John F Clarkin

Weill Cornell Medical College | Cornell · Department of Psychiatry

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and ot...

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of “self affe...

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering differen...

Objective: Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status. Methods: A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspe...

Background: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive fac...

Contemporary models of the diagnosis and classification of personality disorders have diverged from the categorical diagnostic framework of the DSM system. One response to this movement can be found in the Alternative DSM-5 Model for Personality Disorders (AMPD), which uses dimensions of personality functioning, coupled with identification of domin...

Background Both the latest edition of the DSM-5 as well as the new ICD-11 have established a new focus in the diagnosis of personality disorders: the assessment of personality functioning. This recent shift in focus converges with long-standing psychodynamic conceptualizations of personality pathology, particularly Kernberg’s object relations model...

The Pathological Narcissism Inventory (PNI) is extensively used in recent empirical literature on pathological narcissism. However, most studies using the PNI are community-based, and no studies have used the PNI to investigate narcissistic presentations in personality disordered patients. This study investigates measurement invariance of the PNI i...

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whethe...

Transference-focused psychotherapy (TFP) is a principle-driven, transdiagnostic psychodynamic psychotherapy for individuals with personality pathology. Originally developed and empirically validated for patients with the categorical diagnosis of borderline personality disorder (BPD), TFP has since been adapted to meet the clinical needs of the full...

Level of personality organization refers to a system of classification of personality pathology based in object relations theory. Within this framework, personality disorders are characterized according to severity of pathology, ranging from mild to extreme, based on assessment of the individual’s identity, quality of object relations, defensive fu...

Objective: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory...

Recent advances in the understanding of personality pathology have contributed to an emphasis on the core of personality pathology as deficits in self-functioning and interpersonal functioning at different levels of severity that must be assessed for clinical intervention. In concert with these conceptual and empirical advances, transference-focuse...

Adolescence is a crucial period for the development of personality and its dysfunctions. In this regard, it is essential to evaluate the nature and degree of maladaptive personality functioning. However, measures currently available present some limitations, mainly being adaptations from adult’s tailored instruments and length. Moreover, no instrum...

Introduction Effortful control (EC) is the self‐regulatory aspect of temperament that is thought to reflect the efficiency of executive attention (EA). Findings on relationship between EC and performance on EA tasks among adults are still contradictory. This study used a computational approach to clarify whether greater self‐reported EC reflects be...

Background The purpose of the present study was threefold: first, to investigate the facial affective behavior in patients with a borderline personality disorder (BPD); second, to examine whether these patients could be divided into clusters according to facial affective behavior; and third, to test whether these clusters would influence the inpati...

The Alternative Model of DSM-5 combines dimensional ratings of self-functioning, interpersonal functioning, and traits with categorical classification. The object relations model has a long tradition pre-dating the Alternative Model and, in part, has been incorporated into the Alternative Model. The object relations model provides a theoretical bac...

The assessment of personality and personality pathology in adolescence represents a critical topic to understand adolescent’s difficulties, predict long-term outcome in adulthood, and indicate adequate treatment. Personality Organization, and its underlying dimensions, plays an essential role in shaping how adolescents face their developmental task...

The present research case sought to illustrate how self-regulatory patterns of interpersonal behavior manifest within a rejection sensitive individual at the daily level. Cross-sectional research has demonstrated negative relational outcomes associated with rejection sensitivity, but less attention has been paid to how this manifests in daily relat...

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg’s model of personality organization. A heterogeneous, predominantly clinical sample (N = 616) completed the German 83-item version of the IPO. Confirm...

Objective: To examine conformity to prototypical therapeutic principles and its relation with change in reflective functioning in 3 treatments for borderline personality disorder (BPD). Method: Early phase videotaped sessions from a randomized-controlled trial of year-long transference-focused psychotherapy (TFP; n = 27), dialectical behavior th...

The intensive treatment of a patient presenting with major depression, chronic suicidal ideation, and a borderline personality disorder with narcissistic features is described as it developed over an 18‐month treatment. The treatment approach is a transdiagnostic one with an emphasis on change in the patient's representation of self and others, ide...

