REMEDIATION FOR TREATMENT-RESISTANT

BORDERLINE PERSONALITY DISORDER:

Manual of Dynamic Deconstructive Psychotherapy

Robert J. Gregory, M.D.

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DDP

Clinical, Training, and Research Manual

of
Dynamic Deconstructive Psychotherapy ©
v. 8.29.16

Robert J. Gregory, M.D.

Professor of Psychiatry
SUNY Upstate Medical University
750 East Adams Street
Syracuse, NY 13210
[email protected]
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TABLE OF CONTENTS

Pages

Preface 5-6

1. CONCEPTUALIZATION OF BORDERLINE PD 7-16

2. OVERVIEW OF TREATMENT 17-20

3. ESTABLISHING THE FRAME 21-28

1. Gather the history

2. Determine eligibility for dynamic deconstructive therapy
3. Explain the therapy and agree on goals
4. Define roles, boundaries, and expectations
5. Supplemental treatments and activities

4. STAGES OF THERAPY 29-40

I. “Can I be safe here?” Establishing the Ideal Other

II. “Do I have a right to be angry?” Debating justification in relational encounters

III. “Am I worthwhile?” Grieving the loss of a fantasy and worries about self-worth

IV. “Am I ready to leave?” Overcoming barriers towards self-acceptance

5. THE THERAPEUTIC STANCE 41-46

6. STATES OF BEING 47-58

I. Helpless Victim State

II. Guilty Perpetrator State

III. Angry Victim State

IV. Demigod Perpetrator State

Treatment Implications

7. THE DECONSTRUCTIVE EXPERIENCE 59-64

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8. SPECIFIC TECHNIQUES 65-90

I. Associations 65

II. Attributions 70

III. Ideal Other 73

IV. Alterity -- Real Other 77

V. Managing Self-Destructive and Maladaptive Behaviors 83

9. PSYCHOTROPIC MEDICATIONS 91-92

10. PSYCHIATRIC COMORBIDITY 93-98

11. SPECIAL SITUATIONS 99-104

1. Psychiatric hospitalization
2. Severe dissociation
3. Deterioration in clinical condition
4. Boundary intrusions
5. Vacations or absences

12. MEDICAL CARE 105-108

1. Somatization
2. Medical hospitalization
3. Medical complications

13. DEVELOPING A DDP PROGRAM 109-110

1. Training considerations
2. Clinical considerations

APPENDIX A -- DDP Adherence Scale 111-114

APPENDIX B – Upstate Borderline Questionnaire 115-116

APPENDIX C – Upstate Borderline Inventory - 9 117-118

APPENDIX D – Daily Connection Sheet 119-120

BIBIOGRAPHY 121-133
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PREFACE

I have written this manual in order to present a training tool for treatment of borderline
personality disorder (BPD), especially for those patients who are most challenging to engage in a
therapeutic relationship, such as those having substance use disorders or antisocial personality traits. The
purpose is to delineate an approach that is evidence-based, reliable, time-limited, and relatively easy to
learn. On the other hand, I am well aware of the dangers of oversimplifying human pathos and imposing
a reductionistic and rigid treatment model that disregards individual differences. I have therefore
attempted to maintain a balance between clarity and complexity and a broad enough framework to
accommodate different patient needs and individual therapist styles of interaction.
In this manual I introduce a new treatment paradigm, labeled dynamic deconstructive
psychotherapy (DDP). The theoretical basis for DDP integrates translational neuroscience with object
relations theory and Jacques Derrida’s deconstruction philosophy. These three frameworks are
surprisingly compatible with one another, and each contributes a useful perspective on borderline
pathology and treatment. Case vignettes are utilized throughout the manual to illustrate key points. Each
patient provided consent for use of video recorded material in scientific publications. Nevertheless, each
vignette has undergone careful editing to disguise any identifying information and maintain
confidentiality.
The manual incorporates both theory and technique to take the reader step by step through key
concepts and treatment interventions. The first two chapters summarize the treatment model. The next
two chapters, Establishing the Frame and Stages of Therapy, provide a chronological sequence of
treatment, focusing on the major tasks, themes, and interventions that characterize each stage. The
following three chapters, The Therapeutic Stance, States of Being, and The Deconstructive Experience,
focus more in depth on the patient-therapist relationship, including how to promote a therapeutic alliance,
reflective functioning, and individuation, and how to recognize and disrupt emerging enactments. The
next two chapters, Specific Techniques and Psychotropic Medications, delineate core DDP interventions,
as well as provide a brief summary of principles of medication management. The DDP interventions are
organized by the specific neuroaffective deficit that is being targeted for remediation. Each section also
contains a list of proscribed interventions. These chapters are followed by a discussion of circumstances
that sometimes require modification of technique, summarized in three chapters entitled, Psychiatric
Comorbidity, Special Situations, and Medical Care. The final chapter, Developing a DDP Program,
contains guidelines for readers to develop their own training and/or clinical program in DDP and the
requirements for achieving certification of competency.
There is no theoretical explication in the manual of relative contributions of the genetic and
developmental factors that lead to this pathology. This is because the etiology is still under investigation
and speculation regarding origin risks creating a false sense of surety about the disorder that could
unfairly label or stigmatize patients and/or family members. There is evidence supporting both
developmental determinants (Battle et al., 2004; Johnson et al., 2006), intergenerational transmission
(Weiss et al., 1996), as well as genetic factors (Kendler et al., 2008; Distel et al., 2008; Silverman et al.,
1991; Torgersen et al., 2000). But their relative contribution likely varies among different individuals
with the disorder.
The term deconstructive in labeling the treatment method is not meant to indicate a radical
departure from accepted practices or to indicate a destructive process, but rather to describe a confluence
between deconstruction theory and a specific subset of psychoanalytic theory and technique. To give a
few examples, the psychoanalytic emphasis on neutrality that maintains a non-judgmental and non-
directive stance, is consistent with the deconstructive emphasis on openness to the other. The concept of
splitting can be usefully compared to the deconstructive concept of binary oppositions within a text and
intolerance of ambiguity. Psychoanalytic concepts of observing ego, empathy, and mentalization can be
seen as elements of alterity and the movement from subjectivity to objectivity.
Throughout the book, I have endeavored to maintain a multidisciplinary and pantheoretical
orientation. It is likely to be as relevant to psychiatrists as it is to psychologists, clinical social workers,
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and other mental health practitioners. In explaining concepts and methods, I have intentionally attempted
to maintain language that is shared by most mental health disciplines. Nevertheless, I introduce some
terms and concepts from the psychoanalytic, philosophical, and neuroscience literatures that I realize
many readers will find challenging to grasp. I did not want to gloss over difficult but relevant concepts
for the sake of simplicity. I have a deep respect for the complexity, individuality, and endless enigma of
the human experience. My experience with trainees who have employed the manual is that it can be read
on many levels.
Some therapists will have more difficulty than others in learning and applying the techniques
outlined in the manual. The reliance on moment-by-moment inter-subjective experience in DDP
presumes some degree of self-awareness and self-acceptance, toleration of uncertainty and ambiguity, and
openness to change on the part of the therapist (Fishman, 1999). However, after many years of training
therapists in these techniques, the most common reason I have observed for therapists’ failure to reliably
implement the treatment is reluctance to give up sources of gratification inherent in idealized,
authoritative therapist roles. It can be very difficult for many therapists to be truly non-judgmental and to
withhold providing a profound pronouncement, “validating” statement, interpretation, or sage advice.
Empirical research on DDP is substantial and ongoing. This research is summarized on the DDP
website: www.upstate.edu/ddp. Approximately 90% of patients who stay in DDP for a full year of
treatment with achieve substantial improvement in symptoms and functioning. Because of strong
evidence for effectiveness, the federal agency SAMHSA has included DDP on its list of evidence-based
programs and practices (www.nrepp.samhsa.gov).
Independent ratings of video recorded DDP sessions indicate that adherence to DDP techniques is
strongly correlated with treatment outcome (Goldman & Gregory, 2009; 2010). This finding suggests
that the treatment works in a specific way to effect change. Because of the importance of treatment
adherence in optimizing outcomes in this challenging patient population, I have included the DDP
Adherence Scale, along with instructions for rating, in an appendix to this manual. I recommend
employing the scale for monitoring adherence to DDP in clinical, teaching, and/or research programs that
wish to incorporate this promising treatment approach.
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1. CONCEPTUALIZATION OF BORDERLINE PERSONALITY DISORDER

Between the too warm flesh of the literal event and the cold skin of the concept runs meaning (Derrida,
1978, p. 75)

The term, borderline personality disorder (BPD), derives from an older psychoanalytic term of
“borderline personality organization”. A borderline level of personality organization was originally
meant to describe patients who are neither psychotic nor neurotic, but intermediate or on the “borderline”
between these two levels of organization (Stern, 1938). Kernberg (1967) elaborated this concept in a
seminal paper and defined borderline as having a characteristic triad of identity diffusion, generally intact
reality testing, and the use of maladaptive defense mechanisms, especially splitting. Borrowing from
psychoanalytic perspectives of borderline personality organization, Gunderson (1984) helped to establish
borderline personality disorder in formal psychiatric nomenclature as a disorder of identity and self.
According to the DSM-V (American Psychiatric Association, 2013), “the essential feature of borderline
personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and
affects” (p. 663). To meet diagnostic criteria for BPD, persons must have at least 5 of the 9 symptoms
outlined in Figure 1-1. These symptoms are highly correlated with one another, supporting the validity of
the construct of BPD (Clifton, 2007; Johansen, Karterud, Pedersen, Gude, & Falkum, 2004).
Although the diagnosis of BPD has been shown to be valid and reliable, the mechanisms and
etiology of the disorder are still very controversial. The present chapter lays out a theory postulating that
the phenomenology of the disorder is accounted for by a combination of an imbedded sense of badness
and specific neuroaffective deficits in processing of emotional experiences.

Figure 1-1: DSM-V diagnostic criteria of borderline personality disorder

1. Frantic efforts to avoid real or imagined abandonment.

2. Unstable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation.
3. Identity disturbance: unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex,
substance misuse, reckless driving, binge eating).
5. Recurrent suicidal behavior or threats, or self-mutilating behavior.
6. Instability of mood and marked reactivity of mood.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

EMBEDDED BADNESS

Clinical experience, as well as research findings, suggest that a core difficulty of BPD is a deeply
embedded and often unconscious self-perception of inherent badness, i.e. evil, defective, worthless, lazy,
or ugly (Gregory, 2004; Gunderson, 1984; Rüsch et al., 2007). This sense of badness is often not
immediately apparent and difficult to measure in research studies since it can be repressed and denied,
even to the point that patients can appear grandiose with an inflated self-appraisal for much of the time.
The badness can also be projected onto others, such that BPD patients can become mistrustful, avoidant,
or denigrating of others as a way to protect against feelings of shame. The embedded badness can appear
in creative activities or in dreams, often as dangerous shadowy figures chasing the patient.
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Causes for embedded badness may be manifold. In his work with traumatized and delinquent
children, Fairbairn (1943, 1944) noted that they were prone to sacrifice their self-esteem and develop an
inner sense of badness in an attempt to maintain an idealized image of an abusive parent. Fairbairn
hypothesized that the child splits the image of the abusive parent into both good and bad objects and
internalizes the bad object so as to maintain the fantasy of the parent as the idealized good object. Thus
the child is sacrificing his/her own self-esteem and developing a sense of embedded badness by taking on
all the responsibility for the abuse in order to maintain the fantasy of an idealized, safe caregiver.
Both trauma and neglect have been associated with the development of BPD in longitudinal
studies (Johnson, Cohen, Chen, Kasen, & Brook, 2006). However, many patients with BPD have no
history of trauma or neglect, and an embedded sense of inner badness might result from teasing or
bullying at school, problematic early mother-infant attachment (Green & Goldwyn, 2002), or inherited
tendencies towards social inhibition, impulsive aggression, or negative affectivity (Conway, Hammen, &
Brennan, 2015; Kendler et al., 2008).
Regardless of cause, embedded badness can account for much of BPD pathology, such as chronic
dysphoria and low self-esteem, bouts of hostility when the badness is projected onto others, episodes of
severe depression and suicide ideation when the badness is put on oneself, and tendencies towards self-
damaging behaviors, such as cutting or purging. From a social perspective, it may lead to feelings of
embarrassment and anxiety around others, continuous need for reassurance, and trying to put up a false
and compliant front. Imbedded badness and poor self-assertiveness may also account for the tendency of
this population to get into abusive or maladaptive relationships. A central conflict becomes, “do I have a
right to be angry?” or “are my needs legitimate?” (see Chapter 4 on Stages of Therapy).
Interventions that attempt to persuade and reassure BPD patients out of their sense of badness are
generally ineffective, especially in the early stages of treatment. Such efforts tend to come across as
unempathic, as though the listener does not understand how very bad the patient really is. Instead, it is
first necessary to remediate the neuroaffective deficits that interfere with a person’s ability to identify,
acknowledge, and accept painful emotions and attributes that have been avoided or split off. When
negative emotions and painful conflicts can be more fully verbalized and symbolized, it becomes possible
to gradually work towards acceptance of limitations of oneself and others, and to develop more authentic
and fulfilling relationships and self-esteem that is grounded in reality.

NEUROAFFECTIVE DEFICITS

The neuroaffective deficits of BPD do not involve problems with intelligence, but rather involve
problems with identifying, acknowledging, and bearing painful emotions and conflicts. In order to have a
coherent, stable, and differentiated self, it is necessary to have three essential neuroaffective capacities.
These include the ability to identify and verbally acknowledge one’s emotional experiences, to integrate
complex attributions of these experiences, and to be able to assess the accuracy of those attributions in an
objective way. Gregory and Remen (2008) have labeled these three neuroaffective functions as
association, attribution, and alterity.

1. Association
Figure 1-2 is a simplified diagrammatic display of adaptive processing of emotional experiences.
The first step needed for adaptive processing is to encode our experiences into language, metaphor, and
other symbols, so that they can be acknowledged and communicated (Bucci, 2002). We react to a
provocative interpersonal encounter with an affective response, which we experience in our bodies. We
then try to make sense of this experience by creating a verbal/symbolic description. We also need to be
able to sequence the experience, i.e. to connect our response to the initial provocation. As we begin to
make these links, we can make reasonable attributions about ourselves and others, while relying on our
memory of similar encounters, and finally come to a decision as to how best to respond. For example,
when someone makes a demeaning comment, most people will respond by creating an internal dialogue,
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acknowledging to themselves how that person is making them feel. They may then perhaps question
whether the demeaning comment is accurate or whether the person was making an unjustified attack and
respond accordingly.

Figure 1-2: Adaptive emotion processing of experience

action attributions of
self and other

interpersonal label emotions &

stimulus sequence experience

Figure 1-3: Emotion processing in borderline personality disorder

interpersonal distorted/polarized
enactment attributions

1. Impulsive behaviors
2. Symbolic objects
3. Idealized attachment

diffuse
distress

interpersonal label emotions &

encounter sequence experience
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The labeling and sequencing of one’s emotional experiences I am calling association functions.
This capacity helps connect us to our experiences. It also allows a reflective space between the
experiencing and observing parts of the self so that we are able to comment on our experiences in an
internal dialogue and communicate them with others. The ability to observe, label, and comment on
one’s experiences is an essential component of consciousness and a subjective sense of self.
As Figure 1-3 schematically displays, a key hypothesized functional deficit of BPD is the ability
to label and sequence emotional experiences. Persons with BPD often have a rich ability to employ
abstract metaphors and visual symbols through poetry and art, but have much difficulty consciously
linking language and other abstract symbols to their experiences. They often have difficulty interpreting
their poetry or art, pinpointing a particular emotion, or even acknowledging words that they just
employed. A study by Levine, Marziali, and Hood (1997) of 30 subjects with BPD compared to 40
healthy controls indicated that the subjects with BPD had difficulty identifying their own emotions,
differentiating between emotions and correctly identifying facial expressions of emotions. In a study of
252 consecutive individuals seeking treatment at a mental health clinic, BPD was associated with greater
impairment in identifying and describing emotions than any other psychiatric diagnosis (Zlotnick, Mattia,
& Zimmerman, 2001). Employing 24-hour ambulatory monitoring of psychological reactions and
physiological parameters of 50 patients with BPD and 50 healthy controls, Ebner-Priemer and colleagues
(2007) reported that prior to entering treatment, patients with BPD have greater difficulty identifying and
labeling their emotions than healthy controls. The inability to identify, acknowledge, and verbalize
experiences contributes to feelings of emptiness and lack of a subjective sense of self.
Many individuals with BPD also have deficits in episodic or autobiographical memory, i.e. a
limited ability to coherently narrate a specific emotionally-charged interpersonal encounter and put
events, emotions, and actions into a clear sequence. For example, they may complain of depression or
anxiety that comes “out of the blue” and not be able to identify the specific event that triggered their
change in mood. Alternatively, some individuals may produce over-general memories and describe
general patterns of interaction instead of specific incidents. For example, they may glibly verbalize a
litany of complaints about how a given person has mistreated them, but may stutter and stammer when
trying to piece together a specific encounter with that person. The tendency to produce over-general
memories has been linked to depression, dissociation, post-traumatic stress disorder, eating disorders, and
suicide attempts (Arntz, Meeren, & Wessel, 2002; Heard, Startup, Swales, Williams, & Jones, 1999;
Williams et al., 2007).
Episodic memory deficits are most often seen when BPD is accompanied by dissociative
symptoms (Fonagy et al., 1996) or by an incoherent/disorganized attachment style on the adult
attachment interview (Levy et al., 2006; Westen, Nakash, Cannon, & Bradley, 2006). They may have
more marked association deficits, including disorganization, confusion, memory lapses, and incoherence
of narratives, when describing emotionally evocative events. For example, narrative accounts of
interpersonal interactions may suddenly and repeatedly switch contexts to different persons, places, or
times. The listener ends up feeling very confused, as well as often bored and detached. Clinical
experience suggests that the disorganized subgroup of patients need considerable work early in the
treatment on helping them to make basic narrative connections.
One perspective on association deficits, is that they serve a defensive function to exclude certain
aspects of experience from consciousness that are simply too frightening or painful (Wildgoose, Waller,
Clarke, & Reid, 2000). Although retrospective studies have linked dissociation to childhood trauma, two
longitudinal prospective studies have both indicated the importance of early mother-infant attachment,
rather than physical or sexual abuse. Taken together, these studies indicate that maternal
unresponsiveness to infant fear or distress strongly predict the development of dissociative symptoms in
adulthood, regardless of the infant’s attachment style or subsequent abuse (Dutra, Bureau, Holmes,
Lyubchik, & Lyons-Ruth, 2009; Ogawa, Sroufe, Wcinfield, Carlson, & Egeland, 1997). Maternal
inattention to her infant’s negative affect may prevent the infant from acquiring the ability to contain and
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symbolize distressing experiences, which then remain cut off from consciousness and poorly integrated
into the self-structure.

