Homogeneous group therapy of borderline personality disorder

The authors maintained a time-limited, diagnostically homogeneous psychotherapy group of borderline patients for one year. The group progressed through prototypical stages of group development, but each phase was marked by variations of the aggressive drive and defenses against aggression that are characteristic of this disorder. The group provided a well-suited forum for the exploration of suicidal and homicidal impulses and the development of an observing ego. Despite the limits on generalizability from this group, it appears that group psychotherapy can be a valuable adjunctive modality for some borderline patients.Paper presented at the American Psychiatric Association Conference, Montreal, May, 1988.     

Group psychotherapy with borderline patients: Contrasting remainers and dropouts

Borderline patients present major treatment difficulties in almost every treatment modality. The reason borderlines drop out or fail to benefit from therapy are obscure. Some findings points to the important factor of therapist and patient fit. In the present study, two therapy groups with borderline patients were followed for 20 months. In the study, the therapists were found to individualize the process and their interventions were found to be unevenly distributed among future remainers and dropouts especially during periods of group instability. The results were interpreted along with the Pygmalion hypothesis, that is, that the fit and the therapists' perceived trustworthiness were crucial factors for group psychotherapy outcome for borderline patients.     

Family therapy for the borderline patient

Family therapy can be an appropriate modality of treatment for borderline patients: family sessions may be helpful in making order out of chaos in the system. It also takes into account the fear of separation and other developmental issues which are of concern to the borderline patient. Issues related to the structure and format of sessions in the beginning and middle phase of therapy are discussed. Progress and treatment implications including transference reactions are examined. We have concluded that the family members in a case presented have become considerably stronger and more independent. Their current developmental level indicates that we can begin to work on intrapsychic factors.     

Toward optimum group placement from the perspective of the self or self-experience

This paper offers referring and prospective group analysts/therapists a way of conceptualizing optimum placement. This approach, using the charts provided, will aid in determining the patient's current needs based on past and present selfobject functions, deficits/ derailments, and traumatizations. The charts also offer the group analyst/therapist a tool with which to evaluate the present selfobject functions, impingements, and traumatizations that may be available in a prospective group to determine whether the match is appropriate or whether group should be the treatment modality of choice. When the interviewing analyst/therapist has taken all of the current and past selfobject functions and traumatizations into account, the patient can be expected to benefit from the most growth-enhancing placement available.     

Structural models of psychotherapy groups and their effect on inpatients with borderline personality disorders: Patients' perceptions

This research compares the way in which various group structural models affect self-understanding, interpersonal relationships and catharsis in hospitalized patients with borderline personality disorders. Each of the models is characterized by a different combination of group focus and leadership style. Three psychotherapy groups were chosen as paradigms: the dynamic psychotherapy group; the therapeutic games group, and psychodrama group. Sixty three inpatients with borderline personality disorders participated in the study. The one-way ANOVA yielded significant differences between the group models. Results of the post-hoc t-test showed that the dynamic and the games groups were perceived by the patients as more beneficial than psychodrama.     

The borderline self and the jealous object

The purpose of this paper is to show that just as a therapist working with a borderline patient is often induced with many intense and difficult emotions, similarly, a borderline patient is induced with very intense emotions by his object, which are often experienced as foreign and ego alien to the self. As a result, these induced emotions remain repressed or dissociated from the self, but they continue to play a major role in the borderline's lifestyle. It will be demonstrated that the jealous object, and not the self, is the main factor that interferes with the borderline's growth and progress in treatment. Although a borderline patient may employ primitive defenses such as projective identification and splitting as his primary mode of coping with the bad introject as has been stated by Klein, Kernberg and other writers, I would like to suggest that a borderline patient also employs what I would call dual splittingand dual projective identificationin order to maintain a symbiotic relationship between the selfand its jealous object.     

Semantic processing in aphasia: Evidence from an auditory lexical decision task

W. Milberg and S. E. Blumstein (1981, Brain and Language 14, 371–385) demonstrated semantic facilitation effects in a visual lexical decision task administered to Wernicke and other aphasics with severe comprehension deficits. In an attempt to explore the generalizability of these findings in a task where the acoustic-phonetic system could not be bypassed to access meaning, Wernicke's, Global, Broca's, and Conduction aphasics were administered a lexical decision task in the auditory modality. The patients were also given a simple semantic judgment task using the word pairs from the lexical decision task. The aphasic patients showed evidence of semantic facilitation whether they were categorized by diagnostic group or comprehension level. Performance of the semantic judgment task correlated with the severity of auditory comprehension deficits, whereas the consistency of the semantic facilitation effect did not. Even patients with severe comprehension deficits showed semantic facilitation. These results decrease the likelihood that auditory comprehension deficits are due to semantic organization per se and increase the likelihood that the deficits lie in one of the many processes involved in access to that information.     

