THE CORE CONFLICTUAL RELATIONSHIP THEME OF PSYCHOTIC, BORDERLINE, AND NEUROTIC PERSONALITY ORGANIZATIONS

Transcription

1 Psychotherapy Research 11(2) , Society for Psychotherapy Research THE CORE CONFLICTUAL RELATIONSHIP THEME OF PSYCHOTIC, BORDERLINE, AND NEUROTIC PERSONALITY ORGANIZATIONS Louis Diguer Rachel Lefebvre Martin Drapeau Lester Luborsky Jean-Pierre Rousseau Étienne Hébert Jean-Philippe Daoust Sylvie Pelletier Maureen Scullion Jean Descôteaux School of Psychology, Laval University, Quebec, Canada Kernberg s (1984) model of personality describes 3 personality organizations (POs) psychotic, borderline, and neurotic each of which has specific characteristics in terms of relationship schemas, defense mechanisms, identity diffusion, and reality testing. The Core Conflictual Relationship Theme (CCRT) method (Luborsky, 1998a) is a measure of central relationship schemas as revealed by relationship narratives. It identifies 3 components: the patient s wishes (Ws), the responses from others (ROs), and the responses of self (RSs). The goals of this study were to compare 2 methods for scoring ROs and RSs and to examine whether different POs vary in terms of their relationship schemas as measured by the CCRT. Eighty-one participants were included in this study. A PO diagnosis was made with the Personality Organization Diagnostic Form (Diguer & Normandin, 1997). Results showed that both scoring methods were equivalent in all dimensions. We found more similarities than differences between the 3 PO groups with respect to Ws, ROs, and RSs. The psychotic PO group presented the flattest CCRT profiles, the least negative responses, and the lowest narrative complexity. These results are discussed in relation to Kernberg s model and the development of the CCRT method. Relationship schemas can be defined as organized representations of past behavior and experience in interpersonal relationships; these become the individual s personal blueprint for relationships, from which he or she construes his or her future relation- This work was supported by Quebec government Research Grant FCAR 96-NC-1277 and Canada government Research Grants CRSH and Correspondence concerning this article should be addressed to Louis Diguer, École de Psychologie, Université Laval, Québec City, Québec, Canada G1K 7P4. Louis.Diguer@psy.ulaval.ca. 169

2 170 DIGUER ET AL. ships (Baldwin, 1992). This general idea was referred to as relationship templates by Freud (1912/1958), as working models by Bowlby (1969), and as role-relationship models by Horowitz (1989). Several methods have been developed to analyze relationship schemas from relationship narratives: the Core Conflictual Relationship Theme (CCRT) method (Luborsky, 1998a), the Role Relationship Models Configuration method (Horowitz, 1989), the Frame method (Dahl, 1998), and the Idiographic Conflict Formulation method (Perry, 1994). The CCRT (Luborsky, 1998a) is the oldest and most frequently applied method of narrative analysis in psychotherapy research. It can be used with relationship narratives spontaneously produced in psychotherapy sessions or with relationship narratives that are given in interviews held for that specific purpose. For each narrative, the CCRT rater first identifies the presence of three components: the patient s wishes (Ws), the responses from others (ROs), and the responses of self (RSs). These components are then attributed to standard categories provided by the method. The patients most pervasive W, RO, and RS across their own narratives forms their CCRT. The CCRT method also scores the negativity of ROs and RSs, depending on whether these responses promote (positive) or interfere with (negative) the satisfaction of the wish; this rating reflects a long tradition in psychoanalysis (Freud, 1912/1958) wherein transference patterns are understood to be positive or negative. Furthermore, the CCRT estimates the level of a person s awareness of his or her CCRT through the scoring of the level of inference of wishes. Finally, the complexity of the relationship episodes (REs), as measured by the number of different Ws, ROs, and RSs used in each narrative, evaluates the person s capacity to activate several types of relationship patterns. There is considerable evidence that the CCRT has good interrater reliability (Luborsky & Diguer, 1998) and validity (Eckert, Luborsky, Barber, & Crits- Christoph 1990; Luborsky, Barber, & Diguer, 1992). 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., 1992). During discussions at the 1998 Society for Psychotherapy 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 relating to the main other person, as defined in the usual method. 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. However, it is also possible that the inclusion of multiple other persons only repeats trends toward the main other person because of defense mechanisms such as condensation and displacement (Moore & Fine, 1990). To shed light on this question, two scoring methods were compared in the present study: the original, in which only the main other person is scored, and the proposed all other persons method. 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., 1996), mood states (Luborsky, Singer, et al., 1996), symptoms (Luborsky, Diguer, et al., 1996) change in psychotherapy (Crits-Christoph & Luborsky, 1998a), change from adolescence to young adulthood (Waldinger et al., 2000), and different states of consciousness (Popp et al., 1996). Some researchers also used it to examine differences between diagnostic groups, even though the CCRT was not primarily designed for that purpose. Mitchell (1995) reported differences between schizophrenia and affective disorders on the Coherence of Relationship Theme, a measure derived from the CCRT. Luborsky, Barber, Schaffler, and Cacciola (1998)

