Extending Blatt's two-polarity model of personality development to dissociative identity disorder: a theory-building case study

In this theory-building case study, we investigate Blatt's two-polarity model of personality development according to which psychopathology is a consequence of an unbalance between the two developmental lines of interpersonal relatedness and self-definition. Anaclitic psychopathology, such as schizophrenia, histrionic, dependent, and borderline personality disorders, is associated with an excessive and rigid emphasis on interpersonal relatedness. In this theory-building case study, we examine whether this model can be extended to dissociative identity disorder (DID). The patient is a 23-year old Caucasian man who suffers from periodic episodes of dissociation. Consensual qualitative research for case studies is used to quantitatively and qualitatively describe the interplay between symptomatic and interpersonal evolutions throughout 41 sessions of supportive-expressive psychoanalytic psychotherapy. In line with the two-polarity model of personality development, close associations between symptoms of dissociation and dependent interpersonal dynamics were observed. Psychoanalytic interventions focusing on elaboration of the subjective meanings of (past and anticipated) dissociations, and on working through core interpersonal conflicts, are followed by transformations in the patient's interpersonal stances and subjective well-being. No new dissociative episodes were reported during the follow-up assessment three and a half years after the completion of treatment. This case study demonstrates that DID is a form of anaclitic psychopathology as it is associated with a predominant tendency to interpersonal relatedness.

Core Interpersonal Patterns in Complex Trauma and the Process of Change in Psychodynamic Therapy: A Case Comparison Study

We performed a case comparison study to investigate the nature of interpersonal patterns in childhood trauma and the process of change therein. We analyzed three matching cases of childhood trauma that followed a psychodynamic treatment via a mixed-methods design. We found that (1) the core tendency to avoid negative reactions from others through passive behaviors emerged in all three cases, both in childhood and adulthood, (2) core interpersonal patterns transpired in the interaction between patient and therapist and thereby affected the therapeutic relationship, and (3) change ensued when a repetition of core interpersonal patterns was avoided and a new relational experience occurred. The accumulated findings across cases further resulted in several clinical implications and recommendations, such as the importance of the assessment of patients' (covert) conditions, responsiveness, supervision and facilitating patients' agency, and provided several avenues for further research.

Levels of personality organization and internal relational patterns

Background

This study aimed to determine whether level of personality organization is associated with a relational pattern present in an autobiographical narrative about an important interpersonal relationship. The main goals were to explore whether and how the components of the internal relationship pattern, and whether and how the configurations of the components, are related to personality organization, when integrated personality organization (IPO) is taken into account.

Participants and procedure

Assessment of the relational patterns was based on the Core Conflictual Relationship Theme (CCRT) – wishes (WS), responses from others (RO), and responses of the self (RS) – as identified from participants’ self-narratives about important relationships (N = 90).

Results

One-way analysis of variance revealed significant differences between groups with different levels of personality organization, according to one wish of self (WS2 To oppose, hurt, control), five responses of others (RO4 Bad; RO5 Rejecting; RO6 Helpful; RO7 Likes me; RO8 Understanding), and three responses of self (RS1 Helpful; RS4 Oppose and hurt others; RS8 Anxious). Considering the configurations of WS + RO + RS, the results indicate that in the borderline personality organization (BPO) group, the WS Libidinal + RO Frustrating + RS Negative pattern is most prevalent, while in the neurotic personality organization (NPO) and IPO groups, the WS Libidinal + RO Fulfilling + RS Negative and the WS Libidinal + RO Fulfilling + RS Positive configurations are most frequent.

Conclusions

The study supports the thesis that component relationship patterns and their configurations might be related to personality organization. The main differences were found between BPO and IPO with NPO placed between them, in a way congruent with Kernberg’s theory.

Relational schemas as mediators of innovative moments in symptom improvement in major depression

OBJECTIVES

Innovative moments (IMs) are exceptions to the maladaptive framework of meaning that typically motivates clients to seek psychotherapy, and previous studies have shown that IMs are associated with psychotherapy outcomes. While IMs are exceptions that occur at the level of the therapeutic conversation, relational schemas are more stable patterns, and their increased flexibility may facilitate change during psychotherapy. With this in mind, we tested the hypothesis that IMs contribute to outcomes by improving the flexibility of relational schemas.

METHOD

The Core Conflictual Relationship Theme (CCRT) was used to assess relational schemas. IMs were evaluated using the Innovative Moments Coding System. The sample included 22 clients diagnosed with major depressive disorder. The flexibility of the three components of the CCRT (Wishes, responses of the self (RS), and responses of others (RO)) were tested as mediators between IMs and outcomes.

RESULTS

The flexibility of the RS was a mediator between IMs and outcomes, but Wishes and RO were not.

CONCLUSION

These findings align with previous research showing that RS is the component most open to change, whereas the other components seem less sensitive to change during brief therapy. Clinical or methodological significance of this article: This study shows the mediation role of relational schemas in the association between in-session events (innovative moments (IMs)) and the symptoms improvement. It contributes to the literature that emphasizes the importance of relational schemas in psychotherapy by using a mediation model, which has rarely been tested.

