THE CORE CONFLICTUAL RELATIONSHIP THEMES (CCRT) ANALYSIS OF A RELAPSE IN A PATIENT WITH BORDERLINE PERSONALITY DISORDER. J Pers Disord. Aug;23(4) doi: /pedi The Core Conflictual Relationship Themes (CCRT) in borderline personality disorder. It is worth pointing out that the connection between personality disorders and rela - . Core Conflictual Relationship Theme method (CCRT; Luborsky, ;.
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A Psychological Perspective Journal of Personality Assessment, 92, 3, Object relations theory and clinical psychoanalysis. Object relation theory and technique. Self-assessment of interpersonal schemas using the Relationship Patterns Questionnaire: Psychotherapy Research 14, 4, Development and first results of the Borderline Personality Inventory: Numerous studies with the CCRT have allowed researchers to improve the method and extend its applicability; for example, different sets of CCRT categories were proposed and tested, and the validity of the CCRT was tested with videotapes and with children Luborsky et al.
During discussions at the Society for Psy- chotherapy Research CCRT Workshop, it was suggested that the ROs and RSs might be scored for more than one significant other rather than only the components relat- ing to the main other person, as defined in the usual method.
The Core Conflictual Relationship Themes (CCRT) in borderline personality disorder.
Valuable information may be lost when only the main other person is scored, because a single object may not suffice to represent the numerous dimensions of a relationship pattern. To shed light on this question, two scoring methods were compared in the present study: In the past 10 years, research on the CCRT has allowed us to study and better understand the links between relationship patterns and early development Luborsky, Luborsky, et al.
Some researchers also used it to examine differences between diagnostic groups, even though the CCRT was not primarily designed for that purpose. Mitchell reported differences between schizophrenia and affective disorders on the Coherence of Relationship Theme, a measure derived from the CCRT.
However, it is still not clear whether different personality organizations POs actually have different relationship patterns. Although there is an abundance of clinical literature on this topic, empirical studies are scarce.
They found no relationships between personality and CCRT. The only observations made were correlations between negative responses from others and difficulties in relating socially as measured by the KAPP. A PO is a stable, dy- namically organized structure in that it is more than the sum of its parts the traits and it incorporates early experiences and phase-specific drive organization into a new organization Kernberg, The model also includes four dimensions that define and differen- tiate the POs: OR patterns; defense mechanisms; identity diffusion; and reality test- ing.
The PPO presents with symbiotic object relations, archaic defense mechanisms mainly denialsevere identify diffusion, and poor reality testing. The BPO mani- fests anaclitic and dual ORs, with immature defense mechanisms mainly splitting, projective identification and omnipotent controlas well as identity diffusion while reality testing is good. The NPO is characterized by triangular OR schemas based on mature sexual drives, with repression and other mature defense mechanisms, but good sense of identity and reality testing.
The NPO is stronger than the BPO with respect to social adjustment and ego functions self-understanding, impulse control, and capacity to sublimate driveswhereas the PPO shows the weakest of these.
However, these preliminary studies were conducted with only 10 participants in each group. This issue had to be addressed before proceeding with a more complete study on POs, because it was not yet clear whether PPO par- ticipants could produce narratives that were able to be scored with the CCRT. Patients applied for psychotherapy by telephone.
Their requests were dispatched to avail- able psychologists for intake. Four professional psychologists working in these clin- ics participated in the study; during the intake, patients were informed that they could take part in a study that aimed to further the understanding of the correlations among personality, human relationships, and psychological difficulties.
All pa- tients presenting with an active psychosis, brain damage, substance intoxication, or dependence were excluded. A total of patients were evaluated before a mini- mum of 20 participants were accepted for each PO group.