Borderline personality disorder (BPD) is a debilitating condition with significant personal and societal costs. Throughout the history of the conceptualization of borderline pathology as a form of psychopathology, there has been debate concerning the essential attributes of this disorder, which has significant implications for its assessment and tr...

In part 2, the authors argue for a greater focus on a process approach to conceptualizing borderline personality disorder (BPD). The studies reviewed highlight contextual aspects of the pathology, specifically the affective and relational conditions under which BPD features become evident. The authors identify at what level in a complex social cogn...

The authors describe an object-relations based model drawing on the work of Kernberg and colleagues for the assessment of borderline pathology. The substrate of internal object relations that constitutes borderline pathology internally or structurally is described and a model for assessing such pathology in a clinical interview format focusing on i...

Background: Normal and pathological narcissism have been the focus of considerable theoretical discussion and empirical research in recent years in personality psychology and psychopathology. Kernberg [ 1 - 4 ] has argued that there is a particularly dysfunctional and impairing variant of narcissistic disturbance known as malignant narcissism. Thi...

Research on personality in adolescence underlined the importance of adopting a dimensional approach to personality pathology rather than a categorical one. In this regard, the association between maladaptive versions of personality traits and pathological outcomes has been studied, neglecting the study of the severity of personality functioning. Th...

Narcissistic personality disorder (NPD) is associated with both seeming indifference and hypersensitivity to social feedback. This study evaluated whether rejection sensitivity and empathic difficulties in NPD are accounted for by altered facial emotion recognition (FER). Two-hundred non-clinical individuals self-reported NPD features, rejection se...

The Cognitive-Affective Processing System (CAPS) was used to examine effortful control (EC) as a moderator of daily interpersonal behavior. Participants (N = 240) were nonclinical young adults who completed a 7-day event-contingent experience sampling study of interpersonal perception and affect. Multilevel linear models indicated that EC moderated...

Background: Impairment in personality functioning (PF) represents a salient criterion of the DSM-5 alternative diagnostic model for personality disorders (AMPD). The main goal of this study is to analyze the relationship of the borderline personality disorder (BPD) clinical components derived from the DSM-5 categorical diagnostic model (affective...

Despite robust findings identifying impairments in interpersonal functioning associated with rejection sensitivity (RS), the object representations (OR) of self in relation to others from which such rejection expectancies and anxieties arise have not been evaluated. Our study was the first effort to evaluate the structural aspects of object represe...

The most current conceptualization of personality pathology emphasizes the assessment of the severity of selected domains of functioning involving lack of accurate perceptions of self and others that are common across the personality disorder categories. Advances in our understanding of personality pathology have stimulated further development of T...

This study examines psychopathology and clinical characteristics of patients with borderline personality disorder (BPD) and comorbid narcissistic personality disorder (NPD) from two international randomized controlled trials. From a combined sample of 188 patients with BPD, 25 also fulfilled criteria for a comorbid diagnosis of NPD according to DSM...

This article demonstrates the utility of a theory-guided psychodynamic approach to the assessment of personality and personality pathology based on the object relations model developed by Kernberg (1984). We describe a clinical interview, the Structural Interview (SI; Kernberg, 1984), and also a semistructured approach, the Structured Interview of...

Case Studies Within Psychotherapy Trials: Integrating Qualitative and Quantitative Methods presents a specific, mixed-methods approach, called the “Cases Within Trials” (CWT) model, to psychotherapy research combining the results from a randomized clinical trial (RCT); the results of richly and qualitatively detailed systematic case studies involvi...

Individuals high in rejection sensitivity (RS) are at risk for experiencing high levels of interpersonal distress, yet little is known about the interpersonal profiles associated with RS. This investigation examined the interpersonal problems, sensitivities, and values associated with RS in 2 samples: 763 multicultural undergraduate students (Study...

This investigation examined the moderating role of effortful control (EC) in the association between rejection sensitivity (RS) and its subsequent interpersonal distress (IP-distress) on borderline personality disorder (BPD) features. In total, 625 multicultural undergraduates (Study 1) and 562 community international adults (Study 2) completed sca...