Interactions between Obsessional Symptoms and Interpersonal Ambivalences in Psychodynamic Therapy: An Empirical Case Study

The classical symptom specificity hypothesis (Blatt, 1974) particularly associates obsessional symptoms to interpersonal behavior directed at autonomy and separation from others. Cross-sectional group research, however, has yielded inconsistent findings on this predicted association, and a previous empirical case study (Cornelis et al., in press; see Chapter 2) documented obsessional pathology to be rooted in profound ambivalences between autonomous and dependent interpersonal dynamics. Therefore, in the present empirical case study, concrete operationalizations of the classical symptom specificity hypothesis are contrasted to alternative hypotheses based on the observed complexities in Chapter 2. Dynamic associations between obsessional symptoms and interpersonal functioning is further explored, aiming at further contribution to theory building (i.e., through suggestions for potential hypothesis-refinement; Stiles, 2009). Similar to the first empirical case study (Chapter 1), Consensual Qualitative Research for Case studies is used to quantitatively and qualitatively describe the longitudinal, clinical interplay between obsessional symptoms and interpersonal dynamics throughout the process of supportive-expressive psychodynamic therapy. In line with findings from Chapter 1, findings reveal close associations between obsessions and interpersonal dynamics, and therapist interventions focusing on interpersonal conflicts are documented as related to interpersonal and symptomatic alterations. Observations predominantly accord to the ambivalence-hypothesis rather than to the classical symptom specificity hypothesis. Yet, meaningful differences are observed in concrete manifestations of interpersonal ambivalences within significant relationships. Findings are again discussed in light of conceptual and methodological considerations; and limitations and future research indications are addressed.

Change in the core conflictual relationship theme after long-term dynamic psychotherapy

This naturalistic study focuses on changes in central relationship patterns after long-term dynamic psychotherapy (mean duration = 3 years) with experienced psychotherapists. Relationship patterns before and after treatment were assessed according to the core conflictual relationship theme (CCRT) method, which includes 3 components: most frequent wish, response from others, and response of the self. Overall, the main CCRT did not change substantially after therapy. There were, however, a few significant changes for some of the standard cluster categories after therapy. Patients' flexibility regarding their use of different wishes and negative responses from others and the self increased, as did the frequency of positive responses from others and the self. The positive changes in relationship patterns were only rarely related to changes in symptoms and character pathology.

Changes in rigidity and symptoms among adolescents in psychodynamic psychotherapy

The present study examined changes in the rigidity of interpersonal patterns and symptoms in adolescents (ages 15-18) in a year-long psychodynamic psychotherapy. Seventy-two adolescents (30 in treatment and 42 in a non-treatment "community group") underwent Relationship Anecdote Paradigm (RAP) interviews according to the Core Conflictual Relationship Theme method (CCRT; Luborsky & Crits-Christoph, 1998), and completed outcome measures at two time points.

RESULTS

Adolescents in the treatment group became less rigid in their interpersonal patterns and improved significantly in their symptoms, whereas no such changes were observed in the community group. Levels of rigidity were not related to initial symptom distress; however, changes in rigidity were related to improvement in symptoms within the treatment group.

Health and Adaptation in a Multiple Self

It has been suggested recently that the self consists of multifaceted aspects which are not reducible to a singular core or entity. It is unclear whether the degree of multiplicity that individuals with significant pathology experience is linked with health and adaptation. Both an excess and a restricted degree of activity among multiple aspects of the self have been associated with pathology. We explore the evidence that the impact of degree of multiplicity of self upon adaptation may be mediated by: (a) the capacity of the various aspects of the self to engage in a dialogue among each other—that is, to discuss, build upon, or argue with one another; and (b) metacognitive capacity, or the ability to think about one’s own thinking and the thinking of others in a nuanced way and to build an integrated view of different aspects of oneself and others. Implications for conceptualizing psychopathology and psychotherapy research are discussed.

Relationship patterns in alexithymia: a study using the core conflictual relationship theme method

BACKGROUND

Alexithymia is a disturbance in regulating affective states. Clinical observations suggest that alexithymic patients relate to others in a specific way. This paper explores whether specific relationship or transference patterns are typical of alexithymia.

SAMPLING AND METHODS

Relationship patterns were assessed by means of the Core Conflictual Relationship Theme method, standard categories version. This method examines transference patterns and was applied to clinical interview data collected from a sample (n = 31) of mental health outpatients. Alexithymia was assessed by means of a score on the 20-item Toronto Alexithymia Scale corrected for the degree of depression (measured by the Beck Depression Inventory-II). Data were analysed by means of the leaps and bounds regression algorithm for selecting optimal subsets of indicators and by bootstrapping to determine 95% confidence intervals.

