Object Relations in Borderline Adolescents DREW WESTEN, PH.D. , PAM ELA LUD O LPH , PIl .D. , HO W ARD LER NER , PH.D. , STEPHEN RUFFINS, PH.D ., A ND F. CHA RLES W ISS , M .A.
Abstract. Alth ough path ological object relations is a core aspect of bord erline psychopathology, few studi es have examined bor derline obje ct rela tions empirically, and none has focused on borde rline adoles cents. The present study exam ined four dime nsions of obj ect relations, as measured by the Themati c Apperception Tes t, in a sa mple of ado lescen t borderlines, psychiatric comparison subje cts, and nor mals. Th ese dim ensions are complexity of object repre sentat ions , affect-tone of relationship parad igms, capaci ty for emotional investment in relationships and mora l standards, and understan di ng of soc ial causality . Borderlines diff ered significantly from both comparison groups in several distinct ways , suppor ting so me aspects of psychoana lytic theor ies of borderl ine object relat ion s, while challenging other s . Borde rline ado lescents have a male volent object wor ld, a relative incapacity to invest in other s in a non-need-gratifying way , and a tend ency to attrib ute moti vation to others in simpl e , illogical , and idiosyncratic ways. Their object repre sentations, however, can be quite complex , suggesting som ething other than a preoedipal arrest. J . Am . Acad. Child Adol esc. Psychiatry , 1990 , 29 , 3:338-348 . Key Words: borderl ine perso nali ty disor der , object relations, ado lescent psychopathology, personality disorders . Changes in DS M-III-R , perm itting limit ed diagnosis of person alit y disord ers in ado lesce nce, accord with the ex perience of clinician s , who co me in contact dail y with adolescents who meet criteria for Borderline Personality Disorder (BPD) or Kern berg 's (1975) criteria for bord erlin e personality organizatio n. Th ese ado lesce nts typ icall y present with suicide attempts or gestures, and they are characteri zed by the sa me patt ern s of splitting , devaluation , manipulation , need- gratifyin g object re latio ns, impul sivit y , and ego deficits that one find s in bor derline adults (M asterson, 1972 , 1980; Kornberg , 1978 ) . A study by McManus et a!. (1984) found that borderline adolescents could be discriminated from other psychiat ric inpatie nt adolescent s , using the Diag nos tic Interview for Bord erl ines (G underso n et aI. , IlJ8 1). Two rece nt stud ies (Wes ten et al., IYYU ; LUdolph et al., in press) simila rly found not only th at borderline ado lesc ents co uld be d iscriminated from psyc hiatric and norm al compa rison subj ects on the basis of their DIB sco res , but that borderline adolescents differed fro m non bo rderline psychi atr ic patients on a variety of dev elopm ental history variables, including abu se , neglect , matern al reje ction , and multiple caretakers or parenta l surrogates . Th eorists of borderline path ology in ado lesce nce tend to
Accepted May 12, 1989 . From the Departments of Psych ology and Psychiatry, and University Centerfor the Child lind the Fam ily , University oj Michigan. This research was supported by a grant fr om the Department (1 Psychia try, and by the Center fo r the Child and the Family and the Faculty Fund. Department (1 Psychology , University of Michigan. The authors would like to express their appreciation to John Boekump , Laura Gold, Alfred Kellam , Natasha Lifton , and Mara Silverman [o r their help in coding the data; to Tom TenHave Jor statistical consultation; and to members oj the Adolescent Development Study (Anne Jackson, Barbara Misle, Judith Block, and Jean Wixom) for help in data collection and fo r comments on a draft oJ the manuscript . Request reprints fr om Dr . Westen at Department (1 Psych ology , University oj Michigan, 580 Union Drive, Ann Arbor, Michigan 481091346. OR90-8567 /l)0/2903-0338$02 .001O© 1990 by the American Academ y of Child and Ado lesce nt Psychiatr y .
338
stress the continuity of the ado lescent and adult borde rli ne sy ndro me , altho ugh often suggesting that the bord erl ine d iagno sis is more d ifficult to make in ado lescence (Kernberg, 1978) . Kernberg (1975) argues that the roots of borderline object relations in adolescents and adults lie in a development al failure in the pre oed ipal years to integrate posit ive and nega tive representations of the se lf and of others and , hence, to achieve libid inal object co nstancy, that is , the ability to love someone even whe n he or she is not cur rently gratifyi ng . Ma sterson (\ 972, 1978 , 1980 ) locates the or igins of borderline disorders in the same developmental period , namely the rapprochement stag e of sep aration-indi viduation (Mahler et al. , 1975). According to Masterson , the origin of bord erline psychopathology typi call y lies in a mother who has so m uc h dilficulty wi th se para tion-indiv id ua tio n that she will not allow her child to develop auto no mo usly, instead withdraw ing and reject ing the child ' s age-appropriate efforts at indiv iduation . Th e child co nseque ntly splits off two object-relation al part-units: a withdrawing object-re lations unit, whi ch includes a represe ntation of a malevolent moth er abando ning the " bad " child for atte mpts at ind ividuatio n and an affec tive com po ne nt of aba ndo nme ntdepression and rage ; and a rewarding obje ct-re lations unit , which incl udes a representation of a gratify ing moth er , a depe nde nt, "good, " complia nt sel f who mu st sacrifice autonomy to maintain matern al suppl ies , and correspond ing affect. Although the relati on ship betw een the borderline diagn osis in childhoo d and adulthoo d has been a matte r of controversy (Gree nma n et al., 1986) , acc ord ing to most theo ries , adolesce nce is a lik ely period for the emerge nce of bord erline psych opathology , both bec ause of the con solida tion o f pe rso nality struc ture which should occur during that time , and because of the sali en ce of con cerns about identity and indi viduation .
