REFINING THE BORDERLINE PERSONALITY DISORDER PHENOTYPE THROUGH FINITE MIXTURE MODELING
TFP approach to Psychoanalytic Group Psychotherapy
I shall outline, in what follows, strategies, tactics, and techniques of the TFP model of analytic group psychotherapy. The main strategy consists in facilitating the interpretation of Bion’s (1961) basic assumption groups, in the context of a strict focus, on the part of the therapist, on the nature of the primitive object relations and corresponding defensive operations activated in the course of any basic assumption group. In practice, the defensive operations activated in the dependency and in the fight-flight group present the total repertoire of primitive defensive operations based upon splitting mechanisms characteristic for borderline patients. As such, they are eminently relevant for the exploration of the psychopathology of patients with severe personality disorders, who find their dominant emotional reactions powerfully activated in the group situation.
Rather than interpreting the sequential activation of individually determined dominant transferences activated in the course of the group sessions, the therapist’s emphasis is on the sequence of group processes, the progressive and regressive fluctuations of the group tension that facilitates the activation of particular conflicts of individual patients–their “group valence”– at difference times. The individual pathology of any particular patient comes into central focus at a point where he/she occupies one of the polarities of the conflictual dynamics of the group. The fact that the therapist’s interpretations follow the dominant group dynamics, his/her pointing out how this dynamic is played out by different members of the group, practically facilitates interventions geared to individual patients at the time when their corresponding conflicts are affectively dominant. Thus, the TFP principle of interpreting affectively dominant conflicts holds for both the analysis of the group tension (Ezriel, 1950; Sutherland, 1952) and the analysis of the position of key members of the group in the enactment of and reaction to this group tension.
In practice, therefore, after the therapist has interpreted the dominant unconscious dynamics of the prevalent group tension, he may address himself/herself to how this group conflict touches all the individual members’ conflicts in terms of their position taken regarding that particular group conflict. In so far as individual patients’ transferences are directed to other members of the group, to the group as a whole, and to the group leader, moments where all these three vectors come together may provide a powerful source for emotional understanding for individual patients.
The therapist’s interventions in the group are guided by the same principles as the interventions in individual TFP sessions: first, by what is affectively dominant in the group, second, by the nature of dominant transferences operating within the group atmosphere, and third, by his/her countertransference. The therapist’s interventions consist in clarifications–namely, efforts to clarify the dominant issues affecting the group at a certain point; confrontation–namely pointing to the non-verbal behaviors that accompany and often overshadow the verbal communication among group members and of the entire group toward the leader, and interpretation per se–namely, of the unconscious conflict inherent in the activation of a determined group tension and the corresponding basic assumption group. The interpretation consists in focusing on the dominant group theme, by first pointing to the predominant conscious and preconscious experience of the group; then, the opposite, avoided theme and the motives for this avoidance, and finally, the nature of the experienced threat connected with what is avoided.
The therapist maintains an attitude of technical neutrality regarding the developments in the group, limited by his establishing clear rules about what is not tolerated: particularly, physical aggression against the therapist, against other members and property, or gross sexual harassment, such as seductiveness in the form of stripping, or self-destructive behavior, such as self-cutting or burning. The techniques utilized, in short, are interpretation, transference analysis, technical neutrality, and countertransference utilization. Countertransference utilization refers to the analysis in the therapist’s mind, of both concordant and complementary identifications he/she experiences regarding the group as a whole and individual members, followed by the utilization of the understanding of these developments as part of the interpretive formulations.
The technical approach, therefore, follows the same general principles and guidelines of the technical approach in TFP, while the overall strategy, of highlighting and resolving the dominant split off or dissociated primitive internalized object relations of these patients, are systematically explored in the order in which these object relations are achieving dominance as part of the group regression. Dominant object relations may be enacted by the group as a whole in relation to the group leader, by individual members toward the group, the leader, and toward other individual members. By means of the activation of projective identification, the role of self and object representations may be rapidly exchanged among the members of the group as well as between the group and the group leader.