Therapeutic factors in interactional inpatient groups: Results from a Turkish sample

Therapeutic factors in an inpatient group from Turkey are presented. A total of 40 patients were seen over a period of 2 years and each patient was given Yalom's (1983) 60-item therapeutic factor list on discharge. The first four most valued therapeutic factor groups were Catharsis, Existential Factors, Cohesiveness and Hope. There were significant differences in the highly valued factors in different diagnostic groups. Patients with diagnoses of anxiety/somatization and borderline/identity problem preferred factors resembling those in many out-patient studies. The results are discussed in the light of relevant literature.     

Factors associated with Borderline pathology in school-age children

The Diagnostic Interview for Borderlines as revised (DIB-R) for use with children and chart review was completed using the records of 54 children, ages 6 to 12 years, who had been admitted to a public psychiatric hospital. Based on the results of the DIB-R, the children were grouped as borderline and nonborderline. The two groups were then compared with regard to 52 independent variables which have historically been associated with the borderline diagnosis. Stepwise logistic regression was used to identify the cluster of diagnostic and independent variables which best discriminated the borderline subjects. Self-destructive behavior, irritable affect, anhedonia, and an externalizing disorder diagnosis at the time of admission accounted for 95.4% of the borderline children. These findings are in contrast to previous studies which have found an assortment of neuropsychological and/or neurological deficits and stressed the importance of a tendency toward psychotic regression on psychological testing as discriminative variables. The authors underscore the idea that borderline pathology may represent a spectrum of disorders and the need for a more specific psychiatric nosology in describing and diagnosing these children.     

Attentional control in OCD and GAD: specificity and associations with core cognitive symptoms

Obsessive–compulsive disorder (OCD) and generalized anxiety disorder (GAD) are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Accordingly, a common diathesis may influence the emergence of excessive thoughts in both disorders. The present study examined deficits in attentional control as a cognitive vulnerability that may contribute to both obsessional thought and perseverative worry. Patients with OCD (n = 30), GAD (n = 29), and non-clinical controls (NCC; n = 29) completed measures of obsessional thoughts, perseverative worry, and attentional control. Deficits in self-reported attentional control were found in both OCD and GAD relative to the NCC. However, attentional control was only related to excessive cognition in the GAD patient group, where deficits were associated with increased perseverative worry. Mediational modeling suggested that trait anxiety mediated the relationship between attentional control and perseverative worry in GAD. Implications of these findings for conceptualizing the role of attentional control in the genesis of excessive cognitions in OCD and GAD are discussed.     

The effect of therapist interventions on the therapeutic alliance with borderline patients

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.     

REFLECTIVE BORDERLINE GROUP THERAPY: THE PATIENTS' EXPERIENCE OF BEING BORDERLINE

This paper describes a novel 20-week psycho-educational group therapy for borderline patients. The therapy aims to stabilize the disorganized and chaotic presenting behaviours of the patients when they enter the borderline treatment service by providing a group psycho-educational programme based upon a psychodynamic appreciation of symptoms, causes, defences and affects. We think that borderline patients will only take in such understandings if they feel listened to and understood in a way that may not have been available to them as children. To do this, the therapists need to create a reflective space underpinned by psychodynamic thought and respecting the patient's experience of being borderline. The paper illustrates the difficulties encountered and discusses the importance of containing or modifying the counter-transference stresses felt by the therapists.

The authors also report on some recent outcome data collected from the running of the group programme over the last 4 years. Twenty borderline patients were able to complete the pre- and post-treatment self-report questionnaires. The results indicate some positive signs in extra-punitive symptom control and levels of impulsivity. Significant levels of improvement were noted in the BSI total scores (p=0.048) with particular reduction in interpersonal sensitivity (p=0.007) and the hostility (p=0.008) sub scores. Patients also reported a reduction in ‘feeling like’ scores on the Multi Impulsivity Scale – reflecting an improvement in internal affect triggers that might result in impulsive behaviours.

The authors discuss the potential value of this pragmatic model of care that is underpinned by psychoanalytic thinking, and its application to managing long waiting lists in psychotherapy services for borderline patients.     

Psychoanalytic Psychotherapy for Severely Disturbed Borderline Patients: Observations on the Supervision Group of Psychotherapists

The authors describe the role of a supervision group of psychotherapists within a wider therapeutic field for severely disturbed borderline patients. The group concentrates on the transference and countertransference, seen according to Racker’s distinction between concordant and complementary identifications. The implications of the prevalence of the complementary identifications over the concordant identifications of the therapists to their patients and the resulting regression to primitive defense mechanisms can be counterbalanced by the group’s integrative functioning as receiver (1) of a variety of information about the patient, (2) of the therapist’s attempt to understand and synthesize, and (3) of the therapist’s countertransference reactions to his patient. The major discrepancies between the various conceptions of the borderline patients’ psychic world and the appropriate therapeutic technique to be applied are also discussed, as well as the way the group filters the information and integrates the therapeutic thought. It might be said, therefore, that, in the “inpatient” phase of the individual psychotherapy, the group of psychotherapists functions, for the patient and the treatment, in a synthesizing context, as it provides the therapist with a space of integration for his split-off part of self and object representations, which the therapist makes use of for his patient.*Members of the Athens University Project for Borderline Patients’ research team consisting of psychoanalysts and psychotherapists, Eginition Hospital, 74 Vas Sophias Avenue, Athens 11528, Greece.Maria Chatziandreou, M.D., is a member of the Hellenic Psychoanalytical Society.Haris Tsani, M.D., is a candidate of the Hellenic Psychoanalytical Society.Nikos Lamnidis, M.D., is a candidate of the Hellenic Psychoanalytical Society.Claire Synodinou, Ph.D., is a member of the Paris Psychoanalytical Society and an associate professor at Panteion University, Athens.Grigoris Vaslamatzis, M.D., is a training analyst of the Hellenic Society of Psychoanalytic Psychotherapy and an associate professor of psychiatry at Athens University.Address correspondence to: Maria Chatziandreou, M.D., 1-3, Skippi Street, 11525 Athens, Greece.     

