04 Sep The Mechanisms of Change in the Treatment of Borderline Personality Disorder With Transference Focused Psychotherapy
BPD is highly comorbid with other personality disorders, as well as with a number of Axis I disorders, most notably depression, anxiety, eating disorders, posttraumatic stress disorder, and substance abuse (Zanarini et al., 1999). Zanarini and colleagues (Zanarini et al., 1999) found that BPD could be depicted by a pattern of what she called complex comorbidity, characterized by multiple comorbid diagnoses that included both internal- izing and externalizing disorders. Consistently with this finding, Grilo and colleagues (Grilo, Becker, Walker, Edell, & McGlashan, 1997) found that 86% of those meeting criteria for major depression and substance abuse were comorbid for BPD. This is par- ticularly problematic in relation to the finding that treatment outcome studies of Axis I disorders that included comorbid BPD patients have found that BPD has detrimental effects on the treatment of the Axis I disorders—negatively affecting both the psycho- therapeutic and psychopharmacological treatment efficacy for these disorders (see Clar- kin, 1996). Thus, much of what we know about empirically supported treatments for Axis I disorders can be discarded when the patient has a comorbid diagnosis of borderline personality disorder.
Not surprisingly, patients who have borderline personality disorder utilize higher levels of services in emergency rooms, day hospital and partial hospitalization programs, outpatient clinics and inpatient units (Bender et al., 2001). For example, although bor- derline patients made up only 1% of the patient population seen in a psychiatric emer- gency room, they accounted for 12% of all visits (Bongar, Peterson, Golann, & Hardiman, 1990) and 20% of psychiatric hospitalizations (Zanarini & Frankenburg, 2000). In addi- tion, patients who have BPD constitute up to 40% of frequent recidivists in psychiatric hospitals (Geller, 1986; Swigar, Astrachan, Levine, Mayfield, & Radovich, 1991). A survey of Australian psychiatrists found that although patients who have personality dis- orders represented only 6 percent of the patients in treatment, they accounted for 13 percent of the psychiatrists’ treatment time (Andrews & Hadzi-Pavlovic, 1988). Moran, Jenkins, Tylee, Blizard, and Mann (2000) found that those who have personality dis- orders (PDs) are more likely than those who do not have them to consult their general medical practitioner on an emergency basis.
Patients who have BPD typically experience profound impairment in general func- tioning (Bender et al., 2001; Skodal et al., 2002); for example, these patients are often unemployed or underemployed in relation to their capacities, training, and socioeco- nomic status. Perhaps the most perplexing symptom is the high level of parasuicidality (Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983; Zisook, Goff, Sledge, & Schucter,1994), which ranges from 69% to 80%. Parasuicidal behavior predicts suicidality and patients who have BPD have an estimated suicide completion rate of between 8% and 10% (Mc- Glashan, 1986; Stone, 1983).
Several psychotherapy studies have reported evidence for the efficacy (Bateman & Fonagy, 1999; Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Kanter, & Comtois, 1999; Linehan et al., 1999; Linehan et al., 2002; Turner, 2000; Verheul et al., 2003) and effectiveness (Blum, Pfohl, & St. John, 2002; Brown, Newman, Charlesworth, 2004; Clarkin, et al., 2001; Ryle & Golynkina, 2000; Stevenson & Meares, 1992) of specific treatments for patients who have BPD. Furthermore, studies testing the effectiveness and efficacy of new treatments have recently been completed (Giesen-Bloo & Arntz, 2000; Clarkin, Levy, Lenzenweger, & Kernberg, 2005) or are currently being conducted (Markowitz, Skodol, Bleiberg, & Strasser-Vorus, 2004).