3 CCRT AND PERSONALITY ORGANIZATIONS 171 observed some differences on CCRT components between 12 dysthymic and 21 nondysthymic patients. 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. Cierpka et al. (1998) reported that the severity of psychopathology correlated with the consistency of relationship patterns, measured by the CCRT. Wilczek, Weinryb, Barber, Gustavsson, and Åsberg (2000) examined the CCRT of patients having different diagnoses in terms of Diagnostic and Statistical Manual of Mental Disorders (third edition, revised; DSM III R; American Psychiatric Association, 1987) and personality profile, as per the Karolinska Psychodynamic Profile (KAPP; Weinryb, Rössel, & Åsberg, 1991). 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. However, in their sample of 55 patients, only 6 presented with personality disorders, 4 of which were labeled not otherwise specified. Kernberg s model of POs is based on the general concept of relationship patterns or, in more psychoanalytic terms, object relations (ORs). A PO is a stable, dynamically 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, 1984, 1996). The PO performs the function of stabilizing the mental apparatus, mediating between etiological factors and direct behavioral manifestations of illness (Kernberg, 1984, p. 5). Three types of POs are outlined in Kernberg s model: psychotic (PPO), which includes the schizoid, schizotypal, and paranoid subtypes; borderline (BPO), which includes the narcissistic, dependent, passive aggressive, infantile, borderline, and antisocial subtypes; and neurotic (NPO), which includes the masochistic depressive, obsessive compulsive, and hysterical subtypes. The model also includes four dimensions that define and differentiate the POs: OR patterns; defense mechanisms; identity diffusion; and reality testing. The PPO presents with symbiotic object relations, archaic defense mechanisms (mainly denial), severe identify diffusion, and poor reality testing. The BPO manifests anaclitic and dual ORs, with immature defense mechanisms (mainly splitting, projective identification and omnipotent control), as 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 drives), whereas the PPO shows the weakest of these. Our previous CCRT studies indicated the link between relationship patterns and POs. For example, we observed that participants suffering from a DSM III R borderline personality disorder wished to be distant and to be loved, whereas those not suffering from this disorder wished to be loved and to feel good; no differences were observed on the RO and the RS components (Lefebvre, Diguer, Rousseau, & Morissette, 1995). However, these preliminary studies were conducted with only 10 participants in each group. We also observed that the CCRT method could be applied reliably to narratives from participants presenting with a PPO (Diguer, Normandin, Lefebvre, Rousseau, & Morissette, 1996). This issue had to be addressed before proceeding with a more complete study on POs, because it was not yet clear whether PPO participants could produce narratives that were able to be scored with the CCRT. The aims of this study were to compare the original CCRT scoring of ROs and RSs focused on the main other person, with an alternative scoring that includes all

4 172 DIGUER ET AL. types of other persons and to compare different POs in terms of relationship patterns as measured by (a) CCRT profiles, (b) negativity of ROs and RSs and proportion of inferred wishes, and (c) complexity of the CCRTs. Following Kernberg s (1996) model and the CCRT results available, the PPO group should present more negative responses (poor drive satisfaction), more inferred Ws (poor self-understanding), and less complex CCRTs than the NPO group, with the BPO group between the two. The CCRT profile for each PO group should reflect the OR pattern typical of each group (i.e., symbiotic, anaclitic, or triangular for the PPO, BPO, and NPO, respectively). Participants Method Participants were recruited in outpatient clinics either at the School of Psychology of Laval University (58%) or at Quebec City psychiatric hospital (42%). Patients applied for psychotherapy by telephone. Their requests were dispatched to available psychologists for intake. Four professional psychologists working in these clinics 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. Approximatively 80% of the patients solicited accepted to participate and gave informed consent. All patients presenting with an active psychosis, brain damage, substance intoxication, or dependence were excluded. A total of 120 patients were evaluated before a minimum 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: 20 in the PPO group, 31 in the BPO group and 30 in the NPO group. On the average, participants were 33.9 years old (SD = 9.9 years). Forty-nine percent were women, and 31.2% were married or living with a significant other. Twenty-one percent were attending school, 40% worked outside the home, 3% did housekeeping, 15% were unemployed, and 26% were on welfare. Sixty-two percent completed college, and 45.5% had some university education. The average annual personal income was 12,987 Canadian dollars (SD = 10,459). DSM III R examination (see Procedure and Measure section) revealed that 38.3% of the participants presented with a mood disorder, 29.6% with anxiety disorder, and 14.8% with an adjustment disorder. Forty-four percent of the participants had a personality disorder: 12.3%, Cluster A; 27.2 %, Cluster B; 17.3%, Cluster C (the total exceeds 44.4% because of comorbidity). 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. Logically, given group definition, Axis II diagnoses were expected to be more prevalent in the BPO group. Several studies showed that borderline personality diagnoses were more prevalent among women than men (Gunderson, Zanarini, & Kisiel, 1991) and that patients suffering from a psychotic disorder were less educated (Kaplan, Sadock, & Grebb, 1994). The diagnostic measure Personality Organizations Diagnostic Form (PODF: Diguer & Normandin, 1997) reduces the probability of false-positive PPO diagnoses attributable to low education and concrete responses. To make a PODF diagnosis of PPO, the rater must identify the presence of several clear episodes of reality contact impairment; these items show the highest reliability (Hébert, Diguer, Daoust, Rousseau, & Descôteaux, 2000). The overall 50% male ratio, which is more

