Treating Borderline Personality Disorders

Understanding Intense, Impulsive, and Volatile

Relationships

Presented by

Joseph W. Shannon, Ph.D.

Psychologist

Disclosure

Neither Dr. Joseph W. Shannon, the presenting speaker, nor the activity planners of this program are aware

of any actual, potential or perceived conflict of interest

Sponsored by

Institute for Brain Potential

PO Box 2238

Los Banos, CA 93635

COURSE OBJECTIVES

Participants completing this 6-hour seminar should be able to: 1. Describe five clinical criteria for diagnosing personality pathology. 2. List key features of the borderline personality disorder. 3. Compare and contrast different treatments.

Policies and Procedures

1. Questions are encouraged. However, please try to ask questions related to the topic being discussed. You may ask your question by clicking on “chat.” Your questions will be communicated to the presenter during the breaks. Dr. Shannon will be providing registrants with information as to how to reach him by email for questions after the day of the live broadcast. 2. If you enjoyed this lecture and wish to recommend it to a friend or colleague, please feel free to invite your associates to call our registration division at 866-652-7414 or visit our website at www.IBPceu.com to register for a rebroadcast of the program or to purchase a copy of the DVD. 3. If you are unable to view the live web broadcast, you have two options: a) You may elect to download the webinar through February 21st, 2015. IBP will automatically provide you with a new link to receive the program. b) You may request a free copy of the DVD set of this program and the instructional materials. Send an email to IBP at ceu@4brain.org, fax us at 209-710-8306 or mail the IBP Home Study Division at 245 W Pacheco Blvd, Suite C, Los Banos, CA 93635. Please provide us with your mailing address. If you are not fully satisfied with the DVD and instructional materials, return them to IBP and receive a credit for a future seminar or webinar offered within the next 12 months. 4. For American Disability Act accommodations or for addressing a grievance, please contact customer service at 888-202-2938 or write to IBP at PO Box 2238, Los Banos, CA 93635. 5. An evaluation form is available for each participant at the following URL: http://www.ibpceu.com/content/pdf/borderline-s15-eval.pdf All licensed health professionals are required to complete both sides. Please transmit by February 21st, 2015. 6. IMPORTANT: Your certificate of completion will be available by email, mail or fax following receipt of your fully completed evaluation form. If you request the certificate by mail, it will be mailed within 2 business days upon receipt of your fully completed evaluation form. In the unlikely event that you lose your certificate, please send your request in writing and a check for $15 payable to IBP at PO Box 2238, Los Banos, CA 93635 or call 866-652-7414.

IBP is a nonprofit scientific and educational organization dedicated to promoting advances in behavioral medicine. IBP is entirely supported by the tuition it charges for its seminars and the sale of educational materials. Neither IBP, its planning committee, nor any of its instructors has a material or financial interest with any entity, product, or service mentioned in the seminar unless such relationship is disclosed at the beginning of the program. The information presented is of a general nature. For specific advice, please consult a specialist in your area.

JOSEPH W. SHANNON, Ph.D. Psychologist

1 155 West Third Avenue Columbus, Ohio 43212

Telephone: (614) 297-0422

BORDERLINE PERSONALITY DISORDER: EFFECTIVE TREATMENT WITH

THE IMPOSSIBLE CLIENT"

In recent years mental health professionals have become increasingly aware of and concerned with "disorders of the self which include Borderline Personality Disorder (BPD). While it is clear this pervasive and serious disorder involves a deficient emotional investment in the self, there is much disagreement on how best to conceptualize and treat borderline patients. Effi­cacy of treatment is of special concern when dealing with this population given that borderline patients are notoriously difficult to treat and are prone to develop severe and sometimes life-threatening transference reactions in treatment. By attending this practical workshop, partici­pants will learn how to conceptualize and treat BPD, using both dynamic and short-term approaches. The development and maintenance of BPD will also be explored. The workshop will conclude with a detailed overview of a highly strategic approach to treatment of BPD, namely Dialectical Behavioral Therapy.

As a result of attending this program, participants will be able to:

1. List and describe five clinical criteria for the diagnosis of personality pathology (which can be assessed during the intake interview);

2. List clinical/behavioral cues for borderline personality disorder (BPD). 3. Describe the etiology of BPD with specific reference to developmental

theory. 4. Compare and contrast different approaches to treating BPD. 5. Define treatment non-compliance and present specific guidelines for dealing

with same in treatment. 6. Describe Dialectical Behavioral Therapy (DBT) and discuss how this approach

can be utilized effectively with the borderline patient.

