOR do not coalesce - no organized sense of self

§ Impact of splitting -interferes with normal integrative processes

§ Polarization of affective experience

§ Poorly contextualized vacillations between positive and negative affect states

§ Global, severe rigidity in self and interpersonal functioning

O+

S+ S -

O -

O -

Identity Formation in Personality DisordersPredominance of negative affect

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§ Personality disorders as a group understood in terms of failure of integration of psychological structures

§ Failure of identity consolidation central structural feature of all personality disorders

§ Reflects impact of maladaptive (splitting-based) defenses

Object Relations Theory –

Model of Pathology

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§ Assessment focuses on key structures seen to organize self and interpersonal functioning

§ Higher level structures built of organizations of internal object relations

§ Identity, defenses, object relations, moral functioning, aggression

§ Leads to dimensional classification of personality pathology

Approach to Assessment and Classification Linked to Model of Pathology

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Key Psychological

Structures-organizers of

self and interpersonal functioning

•organizes experience of self and others in interaction

Identity

•internal working models of relationships that organize interpersonal functioning

Object relations

•customary ways of coping with external stress and internal conflict

Defensive operations

•ethical behavior, ideals, and values

Moral functioning

•self and/or other-directed

Aggression

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Structural Diagnosis

§ ”Structural Diagnosis” or “Level of Personality Organization”

§ “Neurotic Level of Personality Organization” (NPO)

§ “Borderline Level of Personality Organization” (BPO)

§ NPO - Normal identity formation, higher level defences

§ BPO - Pathology of identity formation, splitting-based defenses

§ High (mild), middle and low (severe) borderline level of personality organization

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Neurotic level of personality organization

EXTRAVERTED

Mild Severity

High borderline level of personality organization

Borderline Personality Disorder

Extreme Severity

Middle to Low borderline level of personality organization

Atypical Psychosis

Hysterical

Histrionic

Narcissistic

Antisocial

Schizoid

Paranoid

Dependent

Avoidant

Depressive

Obsessive- Compulsive

Schizotypal

INTROVERTED

Levels of Personality Organization and Relationship to Familiar Personality Types

Severity ranges from mildest, at the top of the page, to extremely severe at the bottomArrows indicate range of severity for given disorder

§ Capacity for non-exploitative relationships

§ Absence of sociopathy § Conflicts in relation to

dependency and self-esteem with secondary aggression

§ Deteriorating capacity for non-exploitative relationships

§ Significant pathology of moral functioning

§ Deteriorating prognosis§ Conflicts in relation to primary

aggression

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Level of Personality Organization

Normal NPO(LPFS 1)

High BPO (mild)(LPFS 2)

Mid BPO(LPFS 3)

Low BPO (severe)(LPFS 4)

Identity Consolidated Coherentrepresentations of self and others

ConsolidatedCoherentrepresenta-tions of self and others

Partially consolidatedSome distorted and unstable sense of self and others

Poorly consolidated Distorted and unstable sense of self and others

Poorly consolidated Distorted and unstable sense of self and others

Defenses Mature Repression-based

Mixed splitting and repression

Splitting-based

Splitting-based

Object Relations

Mutuality; combines intimacy and sexuality

Mutuality; some rigidity; problems with intimacy

Some capacity for mutual dependency; unstable

Need-fulfilling orientation predominates

Manipulative and exploitive relations with others

Moral Values

Functioning moral compass

Functioning moral compass

Generally adequate

Variablefunctioning

Severe deficits

Aggression Modulated Modulated Self-directed or outbursts, tantrums

Significant destructive features

Severe danger to self/others

IncreasingSeverity

Worsening Prognosis

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The Goals of Treatment: Moving towards greater integration

§ Conceptualized dimensionally (“upwards”)

§ Identity consolidation

§ Shift to more adaptive defenses (to move beyond splitting)

§ Improved self and interpersonal functioning

§ More adaptive coping and adaptation to life

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Treatment: Take 1

Transference-Focused

Psychotherapy (TFP)

