Dr. Christopher Garrison, LPC-S., NBCDCH

doctorcgarrison@aol.com (210) 693-1484

http://doctorgarrison.com/

Learning Objectives

• Learning Objective 1 Review DSM symptoms of Borderline Personality Disorder (BPD)

• Learning Objective 2 Compare current treatment models of BPD and benefits of Object Relations

• Learning Objective 3 Present the major theorists/concepts of Object Relations Theory

• Learning Objective 4 Review and demonstrate object relations interventions with BPD clients.

• Learning Objective 5 Introduce treatment planning issues from an object relations model

Object Relations Interventions with Clients who Struggle with BPD

• Set the therapeutic environment/tone: Unconditional positive regard, “good enough mothering” (Winnicott) or “good enough parenting (Garrison) .

Review DSM symptoms of Borderline Personality Disorder (BPD)

Two or more symptoms from the following: • Cognition (Manner of perceiving, interpreting,

others, situations) • Affectivity (Internal and external responses to

personal/social situations/perceptions/feeings/thoughts

• Inflexibility and enduring patterns in a board range of personal/social contextual situations

DSM Symptoms

• Emotional/behavioral patterns create significant distress in areas of functioning (e.g. work, personal and social relationships)

• The pattern (symptoms/traits) are enduring and there is a history of symptoms (e.g. adolescent years and early adulthood)

• The enduring pattern is not explained by another disorder (e.g. Bipolar Illness) OR physiological reactions to Substance Abuse/Medications

Clinical Themes of BPD • Emotional Deregulation (also known as labile affect) • Love and Hate/Rage – Idealizing/devaluation • Craving Intimacy, fears of engulfment and abandonment • Splitting behaviors and impaired boundaries • Self-cutting behaviors and other self-destructive behaviors. • Passive suicidal/active suicidal thoughts/gestures • Poor self-image • State of Crisis • Unstable relationships • Higher level and lower-level functioning

Question for Participants: “What are additional themes you have seen?”

Current Treatment Methods

• Dialectical Behavior Therapy (DBT) and cognitive behavior therapies (CBT, Rational-Emotive, reality therapy)

• Psychodynamic therapy • Crisis Intervention Plans • Contracts for Safety • Psychiatric medications to stabilize mood and

impulsive control issues.

Current Treatments Continue

• Experiential and expressive therapies (art therapy, sand tray therapy, journaling, psychodrama)

• Clinical Hypnosis • Couples, family and group treatment Question for Participants: What is your clinical experience of treatment modalities?

What is Object Relations Theory/Therapy?

• Object relations theory refers to the concepts and procedures of a specific school within the psychoanalytical model.

• Object relations therapy is also known as the relational model, refers to the modernized version of psychodynamic treatment with an emphasis upon the interpersonal process within the therapeutic relationship.

Object Relations Theory/Therapy

• An emphasis is on the internalization of “objects/relationships” e.g. people and experiences.

• The emphasis of earlier parental attachments and the experiences that shape the self.

• Our felt reactions, memories, experiences is like a photo album and we may act out these experiences unconsciously or on a sub-conscious level (e.g. repetitive compulsions)

Contributors: Object Relations Theory

• The British School of Object Relations: Klein, Fairbairn, Winnicott and Guntrip: Emphasis is on relationship with parents, internal world, good enough mothering, good/bad self, survival of the self.

• The Ego Psychology School: Hartmann and Jacobson: Emphasis is on the ego and survival, self-representation (refers to the relationship with the self and with the internal/external objects)

Object Relations Theory

• The Interpersonal School of Object Relationship: Sullivan, Horney, and Fromm.

• Emphasis is on biological, sociocultural and political variables contribute to the development and overall health of one’s personality functioning.

• Humanistic driven as evidenced by focusing on self-realization, self-actualization and being in the here-and-now.

Object Relations Schools Continue

• The School of Self-psychology Otto Kernberg (1976, 1984) Kohut (1971/1977) and Margaret Mahler (1967): Kernberg emphasized the earliest relationship with the primary caretaker and how this relationships affects later relationships in adult functioning.

• Kernberg’s theory has focused on borderline personality

disorder and emphasis on a bipolar representations: Self-image, image of others and an affective means.

Interpersonal School - Continue

• Kohut (1971/1977) emphasized the therapist’s empathetic attitude toward the therapeutic relationship as a catalyst for personality reconstruction. In other words, if the therapist is able to provide an empathetic therapeutic environment, clients would be able to internalize the therapist as the good object and work through and finally let go of the bad object and have a healthier self.

