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CLINICAL AND RESEARCH REPORT Stages of Change in Dynamic Psychotherapy With Borderline Patients Clinical and JOlIN Implications M.D. GENDERSON, ROBERT N. authors the first therapy stages for of long-tenn the basis dynamic outline methods The treatment personality current personality historical therapy parallels for for vidual bor- disorder with for (BPD) the interest schizophrenia has in psycho- 25 years ago. In both areas, clinicians’ interest has been ulated by the publications of influential choanalytic therapists. psychotherapy by the Optimism of schizophrenia writings Fromm-Reichmann, in the stimpsy- about the was inspired 1940s Arieti, and 50s Searles, of Will, Semrad, Lidz, and others. Beginning in the late 1960s the reports by another distinguished group that included Kernberg, Masterson, Adler, Chessick, and Giovacchini evoked a similar atmosphere of optimism in psychotherapy for the treatment of patients with this disorder. In both instances these therapists suggested that long-term psychoanalytic psychotherapy, ifwell conducted, VOLUME can 2 #{149} NUMBER! in the psy- who were considtreatment resistant benefits in ther- psychotherapy changes documented of phenothi- therapy introduced a for treating schizophreas alternatives to indi- psychotherapy. psychiatric sort out in fundamental azines and behavioral variety of modalities nia that were viewed disorder. interest borderline The cases, measuring points about chopathology of patients ered to be among the most psycho- treated for at different bring on disorder. successfully of psychotherapeutic derline research personality offive the effectiveness, apy, guidelines borderline the authors Pn.D. NAJAVITS, offer for M.D. SABO, M. LISA The M.D. WALDINCER, At.Ex On Research In community the options. response, turned However, the to research to many of the schizophrenia research projects began with rather naive premises about the magnitude of the changes that might be expected and the speed with which they spite all the endorsements pists of the value might written of dynamic occur. Deby thera- therapies schizophrenic patients, it became dramatic or curative results were for clear truly that rare, took a long time, and might depend on either gifted therapists”2 or exceptional patients.3 It took decades of studies to develop appropriate outcome ing attained Received measures; the benefits October 16, 199!; cepted May 29,1992. From cial Research Program, Massachusetts Gunderson 02178. at the Copyright WINTER #{149} 1993 to recognize that of medications revised May !4, the Personality and McLean Hospital, Address above address. © 1993 American reprint !992; ac- PsychosoBelmont, requests Psychiatric havwas to Press, Dr. Inc. CLINICAL AND RESEARCH 65 REPORT often prerequisite (not detrimental) to successful outcome; to identify the unexpected characteristics of those patients who might be crete bility amenable offer the sequencing test to dynamic therapy for therapies; a sufficient its effects. The subsequent treatment shown that psychosocial and then to duration problems to shorter ond, that there of such of schizophrenic medications interventions, literature patients has and more discrete such as social skill The history therapies set the oped or established stage for therapies about namic effectively the still-to-be-develthat can then residual neg- ative-and perhaps “core”-symptoms schizophrenia. It turns out that it is only these negative symptoms that individual ploratory insight-oriented psychotherapy beneficial.5 patients of of for ex- years, has research documented medication and with shown that symptoms,6’7 value therapy. studies have positive borderline potential behavioral chopharmacologic patients minish with the Psy- studying of these claimed to do this. ment of borderline our The literature patients bears authors have however, we of our own of five suc- involve seem so-called unlikely borderline patients meet official DSM to The stages has on treatwitness to five of were destructive. of these cases change from which were borderline prototypic, impulse-laden, and self-destructive, role performance, were dysfunctional and comfortably Interview and DSM-III sessed). Most in therapy. for Borderhines criteria (as had extensive Moreover, because duct of research evaluating of this treatment. Before delineating the phases we that observed dynamic dis- we will highlight with ment should various other of borderline develop recognize, first, the role of individual and its interactions interventions patients. therapeutic the in the Specifically, strategies multiplicity JOURNAL of OF the treat- PSUHOTHERAPY of likely any one therapy PRACTICE with AND long-term these five therathe re- to of the be free therapist. borderline These their and the two observations RESEARCH five as- therapists, are offered because of for both clinical practice during (DIB)’8 the