§ Psychodynamic treatment for borderline personality disorder

§ Individual, out-patient therapy

§ Manualized, evidence-based

§ Duration at least a year

§ Based in object relations theory as developed by Kernberg (1984)

§ Structural goal of treatment is identity consolidation

§ Improved self and interpersonal functioning

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Transference-focused

psychotherapy (TFP)

§ Treatment model combines psychodynamic exploration with structure

§ Create a setting for exploratory work with the BPD patient

§ Psychodynamic exploration of experience of self and other promotes integration of dissociated mental states / internal object relations

§ Exploration is focused on the transference

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TFP -Differences

from Traditional Psychodynamic

Therapy

§ Therapist and patient establish verbal treatment contract before treatment begins

§ Therapist monitors and maintains frame throughout treatment

§ Therapist has predetermined priorities to address (in contrast to pure free association and “evenly hovering attention”)

§ Therapist combines focus on content of session with attention to what is going on in patient’s external life and on treatment goals

§ “Here-and-now focus” for exploration -patient’s moment-to-moment affective experience and behavior in session

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Transference-focused

psychotherapy –extended (TFP-E)

§ TFP model expanded to develop a general model of psychodynamic therapy for personality disorders

§ Trans-diagnostic treatment for personality pathology

§ Organized in terms of general TFP clinical principles and techniques that apply across the range of pathology

§ Tailored to severity of pathology - e.g., degree of structure, emphasis on early vs. more advanced exploratory interventions

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Treatment Implications of Personality OrganizationNPO(LPFS1)

High BPO (LPFS2)

Mid BPO (LPFS3) Severe BPO (LPFS4)

Clinical Objectives

Flexible functioning in area of conflict

Greater depth and stability to experience of self and others

Resolution of destructive behavior; More coherent and integrated experience of self and others

Behavior control; control of aggression; (More coherent experience of self and others)

Structure -Contract and limit-setting

Less need for structured contract

Structured contract brings conflicts into treatment

Carefully structured contract essential Consider secondary gain

Contracting must be extensive; focus on secondary gainsafety of therapist, patient, family

Treatment process

Prognosis

Centrality of verbal communication

Excellent prognosis

Verbal and non-verbal

Very good prognosis in structured treatment

Non-verbal and CT

Good prognosis; Early phase characterized by acting out

Non-verbal and CT

Guarded prognosis; high risk of destructive acting out

Typical CT Familiar range of affective experience

More highly charged and extreme

Highly charged, intense, poorly integrated; intrusive

Highly charged, highly paranoid intense; experienced as alien

Typical transferences

“Transference focused”

Integrated, stable, subtle distortions

Often not affectively dominant

Idealized, superficial, intermittent paranoia

Often affectively dominant

Polarized, mostly paranoid, chagedunstable, concrete

Affectively dominant

Antisocial and paranoidConcrete

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Treatment Model: Creating a Setting for Exploration

Comprehensive assessment

Explicit treatment goals

Structure Contract/ limits

Behavioral controlActivation in the treatment of pathological behaviors and ways of relating

Exploration

Behavior and experience in the moment - affectExploration organized in terms of object relations enacted in current relationships (including with therapist) More severe pathology greater transference focus

Presenting symptomsPersonality functioningPersonality organizationDominant traits/ DSM5Personality disorder dx

Share diagnostic impression

Part of frame

Anchor treatment in reality and functioning

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The Exploratory Process: Supporting Integration

§ TFP-E is an exploratory treatment –therapeutic action located in process of exploration of patient’s internal experience

§ Overall strategy to tease out and articulate IORs organizing patient’s dominant, conscious self experience in the moment

§ Often in transference but need not be

- More severe the pathology – more affectively salient the transference

§ Gradually broaden patient’s awareness to include IORs that are not part of dominant self experience in the moment - i.e., IORs that are defended against

§ Promote their integration into an organized, continuous sense of self

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Definition of Transference in TFP-E