5 CCRT AND PERSONALITY ORGANIZATIONS 173 TABLE 1. Demographic and Clinical Characteristics of the Three Personality Organization Groups Variable PPO BPO NPO Differences N Sex: women/men 11/9 20/11 9/21 v 2 (2, N = 81) = 7.60* Age in years PPO > NPO, F(2, 74) = 3.09* Marital status: spouse/no spouse 15/3 22/8 16/13 v 2 (2, N = 77) = 4.57, ns Education: high school/college/ 10/5/3 16/3/11 3/5/21 v 2 (4, N = 77) = 19.77** university Income: <$20K/$20K $40K/ 14/4/0 25/4/1 20/9/0 v 2( (4, N = 77) = 4.06, ns >$40K Axis I: no Dx/Dx 3/17 4/27 9/21 v 2 (2, N = 81) = 3.19, ns Axis II: no Dx/Dx 8/12 12/19 25/5 v 2 (2, N = 81) = 14.90** Note. Dx = diagnosis; PPO = psychotic personality organization; BPO = borderline personality organization; NPO = neurotic personality organization. *p <.05. **p <.001. than what is commonly observed in outpatient clinics, is probably due to the NPO group, which is composed of 21 men and 9 women. A PODF NPO diagnosis implies the absence of borderline characteristics; logically, the gender differences reported among borderline disorders (Gunderson et al., 1991; Kaplan et al., 1994) may have played a role on the gender distribution of the NPO group. Procedure and Measure All participants were evaluated with the Structural Clinical Interview for DSM III R (SCID)-I and the SCID-II (Spitzer, Williams, Gibbons, & First, 1989) by licensed psychologists or graduate students under supervision. All interviews were videotaped and the diagnoses revised and discussed with at least one other evaluator to ensure their appropriateness. The participants were asked to give 10 narratives relating incidents or events in relation to another person, according to the Relationship Anecdotes Paradigm (RAP) interview method (Luborsky 1998b), which was shown to be a valid method of eliciting relationship narratives (Barber, Luborsky, Crits-Christoph, & Diguer, 1995). Participants were also asked to describe three significant others as well as themselves, according to the instructions and procedure developed by Blatt for his Object Relationship Inventory (ORI; Blatt, Chevron, Quinlan, Schaffer, & Wein, 1992). The relationship narratives and the object and self-descriptions were taperecorded and typed. These descriptions were used, in conjunction with the DSM III R Axis I and Axis II, to score the PODF; the ORI was, therefore, not scored for this study. The PODF, which was designed to score such material as descriptions of others and self, contains clear instructions and examples (Hébert & Diguer, 1999b); this measure is described later. The CCRT was scored according to Luborsky (1998a). First, the narratives were typed and their degree of detailed information on the interaction was evaluated. To qualify for this study, each narrative had to contain a description of the events that occurred and the participants wishes and responses (Luborsky, 1998a). We selected 828 narratives; the average number produced per participant was 10.2 (SD = 1.2). Twelve participants gave only 9, 8, or 7 usable narratives, but these were evenly distributed over the three PO groups, so that no differences between the groups were