The PPO group was the most difficult to fill. Eighty-one participants were included in this study: On the average, partici- pants were Forty-nine percent were women, and Sixty-two percent completed college, and Forty-four percent of the participants had a personality disorder: See Table 1 for PO group comparisons and figures. Significant differences among the three PO groups were expected on Axis II diagnoses, on sex ratios, and on education. A PODF NPO diagnosis implies the absence of borderline characteristics; logically, the gender differences reported among borderline disorders Gunderson et al.
All interviews were videotaped and the diagnoses revised and discussed with at least one other evaluator to ensure their appropriateness. The relationship narratives and the object and self-descriptions were tape- recorded and typed. First, the narratives were typed and their degree of detailed information on the interaction was evaluated. We selected narratives; the average number produced per participant was Next, the REs were read by the raters; all segments of the texts corresponding to a thought unit, as de- fined by Benjaminwere underlined.
The latter provides raters with eight standard clusters each for the Ws, the ROs, and the RSs see Figure 1 for the lists of clusters. The negativity of ROs and RSs was scored according to the original two-category distinction i. A positive score indicates that the narrative describes noninterference with the satisfaction of the wish, whereas a negative score indicates that the participant describes interference with the satisfaction of the wish Luborsky a.
Two levels of inference are distinguished for the wishes. Explicit wishes are directly stated, whereas inferred wishes are not explicit but moderately inferable Luborsky, a. Four raters were trained to score the CCRT method and performed the scoring independently. They were graduate students in clinical psychology with considerable clinical experience.
Information can be gathered from several sources: Four items evaluate identity diffusion: Seven items evaluate the level of defense mecha- nisms: The fourth subscale on ORs has only one item subdivided into three cate- gories: Psychotic ORs are symbiotic with fear of annihilation, borderline ORs are anaclitic with fear either of the object or of its control or abandonment, and neurotic ORs are oedipal with fear of castration.
If a disagreement occurred, raters had to discuss the case until they reached a clinical consensus. One rater was a psychologist with 10 years of experience; the other was a graduate student in clinical psychology with considerable clinical experience.
It allows us to judge the agreement between raters with provision for agreement occurring by chance. In counting the matches between rat- ers, a weight of 1. When the second rank CCRTs of both raters coincided, a weight of. Finally, when there was no agreement be- tween raters for either first- or second-rank CCRT clusters, a weight of 0 was given.
Kappas ranging from 0 to. These REs were randomly selected and raters did not know which REs were used for this purpose. Our results shown in Table 2 fall in the fair to excellent ranges of kappa. In the main other person method, the average frequency scores were then divided by the number of relationship episodes used for each case; in the all other person method, the average frequency scores were divided by the total number of Ws, ROs, or RSs to control variability in the number of different other persons Luborsky, a.
We thus obtained a pervasiveness score for each of the eight W clusters, eight RO clusters, and eight RS clusters. The averaged Pearson correlation was. The two most pervasive clusters of the three CCRT com- ponents were the same regardless of the method used; for Ws, the two top clusters were Clusters 8 to achieve and help and 4 to be distant ; for the ROs, they were Clusters 5 rejecting and 3 upset ; and for the RSs, Clusters 7 disappointed and 3 respected.
Therefore, both methods produced the same CCRT profiles. Similar results were also found within each PO group. Both methods also produced very similar results in terms of the amount of in- ferred Ws: The two methods also yielded very similar scores in terms of negativity of ROs and RSs.
Both methods were also closely correlated in this regard: However, as expected, the all other persons method provided higher numbers than did the main other person method: The same pattern of correlations between the two methods was observed within the three PO groups.
Given that both methods pro- duced very similar results regardless of whether the PO group factor was taken into account, some statistical analyses were made on the original main other person CCRT method only, discussed next. In the PPO group, the pervasiveness scores ranged from. In the BPO group, the pervasiveness scores ranged from. The NPO group scores ranged from. A multivariate analysis of variance MANOVA was calcu- lated first to take into account the relationships between the eight wish-cluster per- vasiveness scores.