One such treatment that has garnered effectiveness and efficacy data in clinical trials is Transference Focused Psychotherapy (TFP; Clarkin et al., 1999, 2001, 2005), a highly structured, twice-weekly modified psychodynamic treatment based on Kernberg’s (1984) object relations model of BPD. Recent studies have demonstrated TFP’s effectiveness in using patients as their own controls (Clarkin et al., 2001) and in comparison to a treatment- as-usual BPD group (Levy, Clarkin, Foelsch, & Kernberg, 2004). In addition, a random- ized control trial (Clarkin, Levy, Lenzenweger, & Kernberg, 2004) comparing TFP, Dialectical Behavioral Therapy (DBT), and supportive psychotherapy (SPT) found reduced suicidality and anger in patients treated with TFP and DBT, but not in those treated with SPT; all three treatments were effective in reducing depression and anxiety and in improv- ing global functioning and social adjustment. Only TFP was consistently related to reduc- tions in aggression (Clarkin et al., 2005) and only TFP showed increases in personality change as indicated by changes in attachment coherence and reflective function1 (Levy, Kelly, Meehan, Reynoso, Clarkin, Lenzenweger, & Kernberg, 2005). Both the findings about aggression and personality organization are important given the focus in TFP on aggression, reflectiveness, and increased integration of representations of self and others.
What is becoming clear is that although BPD is a chronic problem functionally, it is also a highly treatable disorder (Leichsenring & Leibing, 2003; Oldham et al., 2001; Perry, Banon, & Ianni, 1999). What remain uncertain, however, are the mechanisms in the development and maintenance of BPD, the processes of change within patients during treatment, and the specific therapeutic techniques that bring about such changes. Therefore, despite the sup- port for the effectiveness and even efficacy of existing treatments for BPD, researchers are still confronted with a high degree of uncertainty about the underlying processes of change.
In order to conceptualize change mechanisms in psychotherapy, one must address the question of how borderline personality disorder develops. In a series of important articles for conceptualizing child psychotherapy, which are also relevant to the adult literature, Kazdin (1999, 2000, 2001, 2004) proposed that the first stages in treatment development are the following: (1) to elaborate the core affective, cognitive, and behav- ioral mechanisms involved in the development and maintenance of a specific clinical problem; (2) to study multifinality and equifinality for understanding the heterogeneity of a disorder; (3) to understand the relationship between social environments and biological predispositions; and (4) to understand developmental processes, pathways, and the vari- ous courses that the disorder takes. Understanding these questions leads to two additional questions about mechanisms of change: (1) What changes occur within a person? (2) How and why do treatments work for a specific population of clients who have a partic- ular disorder? Or, as Gordon Paul proposed: “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (Paul, 1967, p. 111). Thus, change mechanisms2 can be conceptualized at two levels: (1) what is hypothesized to change in the patient (e.g., increased self-esteem or emotion regulation skills, increased emotional stability, or increased mindfulness) and (2) what are the active ingredients in the treatment that elicit the change in the patient (e.g., the teaching of new skills, interpretation of transference, or provision of emotional support). In the present article we address how TFP conceptualizes mechanisms in the cause and maintenance of BPD as well as change mechanisms both within the patient and in terms of what the therapists does to engender change in the patient.