required dynamic idiosyncrasies cases tions different more their both retrospectively prior experience seemed to sort out psychotherapy five in met sults claim self- At the beginning of treatment, all young adult patients were openly fectiveness in diminishing discrete aspects of borderline patients’ psychopathology.9 As with the development of therapeutic treatments for schizophrenia, research is now that our patients involved of modalities who cri- we derive pies proliferation written in successful dypatients based ef- the work of the timetable 1O13117 knowledge, psychotherapy magnitude and the cessfully treated and carefully diagnosed borderline patients.’4 Identifying such cases seemed especially important because the existing case reports of successful treatments Diagnostic To Such on their clinical experience;’#{176}’3 rely heavily on a reconsideration previously reported case material borderline drugs can help diand using a cog- dynamic aided examples patients. Four for greatly well-documented treated changes. established therapies. been the phases of change therapy with borderline who individual have could have indicated the changes that are possible ni tive-behavioral treatment can markedly reduce suicidality.8 Such interventions may make borderline patients amenable to having their ongoing and perhaps still “core” psychological traits addressed by other still-to-beonly on psychotherapy could successfully be an CHANCE of research first In recent optimal be OF schizophrenia of ongoing may on by address amenaand, sec- treatments. STAGES research their potential interventions, to training and psychoeducation, can dramatically diminish positive symptoms and recidivism.4 This research has also shown that such may and term implicathe con- effectiveness of change psychopatients, that have a 66 CLINICAL direct the bearing current The on first observation cult it was to find fully completed considerable ing such research into derline searchers, relates good examples therapies. to how diffi- lay claim, the literature it proves a “true” seen through noted high elsewhere, frequency drop difficult BPD to identify case that to a successful out of As reflective borderline therapies-rarely more been conclusion. this is partly with which Borderline patients’ change on second of long-term to them. is a very about and how remain observation dynamic is that therapy borcriteria at baseline and after 4 years of therapy 4 Years 3. 4. 5. 6. Impulsivity or unpredictability in at least two areas that are potentially self-damaging, e.g., spending, sex, gambling, substance use, shoplifting, overeating, physically self-damaging acts. ____________________ A pattern relationships, idealization, (consistently _______________________ Inappropriate, anger, e.g., anger. intense anger frequent displays or lack of control of temper, constant X X x x x x ? of x X x of being alone, alone, depressed feelings e.g., frantic efforts when alone. of emptiness x X X x x x X X X _______________________ X X x or x x x ____________________ x or boredom. VOLUME 2 X ? x _______________________ to acts, e.g., suicidal recurrent accidents, X ____________________ Affective instability: marked shifts from normal mood to depression, irritability, or anxiety, usually hasting a few hours and only rarely more than a few days, with a return to normal mood. Chronic x 5 _________________________ 7. Physically self-damaging gestures, self-mutilation, physical fights. 8. x Identity disturbance manifested by uncertainty about several issues relating to identity, such as self-image, gender, identity, long-term goals or career choice, friendship patterns, values and loyalties; e.g., “Who am I?”, “I feel like I am my sister when I am good.” Intolerance avoid being X Cl) 53 53 - intense interpersonal shifts of attitude, manipulation for one’s own ends). the effects 1 shows how changed relaBy the end of Cl) of unstable and e.g., marked devaluation, using others in such for borderline After S 2. psycho- treatment, all five patients were involved in socially productive roles and virtually all impulsive behaviors had disappeared. Relation- is Baseline 1. For resobering that before a random-assigna great deal patients are profound. Table dramatically the five patients tive to the DSM-III criteria. who DSM-ffl to be learned to be engaged The giving therapists, including experts, the satisfaction of bringing the treatment to a mutually satisfactory conclusion.’2’ This observation TABLE!. needs are likely a therapy. of the pa- should be of comfort to the clinicians might otherwise feel that being “dropped” reflective of the inadequacies that their patients attribute however, this REPORT dynamic therapists can successfully engage such patients in therapy or alternatively about how to select borderline patients who in has RESEARCH observation that indicates highly expensive, controlled, ment study can be undertaken, of successDespite