Empirical Studies of Borderllne Object Relations Empirical stud ies of object relati on s in reli abl y diagn osed bord erline pati ent s have foc use d exclu sively on adult subject s and have relied prim aril y on exa mi nation of human
BORDERI ,1NI, ;\1)01,1 ,SCI ,NTS
figure responses on the Rorschach Inkblot Test. Most of these studies have compared borderline patients with schizophrenics on Blatt's Rorschach measure for object relations (Blatt et al., 1976), which assesses several qualities of human figure responses and yields an overall developmental level score, from primitive to mature. Although findings on particular subscales have been less consistent (Gartner, et al., 1989; Lerner and St. Peter, 1984; Spear and Sugarman, 1984; Hymowitz et al., 1983), these studies have found that borderlines typically score higher on developmental level than schizophrenics, as predicted. Most studies have found that borderlines have a more hostile, malevolent object world than other patient groups (Stuart et al., in press; Lerner and St. Peter, 1984; Spear and Sugarman, 1984). Contrary to what one would expect from a developmental theory of borderline object relations, however, two of these studies have found that borderlines produce more cognitive-developmentally advanced representations than even normal or neurotic comparison subjects, manifest in relatively complex representations of the intentions of figures, usually of a malevolent nature, on the Rorschach. For the borderlines, unlike most comparison groups, more cognitively advanced responses typically occur with human figures that are inaccurately perceived, i.e., on responses with low form level (a measure of accuracy of reality testing). In other words, borderlines tend to produce malevolent, idiosyncratic, but in certain respects, cognitivcly rich and complex representations of people on the Rorschach. One recent study has used Thematic Apperception Test (TAT) responses to investigate the object relations of reliably diagnosed adult inpatient borderlines, major depressives, and normals (Westen et al., in press a). The TAT, a projective test in which subjects create stories in response to cards depicting ambiguous social scenes, is a useful test for assessing object relations because, unlike the Rorschach, the stimulus is unambiguously social, and subjects are likely to provide enough detail in describing characters and relationships to provide considerable information about enduring cognitive and affective processes mediating their experience of relationships. Westen and colleagues examined four dimensions of object relations (described in more detail below): complexity of representations of people (the extent to which the subject attributes complex dispositions to characters whose perspectives are clearly differentiated); affect-tone of relationship paradigms (the affective quality of the object world, from malevolent to benevolent); capacity for emotional investment in relationships and moral standards (the extent to which the person transcends a need-gratifying interpersonal orientation); and understanding of social causality (the extent to which attributions of causality in the social realm are logical, complex, and psychologically-minded). As predicted, borderlines and major depressives both produced representations of people and interactions less complex, and at a lower level of understanding of causality than normals. The borderline group produced more poorly differentiated representations and grossly illogical attributions of causality than either comparison group. Borderlines manifested the most malevolent object world, followed by major depresJ.Am.Acad. Child Adolesc. Psychiatry, 29:3, May 1990
sives , and then by normals, with a similar pattern emcrging in capacity for emotional investment, as predicted. The investigators note that although borderlines as a group produced less complex and differentiated representations than normals, a substantial number of borderline subjects produced some responses evidencing a high level of complexity and differentiation of object representations. This finding, like the Rorschach finding, challenges the notion that one can explain borderline object relations as a simple developmental disturbance. An alternative formulation is that object relations consist of a number of distinct but interdependent cognitive and affective processes. Functioning on cach of these eli mensions may vary across individuals as well as within an individual at any given time (Westen, in press a, b , 1989). In other words, while borderlines may manifest a tendency to activate more malevolent representations than other patients, under certain conditions, such as strong affective arousal, these conditions arc not always present. Additionally, the malevolent representations of the borderline patient arc not always "primitive" in a cognitive-developmental sense. There is no evidence to suggest that the malevolent object world of the borderline reflects any observed early stage of normal development, and the tendency to provide grossly illogical but complex attributions of the causes of people's behavior and intentions may represent an idiosyncratic but nonregrcssivc borderline phenomenon. In contrast, the propensity under certain conditions to represent people in shallow and poorly differentiated ways and the need-gratifying interpersonal orientation of borderline patients do appear to reflect developmental arrests, although the precise developmental period implicated is not as clear as many theories suggest. Although no one has empirically examined the objcct relations of borderline adolescents, Rubenstein (1980) and Sugarman ct al. (1980) noted certain characteristics of the borderline adolescent's response on the TAT and other psychological tests. Sugarman and his colleagues note that the pathology of borderline adolescent object relations is often manifest in a paucity of full human responses on the Rorschach, which is comparable to a similar empirically documented phenomenon with adult borderlines (Stuart et al., in press; Spear and Sugarman, 1984). They also note that characters on the TAT arc often empty, with minimal elaboration of motives or thoughts, and with actions occurring in the stories without apparent cause.