So far the strategic and technical applications of TFP to this modified Ezriel-Sutherland model. From the viewpoint of tactical interventions, they include general arrangements that are specific for a group therapy approach, and particular ones corresponding to the specific application of a TFP model. Regarding general tactical interventions, they refer to the selection of members of the group, a complex decision making process, that, in general terms, corresponds to the same criteria for indications of Transference Focused Psychotherapy in individual patients mentioned before. Contraindications include patients with an intelligence level below an IQ of 85 or 90; severe, uncontrollable secondary gain of illness; significant antisocial behavior, that would risk the confidentiality of group processes to which the participants have to commit themselves, and objectively threaten other group members; and severity of acting out or comorbid conditions that could not be easily handled by an individual therapist taking care of those aspects of treatment outside the setting of the group psychotherapy.
The development of particular complications and severe regression of individuals in the group usually can be managed when the overall group setting is clear and consistent. Chronic monopolizers can be managed easily by pointing to the group’s tolerance or unconscious fostering of such behavior, and its meanings under the concrete group circumstances. The chronically silent patient may be much more behaviorally active in the context of shifting group themes than what is revealed by language alone, and varying meanings of the defensive use of silence can be explored in the context of its function as part of the group process. The manifestation of group resistances in the form of shared, extended silences, trivialization of the contents of the group discussion, demonstrative ignoring of the group leader and of his interventions, all become part and parcel of potential transference interpretations.
Research on TFP
Many groups of researchers all over the world are investigating different aspects of Transference-Focused Psychotherapy (TFP). This research can be grouped into (1) theoretical and conceptual work on borderline personality disorder (BPD) and TFP, (2) conceptual and empirical work on diagnostic instruments for the assessment of different aspects of BPD, and (3) empirical research on the outcome of TFP. Recently empirical research on the neurobiological foundations of BPD and its treatment has been begun in New York as well as Germany and Austria.
Theoretical and conceptual research
The major theoretical work on BPD and TFP origins from Otto F. Kernberg. Modern concepts of BPD go back to his perennial work on “Borderline Conditions and Pathological Narcissim” (1975) and “Severe Personality Disorders” (1984). Until today these books have shaped the diagnostic criteria for BPD in psychiatry and its classification systems ICD-10 and DSM-IV. In his recent work, Kernberg kept refining his concepts and applying it to different clinical conditions related to BPD, e.g., narcissistic personality disorder (Kernberg 1992, 2007, 2008, 2011).
From his theoretical and clinical work emerged the description of a specific treatment for patients with BPD (e.g., Kernberg 1975, 1976) that led to the first treatment manual in 1989 (Kernberg et al. 1989). Together with his co-workers, particularly John F. Clarkin and Frank E. Yeomans, to name only two of them, he refined this treatment, which is now called TFP and validly described in a comprehensive treatment manual (Clarkin et al. 2006).
Based on Kernberg´s concepts a number of modifications of TFP have been developed. Paulina Kernberg was the first to describe personality disorders in children and adolescents and their treatment (Kernberg et al. 2000). Her approach has been developed further by a number of researchers, particularly Pamela Foelsch and Lina Normandin, a treatment manual will soon be published. An adaptation of TFP for forensic patients was developed in the German speaking countries (Lackinger et al. 2008), TFP for higher level (neurotic) personality disorders was conceptualized by Eve Caligor and colleagues (Caligor et al. 2007). Moreover, TFP applications for narcissistic patients, elderly patients, and groups, respectively, as well as inpatient TFP are currently in preparation.
Diagnostic instruments and assessment
In 1981 Kernberg published his first paper on Structural interviewing. His clinically oriented Structural Interview aims at the assessment of personality organization, a concept that is now incorporated into modern psychiatric diagnosis: The DSM-5 classification will contain a Levels of Personality Functioning Scale that is derived from Kernberg´s dimensions of personality organization. Clarkin and colleagues (2003) transformed the Structural Interview into a structured interview, the Structured Interview for Personality Organization (STIPO) that allows for quantification of different dimensions of personality organization. A self-rating instrument that is closely related to the STIPO is the Inventory of Personality Organization (IPO; Clarkin et al. 2001a). Stimulated by Kernberg´s diagnostic approach a number of observer-rated and self-rating instruments occurred during the last decade (for review see Doering & Hörz 2012). The assessment of personality organization (synonym: personality structure, personality functioning) nowadays receives increasing attention in psychiatry and clinical psychology. A number of empirical studies have investigated the relationship of personality disorders and personality organization (e.g., Fischer-Kern et al. 2010; Hörz et al. 2009) and the effect of TFP on personality organization (Doering et al. 2010).
