Object Relations and Social Cognition in Borderlines ... - CiteSeerX

Psychological Assessment: A Journal of Consulting and Clinical Psychology 1990, Vol. 2, No. 4, 355-364

Copyright 1990 by the American Psychological Association, Inc. 1040-3590/90/$00.75

Object Relations and Social Cognition in Borderlines, Major Depressives, and Normals: A Thematic Apperception Test Analysis Drew Westen and Naomi Lohr Departments of Psychology and Psychiatry University of Michigan

Kenneth R. Silk, Laura Gold, and Kevin Kerber Department of Psychiatry University of Michigan

This study compared reliably diagnosed borderline personality disorder patients (n = 35) with major depressives (n = 25) and normals (n = 30) on 4 dimensions of object relations and social cognition coded from Thematic Apperception Test (TAT) responses: Complexity of Representations of People, Affect-Tone of Relationship Paradigms (malevolent to benevolent), Capacity for Emotional Investment in Relationships, and Understanding of Social Causality. As predicted, borderlines scored significantly lower on all 4 scales than did normals and lower on Affect-Tone and Capacity for Emotional Investment than did nonborderline major depressives. Borderlines also produced more pathological responses than did both groups on every scale, indicating more poorly differentiated representations, grossly illogical attributions, malevolent expectations, and need-gratifying relationship paradigms. The results suggest the importance of distinguishing several interdependent but distinct cognitive-affective dimensions of object relations and the potential utility of assessing object relations and social cognition from TAT responses.

fective processes underlying interpersonal functioning in patients with BPD. Many of these dimensions have been studied empirically by developmental researchers, particularly those interested in social cognition (for a review, see Shantz, 1983). Like object relations theorists, social-cognition researchers have focused on representational processes underlying interpersonal functioning (see Horowitz, 1987; Singer & Kolligian, 1987; Westen, in press-a). Social-cognition research comes from a different intellectual tradition, studies normative rather than pathological processes, uses experimental rather than clinical methods, focuses on molecular rather than molar processes, and relies on different metaphors of the mind than does psychoanalytic object-relations theory. Nevertheless, this literature addresses issues such as the nature and development of causal attributions (Ruble & Rholes, 1981) and person-schemas (Horowitz, 1987; Livesley & Bromley, 1973; Markus & Wurf, 1987; Singer & Kolligian, 1987) in ways that are likely to lead to refinements of object-relations models (Westen, 1989; in press-a, in press-b). Until recently (see Bell, Billington, Cicchetti, & Gibbons, 1988; Burke, Summers, Selinger, & Polonus, 1986; Westen, Ludolph, Lerner, Ruffins, & Wiss, 1990), empirical studies of object relations in borderline patients have relied exclusively on human-figure responses on the Rorschach test. Nearly all of those studies have compared borderline patients (often diagnosed with unreported or marginal reliability and validity) with schizophrenics. By and large, borderlines typically score higher than schizophrenics on overall developmental level as measured on Blatt's Rorschach measure for object relations (Blatt, Brenneis, & Shimek, 1976), though findings on particu-

The psychological processes underlying the interpersonal pathology of patients with borderline personality disorder (BPD), that is, their distorted object relations, have been conceptualized in various ways by different theorists. Most argue that a disturbance in the first 3 years of life leads to the continued use of developmentally primitive modes of relating in adulthood (Kernberg, 1975; Masterson, 1976). Although theorists and clinicians (see Greenberg & Mitchell, 1983) often speak of levels of object relations as unitary phenomena, from developmentally immature to mature, the term object relations refers to a congeries of cognitive and affective functions and structures, including ways of representing people and relationships, rules of inference for interpreting the causes of people's feelings, behaviors, interpersonal wishes, conflicts, and so forth. The concept of general levels of object relations is clinically an indispensable heuristic, but these levels should be understood as being composed of several interdependent but distinct developmental lines that differ in their maturity and quality among individuals as well as within a single individual at any given time (Westen, 1989, 1990, in press-b). The aim of the present study is to explore the nature of different dimensions of the cognitive-af-

This research was supported by a grant from the Department of Psychiatry, University of Michigan. We thank Alfred Kellam, Natasha Lifton, and John Boekamp for help in coding the data. Correspondence concerning this article should be addressed to Drew Westen, University of Michigan, Department of Psychology,580 Union Drive, Ann Arbor, Michigan 48109-1346 355