Hypotheses In the present study, TAT responses from a sample of inpatient borderlines, psychiatric comparison subjects, and normal adolescents were coded on the four dimensions of object relations measured by Westen et al. These four dimensions, and their five levels of functioning, as measured in this study, are shown in Table I. Several studies just completed suggest that these measures do, indeed, assess dimensions of object relations (Westen, in press a). In both normal and clinical samples these measures were able to predict both self-reported and clinician-reported social adjustment, as well as relevant subscalcs (such as hostility, 339
WESTL,N ET At.. TABLE
I. Brief Synopsis of Measures of Object Relations
Complexity or Representations 01' People
Affect-tone of Relationship Paradigms
Capacity for Emotional Investment
Understanding of Social Causality
Principle
Scale measures thc extent to which the subject clearly differentiates the perspectives of self and others; sees the self and others as having stable, enduring, multidimensional dispositions: and sees the self and others as psychological beings with complex motives and subjective experience.
Scalc measures affective quality of representations of people and relationships. It attempts to assess the extent to which the person expects from the world, and particularly the world of people, profound malevolence or overwhelming pain, or views social interaction as basically benign and enriching.
Scales measures the extent to which others are treated as ends rather than means, events are regarded in terms other than need gratification, and moral standards arc developed and considered.
Scale measures the extent to which attributions about the causes of people's actions, thoughts, and feelings arc logical, accurate, complex, and psychologically-minded.
Level I
Pcople arc not clearly differen- Malevolent representations; Need-gratifying orientation; Noncausal or grossly illogical tiated; confusion of points of view. gratuitous violence or gross profound self-preoccupation. depictions of psychological negligence by significant othand interpersonal events. ers.
L.evel 2
Simple, unidimensional represen- Representation of relationships tations; focus on actions: traits arc as hostile, empty, or capricious, but not profoundly malevolent; global and univalent. profound loneliness or disappointment in relationships.
Limited investment in people, relationships, and moral standards; conflicting interests recognized, but gratification remains primary aim; moral standards developmentally primitive and un integrated or followed to avoid punishment.
Rudimentary understanding of social causality; minor logic errors or unexplained transitions; simple stimulus-response causality.
Level :I
Minor elaboration of mental life or Mixed representations with Conventional investment in personality. mildly negative tone. people and moral standards; stereotypic compassion, mutuality, or helping orientation; guilt at moral transgressions.
Complex, accurate situational causality and rudimentary understanding of the role of thoughts and feelings in mediating action.
Level 4
Expanded appreciation of complex- Mixed representations with Mature, committed investment ity of subjective experience and neutral or balanced tone. in relationships and values; mupcrsonality dispositions; absence of tual empathy and concern, comrepresentations integrating life hismitment to abstract values. tory, complex subjectivity, and personal ity processes.
Expanded appreciation of the role of mental processes in generating thoughts, feelings, behaviors, and interpersonal interactions.
Level 5
Complex representations, indicat- Predominately positive repreing undcrstanding of interaction of scntations; benign and enrichenduring and momentary psycho- ing interactions. logical experience; understanding of personality as system of proccsscs interacting with each other and the environmcnt.
Complex appreciation of the role of mental processes in generating thoughts, feelings, behaviors, and interpersonal interactions; understanding of unconscious motivational processes.
paranoia, and interpersonal sensitivity) of the Symptom Checklist 90 --- Revised (Derogatis, 1977). Research with a normal sample documented significant correlations between thcsc measures and analogous measures developed for usc with interview data, such as psychiatric interviews (c.g., a tendency to produce malevolent representations on the TAT is associated with a similar tendency in descriptions of relationships with significant others [Barends et al., in press J). This research also found predicted correlations between these measures and theoretically related validated instruments, such as Loevinger's (1970) test of ego development and Blatt et al.'s (1979) measures of quality of parental representations. For example, Loevingers measure of ego development, which primarily assesses more affec340
Autonomous selfhood in the context of committed relationships; recognition of conventional nature of moral rules in the context of carefully considered standards or concern for concrete people or relationships.
