The All-or-None The All-or-None Phenomenon in Borderline Phenomenon in Borderline

Personality DisorderPersonality Disorder

By Keith Hannan, Ph.D.By Keith Hannan, Ph.D.

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

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.

Clarence Schulz, M.D.Clarence Schulz, M.D.

Schulz, C. G. (1980a). All-or-none phenomena in the Schulz, C. G. (1980a). All-or-none phenomena in the psychotherapy of severe disorders. In J. S. Straus, M. psychotherapy of severe disorders. In J. S. Straus, M. Bowers, T. W. Downey, S. Fleck, S. Jackson, & I. Levine Bowers, T. W. Downey, S. Fleck, S. Jackson, & I. Levine (Eds.), (Eds.), The psychotherapy of schizophreniaThe psychotherapy of schizophrenia (pp. 181– (pp. 181–189). New York: Plenum Medical Book.189). New York: Plenum Medical Book.

Expands on the psychoanalytic concept of splitting-Expands on the psychoanalytic concept of splitting-seeing objects as “all good” or “all bad”seeing objects as “all good” or “all bad”

A useful construct in the treatment of patients with A useful construct in the treatment of patients with Borderline Personality Disorder.Borderline Personality Disorder.

A valuable construct for therapists who are A valuable construct for therapists who are Psychodynamic or Cognitive-BehavioralPsychodynamic or Cognitive-Behavioral

Schulz: All Or None Schulz: All Or None AttitudesAttitudes

All-or-noneAll-or-none IntegratedIntegrated Rigid overcontrol vs. loss of controlRigid overcontrol vs. loss of control Attack entire problem vs. avoidance of Attack entire problem vs. avoidance of

problemproblem Now or neverNow or never Murderous rage or total denial of Murderous rage or total denial of

angeranger Infatuation or denial of dependencyInfatuation or denial of dependency My way or your wayMy way or your way Optimism vs hopelessnessOptimism vs hopelessness Impulsivity vs. failure to actImpulsivity vs. failure to act Extreme attachment vs. rejection of Extreme attachment vs. rejection of

objectobject Harsh disapproval, self-injury vs. Harsh disapproval, self-injury vs.

absent moral constraintabsent moral constraint Narcissistic ideal expectation vs. Narcissistic ideal expectation vs.

despair of accomplishing anythingdespair of accomplishing anything Instant recovery vs. no progressInstant recovery vs. no progress

Modulated expression of affectModulated expression of affect Breakdown problem into manageable Breakdown problem into manageable

partsparts

Ability to tolerate delayAbility to tolerate delay Partial expression of angerPartial expression of anger Mature object dependencyMature object dependency Shared responsibility, cooperationShared responsibility, cooperation Realistic appraisal of limitationsRealistic appraisal of limitations Appropriate decision makingAppropriate decision making

Stable interpersonal relationshipsStable interpersonal relationships Fairly consistent moral regulationsFairly consistent moral regulations

Reasonable, stable goalsReasonable, stable goals

Improvement by small incrementsImprovement by small increments

Clinical Examples of All-or-None Clinical Examples of All-or-None ThinkingThinking

Patient with addiction who vacillates between being Patient with addiction who vacillates between being hopeless about recovery and speaking as though hopeless about recovery and speaking as though sobriety will be easy.sobriety will be easy.

Patient who wanted something from boss. Couldn’t Patient who wanted something from boss. Couldn’t handle the suspense of not knowing whether he would handle the suspense of not knowing whether he would get it. Assumed boss would be withholding. Verbally get it. Assumed boss would be withholding. Verbally attacked boss as being unsupportive. When attacked boss as being unsupportive. When confronted, berated himself for not being good confronted, berated himself for not being good enough.enough.

Patient whose wife berates him, comes home from Patient whose wife berates him, comes home from work saying, “I’m not going to get angry tonight,” only work saying, “I’m not going to get angry tonight,” only to explode and yell at her later.to explode and yell at her later.