AimBorderline personality disorder (BPD) is characterized by self-regulation deficits, including impulsivity and affective lability. Transference-Focused Psychotherapy (TFP) is an evidence-based treatment proven to reduce symptoms across multiple cognitive-emotional domains in BPD. This pilot study aims to investigate neural activation associated w...

Personality disorders are both prevalent and debilitating, but controversies abound concerning the definition, assessment and treatment of these conditions. This review examines major approaches to conceptualizing the personality disorders, as recently emerging in DSM-5, Section III, and the research domain criteria initiative of the National Insti...

This work aims to further validate the object-relations-based model of personality pathology assessment, evaluating the psychometric properties of the Italian version of the Inventory of Personality Organization (IPO), a self-report instrument for the assessment of personality organization according to O. Kernberg's model of personality pathology....

We describe a framework for the application of treatment modules to the major domains of dysfunction manifested by clients with personality disorder. This integrated approach takes the clinician beyond the existing limited treatment research by using strategies and techniques from all the major treatment schools and orientations. This effort is nec...

We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Atta...

Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in t...

Die Psychodynamische Therapie höher strukturierter Persönlichkeitsstörungen (PTSP) ist eine spezifische Behandlungsmethode für Patienten mit neurotischer Persönlichkeitsstruktur entwickelt von einer Studiengruppe um Otto F. Kernberg. Das praxisnahe Therapiehandbuch bietet neben theoretischen Grundlagen über Persönlichkeitsstörungen und Strukturnive...

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experie...

The present study evaluates the relationship between effortful control (EC) and externalizing psychopathology in young adults. EC, the capacity to delay immediate impulses in favor of long-term goals, has been robustly linked to externalizing behaviors in children and adolescents. However, such data is limited in adults, and mechanisms underlying t...

Research has linked individual differences in effortful control (EC) with variations in interpersonal functioning in children and adolescents. Using the Inventory of Interpersonal Problems-Short Circumplex (Hopwood, Pincus, DeMoor, & Koonce, 2008), this study investigated interpersonal problem profiles associated with EC in 763 nonclinical young ad...

The aim of this study was to investigate the effectiveness of long-term psychoanalytic and psychodynamic psychotherapies. In a prospective, randomized outcome study, psychoanalytic (mean duration: 39 months, mean dose: 234 sessions) and psychodynamic (mean duration: 34 months, mean dose: 88 sessions) therapy were compared at post-treatment and at o...

In this longitudinal study, we examined within a dyadic perspective how romantic attachment and depressive-masochistic personality (DMP) predicted initial and long-term relationship satisfaction 1 year and 3 years after initial testing through direct and interaction effects. A sample of 299 couples completed romantic attachment, personality organiz...

The definition of personality disorder has evolved from agrowing clinical consensus to official status in the DSM diagnosticsystem since DSM-III. The definition proposed for DSM-5 highlightsimpairments in self and interpersonal functioning and thepresence of pathological personality traits. There remains a cleartension in this definition. Researche...

This paper introduces a German short form of the Inventory of Personality Organization (IPO-16). The IPO long form is a self-report instrument for the assessment of personality dysfunction in the domains of identity, defense, and reality testing. The IPO-16 measures general personality dysfunction and is based on 16 items representing the common de...

Advances in our understanding of complex psychopathology will likely benefit from approaches to mind, brain, and behavior that seek to (a) specify those general neurobehavioral processes underpinning pathology and (b) bridge to other process-based models of psychopathology at different levels of analysis. Well-defined neurobehavioral processes (e.g...

QUESTION Question: What are the effects of psychological interventions for borderline personality disorder (BPD)? Outcomes: Overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with, but not specific to, BPD, attrition from the study and adverse effects. METHODS Design: Systematic review and meta-analysis. Data sources:...

Drawing on a sample of 372 French-Canadian couples, this study examined the factorial structure of a 20-item abbreviated version of the Inventory of Personality Organization (IPO) across a sample of couples and tested if identity diffusion, primitive defenses, and reality testing explain additional variance in couple distress when controlling for n...

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and...