JOSEPH W. SHANNON, Ph.D. Psychologist

1155 West Third Avenue Columbus, Ohio 43212

Telephone: (614) 297-0422

Borderline Personality Disorder: Effective Treatment with the Impossible Client

AGENDA

8:30 - 9:00AM

9:00 - 10:45AM

10:45 - 11:00AM

11:00AM- 12:40PM

12:40 - 1:40PM

1:40 - 2:45PM

2:45 - 3:00PM

3:00 - 4:00PM

4:00PM -

Registration

Definitions and Concepts Diagnostic criteria for BPD

Morning Break

BPD: Clinical Clues Etiology of BPD General Treatment Guidelines

Lunch

Approaches to Treatment/ Consultation

Afternoon Break

Dialectical Behavioral Therapy

Questions, Closure

JOSEPH W. SHANNON, Ph.D. Psychologist

1155 West Third Avenue Columbus, Ohio 43212

Telephone: (614) 297-0422

"BORDERLINE PERSONALITY DISORDER: EFFECTIVE TREATMENT WITH THE

IMPOSSIBLE CLIENT"

I . Introduction : Five Clinical Criteria for Personality Pathology

A. Adaptive inflexibility - rigidity; reluctance to learn new ways of coping; neurotic adherence to old ways of coping which have long-ago outlived their usefulness

B. Tendency to foster vicious cycles - typically lack or have a poorly-defin­ed observing ego; do not benefit from feedback; make same mistakes repeatedly

C. Tenuous stability - problems are extreme and date back to early childhood; "therapy junkies"; "thick file"

D. Cluelessness - are typically oblivious to the severity of their pathology; remarkable ability to project blame or otherwise not take responsibility for their behavior; oftentimes lack awareness regarding the impact of their behavior on others

E. Pathological problem solving - create "psychodramas" in lieu of dealing with problems in a more constructive fashion

II. Diagnostic Criteria: BPD

A. DSMIV (very behavioral and tends to focus on extremes);

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Impulsivity/unpredictability 2. Pattern of unstable and intense interpersonal relationships 3. Inappropriate rage; affective instability, in general 4. Identity disturbance 5. Intolerance of being alone 6. Physically self-damaging acts 7. Chronic feelings of emptiness/boredom 8. Inappropriate, intense anger or difficulty controlling anger (e.g.,

frequent displays of temper, constant anger, recurrent physical (1)

fights) 9. Transient, stress-related paranoid ideation or severe disassociative

symptoms

B. Masterson's (Psvchodvnamic) Definition:

1. Ego defects - Poor reality perception, frustration tolerance and impulse control; will also lack clear ego boundaries - e.g., may feel what others feel in order to avoid individuation

2. Primitive ego-defense mechanisms - Defend against painful emotions by splitting, acting out, clinging, avoiding conflict, denying affect, pro­jecting emotions onto others and identifying with others

3. Object relations are disturbed- They often lack object constancy thus they perceive others in all good or all bad terms.

4. "Borderline triad" - Separation-individuation leads to depression which leads to defense; this is the primary dynamic in working with the border­line client.

a. Separation-individuation - Borderlines are afraid/unable to separate and establish a personal identity; to be effective therapy must be directed toward fostering individuation.

b. Depression - when faced with a push or need to individuate, the borderline will become depressed; this is a re-enactment of the fear of being abandoned by caretakers) when the borderline was attempting to individuate during early development.

c. Defense - Since the depression is painful, the borderline will defend against the push to individuate in order to prevent depression , will act out in an angry self-punishing manner or in a manner that leads to clinging passivity.

C. Freeman's Cognitive -Behavioral Conceptualization: Focuses on these "Schema":

1. I am not sure who I am. 2. I will eventually be abandoned. 3. My (psychic) pain is so intense that I cannot bear it. 4. My anger controls me. I am incapable of modulating my behavior. 5. My feelings control me. I cannot modulate my feelings. 6. He/she is so very, very good that I am so lucky. 7. He/she is so very very, very awful that I cannot bear them. 8. When I am overwhelmed I must escape (by flight or suicide).