Evidence-Based Treatments Evidence-Based Treatments for BPDfor BPD

Incorporate Schulz’s concept of all-or-Incorporate Schulz’s concept of all-or-none thinkingnone thinking

Dialectical Behavior Therapy-Linehan Dialectical Behavior Therapy-Linehan utilizes the concept of dialects to utilizes the concept of dialects to conceptualize the thinking of patients conceptualize the thinking of patients with BPDwith BPD

Transference-Focused Psychotherapy-Transference-Focused Psychotherapy-Kernberg focuses on splitting in the Kernberg focuses on splitting in the transferencetransference

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

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

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.”

All-or-None ThinkingAll-or-None Thinking

Researchers view emotion dysregulation as Researchers view emotion dysregulation as being at the root of BPD.being at the root of BPD.

From a Cognitive-Behavioral perspective, all-From a Cognitive-Behavioral perspective, all-or-none thinking leads to emotion or-none thinking leads to emotion dysregulation.dysregulation.

From a psychodynamic perspective, all-or-none From a psychodynamic perspective, all-or-none thinking is a manifestation of splitting, where thinking is a manifestation of splitting, where patients with BPD cannot simultaneously hold patients with BPD cannot simultaneously hold positive and negative images of self or others. positive and negative images of self or others. Images are “all good” or “all bad.”Images are “all good” or “all bad.”

Countertransference and All-or-Countertransference and All-or-None ThinkingNone Thinking

Patients who respond in extreme ways tend to Patients who respond in extreme ways tend to provoke the strongest countertransference. provoke the strongest countertransference.

Therapists think about BPD patient outside of Therapists think about BPD patient outside of treatmenttreatment

Staff more likely to cross boundaries with BPD Staff more likely to cross boundaries with BPD patientspatients

Projective Identification-the patient behaves in Projective Identification-the patient behaves in ways that provoke the therapist to feel what they ways that provoke the therapist to feel what they are feeling. They externalize their conflict.are feeling. They externalize their conflict.

BPD patients cannot contain.BPD patients cannot contain.

Projective IdentificationProjective Identification

Projective identification on the Projective identification on the inpatient unit (Gabbard) inpatient unit (Gabbard) Occurs at unconscious levelOccurs at unconscious level Pt views and treats staff differentlyPt views and treats staff differently Staff react to pt as though they were the Staff react to pt as though they were the

projected aspectprojected aspect Staff assume highly polarized views of ptStaff assume highly polarized views of pt

Projective IdentificationProjective Identification

Function of projective identification (Gabbard)Function of projective identification (Gabbard) Active mastery of passively experienced traumaActive mastery of passively experienced trauma Maintenance of attachmentsMaintenance of attachments A cry for helpA cry for help A wish for transformationA wish for transformation

• Goals in dealing with projective identificationGoals in dealing with projective identification Engage and reactEngage and react Polarized staff communicate-process the Polarized staff communicate-process the

projectionsprojections Projections are given back to pt in modified formProjections are given back to pt in modified form

Examples of Projective Examples of Projective IdentificationIdentification

Patient afraid at the time of Patient afraid at the time of discharge behaved in ways that left discharge behaved in ways that left me conflicted about whether to re-me conflicted about whether to re-hospitalize her.hospitalize her.

Patient angry with mother reports Patient angry with mother reports mother’s behavior and I feel angry mother’s behavior and I feel angry with mother. Patient denies being with mother. Patient denies being angry with mother.angry with mother.

Schulz: CountertransferenceSchulz: Countertransference Symptom Overidentification Observation Rejection Symptom Overidentification Observation Rejection

Unstable intense Unstable intense relationshipsrelationships

Sides with split Sides with split aspect, accepts as aspect, accepts as realityreality

Keeps split parts Keeps split parts communicatingcommunicating

sees pt as pitting sees pt as pitting staff against each staff against each otherother

Impulsivity, Impulsivity, substance abuse, substance abuse, acting outacting out

Vicariously enjoys the Vicariously enjoys the behaviorbehavior

curbs acting out, sees curbs acting out, sees it as a it as a communicationcommunication

Punishes acting out, Punishes acting out, removes from removes from therapytherapy

Affective instabilityAffective instability Becomes frantic with Becomes frantic with pt, insists on medspt, insists on meds

Empathy, confident Empathy, confident of resolutionof resolution

Ridicules pts feelings, Ridicules pts feelings, premature use of premature use of medsmeds

Intense anger, rageIntense anger, rage Seeks justification in Seeks justification in pts anger, sides with pts anger, sides with ptpt

