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Section 21
Assessing BPD Clients

Question 21 | Test | Table of Contents

The Rorschach Oral Dependency scale (ROD; Masling, Rabie, & Blondheim, 1967) was developed as a psychoanalytic content scale to assess oral/dependent imagery. A response is defined as oral dependent if it falls into any of the following categories: food and drinks, food sources, food objects, food providers, passive food receivers, food organs, supplicants, nurturers, gifts and gift givers, good luck symbols, oral activity, passivity and helplessness, pregnancy and reproductive anatomy, and negations of oral percepts (e.g., not pregnant; man with no mouth). The construct validity and interrater reliability regarding this measure have proven to be excellent in more than 90 experimental studies utilizing various populations (Bornstein, 1996).

The Mutuality of Autonomy Scale (MOA; Urist, 1977) assesses the thematic content of relationships (stated or implied) between animal, inanimate, and human representations in Rorschach percepts. The scale was developed to assess the degree of differentiation of object representations, focusing primarily on the developmental progression of separation-individuation from engulfing, fused relations to highly differentiated self-other representations. Scale points 1 and 2 reflect the capacity to construe self- and other representations as structurally differentiated and engaged in mutually interactive or parallel activity (e.g., "two people talking about grocery prices, pushing shopping carts"). Scale points 3 and 4 capture dependent and mirroring object relationships and often reveal an emerging loss of autonomy between figures (e.g., "Siamese twins connected at the waist"). Scale points 5, 6, and 7 reflect not only the loss of the capacity for separateness but also increasing malevolence (e.g., "an evil fog engulfing this frog ... smothering it"). Reliability data are excellent (Tuber, 1989), and the scale has demonstrated a high degree of construct validity with behavioral ratings (Ryan, Avery, & Grolnick, 1985; Urist, 1977; Urist & Schill, 1982), assessment of therapeutic change (Blatt & Ford, 1994), and multimethod assessment of the construct (Fowler, Hilsenroth & Handler, 1995; Urist, 1977). For this study, we chose a composite score of all level 5, 6, and 7 pathological scores (PATH; Berg, Packer, & Nunno, 1993) because it has been found to be a robust and stable measure of pathological object relations.

Defensive structures may be assessed using the Lerner Defense Scale (LDS; Lerner & Lerner, 1980). This scale is based on Kernberg's (1975) theoretical conceptualizations and other commentators' clinical observations (Holt, 1977; Mayman, 1967; Peebles, 1975). Primitive defenses of splitting, idealization, devaluation, and denial represented in percepts of human, quasi-human, and human detail (Hd) responses were assessed for this study. The LDS has shown good construct validity and high interrater reliability (Lerner, 1991). To use more stringent parametric statistics in the analysis of those defenses that are ranked on a continuum from high to low order (devaluation, 1-5; idealization, 1-5; and denial, 1-3), defenses were weighted according to rank and then were collapsed into an overall score for that category. For example, if there are three instances of idealization on a subject's protocol, one Level 1 and the other two instances at Level 3, the subject would receive a total idealization score of 7 (1 + 3 + 3 = 7).

The Boundary Disturbance and Thought Disorder Scale (BDS; Blatt & Ritzler, 1974) assesses an individual's capacity to maintain distinctions between objects along cognitive/perceptual and affective dimensions. Blatt and Ritzler drew connections between the degree of thought disorder present on the Rorschach and the concomitant degree of ego boundary dysfunction. Drawing on Rapaport's indices of thought disorder, they proposed the following hypotheses: (1) Mild forms of ego boundary fragmentation or looseness of boundary (boundary laxness) could be measured by fabulized combination. (2) More severe problems of differentiating fantasy from reality (inner/outer boundary disturbance) would be represented in responses containing confabulations. (3) The most severe form of boundary fragmentation and disintegration (self/other boundary disturbance) would be captured in the severely thought-disordered responses known as contaminations. Several studies (Blatt & Ritzler, 1974; Lerner, Sugarman, & Barbour, 1985; Wilson, 1985) have found that borderline patients typically have greater difficulty with boundary laxness and inner/outer boundaries, whereas schizophrenic patients typically have greater difficulty distinguishing between self/other boundaries. The more severe self/other boundary disturbance may correspond to what many have described as the crumbling ego boundaries, dissociation, and drug-flee hallucinations observed in many patients who self-mutilate.
- Fowler, J. Christopher, Mark Hilsenroth, and Eric Nolan; Exploring the inner world of self-mutilating borderline patients: A Rorschach investigation; Bulletin of the Menninger Clinic; Summer 2000; Vol. 64 Issue 3.

Personal Reflection Exercise #7
The preceding section contained information about assessing BPD clients using Rorschach cards .  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Improving the Methodological Quality
of Randomized Clinical Trials Assessing
Psychotherapy for Borderline Personality
Disorder: Recommendations for the Future

- Juul S. (2022). Improving the methodological quality of randomized clinical trials assessing psychotherapy for borderline personality disorder: Recommendations for the future. Frontiers in psychiatry, 13, 1053844.

Peer-Reviewed Journal Article References:
DeShong, H. L., Grant, D. M., & Mullins-Sweatt, S. N. (2019). Precursors of the emotional cascade model of borderline personality disorder: The role of neuroticism, childhood emotional vulnerability, and parental invalidation. Personality Disorders: Theory, Research, and Treatment, 10(4), 317–329.

Dick, A. M., & Suvak, M. K. (2018). Borderline personality disorder affective instability: What you know impacts how you feel. Personality Disorders: Theory, Research, and Treatment, 9(4), 369–378.

Harpøth, T. S. D., Kongerslev, M. T., Moeyaert, M., Bo, S., Bateman, A. W., & Simonsen, E. (2020). Evaluating “mentalizing positive affect” as an intervention for enhancing positive affectivity in borderline personality disorder using a single-case multiple-baseline design. Psychotherapy, 57(4), 580–586.

QUESTION 21
What is a key difference in boundary difficulties occurring in BPD clients and schizophrenic clients? To select and enter your answer go to Test.

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