§ Patient’s moment-to-moment experience of the relationship with therapist

§ Reflects activation of internal object relation, which is then enacted in relation to therapist

§ Transference is window into patient’s internal object relations and interpersonal difficulties

§ Transference IS NOT a realistic window into patient’s developmental history

§ Transference may or may not be affectively salient at a given moment

Patient’s view of Therapist

Patient

Patient’s internal representations

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Utilization of Transference in TFP-E

§ Transference is a window into world of internal object relations

§ An intermediate space in which internal structures are actualized

§ Can be characterized and explored

§ Transference helps us understand patient’s interpersonal problems -transference developments mirror what happens in all significant relationships

§ Interpersonal problems predict developments in transference (at least in retrospect)

Patient’s view of Therapist

Patient

Patient’s internal representations

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Quality of Transference in PDs

§ Rapidly developing

§ Polarized - Idealized or paranoid

§ Extreme and distorted

§ Often affectively charged

§ Poorly contextualized – often concrete

§ Predictably unstable

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• Patient simultaneously identified with both sides of a single dyad• Usually expressed in behavior, dissociated from dominant conscious

experience, or viewed as justified reaction to attack• Impact of projective identification

Self Experience Experience of Therapist

FrustratedWithholding

Withholding Frustrated

Patient’s dominant, conscious experience

Dissociated, enacted aspects of experience

HOSTILITY

HOSTILITY

Instability of Identifications within a DyadTransference and interpersonal conflicts in BPO

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Paranoid-feared object relation

Idealized-wished for object relation

Withholding Frustrated

Perfectly Attentive Caretaker

Perfectly cared for

HOSTILITY

GRATIFICATION

§ Idealized and paranoid object relations defend against one another § Patient shifts between equally distorted, polarized states§ Both conscious but at different times – “mutually dissociated”§ Impact of splitting

Self ExperienceExperience of Therapist

Instability Across DyadsTransference and interpersonal instability in BPO

ALL

CONSCIOUS

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Promoting Integrative Processes: Exploration of Internal Experience in TFP-E

§ Brief clinical illustration

§ Focus on clinical process and the strategies of treatment

§ Strategies guide therapist’s attention and inquiry

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Clinical Example

Presentation: 35 yo executive came to treatment at urging of wife, after being let go from yet another in a series of jobs

Though competent, pattern of idealizing and then abruptly becoming disenchanted with people he worked with, both his bosses and colleagues, and was prone to hostile outbursts at those times. Pattern of provoking and alienating others without really understanding what he was doing or why he kept getting fired. Rather than concerned or able to make changes, he simply felt angry and unfairly treated, also increasingly diminished and inadequate with each failure.

Diagnosis: Mixed PD, prominent sadomasochistic and narcissistic featuresHigh borderline level of personality organization – Adequate moral functioning, capacity for non-exploitative relationships, no evident secondary gainWell defined treatment contract with emphasis on consistent attendance and participation in treatment; specific treatment goal

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Patient came in to say he had just come from his review and had been given negative feedback; he was certain his boss, a “sadistic son of a bitch,” had “enjoyed every moment.”

As he continued to complain about his boss’s character, I attempted to get a clearer understanding of what had happened (clarification). Patient became increasingly agitated and impatient.

I pointed out he seemed agitated by my questions; he responded that I couldn’t possibly understand what it was like to be so unfairly devalued and treated with contempt. I was just another “superior bitch,” just like his boss. His tone was depreciative, hostile and seemed to be escalating

On several occasions when I had tried to speak he quickly interrupted to dismiss me, or to contemptuously mock me by parroting my words,. In CT noted feeling depreciated, attacked and angry.

Clinical Situation

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Therapist’s tasks as she teases out affectively salient object relation

§ Contain affect – therapist’s and patient’s § Listen to three channels of communication

§ Verbal§ Non-verbal § CT

§ Patient saying boss is superior and devaluing; patient feels diminished and angry à

§ Opposite configuration expressed in patient’s behavior in session and CT

§ Object relation of superior, devaluing, sadistic figure in relation to diminished disempowered figure

§ Feelings of humiliation and resentment

§ Patient’s dominant conscious identification is with victim role; unaware of identification with victimizer

§ Where is the dominant affect?