the experience in successfully treatpatients to which many therapists can tients conducting subject. AND NUMBER! #{149} x WINTER #{149} x 1993 x ? X CLINICAL ships, AND both RESEARCH within and were infused with and good will that 67 REPORT outside of an ambience had replaced In the third year, acting out greatly diminished, but acting in (in the form of testing therapy, of affection the distrust and hostility of earlier periods. inferred from these cases that In short, we dramatic char- acter within changes period previous had occurred of 4-5#{189}years-changes therapy had helped still seem about the Figure change behaviors around and within the therapy) intensified. The patients’ emerging trust in the fact that the therapists cared about them a time was accompanied by increased expression of hostility in reaction to limitations or disap- that, even if pave the way, pointments ship. The incompatible with what is known normal course of this disorder. 1 presents a condensed view of the processes that were observed sence in the demanding-based powerful protector, the patients had sponses to the these roles. The functional. The second therapists’ patients the year characteristics diminished tions and employment routine self-destructive contacts. of the craving a more explicit edgment of dependency Four patients found Proceas upon part-time involving with change Thus, acThere e observed in five Impulsive Suicidal Affects Desperate Rageful Relationship Unemployed Year and more Only OF PS’HOTHERAPY responsithen did RESEARCH available N S case studies that over have implications. by which or on preced- time period. clinical and In particular, by which lack of researchers ate measures vals to assess a longer powerful it can they Three areas in which give therapists can within therapy find appropri- that require shorter time whether the psychotherapy the inter- effective- patients 2 Year 3 Ye ar 4 PRACTICE Anxious Sad Vo cationa Employed Dependent YearS Testing “Owned” Anger ‘ within of therapy, their social schizophrenia Self-destructive Distrustful JOURNAL for rise to hypotheses gauge progress borderline 1 to the is possible these cases effective. of chang both research on the subject, these cases that specific changes are possible discrete periods and that profound research for actual acknowl- nondemanding, Action Therapeutic contrast ed the suggest within the therapist. and/or low- Year Function AND ab- increased of affects M P L I C A T 1 0 psychotherapy tasks. FIGURE!. Social In of but relative with to include ambitions. friendships. CLINICAl, director, angry re- year relation- years’ associated of a range I a continuation first severity of the extratherapeutic was some diminution signs of caring and level saw fifth was role performance bility and career patients develop failures to fulfill were all socially dys- of the and therapeutic and outside of therapy. Outside patients significantly enhanced on idealization as a potentially or nurturer-and the fourth of action expression five patients. A brief summary of these stages follows. The first year of treatment was primarily marked by a broad range of acting-out behaviors, including self-destructive acts and threats and multiple intersession contacts. The relationship to the therapist was intermittently within ‘ Collaborative AND RESEARCH Goals Friendships Warm is 68 CLINICAL ness of a therapy might be assessed apeutic alliance, impulse/action pecially self-destructiveness), adaptation. are ther- patterns (esand social reach which these they Therapeutic Alliance Borderline patients in intensive psychotherapy are dynamic to show a their warmth, thera- gradual growth in the trust, and collaborativeness attachment, with pist. Previous if not most, has shown that many, patients who are be- ginning psychotherapy attachment ous research dicates that months independently evaluation means should that and do a good develop out within the that at 6 months, show alliance that a large not develop evidence part features therapist, this an of psychotherapy as- such as positive positive attitudes research first half rative, pected of attachment and the of year than this offers therapeutic therapy should tive feelings going and treatment posiand latter, alliance half. significantly than in the area in which it is possifor change Specificacts will be likely in the first 6 months 6 months and in the first in the second year. For researchers, a relatively short-term way to assess effectiveness. For clinicians, onserious should suicide risk after raise the question acknowledge dependency upon him or her. Although such feelings may appear to be present very early in therapy, when they are apeutic more failure directly or at best an impasse. related to the concept pulse control is the based ments other types of self-destructive as self-mutilation, substance on idealization will often not or fantasy, the be secure enough sentito be