356

WESTEN, LOHR, SILK, GOLD, KERBER

lar subscales have been less consistent (Gartner, Hurt, & Gartner, 1989; Hymowitz, Hunt, Cart, Hurt, & Spear, 1983; Lerner & St. Peter, 1984; Spear & Sugarman, 1984). Lerner and St. Peter (1984) and Stuart et al. (1990) found that borderlines tend to produce malevolent, idiosyncratic, but cognitive-developmentally advanced representations of people's intentions on the Rorschach. This finding is not entirely consistent with developmental object-relations theory: Malevolence is not likely to reflect a normal developmental stage, and cognitively advanced representations, even if perceived in a manner suggestive of marginal reality testing, are not easily construed as reflecting preoedipal regression or fixation. When multiple facets of object relations are clearly differentiated, many hypotheses about their developmental course and their quality in severe character pathology can be studied empirically. This study focuses on four dimensions of object relations and social cognition, as measured from Thematic Apperception Test (TAT; Murray, 1938) responses: Complexity of Representations of People (tendency to represent people in complex ways and to distinguish clearly their subjective experience and points of view), Affect-Tone of Relationship Paradigms (affective quality of the object world or interpersonal expectations, from malevolent to benevolent), Capacity for Emotional Investment in Relationships and Moral Standards (need-gratifying orientation to the social world versus investment in values, ideals, and committed relationships), and Understanding of Social Causality (tendency to attribute causes of behaviors, thoughts, and emotions in a complex, accurate, and psychologically minded way). Each dimension is assessed with a five-level scale (Westen, Lohr, Silk, & Kerber, 1985). With the exception of Affect-Tone, the scales attempt to measure developmental dimensions; Level I is relatively primitive, and Level 5 is mature. The TAT is an excellent test for assessing object relations and social cognition because, unlike the Rorschach (1942) blots, the stimulus is unambiguously social, and subjects are likely to provide enough detail in describing characters and relationships as to provide considerable access to cognitive-affective patterns related to interpersonal functioning. The measures used here were derived from clinical observation, object-relations theory and research (see Blatt & Lerner, 1983; Greenberg & Mitchell, 1983; Thompson, 1981; Urist, 1980), and research in developmental social cognition (Bogen, 1982; Damon, 1977; Selman, 1980; Shantz, 1983). Recently completed research has begun validating the measures with both normal and clinical populations. Research with undergraduates has found significant correlations between the TAT measures and analogous measures devised for use with interview data, such as psychotherapy transcripts and research interviews (e.g., complexity of TAT characters correlates with complexity of people in descriptions of actual interpersonal episodes; see Barends, Westen, Leigh, Silbert, & Byers, 1990; Leigh, Westen, Barends, & Mendel, 1989). This research has also found predicted correlations between the four TAT scales and validated instruments, such as Blatt, Wein, Chevron, & Quinlan's (1979) measures of complexity and affective quality of parental representations applied to descriptions of significant others. For example, as predicted, Blatt's "conceptual level" measure correlates with Complexity and Social Causality but not with Affect-Tone or Emotional

Investment. The scales were also able to predict social adjustment as measured by Weissman's Social Adjustment Scale (Weissman & Bothwell, 1976) in both clinical and nonclinical samples. Two developmental studies have documented developmental differences using both TAT and interview responses in all measures except Affect-Tone, with one study comparing second and fifth graders and the other comparing early and late adolescents (Westen, Klepser, et al., 1989). Borderline adolescents have been shown to differ from psychiatric and normal comparison subjects on the four scales (Westen, Ludolph, Lerner, et al., 1990), and borderline adults and adolescents have been shown to differ from each other in ways suggestive of needed refinements in theory (Westen, Ludolph, Silk, et al., 1990). Schneider (1990) has recently assessed these dimensions from psychotherapy transcripts using an analogous instrument for narrative data and found increases in complexity o frepresentations and capacity for emotional investment over the course of brief psychoanalytic psychotherapy and at follow-up. Internal consistency (Cronbach's alpha) has varied depending on the number of TAT responses and between-subject variance, ranging from .59 to .77 in clinical samples using five to seven cards. In the present study, we compared the TAT responses of a sample of BPD patients with responses of patients with major depressive disorder (MDD) and normals. Hypotheses were the following. Bordedines should have lower mean scores and a higher percentage of pathological (Level 1) responses on all four scales than normals. On Affect-Tone of Relationship Paradigms and Capacity for Emotional Investment, borderlines should have lower mean scores than major depressives and should have a higher percentage of Level 1 scores, reflecting expectations of malevolence and a need-gratifying orientation to the social world. Although major depressives should not differ from borderlines in mean Complexity of Representations of People or Social Causality because of the cognitive constriction characteristic of depressives, which should apply to their representations of people as well, borderlines should have more poorly differentiated characters (scored Level 1 on Complexity of Representations) and grossly illogical causal sequences (scored Level I on Social Causality) than major depressives. This pattern is expected to hold for borderlines who are concurrently in a major depressive episode as compared with nonborderline major depressives as well.

Method Subjects The patients used as subjects for this study were drawn from two inpatient units of the University of Michigan Medical Center. To be considered for inclusion in the study, as an initial screening procedure, potential subjects had to meet at least two criteria of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II1 or DSM-111-R [revised ]; American Psychiatric Association, 1980, 1987) for BPD or schizotypal personality disorder or three such criteria for major depressive episode on admission. Exclusion criteria included chronic psychosis or medical problems that would prohibit a 2-week drug-free period or would confound biological test results. Ninety-two percent of eligible subjects consented to be considered

OBJECT RELATIONS IN BORDERLINES for inclusion in the research. While consenting subjects were drug-free, they were administered the Diagnostic Interview for Borderlines (DIB; Gunderson, Kolb, & Austin, 1981), which has been shown in several studies to predict clinician diagnosis of BPD using DSM-IIIor DSMII1-R criteria with sensitivity and specificity above 80% (Armelius, Jullgran, & Renberg, 1985). Interrater reliability (K= .78) by our group has been described elsewhere (Cornell, Silk, Ludolph, & Lohr, 1983), and reliability has been maintained through periodic retraining and assessment. Diagnosis of depression was made by Research Diagnostic Criteria (RDC; Spitzer, Endicott, Gibbon, & Robbins, 1975), a precursor to DSM-III for research purposes, by a member of the research team, based on interviews with the patient and the patient's primary therapist. Interrater reliability on the diagnosis of depression was .92 (weighted kappa; Cohen, 1968), with a range of pairwise reliability of .88 to .94. As in previous research using the DIB, patients were admitted to the BPD cohort by obtaining a DIB score of>~7. Nonbordedine MDD comparison subjects scored ~