live dimensions such as the experience of relationships as exploitative, correlates with affect-tone of relationship paradigms and capacity for emotional investment in relationships. Complexity of free-response descriptions of significant others, using the Blatt measure, correlates with both complexity of representations and social causality as assessed from TAT responses. Two studies found predicted developmental differences between second and fifth graders and between early and late adolescents (Westen et al., unpublished manuscript). (Analogous instruments applied to psychotherapy transcripts have documented changes over the course of brief psychodynamic psychotherapy [Schneider, unpublished manuscript].) Together these studies suggest that object relations can be validly assessed from TAT J. Am. Acad. Child Adolesc. Psychiatry, 29:3, May 1990
1l0R I )I ,I{ I ~I N E
responses , and that the TA T can det ect both ind ividual and deve lopmental differences . It was predicted, first, that borderl ines would manifest lower-level functioning on all four scales than normals . Th e bord erli ne group should not differ significantly on me an complex ity of representation s and soc ial ca usality from the psyc hiatri c comparison group, whi ch co nsists largely of depres sives , non-bord erli ne charac ter disorde rs , and anorexics; however, the borderlines should have lower mean scores on affec t-tone and capac ity for emotional investment than non-borderli ne psychiatric patients . Second , borderlines should prod uce more gross ly patho logical respon ses (Level 1) on all four scales than psychi atr ic and normal co mpariso n subjects, for the fo llowing reasons. Because of their pro found egocentrism and boundary disturbanc es, borde rlines should prod uce mor e poorly differentiat ed rep resentations of peopl e on the co mplexity scale (sco red Level I). On affec t-tone of relati onship par adigm s , borderl ines should also pro duce more pure malev olen t response s (sco red Level I) than either co mparison gro up . Although ma ny of the inpatient comparison subjects were depressed and co uld thus be expected to have negative ly toned representations, they should experience the object worl d as less malevolent than the borderlines. Becaus e of their mo re need -gratifying , exploita tive interpersonal stan ce , borderlines shou ld produce more pure need-gratifying responses (sco red Level I) on capacit y for emotional investment, and their tenden cy to produce grossly illogica l soc ial attr ibutions shou ld lead to more scor es of Level I on social ca usalit y than the other groups .
Methods Subject s
Potential subj ects for the patient samples were 14- to 18year-o lds drawn from the inp atien t adol escent unit at the University of Mi chi gan Medical Cen ter and the inpatient adolescent unit at Wyandotte General Hospital. The present study ineluded only female subjec ts, reflecting the predom inance of females in the popu latio n of BPD . Patients with chronic psychosis , c lear evidenc e of neurop athology (such as docum ented epilepsy or severe head injury), IQ below 70 , or medical problems that would co mplicate dia gnosi s or psychol ogical testin g were excluded fro m the study . Potential sub jects who con sented (and whose parents consented) were adm inistered the Diagnostic Interview for Borderli nes (D lB) . The D lB is the mos t widely used research instrum ent in the adult literature for diagnos ing BPD. It is a well-valid ated instrume nt which has heen shown to distinguish DSM -III borderline s with sensi tivity and spec ificity typically above 0 .80 (A rrn e lius et al ., (985). Th e DIB was modified slightly for admini stration to adolesce nts (Block et al . , unp ublished manuscript) ; the maj or modificatio n was that subjects were aske d abou t sev eral relationship s , rather tha n ju st about one major re lations hip, in assessing pattern s of interpersonal pathology , because presenc e of a single long-term relation sh ip is not normative in adolescen ce. As in other research usin g DIB, patients were defined as meet ing crit eri a for BPD (N = 33) by obt aini ng a D IB score l .A m .Acad. Child Ado/esc .Psychiatry, 29 :3 , May 1990
!\ D O LESCTN TS
gre ater than or equa l to 7. Psychiatric compar ison subjects (N = 2 1) received [) IJ3 score s of less tha n or equal [0 5 ; subje cts rece iving a score o r 6 we re e liminated, as decided in adva nce , to avoi d group over lap . Recentl y co mp leted research (cited ear lier) , using a subse t of thi s sa mple, found highl y significa nt differen ces (mostly p < 0 .00 I) between the BPD and non-borderl ine psych iatric gro up on bord er line symptoms (such as suicide gestures , promis cuity , and impulsivity) , as we ll as on severa l theoreticall y re levant developmen tal hist ory variab les , suggesting that the cutoff of 7 is appropriate for ado lesce nts , as for adults . Man y of the BPD subjects had discharge dia gno ses o r dy sth ymi c d isorder or maj or depr essive disord er along w ith an Ax is II dia gno sis of BPD . A ch art review or a subsamp le of the BP J) group found no ease s meeting crite ria 1'01' melan cho lia . Clinically , the vast majority of BP O subjects were prot otypicall y borderline, formin g passionate attachme nts on the un it, splitting staff, findin g broken glass and plastic knives on the unit to scratch their wrists , and altern ately desp erate ly clingi ng to , or angr ily reject ing staff and fam ily . Durin g 1983 and 1984 , co nsecutive pat ient s at the Universit y of Michi gan Hospital were administered the DIB by interviewers who had achieve d intcrratcr rel iability on di agnosi s or O. 80 (ka ppa). In orde r to fill the bord erline group and to obt ai n appropriate co mpar ison subj ects , po tential subjects were targeted at the Univer sity o f Michigan Hospit al and at Wyandotte Genera l Hospita l betwee n 1985 and 1987 . These subjects met at least four D5"M-III or D5'M-I/I R criteria for BPD , cr iteria fo r anorex ia nervosa , or two criter ia for major depre ssion or dysthymic disorder on admission. Two 0 1B interviewers, wit h pre vious ly established reliability with an adu lt borderline project (ka ppa, 0 .78 , Corn ell et aI. , 1983) , train ed additi ona l inter view ers , who achie ved perfect agreeme nt on Dl B di agno sis with a sa mple of con secuti ve taped intervi ews and fell within onc scaled point of criteri on coder on every sec tion and fina l score . No n-borde rline psychiatri c comparison subjects rece ived a num ber of DSM -Ill disch arge dia gnoses, pri mar ily affect ive disorder, anore xia, and (nonb orderline) pers onality disor ders . Prior to ex amination of the dat a, comparison subjects were e liminated who rece ived a primary or seco ndary D,