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D. Clinical clues: BPD (Shannon 2003)

1. Strong countertransference from the very beginning of treatment 2. Extensive therapy history with many different therapists 3. Typically enter treatment in crisis and present symptoms of major

depression, an anxiety disorder or a somatization disorder 4. Client will test limits from the very beginning of treatment 5. Extensive history of self-destructive behavior (not necessarily self-

mutilation) 6. Alternate between emotional intensity and flat affect 7. Boundless rage which is typically expressed inappropriately 8. Poorly developed observing ego 9. Primitive defenses, most notably splitting, denial and projection 10. Characteristically misread, misinterpret and overreact to the behavior

of others 11. Intolerance of being alone (because they don't like themselves, don't

know how to self-soothe and to make lousy decisions) 12. Narcissistic- the world should revolve around them; you can never do

enough for them; impossible to establish a "track record" with the BPD 13. Intense transference reactions/poor object relations; this leads to chaotic

relationships 14. Typically report history of being abused or neglected by parents; tend to

see themselves as victims; often distort "history" to suit their view of themselves and their world view

15. Psychic/intuitive

16. Typically litigious; the highest risk clients from a malpractice point of view

IH. Etiology ofB.P.D. A. Developmental theories - e.g. object-relations theory and separation-individuation

fixation B. Cognitive - behavioral theories- e.g. Freeman's "schema" model C. Biological/Biogenetic theories

IV. Treatment: General Guidelines

A. Use the client's language. B. Be empathetic, honest and direct. C. Set limits in a clear, respectful manner; written contract/treatment plan is often

helpful. D. Offer the client an explanation of their diagnosis and for the treatment plan you

intend to employ. E. Explain any major therapeutic interventions- i f you spring an intervention on a

client without explaining it, it will raise resistance and anxiety. (3)

F. Help the client identify resources (i.e., people and coping responses) already available to them; reinforce positive coping mechanisms.

G. Review treatment plan from time to time and ask the client for feedback - enhance collaboration; value the client's feedback and don't assume client is being mani­pulative or "gamey".

H. Make diagnostic and therapeutic use of negative interactions with the client. I . Be aware of your countertransference reactions but say nothing to the client;

maintain therapeutic neutrality.

Treatment: Developmental/Psychodvnamic Approach (Goldstein, 1988: Mahler, 1991; Masterson, 1981)

A. Treatment essentially involves "re-parenting" the client. B. Treatment involves three distinct phases:

Deal with the inadequate holding of introiects

a. Therapist is to emphasize nurturing role. b. Task is to be soothing, reassuring, and as flexible a possible. c. Develop "fire drill list" - e.g., three things you do or three

people you can call when you're in pain. d. Foster object constancy - e.g., giving client your business card. e. Honor the client's anger.

"Optimal Disillusionment"

a. At some point, therapist will disappoint, not respond in the hoped for manner.

b. "Let me know when I disappoint you; use words and not your fists to let me know this..."

c. Honor client's anger, but set clear limits on how it can/cannot be expressed.

d. Set firmer limits to encourage independence-e.g., fewer sessions per week.

e. Reward containment of emotions. f. Reward healthy narcissism, i.e., self-soothing behaviors.

3. Encourage Greater Autonomy

a. Goal is for client to see therapist as separate but caring. b. Encourage client to examine attitudes and behaviors which get in

the way of self-mastery, developing positive self-esteem; the deve­lopment of an observing ego (super-ego) is focus.

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C. Throughout each phase of treatment, the primary "meat" of the therapy will be the processing of transference reactions and the management of resistance.

D. Therapy begins as highly structured and directive and becomes more non-directive as client moves through phases.

E. In the early phases of treatment, focus on Axix I issues, symptom reduction; in later stages, focus on modifying attitudinal patterns - i.e., characterological change.

F. Length of Treatment: One year, bi-weekly; open-ended thereafter.

G. Countertransference: Feelings evoked in psychotherapists.

1. Apathy, boredom 2. Rescuer/caretaker fantasy 3. Contempt 4. Fear Be aware of, but "keep your mouth shut" 5. Guilt 6. Helplessness 7. Intruded upon 8. Worthless 9. Nullified

Treatment: Dialectical-Behavior Therapy (DBT) (Lineham, 1993; Beck&Freeman, 1991)

A. Key components of DBT;

1. Change vs . Acceptance 2. Problem solving vs. Validation 3. Irreverence vs. Genuineness, Caring & Warmth 4. Consultation vs. Intervention

B. Goals of DBT:

1. Address skill deficits, especially in problem- solving. 2. Address motivational factors:

a. Faulty beliefs b. Secondary gain for acting out c. Irrational fears about change

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3. Address application of skills in the "real world" via strategic coaching (i.e., telephone calls).