§ Affective salience in beginning of session in relationship with boss

§ As I attempt to clarify affective salience shifts to transference

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strategy 1: putting words to experience

Identify and describe object relation this isaffectively salient

“It seems you see me as looking down on you, maybe even secretly enjoying your sense of humiliation…

… I understand this leaves you angry, and also makes it painful to be here”

Approaching the material through patient’s subjectivity

§ Provides affective containment

§ Communicates empathy

§ Does not suggest that there is a distortion -does not invite patient to step out of his immediate subjectivity

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strategy 1: putting words to experience

Calling attention to the repetitive nature of experience

“Once again you find yourself feeling looked down upon, today with your colleague, as you did last week with me, and also with your boss”

§ Begins to support self-awareness in moment

§ Increased awareness of affect states§ Helps patient to stand back and

observe his experience

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Strategy 2 : calling attention to aspects of immediate experience that are dissociated and denied (within the dyad)

“A bid for reflection”

“ At the same time you see me as looking down on you, it seems you behave in ways, perhaps out of your awareness, likely to leave me feeling put down, or that you hold me in contempt. For example when you mocked me just now and described my comment as ‘pathetic’”

Broaden view to include contradictory and dissociated aspects of immediate experience (“role reversals”)

§ Promoting capacity to step back, observe denied aspects of behavior and experience

§ Introducing alternative perspectives

§ Promoting reflection on internal states

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Strategy 3 : calling attention to aspects of experience that are dissociated and denied (across dyads)

“A bid for reflection”

�I can see that your attitude here today, expressing how lucky you feel to have me as your therapist is clearly heartfelt; at the same time I can’t help but remember our last session, when you were insisting that I am depreciative and unable to understand you.”

Bridge contradictory, views of self and other dissociated across time (splitting)

§ Link defensively dissociated aspects of experience / IORs

§ Promoting contextualization of experience

§ Promoting transient integration (cognitive)§ Promoting reflective processes§ Appreciation of constructed nature of experience § Why would I organize my experience in this way?

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Strategy 3: exploring motivation for defensively splitting off aspects of experience

Focusing on unconscious meanings and motivations: An advanced intervention in TFP-E

�Perhaps you need to forget the negative view of our relationship you experienced last time because you fear those feelings could destroy the positive feelings you have today…. It is as if the negative feelings are too powerful and could too easily swamp the more fragile positive ones”

Hypothesis about meanings of patient’s experience and behavior

§ Promoting self understanding§ When patient is able to tolerate integration in

the moment and is able to reflect….§ Self-understanding promotes containment of

anxiety motivating defense§ Leads to gradual relinquishing maladaptive

defense§ Coalescence of mutually dissociated sectors of

experience§ Personality integration

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The Role of Self Understanding

§ Conventional psychodynamic therapy focuses on promoting self-understanding

§ TFP-E focuses on promoting integrative processes

§ Interpreting unconscious conflict is relatively advanced intervention

§ Especially with more severe pathology

§ More basic interventions support: - Affect containment- Self-observation and self-awareness - Entertain alternate perspectives- Reflect on internal states – mentalize- Contextualize of experience

§ Compromised in areas of conflict in PDs

§ Needed to enable integrative processes

§ Needed to enable the patient to translate self-understanding into therapeutic gain

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TFP-E§ Trans diagnostic psychodynamic therapy for

personality pathology based in object relations theory

§ Embedded in a empirically supported model of pathology linked to model of classification, assessment and treatment

§ Conceptual focus on psychological structures organizing self and interpersonal functioning

§ Clinical focus on patient’s moment to moment experience and behavior in session

§ Objective to promote integrative processes in patient

§ Goal is improved self and interpersonal functioning

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THANK YOU FOR YOUR ATTENTION!