The two highest Ws were Clusters 4 to be distant and avoid conflicts and 8 to achieve and help others see Figure 1. In all three groups, the most commonly expressed RO was Cluster 5 rejecting and opposing. In the PPO group, three clusters had very close pervasiveness scores and competed for the second rank: Clusters 7 likes me6 helpfuland 3 upset. Between groups, pervasiveness score differences were examined, because having the same most common cluster does not exclude the possibility of intergroup differ- ences.
In summary, these tests reveal a flatter PPO profile: Its highest points RO clusters rejecting and upset are significantly lower than those of the other two groups. For all three groups, the most common RS was Cluster 7 disappointed and de- pressed. W, RO, and RS profiles means of pervasiveness scores for each cluster by personality organizations groups. Values are presented according to European conventions. The mean negativity score of both the ROs and the RSs was.
For all 81 participants, the mean number of different Ws per narratives was 1. The same pattern of differences was found for RS: The reliability of PO diagnosis was also excellent.
The measure contains some very clear cutoff criteria, such as the presence of psychotic experi- ences and immature defense mechanisms splitting and denial.
However, this high reliability was obtained for the final PO score, which is a synthesis of the 20 items; at the item level, kappas ranged from. Both methods yielded very similar results, and the nonsignificant differences observed did not warrant the amount of time required by all other persons method.
The same general conclusion pertaining to similarity of results holds true for the other CCRT variables as well the amount of inferred Ws, the negativity of ROs and RSs, and the complexity of the REs regardless of whether the PO groups are confounded or entered in the analyses as a factor.
The alternative method of CCRT scoring suggested at the CCRT Workshop proved not to provide us with new and useful information concerning the internal schema of object relationships. Therefore, it seems that, even if relationship narra- tives do involve more than one other person, they nonetheless relate dual relation- ships.
The psychological process of displacement may play an important role in the organization of relationship narratives: Several persons in a narrative may actually manifest the same latent object. However, the ab- sence of additional significant others contradicts abundant findings in clinical litera- ture on more complex relationship schemas, such as triangular or oedipal ORs.
In more complex oedipal schemas, the patient usually has two different significant oth- ers, each of whom has distinct responses and toward whom the patient has distinct Ws and RSs. It is possible that the instructions given to the participants in the RAP session solicited dual-relationship narratives and inhibited triangular relationship narratives.
If so, these instructions may even have lowered the discriminant validity of the CCRT method, because it is theoretically expected that NPO presents triangu- lar relationship narratives and that BPO presents narratives with dual relationships Kernberg, Indeed, the instructions read: For each one tell 1 when it occurred 2 who was the other person it was with.
However, their sample did not control the distribution of per- sonality variables, whereas our study did. Furthermore, our study entailed more detailed analyses, because we exam- ined the pervasiveness scores for each cluster rather than the two top clusters alone, as did theirs. It would, therefore, be useful at this stage of CCRT research to better evaluate the impact of the RAP instructions on the structure of relationship narra- tives.
The Core Conflictual Relationship Themes (CCRT) in borderline personality disorder.
For example, it would be interesting to experiment with RAP instructions that would either not specify the number of other persons or, on the contrary, require more than one other person. Finally, the two CCRT methods need to be examined to observe whether they yield similar results when applied to spontaneous narratives from therapy sessions.
All three groups had the same two most common W clusters: The most common RO was the same for the three groups rejecting and opposingalthough the PPO group had significantly lower pervasiveness scores on this cluster than did the two others. These results suggest that responses from others were perceived negatively rejecting by all participants and even more so for NPO and BPO participants than for the PPOs.
The two most common RSs were the same for the three groups disappointed and depressed, and respectedbut again the PPO group had significantly lower pervasiveness scores on this cluster. It is interesting to compare our results to those obtained in previous studies. For example, in Luborsky et al. In Waldinger et al. For the most part, the relationship schemas in these three studies yielded identical results except for the ending, which was positive for the third one.