C. Modes of intervention with DBT:

1. Individual psychotherapy

a. Address behaviors that undermine the process of treatment. b. Target/address all life-threatening behaviors. c. Target/address quality of life issues. d. Teach problem analysis/solution analysis skills that can be

generalized to real-life situations.

2. Group skills training

a. Acceptance skills - e.g. mindfulness; stress tolerance , or management skills

b. Change skills - e.g., enhancing interpersonal effectiveness; emotional regulation skills

3. Treatment team meetings - i.e., peer supervision/case consultation

4. Ancillary services - e.g., referring client to other agencies/programs for additional services

VI. Sources of Non-Compliance (See Handout #1)

VII. Questions, Closure

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REFERENCES

Beck, A.T. and Freeman, (1991). Cognitive therapy for personality disorders. New York: Guilford.

Beutler, L .E . and Clarkin, J.F. (1990). Systematic treatment selection. New York: Bruner

Duncan, B. L. , Hubble, M.A. & Miller, S.D. (1997). Psychotherapy with "impossible cases": The efficient treatment of therapy veterans. New York: W.W. Norton & Co.

Freeman, A. and Greenwood, V. (Eds.) (1987). Cognitive Therapy: Applications in psychiatric and medical settings. New York: Human Sciences Press.

Freeman, A., Simon, K.M., Beutler, L . , and Arkowitz, H. (Eds.), (1989). Comprehensive Handbook of cognitive therapy. New York: Plenum Publishers.

Goldstein, W. (1988). An introduction to borderline conditions. Northvale, NJ: Jason Aronson, Inc.

Grinspoon, L . (Ed.) (1987). Personality and personality disorders. Harvard Mental Health Letter. 4 (3), 1-4.

Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.

Linehan, M. (1993); Skills training manual for treating Borderline Personality Disorder. New York: Guilford Press.

Livesley, W.J. (Ed.) (2001). Handbook of personality disorders: Theory, research, and treatment. New York: Guilford Press.

Magnavita, J.J. (1997). Restructuring personality disorders: A short-term, dynamic approach. New York: Guilford Press.

Mahler, M.S. (1971). A study of separation-individuation process and its possible application to borderline phenomena in the psychoanalytical situation. Psychoanalytic Study of the Child. (26), 403-424. New York/Chicago: Quadrangle Books.

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References continued:

Masterson, J- and Rinsley, D. (1975). The borderline syndrome: The role of the mother in genesis and psychic structure of borderline personality. International Journal of Psychoanalysis. 56,163-177.

Masterson, J.F. (1983). Countertransference and psychotherapeutic technique. New York: Bruner/Mazel.

Meichenbaum, D. (1977). Cognitive behavior modification. New York: Plenum Publishers.

Millon, T. (1981). Disorders of personality. New York: John Wiley & Sons.

Shannon, J.W. (2003). "Understanding Anger: Managing Aggression and Hostility." (6 hour, 4 C-D audio seminar). Santa Clara, CA: Cortext Educational Seminars, (1-888-267-8398).

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JOSEPH W. SHANNON, Ph.D. Psychologist

1155 West Third Avenue Columbus, Ohio 43212

Telephone: (614) 297-0422

B o r d e r l i n e P e r s o n a l i t y D i s o r d e r : E f f e c t i v e Therapeutic I n t e r v e n t i o n s w i t h

the "Impossible C l i e n t "

A d d i t i o n a l R e f e r e n c e s :

Bateman, A. and Fonagy, P. (2004). Psychotherapy f o r b o r d e r l i n e p e r s o n a l i ­ty d i s o r d e r : M e n t a l i z a t i o n - b a s e d treatment. New York: Oxford Uni­v e r s i t y P r e s s .

Beck, A., Freeman, A., and Davis, D.D. (2004). C o g n i t i v e therapy of p e r s o n a l i t y d i s o r d e r s , (2nd E d . ) . New York: G u i l f o r d P r e s s .