Abstract. Alth ough path ological object relations is a core aspect of bord erline psychopathology, few studi es have examined bor derline obje ct rela tions empirically, and none has focused on borde rline adoles cents. The present study exam ined four dime nsions of obj ect relations, as measured by the Themati c Apperception Tes t, in a sa mple of ado lescen t borderlines, psychiatric comparison subje cts, and nor mals. Th ese dim ensions are complexity of object repre sentat ions , affect-tone of relationship parad igms, capaci ty for emotional investment in relationships and mora l standards, and understan di ng of soc ial causality . Borderlines diff ered significantly from both comparison groups in several distinct ways , suppor ting so me aspects of psychoana lytic theor ies of borderl ine object relat ion s, while challenging other s . Borde rline ado lescents have a male volent object wor ld, a relative incapacity to invest in other s in a non-need-gratifying way , and a tend ency to attrib ute moti vation to others in simpl e , illogical , and idiosyncratic ways. Their object repre sentations, however, can be quite complex , suggesting som ething other than a preoedipal arrest. J . Am . Acad. Child Adol esc. Psychiatry , 1990 , 29 , 3:338-348 . Key Words: borderl ine perso nali ty disor der , object relations, ado lescent psychopathology, personality disorders . Changes in DS M-III-R , perm itting limit ed diagnosis of person alit y disord ers in ado lesce nce, accord with the ex perience of clinician s , who co me in contact dail y with adolescents who meet criteria for Borderline Personality Disorder (BPD) or Kern berg 's (1975) criteria for bord erlin e personality organizatio n. Th ese ado lesce nts typ icall y present with suicide attempts or gestures, and they are characteri zed by the sa me patt ern s of splitting , devaluation , manipulation , need- gratifyin g object re latio ns, impul sivit y , and ego deficits that one find s in bor derline adults (M asterson, 1972 , 1980; Kornberg , 1978 ) . A study by McManus et a!. (1984) found that borderline adolescents could be discriminated from other psychiat ric inpatie nt adolescent s , using the Diag nos tic Interview for Bord erl ines (G underso n et aI. , IlJ8 1). Two rece nt stud ies (Wes ten et al., IYYU ; LUdolph et al., in press) simila rly found not only th at borderline ado lesc ents co uld be d iscriminated from psyc hiatric and norm al compa rison subj ects on the basis of their DIB sco res , but that borderline adolescents differed fro m non bo rderline psychi atr ic patients on a variety of dev elopm ental history variables, including abu se , neglect , matern al reje ction , and multiple caretakers or parenta l surrogates . Th eorists of borderline path ology in ado lesce nce tend to
Accepted May 12, 1989 . From the Departments of Psych ology and Psychiatry, and University Centerfor the Child lind the Fam ily , University oj Michigan. This research was supported by a grant fr om the Department (1 Psychia try, and by the Center fo r the Child and the Family and the Faculty Fund. Department (1 Psychology , University of Michigan. The authors would like to express their appreciation to John Boekump , Laura Gold, Alfred Kellam , Natasha Lifton , and Mara Silverman [o r their help in coding the data; to Tom TenHave Jor statistical consultation; and to members oj the Adolescent Development Study (Anne Jackson, Barbara Misle, Judith Block, and Jean Wixom) for help in data collection and fo r comments on a draft oJ the manuscript . Request reprints fr om Dr . Westen at Department (1 Psych ology , University oj Michigan, 580 Union Drive, Ann Arbor, Michigan 481091346. OR90-8567 /l)0/2903-0338$02 .001O© 1990 by the American Academ y of Child and Ado lesce nt Psychiatr y .
338
stress the continuity of the ado lescent and adult borde rli ne sy ndro me , altho ugh often suggesting that the bord erl ine d iagno sis is more d ifficult to make in ado lescence (Kernberg, 1978) . Kernberg (1975) argues that the roots of borderline object relations in adolescents and adults lie in a development al failure in the pre oed ipal years to integrate posit ive and nega tive representations of the se lf and of others and , hence, to achieve libid inal object co nstancy, that is , the ability to love someone even whe n he or she is not cur rently gratifyi ng . Ma sterson (\ 972, 1978 , 1980 ) locates the or igins of borderline disorders in the same developmental period , namely the rapprochement stag e of sep aration-indi viduation (Mahler et al. , 1975). According to Masterson , the origin of bord erline psychopathology typi call y lies in a mother who has so m uc h dilficulty wi th se para tion-indiv id ua tio n that she will not allow her child to develop auto no mo usly, instead withdraw ing and reject ing the child ' s age-appropriate efforts at indiv iduation . Th e child co nseque ntly splits off two object-relation al part-units: a withdrawing object-re lations unit, whi ch includes a represe ntation of a malevolent moth er abando ning the " bad " child for atte mpts at ind ividuatio n and an affec tive com po ne nt of aba ndo nme ntdepression and rage ; and a rewarding obje ct-re lations unit , which incl udes a representation of a gratify ing moth er , a depe nde nt, "good, " complia nt sel f who mu st sacrifice autonomy to maintain matern al suppl ies , and correspond ing affect. Although the relati on ship betw een the borderline diagn osis in childhoo d and adulthoo d has been a matte r of controversy (Gree nma n et al., 1986) , acc ord ing to most theo ries , adolesce nce is a lik ely period for the emerge nce of bord erline psych opathology , both bec ause of the con solida tion o f pe rso nality struc ture which should occur during that time , and because of the sali en ce of con cerns about identity and indi viduation .