Interpersonal School Continue

• Margaret Mahler (1967) formulated a theory of human growth that describes infants develop from autism, symbiosis to object constancy.

• Providing a child became stuck in the earlier two stages, growth is stagnated and differentiation of the self becomes impaired and separation-individuation does not occur.

Object Relations Treatment: BPD

• Set the therapeutic tone/environment: Unconditional positive regard.

• The therapist is to maintain a holding environment of nurturing and balance.

• The clinical evaluation/assessment is crucial: Listen to the client’s overall history of relationships with earlier care-givers (parents), siblings, peers and society at large. Determine the themes, messages and facts.

Object Relations Treatment: BPD - Continue

• Ask the client what he or she learned from these experiences and the messages they heard.

• Educate the client on BPD and symptoms • Normalize the client’s experiences and

diagnosis by affirming there are reasons for the issues.

• Instill hope/responsibility: “You can get well, and it will take work.”

Object Relations Treatment: BPD - Continue

• Set the boundaries: Therapeutic expectations and procedures.

• Consistently use advanced accurate empathy: Step into the clients world, sense the feelings, thoughts, experiences and step out to reflect it back by relying on your experiences. “I sense this must be ….”

• Provide coaching on appropriate responses/behaviors and issue contracts and home-work assignments.

Object Relations Treatment: BPD - Continue

• Validate the client’s strengths and accomplishments.

• Gently confront the challenging areas: “I feel sad when you…..your self-cutting behaviors are not helping you and let’s think together what we can do to help you love yourself…”

• Expect the client to have transference and normalize it.

Object Relations Treatment: BPD - Continue

• Rely on your countertransference to help you to re-frame your felt-reactions as a powerful therapeutic interventions without feeding into it or self-disclosing your struggles!

Do you wish to know more? Yes or No or Maybe?! .

Object Relations Treatment: BPD - Continue

• Set clear and reality-based treatment goals: Please review the handouts on the case-study and treatment plan (these handouts will be distributed in the learning session). Questions and Answers Thank you for attending!

References

Cashdan, S. (1988). Object Relations Therapy Using the Relationship. New York: W. Norton & Company. Celani, D. P. (1993). The Treatment of the Borderline Client: Applying Fairbairn’s Object Relations Theory in the Clinical Setting. Madison, CT: International Universities.

References - Continue

Courtois, A. C. (1988). Healing the Incest Wound: Adult Survivors in Therapy. New York: W. W. Norton & Company. Courtois, A. C. (1997). Guidelines for the treatment of adults abused or possibly abused as children. American Journal of Psychotherapy, 51. (4) 497-511.

References - Continue

Everest, P. (1999). The multiple self: Working with dissociation and trauma. Journal of Analytical Psychology, 44. (4), 443-463. Fairbairn, W.R.D. (1954). An Object Relations theory of the Personality. New York: Basic Books.

References Continue

Everest, P. (1999). The multiple self: Working with dissociation and trauma. Journal of Analytical Psychology, 44. (4), 443-463. Fairbairn, W.R.D. (1954). An Object Relations theory of the Personality. New York: Basic Books.

References Continue

Guntrip, H. (1969). Schizoid Phenomena, Object Relations and the Self. New York: International Universities Press. Guntrip, H. (1971). Psychoanalytic Theory, Therapy, and the Self. New York: Basic Books.

References Continue

Hamilton, N. G. (1995). Object relations units and the ego. Bulletin of the Menninger Clinic, 59 (4), 416-427.Hamilton, N. G. (1988). Self and Others: Object Relations Theory in Practice. Northvale, New Jersey: Jason Aronson, Inc Hartmann, H. (1964). Essays on Ego Psychology. New York: International Universities Press.

References Continue

Horner, A. J. (1984). Object Relations and the Developing Ego in Therapy. New York: Jason Aronson, Inc. Horner, A. J. (1991). Psychoanalytic Object Relations Theory. Northvale, New Jersey: Jason Aronson, Inc. Horney, K. (1939). New Ways in Psychoanalysis. New York: Norton.

References Continue

Mahler, M. (1967). On human symbiosis and the vicissitudes of individuation. Journal of the American Psychoanalytic Association. 15: 740-763. Mahler, M., R. Pine & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books.

References Continue

Mitchell, S. A. (1988). Relational Concepts in Psychoanalysis. Cambridge, MA: Harvard University Press. Schermer, L. V. (2000). Contributions of object relations theory and self psychology to relational psychology and group psychotherapy. International Journal of Group Psychotherapy, 50, (2), 199-217.