acknowledged until there is more of a reality base and a sense of security in the relationship. The generally positive tone assigned the relationship will be recurrently until late in the therapy-perhaps to a stable, less rative relationship The therapist to meet these the whose criteria designated consultation. There degree idealized, in the time is considerable to which borderline to disturbed changing patient fails at each of should consider variation in patients VOLUME the may 2 recklessness. tions change period that and more collabofourth or fifth year. borderline for change periods and NUMBER! #{149} first Our Perhaps of im- diminution in behaviors, such abuse, buhimia, unpublished observa- is because these behaviors are more connected to the borderline person’s of him or herself as bad. Indeed, in the year tually insofar gradual 2 years in of a ther- have suggested that these behaviors more gradually and over a longer of time than suicidal acts. We believe this closely image ex- Patterns major more second in collabo- is to be ble to develop specific hypotheses involves impulse/action patterns. ally, we hypothesize that suicidal alignment with basic treatment goals (e.g., understanding his or her behaviors, developing trust). At best, patients may even accept the idea that the therapist is trying to be helpful. Between 12 and 24 months, psychohelp the patient to have toward the therapist of treatment, A second analytic defirelationship common purposes. can be expected Impulse/Action next 3 months.22 We borderline patients toward the the value of traditional working aspect of a good only in the second is unlikely majority (72%) of such an alliance of the therameasures of feeling about with separate roles but Whereas positive feelings the to if evaluated. Yet independent these changes would be for the therapy, and the nition of a collaborative or trust in their therapist.2’ Previwith schizophrenic patients ina poor therapeutic alliance at 6 to develop those who will drop propose never REPORT sessment. Certainly assessments peutic alliance must encompass hypothesized research borderline RESEARCH landmarks and the degree may be able to profess them important The AND of treatment, see some as many expansion borderline the therapist of these patients may ac- activities use such actions to evoke protective responses and test the resilience and reactivity of their therapists. Gradual diminution in the severity and WINTER #{149} 1993 CLINICAL AND RESEARCH 69 REPORT frequency of such actions should be observed from the second through the fourth years as the patient begins to unconsciously internalize some self-worth of feeling through cared about. the experience Because of both the public health significance (in terms of health service utilization and burden to others) and the relative ease of documenting overt selfdestructive and suicidal acts, change in this domain is particularly important to clinicians and particularly promising for researchers. The initial years of therapy are all marked by problems in managing the boundaries the psychotherapy; namely, the payment bills, between-session contacts, self-destructiveness, of of scheduling, substance abuse, (without diagnosis). implications. which This one might observation First, therapists’ doubt but probably should be expected to persome productive vocational role in the second year. Achieving work identifying career goals and the fourth table can and lies gear their more realistically-in other second sorts year has two research management unstable, and for friendship now sought research. deed, such Kernberg an effort. third year. cannot guided overlook dynamic our deep therapists fears will that lose performance the In- the type same year exploitative until emerges-potentially but more usually the in C 0 N C L U 5 1 0 N led us to develop a measure by which such actions can be weighed, quantified, and placed within a common conceptual sure of change (see Social A third major is the domain observable patient’s scheme Appendix as a major A). mea- a sequence of changes can be delineated level of social adaptation. One area involves vocational rehabilitation. The borderline patient in a useful psychotherapy might not function at work during the first JOURNAL the fourth effectiveness patients. of their treatment of These stages of change are relevant to research namic psychotherapy tients. It should on with be understood the stages of change usually well-informed phases of treatment in evalu- described clinical long-term borderline that dypa- although here are unhypotheses, that is all they are. If, but only if, prospective research confirms them, unsupported clinical judgments of the effectiveness of therapy Adaptation in which capacity in the S ating the borderline has in- we manualmuch of own impulses and actions can be a reliable measure for change in the observation the and about personal issues much later. Heterosexual