2. Attribution
In addition to association functions, a second neuroaffective component of our emotion
processing involves attributing meaning to those experiences. From our experiences we learn about our
strengths and limitations, and those of others. We learn what responses and behaviors to expect from
ourselves in diverse situations, and what kind of responses to expect from others. We make attributions
regarding responsibility, praise, and blame, portioning out agency to self or others according to the
situation. Our attributions of value, motivation, and agency are extremely complex and sometimes
painful to acknowledge. For example, it is painful to acknowledge that the person we are in love with
may not love us back. It is painful to acknowledge that we are mostly to blame for certain unpleasant
circumstances in our lives.
This capacity to formulate realistic and complex attributions of oneself and others is deficient in
persons with BPD. Instead, they tend to form simplistic, distorted, and polarized attributions of their
experiences (Coifman, Berenson, Rafaeli, & Downey, 2012). Thus the person with BPD lives in a black
and white fantasy world, full of cardboard cut-out villains and heroes. Polarization of self and other into
all-good and all-bad has been labeled splitting in the psychoanalytic literature (Kernberg, 1975).
Polarized attributions may serve to help limit the pain and dysfunction of embedded badness.
One strategy for coping with embedded badness is to repress negative aspects of the self from
consciousness and project those onto others. Employing this strategy, self-image is transformed into an
all-good idealized self-image, innocent of any wrong-doing, whereas others are perceived as trouble-
makers. However, this coping strategy is unstable, and persons with BPD often alternate between a self-
image that is either all-good or all-bad. The oscillation in self-image contributes to an identity
disturbance, to an unstable relatedness pattern of idealization and devaluation, and to symptoms of mood
lability (Koenigsberg et al., 2001). When the self is perceived as all-bad, then mood becomes depressed,
but relatedness is maintained with an all-good other. When the badness is projected onto others, then
mood becomes angry or elated, but relatedness is compromised (see chapter on States of Being).
Another function of a polarized attribution system is to maintain a sense of certainty. Research in
experimental psychology suggests that uncertainty drives our tendencies to make attributions of causality
(Burger & Hemans, 1988; Pittman & Pittman, 1980; Weiner, 1985). Because of their inability to identify
and verbalize their emotional experiences, persons with BPD are essentially emotionally “blind” and live
in an uncertain world. Neuroscience research suggests that during an interpersonal encounter, the kind of
attributions we make regarding self and others are closely linked to the specific emotions that we
experience (Olsson & Ochsner, 2007). In the absence of an emotion anchor, polarized attributions put
things into black and white, eliminate ambiguity and create an artificial sense of certainty.
Persons with BPD have been noted to have a need for certainty and for complete understanding
from others (Bateman, 1996; Shapiro, 1992). They employ a binary system of logic and attribution that
excludes alternative perspectives that may create ambiguity. For example, they may tell their therapists,
“If you really cared about me, then you would let me call more often. All you care about is your money.”
On the surface, the proposition appears logical and irrefutable. However, there is an underlying
assumption that the therapist’s primary mission should be to care and nurture their patients like a mother.
There is also an implied dichotomy or split in the perspective of the therapist as either totally caring and
accommodative, or totally cold and callous. There is no room in such a polarized attribution system for a
more ambiguous and realistic perspective of the therapist as having complex motivations, including some
genuine caring for the patient, but within certain limits.

3. Alterity
Although the ability to describe experiences and attribute meaning to them is necessary for a
coherent sense of self, an additional neuroaffective capacity is needed in order to develop a differentiated
self. Alterity is a word borrowed from the philosophical literature meaning a reference point outside the
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subjectivity of the self, what Derrida described as an absolute outside (Derrida, 1978, p. 106). This is
analogous to a ship’s need for an outside reference point, such as a lighthouse, star system, or satellite, in
order to know its position. Alterity enables us to reflect on ourselves from an outside or “objective”
perspective, i.e. “How realistic are my attributions?”
When the capacity for alterity is diminished, individuals live in a magical world, where
subjectivity is ungrounded in reality. In this magical world, behaviors such as cutting, purging,
restricting, and substance use can take on special significance and be used for coping (Gregory &
Mustata, 2012). For example, a person with an alterity deficit can cut his/her arm and believe that the
blood pouring out of the body is “the badness flowing out of me.” In this instance, the blood symbolizes
the self’s inner badness and to find relief from the sense of badness through cutting. Likewise alcohol
and other drugs can magically substitute for interpersonal relationships (“my best friend is the bottle”)
and thus help meet attachment needs (see chapter on Psychiatric Comorbidity for further discussion).
Another consequence of a diminished capacity for alterity is an inability to objectively assess the
accuracy and realistic consequences of our attributions and motivations, and those of others. A realistic
appreciation of the attributions and motivations of other persons has been called mentalization (Fonagy &
Target, 1996) derived from theory of mind (Premack & Woodruff, 1978). For persons with BPD, the
deficit in alterity contributes to their ability to maintain very distorted and polarized attributions in the
face of contradictory evidence. For example, persons with BPD have been shown to misread others’
intentions in an economic game of trust, thus leading to poor overall performance (King-Casas et al.,
2008).
A third consequence of a deficit in alterity is a lack of a clear boundary between self and other
that includes an inability to differentiate between one’s own wishes, emotions, and attributions and those
of others. The capacity to be oneself in relationships I am labeling as differentiated relatedness. Every
patient with BPD I have met thus far is lacking in this capacity. They adopt the values and opinions of
the other person in order to maintain relatedness, much like a chameleon. Alternatively, in order to
maintain a stable sense of self and others, they may distance themselves in a paranoid or narcissistic
manner. For example, persons with BPD may assume that others are looking at them in a derogatory
way, when in fact it is they themselves who are feeling ashamed. Similar to attribution deficits, deficits in
alterity may be driven in part by a need for certainty. In psychology research, high levels of uncertainty
can result in a tendency to stereotype others (Neuberg & Newsom, 1993), in illusory pattern perceptions,
and in perception of conspiracies (Whitson & Galinsky, 2008).
In philosophical terms, the person with BPD can be viewed as having unchallenged and unlimited
subjectivity and an inability to incorporate recollections of interpersonal experiences that are inconsistent
with their expectations. Patients with BPD seem to be unable to learn from experience and repeat
maladaptive interactions over and over again. They hold on tightly to their attributions and patterns of
behaviors despite negative consequences.
What makes working with this population so difficult is the patient’s ability to provoke others
into responding in a way that is consistent with the patient’s attributions and expectations. In other
words, the patient expects others (including the therapist) to behave in a certain way and the therapist may
feel compelled to behave in a way that is consistent with the patient’s expectations, an interpersonal
process that has been called enactment. The confluence between the patient’s expectations of others and
the actual behavior of the therapist results in reinforcing the patient’s expectations and the distorted
attributions of self and other upon which those expectations are based (see Figure 1-3). Therapists may
have a difficult time discerning whether negative encounters with a patient resulted from the patient’s
attributions and responses or from the therapist’s (Racker, 1957).
Healing comes, in part, from the discovery of the person of the therapist as not me (i.e. contrary to
stereotyped projected expectations). This discovery provides an essential referent point for defining the
boundaries of the self. In order for patients to develop objectivity and differentiate self from other, the
therapist must disrupt patient-therapist enactments by interacting in ways that challenge expectations and
create opportunities for relating as two separate individuals. Derrida (1997a) addressed this issue as
follows, “Separation is the condition of my relation to the other. I can address the other only to extent
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that there is a separation…so that I cannot replace the other and vice versa” (p. 14). The experience of
achieving a relationship that is both close and separate is a novel experience for the BPD patient and is
one of the goals of treatment.

NEUROBIOLOGY OF BPD

Neural networks for association, attribution, and alterity functions

In this section, I put forward the Emotion Processing Hypothesis. Instead of BPD being a
disorder of emotion dysregulation, i.e. a problem with how patients regulate and cope with emotions, I am
positing that BPD is a disorder of emotion processing. There is evidence to suggest that in normal and
adaptive processing of emotional experience there is a lateral to medial movement of information through
the prefrontal cortex and integration of cortical and subcortical neuronal networks. However, in response
to interpersonal stress, persons with BPD appear to exhibit relatively less activation of the prefrontal
cortices, greater activation of subcortical limbic structures, such as the ventral striatum and amygdala, and
less integration of cortical and subcortical networks. These differences in processing of emotion
processing through the central nervous system may account for the association, attribution, and alterity
deficits mentioned in the previous section.
Association capacity, i.e. the encoding of emotional experience into language, may be mediated
through the temporal lobes and prefrontal cortex. Within the medial temporal lobe, the hippocampus may
be responsible for integrating episodic memories with spatial-temporal contextual input from the
parahippocampal cortex and the perirhinal cortex may place events into a temporal sequence
(Eichenbaum, 2010; Naya & Suzuki, 2011; Smith, Henson, Dolan, & Rugg, 2004). Other cortical regions,
including the insula, medial prefrontal and ventrolateral cortices may be responsible for encoding episodic
memories and affect into language (Buccino, Binkofski, & Riggio, 2004; Nelissen, Luppino, Vanduffel,
Rizzolatti, & Orban, 2005; Ochsner et al., 2004). There is also evidence that labeling of emotions
requires coupling of prefrontal activity to the subcortical limbic system, perhaps mediated through the
anterior cingulate gyrus (Lane et al., 1998; Lieberman et al., 2007; Wager, Davidson, Hughes, Lindquist,
& Ochsner, 2007).
On the other hand, attribution capacity may be mediated through medial parietal regions,
especially the precuneus and posterior cingulate cortex. These regions are highly active in the resting
state and interconnected with other brain regions, including the thalamus, hippocampus, and medial
prefrontal cortex. Based on functional imaging and lesion studies, the precuneus and posterior cingulate
cortex have been implicated in mediating awareness and ownership of one’s body (Ruby & Decety, 2001;
Vogt & Laureys, 2005), reflecting on one’s personal characteristics (Kjaer, Nowak, & Lou, 2002; Lou,
Nowak, & Kjaer, 2005) and those of others (Modinos, Ormel, & Aleman, 2009). Attributing agency to
self versus others may be mediated via the cingulate cortex and mapped along anterior to posterior
regions (Tomlin et al., 2006). Together, the studies suggest that these regions are responsible for
maintaining attributions of self and others, states of being, embodiment, consciousness, and a subjective
sense of self.
Whereas the medial parietal regions appear to maintain attributions in the brain’s resting state, the
medial prefrontal cortex, including the anterior cingulate gyrus and Brodman areas 9, 10, and 11, enables
individuals to change attributions based on new information and is activated in response to emotional
cues (Koenigs & Tranel, 2007; Noël, Van Der Linden, & Bechara, 2006, Tse et al., 2011). The capacity
to integrate new affective information and change attributions suggests that the medial prefrontal cortical
regions mediate alterity functions. This hypothesis is supported by studies locating reflective functions,
such as mentalization (Gallagher et al., 2000), empathy (Shamay-Tsoory, Tomer, Berger, Goldsher, &
Aharon-Peretz-Tsoory, 2005), moral judgment (Greene & Haidt, 2002), toleration of uncertainty (Krain et
al., 2006), and self-awareness (Gusnard, Akbudak, Shulman, & Raichle, 2001) to this region.
Furthermore, imaging studies suggest that idealized love can deactivate the medial prefrontal cortex, i.e.
“love is blind” (Bartels & Zeki, 2004).
 14

This region also appears to be responsible for self-other differentiation, an important aspect of
alterity (Mitchell, Banaji, & Macrae, 2005). Mentalizing about others deemed similar to oneself activates
the ventral region of the medial prefrontal cortex (BA 9), whereas mentalizing about others deemed
different from oneself activates the dorsal region (BA 10, 11).

Aberrant networks of borderline personality disorder

Instead of verbal/symbolic linking and reflective modulation in a lateral to medial processing
through the temporal lobe and prefrontal cortex, emotional experiences in persons with BPD appear to be
processed through pathways in the subcortical limbic system. Structural and functional deficits have been
identified in regions responsible for emotion processing, including the amygdala, hippocampus, anterior
cingulate gyrus, and medial prefrontal cortex (Bohus, Schmahl, & Lieb, 2004; Nunes et al., 2009;
Schmahl & Bremner, 2006).
Patients with BPD respond to emotional stimuli, such as facial expressions, trauma scripts,
aversive pictures, or negative word cues, through greater activation of subcortical limbic structures,
including the amygdala, hippocampus, and ventral striatum than healthy controls (Donegan et al., 2003;
Herpetz et al., 2001). One consequence of amygdala activation is diffuse distress and hyperarousal, with
symptoms of anxiety, restlessness, insomnia, and irritability (Ebner-Priemer et al., 2008; Fitzgerald,
Angstadt, Jelsone, Nathan, & Phan, 2006; Stein, Simmons, Feinstein, & Paulus, 2007; Stiglmayr et al.,
2005).
On the other hand, there is relative deactivation of the anterior cingulate gyrus and medial
prefrontal cortex under conditions of strong emotional stimulation (Donegan et al., 2003; Schmahl,
Vermetten, Elzinga, & Bremner, 2004; Silbersweig et al., 2007), as well as decoupling of limbic and
cortical networks (New et al., 2007). One consequence of deactivating these regions is an association
deficit characterized by difficulty encoding experience into language, including difficulty identifying,
labeling, and acknowledging emotions (Ebner-Premier et al., 2007; Levine, Marziali, & Hood, 1997;
Zlotnick, Mattia, & Zimmerman, 2001). Failure to identify and label emotions among individuals with
BPD and other populations has been associated with hyperarousal, autonomic activation, and amygdala
activity (Ebner-Premier et al., 2008; Gur et al., 2007; Lieberman et al., 2007). Thus, instead of being able
to experience and describe discrete emotions in response to interpersonal encounters, individuals with
BPD are likely to experience diffuse distress and/or sense of impending doom.
Panksepp has written that amygdala activation triggers a primitive neural pathway labeled the
PANIC system, which is associated with separation distress in laboratory animals and is mediated through
glutamate transmission (Zellner, Watt, Solms, & Panksepp, 2011). Normally, this system is time-limited
as separation distress turns to bereavement or despair. The PANIC system is down-regulated through
kappa-opioid receptors. Individuals with BPD have been reported to have a deficiency in endogenous
opioids (Stanley & Siever, 2010); it is possible that they are unable to turn off the PANIC system because
of defective transmission to kappa-opioid receptors. Furthermore, alterity deficits make it more difficult
for persons with BPD to deactivate amygdala activity through cognitive strategies of reinterpretation of
attributions or distancing as an outside observer (Koenigsberg et al., 2009).
Commonly, individuals with BPD attempt to alleviate the distress of the PANIC system by either
attempting to discharge unprocessed and overwhelming affect through self-destructive or hostile actions,
or by engaging in self-soothing coping mechanisms that activate their ventral striatal region, such as
seeking attachment figures for reassurance or impulsive pleasure-seeking. Panksepp has labeled the latter
the PLEASURE system, which seeks sensory rewards through attachment, substances, and other
pleasurable activities, such as shopping, gambling, or bingeing (Zellner et al., 2011). A hug and a drug
can provide identical pleasure sensations and provide the same soothing qualities. The PLEASURE
system is mediated through mu-opioid receptors, which have been found to be up-regulated in BPD
(Prossin, Silk, Love, & Zubieta, 2008). Animal and human studies have indicated that activation of the
ventral striatum can modulate the amygdala (Ernst et al, 2005; Koelsch, Fritz, Cramon, Muller, &
Friederici, 2006; Louilot, Simon, Taghzouti, & Le Moal, 1985; Yim & Morgenson, 1989). Thus
activation of the PLEASURE system may be an alternate coping strategy for individuals who are not able
 15

to employ to label emotions or to apply cognitive modulation of emotions through prefrontal pathways.
In other words, persons with BPD employ limbic solutions to interpersonal problems. The mechanism
may well account for impulsive pleasure seeking of persons with BPD, as well as their strong need for
attachment.
Dissociation may be a second pathway through which individuals with BPD down-regulate
hyperarousal and amygdala activation. Neuroimaging studies of patients with BPD have indicated that
during conditions of aversive stimuli, increased dissociation is correlated with decreased activation of the
amygdala (Hazlett et al., 2012; Krause-Utz et al., 2012).
It is unclear why persons with BPD have aberrant neural pathways and/or atrophy of the brain
structures responsible for adaptive processing of emotional experience. Is it an inherited defect or are the
biological deficits a result of adaptation to the early social environment? Object relations and attachment
theories presume that human infants have an essential need for bonding or attachment to an attentive and
nurturing mother (Bowlby, 1958). There is evidence that if the infant has been unable to form this kind of
bonding with mother, e.g. due to illness in the mother, long-term neurological changes may ensue,
including a reduction in myelination and in the size of the corpus callosum (Teicher et al., 2004). Other
neurobehavioral consequences can include impaired learning and difficulty managing arousal (Pryce,
Dettling, Spengler, Schnell, & Feldon, 2004). However, it is also possible that the shutting down of
structures that enable reflection on emotional experience serves a defensive function, enabling the person
to block awareness of painful emotions and thus cope with severe interpersonal stresses. Defense may
turn to defect over time if certain brain regions remain underutilized.
For more severe cases of BPD, especially those with histories of trauma, psychosis, or
dissociation, neural deficits may go beyond emotion processing networks to include diminished baseline
tonic activity within certain brain regions. In a PET imaging study of 17 BPD women with histories of
childhood abuse and severe dissociation, Lange and colleagues (2005) found deficits in episodic memory
associated with hypometabolism of the ventromedial and lateral temporal cortices, as well as finding
hypometabolism of the precuneus and posterior cingulate gyrus. Since the latter regions are responsible
for maintaining various self-referential functions, such as attributions, embodiment, and subjective sense
of self, their disruption may cause rapidly fluctuating attributions and inability to maintain an embodied
self. Disembodiment may result in patients feeling like a zombie (a soulless body) or like a ghost (a
bodiless soul).
16
 17