Sensitive to Sensitive to precipitantsprecipitants

Retaliates or Retaliates or untouched by angeruntouched by anger

Recurrent suicidal Recurrent suicidal threats, self-threats, self-mutilationmutilation

Anxious response, Anxious response, assume responsibilityassume responsibility

Responds with Responds with support and explore support and explore behaviorbehavior

Ignores threats or Ignores threats or terminates treatmentterminates treatment

Identity diffusion, Identity diffusion, negativismnegativism

Feels rejected by pt, Feels rejected by pt, decides things for ptdecides things for pt

Optimal distance with Optimal distance with engagementengagement

Rejects or opposes ptRejects or opposes pt

Emptiness, boredomEmptiness, boredom Tries to entertain ptTries to entertain pt Defense against Defense against affects of affects of achievementachievement

Sees it as pt’s Sees it as pt’s problemproblem

Avoidance of Avoidance of abandonmentabandonment

Dependent Dependent gratificationgratification

Fosters mature Fosters mature dependencydependency

Insists on Insists on autonomous autonomous functioningfunctioning

Helping Patients with All-Helping Patients with All-or-None Thinkingor-None Thinking

Tension between:Tension between: Empathy and interpreting distortionEmpathy and interpreting distortion Engagement and non-reactivityEngagement and non-reactivity Acceptance and desire for changeAcceptance and desire for change Being supportive and fostering independenceBeing supportive and fostering independence

• The environment should:The environment should: Tolerate intense affectTolerate intense affect Non-judgmental, but with a healthy respect for Non-judgmental, but with a healthy respect for

the potential damage caused by acting outthe potential damage caused by acting out Integrate splitsIntegrate splits Communicate wellCommunicate well Encourage modulated verbal expression of Encourage modulated verbal expression of

feelingsfeelings

Treatment TechniquesTreatment Techniques The BasicsThe Basics

““Put your feelings into words”Put your feelings into words” Challenge all or none thinking-help them Challenge all or none thinking-help them

integrate splits, modulate affectintegrate splits, modulate affect Be engaged enough to get “sucked in,” then Be engaged enough to get “sucked in,” then

reflect on itreflect on it Treatment team understands projective Treatment team understands projective

identification and continues to communicateidentification and continues to communicate Progress-two steps forward and one backProgress-two steps forward and one back

Defense against the affects associated Defense against the affects associated with achievement, fear of destructive with achievement, fear of destructive sideside

Countertransference-self-protective Countertransference-self-protective cynicism vs. naïve optimismcynicism vs. naïve optimism

Treatment TechniquesTreatment Techniques Idealization Idealization

Point it out-predict disappointmentPoint it out-predict disappointment Positive and negative sides to itPositive and negative sides to it Avoid being saintly, recognize the splitting Avoid being saintly, recognize the splitting

processprocess Open to the perspective of those being Open to the perspective of those being

devalueddevalued If you overindulge pt, acknowledge this, and If you overindulge pt, acknowledge this, and

process itprocess it• Devaluation Devaluation

Non-defensive without being defenselessNon-defensive without being defenseless Remain in communicationRemain in communication Confident in problem resolutionConfident in problem resolution Aware of pts disorder, real sufferingAware of pts disorder, real suffering If you respond angrily or become avoidant, If you respond angrily or become avoidant,

acknowledge this, and process itacknowledge this, and process it

Negative TransferenceNegative Transference

Negativism-the search for a bad objectNegativism-the search for a bad object ““Warmth through friction”-SchulzWarmth through friction”-Schulz Seeks negative response-pt isn’t the only Seeks negative response-pt isn’t the only

angry person in the roomangry person in the room Staff acknowledge feelings or pt will Staff acknowledge feelings or pt will

escalate, acknowledging anger makes escalate, acknowledging anger makes anger acceptable anger acceptable

Explore why pt wants to elicit such feelingsExplore why pt wants to elicit such feelings Requires staff to feel, then reflectRequires staff to feel, then reflect

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

Our WebinarsKeith 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 AmericansPhil Rich, Ed.D, “Working With Sexually Abusive Youth: Current Perspectives and Approaches”Emerson Wickwire, Ph.D on “Assessment and Treatment of Sleep Disorders.”

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