As do other theories of BPD (e.g., Bateman & Fonagy, 2003; Linehan, 1993), TFP con- ceptualizes the basic etiological elements of BPD as an interaction between constitutional and environmental factors that results in a personality structure or organization character- ized by identity disturbance; use of immature or low-level defense mechanisms such as pro- jective identification, splitting, and omnipotent control; and deficits in social reality testing (although perceptual reality testing is generally maintained). Regarding the interaction between biological constitution and environment, Kernberg (1984) posits that BPD patients have difficulty integrating disparate representations of themselves and others, in part, because negative emotions, particularly aggression, disrupt one’s capacity to integrate these partial representations. Strong unmetabolized or unprocessed emotions have the capacity to over- whelm positive representations. Kernberg further hypothesizes that individuals may there- fore be motivated to keep these representations separate or split in an effort to protect the positive representations of themselves and others (or some combination of self and other representations). These high levels of negative emotionality and aggression can be consti- tutional or engendered through experience, or some combination of the two. Regardless of origin, high levels of aggression interfere with the normative developmental process of inte- grating disparate representations, and instead the high levels of aggression result in a divi- sion between positive and negative representations. Likewise, Siever and colleagues (Gurvits, Koenigsberg, & Siever, 2000) point out that affective instability may interfere with the abil- ity to develop stable perceptions of self and others. They note that both the specific role of aggression and the more general role of affect lability may make the developmental task of integrating stable representations of self and others more difficult to accomplish. However, Kernberg and colleagues (Clarkin, Yeomans, & Kernberg, 2006) also note that emotional instability in borderline personality disorder can be secondary to a lack of differentiation and integration of internal images of self and others, which leads to instability in one’s sense of self and ultimately to affective instability. Thus, the relationship between lack of inte- gration of representations and affective instability may operate in a vicious circle, as the inten- sity of early affects results in a split experience of self and others to protect positive representations, which then may lead to further affective instability by failing to provide a foundation from which to understand oneself and others.
Common factors are usually only conceptualized as elements of psychotherapy that converge across different treatment approaches; however, common factors may also exist in etiological theories. One potential common etiological mechanism in BPD, although articulated in subtly divergent ways, is what Kernberg (1984) calls identity diffusion (an absence of identity consolidation), what Bateman and Fonagy (2003) call a deficit or inhibition of mentalization, and what Linehan (1993) calls a deficit in mindfulness. All of these terms describe a lack of metasocial-cognitive ability to observe, reflect, and describe emotional states; predict and understand behavior; and recognize the difference between inner and outer reality and the capacity to reconcile opposing thoughts or mental states. Likewise, Kernberg, Fonagy, and Linehan all suggest environmental contributions to the development of BPD. Linehan (1993) posits an environment in which the child’s emo- tional experiences have been invalidated. Fonagy and colleagues (Fonagy, Target, Gergely, Allen, & Bateman, 2003) suggest a similar process by which the parent fails to compre- hend the child’s mind. This process results in the child’s having difficulty thinking about his or her own mind and that of others and leaves the child holding the caregiver’s mind. Fonagy contends that the child experiences the caregiver’s projections as “alien” or as an “alien self,” which in Winnicott’s words is experienced as a “false self.” This alien self leaves the child feeling disconnected from his or her true internal world and needing to project the alien self onto others. Likewise, Kernberg describes similar experiences in childhood. Moving beyond these similarities, there are differences in the techniques of how these problems should be addressed and the question of whether these patients can achieve “normal” personality functioning.3 Kernberg’s (1984) concept of identity consolidation, which is characterized by the integration of mental representations of self, others, and affective experience, also appears to be strongly related to patterns of affect and self-regulation. Levy (2000) found that less differentiated and integrated representa- tions of self and other were significantly related to the self-reported use of more mal- adaptive strategies (e.g., self-injurious behaviors, promiscuous sex, illicit drug use, and violent fantasies and behaviors) to regulate negative affective states.
In TFP, hypothesized mechanisms of change derive from Kernberg’s (1984) developmen- tally based theory of BPD, which conceptualizes the disorder in terms of unintegrated and undifferentiated affects and representations (or concepts) of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relations dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a “split” psychological structure in which totally negative representations are split off/ segregated from idealized positive representations of self and other (Figure 1). The puta- tive global mechanism of change in patients treated with TFP is the integration of these polarized affect states and representations of self and other into a more coherent whole. Through the exploration and integration of these “split off” cognitive-affective units of self and other representations, Kernberg postulates that the patient’s awareness and expe- rience in life become more enriched and modulated, and the patient develops the capacity to think more flexibly, realistically, and benevolently. The integration of the split and polarized concepts of self and others leads to a more complex, differentiated, and realistic sense of self and others that allows for better modulation of affects and in turn clearer thinking (Figure 2). Therefore, as split-off representations become integrated, patients tend to experience increased coherence of identity, relationships that are balanced and not at risk of being overwhelmed by aggressive affect, greater capacity for intimacy, reduc- tion in self-destructive behaviors, and general improvement in functioning. This initial conceptualization has been elaborated in light of an evolving developmental and neuro- science empirical literature (Clarkin, in press; Posner et al., 2003).