2. OVERVIEW OF TREATMENT

The tension between play and presence. Play is the disruption of presence (Derrida, 1978, p.292)

Dynamic Deconstructive Psychotherapy (DDP) is a 12-month treatment for borderline personality

disorder and other complex behavior problems, such as alcohol or drug dependence, self-harm, eating
disorders, and recurrent suicide attempts. DDP helps clients connect with their experiences and develop
authentic and fulfilling connections with others. During weekly, 1-hour individually adapted sessions,
clients discuss recent interpersonal experiences and label their emotions, reflect upon their experiences in
increasingly integrative, accepting, and realistic ways, and learn how to develop close relationships with
others while maintaining their own sense of self.
Treatment is divided into four stages (see chapter on Stages of Therapy). Twelve months is
optimal for most patients to work through the stages. Setting the time frame at the beginning of treatment
helps to establish the boundaries of the treatment relationship, limits excessive or prolonged dependency,
and facilitates more rapid movement through the stages.
The four stages have overlapping tasks (see chapter on Stages of Therapy). The first stage
involves establishing the treatment framework and the therapeutic alliance (see chapter on Establishing
the Frame). The specific objectives for this stage include setting very clear expectations for the
treatment, developing autonomous motivation, and facilitating the kind of treatment relationship that will
foster the development of what I am calling individuated relatedness, i.e. the ability of the patient to be
his/her own person in a relationship. Facilitating individuated relatedness includes avoiding making
authoritative assertions or giving advice, and being receptive to patient disagreements or criticisms. This
may seem easy in theory but can be extremely difficult in practice and involves a certain amount of faith
on the part of the therapist that the patients themselves are ultimately better able to find and decide upon
the solutions for their own life problems.
Patients will develop a negative transference at various times, characterized by expectations for
the therapist to be abandoning, humiliating, intrusive ineffective, or unreliable. These negative
expectations need to be deconstructed in order to establish or restore the therapeutic alliance (see chapters
on States of Being and The Deconstructive Experience).
During the first stage, therapists also begin to apply association techniques whereby patients
recount recent interpersonal experiences, including identifying and acknowledging emotional reactions to
the encounter, putting interactions into a chronological sequence, and linking emotions and events to
maladaptive behaviors (see chapter on Specific Techniques). Very often, arousal and anxiety markedly
diminish during this stage as patients begin to verbalize their experiences and an alliance is formed. In a
meta-analysis of studies of psychodynamic psychotherapy, a focus of helping patients to identify and
verbalize their emotional experiences has been shown to be an important predictor for outcome (Diener,
Hilsenroth, & Weinberger, 2007). In DDP research, association techniques have been shown to have a
greater overall impact on outcomes than any other set of techniques (Goldman & Gregory, 2010).
During the second stage, patients continue to explore recent interpersonal experiences and
become more aware of how they attribute meaning to experiences. The therapist employs attribution
techniques to helps patients develop a more complex and integrated perspective on their experiences (see
chapter on Specific Techniques). The therapist tries to stay neutral between two opposing attributions,
neither supporting one side nor the other. In this way, polarized attributions turn into conscious conflicts
that can be acknowledged and resolved (see chapter on The Therapeutic Stance).
The development of a capacity for alterity primarily occurs in the last two stages of treatment as
patients begin to more realistically appraise their attributions and mourn the loss of idealized fantasies
about self and others. The development alterity entails coming to terms with the realities of past and
present relationships, experiences, and abilities. It includes mourning the loss of idealized fantasies
regarding parental figures and of what was missing in childhood. Patients must also mourn the loss of
grandiose fantasies and come to terms with the reality of their own limitations. In the final stage, patients
must let go of idealizing fantasies they hold regarding the therapist and to understand that the therapist
 18

has a limited capacity for love and empathy, and can never complete what has been missing in the
patient’s life. The process of mourning limitations and the development of objectivity leads to self-
acceptance, the capacity for empathy, and the development of more adaptive modes of relatedness.
The therapist’s general stance seeks a balance between satisfaction of the patient’s wishes for a
soothing, idealized therapy relationship, with the patient’s needs for objectivity, individuation, and
differentiation. The therapist must have the same qualities as transitional object, i.e. understanding and
soothing like mother on the one hand, but separate or not me on the other hand (Winnicott, 1953). The
therapist serves as an intermediary between self and other, where the other represents the real or the not
me, as opposed to the imaginary projections of the self. The gradual introduction of the therapist’s role as
Real Other into the patient-therapist relationship facilitates the patient’s differentiation and individuation
(see chapter on The Deconstructive Experience). The dual role of the therapist in DDP as intermediary
between Ideal Other and Real Other is outlined in Figure 2-1.

Figure 2-1. Role of therapist as intermediary between self and other.

Self-Image

Therapeutic
Relationship

Ideal Other Real Other

In summary, DDP interventions involve:

 Establishing an initial written treatment contract including explicit expectations for patient and
therapist
 Fostering verbalization of recent affect-laden interpersonal experiences into simple narratives
 Exploring alternative or opposing attributions towards self and other, while remaining generally
non-directive and non-judgmental
 Providing novel experiences in the patient-therapist relationship that promote self-other
differentiation and deconstruct enactments
 Facilitating mourning regarding the limitations of self and others

Comparison with Other Psychodynamic Approaches

There are similarities and differences between DDP and other psychodynamic approaches to
BPD. In fact, a typical session of DDP might look very similar to a typical session of other structured
psychodynamic treatments, so many of the differences are in emphasis, rather than absolutes.
Peter Fonagy (2000) has extended Bowlby’s attachment theory to the etiology of borderline
personality. He emphasizes a deficit in the capacity for reflection and understanding of self and others’
 19

mental states (mentalization) as the central problem in borderline pathology. The deficit in mentalization
is thought to result from insecure attachment with mother and contributes to an identity disturbance
(Fonagy, 1998).
Applying this theoretical model, Bateman and Fonagy (1999) demonstrated the effectiveness of a
psychodynamically-oriented partial hospitalization program for patients with BPD. Self-destructive
behaviors, inpatient days, depression, and social functioning demonstrated significantly greater
improvement with psychodynamic treatment as compared to usual care. They have labeled their
approach as mentalization-based treatment (MBT--Bateman & Fonagy, 2004). They emphasize
exploration and clarification of perceptions and motivations of self and others in the here-and-now of the
patient-therapist relationship and in other recent interpersonal interactions.
Like DDP, MBT posits that the development of the capacity for reflecting on experiences is a
major goal of treatment. With both treatments, there is considerable time spent identifying and exploring
specific emotions and linking them to stressors, wishes, and actions. However, DDP is more explicit in
its emphasis on narrative construction and labeling emotions through association techniques and on the
development of a differentiated self through transformative experiences within the patient-therapist
relationship. MBT includes a more explicitly supportive and directive therapist stance than DDP.
American object relations models have emphasized drive theory, the structural model, and
Kleinian theories of splitting. According to this theory, an excess of aggressive drive leads to dissociative
splitting of the ego into positive and negative introjects and the use of other primitive defenses (Kernberg
1975). Each introject or ego state is dyadic and contains an “object image, connected with a
complementary self-image and a certain affect disposition which was active at the time when that
particular internalization took place” (Kernberg 1975, p.34). The clinical application of this theory,
labeled transference-focused psychotherapy (TFP), involves bringing these conflicting self-other dyads
into consciousness by clarifying and interpreting defenses employed in here-and-now interactions
between the patient and therapist (Clarkin, Yeomans, & Kernberg, 2006). In a study comparing TFP to
dialectical behavior therapy (DBT) and a manual-based supportive psychotherapy, Clarkin and colleagues
(2007) demonstrated comparable 12-month efficacy among the three treatments, with TFP improving a
wider range of outcomes.
Both DDP and TFP establish a detailed initial frame by defining the parameters of treatment and
making treatment expectations clear and explicit. Clarification of role expectations within the patient-
therapist relationship serves to contain wishes, anxiety, and aggression so that patients are less anxious
regarding boundary violations and destructiveness.
Both DDP and TFP explore polarized attributions and attempt to help patients to work towards
integrating them. TFP, however, focuses primarily on the patient-therapist relationship. DDP’s primary
focus is on recent interpersonal encounters outside of the patient-therapist relationship, but will also
address negative transference reactions. DDP is similar to the approach advocated by Buie and Adler
(1982) in this respect, tolerating an idealized transference in the initial stages of treatment in order to
facilitate soothing aspects of patient-therapist interactions. A positive transference serves to help the
patient face difficult emotions and painful realities. However, in the final stage of therapy, the
idealization of the therapist must also be deconstructed.
Although both treatments attempt to integrate polarized attributions, DDP more explicitly
emphasizes narrative construction through associative techniques. Moreover, a deconstructive experience
between patient and therapist that promotes differentiation is considered an important component of
recovery in DDP, but is not emphasized in TFP.
In addition to these differences in process, the treatment structure also differs in MBT and TFP.
MBT involves weekly individual and group therapy and TFP involves twice weekly individual sessions
with no clear limit on duration. DDP comprises only once a week individual sessions and has a
predetermined duration.
In addition to MBT and TFP, unstructured forms of psychodynamic psychotherapy are often
employed in the treatment of BPD. DDP is modified from unstructured psychodynamic psychotherapy as
it is typically administered in the community in the following ways:
 20

 Treatment includes an explicit written treatment contract and is time-limited

 The therapist does not link patient’s current perceptions to experiences in the past (except in
Stage IV)
 The therapist does not focus on childhood trauma
 The therapist does not focus on similarities among the patient’s relationships repeated over time
or setting
 The therapist does not attempt to interpret or make sense of the patient’s experiences (except
through framing interventions in Stage I)

Comparison with Cognitive-Behavioral and Supportive Approaches

A number of supportive and cognitive-behavioral approaches have been developed for treatment
of BPD and have been tested in randomized controlled trials (Blum, Pfohl, John, Monahan, & Black,
2002; Giesen-Bloo et al., 2006; Linehan, 1993; Rockland, 1992; Tyrer et al., 2004). Of these, DBT
comes closest to DDP and has the most established track record (Linehan, Armstrong, Suarez, Allmon, &
Heard, 1991). Both DBT and DDP emphasize on-going clinical supervision of therapists and clear
patient expectations, limits, and boundaries. Moreover, both attempt to establish links between stressors,
feelings, and maladaptive or self-destructive behaviors.
However, there are important differences between DDP and DBT. They differ in their theoretical
models of BPD pathology, goals of treatment, mechanisms for change, specific techniques, and therapist
stance. Whereas DBT hypothesizes that BPD is a disorder of emotion regulation, DDP hypothesizes that
BPD is a disorder of emotion processing. Whereas the DBT therapist explores interpersonal issues for the
purpose of identifying problem areas and teaching new skills, the DDP therapist explores interpersonal
issues for the purpose of activating and remediating specific neuroaffective capacities. Whereas the
stance of the DBT therapist is that of an advisor, coach, and cheerleader, the DDP therapist avoids (as
much as possible) imposing his/her own values or meanings.
Moreover, DDP is far less directive than DBT. DDP includes almost no educative component,
except during the Stage I, and explicitly avoids advice, validation, encouragement, or suggestions. A
study by Karno and Longabaugh (2005) indicated that the outcome of alcoholic patients with moderate or
high reactance is strongly and negatively related to the degree of therapist directiveness. Patients who
have a co-occurring substance use disorder or those having narcissistic or antisocial traits may particularly
benefit from less directive approaches.
Aspects of DDP that differ from CBT and supportive approaches are summarized below:
 The therapist does not give advice or direct suggestions
 The therapist generally does not initiate topics
 The therapist does not help the patient solve problems
 The therapist does not teach the patient new coping skills
 The therapist does not provide reassurance or encouragement
 The therapist does not make judgments as to whether the patient’s emotions and attributions are
valid or invalid
The next chapter, entitled Establishing the Frame, summarizes how to get started with DDP. The
initial sessions establish the framework and parameters of DDP, and also set the tone of the patient-
therapist relationship.
 21

3. ESTABLISHING THE FRAME

Before setting up an initial meeting with a prospective patient, I mail to the patient a packet of
self-report questionnaires and then score and review them. Questionnaires provide an outside perspective
on a patient’s pathology and a reference point for monitoring progress during the course of treatment. In
general, I employ questionnaires that are easy for the patient to understand, take a minimal amount of
time to complete, and provide much useful information. There are a number of different anxiety,
depression, and functional scales that can be used. In order to screen for borderline personality traits, I
use the Upstate Borderline Questionnaire (UBQ; see Appendix B). A useful and quick measure of
maladaptive behaviors is the Upstate Behavior Inventory (see Appendix C). A brief and well-validated
way to assess improvement in symptoms of borderline personality disorder is to use the Borderline
Evaluation of Severity over Time (Blum et al., 2002). If patients endorse at least 6 items on the UBQ,
they have a 90% probability of meeting diagnostic criteria for BPD and are appropriate for a trial of DDP.
The initial sessions are extremely important for establishing autonomous motivation, the
parameters of treatment, and a strong therapeutic alliance. During these sessions, the therapist must
perform a thorough evaluation, determine eligibility, facilitate differentiated relatedness, and clarify
treatment expectations and the boundaries of the patient-therapist relationship. See Figure 3-1 for a
summary of the tasks for these sessions.