Empirical outcome research
Transference-Focused Psychotherapy (TFP) is an empirically-validated treatment for personality disorder that has proven its efficacy in three uncontrolled studies (Clarkin et al. 2001b, Cuevas et al. 2000, Lopez et al. 2004). These three investigations demonstrated significant improvements in psychopathology, self-mutilizing behaviour, and psychiatric hospitalizations after one year of TFP. Three randomized controlled trials (RCT) evaluated the efficacy of TFP. In the study of Giesen-Bloo et al. (2006) TFP was comparator for Schema Therapy. Both treatments improved psycho- and personality pathology significantly, but Schema Therapy was superior after three years of treatment. These results have been criticised for methodological reasons (Yeomans 2007). A second RCT compared TFP with Diallectic Behavioral Treatment (DBT) and Psychodynamic Supportive Therapy (SPT) (Clarkin et al. 2007). Ninety borderline patients were included into the study and received psychotherapy for one year. All three groups showed significant positive change in depression, anxiety, global functioning, and social adjustment in a multiwave design. TFP and DBT were associated with a significant improvement of suicidality, TFP and SPT improved facets of impulsivity, and only TFP yielded a significant improvement in anger, irritability, and verbal and direct assault. Moreover, only patients that received TFP improved significantly in their reflective function and their attachment style; 28.6% of the TFP patients changed from an insecure to a secure attachment style, whereas none of the DBT and SPT patients did (Levy et al. 2006). In a third RCT TFP was compared to treatment by experienced psychotherapists in the field (Doering et al. 2010). One hundred and four patients were treated for one year in Munich and Vienna, respectively. TFP resulted in a significantly higher remission rate, fewer drop-outs, fewer suicide attempts, fewer psychiatric in-patient admissions, higher improvement of personality structure and psychosocial functioning. A RCT on TFP for adolescents is about to be finalized and reveals encouraging results so far. Taken together, three uncontrolled studies and two randomized controlled trials from independent groups demonstrated the efficacy of TFP for the treatment of borderline personality disorder. A recent Cochrane review on psychotherapy for BPD counts TFP among the “beneficial” borderline treatments together with Dialectc behaviour Therapy (DBT), Mentalization-based Therapy (MBT), Schema Therapy, and STEPPS (Stoffers et al. 2012).
TFP for Narcissistic Patients
Clinical experience involving the treatment of patients with severe narcissistic pathology suggests that this patient population is among the more treatment refractory within the personality disorder spectrum. Recent studies have suggested that patients with Narcissistic Personality Disorder (NPD) now encompass about 6.2% in community samples (Dhawan et al. 2010) and up to 35.7% of clinical populations (Zimmerman et al. 2005). There are also some indications that NPD is more prevalent among young adults in the U.S. (Stinson et al. 2008), and that narcissistic personality traits in the nonclinical young adult population are on the rise (Twenge & Campbell 2009). In addition numerous studies have shown a high degree of co-occurrence of NPD with other Axis II disorders, especially cluster B (borderline, anti-social, histrionic personality disorders), and Axis I disorders, particularly affective disorders (unipolar and bipolar depression), substance use disorders, anxiety disorders, and eating disorders (Fossati et al. 2000, Simonson & Simonson 2012, Zimmerman et al. 2005). Complicating the diagnostic picture is the fact that pathological narcissism spans a spectrum of pathology from neurotic to borderline levels of organization. Indeed, there has been increasing attention to conceptualizing narcissistic disorders as dimensional disorders with varying degrees of pathology of self and object relations, reflected in the current drafts of the DSM-5 (www.dsm-5.org; Bender et al. 2011). The high level of comorbidity along with increasing attention to the dimensional as well as categorical aspects of personality disorders suggest that narcissistic pathology may be a major factor across the personality disorder spectrum (Ronningstam, 2010, 2011).