With regard to the flow of treatment, the structured frame of TFP facilitates the full activation of the patient’s distorted internal representations of self and other in the ongoing relationship between patient and therapist, which constitutes the transference. It is expected that the unintegrated representations of self and other will be activated in the treatment setting as they are in every aspect of the patient’s life. These partial representations are constantly active in determining the patient’s experience of real life interactions and in motivating the patient’s behavior. The difference in the therapy is that the therapist both experiences the patient’s representation of the interaction and nonjudgmentally observes and comments on it (within the psychoanalytic literature, which is known as the third position). This process is facilitated by the therapist’s establishing a treatment frame (e.g., contract), which, in addition to providing structure and holding for the patient and a consensual reality from which to examine acting out behavior, minimizes the therapist’s potential for acting in iatrogenic ways. The therapist does not respond to the patient’s fragmented one-dimensional partial representation but helps the patient observe it and the implied other that is paired with it.
On the practical level, the relationship with the therapist in TFP is structured under controlled conditions in order to allow the patient to experience affects without their overwhelming the situation and destroying communication. The negotiation of a treat- ment frame provides a safe setting—a containment or holding environment—for the reactivation of the internalized relation paradigms. The safety and stability of the thera- peutic environment permit the patient to begin to reflect about what is going on in the present with another person, in light of these internalized paradigms. The process is similar to what attachment theorists would describe as a safe haven, which along with the guidance of an attachment figure allows for the exploration of the content of the mind. With guidance from the therapist, the patient becomes aware of the extent to which his or her perceptions are based more on internalized representations than on what is occurring now. The therapist’s help to structure cognitively what at first seemed chaotic also pro- vides a containing function for the patient’s affects.
TFP fosters change by allowing this reactivation of unintegrated object relations under controlled circumstances that inhibit the vicious circle of setting off reactions in others that often occurs when the patient behaves with emotion dysregulation in the “real” world (often eliciting the very responses that the patient fears from others). The objective and nonjudgmental attitude of the therapist (therapeutic neutrality)4 assists in the reactivation of the internalized experience patterns, their containment, and their explo- ration for new understandings. In this way TFP suspends the ordinary reaction of the social environment in reaction to a disturbed patient and lets the patient live out his or her internal representations in the treatment setting. Then, instead of attempting to deter these behaviors by educative means, TFP draws the patient’s attention to the internal mental representations behind them, with the goal of understanding, modifying, and integrating them. It is believed that this focus on the activation of the patient’s internal world in the therapeutic setting generally leads to a decrease in the level of acting out and chaos in the patient’s life outside the therapy. The therapist is careful to monitor conditions in the patient’s life at the same time as he or she focuses on what plays out in the therapy.
Evidence for Mechanisms of Change: Reflective Functioning as a Measure of Change
Both experimental research and psychotherapy research are useful for studying putative mechanisms of change. In this section, we present research findings from our group related to the hypothesized mechanisms of change explicated previously.