Goleman, D. (2006). S o c i a l i n t e l l i g e n c e . New York: Bantam Books.

Hooley, J.M., Gruber, S.A., Parker, H.A., Guillaumot, J . , Ragowska, J . and Yurgelun-Todd, D.A. (2010). Neural p r o c e s s i n g of emotional overinvolvement i n b o r d e r l i n e p e r s o n a l i t y d i s o r d e r . J o u r n a l of C l i n i c a l P s y c h i a t r y . Department of Psychology, Harvard U n i v e r s i t y .

Porr, V. (2010). Overcoming b o r d e r l i n e p e r s o n a l i t y d i s o r d e r : A fam i l y guide fo r h e a l i n g and change. New York: Oxford U n i v e r s i t y P r e s s .

Yudofsky, S. C. (2005). F a t a l f l a w s : Navigating d e s t r u c t i v e r e l a t i o n s h i p s w i t h people w i t h d i s o r d e r s of p e r s o n a l i t y and character.Washington, D.C.: American P s y c h i a t r i c P u b l i s h i n g .

Zetzsche, T., F r o d l , T., Preuss, U.W., Schmitt, G., S e i f o r t , D., L e i n s i n g e r , G., Born, C , R e i s e r , M., Moller, H.J., and Meisenzahl, E.M. (2009) . Amygdala volume and d e p r e s s i v e sym­ptoms i n p a t i e n t s w i t h b o r d e r l i n e p e r s o n a l i t y d i s o r d e r . B i o l o g i c a l P s y c h i a t r y , 60 ( 3 ) , 302-310.

*N0TE: These should be added to the l i s t C l a i r e has a l r e a d y on f i l e . Thank you...JWS

Handout #1

TREATMENT OF NON-COMPLIANCE From: Beck and Freeman (1991)

1. Lack of patient skill to collaborate

2. Lack of therapist skill to develop collaboration

3. Environmental stressors preclude changing or reinforce behavior.

4. The patient's ideas and beliefs regarding their potential failure in therapy

5. Patient ideas and beliefs regarding consequences of the patient changing to others

6. Patient ideas and beliefs regarding changing and the "new" self

7. Patient and therapist distortions are congruent.

8. Poor socialization to the therapy model

9. Secondary gain from maintaining the dysfunctional pattern

10. Lack of therapeutic collaboration and alliance

11. Poor timing of interventions

12. Lack of patient motivation

13. Patient rigidity foils compliance

14. Patient has poor impulse control.

15. The goals of therapy are unrealistic, amorphous or vague.

16. The goals of therapy are unstated.

17. There has been no agreement relative to therapy goals.

18. The patient may attempt to assert power.

19. Patient frustration related to lack of therapy progress.

20. Patient's perceptions of lowered status or self-esteem

Psychology in Advertising 173

Unpredictable. T)i met her downtown at a Vorpel Gallery opening. (I was invited, she crashed.) Dressed

In red—the color of a tire truck—she was meant to start tires, not to put them out. I could hear her laughter from across the room. Everyone

could. Her presence drew me to her. Like a moth to a

Intense. fatal flame. Enticing. Consuming. She left soon after arriving, quickly bored and

I by her side. We escaped into the darkness of her loft. We drank. We danced. We thrilled to the night until Dawn—her former bisexual lover and current roommate—objected

to the noise. Passionate and reckless, she threatened to punch out

Reckless. Dawn's lights. Hit was a stormy relationship. She was a rollercoaster of emotion.

Quick to tears. Then to laughter. I was the best thing in her life. I was the worst. It was hard to keep up with her. She was a whirlwind of

activity. Shopping. Drinking. Partying. More shopping. The sex

Provocative. was good. Actually, it was great. Until I found her in bed with another man

and a woman. She was just having fun, she said. She told me she loved me so much she would kill herself (after killing me) if I ever tried to leave her.

She was so emotional, so provocative. Never dull.

Concept, design. A advertising copy: Glenn C. Etlenbogen. Ph.D. Photography: Donna Lynn Brophy

DSM-V Diagnostic Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal

or self-injuring behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by

alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., substance

abuse, binge eating, and reckless driving). (Note: Do not include suicidal or self-injuring behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic

dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of

temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.