6 174 DIGUER ET AL. found in terms of the number of narratives, F(2, 78) =.89, p =.12. Despite this minor lack, we obtained more than 810 (81 10) relationship narratives because, as occasionally happens in CCRT studies, some narratives actually contain two distinct relationship narratives, according to Luborsky s (1998a) definition. Next, the REs were read by the raters; all segments of the texts corresponding to a thought unit, as defined by Benjamin (1986), were underlined. These thought units were then scored for the three CCRT components (W, RO, and RS), for the negativity of ROs and RSs, and for the inference of the Ws. Because CCRT Edition 2 categories were shown to overlap (Barber, Crits-Christoph, & Luborsky, 1998), Edition 3 was used. 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 CCRT of each participant includes the most frequent and second most frequent CCRT clusters. The negativity of ROs and RSs was scored according to the original two-category distinction (i.e., positive or negative). 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 1998a). Two levels of inference are distinguished for the wishes. Explicit wishes are directly stated, whereas inferred wishes are not explicit but moderately inferable (Luborsky, 1998a). The degree of inference of Ws measures of the participants awareness of their relationship patterns. 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. The PODF (Diguer & Normandin, 1997) allows evaluation of POs according to Kernberg s model (Kernberg, 1984, 1996). Information can be gathered from several sources: intakes, therapy sessions, object and self-descriptions, DSM evaluation, and relationship narratives. The psychometric properties of this new measure were previously evaluated in Hébert and Diguer (1999a) and Hébert et al. (2000). These two studies (ns = 30 and 130, respectively) showed that the PODF had fair to excellent interrater reliability (mean ks of.46 and.79, respectively), whereas the latter study showed that it had good construct validity and internal consistency. The PODF differs from the few other existing PO measures in that it is observer rated (contrary to the Inventory of Personality Organization; Clarkin, Foelsch, & Kernberg, 1986) and the PO diagnosis is a comprehensive synthesis of Kernberg s four dimensions, unlike the KAPP (Weinryb et al., 1991), which includes only one global item on PO. In fact, the PODF includes 20 items with four subscales, each representing one dimension of Kernberg s model: primitive defense mechanisms, identity diffusion, reality testing and ORs. Four items evaluate identity diffusion: subjective experience of emptiness, contradictory self- and object perceptions, Contradictory behaviors, and Impoverished perceptions of others. Seven items evaluate the level of defense mechanisms: splitting, primitive idealization, projective identification, denial, omnipotent self-representations, devaluation of others, and omnipotent control. The four Reality Testing items are lack of differentiation between self and others, failure to identify the origins of perceptions, lack of the capacity to evaluate one s experience in terms of ordinary social norms, and presence of grossly inappropriate affects, thoughts, or behaviors. The fourth subscale on ORs has only one item subdivided into three categories: 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. Because a complete description of the PODF is far beyond the limits of this article, the interested reader should consult the PODF scoring manual (Hébert & Diguer, 1999b) for more information. The PODF was scored

7 CCRT AND PERSONALITY ORGANIZATIONS 175 by two independent judges based on SCID-I, SCID-II, and object and self-descriptions. 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. Reliability Results Reliability of the CCRT scoring was assessed using weighted kappa (Cohen, 1968), which has become the standard method to estimate the reliability of the CCRT (Luborsky & Diguer, 1998). It allows us to judge the agreement between raters with provision for agreement occurring by chance. In counting the matches between raters, a weight of 1.0 was given when the match was based on the two raters agreement as to what ranked first and second on the CCRT cluster. A weight of.66 was given when the match was based on agreement between the first rater s first rank and the second rater s second rank. When the second rank CCRTs of both raters coincided, a weight of.33 was given. Finally, when there was no agreement between raters for either first- or second-rank CCRT clusters, a weight of 0 was given. Kappas ranging from 0 to.39 suggest poor agreement; from.40 to.74, fair to good agreement; and from.75 to 1.00, excellent agreement (Landis & Koch, 1977). The CCRT interrater reliability was calculated on the thought units of at least 20% of the REs, depending on the pairs of raters (the averaged number of thought units used for reliability estimation is 314). 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. TABLE 2. Reliability of the CCRT on the Main Other Persons Method and the All Other Persons Method Main other persons All other persons Judge Ws ROs RSs Ws ROs RSs 1 vs. 2 Weighted j No. segments vs. 3 Weighted j No. segments vs. 2 Weighted j No. segments vs. 4 Weighted j No. segments M Note. CCRT = Core Conflictual Relationship Theme; Ws = patient s wishes; ROs = responses from others; RSs = responses of self.

8 176 DIGUER ET AL. The PODF interrater reliability was calculated on the basis of data from 31 participants (38% of the total sample), who were randomly selected from the sample and rated independently by two raters according to the PODF scoring manual (Hébert & Diguer, 1999b). They agreed on all participants (weighted j = 1.00), which, of course, eliminated the need for further discussion to reach consensus. Comparisons of Two CCRT Alternative Methods for Scoring the ROS and the RSS The pervasiveness score, a CCRT statistic, was used in this study as it is in most CCRT studies. Frequency scores were derived for each cluster of the CCRT components (W, RO, and RS) by taking the average of the different raters frequency scores. 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, 1998a). We thus obtained a pervasiveness score for each of the eight W clusters, eight RO clusters, and eight RS clusters. Correlations between the main other person method and the all other persons method, in terms of pervasiveness scores, were all significant (p =.0001, n = 81). The averaged Pearson correlation was.82 (range =.59.91) for the eight W clusters;.80 (range =.74.88) for the ROs; and.82 (range =.75.91) for the RSs. Moreover, the average Pervasiveness Score difference between the two methods was less than 1%. The two most pervasive clusters of the three CCRT components 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. Actually, the averaged pervasiveness score difference between the two methods was 1% in the PPO group, 0.5% in the BPO group, and 0.4% in the NPO group. Pearson correlations (all ps <.01) also indicated that the two methods gave very close results: In the PPO group W r =.73; RO r =.70, and RS r =.64; in the BPO group, W r =.85; RO r =.82, and RS r =.87; and in the NPO group, W r =.84, RO r =.81, and RS r =.83. Both methods also produced very similar results in terms of the amount of inferred Ws: r =.89 (p =.0001) with an average difference of 5% between them; this phenomenon was observed within each PO group: in the PPO group, r =.70 (p =.0006) with an average difference of 10%; in the BPO group, r =.91 (p =.0001) with an average difference of 4%; and in the NPO group, r =.91 (p =.0001) with an average difference of 4%. The two methods also yielded very similar scores in terms of negativity of ROs and RSs. For the ROs, r =. 85 (p =.0001), with an average difference of 1% between them; for the RSs r =.85 (p =.0001), with an average difference of 17% (more negative RS in the all other persons method). Comparable results were obtained in the three PO groups (all ps <.0001): In the PPO group, for ROs r =.89 (p =.0001) with an average difference of 3%, and for RSs r =.76 (p =.0006) with an average difference of 12%; in the BPO group, for ROs r =.79 (p =.0006) with an average difference of 1%, and for RSs r =.92 (p =.0006) with an average difference of 26%; in the NPO group, for ROs r =.76 (p =.0006) with an average difference of 0.08%, and for RSs r =.81 (p =.0006) with an average difference of 12%.