One of the important tactics in TFP is the use of treatment contracts, which occurs before the treatment begins. The function of the contract is to define the responsibilities of patient and therapist, protecting the therapist’s ability to think clearly and reflect, provide a safe place for the patient’s dynamics to unfold, set the stage for interpreting the meaning of deviations from the contract as they occur later in therapy, and provide an organizing therapeutic frame that permits therapy to become an anchor in the patient’s life. The contract specifies the patient responsibilities, such as attendance and participation, pay- ing of fees, and reporting of thoughts and feelings without censoring. The contract also specifies the therapist’s responsibilities, including attending to the schedule; making every effort to understand and, when useful, comment; clarifying the limits of his or her involve- ment; and predicting threats to the treatment. Essentially, the treatment contract makes the expectations of the therapy explicit (Clarkin, 1996). There is some controversy regard- ing the value of treatment contracting. The American Psychiatric Association guidelines recommend that the therapist base the contract on issues of safety (Oldham et al., 2001). Others (Sanderson, Swenson, & Bohus, 2002) have suggested that the evidence contra- indicates their use and shows them to be ineffective (Kroll, 2000). However, Kroll’s study (2000) was designed to determine the extent of no-suicide contracts (which was found to be 57%) and although 42% of psychiatrists who used no-suicide contracts had patients who either committed suicide or made a serious attempt, the design of the study does not allow for assessment of the efficacy of no-suicide contracts. Other data suggest the utility of contracting around self-destructive behavior and treatment threats (Clarkin et al., 2001; Clarkin et al., 2005; Levy et al., 2005; Smith, Koenigsberg, Yeomans, Clar- kin, & Selzer, 1995; Yeomans et al., 1994). For example, Yeomans and colleagues (Yeo- mans et al., 1994) in a pre–post study of 36 BPD patients found that the quality of the therapist’s presentation and handling of the patient’s response to the treatment contract correlated with treatment alliance and the length of treatment. In addition, in our earlier work (Smith et al., 1995), when we did not stress treatment contracting, our dropout rates were high: 31% and 36% at the 3-month and 6-month marks of treatment. However, on the basis of the findings of Yeomans and associates (1994), we further systematized and stressed the importance of the treatment contract, and in later studies (Clarkin et al., 2001, 2005; Levy et al., 2005) we found lower rates of dropout (19%, 13%, and 25%) even over a year-long period of treatment. We suggest that these findings taken together suggest that the treatment contract may have the desired effect of resulting in less dropout and longer treatments. Future research will need to address the issue of treatment con- tracts more directly.
As the patient progresses in the course of TFP from split-off contradictory self-states to reflectiveness and integration, from action to reflection, this increase in reflectiveness involves two specific levels. The first level entails an articulation and reflection of what one feels in the moment. The patient increases in his or her ability to experience, articu- late, and contain an affect and to contextualize it in the moment. This contextualizing of affect in the moment can involve complex and accurate perceptions of both what one (the patient) is experiencing and an understanding of what the other (e.g., the therapist) is experiencing. This level of reflective functioning (RF) may correspond to the therapeutic work of clarifying cognitively what the patient is experiencing in the moment.
A second, more advanced level of reflection is the ability to place the understanding of momentary affect states of self and others into a general context of a relationship between self and others across time. This level of RF reflects the establishment of an integrated sense of self and others—a sense against which momentary perceptions can be compared and put in perspective. We suggest this level of RF is achieved when the therapist moves on from the stage of clarifying the patient’s momentary perceptions of self and other to confronting the contrast and contradictions between different states within the patient’s psyche and interpreting the reasons that these internal states have remained split off. Borderline patients are quite sensitive, for example, to any behavior of others (i.e., the therapist) that suggests disrespect, a personal slight, or abandonment. Early in TFP, one patient experienced the therapist’s arriving 3 minutes late to a session on a snowy morning as proof that the therapist did not like her and did not want to see her. She reacted with rage and hatred in the moment. Gradually, she understood that the “pure” quality of her rage and hatred coexisted, but did not mix, with moments of expe- riencing her therapist as the “perfect” provider. She further understood that in her system, negative affect could not come near the pure positive image of her therapist for fear that it would overwhelm and destroy the latter. As this understanding fostered a growing integration of her image of the therapist as someone who was well intentioned but not perfect, and toward whom she could experience anger, the patient could place frustrating interactions with him in the context of a relationship in which there were also support and consistency from him, so that her reaction at any moment was no longer determined solely by the event of the moment but was modulated by understanding of each specific event in the context of a broader internal image.