RESULTS

First, we observed that alexithymia can be meaningfully explained by typical wishes, typical subjective perceptions of how others respond and one's own typical responses to others. This result indicates that the more marked a patient's alexithymic traits are, the more probable it is that specific transference themes come to the fore. Second, a set of three core indicators of trait alexithymia was mapped: little concern about being good to others, a strong perception of others as cooperative, and weak levels of reacting to others and to conflict by means of somatic symptoms.

CONCLUSION

Alexithymia is related to a double interpersonal indifference: not much is expected from others, nor is there a personal urge to fulfill the expectations of others. Moreover, in alexithymia somatic symptoms proved to be non-reactive to interpersonal situations. Implications for diagnosis and treatment are highlighted. Limitations of our study are that alexithymia was only assessed with a self-report measure and that conclusions are based only upon data from a heterogeneous mental health sample.

Welche Kategorien des zentralen Beziehungs- Konflikt-Themas stehen in Zusammenhang mit Depressions-Symptomen? Eine explorative Studie/ Which core conflictual relationship themes are consistent with depressive symptoms? An exploratory study

OBJECTIVES

We study the pattern of interpersonal alliances typical of depressive symptoms by means of the Core Conflictual Relationship Theme (CCRT) method. In an exploratory manner we examine which CCRT-coded wishes, perceived responses from the other and associated responses of the self predict the magnitude of a score on the Beck Depression Inventory-II.

METHODS

Interview data from 31 mental health patients were coded (CCRT expanded standard categories system). Relations between the CCRT categories and the dependent variable were examined by combining 1000-fold forward stepwise regression analyses, and multiple regression analyses in which confidence intervals were estimated with the bootstrap technique.

RESULTS

Three CCRT categories that jointly explain more than half of the variance were selected: diminished levels of the wish to be understood, and elevated levels of disliking others and of feeling helpless.

CONCLUSIONS

The results and implications for psychotherapy are discussed within a psychoanalytic context. Suggestions for further research are indicated.

Childhood trauma and adult interpersonal functioning: a study using the Core Conflictual Relationship Theme Method (CCRT)

OBJECTIVE

This study aimed to examine the long-term correlates of childhood trauma in regard to interpersonal functioning in adulthood.

METHOD

One hundred and nineteen (N=119) subjects from the Austen Riggs Follow-along Study were included in the study. The Traumatic Antecedent Interview scoring method was used to assess 10 types of childhood trauma. Two additional positive variables were also assessed. Interpersonal patterns in adulthood were assessed using the Core Conflictual Relationship Theme Method.

RESULTS

Subjects reporting childhood physical abuse had a higher prevalence of the wish to be hurt, and experienced others as strict and stern. Those reporting physical neglect had a higher prevalence of the need to be comforted. Subjects who had experienced significant separations during childhood later felt less self-confident in interpersonal situations. Results also showed that subjects who had access to a caretaker/confidant had less need for love. A number of additional findings were nominally significant but did not remain so after correction for multiple comparisons.

CONCLUSIONS

The findings indicate that internalized thoughts and affects regarding childhood traumatic events may still play a role long after the time period of the events. Results also suggest that a continuous measurement approach to the study of traumata may provide information not captured by a dichotomous approach.

Personality traits predicting long-term adjustment after surgery for ulcerative colitis

Very few studies have examined the relationship between personality traits and long-term postoperative psychosocial adjustment. In a sample of 46 patients, we examined the relation between personality traits before pelvic pouch surgery for ulcerative colitis and psychosocial adjustment seven years postoperatively, controlling for the effects of surgical functional outcome. The Karolinska Psychodynamic Profile (KAPP) was used for personality assessment. Surgical functional outcome scales and the Psychosocial Adjustment to Illness Scale were also used. As assessed by the KAPP, poor frustration tolerance, long-standing preoperative problems in sexual functioning, perfectionistic body ideals, and lack of alexithymia predicted poorer postoperative long-term psychosocial adjustment in the areas of health concerns, sexuality, family relations, and psychological distress. Surgical functional outcome itself was a poor predictor of long-term adjustment. The results indicate that it may be beneficial to take personality factors into account in preoperative assessment.

The Same Old Song?-Stability and Change in Relationship Schemas From Adolescence to Young Adulthood

Relationship schemas are core elements of personality that guide interpersonal functioning. The aim of this study is to examine stability and change in relationship schemas across two developmental epochs-adolescence and young adulthood-in the stories that people tell about their interactions with others. Using the Core Conflictual Relationship Theme Method, relationship themes were coded from semistructured interviews conducted in adolescence and again at age 25. The sample consisted of 40 participants in a longitudinal study of adolescent and young adult psychological development. There was considerable stability in the frequency with which particular themes were expressed in the narratives of adolescents and young adults. Significant changes from adolescence to young adulthood included a decrease in the perception of others as rejecting and of the self as opposing others. Young adults saw themselves and others more positively, and used a broader repertoire of themes in their relationship narratives than they had as adolescents. The basic continuity and particular changes in relationship schemas found in this study are consistent with knowledge about the adolescent-to-young-adult transition derived from other empirical and clinical findings. Relationship schemas may be rich units of study for learning about the development of interpersonal functioning.