9 CCRT AND PERSONALITY ORGANIZATIONS 177 The number of different Ws, ROs, and RSs used in each RE reflects the level of complexity. Both methods were also closely correlated in this regard: For Ws r =.83; for ROs r =.76; and for RSs r =.76, (all ps =.0001). However, as expected, the all other persons method provided higher numbers than did the main other person method: 22% more Ws, 30% more ROs, and 26% more RSs. The same pattern of correlations between the two methods was observed within the three PO groups. In the PPO group, for Ws r =.68, for ROs r =.67, and for RSs r =.82; in the BPO group, for Ws r =.83, for ROs r =.76, and for RSs r =.73; in the NPO group, for Ws r =.87, for ROs r =.80, and for RSs r =.72 (all ps =.0001). Given that both methods produced 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. CCRT Profiles of the Three Personality Organizations A CCRT profile is the set of pervasiveness scores for all CCRT clusters (W, RO, and RS). In the PPO group, the pervasiveness scores ranged from.02 to.37 (mean =.18) (see Figure 1) and the standard deviations ranged from.04 to.21 (mean =.21). In the BPO group, the pervasiveness scores ranged from.01 to.50 (mean =.228) and the standard deviations ranged from.05 to.23 (mean =.15). The NPO group scores ranged from.01 to.51 (mean =.25) and their standard deviations ranged from.04 to.22 (mean =.17). A multivariate analysis of variance (MANOVA) was calculated first to take into account the relationships between the eight wish-cluster pervasiveness scores. Because no multivariate difference was detected, F(16, 142) = 1.24, p =.25), no univariate analyses of variance (ANOVAs) followed. 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). The second most common was Cluster 3 (upset) for the NPO and BPO groups. In the PPO group, three clusters had very close pervasiveness scores and competed for the second rank: Clusters 7 (likes me), 6 (helpful), and 3 (upset). Between groups, pervasiveness score differences were examined, because having the same most common cluster does not exclude the possibility of intergroup differences. Actually, the MANOVA revealed a significant multivariate difference between the PO groups on ROs, F(16, 142) = 2.09, p =.01. Post hoc univariate and Tukey tests showed that, on average, significantly fewer rejecting ROs were reported by the PPO group compared with the BPO and NPO groups, and significantly fewer upset ROs were reported by the PPO group than by the NPO group. 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 depressed). The second most common was Cluster 3 (respected) for the PPO group, Clusters 8 (anxious) and 3 (respected) for the BPO group, and Clusters 3 (respected) and 1 (helpful) for the NPO group. MANOVA results revealed a significant multivariate difference among the three PO groups on RSs, F(16, 142) = 2.23, p =.007). Post hoc univariate ANOVAs showed that all three PO groups had different pervasiveness scores on RSs on Clusters 1 (helpful), 7 (disappointed and depressed), and 8 (anxious and ashamed). Tukey tests revealed that NPO participants saw themselves as more helpful and more disappointed and depressed than PPO individuals, whereas

10 178 DIGUER ET AL. CCRT cluster Ws ROs RSs 8: to achieve and help 8: Understanding 8: Anxious: PPO < BPO + NPO* 7: to feel good 7: likes me 7: disappointed: PPO < NPO* 6: to be loved 6: helpful 6: helpless 5: to be close 5: rejecting: PPO < BPO + NPO* 5: self-controlled 4: to be distant 4: bad 4: to oppose 3: to be controlled 3: upset: PPO < BPO + NPO* 3: respected 2: to feel oppose 2: controlling 2: unreceptive 1: to assert 1: strong 1: helpful: PPO < NPO* FIGURE 1. W, RO, and RS profiles (means of pervasiveness scores for each cluster) by personality organizations groups. * represents significant group differences. NPO = neurotic personality organization (n = 20); BPO = borderline personality organization (n = 31); PPO = psychotic personality organizations (n = 20); Ws = patient s wishes; ROs = responses from others; RSs = responses of self; CCRT = Core Conflictual Relationship Theme. Values are presented according to European conventions. the BPO group showed no difference from the two other groups. However, both NPO and BPO participants saw themselves as more anxious and ashamed that the PPO participants. Inferred Wishes and Negativity of the ROs and the RSs In the entire sample, the proportion of inferred wishes was 43%, and it did not differ from one group to another, F(2, 78) = 1.52, p =.22. The mean negativity score of both the ROs and the RSs was.55 for all 81 participants. Because the negativity scores of ROs and RSs were correlated (r =.67, p <.0001), a MANOVA was run before univariate comparisons; it revealed a significant difference between groups, F(4, 154) = 3.92, p <.01. ANOVAs and Tukey tests showed that NPO and BPO participants (Ms =.57 and.60, respectively) viewed ROs more negatively than PPO participants (M =.42), F(2, 78) = 7.81, p = In terms of RSs, the PPO group was