The unresolved classification can be the primary clas- sification or the secondary classification in addition to the assignment of an organized style. The AAI is also scored with the Reflective Function Scale (Fonagy, Steele, Steele, & Target, 1997), a 9-point scale, which ranges from 1 (negative RF, in which inter- views are overly concrete, totally barren of mentalization, or grossly distorting of the mental states of others) to 9 (exceptional RF, in which interviews show unusually com- plex, elaborate, or original reasoning about mental states). We believe that the coherence of narrative score and the reflective functioning (RF) score obtained from the Adult Attachment Interview are appropriate operationalized measures of the multilayered inte- grative and reflective process that Kernberg describes. We believe that the reason for change in coherence and reflective function in the TFP treatment, but not in the other two treatments, is that TFP specifically focuses on the integration of disparate mental states and representations. We hypothesize that the TFP therapists would make more bids or appeals for RF. Of course, a question arises about the value of RF as a construct. Fonagy and colleagues (Fonagy, Steele, Moran, Steele, & Higgitt, 1991) found that RF mediated the relationship between parental attachment security and infant attachment security in Ainsworth’s Strange Situation laboratory procedure (Ainsworth, Blehar, Waters, & Wall, 1978). Slade and colleagues (Grienenberger, Kelly, & Slade, 2005; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005) found that a mother’s RF mediates the relationship between atypical maternal behaviors and attachment security in her infants. Fonagy and colleagues (Fonagy et al., 1996) found that among psychiatric patients reporting abuse, those who scored low on RF were more likely to be diagnosed with BPD compared to those who were abused but scored high on RF. However, the importance of these findings is clouded by the relative paucity of research on RF. Certainly RF has been established as an important construct for thinking about parenting behavior; however, less is known about its broader significance. Establishing the validity of the concept is an important step to providing empirical support for the psychoanalytic notion of structural change as a central aspect of change in psychotherapy. Later we present data on the validity of the RF construct by relating it to external measures of neurocognitive functioning, specifi- cally impulsivity and concept formation as measured by the Continuous Performance Task and the Wisconsin Card Sorting Test, respectively.
Impulsivity. On the CPT, RF was not correlated with d9, a measure of sustained atten- tion. However, there was a significant inverse relationship between RF and b, a measure of impulsivity. These findings were similar in the BPD and the comparison samples. Given that sustained attention was maintained, the relationship between RF and impul- sivity is likely not a function of poor attention.
Concept Formation. On the Wisconsin Card Sorting Test, there was no relationship between RF and nonperseverative errors, categories completed, or trials needed to com- plete the task. However, there was a significant inverse relationship between RF and both perseverative errors (i.e., when a participant persists with the wrong answer despite feed- back that it is incorrect) and failure to maintain the set (i.e., when a participant changes a correct answer to an incorrect response despite feedback that the initial answer was cor- rect). Higher RF was correlated with fewer errors of both types. These findings were significant in both the BPD and comparison samples. Perseverative errors are not uncom- mon and are characteristic of a number of other psychiatric conditions. Failure to main- tain the set is a relatively rare response, and a review of the literature suggests that this type of error is characteristic of only one other psychiatric condition, schizotypy. The literature regarding schizotypes suggests that they make these types of errors because of attentional problems (Lenzenweger, personal communication, March 17, 2004). Given that sustained attention was maintained on the CPT, the relationship between RF and failure to maintain the set is likely not a function of poor attention. We suggest that the relationship is a function of a lack of contingency in the mind of patients who have BPD. We believe that this lack of contingency is a function of fluctuating mental states and unintegrated representations of experience.
Affect. Kernberg’s (1984) concept of identity consolidation, which is characterized by the integration of mental representations of self, others, and affective experience, also appears to be strongly related to patterns of affect and self-regulation. Using Blatt’s Object Representation Inventory, Levy (2000) found that less differentiated and inte- grated representations of self and other were significantly related to the self-reported use of more maladaptive strategies (e.g., self-injurious behaviors, promiscuous sex, illicit drug use, and violent fantasies and behaviors) to regulate negative affective states.