will remain intermittent, his or her reasonably This psy- psychotherapy. friendships This report has identified specific change within psychotherapeutic that clinicians can use as guidelines years. fami- expectations way that the spontaneity and creativity required for effective psychotherapy for this patient group.24 Second, a patient’s ability to manage early of time- in helping individual of stable volving self-disclosure will not occur until involvements, too, to a clinically of the kind psychotherapy This benefit is likely to emerge during but will remain intermittent quirement for The development the et al.23 recently publishedjust Although we applaud this, years. and await choeducation has been shown to help families of schizophrenic individuals. In the area of social support, involvement with organizations or social groups of of such actions could lend itself meaningful, prescriptive manual in fifth be of great satisfaction ambitions conflicted. Sometimes this process can be facilitated if involvement with a group therapy or self-help organization is made a re- promis- cuity, etc. As distressing as these problems are, they are the familiar and even routine problems that are associated with this patient group year form OF PS’sCHOTHERAPY will be rendered less necessary. We are especially sensitive amined possibility that prior to the therapies unexmay have laid an unusually good base (e.g., diminished testing behaviors) from which the course of change seen in these successful PRACTICE AND RESEARCH 70 CLINICAL cases began. by prior This possibility prospective is underscored research showing that both tients borderline2’ and schizophrenic22 who had more prior therapy were pamore likely to engage in a new It seems clear that sons with BPD, as for therapy. psychotherapy those with for perschizophre- nia, involves a variety of sectors behavioral, interpersonal, familial, al, cognitive), each of which may sive to different modalities. Even area of individual of interventions fessional, ments psychotherapy, seems likely. (affective, vocationbe responwithin the a sequence The more pro- authoritarian, and supportive of psychotherapy may be ele- particularly AND RESEARCH ogy are more assessable. a sequence could explain REPORT Recognition why those of such who ad- vocate a psychoanalytic model for treatment of BPD often write about patients who lack the prototypic situational and behavioral problems that are usually presenting prob- hems for borderline patients. In view of the multiple modalities of treatment that are deemed useful for treating borderline patients and in view of the complex sequence significant of changes modification accomplished, any large-scale, trolled therapy that is involved in personality before can be it seems premature to initiate randomized, assignment-con- study with on the effects of dynamic psychoborderline patients. We feel that effective early in treatment, when the sectors of impulsive behaviors, familial conflict, and it is more unemployment are most disabling. The more unstructured exploratory characteristics of traditional transference-based psychodynamic therapy that require more collabora- search efforts in methodological developments, in shorter term strategies, or in the first stages of long-term therapies. In this article we have suggested strategies for making such in- tion vestments in research namic psychotherapy. may exert benefits later, affective sectors R E F 1. May E R PRA: their particular when the of borderline F N C E Treatment tive Study of Science House, and sonal Gen accounts Psychiatry 4. GundersonJG: tic approaches of Schizophrenia: A Compara- Methods. New 1983, 5. Katz of patients with 1981; 38:133-137 sonality 7. Cowdry in per- “schizophrenia.”Arch HM, for Meeting, 1989 in psychotherapeudisorders, in Affec- Individual the re- effects of dy- in Personality Disorders: Symposium Conducted Behavat the As- in personality treatment disorder. Arch of bor- Gen of VOLUME Etiology Psychiatry borderline 2 Washington, G: Borderline Northvale, NUMBER! of borderline in Borderline Treatment, American of the DC, edited Psychiatric Borderline Adult. and Its Treat- 1976 Psychopathology NJ,Jason Borderline son, 1987 14. Waldinger Aronson, 1985 Personality R, GundersonJ: With Borderline DC, American 15. Adler G: The WINTER #{149} Patients: Psychiatric Disorder. R Effective Wash- Intensive !993 AmJ Psychotherapy Case Studies. Press, 1989 borderline-narcissistic continuum. 16. Chessick #{149} and DC, Therapy Washington, ington, DC, American Psychiatric Press, 1984 13. Volkan VD: Six Steps in the Treatment of Borderline Personality Organization. Northvale, NJ,Jason Aron- order treatment Disorder: 12. GundersonJ: disorders?: an Journal of Per- Behavior AN: Treatment a critical review, York, Brunner/Mazel, 11. Adler of SchizoDothertyJP. of JG, Sabo disorder: J. Paris Advancement Press (in press) 10. MastersonJ: Psychotherapy New psychodynamic Treatment Keith ST, Disorders 1990; 4:233-243 RW, Gardner DL: Pharmacotherapy Behavioral on to invest (Chair). 