The present study evaluates the psychometric properties of a therapist measure for evaluating the affective communication created between the patient and therapist during the initial stages of treatment. The Affective Communication Questionnaire (ACQ) was administered to a sample of 81 therapists, each rating a single patient, and principal compone...

Personality disordered patients present with multiple problem areas and potential targets of change. This complex clinical situation can be addressed by an integrated approach to the treatment by using treatment strategies and techniques from the various schools of therapy, sequenced and adapted to the individual patient. An optimal choice and sequ...

What changes and how quickly these changes occur as a result of therapy in borderline personality disorder (BPD) is an important ongoing question. The features of BPD patients that are most predictive of rates of change in such patients remain largely unknown. Using the Cornell Personality Disorders Institute (CPDI) randomized controlled trial data...

Abstract: In the field of developmental research, there is a pressing need to develop clinically sounded and empirically grounded tools for the assessment of personality development in adolescence. After a review of the relevant literature on adolescent personality disorders we present through empirical data and clinical material the IPOP-A, a semi...

In the field of developmental research, there is a pressing need to develop clinically sounded and empirically grounded tools for the assessment of personality development in adolescence. After a review of the relevant literature on adolescent personality disorders we present through empirical data and clinical material the IPOP-A, a semi-structure...

From initial consultation to termination of treatment, psychologists and other mental health practitioners make a series of crucial decisions to determine the progress and therapy of the patient. These decisions have varied implications such as the clinical course of the patient, the efficacy and efficiency of the treatment, and the cost of the ses...

The assessment and diagnosis of personality disorders for clinical intervention and research purposes is at crossroads. The diagnostic criteria for the personality disorders in DSM-IV TR Axis II are a listing of symptoms in search of a unifying assessment of personality dysfunction. The utilization of the diagnosis of these criteria has resulted in...

Dropout from psychotherapy is a serious impediment to treatment (Clarkin & Levy, 2004). This is especially true for patients with certain disorders such as borderline personality disorder (BPD; Yeomans et al., 1994). In the present study, we report findings regarding the reasons for termination from therapy for 30 outpatients with BPD who had dropp...

On February 10, 2010, the official proposals for the personality disorders section of the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were posted (see www.dsm5.org ). The posting by the DSM-5 Personality and Personality Disorders Work Group has been helpful in informing...

The Work Group for the DSM-5 personality disorders has submitted their proposal to the professional community. In this paper, we consider the proposal in light of its ability to meet criteria for clinical utility as proposed by First and colleagues (2004). While the Work Group's proposal has addressed some of these concerns, we conclude that there...

Clinicians routinely note the challenges involved in psychotherapy with individuals with BPD, yet little research exists on the therapeutic alliance with this population. An important question is, what patient factors contribute to a disturbed alliance with individuals with BPD? Executive attention has been identified as a mechanism of BPD, and men...

An interpersonal perspective is essential for understanding personality disorders, or maladaptive and inflexible patterns of perceiving and relating to oneself and one's environment. This chapter reviews current theories of personality disorders, including their relationship to major theories of normal personality (especially interpersonally orient...

Cli nicians treating patients with personality disorders commonly grapple with several key questions: ◆ What is the relationship between normal personality functioning and personality pathology? ◆ What are pathological aspects of personality functioning common to many or most of the personality disorders? ◆ What relationships exist among the higher...

In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disord...

P>Narcissistic personality disorder (NPD) is characterized by a pervasive pattern of grandiosity, a sense of privilege or entitlement, an expectation of preferential treatment, an exaggerated sense of self-importance, and arrogant, haughty behaviors or attitudes. Although the concept of narcissism is often used in clinical and social settings, the...

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing eff...

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contem...

Considerable heterogeneity exists in the comorbid Axis II features that frequently accompany borderline personality disorder (BPD). These features have potential to be meaningfully organized, relate to specific BPD presentation, and have implications for treatment process and outcome. The present study explored patterns of Axis II comorbidity in or...

In a review of six clinical cases involving the treatment of a patient with two or more personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV; American Psychiatric Association, 1994), five key decisions that have an impact on treatment emerged. The clinical cases are discu...