Empirical Studies of Borderllne Object Relations Empirical stud ies of object relati on s in reli abl y diagn osed bord erline pati ent s have foc use d exclu sively on adult subject s and have relied prim aril y on exa mi nation of human
BORDERI ,1NI, ;\1)01,1 ,SCI ,NTS
figure responses on the Rorschach Inkblot Test. Most of these studies have compared borderline patients with schizophrenics on Blatt's Rorschach measure for object relations (Blatt et al., 1976), which assesses several qualities of human figure responses and yields an overall developmental level score, from primitive to mature. Although findings on particular subscales have been less consistent (Gartner, et al., 1989; Lerner and St. Peter, 1984; Spear and Sugarman, 1984; Hymowitz et al., 1983), these studies have found that borderlines typically score higher on developmental level than schizophrenics, as predicted. Most studies have found that borderlines have a more hostile, malevolent object world than other patient groups (Stuart et al., in press; Lerner and St. Peter, 1984; Spear and Sugarman, 1984). Contrary to what one would expect from a developmental theory of borderline object relations, however, two of these studies have found that borderlines produce more cognitive-developmentally advanced representations than even normal or neurotic comparison subjects, manifest in relatively complex representations of the intentions of figures, usually of a malevolent nature, on the Rorschach. For the borderlines, unlike most comparison groups, more cognitively advanced responses typically occur with human figures that are inaccurately perceived, i.e., on responses with low form level (a measure of accuracy of reality testing). In other words, borderlines tend to produce malevolent, idiosyncratic, but in certain respects, cognitivcly rich and complex representations of people on the Rorschach. One recent study has used Thematic Apperception Test (TAT) responses to investigate the object relations of reliably diagnosed adult inpatient borderlines, major depressives, and normals (Westen et al., in press a). The TAT, a projective test in which subjects create stories in response to cards depicting ambiguous social scenes, is a useful test for assessing object relations because, unlike the Rorschach, the stimulus is unambiguously social, and subjects are likely to provide enough detail in describing characters and relationships to provide considerable information about enduring cognitive and affective processes mediating their experience of relationships. Westen and colleagues examined four dimensions of object relations (described in more detail below): complexity of representations of people (the extent to which the subject attributes complex dispositions to characters whose perspectives are clearly differentiated); affect-tone of relationship paradigms (the affective quality of the object world, from malevolent to benevolent); capacity for emotional investment in relationships and moral standards (the extent to which the person transcends a need-gratifying interpersonal orientation); and understanding of social causality (the extent to which attributions of causality in the social realm are logical, complex, and psychologically-minded). As predicted, borderlines and major depressives both produced representations of people and interactions less complex, and at a lower level of understanding of causality than normals. The borderline group produced more poorly differentiated representations and grossly illogical attributions of causality than either comparison group. Borderlines manifested the most malevolent object world, followed by major depresJ.Am.Acad. Child Adolesc. Psychiatry, 29:3, May 1990
sives , and then by normals, with a similar pattern emcrging in capacity for emotional investment, as predicted. The investigators note that although borderlines as a group produced less complex and differentiated representations than normals, a substantial number of borderline subjects produced some responses evidencing a high level of complexity and differentiation of object representations. This finding, like the Rorschach finding, challenges the notion that one can explain borderline object relations as a simple developmental disturbance. An alternative formulation is that object relations consist of a number of distinct but interdependent cognitive and affective processes. Functioning on cach of these eli mensions may vary across individuals as well as within an individual at any given time (Westen, in press a, b , 1989). In other words, while borderlines may manifest a tendency to activate more malevolent representations than other patients, under certain conditions, such as strong affective arousal, these conditions arc not always present. Additionally, the malevolent representations of the borderline patient arc not always "primitive" in a cognitive-developmental sense. There is no evidence to suggest that the malevolent object world of the borderline reflects any observed early stage of normal development, and the tendency to provide grossly illogical but complex attributions of the causes of people's behavior and intentions may represent an idiosyncratic but nonregrcssivc borderline phenomenon. In contrast, the propensity under certain conditions to represent people in shallow and poorly differentiated ways and the need-gratifying interpersonal orientation of borderline patients do appear to reflect developmental arrests, although the precise developmental period implicated is not as clear as many theories suggest. Although no one has empirically examined the objcct relations of borderline adolescents, Rubenstein (1980) and Sugarman ct al. (1980) noted certain characteristics of the borderline adolescent's response on the TAT and other psychological tests. Sugarman and his colleagues note that the pathology of borderline adolescent object relations is often manifest in a paucity of full human responses on the Rorschach, which is comparable to a similar empirically documented phenomenon with adult borderlines (Stuart et al., in press; Spear and Sugarman, 1984). They also note that characters on the TAT arc often empty, with minimal elaboration of motives or thoughts, and with actions occurring in the stories without apparent cause.