Figure 3-1. Therapist’s tasks in the first 2-3 sessions

Session 1
 Gather initial history and perform mental status examination
 Determine eligibility for Dynamic Deconstructive Psychotherapy
 Provide patients with a formulation or reframing of their pathology that
incorporates chief complaint and need for exploratory therapy
 Inquire whether the patient agrees with the formulation and wishes to pursue
treatment

Sessions 2 and 3
 Finish gathering the history
 Explain the treatment in more depth, including process, frequency, and
duration
 Review the written treatment expectations and their rationales
 Discuss issues of medication management and group therapy
 Obtain written consents as applicable, including videotaping, treatment plan,
release of information
 Inquire whether the patient still wishes to pursue treatment

I. GATHER THE HISTORY

The treatment process begins at the first meeting between patient and therapist when the chief
complaint is elicited, i.e. asking what the patient would like from treatment. Having patients come up
with a chief complaint gives them a sense of ownership of their disorder and their desire to recover from
it. It is the beginning of facilitating autonomous motivation and individuated relatedness with the
therapist. This seemingly simple task can be very difficult for patients with BPD; they may disown a
chief complaint and respond, “I’m only here because my parent wants me to.” It may be necessary for the
 22

therapist to first move to other parts of the history to gather evidence for symptoms and functional
impairments that the patient would like improved.
After eliciting the chief complaint, it is helpful to begin with relatively non-threatening questions,
including present symptoms, onset, course, medications, and medical issues. Explicitly screen for
common comorbid psychiatric conditions, including major depressive disorder, bipolar disorder,
obsessive compulsive disorder, eating disorders, and psychosis. Suicide ideation, intent, means, and plan
should be elicited, as well as previous attempts. Posttraumatic stress disorder should be screened for later
in the interview, as screening for that disorder can sometimes generate considerable anxiety.
Explore major coping and defense mechanisms. What does the patient do when feeling stressed?
Does the patient dissociate under stress? Does the patient tend to blame self or others for problems that
have come up? Ask specifically about impulsive behaviors, such as risky driving, promiscuity, bingeing,
and excessive spending. Self-destructive behaviors should be elicited, including cutting, overdosing,
bingeing, purging, and pulling hair. Also ask specific questions about addictive behaviors, including
alcohol, gambling, and recreational drug use. Include the CAGE screening items and ask about history of
blackouts and DWIs.
Review previous treatments, including details about medications and past therapy relationships.
Try to get a sense a typical psychotherapy session and why the therapy ended. Speaking with a previous
therapist or a family member (after obtaining consent) can provide useful information. However, there is
a risk that the patient will believe that the present therapist is now colluding with them.
Ask about current relationships with family and friends. Is there a sense of emotional closeness?
How do they spend time together? How do they resolve conflicts? Have there been any romantic
relationships? Have there been significant losses of people to whom the patient felt close? How do these
relationships typically end?
Inquire about occupational and legal history. What is the longest period of time the patient has
been employed? How did the patient get along with co-workers and supervisors? Has the patient ever
been arrested?
Explore childhood relationships, including parental separation, illness, peer relations, family
relations, school performance, physical abuse, and sexual molestation. It is helpful to remind the patient
before asking questions in this section that some of the material may be painful to think about and if the
patient is not ready to talk about it right now, that’s okay. Do not suggest or imply that the patient has
undergone abuse or trauma unless the patient specifically puts past experience in those terms.
Perform basic cognitive testing to assess attention, concentration, and intelligence. High
intelligence is a good prognostic indicator for DDP. However, I have also seen patients with IQ in the
70’s achieve significant, albeit more modest, benefits from DDP. I have found the following three tests
particularly useful for screening, and look for adequate performance on at least two of the three:

1. Performing serial 7s (5/5 calculations correct).

2. Copying interlocking pentagons (5 corners to each and a diamond shape where intersected).
3. Interpreting a simple proverb abstractly (e.g. “don’t cry over spilt milk”).

II. DETERMINE ELIGIBILITY

After a detailed evaluation, the therapist is in a better position to determine whether DDP is
indicated and to anticipate problems that may arise. Although there are no absolute contraindications for
the use of DDP for BPD, some of the factors that worsen prognosis include developmental disability,
older age, and co-occurring schizophrenia. Treatment may still be helpful, but progress is usually slower
and retention is more challenging.
Treatment of patients with comorbid antisocial personality disorder can be very challenging, but
can still be effective. Many of these patients derive self-esteem from antisocial behaviors and may relish
their ability to fool the therapist (see the Demigod Perpetrator State in the chapter, States of Being).
 23

I generally do not employ DDP for teenage minors unless they are in a stable and supportive
family environment. Patients describe DDP as an awakening to the reality around them. If they awaken
to a traumatic or unloving environment, and are disempowered to change their environment because of
their age, the result can be despair and increased suicide risk. For teens in a chaotic or abusive home
environment, I recommend a different treatment approach, such as family therapy and/or a focus on
learning coping skills, such as with dialectical behavior therapy.
I have found that the patients with the best prognosis are those who are emotionally engaged with
the therapist within the first couple of sessions, and are 25 to 35 years of age. By age 25, most patients
have discovered that other solutions don’t work very well, e.g. medications, drugs, or non-specific
counseling, and they are more willing to commit to DDP. Many older patients have adjusted to being
chronically ill, and may be less motivated to do the difficult, frightening, and painful work of recovery.
Consideration must also be made for patient resources of time and money. Does the patient’s
insurance cover weekly psychotherapy visits for at least a year? If not, does the patient have the financial
resources to make up the difference? If the patient has to leave treatment in the early stages because of
inability to pay, this can lead the patient to feel re-traumatized, used, betrayed, rejected, and/or
abandoned. On the other hand, if the therapist sees the patient for little or no fee, this can paradoxically
worsen the treatment alliance through blurring of boundaries and roles.
Finally, the patient must agree on the goals, conditions, and expectations of DDP. These will be
discussed in the next two sessions.

III. EXPLAIN THE THERAPY AND ELICIT AGREEMENT ON GOALS

It is important for patients to have a basic understanding of their illness and the process and goals
of therapy. Defining the parameters of treatment helps create a sense of safety in the relationship. They
must be given some sense of what to expect from the therapist and what is expected of them. Explaining
the therapy also fosters autonomous motivation and individuation in that patients can make an informed
decision about whether or not they want to engage in treatment.
Furthermore, a framework for the process and goals of therapy gives patients who are desperate
for answers a sense of hope and direction. Because of the lack of integration in their sense of self,
responses of patients to different situations can seem erratic and confusing, even to themselves.
Sometimes their desperation for answers can lead to some bad choices as they try to convince themselves
that they are medically ill, survivors of an alien capture, the wrong gender, etc. The therapist must be
careful not to make tacit assumptions about whether or not narrated events actually happened in the past,
but instead to make a formulation based on the remembrances of the patient.
The initial framework that is presented to the patient should include several components:

1. A recapitulation and summary of pertinent aspects of the patient’s history that has led him/her to
treatment.
2. A brief formulation of the patient’s difficulties employing common language and incorporating the
patient’s chief complaint. The depth of the formulation will depend on the patient’s psychological
mindedness and on the material that was presented during the history taking. The formulation should
support the need for further exploration.
3. The goals and the tasks of the therapy; for example, activation of the areas of the brain responsible
for processing of emotional experiences, which leads to improved symptoms and a capacity for
differentiated relatedness.
4. The process of therapy, i.e. creative exploration involving verbalization of recent social encounters,
or exploration of dreams, poems, or creative artwork.

An example of a framework for a patient with a history of childhood abuse might be as follows:
 24

You seem to be stuck in a rut. You have had a lot of bad things happen to you growing up, and
that can sometimes lead to your brain shutting down awareness of emotions and of the
experiences around you. Early trauma can also lead to an inner sense of badness and confusion as
to whether you are a bad person or a good person. That inner sense of badness may have been
confirmed by some of the bad things you have done in your life and by trauma that you suffered
as an adult. Part of you may believe that you deserve all the problems in your life because of
your bad thoughts and behaviors, but the other part of you may want to blame other people. The
goal of therapy is therefore to help you activate the parts of the brain that have been shut down so
that you are more aware of yourself and your experiences and can start to figure out who you are.
Treatment doesn’t necessarily involve digging up and re-hashing old dirt, but instead starting to
talk about your recent experiences and find yourself. This may involve telling me about
something that happened recently in a relationship. Or you may find it helpful to explore your
dreams, poems, or art with me. Through this process of exploration, you may find that a more
positive, complete, and secure self starts to emerge. Does this sound like something you would
like to try?

Note that the initial framework should end with a question as to whether the patient agrees with
the formulation and wants to undertake this kind of treatment. It is essential that the patient be an active
participant and commit himself/herself to treatment for it to be successful. Recent studies suggest that
autonomous motivation may be an even more important predictor of outcome than the therapeutic alliance
(Zuroff et al., 2007). Statements such as, “You’re the doctor, whatever you think is best” need to be
challenged so that the patient has a sense of ownership of the treatment. A suitable response to this
statement would be, “Although this is what I am recommending, only you can decide if it makes sense to
you and if you want to give it a try. Therapy is gratifying, but also very difficult. And moving on with
your life can be scary. It’s very reasonable to say I’m not ready for this. Are you sure you want to give
this treatment a try?” Note that the therapist is assisting the patient in his/her decision by pointing out
pros and cons, but is nevertheless respecting the decision-making capacity of the patient to ultimately
decide what is in his/her own best interest.
On occasion, patients may become defensive during the initial interviews, particularly if they use
projective defenses. Establishing a dialogue early on regarding here-and-now patient-therapist
interactions helps to disrupt negative transference distortions and also sets the stage for later explorations
of the transference.
Many patients will not present a history of trauma or neglect. The formulation would then have
to be modified from the example above. For example, the formulation might focus instead on the sense of
emptiness or disconnectedness with what’s going on around them. The rationale for psychotherapy
would emphasize the importance of getting to know themselves and their feelings, so that they can
experience a sense of wholeness and develop more fulfilling relationships. For example, the therapist
could state,

You seem to be stuck in a rut. You are experiencing chronic depression and feelings of emptiness
inside without knowing where that is coming from. You also mentioned that you feel pulled in
different directions and don’t have a clear sense of who you are or where you’re going. I noticed
in the interview that you had difficulty describing some of your experiences and knowing exactly
what you are feeling at any given time. When people are out of touch with their experiences, it
can lead to feelings of emptiness, confusion, and a lack of a sense of self. The goal of this
therapy is therefore to help you become more aware of different parts of yourself, start to figure
out who you are, and work towards self-acceptance. Treatment involves exploration of your
emotions and experiences. Often a useful emphasis is to talk about recent encounters you have
had with other people. Or you may find it helpful to explore your dreams, poems, or art with me.
Through this process, you may find that a more positive, complete, and secure self starts to
emerge. Does this sound like something you would like to try?
 25

Patients with co-occurring substance use disorders can be especially difficult to engage in
treatment. They tend to be very medication focused, seeking a magical potion (medication) or substance
that will relieve their symptoms without having to engage in a close therapeutic relationship. “You need
to give me something to calm my nerves” is a frequent refrain. Patients with BPD frequently meet
diagnostic criteria for multiple Axis I mental disorders, and this serves as a justifiable rationale for this
demand (see chapter on Psychiatric Comorbidity). Even patients who have failed multiple trials of all the
major classes of psychotropic medications may nevertheless demand a primary pharmacological solution
to their difficulties. Such patients require a re-framing of their condition from a biological point of
reference to a biopsychosocial model. A suitable response to patients who believe that all their problems
would be solved by another trial of an antidepressant medication would be to state:

Given that you have been on multiple antidepressant medications and none of them have helped
very much, it seems likely to me that you have a type of depression that doesn’t adequately
respond to medication. I think your depression is related to poorly integrated images you have of
yourself and how you have been coping with some of the stressors in your life. Even during our
interview I noticed that you can switch between blaming others for your difficulties to total self-
blame for every problem that has ever happened in your life. Recovery from depression will
involve getting in touch with your feelings and experiences and working towards developing into
a whole and integrated person. Medications can take the edge off symptoms, but are not likely to
help as much as psychotherapy. Is this treatment something you’d like to try?

Although many patients with BPD have unrealistic expectations about medications, they usually
can receive at least a modest benefit from them. The exception may be benzodiazepines and I usually
insist that we taper off medications of this class as a precondition of treatment. The rationale for this is
that although benzodiazepines can decrease anxiety, they can worsen the course of the disorder and
impede recovery through shutting down emotional awareness and decreasing the patient’s self control of
destructive impulses and mood lability through disinhibition (see chapter on Psychotropic Medications).
Patients usually understand this rationale and often have had similar concerns, though may be reluctant to
admit it.
I try to complete all of the above tasks in the first session. In order to complete all the tasks
outlined in the figure, the therapist will need to stop gathering history before the end of the session and
leave about 20 minutes for presenting the formulation of the patient’s difficulties and the goals and tasks
of treatment. Thus history-taking in this first session should focus on determining eligibility and the
central relationship issues that are keeping the patient stuck. I find it helpful to schedule 90 minutes for
the first session to ensure sufficient time for this very important meeting. At the end of the first session, I
will also hand the patient an informational sheet on borderline personality disorder. In the following
session(s), questions and concerns can be addressed, a more complete history can be obtained, and
explicit treatment expectations reviewed.

IV. DEFINE ROLES, BOUNDARIES, AND EXPECTATIONS

During the first 2-3 sessions, it is extremely important to clearly define treatment expectations
and parameters. Conveying explicit expectations and parameters meets the BPD patient’s need for
certainty and also addresses potential safety concerns regarding abandonment and containment (see next
chapter on Stages of Treatment).
Active substance use must be taken into account when setting up the parameters of treatment.
Substance misuse is an important coping mechanism used by many individuals with BPD. It is an
effective strategy for dampening anxiety and arousal associated with amygdala activation under
conditions of emotional stimulation. However, substance use exacerbates disconnection from emotions
 26

and experiences, and therefore prolongs recovery, interferes with relationships and functioning, and
contributes to a sense of emptiness. Moreover, patients are likely to have exacerbation of underlying
shame and guilt through repeated relapses and may be vulnerable to getting traumatized while
intoxicated.
However, it is unrealistic to insist that patients maintain abstinence before or during DDP given
that substance use disorders are chronic and relapsing conditions. Under these circumstances, patients are
likely to simply lie about their substance use and get into external control struggles, viewing their
therapist as harsh and judgmental. It is far more helpful to encourage on-going substance-related
treatment, either through rehabilitation groups or Alcoholics Anonymous (AA). During treatment with
DDP, frequent checking in with the patient regarding substance use is also helpful (see section on
Managing Maladaptive and Self-Destructive Behaviors in the chapter on Specific Techniques).
As treatment with DDP progresses, patients will often enact conflicting wishes for dependency
and autonomy in the patient-therapist relationship. Establishing clear roles and parameters at the
beginning of treatment helps prevent boundary violations derived from complicit unconscious
gratifications, such as physical contact between patient and therapist (Langs, 1975). Minimal treatment
parameters should include:

 limiting physical contact to hand-to-hand, e.g. shaking hands

 limiting sessions to weekly with rare exceptions
 limiting contact outside of sessions to occasional brief phone calls
 strictly adhering to the time limits of sessions
 adhering to the established rules and parameters set at the beginning of treatment
 ending regular person-to-person contact after therapy termination
 refusing to divulge personal information when asked, e.g. “Do you have children?”

Requests from patients to go beyond these limits and inner urges by therapists to make exceptions
to these rules are common in the treatment of BPD. In part these demands reflect patients’ unmet
dependency needs. In part they also reflect poor boundaries between self and other, enactment of
pathological attributions, unconscious testing of safety concerns, and the unconscious wish for the
therapist to set limits and contain their neediness. If the patient appears to need more support than is met
with the current treatment plan, it is better to add different types of treatment, such as group therapy or
AA, rather than increasing the frequency of individual psychotherapy or telephone contact.
Treatment parameters and boundaries can sometimes seem rejecting, arbitrary or punitive to
patients and they often question them. After exploring the patient’s feelings about a given boundary, a
non-rejecting framing response can be provided if the issue comes up early in treatment (see chapter on
Specific Techniques). An example would be to state, “I know it’s hard that I keep refusing to answer
personal questions, but I want this treatment to be about you, rather than about me. I want this to feel like
a judgment-free zone, where you don’t have to worry about others’ needs or how they will react to things
you bring up. This is an opportunity for you to creatively explore and find yourself.”
In addition to verbal discussion, it is extremely helpful to have a written agreement of treatment
expectations to maximize clarity and prevent future misunderstandings. A written agreement helps to
decrease anxiety by making expectations clear, facilitates containment of hostility by outlining prohibited
behaviors, and also provides a forum for exploring future breaches of the treatment parameters (Yeomans,
Selzer, & Clarkin 1992).
Major components of a written agreement should include responsibilities of the patient,
unacceptable hostile behaviors, and conditions for discharge. The specific content will vary depending on
therapist tolerance and the particular needs of a given patient. For example, patients with severe eating
disorders should be required to maintain regular visits with a primary care physician, to allow contact
between the therapist and the primary care physician, and to maintain a minimum weight of 10-15%
below ideal body weight. Patients can be given a copy of the agreement, with a copy kept in the medical
 27

chart. I do not recommend having the patient sign the agreement, since this tends to distort the therapy
relationship into a legalistic arrangement.
A sample written agreement is outlined in Figure 3-2. Note that the expectations are generally
phrased in positive expected behaviors, rather than prohibited behaviors (the exception is #6). When
discussing the rationale for each of these limits, it is important to avoid the appearance of being punitive
or rejecting. A good way, for instance, to phrase the reason for limiting phone calls is to state, “This
limitation is essential to prevent me from getting burnt out so I can remain emotionally available to you
and effective as a therapist.”

Figure 3-2. Example of Written Treatment Expectations

1. Come to weekly 45 to 50-minute sessions on time. Cancellations should be at least 24

hours in advance. Multiple cancellations or long gaps can set treatment back.
2. Pay insurance co-pays at the beginning of each session. This demonstrates that you are
serious about treatment and recovery.
3. Actively participate in treatment. This can include bringing up relational issues or
discussing thoughts, feelings, or behaviors. You are also encouraged to bring in dreams,
creative writings, and/or drawings to share and explore. Active participation
demonstrates a commitment to recovery and is necessary for treatment to be effective.
4. Participate in quality assurance, including completion of questionnaires and video
recording of sessions. These allow the quality and consistency of treatment to be
maintained.
5. Keep yourself safe during treatment. That includes admitting yourself to the hospital
when necessary, taking medications as prescribed, and obtaining appropriate medical
care. These steps demonstrate that you are serious about recovery. I can only be helpful
if you want to be helped.
6. No hostile behaviors during sessions, including profanity, lying, violence, or threats. Such
behaviors are destructive to the treatment relationship.
7. Brief telephone calls are acceptable. But they should be limited to twice a week. I
cannot provide effective psychotherapy over the telephone.

