CC18 Workshop 15 - Personality Disorders in Couple Therapy: Borderlines, Narcissists, and Schizoid...Oh My! - Stan Tatkin, PsyD, MFT

Description:

For decades, psychoanalytic models of individual therapy were retrofitted into marital treatment models. These approaches tended to be ineffective with character disordered partners. With the recent emergence of polytheoretical, psychobiological approaches to couple therapy, the clinician can now be more effective with character disordered partners. This two hour workshop will help clinicians differentiate between those partners who are psychoneurotic, insecurely attached, or undifferentiated, and those who are personality disordered. The workshop will focus primarily on borderline and narcissistic spectrum disorders and provide practical interventions for working with these patients within the context of couple therapy.

Educational Objectives:

1. List at least five defining features of personality disorders.
2. List at least three methods of gaining a therapeutic alliance with personality disordered partners.
3. Describe at least two interventions to move partners toward secure functioning.

*Sessions may be edited for content and to preserve confidentiality*

Outline:

Workshop Introduction

• Workshop led by Stan Tatkin on personality disorders in couple therapy (e.g., borderline, narcissistic, schizoid).

Therapist’s Background and Mentorship

• Presenter shares training history (family systems, Gestalt) and challenges at the John Bradshaw Institute.

• Mentored by James Masterson on disorders of the self.

• Emphasizes importance of continued work with personality disorders despite shifting clinical trends.

Understanding Personality Disorders

• Personality disorders involve attachment patterns like distancing and clinging.

• DSM limitations acknowledged; deeper understanding needed.

• Emphasizes developmental origins and accurate diagnosis.

Disorder Severity Levels

• Low-level: common in institutions, involve dysregulation, self-harm.

• Mid-level: often mistaken for neurosis.

• High-level: found in successful individuals but still driven by maladaptive defenses.

• Key defense: dissociative splitting.

Therapeutic Challenges and Techniques

• Importance of understanding transference, projective identification.

• Therapists must maintain neutrality, handle manipulation, and manage “thirds” (outside people/events).

• Be prepared for self-harm behaviors and intense emotional dynamics.

Theoretical Approaches

• American vs. British object relations and self-psychology contrasted.

• Focus on strengthening the reality ego and integrating part-object representations.

• Developmental perspectives emphasized.

Intervention Strategies

• Use of triadic structure: pain, self-defense, confrontation.

• Therapeutic neutrality critical for dealing with narcissistic/borderline clients.

• Supportive confrontation should be structured and strategic.

Couples Therapy with Personality Disorders

• Challenges arise when one or both partners have personality disorders.

• Address both partners’ defenses and support self-activation and entitlement.

• Intense emotional responses are common and must be managed by the therapist.

Case Study and Application

• Example couple used to demonstrate defense patterns and therapeutic strategy.

• Supportive confrontation and structured sessions emphasized.

Ethics and Frame Management

• Maintain a clear couple-focused frame; refer out for individual therapy if needed.

• Avoid seeing partners privately, and keep joint communication (e.g., shared emails).

• Protect couple’s privacy; no gossip or triangulation.

Setting Up the Room

• Mobile chairs used for flexibility and control over dynamics.

• Therapist remains central in the room for balance.

• Keep setup professional and intentional.

Managing Reactions and Energy

• Stay centered even during provocation; use humor and inspiration, not reactivity.

• Serenity Prayer cited as helpful for therapist regulation.

• Maintain a dynamic, engaging environment.

In-Session Conflict Examples

• Couple discusses past conflict (e.g., smashed phone).

• Therapist probes into deeper relationship patterns and triggers.

• Emphasizes addressing patterns, not isolated incidents.

Projective Identification and Deeper Dynamics

• Explore history to understand current emotional responses.

• Help clients see their role in projection and reenactment.

Balancing Intervention

• Know when to step in vs. allow processing.

• Set clear goals and adapt based on progress.

• Frame should remain focused and consistent.

Power Dynamics

• Address how both partners contribute to imbalances.

• Revisit projective identification as a dynamic that fuels power struggles.

Creating a Safe Space

• No formal ground rules, but therapist must be vigilant.

• Intervene when needed to protect safety without overstructuring.

• Balance each partner’s needs in real-time.

Session Frequency and Triage

• Frequency depends on severity and needs.

• Use triage principles to address most urgent dynamics.

• Be flexible in response to couple’s evolution.

Trauma and Accountability

• Trauma acknowledged, but all clients must behave responsibly.

• Use clear boundaries and expectations to guide behavior.

• Support fair, socially just interactions in relationships.