Hypotheses In the present study, TAT responses from a sample of inpatient borderlines, psychiatric comparison subjects, and normal adolescents were coded on the four dimensions of object relations measured by Westen et al. These four dimensions, and their five levels of functioning, as measured in this study, are shown in Table I. Several studies just completed suggest that these measures do, indeed, assess dimensions of object relations (Westen, in press a). In both normal and clinical samples these measures were able to predict both self-reported and clinician-reported social adjustment, as well as relevant subscalcs (such as hostility, 339
WESTL,N ET At.. TABLE
I. Brief Synopsis of Measures of Object Relations
Complexity or Representations 01' People
Affect-tone of Relationship Paradigms
Capacity for Emotional Investment
Understanding of Social Causality
Principle
Scale measures thc extent to which the subject clearly differentiates the perspectives of self and others; sees the self and others as having stable, enduring, multidimensional dispositions: and sees the self and others as psychological beings with complex motives and subjective experience.
Scalc measures affective quality of representations of people and relationships. It attempts to assess the extent to which the person expects from the world, and particularly the world of people, profound malevolence or overwhelming pain, or views social interaction as basically benign and enriching.
Scales measures the extent to which others are treated as ends rather than means, events are regarded in terms other than need gratification, and moral standards arc developed and considered.
Scale measures the extent to which attributions about the causes of people's actions, thoughts, and feelings arc logical, accurate, complex, and psychologically-minded.
Level I
Pcople arc not clearly differen- Malevolent representations; Need-gratifying orientation; Noncausal or grossly illogical tiated; confusion of points of view. gratuitous violence or gross profound self-preoccupation. depictions of psychological negligence by significant othand interpersonal events. ers.
L.evel 2
Simple, unidimensional represen- Representation of relationships tations; focus on actions: traits arc as hostile, empty, or capricious, but not profoundly malevolent; global and univalent. profound loneliness or disappointment in relationships.
Limited investment in people, relationships, and moral standards; conflicting interests recognized, but gratification remains primary aim; moral standards developmentally primitive and un integrated or followed to avoid punishment.
Rudimentary understanding of social causality; minor logic errors or unexplained transitions; simple stimulus-response causality.
Level :I
Minor elaboration of mental life or Mixed representations with Conventional investment in personality. mildly negative tone. people and moral standards; stereotypic compassion, mutuality, or helping orientation; guilt at moral transgressions.
Complex, accurate situational causality and rudimentary understanding of the role of thoughts and feelings in mediating action.
Level 4
Expanded appreciation of complex- Mixed representations with Mature, committed investment ity of subjective experience and neutral or balanced tone. in relationships and values; mupcrsonality dispositions; absence of tual empathy and concern, comrepresentations integrating life hismitment to abstract values. tory, complex subjectivity, and personal ity processes.
Expanded appreciation of the role of mental processes in generating thoughts, feelings, behaviors, and interpersonal interactions.
Level 5
Complex representations, indicat- Predominately positive repreing undcrstanding of interaction of scntations; benign and enrichenduring and momentary psycho- ing interactions. logical experience; understanding of personality as system of proccsscs interacting with each other and the environmcnt.
Complex appreciation of the role of mental processes in generating thoughts, feelings, behaviors, and interpersonal interactions; understanding of unconscious motivational processes.
paranoia, and interpersonal sensitivity) of the Symptom Checklist 90 --- Revised (Derogatis, 1977). Research with a normal sample documented significant correlations between thcsc measures and analogous measures developed for usc with interview data, such as psychiatric interviews (c.g., a tendency to produce malevolent representations on the TAT is associated with a similar tendency in descriptions of relationships with significant others [Barends et al., in press J). This research also found predicted correlations between these measures and theoretically related validated instruments, such as Loevinger's (1970) test of ego development and Blatt et al.'s (1979) measures of quality of parental representations. For example, Loevingers measure of ego development, which primarily assesses more affec340
Autonomous selfhood in the context of committed relationships; recognition of conventional nature of moral rules in the context of carefully considered standards or concern for concrete people or relationships.
live dimensions such as the experience of relationships as exploitative, correlates with affect-tone of relationship paradigms and capacity for emotional investment in relationships. Complexity of free-response descriptions of significant others, using the Blatt measure, correlates with both complexity of representations and social causality as assessed from TAT responses. Two studies found predicted developmental differences between second and fifth graders and between early and late adolescents (Westen et al., unpublished manuscript). (Analogous instruments applied to psychotherapy transcripts have documented changes over the course of brief psychodynamic psychotherapy [Schneider, unpublished manuscript].) Together these studies suggest that object relations can be validly assessed from TAT J. Am. Acad. Child Adolesc. Psychiatry, 29:3, May 1990
1l0R I )I ,I{ I ~I N E
responses , and that the TA T can det ect both ind ividual and deve lopmental differences . It was predicted, first, that borderl ines would manifest lower-level functioning on all four scales than normals . Th e bord erli ne group should not differ significantly on me an complex ity of representation s and soc ial ca usality from the psyc hiatri c comparison group, whi ch co nsists largely of depres sives , non-bord erli ne charac ter disorde rs , and anorexics; however, the borderlines should have lower mean scores on affec t-tone and capac ity for emotional investment than non-borderli ne psychiatric patients . Second , borderlines should prod uce more gross ly patho logical respon ses (Level 1) on all four scales than psychi atr ic and normal co mpariso n subjects, for the fo llowing reasons. Because of their pro found egocentrism and boundary disturbanc es, borde rlines should prod uce mor e poorly differentiat ed rep resentations of peopl e on the co mplexity scale (sco red Level I). On affec t-tone of relati onship par adigm s , borderl ines should also pro duce more pure malev olen t response s (sco red Level I) than either co mparison gro up . Although ma ny of the inpatient comparison subjects were depressed and co uld thus be expected to have negative ly toned representations, they should experience the object worl d as less malevolent than the borderlines. Becaus e of their mo re need -gratifying , exploita tive interpersonal stan ce , borderlines shou ld produce more pure need-gratifying responses (sco red Level I) on capacit y for emotional investment, and their tenden cy to produce grossly illogica l soc ial attr ibutions shou ld lead to more scor es of Level I on social ca usalit y than the other groups .