V. SUPPLEMENTAL TREATMENT AND ACTIVITIES

Other Counseling: One of the preconditions of DDP is that the patient is not engaged in any other form
of individual psychotherapy. Because of their polarized attributions, patients with BPD have a tendency
to idealize one therapy and devalue the other. Nevertheless, individual counseling at rehabilitation
centers can sometimes by a useful supplemental treatment if the focus there stays on substance-related
issues. However, if the alcohol/drug counselor maintains a broader interpersonal focus, this can be
counterproductive due to potential for incompatible formulations of difficulties and treatment goals, as
well as patient tendencies towards idealization and devaluation. Thus it is important for the DDP
therapist to call the counselor to ensure agreement on respective roles.
Medications: Medications can be either prescribed by the therapist (if he/she has prescribing privileges)
or by another provider (see Chapter 9). If the latter scenario pertains, however, the therapist must already
have established a good working relationship with the prescriber and maintain frequent direct contact.
Ideally, the prescriber should understand the goals and structure of treatment and agree with the major
treatment principles. If these contingencies are not met, the outside prescriber can often undermine the
therapeutic alliance by suggesting alternative formulations or solutions to the patient’s difficulties, i.e.
“You simply have a chemical imbalance.”
 28

Group Therapy: Concurrent group therapy can sometimes be very helpful for successful use of DDP.
Group therapy provides another avenue for support and opportunities to develop more authentic
relatedness. Multi-modal treatment also helps to “spread the transference” so that individual therapy is
less likely to become overwhelmed by transference distortions (Alexander, 1950). Groups often help
patients to realize that they are not just a weird crazy person, but that other persons have similar struggles.
Concurrent treatments that I have seen successfully employed for this purpose include art therapy,
psychodrama, psychodynamic or interpersonal groups (such as Systems Centered Therapy), DBT skills
group, and self-help groups, including AA, Al-Anon, and Adult Children of Alcoholics (ACOA). On the
other hand, certain types of support groups defined by a particular diagnosis may be counterproductive
and serve to either reify biologically based explanations of impairment or to encourage pursuit of more
aggressive pharmacological modalities of treatment. Likewise, some trauma groups may be
contraindicated if the focus is sharing explicit traumatic memories within the group.
Many patients need to be in DDP for awhile before they are willing to join a group or use it
productively. For example, many patients are in denial regarding their substance misuse and the negative
consequences that arise from it. Non-judgmental exploration of the antecedents and of the positive and
negative consequences of the patient’s substance use gradually leads to increased motivation for
achieving abstinence.
Family Involvement: Often family members will want to be involved in the patient’s care, especially
seeking input as to how to manage the patient’s outbursts and impulsive behaviors. However, in order to
maintain a focus on the patient’s goals, instead of the family’s, and to establish trust in the patient-
therapist relationship, the DDP therapist attempts to limit contact with family members after the initial
sessions, except in emergencies. For teens or young adults who are still living with their parents, a 20-
minute educational meeting with family members during the third or fourth session can help provide them
with information about the disorder, treatment, and prognosis, and also establish the importance of
boundaries between therapist and family members. Input from family members may also provide
important information that was not gleaned from the patient interview. However, if the patient and family
want further sessions together, they should be referred to a family therapist.
School or Job: Patients will also often ask whether they should return to school or work full-time while
in treatment. Often underlying this question is the central thematic question of ‘Are my needs
legitimate?’ i.e. ‘Do I have a legitimate disorder or do I just need to pull up my bootstraps and get to
work?’ In general, having some structure to the day and opportunities to interact meaningfully with other
people is helpful to the recovery process. However, patients should be informed that research indicates
that BPD is a very disabling illness, more so than major depressive disorder and many chronic medical
illnesses (Skodol et al., 2005). This information serves to reduce pressure from unreasonable
expectations, and paradoxically increases the chances for improved functioning. Very few BPD patients
early in recovery are able to go to school full-time or maintain full-time employment. It’s generally more
helpful to maintain part-time school or work activities, or to start volunteer work if these are not feasible.
Workbooks: The most important supplemental treatment or activity is the use of Daily Connection
Sheets (see Appendix D). These sheets involve a very brief daily record of interpersonal encounters and
the emotions that were elicited in the patient during these encounters. They provide a way to extend the
process of connecting to emotional experiences beyond the weekly 50 minute sessions. They also serve
to encourage active participation in treatment and recovery, enabling the patient to gain a sense of
ownership of it, and can be used to identify and discuss ambivalence towards treatment when (as is often
the case) the sheets are not completed. Almost every patient who completes Daily Connection Sheets
finds them to be helpful, but every patient finds them extraordinarily difficult to complete.
The next chapter summarizes the sequential stages of recovery in the treatment of borderline
personality disorder. Each of the four stages has a central thematic question that must be resolved before
the patient progresses to the next stage (Gregory 2004).
 29

4. STAGES OF THERAPY

STAGE I. “CAN I BE SAFE HERE?” ESTABLISHING THE TREATMENT ALLIANCE

…the negation of alterity first necessary in order to become ‘self-consciousness’ ‘certain of itself’
(Derrida, 1978, p. 92)

The first 2-3 sessions are necessarily fairly directive and structured in order to accomplish the
many tasks necessary during the evaluation process. The therapist must switch to a non-directive and
exploratory stance after these initial sessions so that the patient can become a more active participant.
This sudden switch in therapist stance is helped by some brief re-framing, e.g. “I know the last couple of
sessions I have been asking a lot of questions. For this next session, I’m going to stop talking so much so
that you have a chance to bring up what you think you would like to explore. There are no right or wrong
issues to bring up here.”
The first stage of DDP can sometimes be stormy and tumultuous, or disconnected. The patient-
therapist relationship during Stage I is analogous to Searles’ (1961) first two phases in the treatment of
schizophrenia. Searles described patients moving from “out of contact” characterized by disengagement
to an “ambivalent symbiosis” characterized by testing of the therapist. Unconsciously, patients are testing
whether their therapists are going to respond to them in the ways they hope, fear, and expect. Will the
behavior of my therapist match my hopes for an all-loving, all-knowing, all-good, and all-powerful Ideal
Other, or will the therapist match my fears of a devaluing, controlling, intrusive, and persecutory other?
These questions underlie poorly integrated competing motivations within the patient of autonomy vs.
dependency. Thus the borderline patient begins a relationship with the therapist with the primary
thematic question of “can I be safe here?” The development of attachment to the figure of the therapist is
contingent on establishing a sense of safety (Ainsworth, 1989).
The three basic components to these concerns are outlined in Figure 4-1. These concerns could
be summed up as caring, respect, and containment.

Figure 4-1. The Three Basic Safety Concerns of Stage I

1. Caring. Will my therapist provide the kind of nurturance and support that I so
desperately want and need, or will he/she be cold, humiliating, or abandoning?

2. Respect. Will my therapist support my independent decision-making and

differentiation, or will he/she take away my autonomy and sense of self through
infantilizing, intrusiveness, control, and smothering?

3. Containment. Will my therapist be able to contain my neediness, grandiosity,

and rage, or will I end up destroying the relationship?

Each component question regarding safety is usually unconscious, but is tested in the patient-
therapist relationship. The therapist who fails to address these concerns runs the risk of a shaky
therapeutic alliance, clinical deterioration, and poor retention.


This chapter is based on a previously published paper: Gregory RJ (2004). Thematic stages of recovery in the
treatment of borderline personality disorder. American Journal of Psychotherapy, 58, 335-348.
 30

One could ask why these particular concerns are so important to this patient population? One
possibility is that the safety concerns relate to patients’ poorly integrated and opposing motivations for
dependency vs. autonomy and the associated fears of separation and merger. An additional possibility is
that the patient is seeking in the therapist the very qualities that he/she is lacking, i.e. acceptance, respect,
and impulse control. This latter hypothesis is consistent with the idea of poor self-differentiation and
blurring of the boundaries between self and other. The Ideal Other fulfills what is lacking in the patient’s
self and (if tested to be durable and real) presents the possibility for these qualities to be owned by the
self.
Stage I is characterized by testing and double binds. There are trade-offs to each of the safety
concerns. In order to successfully help the patient to negotiate this stage of treatment, the therapist must
exhibit qualities of warmth, acceptance, and empathy, while supporting autonomous decision-making. To
ensure containment, the therapist also must be very clear regarding respective roles, boundaries,
expectations, and parameters of treatment (see chapters on Establishing the Frame and The Therapeutic
Stance).
Some of the sessions will be spent on exploring why patients are having difficulty meeting
treatment expectations. These discussions typically follow a pattern of the patient breaking a rule, e.g. not
showing up to a session without prior notification; the therapist pointing it out and asking about it; the
patient providing a rationale, e.g. “I had a dentist appointment;” and the therapist then trying to explore
possible other reasons, e.g. fears of closeness/merger with the therapist, anger over perceived rejection,
hopelessness. This kind of discussion continues to some extent throughout the course of treatment, but is
most prevalent while the treatment alliance is being established. A combination of direct questioning of
parameter violations, non-defensive receptivity to implied criticisms, and maintenance of strict
boundaries are most likely to be helpful in re-establishing a fractured alliance.
The limit of the therapist’s caring (safety concern #1) is often tested through pushing the agreed
parameters and boundaries of the patient-therapist relationship. Prolonged engagement with a nurturing
therapist can intensify dependency wishes and lead to desperate attempts to engage the therapist (i.e.
safety concern #3 regarding containment of uncontrolled neediness is triggered). The empathic therapist
will detect the patient’s desperation and child-like qualities, and naturally respond with rescue fantasies of
his/her own. If treatment parameters are not maintained, a vicious cycle may ensue entailing progressive
regression to a helpless, infantile, and dependent state, alternating with rage and/or self-destructive
behaviors. The therapist has the feeling that he/she is in the midst of a feeding frenzy.
Likewise, therapists should avoid infantilizing or smothering the patient through providing
suggestion, advice, and reassurance. These interventions threaten safety concern #2 that the therapist is
going to take away the patient’s autonomy. Patients will often strongly seek such responses, e.g. “I get so
anxious sometimes that I can’t think and can’t function at all. What should I do when that happens?” A
good rule of thumb is that the more strongly a therapist feels compelled to offer suggestions or
reassurance, the less beneficial these interventions are likely to be. It is more helpful instead for
therapists to ask themselves whether they are participating in an enactment. In the above example, a
suitable response would be to make an empathic comment, a framing comment, and then to explore the
feelings in more depth. For example, “So the anxiety becomes really overwhelming for you? That’s very
common when people have a lot of unprocessed emotion. Let’s see if we can find out where the anxiety
is coming from. Can you tell me about the last instance when this happened?”
For patients who remain mostly in the autonomous states, i.e. angry victim or demigod
perpetrator, a fear of merger (safety concern #2) supercedes their wish for closeness. They fear losing
their nascent autonomous functioning and slipping into a dissociative or regressed infantile state when
they detect a therapist’s nurturing attitude. Kohut (1971) has referred to this fear of losing a fragile self as
annihilation anxiety. This fear is mostly unconscious, but is tested in numerous ways throughout Stage I.
A common way in Stage I that patients test safety concern #2 is by expressing difficulty
bringing in material for exploration. They may state, “I can’t think of anything to bring up today. Ask
me some questions.” It is usually helpful at this point to reiterate that the patient may bring up for
discussion anything that is on his/her mind that he/she would like to explore. If this intervention fails, it
 31

may be helpful to remind the therapist is unable to help unless the patient actively participates and that if
the therapist is the one setting the agenda, then the treatment is about the therapist, not the patient. A
common mistake is for the therapist to respond to the passive patient by becoming more directive and
authoritative and asking a multitude of specific questions. Such interventions represent an enactment of
an intrusive interrogation of a helpless child and take away the patient’s sense of autonomy.
Another common way that safety concern #2 is tested in Stage I is through contact with family
members. Some version of the following scenario often plays out early in treatment. In this example, an
(adult) patient calls the therapist and hands the phone to his mother:

Patient: Doctor? My mother wants to talk to you. Here she is.

Therapist: Wait!
Mother: Doctor, I’m really worried about my son. He just cut his wrists. What should I do?
Therapist: How serious are the wounds?
Mother: Well they’re dripping blood. What do you expect?
Therapist: Sounds like he may need to go to the emergency room to get checked out. Let me speak
with him.
Mother: Doctor, when is all this going to end? Things can’t keep going on like this. I need to
know what’s happening with my son so that I can be more helpful. I don’t know what to
do.
Therapist: I understand how difficult it must be to see your son suffering and not knowing what to
do. However, as I mentioned before it’s very important that he have a treatment that is
just his and doesn’t involve the family. I’d be very happy to refer you to an individual or
family therapist who may be able to help you deal with your very legitimate concerns.
You also always have the option of calling the police if you feel your son is in imminent
danger and is refusing help.
Mother: Can you at least give me some inkling as to what he’s been discussing in his treatment
with you? We need some help here!
Therapist: I understand your frustration and I’m glad that you told me of your concerns. If you give
me a call tomorrow, I can discuss some referral options for you. But right now, I’m
worried about your son’s injuries. May I please speak to him?

It is difficult for such conversations not to end on an angry note if the therapist maintains strict
boundaries. However, it is imperative in this form of therapy that contact between the patient’s therapist
and family members be limited to a single meeting early in treatment to provide information about the
disorder and the treatment frame. Further contact should be restricted to emergency situations, even
though family concerns may be legitimate and even though the patient has given the therapist permission
to communicate with family members. Patients with BPD struggle with individuation and self/other
differentiation. So maintaining the boundaries of the therapist-patient relationship distinct from the
patient-family relationship and supporting patient autonomy despite outside pressures provide a novel and
deconstructive experience for many patients. Patients need a place that they feel is just for them, free of
judgment, where they can feel free to bring up any topic within the parameters of the treatment frame
without fear of retribution.
Safety concern #3 may be also be tested in Stage I. Common ways include verbal hostility
(including lying, profanity, or demeaning comments), threats or innuendos, frequent telephone calls, and
non-compliance with medication recommendations. Winnicott (1969) stressed that the use of an object is
dependent on its ability to survive the patient’s neediness and rage without collusion, retaliation or
abandonment Safety concern #3 can be adequately addressed only if therapists first acknowledge,
identify, and accept negative countertransference reactions within themselves when they occur
(Winnicott, 1949). Therapists are then in a position to evaluate the patient’s state of being and provide an
appropriate response to deconstruct that state (see chapter on States of Being). Depending on the
 32

particular state of being, appropriate responses may include receptivity and acceptance of implied
criticism or, on the other hand, experiential challenge and limit setting.
Patients may sometimes test safety concerns by making devaluing comments to the therapist, e.g.
ridiculing their level of training, interventions, or expertise, or through intrusive or controlling actions,
e.g. insisting that the therapist read a certain book or interact in a certain way. Such comments or actions
occurring early in the therapy are testing whether the therapist is going to accept or reject such a “nasty”
patient (safety concern #1), whether the therapist will be humiliating or controlling in return (safety
concern #2), and whether the therapist is going to find a way to limit the patient’s hostility (safety concern
#3). The therapist feels trapped into making a comment that is going to jeopardize the therapeutic
alliance, regardless of how he/she responds. In general, when a therapist feels trapped by competing
safety concerns in Stage I, it is often best just to state that and to use the opportunity to acquaint patients
with their competing safety concerns or opposing attributions. For example, a therapist can state,

Your request that I give you a hug at the end of this session puts me in a dilemma. On the one
hand, if I refuse to hug you, it’s going to come across as uncaring. On the other hand, if I go
along with it, we will be crossing usual patient-therapist boundaries and I’ll come across as
unreliable. Either way I come out the bad guy. Your request reflects different and poorly
integrated safety needs that you have in relationships, including the patient-therapist relationship.
You need a relationship that is caring, but also respectful and reliable. So the question is, can you
see me as caring, even if I don’t cross boundaries and give you a hug?

In addition to framing the safety concerns and core conflicts, the therapist must set limits on
certain behaviors. If the patient’s behavior is frankly hostile, intrusive or controlling and the behaviors
are based on grandiosity rather than paranoia, then the patient is likely in the demigod perpetrator state
and these behaviors should be met with experiential challenge (see chapters on States of Being and
Specific Techniques). Defining and maintaining the parameters of treatment, including setting limits on
certain types of behaviors, serves several functions:

 Avoids excessive gratification of dependency wishes and unrealistic expectations of the

therapist-patient relationship
 Restraining merger wishes and fears by clearly defining the type and frequency of
patient-therapist contact.
 Diminishing fears of rejection and abandonment by explaining the rationale for limiting
patient-therapist contact and by clearly defining the conditions for termination of the
relationship.
 Containing patient aggression by forbidding explicit hostile behaviors within the session.
 Creating a basis for future exploration and discussion of deviations from the agreed
parameters.