11 CCRT AND PERSONALITY ORGANIZATIONS 179 again less negative than the BPO group (M =.45 vs..61). This time, however, the NPO group (M =.56) fell between the two, F(2, 78) = 4.79, p =.01. Complexity of the CCRT The number of different Ws, ROs, and RSs contained in a participant s narratives is used to estimate the level of complexity of his or her relationship patterns. For all 81 participants, the mean number of different Ws per narratives was 1.33; the mean number of ROs was 1.71, and the mean number of RSs was The numbers of Ws, ROs, and RSs were intercorrelated: Ws versus ROs, r =.51; Ws versus RSs, r =.50; ROs versus RSs, r =.66 (all ps <.0001). A MANOVA was run on these three variables before univariate tests to take these intercorrelations into account, and it was found to be significant, F(6, 152) = 2.38, p =.03. ANOVAs and Tukey tests (a <.05) revealed an average of 1.05 Ws per narrative in the PPO group, 1.36 Ws in the BPO group, and 1.48 Ws in the NPO group, F(2, 80) = 4.41, p =.02. Actually, the PPO group differs from the NPO group but not from the BPO group; the BPO and NPO groups do not differ either. The average number of ROs was smaller for the PPO group (1.41) than for the BPO (1.76) and the NPO (1.85) groups, F(2, 80) = 4.74, p =.01. The same pattern of differences was found for RS: The PPO group had smaller amounts of these responses (M = 1.96) than the BPO (M = 2.46) and the NPO (M = 2.64) groups, F(2,80) = 6.03, p =.004. Reliability of the CCRT and the PODF Discussion The kappas for the CCRT reliability fell in the fair to excellent range and were comparable to those reported previously (Luborsky & Diguer, 1998). The reliability of PO diagnosis was also excellent. One study showed that a good to excellent agreement on the PODF was relatively easy to reach, particularly when based on several sources of information (Hébert & Diguer, 1999a; Hébert et al., 2000). The measure contains some very clear cutoff criteria, such as the presence of psychotic experiences 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.59 to 1.00 (mean =.79), which is still in the good to excellent range and comparable to results obtained in Hébert et al. (2000) and Hébert and Diguer (1999a). The Comparison of Two CCRT Scoring Methods The first goal of this study was to compare two methods of CCRT scoring (i.e., the main person method and the all other persons method). Both methods yielded very similar results, and the nonsignificant differences observed did not warrant the amount of time required by all other persons method. In terms of CCRT profiles, both methods gave exactly the same two top W, RO, and RS clusters; the differences in pervasiveness scores between them were less than 1%. 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.

12 180 DIGUER ET AL. The alternative method of CCRT scoring suggested at the 1998 CCRT Workshop proved not to provide us with new and useful information concerning the internal schema of object relationships. The Ws, ROs, and RSs of the other person duplicated those of the main other person. Therefore, it seems that, even if relationship narratives do involve more than one other person, they nonetheless relate dual relationships. 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. Displacement was first identified by Freud in his work on dreams (1900/1953) and since then has often been shown to have a major impact in ORs, transference, and defenses (Moore & Fine, 1990). However, the absence of additional significant others contradicts abundant findings in clinical literature on more complex relationship schemas, such as triangular or oedipal ORs. In more complex oedipal schemas, the patient usually has two different significant others, 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 triangular relationship narratives and that BPO presents narratives with dual relationships (Kernberg, 1996). Indeed, the instructions read: Please tell me some incidents or events, each involving yourself in relation to another person.... For each one tell (1) when it occurred (2) who was the other person it was with.... The other person may be anyone (Luborsky, 1998b, p. 110). Barber et al. (1995) observed similarities between relationship narratives related in the early phase of psychotherapy and those from RAP interviews. However, their sample did not control the distribution of personality variables, whereas our study did. Also, all their participants presented with a DSM III R major depression, whereas ours presented with a variety of Axis I disorders. Furthermore, our study entailed more detailed analyses, because we examined 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 narratives. 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. CCRT of Personality Organizations There are more similarities than differences between the PO groups. All three groups had the same two most common W clusters: to be distant and avoid conflict and to achieve and help others. The most common RO was the same for the three groups (rejecting and opposing), although the PPO group had significantly lower pervasiveness scores on this cluster than did the two others. The second most common RO in the NPO and BPO groups was upset, whereas it was likes me, helpful, and upset for the PPO group. 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 respected), but again the PPO group had significantly lower pervasiveness scores on this cluster. The BPO partici-