Methods Subject s
Potential subj ects for the patient samples were 14- to 18year-o lds drawn from the inp atien t adol escent unit at the University of Mi chi gan Medical Cen ter and the inpatient adolescent unit at Wyandotte General Hospital. The present study ineluded only female subjec ts, reflecting the predom inance of females in the popu latio n of BPD . Patients with chronic psychosis , c lear evidenc e of neurop athology (such as docum ented epilepsy or severe head injury), IQ below 70 , or medical problems that would co mplicate dia gnosi s or psychol ogical testin g were excluded fro m the study . Potential sub jects who con sented (and whose parents consented) were adm inistered the Diagnostic Interview for Borderli nes (D lB) . The D lB is the mos t widely used research instrum ent in the adult literature for diagnos ing BPD. It is a well-valid ated instrume nt which has heen shown to distinguish DSM -III borderline s with sensi tivity and spec ificity typically above 0 .80 (A rrn e lius et al ., (985). Th e DIB was modified slightly for admini stration to adolesce nts (Block et al . , unp ublished manuscript) ; the maj or modificatio n was that subjects were aske d abou t sev eral relationship s , rather tha n ju st about one major re lations hip, in assessing pattern s of interpersonal pathology , because presenc e of a single long-term relation sh ip is not normative in adolescen ce. As in other research usin g DIB, patients were defined as meet ing crit eri a for BPD (N = 33) by obt aini ng a D IB score l .A m .Acad. Child Ado/esc .Psychiatry, 29 :3 , May 1990
!\ D O LESCTN TS
gre ater than or equa l to 7. Psychiatric compar ison subjects (N = 2 1) received [) IJ3 score s of less tha n or equal [0 5 ; subje cts rece iving a score o r 6 we re e liminated, as decided in adva nce , to avoi d group over lap . Recentl y co mp leted research (cited ear lier) , using a subse t of thi s sa mple, found highl y significa nt differen ces (mostly p < 0 .00 I) between the BPD and non-borderl ine psych iatric gro up on bord er line symptoms (such as suicide gestures , promis cuity , and impulsivity) , as we ll as on severa l theoreticall y re levant developmen tal hist ory variab les , suggesting that the cutoff of 7 is appropriate for ado lesce nts , as for adults . Man y of the BPD subjects had discharge dia gno ses o r dy sth ymi c d isorder or maj or depr essive disord er along w ith an Ax is II dia gno sis of BPD . A ch art review or a subsamp le of the BP J) group found no ease s meeting crite ria 1'01' melan cho lia . Clinically , the vast majority of BP O subjects were prot otypicall y borderline, formin g passionate attachme nts on the un it, splitting staff, findin g broken glass and plastic knives on the unit to scratch their wrists , and altern ately desp erate ly clingi ng to , or angr ily reject ing staff and fam ily . Durin g 1983 and 1984 , co nsecutive pat ient s at the Universit y of Michi gan Hospital were administered the DIB by interviewers who had achieve d intcrratcr rel iability on di agnosi s or O. 80 (ka ppa). In orde r to fill the bord erline group and to obt ai n appropriate co mpar ison subj ects , po tential subjects were targeted at the Univer sity o f Michigan Hospit al and at Wyandotte Genera l Hospita l betwee n 1985 and 1987 . These subjects met at least four D5"M-III or D5'M-I/I R criteria for BPD , cr iteria fo r anorex ia nervosa , or two criter ia for major depre ssion or dysthymic disorder on admission. Two 0 1B interviewers, wit h pre vious ly established reliability with an adu lt borderline project (ka ppa, 0 .78 , Corn ell et aI. , 1983) , train ed additi ona l inter view ers , who achie ved perfect agreeme nt on Dl B di agno sis with a sa mple of con secuti ve taped intervi ews and fell within onc scaled point of criteri on coder on every sec tion and fina l score . No n-borde rline psychiatri c comparison subjects rece ived a num ber of DSM -Ill disch arge dia gnoses, pri mar ily affect ive disorder, anore xia, and (nonb orderline) pers onality disor ders . Prior to ex amination of the dat a, comparison subjects were e liminated who rece ived a primary or seco ndary D,