Sensitive limit-setting becomes a deconstructive experience by preventing enactment of

uncontained aggression. The therapist’s ability to set limits deconstructs the patient’s attribution of the
other as being without agency and the expectation that aggression or neediness will not be able to be
contained. The patient usually greets limit setting with a sigh of relief if it is done early in the course of
treatment and with empathy.
In addition to testing safety concerns, much of the first stage of treatment is spent developing a
rhythm to the pattern of interactions between patient and therapist that prepares them to go beyond safety
concerns into reflective exploration. If the treatment is going well, patients will begin to bring up recent
relational episodes during sessions. The therapist should look for these opportunities and apply
associative techniques to develop narratives. For example, when a patient states, “My husband was
hassling me yesterday”, the therapist can ask questions to develop the narrative, such as “What did he
 33

say?” “How did you respond?” “How did that make you feel?” See chapter on Specific Techniques –
Associations for a more complete summary of interventions at this level of discourse.
The patient can also be encouraged to share dreams or creative endeavors such as poetry, creative
writing, or artwork. Some patients find it helpful to keep a journal, but this is generally not encouraged
since journals can sometimes serve to reinforce negative expectations of self and others within the
patient’s distorted attribution system. Creative endeavors allow feelings to be symbolically processed
into images or words, therefore providing space for acknowledgement and reflection of experiences.
Moreover, allowing the patient to choose the topics for exploration facilitates an active and responsible
role for the patient in the treatment, creates a sense of ownership for the treatment, and helps prevent
regression to a passive and dependent stance.
The therapist’s stance during the patient’s active exploration of experiences should be that of a
mirror. This includes repeating back narrative connections in order to reify them and convey empathic
understanding, repeating back positive self-attributions in grandiose patients in order to support self-
esteem, empathically attending to affect in the here-and-now, and providing a framework to help patients
understand their safety concerns, core conflicts, and central thematic questions (see chapter on Specific
Techniques – Ideal Other).
During the process of exploring interpersonal experiences, there are three patient constructions
that should never be challenged during Stage 1. These include:

1. Bad things that happened to me in the past are best forgotten.

2. I am not an angry person.
3. Deep down my caregivers really loved me.

These constructions are so central to the borderline’s state of being that challenging them
provokes high anxiety and defensive reactions that threaten the patient-therapist alliance, increase
dysfunction, and undermine the establishment of safety. Therefore the areas of exploration that should
generally be avoided during Stage 1include details of early trauma, feelings of anger, and ambivalence
towards parental figures. At later stages in the treatment, all these issues can be explored and worked
through as they relate to attributions of self and others. It is also helpful to provide an educative frame
regarding the difference between the feeling of anger, the destructive actions of hostility, and identity as a
bad person (see chapter on Specific Techniques).
The development of a fairly stable idealizing transference (therapist as soothing and safe
presence) marks the end of Stage I. In Searles’ (1961) terminology, the patient-therapist relationship has
moved to “full symbiosis” and the therapist has the feeling of a “Good Mother”. The patient is engaged
in the treatment process and is experiencing moderately decreased symptoms in all domains as a result of
a positive therapeutic alliance and verbalization of emotional experiences. The patient spends more time
exploring interpersonal interactions and less time testing the three safety concerns. There is an increased
awareness of emotions, and some ability to connect feelings with actions. The duration of Stage I is
generally a few months, but in more detached or disorganized patients may last much longer, even with
optimal treatment.

STAGE II. “DO I HAVE A RIGHT TO BE ANGRY?”

Meaning must await being said or written in order to inhabit itself, and in order to become, by differing
from itself (Derrida, 1978, p. 11).

The question of justification underlies one of the core unconscious conflicts of BPD. Ways to
phrase the question include, “Do I have a right to be angry?” “Have my relationships been so awful
because people have treated me unfairly, or am I the cause of my awful relationships because I am so
ugly, defective, and evil as to be unlovable?” “Am I to blame, or are they?” The primary attribution
 34

underlying these questions is that of agency and the accompanying split into opposing self-images of
either victim or perpetrator. This opposition can be a response to severe trauma or traumatic loss, but is
also evident in persons with BPD who deny a history of trauma. In the victim role the patient can appear
helpless, passive and dependent, or enraged and self-righteous. In the perpetrator role, the patient is
depressed, guilt-ridden, suicidal, and/or self-destructive.
Helping the patient to integrate these opposing attributions into some sort of reflective
ambivalence is a long-term process and typically proceeds throughout all 4 stages. For the patient, it
often involves repeated testing and engagement in maladaptive relationships. For example, a woman with
BPD involved in a physically abusive marriage had experienced feelings of self-righteous anger towards
her husband with wishes to separate, alternating with feelings of self-condemnation. This latter frame of
mind would become stronger during periods of abuse, and suicide attempts would regularly follow
traumatic incidents.
Polarized and poorly integrated attributions of motivation also enter into the second stage.
Patients are struggling with finding a comfortable interpersonal space where they can maintain their
individuality and yet feel close. The central conflict is one of autonomy vs. dependency and is another
aspect of the question of justification. Ways that patients may phrase this dilemma include, “Do I need to
put my own needs and desires aside and create a false compliant persona in order to maintain a close
relationship?” “Are my wants, needs and opinions legitimate, or am I just a crazy person?”
The predominant transference during Stage II is idealized and maternal. The patient views the
therapist as caring, warm, and protective, but unconsciously still worries about being smothered,
controlled, intruded upon, or abandoned. These worries are related to the central thematic question of
Stage II and get played out in the transference, especially around vacations. I.e. “Do I have a right to be
angry that my therapist abandoned me at a critical time in my treatment, or should I be understanding that
he/she needs a break and just keep my stupid mouth shut?” “If I protest too loudly, will my therapist get
rid of me?” Non-judgmental exploration of feelings both preceding and following the vacation with
appropriate framing of these thematic questions is most likely to be helpful.
A common trap that therapists fall into during Stage II is to become overprotective or intrusive
regarding maladaptive relationships that the patient is engaged in. This includes deviating from a non-
judgmental position of neutrality and telling the patient that he/she should get out of the relationship. This
“good advice” becomes an enactment of a controlling and devaluing maternal transference and
undermines the patient’s strength and autonomy. Moreover, when the therapist strongly sides with one
side of a polarized attribution, it allows encourages the patient to take the opposing side, i.e. “But I don’t
want to leave him. I love him” and thereby enables the patient to avoid struggling with the central
thematic question. What should have been an internal conflict (“Do I have a right to be angry at my
abusive husband?” “Should I leave him?) has now become an external opposition between the patient and
therapist (“I really love my husband and we would be fine together if this therapist did not keep
interfering”).
It is far more helpful in this situation to be direct about the devastating effects of abusive
relationships, but balance that with an exploration and affirmation of positive aspects of the relationship.
The general rule is to keep the conflict within the patient. A sign that the therapy is heading in the wrong
direction is if therapists find themselves getting into arguments or control struggles with their patients.
Thus the conflict should be defined and explored, but the patient resolves it for himself/herself. For
example, it is helpful to make framing statements or exploratory questions that help the patient see the
harmful aspects of the relationship. Some examples include:

 “It’s difficult to move on in recovery if there is on-going abuse because it reinforces your self-
image as bad and makes it difficult to integrate opposing parts of yourself.”
 “All your suicide attempts have been preceded by violence from your husband. Do you think
there’s a connection?”
 “Abuse creates an internal sense of badness and a tendency to blame oneself.”
 35

On the other hand, it is important to explore and discuss the other side of the ambivalence in a
non-judgmental manner. For example, it is helpful to state,

 “So you are saying you are very attached to your husband, rely on him greatly, and worry if you
would be able to find anyone else if you separated.”
 “Although you’re angry at your parents for how they’re acting, are you also wondering whether
you provoked them into responding to you like that?”

Note that in each of these examples, the therapist is helping patients to see both sides of their
polarized attributions, thereby creating a conscious conflict. The therapist provides information about the
detrimental effects of abuse, but this is balanced by a discussion of positive aspects of the relationship.
The therapist avoids suggesting that the patient either leave or stay, or that the patient’s anger is either
justified or unjustified. The conflict therefore remains in the patient. By becoming conflicted about
maladaptive relationships or behaviors, the patient is in a position to begin to change them. Prior to this
kind of intervention, the patient may have never been in conflict because one part of the opposition had
always been excluded from consciousness and/or projected onto another person. For example, when
patients become overly dependent in relationships, they often blame themselves for any difficulties that
arise. However, by doing so, they are excluding from consciousness the part of them that resents the
dependency, smothering, and control.
During Stage II, as patients learn to verbalize their experiences and become more aware of their
conflicts in relation to the central thematic question, they will feel less anxious and more willing to
acknowledge feelings of anger and dissatisfaction about current and past relationships. However, open
acknowledgement of anger and resentment increases separation anxiety. As separation anxiety increases,
the patient may enter the Guilty Perpetrator State periodically (see chapter on States of Being) and have
bouts of increased depression and suicide ideation.
Patients usually continue to engage in maladaptive or abusive interactions in Stage II as they
attempt to answer the question of justification. Although patients tend to be the most engaged in
treatment during Stage II, they are still ambivalent about the recovery process. Ambivalence during this
stage is often related to becoming more aware of their anger and of alternating self attributions of victim
vs. perpetrator. Ambivalence may also simply reflect an attitude of not prioritizing themselves or their
recovery over other concerns. This relates to the central thematic question of whether they are justified to
receive treatment, e.g. “Are my needs legitimate?”
If the patient appears ambivalent, the therapist should also consider whether the patient has
unspoken anger towards the therapist and is trying to settle the question of “right to be angry” in the
transference. Non-judgmental exploration of these possibilities usually reveals whether this is the case
and helps gives the patient the message that he/she is free to bring up any concerns or disagreements in
the therapy relationship. Non-judgmental acceptance by the therapist of the patient’s anger or
dissatisfaction represents a deconstructive experience of supporting differentiation and opens up new
interpersonal potential.
If the patient shows evidence of clinical deterioration during this stage it could be due to a
number of factors. Often clinical deterioration will follow a traumatic incident, which the patient may or
may not volunteer. It may also follow increased assertiveness in relationships followed by increased
separation fears or depression. When the therapist observes clinical deterioration, he/she should also
consider whether the patient is re-engaging in traumatic relationships or impulsive behaviors that the
patient is not sharing during sessions. Excessive drinking or drug use can lead to increased mood lability
and increased dysphoria.
As patients continue to work through the central thematic question in different relationships and
contexts, the therapist can provide a variety of useful interventions. These include empathic and
reflective listening, facilitating the development of affect-laden narratives, framing regarding the central
thematic question and the core conflicts, exploring the patient’s poorly integrated and conflicted feelings
and attributions towards friends or relatives, and supporting autonomous motivation by emphasizing that
 36

the patient can choose not to engage in such relationships, not to be self-destructive, to stay in treatment,
and to move on with his/her life. The idea of choice challenges opposing self-attributions as either
helpless victim or guilty perpetrator and suggests a third alternative as a strong, assertive, and
autonomous individual.
The split between competing self-attributions of victim vs. perpetrator influences the patient’s
understanding and handling of even minor stresses. For example, a patient whose cell phone was stolen
came to a session complaining of feeling traumatized and violated. However, she also felt more
depressed and had urges to cut herself and commit suicide. As we explored the incident further, the
patient realized that she felt totally responsible for the incident, i.e. “bad things happen to me because I’m
evil.”
In some individuals, the dissociative split in polarized attributions is so severe that the patient
may form separate competing identities, i.e. dissociative identity disorder. This is best handled by
framing the different identities as conflicting aspects of the same person, rather than separate individuals.
I strongly discourage the therapist from calling each of the identities by name or attempting to speak with
just one of them at a time since this is likely to strengthen the dissociation (see chapter on Special
Situations).
Through repeated exploration and processing of interpersonal interactions and maladaptive
behaviors, and bringing conflicts into consciousness, patients gradually improve. The first aspects of
BPD to improve are self-destructive behaviors, dissociation, and inpatient utilization as patients feel
soothed by the Ideal Other of the therapist. Progress in these areas, however, will vary from day to day
and week to week. Occupational and social functioning is likely to remain marginal during this period.
Mood lability and impulsive behaviors, including substance use, usually continue, but to a lesser extent.
Also during this period, the patient notices that a new, more cohesive and more positive sense of self is
starting to emerge and the patient starts to feel like he/she “has a voice.” This new emerging self,
however, tends to be transient during this stage and easily overpowered by negative self-images and
negative self-talk.

STAGE III. “AM I WORTHWHILE?” GRIEVING THE LOSS OF AN IDEAL AND WORRIES
ABOUT SELF-WORTH

Why would one mourn for the center? Is not the center, the absence of play and difference, another name
for death? (Derrida, 1978, p. 297)

New themes begin to emerge in Stage III that reflect patients’ growing awareness of their
experiences and increasingly realistic appraisals of self and others. Sustaining idealizations of self and/or
others begin to be challenged and worries about competency emerge as patients try to find their place in
the world and become more aware of their imbedded sense of badness. Stage III is characterized by
mourning for what is being lost, even as the patient moves forward towards independent functioning,
more authentic relationships, and realistic self-esteem. In philosophical terms, there is a movement away
from pure subjectivity and towards the development of alterity.
Patients with BPD carry with them sustaining idealizations that help them to survive a life of
continued disappointments in themselves and in others. Sustaining idealizations of self take the form of
grandiose fantasies. This is most evident in patients with prominent narcissistic traits, but, paradoxically,
may also be found in patients with low self-esteem and frequent bouts of depression. For example, “If I
ever really tried, I could breeze through college with straight A’s.” In Stage III such grandiose fantasies
begin to be challenged as patients relinquish the sick role and face adult responsibilities and realities.
Those patients with a history of abusive caregivers or partners rely heavily on idealizing fantasies
of the all-loving other in order to sustain them. Thus, answering the question of “whether I have a right to
be angry” poses a major problem. For if the abuse from caregivers was not entirely my fault, it means
that those persons may not have been as loving and perfect as I had presumed. The fantasy is that “my
 37

family, spouse, etc. deep down really loved me. They just didn’t get a chance to show how much they
loved me because I was so bad.” There is considerable anxiety associated with challenging this fantasy of
idealized others who never had a chance to show how much they really cared. When the patient is ready
to relinquish this fantasy of secret love, it feels like a loss and there is a grieving process involved
(Searles, 1985). At the same time, fears of separation and individuation are still present. So the patient is
in the process of separating both literally and intrapsychically on the one hand, and worrying about
competency and ability to form relationships on the other hand.
As patients begin to realize their loss of sustaining idealizations and face the challenges of
independent living, doubt and misgivings about the recovery process begins to grow. Patients can
develop periods of deep depression and hopelessness early in this stage as they grieve losses or become
overwhelmed by new responsibilities. Patients should not be pushed towards separation or towards
treatment, but instead issues of loss and ambivalence should be brought to consciousness and discussed.
Regression to earlier modes of coping and relatedness is common in Stage III, accompanied by
symptomatic worsening. Because of imbedded badness, sometimes previous modes of interaction seem
more real and alive, than healthier modes. There may be reengagement in maladaptive or abusive
relationships. Suicidal and self-destructive behaviors become more prevalent and the patient is likely to
relapse into maladaptive coping, such as drinking behaviors.
Regression to earlier modes of maladaptive coping is a manifestation of ambivalence about the
recovery process. One common cause for misgivings about treatment and recovery during this stage is an
increasing sense of uncertainty as patients begin to integrate their opposing attributions. When I asked a
patient what she found most difficult about treatment, she stated: “There is no longer any certainty…and
I don’t know what to do and I don’t know what I want. I get so many ideas that are so opposite and I
don’t know how to weigh one out more than the other.” The patient is describing the development of an
integrated self that no longer has split-off polarized attributions, but is instead capable of conscious
conflict. Attributions of self and others are no longer black and white, but become gray and ambiguous.
However, the price of integration is uncertainty and the responsibility of having to make decisions for
oneself.
Other patients will speak of recovery as feeling like losing a part of themselves. Their previous
identity may have been formed around the sick role, e.g. as being “bipolar” or “a cutter”. One aspect of
the sick role is not having to take responsibility for success or failure and to rely on others for support or
care-giving. Sometimes patients describe feeling most loved by caregivers when the patients are sick. As
they become more autonomous and healthy, patients with BPD must relinquish the sick role and
undertake the overwhelming task of finding a place in the adult world with adult responsibilities.
Other patterns of relatedness are also changing. In the past, patients may have felt most alive
when engaged in the drama of sadomasochistic relationships. Patients with antisocial traits may have
derived self-esteem from their sense of powerful badness and their ability to manipulate others. As these
are relinquished, patients often complain that “all the passion has gone out of my life.” Now the patient is
faced with fears of having to develop closer relationships characterized by increased honesty and
vulnerability. A major task for the therapist during Stage III is to bring the patient’s ambivalence about
recovery into consciousness where it can be worked through and to help the patient to mourn his/her very
real losses.
As patients develop increased strength and autonomy, the families of some patients can be very
supportive, and new and healthier ties between the patient and family members can develop. Other
families, however, are very pathological and may have scapegoated the patient and used his/or sickness as
an excuse for all the problems within the family. For such families, recovery poses a major threat to the
integrity of the family unit and members may try to undermine patient success, either directly or
indirectly. For instance, they may cut off financial support or give the patient negative messages e.g.
“you think you can make it on your own? That’s a laugh.” It is helpful for the therapist to explore the
patient’s ambivalent feelings regarding such encounters. It is equally important for the therapist to avoid
advising the patient how to respond to such an encounter. Otherwise, the therapist will be taking one side
of the patient’s ambivalence and not allow him/her to resolve it.
 38