13 CCRT AND PERSONALITY ORGANIZATIONS 181 pants had higher pervasiveness scores on the RS anxious, whereas NPO participants scored higher on the RS helpful. It is interesting to compare our results to those obtained in previous studies. For example, in Luborsky et al. (1998), who compared 12 dysthymic and 21 nondysthymic patients, the most prevalent CCRT components for the Ws were to be close and to be independent; for the ROs, rejecting and opposing; for the RSs, disappointed and depressed. Wilczek et al. (2000) found the same CCRT profile in a 55-patient sample. In Waldinger et al. (2000), the most prevalent CCRT among young adults for the Ws was to be close and to be independent; for the ROs, rejecting and opposing; for the RSs, helpful and respected. 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. In terms of Ws, the present study s sample put more emphasis on avoiding conflicts, self-achievement, and helping others than on being close and loved, which ranked third and fourth, respectively. Rejection and opposition from the other person were confirmed as the most prevalent of ROs, and the two most prevalent RSs correspond with one from each of these two studies. At this stage of CCRT research, we can only hypothetically explain the main difference between our sample and the others regarding the Ws: Cultural and linguistic factors may have played a role in view of the fact that our sample was composed entirely of French Canadians. Furthermore, many of our participants were more severely ill than those in studies by Luborsky et al. (1998) and Wilczek et al. (2000), particularly in the PPO and BPO groups. One other possible explanation is that the instructions differed in the three studies. Our participants were simply asked to give narratives about relationships with other persons; no specifications were added as to the type of other person (the RAP interview). In Waldinger et al. (2000), young adult participants were asked for narratives concerning their two closest peer relationships (one romantic and one nonromantic). This type of instruction would obviously lead to a higher frequency of the wish to be close. The same hypothetical explanation applies to Luborsky et al. (1998), in which narratives were extracted from therapy sessions and mostly involved intimate relationships. In Wilczek et al. (2000), narratives were extracted from RAP interviews, but their sample was not severely ill (26 of 55 participants had no DSM III R diagnosis) and, as previously stated, only 6 presented with personality disorders. The relatively small differences observed between the three PO groups may have been caused not only by the possible bias of the RAP interview instructions but also by the limitations of the CCRT clusters. As previously explained, RAP instructions emphasize dual relationships and may have inhibited the production of the triangular relationships narratives typical of the NPO (Kernberg, 1996). Furthermore, as Wilczek et al. (2000) noted, the eight CCRT clusters for Ws, ROs, and RSs may be too large to grasp the differences that may exist between PO groups. For example, two standard categories were combined into the W cluster to be distant and to achieve and help when, in fact, they may express quite different OR schemas. According to Kernberg s model, this combination may express either the splitting of the object, which is characteristic of PPO and BPO, or ambivalence toward the object, which is typical of NPO. This problem might be solved either by increasing the number of clusters or by working with the 35 categories of Edition 2. However, in pilot studies, we observed that it was difficult to attain an acceptable reliability on the 35 categories because many overlap, as was shown in Barber et al. (1995). Moreover, calculating reliability on the 35 categories requires very large samples. Further work could aim at defining cluster categories better while reducing the 35 categories of Edition 2 to 12.