Delis-Kaplan Executive Function System

The purpose of the current study was to examine the performance of children with and without ADHD in time reproduction tasks involving varying durations and modalities. Twenty children with ADHD and 20 healthy controls completed time reproduction tasks in three modalities (auditory, visual, and a unique combined auditory/visual condition) and six durations (1 second, 4 seconds, 12 seconds, 24 seconds, 48 seconds, and 60 seconds). Consistent with our predictions, we found main effects of group (participants with ADHD were significantly less accurate than those without ADHD), duration (accuracy decreased as temporal duration increased), and modality (responses in the combined condition were more accurate than those in the auditory condition, which in turn were more accurate than those in the visual condition). Furthermore, predicted interactions between group and duration (the discrepancy in performance between the two groups grew as temporal duration increased), and group and modality (the modality effect was of greater for participants with ADHD) were supported. A marginal, nonsignificant interaction between group, modality, and duration was also found. These findings are discussed in relation to current theory on the nature of cognitive deficits evident in individuals with ADHD, and methodological limitations are noted.     

Some comments on the role of cotherapists in group psychotherapy with borderline patients

This paper points out examples of patients in a psychotherapy group who meet DSM-III criteria for the diagnosis of borderline personality disorder and who are treated by cotherapists utilizing object relations theory. Interpretations of phenomena shown by borderline patients—splitting, projective identification and denial—are illustrated. How cotherapy lends itself to the recognition and management of the problems these patients bring to group psychotherapy is illustrated.Hope Aspell assisted in the editing of this paper.     

DSM-IV criteria for borderline personality disorder: A critical evaluation

The present article critically examines the diagnostic criteria for borderline personality disorder (BPD) recently proposed by the DSM-IV Axis II work group (Gunderson, J. G., et al., Journal of Personality Disorders, 5, 340–352, 1991). It is concluded that some of the revisions are trivial and there is insufficient justification for others. The revisions are likely to increase the overlap between BPD and other disorders and represent an attempt to retain a categorical classification in the face of evidence that a dimensional model is more appropriate. Evidence suggests that many borderline traits are manifestations of extreme neuroticism.     

Cognitive and attentional deficits in children vulnerable to psychopathology

Cognitive and attentional deficits were assessed in children with either a schizophrenic, an affectively disordered or a normal parent. The children were grouped both by their parents' DSM-II diagnoses (broadly defined group of schizophrenics and heterogeneous group of depressives)and by a new set of diagnoses (narrowly defined group of schizophrenics, unipolar depressive group and bipolar group). Children whose parents met the more stringent criteria for schizoprhenia performed somewhat more deviantly than children whose parents met only DSM-II criteria. In addition, the importance of splitting the heterogeneous depressive group into more homogeneous subgroups is indicated by the findings that children of unipolar parents generally could not be distinguished from children whose parents are schizophrenic. On the other hand, children of bipolar parents performed reliably better than children of schizophrenics. These findings are viewed within the context of current high-risk studies and psychological deficit literature and suggest that diagnostic issues require more attention by researchers in these areas.This research was supported by Grant MH 21145 from the National Institute of Mental Health. The authors are indebted to Lina Jandorf for assistance in testing the children and with the data analyses.     

Preadolescents' borderline personality features in a non‐Western urban context: Concurrent and longitudinal associations with physical and relational aggression,friendship exclusivity and peer victimization

The present study examined children's borderline personality features and their association with developmentally appropriate factors, including friendship exclusivity, forms of aggression and peer maltreatment with a non‐Western urban sample. The participants consisted of 234 Japanese preadolescents who were in the fourth and fifth grade (50% girls; ages: 9–11). Results of correlational analyses show that borderline personality features were stable during a six‐month period (r = 0.55). Moreover, results of mixed linear models indicate that friendship exclusivity was associated with elevated borderline personality features concurrently and longitudinally, after controlling for the effects of physical and relational aggression. Physical aggression (not relational aggression) and physical victimization (not relational victimization) also predicted relative increases in borderline personality features. These findings are discussed from a cultural‐developmental perspective.     

The Therapeutic Community Sing: Music Therapy Inpatient Group Process

Early psychoanalytic authors and music educators in both Europe and the United States pointed to the contemporary use of music therapy as a powerful modality in an inpatient psychiatric unit. The inpatient community sing is discussed in its capacity to address both individual and group goals. A clinical vignette from such a group is presented and discussed.