Frequent fears of patients during this stage include fears of eternal aloneness and incompetency,
and feeling pressured by new responsibilities, i.e. “I’m never going to find someone” and “I just can’t do
this.” Paradoxically, a great deal of this stress emanates from increased hope they have for themselves.
In a life without hope, there is no pressure or expectation to succeed. The presence of hope leads to self-
expectations of competency, responsible behavior, and reliability. Living up to these new expectations
can feel overwhelming, and there is often a longing for the simpler times of the sick role and freedom
from responsibility. The pressures of recovery contribute to patients’ tendency to regress during this
stage. Old behaviors, such as substance use, may crop up and should be monitored. Patients will often
not want to admit to themselves or their therapist that they are doing worse again. During those times
when patients are regressed and depressed in Stage III, they need to be directly challenged about the pros
and cons of either remaining the sick child or moving on in the hard work of therapy.
Fortunately, during this stage patients often begin to develop closer, healthier, and more authentic
relationships outside of therapy. Such relationships are critical for letting go of the sense of imbedded
badness, realizing that they can be loved and accepted by others for who they really are. This experience,
in turn, leads to increased self-acceptance and acceptance of others’ limitations. Patients will also often
improve their capacity for employment during this stage, but need to let go and grieve grandiose hopes
and ambitions that had sustained them previously and set more realistic occupational goals.
A regressive wish and emerging fear of abandonment can play out in the therapy relationship
with increased demands for therapist time. The therapist going on vacation or sick leave may create large
anxieties that were not present in Stage II. The therapist may react with countertransference feelings of
guilt and excessively reassure the patient, instead of exploring and allowing the patient’s fears to be
brought to consciousness. The patient may misinterpret therapist words or actions as wishes to terminate
the therapy.
Commonly the transference shifts from a warm and nurturing maternal figure to a strong, moral,
idealized paternal figure during this stage, sometimes with an erotic component. In part, this shift can be
seen as a way to overcome fears of incompetence or unattractiveness by merger and identification with an
idealized image of the therapist. In part, it can also be seen as a way of postponing the necessary work of
mourning and individuation, and instead merging with an idealized all good, caring, and powerful person,
the so-called “golden fantasy” (Smith, 1977).
Frequent countertransference reactions of therapists to this shift in transference include feeling
frightened, embarrassed, grandiose, attracted, or repulsed. It is important for the therapist neither to
condemn patient feelings as “inappropriate” nor to defensively interpret the transference as a way of
keeping it at a safe intellectualized distance, e.g. “Those are the same feelings you had about your father
and they’re being played out in the transference with me.” Instead, it is more helpful to explore,
acknowledge, tolerate, and accept the patient’s idealizing and/or erotic feelings and fantasies. The
identification and idealization process can be an important step in recovery. Of course, boundaries should
be maintained, but care should be made to not reject the patient by continually reiterating boundaries as a
defensive response to countertransference feelings.
As patients start to discover their unique attributes and gain realistic self-esteem, the nascent self
becomes stronger and more integrated, with a sense of continuity and identity. A true sense of morality
and empathy also begins to form as patients develop richer, more realistic and comprehensive
understanding of the perspectives and motives of other persons and become conflicted about some of their
impulsive or antisocial behaviors.

STAGE IV. “AM I READY TO LEAVE?” OVERCOMING BARRIERS TOWARDS SELF-

ACCEPTANCE AND LONG-TERM RELATIONSHIPS

The disciple must break the glass, or better the mirror, the reflection, his infinite speculation on the
master. And start to speak. (Derrida, 1978, p. 32)
 39

Successful negotiation of Stage IV is marked by further movement towards a realistic perspective

of self and others, as well as gaining a capacity to bear sadness and loss. As difficult and painful as
termination is, learning to leave relationships without feeling rejected or abandoned is a new experience
for patients with BPD that helps them to develop a more integrated self and diminished fears of
abandonment. The desired end point is characterized by increasingly realistic, integrated, and complex
perspectives on oneself and others, and a capacity for more fulfilling and authentic relationships.
As in Stage III, there is continued work on developing more realistic appraisals of themselves and
others. Patients must still work through their deep-seated sense of badness as they try to find their place
in the world and where they fit in. There may be frantic efforts to improve self-esteem. These may
include buying expensive clothes or equipment to feel “normal” or becoming a workaholic to generate
more money. There may be feelings of alienation commingled with resentment, as patients perceive
themselves as being different from all the “perfect” people around them, along with increased sensitivity
to criticism, real or imagined. At some level, this striving for perfection can be seen as a form of
avoidance. It indicates a desire to be free from blemishes so that they can never be criticized, as well as
detached from emotions and in control of others so that they can never be hurt. A useful metaphor to
bring up with patients is the ideal of the “ice queen” or “ice king”, cold, cool, and collected. The therapist
can question them, “Are you sure this is what you want? Or do you want loving and fulfilling
relationships? If you want the latter, then you need to take some risks and be willing to feel both pain and
loss, as well as great joy.”
It’s incredibly anxiety-provoking for patients to think of removing the camouflage and armor that
they have encased themselves with, and to gradually self-disclose and becoming more authentic in their
relationships. As patients find that others accept and appreciate them for who they are, despite all their
faults, they begin to become more confident in relationships. Group therapy is often a relatively safe
place to practice limited self-disclosure and gauge reactions from others.
Until patients move toward acceptance of limitations of self and others, healthy long-term
relationships are impossible. In addition, re-engaging in romantic relationships may symbolize total
submission and loss of the fledgling self. There are also fears of becoming re-traumatized. One role of
the therapist is to bring these fears and concerns into consciousness. Developing close, fulfilling, and
non-traumatic romantic relationships is one of the most difficult tasks in recovery from BPD (Stone,
1990; Paris, 2003).
Acceptance by others also facilitates becoming more accepting of self, no longer as afraid of the
“monster” inside. A central goal of therapy during this stage is to help the patient continue to mourn the
limitations of self and others so that he/she can move towards realistic self-esteem and balanced
relationships, acknowledging and accepting both strengths and limitations.
One important limitation that the patient needs to come to terms with is the limitation of the
therapist and the patient-therapist relationship. Because of pending termination, it becomes increasingly
clear to the patient that the therapist is not a parent-substitute who will be there forever. The nature of the
therapist-patient relationship shifts to what Searles (1961) termed “resolution of symbiosis”. A major
task for the patient is to develop a capacity to perceive the therapist more realistically, reviewing the
course of treatment while integrating both positive and negative aspects, and seeing the therapist as a
separate person with his/her own needs, limitations, and points of view. Realistic and differentiated
attributions of the therapist help promote realistic and differentiated self-attributions (Harpaz-Rotem &
Blatt, 2009). Fairbairn (1941) described the transition from identification with the object to
differentiation from the object as a necessary stage of maturation.
The therapist will know that patients are in Stage IV because of the increasing emergence of
themes of loss, rejection, and abandonment; usually these will appear to be totally unrelated to therapy
ending. If patients do not bring up termination within 4 months of their scheduled end date, the therapist
should find an opportune time to do so that coincides with discussion of related themes. For example, the
therapist can state, “you mention feeling very disappointed and abandoned by your mother during times
that she ignored your distress. I wonder if you are also feeling that way about me as we near
termination?” Although this may sound relatively simple to do, most therapists find it extremely difficult
 40

because of their own feelings of concern, worry, sadness, and guilt regarding terminating the therapy
relationship. To some degree, there is commonly a shared avoidance of the topic.
The anxiety experienced by patients regarding termination cannot be overstated and can present
as panic attacks. Increased anxiety is not only related to separation fears, but is usually a manifestation of
unacknowledged emotions of anger and shame. Patients will attempt to cope with the anxiety and
underlying emotions in different ways. Some patients will attempt to avoid their emotions by turning
again to substance use. Others may start to miss appointments. Still other patients will attempt to
diminish the importance of the therapy relationship and be very devaluing of it or the therapist, thereby
avoiding the pain of separation. For example, the patient may state, “The therapy hasn’t helped me at all.
You have never cared about me and now just want to get rid of me!” Therapist comments that were seen
as amazingly insightful just a few months ago may now be ridiculed as way off the mark. The therapist’s
non-defensive receptivity to devaluing attacks, even if they are very unjust, will help move the patient
into a more reflective state and restore the alliance. Once the alliance is restored, it is helpful for the
therapist to point out that the devaluation may be an attempt to create distance in the relationship so as to
avoid feelings of sadness and loss. For example, the therapist can state, “The challenge for you as we
terminate will be to not put me in the box of being like every other person in your life who has failed you.
Something different has happened here and it’s going to be a challenge for you to hang on to that good,
despite the sadness and despite the realization of my many limitations.”
Alternatively, patients may deal with unconscious anger be displacing it onto themselves. Instead
of being devaluing towards the therapist and feeling abandoned and betrayed, the patient may instead turn
the rage on themselves and become depressed and suicidal, or engage in self-harm. The fantasy here,
which is often unconscious, is that the therapist is terminating the relationship because the patient is
fundamentally bad and unlovable, not worthy of attention. Patients usually experience the depression as
coming out of the blue, or due to some external factor, and the first step for the therapist is to ask whether
it is connected to the pending termination and feelings of rejection? If the patient can acknowledge
perceived rejection, then the therapist can move onto other interventions. Reassurance of the worthiness
of the patient at this stage is unlikely to be helpful. Instead, the therapist needs to try to integrate the split
of bad patient versus bad therapist, and then to try to help the patient move beyond the split to a place of
sadness and loss, where no one is bad and no one is to blame.
An Attribution technique to work towards integration would be to proceed through a series of
questions and explorations: “Even though part of you sees yourself as the bad one, unworthy of attention,
and thus to blame for the upcoming termination, I wonder if another part of you sees me as the bad one?
After all, I’m the one terminating treatment.” Regardless of the patient’s response to this question, it is
helpful to follow it with the following interpretation that sets the stage for the remainder of the treatment:
“The major task for you in the remainder of our time together is to get out of the blame game and to allow
yourself to be sad about ending our relationship. We are not ending because you are bad and we are not
ending because I am bad. No one is to blame. We have had a close relationship with a lot of good in it.
So it’s a loss for both of us, and it’s going to be sad. The challenge for you will be to feel the loss, grieve
it, and feel sad, rather than feeling rejected or abandoned like all your prior endings. To end a
relationship in a good way is new for you, and it’s going to be painful and difficult.” Sadness implies loss
and is an integrative emotion. To end treatment with sadness will enable patients to tolerate and move on
from other losses in their lives and will diminish their fears of abandonment.
During Stage IV, there is sometimes an unspoken or spoken wish by the patient for the
relationship with the therapist to continue in a different form after termination, i.e. a friendship or
romance (Freud, 1914; Smith, 1977). The patient’s wish may be mirrored by a similar wish within the
therapist and represents the final form of avoidance of the pain of termination and a trap that the therapist
must avoid in order to prevent disastrous consequences. The therapist-patient relationship is
fundamentally different from other relationships and cannot be converted to a friendship or romance
following termination without ultimately harming the patient or impeding his/her recovery. Frequently the
therapist experiences feelings of pride and satisfaction co-mingled with feelings of sadness and loss; loss
of both the close relationship with the patient and loss of the pleasure in the patient’s idealization. After
 41

termination of therapy, the relationship should be limited to infrequent and brief written correspondence
to “let me know how you’re doing”.
During the last few months of treatment, the patient will need to make a decision whether to
pursue psychotherapy after termination of weekly DDP. Patients should be reminded that recovery is a
lifelong process and that they will not be completely better by the end of treatment. Most patients are
taking stable dosages of psychotropic medications at the time of termination and can usually find primary
care physicians willing to take on a prescribing role. Patients who were involved in group psychotherapy
during DDP may elect to give up weekly individual therapy but to continue the group.
For those patients who have had a good or partial response to the initial 12-month trial of DDP,
the therapist can ask the patient’s preference to either take a break from all psychotherapy or to continue
to meet on a monthly basis for maintenance therapy. An offer of continued low intensity treatment helps
ease patient anxiety about termination. Maintenance therapy includes a combination of supportive and
DDP techniques. A common focus is to help patients identify ways that they are returning to earlier
avoidant coping mechanisms, so that they can get back on track with recovery.
Although most patients do well after termination of weekly visits, some need another round of
intensive DDP. If patients start to decompensate during the maintenance phase, they can be offered a 6-
month course of weekly intensive DDP booster sessions. In my experience, patients usually make far
more gains during those 6 months than if they had continued for an additional 6 months of treatment
without attempting termination.
If there is no substantial evidence of improvement after the initial 12 month trial of DDP or after
the 6 month booster, patients should be referred to a different evidence-based treatment modality, such as
dialectical behavior therapy, mentalization based treatment, or transference focused psychotherapy. If
these are not feasible or do not work out, it is sometimes helpful for the patient to restart DDP with a
different therapist.

5. THE THERAPEUTIC STANCE – FINDING BALANCE

This chapter describes the optimal stance for therapists employing DDP. A proper stance is
essential for facilitating exploration, the therapeutic alliance, and self-other differentiation. It involves a
balance along four different dimensions, as outlined below. However, it is also important to note that a
perfectly optimal stance is impossible to achieve.

1. Balancing Attention

The schema of the double register: narration and look at the narration. (Derrida, 1978, p. 21)

The therapist must simultaneously attend to patients’ narrations of their experiences, as well as to
the process of how the narrations are being conveyed and listened to. The term, process, refers to the
interaction between patient and therapist in the present moment. The process of the interaction is
different from the content of what the patient is saying. For example, a patient may be describing a recent
interaction with his mother (the content), but the patient may be presenting the narrative in a whiny
manner that induces feelings of irritation in the therapist (the process). The therapist must try to fully
listen and empathize with the content of the patient’s narratives and attributions as a participant in the
inter-subjective moment. Paradoxically, the therapist must also serve the role of an outside observer who
is attending to and reflecting on the process. In this way, the therapist serves as intermediary between self
and other, developing both the subjective and objective aspects of the patient’s self structure.
 42

PROCESS ↔ CONTENT

Therapists’ reflection on their own countertransference responses is the single most important
guide to the process and is a compass for the direction the treatment needs to take. For example, a patient
was complaining bitterly about the actions that Child Protective Services was taking to keep her from
seeing her children, and yet she had a sad look on her face and the therapist felt sad with the patient’s
sadness. Instead of focusing what actions the agency was taking, the therapist responded, “are you
thinking about missing your children right now?” This helped the patient realize the depth of her sadness
and longing, as well as to feel understood by the therapist.
Therapists’ lack of awareness of their own countertransference responses and sources of
gratification almost inevitably leads to enactment of the patients’ projected expectations (see chapter on
States of Being). Therapist enactments can include subtle forms of rejection, devaluation, control,
intimidation, or rescue. It is important for the therapist to be aware of negative emotions (such as anger,
despair, helplessness, boredom, intimidation, or devaluation), positive emotions (pride, sympathy,
attraction), and the subsequent urges to either seek relief from negative emotions or to enhance positive
emotions through interventions such as advising, educating, reassuring, interpreting, or limit-setting. A
good general rule is that the stronger the urge to make an intervention with a patient, the more likely it is
going to be an enactment that only serves to reinforce the patient’s pathology.