14 182 DIGUER ET AL. Another possible explanation for the apparent lack of discrimination of the CCRT clusters might be the distribution of the POs within the sample originally used to define them. We do not know whether the number of participants taken from each of the three groups (PPO, BPO, NPO) was large enough to allow for the emergence of psychological characteristics that clearly define the level of psychic functioning typical of each PO (see Barber et al., 1998). Actually, this is not very surprising because the CCRT was primarily designed not to discriminate PO groups but rather to extract the main relationship patterns of individuals. In fact, during the scoring, our raters sometimes believed that it was difficult to find the right cluster when narratives included (e.g., to admire, to understand the other person as Ws; to be helpless as RO; and to be suspicious, to feel exploited, to feel in love as RSs). Moreover, the strongest difference between PPO and the two other groups was that they failed to maintain reality testing, which was recognized by inappropriate or bizarre affect, behavior, and thought content in terms of ordinary norms. However, at this stage of their development, the CCRT clusters do not allow for this evaluation. The most significant observation in terms of PO group differences was that, compared with other participants, PPO participants had flatter RO and RS profiles. This appears to support Kernberg s postulate that PPO patients present high identity diffusion, which he described as a poorly integrated concept of the self and of others, as is reflected in contradictory self-perceptions and shallow, flat, impoverished perceptions of others (Kernberg, 1984, p.12). Identity diffusion, however, is also characteristic of BPO, albeit less intensely. Considering these last comments and the limited distribution of personality variables in the samples that were used to draw the CCRT clusters, it, therefore, appears that the CCRT applied to RAP interviews lacks sensitivity regarding POs. The degree of inference of Ws in participants narratives measures the extent to which they are aware of their relationship patterns. Only a few empirical results (Crits- Christoph & Luborsky, 1998b) using other conditions and measures have been published on self-understanding of the CCRT, making it impossible to compare the 43% inferred Ws we observed. The absence of differences among the PO groups may be misleading, however, because according to Kernberg s model, the PPO and BPO patients use denial as a defense against becoming aware of their wishes and other psychological contents, whereas NPO patients use repression. The present CCRT method does not allow for this differentiation. In our study, 55% of both ROs and RSs were found to be negative, which is inferior to findings in other clinical samples and closer to the negative quality found in normal samples. In samples mainly composed of patients presenting with mood or anxiety disorders, between 70% and 90% of the ROs or RSs were negative (Grenyer & Luborsky, 1998; Luborsky et al., 1998). Normal adults also were more negative than positive, albeit in a smaller proportion than in clinical samples. Dahlbender et al. (1992), Cierpka et al. (1992), and Waldinger et al. (2000) reported a negative response rate of approximately 60% in normal samples. The preponderance of negative responses from others and self in all CCRT studies has already been examined. It has been suggested that negative interactions are more readily told because they are more memorable than positive ones; they deal with hard-to-master conflicts in relationships (Luborsky et al., 1992). It is more difficult to explain why the clinical sample of our study showed negativity values closer to those found in normal samples, although some cultural factors and sample characteristics (sex ratio, DSM III R diagnoses, and education) may have played a role, along with the different conditions

15 CCRT AND PERSONALITY ORGANIZATIONS 183 under which the sets of narratives were collected (i.e., the RAP interview in our study vs. narratives told in therapy sessions). Differences between PO groups showed the PPO participants to be less negative than the others and thus more optimistic toward wish satisfaction in their relationships with others. These results are the first to be published on the negativity of PPOs. At this stage, we can only hypothetically assume that, per Kernberg (1996), these results reflect the typically strong regression of PPO, which leads these patients to resort profusely to primitive idealization and fantasies of magically satisfied wishes. This hypothesis is supported by Luborsky, Luborsky et al. (1996), who observed that at ages 3 and 5, children clearly showed less negative ROs and RSs than did adults. Furthermore, Waldinger et al. (submitted) reported significant shifts from predominantly negative to more positive responses of other and self, from adolescence to young adulthood. In the Luborsky et al. (1998) study that included dysthymic and nondysthymic participants, a mean of three Ws and a mean of four ROs and RSs were found per narrative. No difference was reported between the two subgroups. In Waldinger et al. (2000), young adults gave narratives that contained 5.08 Ws, 7.02 ROs, and 7.45 RSs. For all 81 participants in our study, the mean numbers of different Ws, ROs, and RSs were lower (1.33, 1.71, and 2.40, respectively). Moreover, we observed that the PPO group had fewer Ws than the NPO group, and it had fewer ROs and RSs than both BPO and PPO groups. These figures estimate the flexibility of the narratives; a larger number of different Ws, ROs, and RSs is typical of a better capacity to activate several types of relationship patterns. The lower numbers found in the present study tend to indicate that the RAP interview may produce simpler narratives than do the psychotherapy sessions used by Luborsky et al. (1998); their study gave neither restrictions nor instructions, and the general context of psychodynamic therapy allowed patients to freely develop their narratives. Furthermore, our findings on PO group differences are consistent with those of Cierpka et al. (1998), who observed that normal adults presented more flexible CCRT patterns than did clinical patients and that consistency of patterns seemed to be related to the severity of psychopathology. Our findings also tend to confirm Kernberg s (1984) model concerning the ego weakness of PPO as well as their high identity diffusion and their tendency toward object-self fusion. It is also possible that slight paranoid regression occurred in the relationship between a PPO participant and the evaluator; a suspicious participant will tend to simplify narratives to protect intimacy (Kernberg, 1984, p. 270). Limited education of the PPO group, sex ratio, and DSM III R diagnosis differences across the three PO groups, although congruent with common observations (Kaplan et al., 1994), may also have had an impact on our results. Our study allows neither control nor estimation of the impact of these sampling characteristics, which proves to be a limitation. Future studies should include larger samples that allow finer analysis of the impact of variables such as level of psychosocial functioning, sex, age, and education. In conclusion, this study on the CCRT revealed several similarities and some interesting differences between POs in that the PPO group presented a flatter CCRT profile, less negativity of ROs and RSs, and a lower level of complexity than the BPO and the NPO groups. These results suggest that the development of the CCRT method should include further studies on the discriminant validity of the method. More specifically, these studies should allow us to ensure that the clusters cover a large range of ORs (from psychotic to neurotic) and to reexamine the impact of RAP instruction on narratives.