The current DSM V proposal puts new emphasis on structures and mechanisms related to impairments of self and interpersonal relations in all personality disorders including NPD. Narcissistic disorders are thought to involve 1) Impairments in identity, characterized by a specific pattern or style of unrealistic self experiences, including particularly exaggerated self appraisals; grandiosity expressed either covertly or overtly (exaggerated sense of superiority or inferiority or shifts between the two); and, in some patients, an overreliance on others for shaping the patient’s sense of identity and self definition; 2) Impairments in interpersonal functioning, particularly the use of others for self esteem regulation; superficial, shallow relationships, lacking in empathy, and designed to fulfill the patient’s need for admiration, attention, and validation; and antagonism as opposed to agreeableness in relationships (shown to be associated with narcissistic personality disorder in DSM-5 field trials). Such difficulties in the regulation of aggression along with other impairments in self and interpersonal functioning for individuals with NPD stem from a particular configuration of self and object representations, the pathological grandiose self, which involves a condensation of ideal self, ideal other, and real self representations. Such a self structure excludes the possibility of engaging in relations in depth – there is a “dismantling” of relations with others because of chronic devaluing of others. Negative affects, particularly devalued aspects of self are split off, denied and projected onto others leading to antagonism towards others and an inner sense of emptiness.
As Kernberg (1975) stated, “Pathological vicissitudes of aggression may determine the failure of such … an integration of object representations, with the subsequent development of pathological object relations and a pathological, grandiose self.” (p. 246) Transference Focused Psychotheapy (TFP) is a psychodynamic approach to psychotherapy developed to treat patients with a range of personality disorders at different levels of severity, including individuals with NPD. Borderline and narcissistic personalities share core structural features, specifically, identity pathology, supported by the operation of “primitive” defensive strategies for the unconscious management of intolerable self-states and affects. The central focus of TFP is the identification and naming of maladaptive, distorted self representations, along with their complementary distorted object representations, in the service of interpreting and ultimately resolving the splitting and other primitive defensive operations which prevent a more realistic, integrated, differentiated assessment of self and others. Through the tracking of these self-object dyads in the patient’s internal world, and identifying the defensive processes which support them, through working with negative affects (antagonism) and the object relational dyads that fuel them, TFP constitutes an effective treatment for a spectrum of narcissistic disorders from low to high functioning, i.e., grandiose, vulnerable, malignant. In addition, since TFP emphasizes the identification with both self and object poles of the object relational dyads that comprise the internal world (e.g. grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the different phenotypic presentations, forms of expression, and/or fluctuating mental states from grandiose to vulnerable, from arrogant/entitled to depressed/depleted that may characterize narcissistic personality disturbances (Cain et al. 2011, PDM Task Force 2006).
Based on our clinical experience with and research data on patients with narcissistic personality disorders, we have developed modifications of Transference-Focused Psychotherapy (TFP) to treat patients with different levels of severity of narcissistic pathology (Diamond et al, 2011; Diamond et al. in press). These modifications focus around the centrality of the grandiose self, its central defensive role in psychological structure of the patient with NPD, and how best to address this rigid defensive system. Modifications to standard TFP technique at all stages of TFP include the following: 1) Modifications to the assessment and treatment contracting phase of TFP including a more prolonged and flexible phase of contract setting; 2) A more prolonged phase of inquiry-based interpretive efforts, i.e., those aspects of the interpretive process that focus on requesting clarification from the patient about his or her mental life rather than the more traditional delivery of interpretations by the therapist; and 3) the enumeration of several technical strategies that support the patient’s ability to tolerate the necessarily painful and threatening feelings (e.g., anxiety, rage, a sense of disorientation and/or annihilation) that accompany the more challenging aspects of interpretive work in a psychoanalytic psychotherapy with narcissistic patients. Our clinical formulations have been informed by our research on patients with co-morbid borderline and narcissistic disorders (NPD/BPD) from three international samples of BPD patients in Transference-Focused Psychotherapy. In brief our findings suggest that the NPD/BPD patients may be distinguished from BPD patients without NPD on a variety of clinical dimensions including: 1) a particular pattern of co-morbidity with other AXIS II disorders (histrionic, anti-social, schizoptypal and paranoid) and 2) distinctive internal working models of attachment (Diamond et al. in press). In brief, individuals with NPD/BPD are characterized by attachment representions including dismissing devaluation of attachment relationships, preoccupation with unresolved anger about early attachment experiences, often oscillating between these two contradictory states of mind with respect to attachment—which helps us to understand the fluctuations in narcissistic resistances and transferences that make these patients so challenging to treat. Our research and clinical findings have been presented in a number of publications and presentations that are available on our website. In addition, our faculty have been involved in training and teaching TFP for NPD internationally.