9. Gunderson personality ment. PH: What’s new on pharmacologic wiser R. Nelson-Gray Personality Disorders: New Approaches by Zales MR. Brunner/Mazel, GundersonJG: MM: personality disorder, ioral Perspectives. by pp 207-221 derline personality 1988; 45:!!!-! 19 8. Linehan Schizophrenia: Baltimore, discrepancy Recent advances to schizophrenic psychotherapy, in Psychosocial phrenia, edited by Herz MI, Amsterdam, Elsevier, 1990 6. Soloff update York, sociation R: Diagnostic tive and Schizophrenic to Diagnosis, edited far S Five Treatment 1968 C, Cadoret and and psychopathol- 2. Grinspoon L, Ewalt JR. Shader RI: Pharmacotherapy and Psychotherapy. MD, Williams and Wilkins, 1972 3. North specific interpersonal timely Psychiatry psychotherapy Washington, personality 1981; 138:46-SO of a borderline dis- CLINICAL AND RESEARCH patient. Arch Gen Psychiatry 17.Abend 5, Porder M, Wilhick Psychoanalytic Perspectives. Universities 18. Gunderson Press, 1983 JG, KoIb JE, interview 1981; 19. Skodal istic for pattern with 1983; 171:405-410 20. Waldinger pies with V: The patients. Am 21. GundersonJ, Frank A, Ronningstam ER, et ah: Early discontinuance of borderline patients from psychotherapy.J Nerv Ment Dis 1989; 177:38-42 22. FrankAF, GundersonJG: The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and outcome. Arch Gen Psychiatry diagnostic J Psychiatry 47:228-236 1990; P, Charles to the patients 1982; 39:413-419 M: Borderline Patients: New York, International Austin borderline 138:896-903 A, Buckley 71 REPORT borderline treatment E: Is there history personality?J a characterof clinical Nerv Ment 23. Kernberg outDis chodynamic New Completed psychotheraAmJ Psychother 1984; 38:190-202 JOURNAL OF PSWHOTHERAPY SeIzer MA, Koenigsberg Psychotherapy York, Basic Books, 24. KoIbJE, R, GundersonJ: borderline patients. 0, GundersonJG: of AND RESEARCH et al: PsyPatients. 1989 Psychodynamic apy of Borderline Patients by Kernberg Koenigsberg HW (review). International Psychoanalysis 1990; 17:S13-S16 PRACTICE HW, Borderline Psychother0, Selzer Review M, of 72 CLINICAL APPENDIX A. Action AND RESEARCH REPORT scale RATER DATE NAME OR Actions I-A Weighting Suicidal Acts (past 6 months) 1. Not life-threatening (e.g., scratch, 2. Life-threatening(e.g., overdose) 3. Deliberately lethal I-B small Self-mutilation (past 6 months) 1. Not life-threatening (e.g., scratching, 2. Disfiguring (e.g., deep burns, slashes) 3. Disabling (e.g., cut tendons) Il-A Substance Abuse (past 3 months) 1. Without health risk 2. With health risk (e.g., potentially somatic symptoms) 3. Life-threatening drug/alcohol Il-B number biting of pills) Sexual Misconduct (past 1. Promiscuity, adultery II-E 2. Incest (perpetrating) 3. Sexual contact Eating Disturbances 1. Without health 2. Health-endangering 3. Life-endangering Ill-A Ill-B self-destructive __________ __________ = _________ = _________ = _________ __________ _________ _________ ________ __________ = = = _________ (e.g., = _________ = _________ excessive (2) career, or family out on spouse) threats does not here) (5) (20) go (2) (5) (20) __________ __________ __________ = _________ 3 months) safety (3) (10) (20) at risk (past 3 months) risks (anemia, chronic ____________ Check one Only _______ _____ _______ _______ _______ hypokahemia) _______ (3) (10) NA NA (20) NA (1) threats, etc.) to limits) actions; __________ TOTAL (5) (20) abuse (2) (3) In-session Resistance (past 1 month) 1. Purposeful obfuscations (avoids meaningful subjects, refuses to respond to therapist intervention, extended silences) 2. Bodily behaviors (e.g., refusing eye contact, sexual exhibitionism, facing away, or leaving chair) 3. Lying to therapist = Frequency of episodes causing Testing of Therapeutic Boundaries (past 1 month) 1. Unscheduled contacts, or attempts at contact (e.g., phone calls, tape recordings, letters, attempts at social interaction) 2. “Testing behaviors” (e.g., tardiness, leaves early, late bills, 3. Behaviors that threaten the viability of the therapeutic relationship (repeated absences, serious payment conflicts, nonresponse I. placing (5) (10) (20) X (2) addictive Aggressivity (past 3 months) 1. Hot-tempered, belligerent, or threatening (angry of self-destruction or taunting, intimidation which on to actual assaultive behavior should be recorded 2. Destructive acts to property, minor assaultiveness 3. Severe assaultiveness II-D (5) (20) (50) self) Impulsive Recklessness (past 3 months) 1. Reckless acts not seriously endangering self/others money spending, accident proneness) 2. Reckless acts potentially endangering reputation, life (e.g., suddenly quitting needed job or walking 3. Reckless acts that seriously endanger self/others Il-C ID. II = impulsivity; VOLUME III = 2 actions NUMBER! #{149} (1) (2) (3) in therapy. WINTER #{149} 1993 =_______ = =