These findings taken together suggest, as Kernberg and Fonagy contend, that deficits in reflective function may result in difficulties with impulsivity and affective instability.
Summary and Conclusions
TFP, similarly to most prominent theories of borderline personality disorder, hypoth- esizes an interaction between a constitutional emotional vulnerability and environmental experiences. The exact nature of the constitutional vulnerability can vary but is generally thought to involve an abundance of negative affect, particularly aggression, in ratio to positive affect. Research has shown that positive affect acts as a buffer to negative expe- riences, including one’s own internal negative mental states (Fredrickson, 1998). Without the buffer of positive affect, negative affect colors the perceptions of interactions and distorts internal representations. Despite support from neurobiological and social person- ality research, some have criticized Kernberg’s hypothesis of a constitutional aspect of BPD. Some have argued that the negative affect and aggression seen in BPD patients are solely the result of real traumatic experiences. Although a large and significant portion of patients who have borderline personality disorder have experienced varying types of traumatic experiences, including sexual abuse, which may result in increased levels of aggression, many, and in some samples most, BPD patients have not experienced such traumatic events. In addition, many other disorders are characterized by equivalent types and levels of abuse but do not show the same symptom pattern or pervasive disruptions that are seen in BPD. Thus, although a significant proportion of BPD patients may have achieved their level of anger because of real experience, we need a theory that is broader than the simple “abuse equals aggression in BPD.” Within psychoanalytic circles, some have criticized Kernberg’s focus on constitutional factors, suggesting that they are not necessary for his conceptualization of BPD but instead are a vestige of his loyalty to Freudian theory (e.g., Mitchell, 1988). These critics ignore the growing evidence from neuroscience suggesting endogenous temperamental inputs that a child (and by exten- sion, parents) must grapple with and metabolize. Nevertheless, there are probably mul- tiple pathways for development of BPD, one of which involves serious, prolonged trauma, particularly sexual abuse, that, regardless of constitutional factors, would overwhelm almost anyone’s capacity to integrate the experience (Pynoos, 1993). Other pathways might include disruptions in psychological coherence resulting from high levels of aggres- sion that cannot be metabolized normally.
The concept of mindfulness, which Linehan (1993) integrated into DBT treatment, bears a striking similarity to Bateman and Fonagy’s (2003) concept of mentalization and, as can mentalization, can be seen as a product of integrated representations (Levy, 2004). Mind- fulness is becoming increasingly central in Linehan’s conceptualization of the treatment of BPD (Brodsky & Stanley, 2002; Dimidjian & Linehan, 2003; Robins, 2002). Mindfulness involves the ability to observe, reflect, and describe emotional states while developing focused attention, and it is thought to help BPD patients to develop perspective and tolerate and reg- ulate negative affective experiences without being overwhelmed. According to Linehan, and similarly to Kernberg’s conceptualization, the patient begins to understand a separation between the observer and the observed, and thoughts are not taken as literally “true” and to be acted on. Although there are subtle differences, the concepts of mindfulness, mental- ization, and integrated representation share important conceptual overlaps. Fonagy (Fon- agy et al., 1997) notes that RF is intimately related to the representation of the self (Fonagy & Target, 1995, 1996; Target & Fonagy, 1996).
[fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”]
Working with Personality Disorders at Trauma Recovery Institute
Trauma Recovery Institute offers unparalleled services and treatment approach through unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP) with an added focus on Transference as with transference Focused psychotherapy mentionaed above. This is a highly effect treatment approach with positive treatment outcomes for people suffering with personality disorders.
Dynamic Psychosocialsomatic Psychotherapy (DPP) at Trauma Recovery Institute Dublin
Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.
Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.
“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as clients and therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking and behaviour.”