2. Balancing Between the Oppositions

To risk meaning nothing is to start to play (Derrida, 1981, p. 14)

Neutrality has been defined and applied in different ways, including therapist withholding
emotional responsiveness in an attempt to maintain “the same measure of calm, quiet attentiveness – of
evenly-hovering attention” (Freud, 1912, p.324). The rational for ‘evenly-hovering attention’ is to
facilitate the patient’s free association. If the therapist shows more interest in one topic versus another, it
has the potential to disrupt associations and encourage patients to select topics that they believe might
most please the therapist.
However, patients having borderline personality disorder generally cannot tolerate evenly
hovering attention. Many patients will interpret even attention as indicating that the therapist is callous,
cold, and uncaring. Thus Safety Concern #1 (i.e. dependency needs) is not met and there is difficulty
establishing a therapeutic alliance. ‘Evenly-hovering attention’ also makes the therapist an easier target
for the patient’s projections and can lead to unmanageably strong negative distortions of the therapist’s
intentions.
Although “evenly-hovering attention” is not useful for treatment of BPD, “balance” is critically
important. I am using the term “balance” to refer to a different aspect of neutrality, i.e. remaining
“equidistant” between competing aspects of the self (Freud, 1936). Although Anna Freud was referring
to being equidistant among ego, id, and superego, I am referring to remaining equidistant between
polarized attributions. This stance helps patients to feel free to explore different or opposing parts of
themselves without worrying excessively about the therapist’s approval. Neutrality also implies a warm
and supportive, but non-directive stance (maintaining balance between dependency and autonomy). A
non-directive and non-judgmental stance helps to keep the patient’s poorly integrated polarized
attributions from being externalized into a conflict between therapist and patient, and instead keeps the
attributions internal, where they can be acknowledged, reflected upon and integrated into a conscious
conflict. In order to resolve a conflict, it must first be acknowledged.
The idea of neutrality as balance between opposing attributions is consistent with other
definitions of neutrality. Moore and Fine (1990) in their compendium of psychoanalytic terms define
neutrality as “avoiding the imposition of one’s own values on the patient…to minimize distortions that
 43

might be introduced if he or she attempts to educate, advise or impose values on the patient based on the
analyst’s countertransference” (p.127). Similarly, in The Psychoanalytic Attitude, Roy Schafer (1983)
describes the neutral analyst as “attempting to avoid both the imposition of his or her personal values on
the analysand and the unquestioning acceptance of the analysand’s initial value-judgments” (p.6).
Neutality has been found to be a strong predictor of positive outcomes with psychodynamic or eclectic
psychotherapy (Sandell et al., 2006). In that study, neutrality included the therapist not answering
personal questions or sharing feelings, keeping verbal interventions brief, avoiding physical contact or
extended communication with family members, maintaining the therapeutic frame, encouraging
expression of emotions, and utilizing countertransference reactions to inform therapeutic interventions.
Each of these aspects of neutrality is consistent with DDP.
For the opposing attributions of dependency vs. autonomy, neutrality entails simultaneously
attending to the part of the patient’s self that wishes for closeness or dependency, and attending to the part
of the self that wishes for separateness or autonomy. Neither side should be excessively gratified at the
expense of the other. For example, advising patients on their finances gratifies dependency at the expense
of autonomy (see discussion below on “Balancing Between the Safety Concerns”).
For the opposing attributions of victim vs. perpetrator, neutrality entails the therapist neither
siding with the part of the self that puts blame on others, nor with the side that takes on total
responsibility. In other words, the therapist must neither imply that the patient is an innocent victim of
others’ transgressions, nor that the patient is either bad or ungrateful. For example, if the patient seems to
be misunderstanding the intentions or actions of a parent, it is very difficult for the therapist not to point
that out (thereby siding with the part of the patient that blames himself/herself). On the other hand, if a
patient is making excuses for a parent’s derogatory or manipulative comments, it is difficult to not point
out that the comments were unjustified and inappropriate (thereby siding with the part of the patient that
feels victimized). Although these interventions seem reasonable, taking one side of the polarity allows
the patient to take the other side and thus avoid acknowledging the conflict and taking steps to resolve it.
Balance tends to be the most difficult aspect of the therapeutic stance. As therapists we have a
need to feel we are competent and effective. In order to meet that need, our tendency is to rescue through
taking charge, giving advice, becoming a legal advocate, and trying to “fix” maladaptive behaviors, such
as drinking, cutting, violence, etc. Therapists have to sometimes remind themselves that the primary aim
of DDP is not for patients to work through early trauma, leave or repair current abusive relationships, gain
self-esteem, decrease maladaptive behaviors, or improve occupational functioning. The paradox is that
although each of these aspects often improves during DDP, if the therapist directly intervenes towards
these aims, positive change is unlikely to happen. Instead, the therapist must keep the focus on
remediating patients’ ability to process emotional experiences so that they can develop a coherent and
differentiated self.
Maintaining a balanced stance is also very difficult when it comes to patient attributions
regarding maladaptive behaviors, especially drinking (see section on Managing Self-Destructive and
Maladaptive Behaviors in Chapter 8, Specific Techniques). A common polarity regarding drinking
behavior is that alcohol is fun and helpful versus alcohol is bad and shameful. For example, a patient in
Stage I was describing how she had recently had a bout of heavy drinking with a male “friend” and then
was subsequently beaten and raped by him. The therapist remembered that the patient had experienced
similar incidents in the past. The therapist then acted upon an overwhelming urge to suggest that the
patient should stop drinking. By doing so, however, the therapist was enacting the patient’s attribution of
the other as shaming and controlling. The patient became defensive and a control struggle developed
regarding the patient’s drinking. A better response for the therapist in this situation would have been to
empathically explore the patient’s reactions to the incident and then to non-judgmentally point out the
pattern of the patient’s drinking behavior and subsequent trauma. This would include mentioning that the
drinking must somehow be very helpful in some way; otherwise she would not continue doing so despite
such negative consequences.
 44

3. Balancing Between Competing Needs in the Role of Ideal Other

By virtue of hearing oneself speak…the subject affects itself and is related to itself in the element of
ideality (Derrida, 1997b, p. 11)

One challenge for the therapist in the first stage of treatment and recovery is to satisfy the
patient’s needs for an Ideal Other (also see chapter on Stages of Therapy – Stage I). These needs could
be summarized as dependency, autonomy, and containment, i.e. Does the therapist care? Will the
therapist respect my wishes and decisions? And will the therapist contain my neediness and rage? It is
partially the satisfaction of such needs that helps the patient to look forward to visits and keep
appointments. The Ideal Other serves to facilitate soothing, which promotes reflective functioning and
reduces distress and maladaptive behaviors.
The therapist can convey caring by expressing warmth and sympathy regarding difficult
situations and concern regarding dangerous situations. Caring is also conveyed by availability (within
limits) and by the simple act of listening to what the patient has to say.
Caring involves more than expressing concern. It involves expressing active interest and non-
judgmental acceptance for any topic that the patient brings to session (within the limits set at the
beginning), tolerating the patient’s dependency needs, and not challenging the patient’s expectation for
perfect empathic understanding between the self and the Ideal Other. Many patients also seek advice,
direction, and reassurance from their therapists in order to meet their dependency needs. However,
therapists must avoid gratifying their patients (and themselves) in this way since it undermines their
patients’ need for autonomy and their progress towards individuation.

Dependency
Figure 5-1

Ideal Other

Autonomy Containment

The therapist can convey respect and support autonomy in several ways. By putting the patient in
charge of the agenda for sessions, by seeking agreement on goals and objectives, by allowing the patient
to disagree or criticize the therapist, by remaining neutral between the oppositions, and by supporting
independent decision-making, especially regarding decisions that the therapist may disagree with, such as
drinking. In order to make these interventions, the therapist must adopt an essential optimism regarding
the capacity of intelligent individuals to find their own solutions to life’s difficulties, even if those
solutions differ from what the therapist thinks is best. The job of the therapist is not to provide solutions
or to disagree with bad decisions, but instead to help the patient to become aware of conflicting aspects,
desires, and fears, so that he/she can get unstuck and decide what to do.
 45

Therapists’ support of autonomy includes never putting themselves on the judgment seat by
saying, “should”. Therapists can also convey respect by not making a priori assumptions about what the
patient is experiencing or why. Therapists continually generate hypotheses about patient perceptions and
motivations during sessions based on their prior experiences with other patients and based on dearly held
theories. To maximize therapeutic effectiveness, however, therapists must adopt a receptive attitude,
keep their assumptions, theories, and hypotheses on a back burner, and look at each patient as a unique
individual with a unique background, struggles, desires, and needs, and who is involved in a creative
process of exploration.
The therapist attempts to walk a fine line between conveying caring on the one hand, while
avoiding smothering, control, and intrusion on the other. For example, a patient may ask for advice on
how to go about getting a job. This puts the therapist in a dilemma. On the one hand, by giving advice
the therapist is demonstrating concern, understanding, and knowledge, and is therefore meeting the
patient’s need for dependency. Refusing to give advice under these circumstances comes across as
withholding, rejecting, and uncaring. However, giving advice jeopardizes the patient’s opposing need for
autonomy. It involves a paternalistic and self-gratifying attitude of therapist as expert job seeker that
says, “I know better than you how you should live your life and resolve your conflicts. You are just an
incompetent and helpless child.” The role of authoritative expert represents an enactment that invites
control struggles and can undermine the establishment of a therapeutic alliance, especially for patients
who remain mostly in the autonomous states of being.
Strength, certainty, and reliability are also important idealized qualities and relate to need #3, i.e.
containment. Strength does not refer to dominating or controlling the patient. Nor does it mean that
therapists can never change their minds, apologize, or give in to patient demands. Strength here refers to
drawing a line in the sand that cannot be breached in order to keep the therapeutic relationship from being
destroyed through transgressions. Although it is helpful for therapists to demonstrate flexibility, there are
two boundaries that require consistency despite both internal and external pressures. These include
refusing to be threatened or intimidated, and avoiding physical contact. Unconscious fear and desire can
pressure the therapist to breach these boundaries, but both represent enactments having high potential for
harm. Therapist reliability is closely related and provides the patient the message that this person can be
trusted and counted on with a high degree of certainty. Therapists convey reliability through actions, such
as starting appointments on time, returning telephone calls promptly, and refusing to make promises that
may not be possible to keep, e.g. “I’ll never abandon you.”
Limit-setting is important, but should be couched in language that supports dependency and
autonomy, instead of threatening the patient with abandonment. For example, the rationale for each of
the written patient expectations should be carefully explained as necessary for the therapist to be helpful,
rather than intended to find ways to kick the patient out of treatment, but (see chapter on Establishing the
Frame).
Patients having schizoid or schizotypal traits may be especially difficult to engage and may
require a more active stance than with other patients. With this subgroup, therapists often feel
emotionally cut-off, anxious, scattered, or bored, and have difficulty making an empathic connection.
Patients may become fixated on topics or talk about superficial everyday events, such as what they
purchased at the store. They may describe themselves as feeling dead, or like a zombie. If the therapist
becomes more directive and tries to structure the session, assign tasks, and ask more questions, the
process becomes an interrogation and patients may subsequently become more paranoid or detached.
Often a playful attitude is most successful with this subgroup to engage and enliven them, e.g. asking
absurd questions or playing with a metaphor in a different context. For example, “So you’re feeling like a
zombie. What do zombies eat? Aren’t zombies a little dangerous?”
 46

4. Maintaining Balance Between the Ideal Other and Real Other

Affecting oneself by another presence, one corrupts oneself, makes oneself other (Derrida, 1997b, p. 153)

As mentioned above, in order to establish and maintain a therapeutic alliance, it is necessary for
the therapist to become the patient’s Ideal Other. However, this stance is insufficient to facilitate the
patient’s movement through treatment and recovery.
The problem with therapists attempting to maintain an extended role as the Ideal Other is that this
stance does not allow patients to integrate devalued and idealized aspects of the self and to differentiate
self from other. Sigmund Freud’s wrote, “We rejected most emphatically the view that we should convert
into our own property the patient who puts himself into our hands in seek of help, should carve his
destiny for him, force our own ideals upon him, and with the arrogance of a Creator form him in our own
image and see that it was good” (Freud, 1919, p.398). The challenge in following Freud’s advice is that it
can be extremely difficult for therapists to give up the immense gratification inherent in becoming an
omniscient parental figure whom patients increasingly depend upon for guidance and support.
Although symptomatic improvement can occur if the idealized therapeutic relationship is
maintained (through soothing attachment functions of the Ideal Other), treatment can become prolonged
and characterized by excessive dependency or regression. In order for the patient to progress to
independent role functioning, the therapist must be willing to relinquish the role of the Ideal Other and
begin to introduce the Real, i.e. the not me, into the treatment. The therapist therefore tries to find a
balance between experientially signifying the Ideal Other who satisfies the patient’s logocentric needs for
certainty, understanding, and idealization; and the Real Other or not me object (Winnicott, 1953).
The Real is introduced by all the ways the therapist disappoints the patient, i.e. ending sessions on
time, limiting the number of phone calls, making unempathic comments, refusing to give advice or
reassurance, going on vacation, and, especially, ending treatment at 12 months. The inevitable
introduction of the Real Other can jeopardize the treatment and the therapeutic alliance. But it also
creates opportunities for strengthening the patient and fostering an adult role. The patient’s realization of
a not me other in the person of the therapist facilitates differentiation of self from other, and the
opportunity to reflect upon and define the self from a position exterior to the self (See Stages of Therapy –
Stage IV).
 47

6. STATES OF BEING

Being must hide itself if the other is to appear (Derrida, 1978, p. 29)

A diagnostic symptom of BPD is “identity disturbance: markedly and persistently unstable self-
image or sense of self” (American Psychiatric Association, 2013, p. 663). Persons with BPD will often
display a different interactional pattern, self-image, and mood in different situations, consistent with the
concept of shifting and poorly defined self-states. Kernberg (1975) has explained this identity
disturbance on the basis of poorly integrated (split) object relations. Other investigators have employed
attachment theory to explain the identity disturbance of BPD. Ainsworth (1993) reported that internal
working models of infant attachment could be classified into secure or anxious categories. Main, Kaplan,
and Cassidy (1985) extended the concept of internal working models to involve mental representations of
“others, self, and the relationship to others that is of special significance to the individual” (p.68).
Instability of internal working models of attachment, including conflicting representations of self and
others (Liotti, 2004), provides an alternative explanatory model for the identity disturbance noted by
Kernberg of borderline personality organization.
Common to each of these models (i.e. phenomenological, object relations, and attachment) is that
an essential feature of BPD is a poorly integrated identity or sense of self, characterized by instability of
relationships, self-image, and emotions. DDP hypothesizes that an important cause of this identity
disturbance is a deficit in the ability to integrate polarized attributions or beliefs. Persons with BPD
assign polarized, binary attributions to their experiences for the purposes of generating meaning,
eliminating ambiguity, and maintaining idealizations. In this chapter I will delineate two types of binary
attributions of self and other, i.e. value and agency, and discuss how these attributions interact to form
discrete states of being.

Binary Attributions of Value

The observation that patients with BPD exhibit opposing, binary attributions has been
incorporated into psychiatry’s modern diagnostic classification system. Perceptions of self and others are
noted to be either all-good or all-bad, i.e. “characterized by alternating between extremes of idealization
and devaluation” (American Psychiatric Association, 2013, p. 663). The phenomenon of perceiving
others as all good or all bad has been labeled as “splitting”. Splitting serves to maintain an artificial sense
of certainty, as well as to split off the embedded sense of badness and maintain idealized attributions of
self and others.

Binary Attributions of Agency

Another type of attribution that becomes polarized in persons with BPD is that of agency, i.e. the
agent of change is attributed to either self or others. If self or others are assigned agency, they are
perceived as powerful, responsible, effective, or guilty. If self or others are lacking agency, they are
perceived as helpless, blameless, ineffective, or innocent. As agency shifts from self to other, the locus of
control shifts from internal to external. In persons with BPD, agency can rapidly shift from self to other
and back again. The following case illustrates this point.
Mr. R was a man in his early twenties seen in the emergency department (ED) following
lacerations to his wrist. The incident began when he was out with a group of friends, including his
girlfriend. During the outing, his girlfriend was paying him little attention except to jokingly belittle him
in front of his friends. He took great offense to this and loudly berated her, feeling totally justified in so
doing. When he returned to his apartment, however, he began to feel ashamed and remorseful and also
feared that she would end their relationship. He then grabbed a knife and deeply slashed his wrists
hoping to die. When Mr. R saw the blood pouring out, he experienced some relief from his dysphoria and


This chapter is based in part on a previously published paper: Gregory RJ (2007). Borderline attributions.
American Journal of Psychotherapy, 61, 131-147.
 48

decided to get help. So he called for an ambulance and was rushed to the emergency department (ED).
As soon as he arrived there he telephoned his girlfriend and told her what had happened to him.
This case illustrates how binary attributions of value and agency can be clinically manifested.
Initially, attributions of agency were entirely in the other and not in the self, i.e. locus of control was
initially external. Mr. R’s self-perception was as an innocent victim with total justification for his anger
towards his bad girlfriend. Self-perception then dramatically shifted into a guilty perpetrator assuming
total responsibility for the incident. In other words, the agency or locus of control shifted from other to
self. Cutting then served as a form of atonement for his actions through discharging aggression towards
the self, getting the badness out of his body symbolically through release of blood (Gregory & Mustata,
2012), and indirectly back again at the girlfriend via the telephone call from the ED.
Karpman (1968) has noted a “drama triangle” of victim, persecutor, and rescuer that constitutes
the basic structure of fairy tales and heroic narratives within the classic literature. Liotti (2004) has
employed this drama triangle to explain shifts in the internal working models of persons having a
disorganized/disoriented attachment style and a history of trauma. “These two opposed representations of
the attachment figure (persecutor and rescuer) meeting a vulnerable and helpless (victim) self” (p.479).
In the drama triangle, the agency is shared between the evil persecutor and the good rescuer, but the
victim has none. Similarly, Blizard (2001) has proposed that borderline personality disorder is a form of
dissociation between opposing ego states of victim and perpetrator and alternating attachment styles of
either anxious/preoccupied or avoidant/dismissive. Mr. R’s perspectives of himself and his girlfriend
alternated between victim and perpetrator with the ED as rescuer.
The shift in self attributions from victim to perpetrator described by these investigators
corresponds to observations by Kernberg and Meissner. In his later work, Kernberg (2003) has postulated
that a dominant object relation of borderline personality organization is victim and victimizer with rage as
the underlying affect. Similarly, Meissner (1993) has posited that the central transference configuration
within borderline personality is comprised of a dialectic between a victim introject and an aggressor
introject. These investigators might explain Mr. R’s shift in the attribution of agency as alternating shifts
in identification between victim and perpetrator.
Although each of these investigators brings in diverse theoretical perspectives of borderline
personality, there are also commonalities. Each of them has described how agency and responsibility is
shifted back and forth between self and others. That is, the locus of responsibility is shifted from a
position of no responsibility for consequences as victim, to total responsibility for negative consequences
as perpetrator.

States of Being
The two different types of binary attributions, i.e. value and agency, interact to form dissociated
self-structures or states of being within any given person (see Figure 6-1). Each state of being is
characterized by an attributional system of well-defined (though simple and distorted) perceptions and
expectations for self and other. At any given moment there is a level of certainty about the attributions
and expectations of self and others and an inability to integrate conflicting perspectives (Akhtar, 1998).
Polarity of the attributions of self and other within each state leads to repetitive stereotyped
patterns of interpersonal relatedness. Thus each state is characterized by a pseudo-personality or way of
being in the world that is complete in itself, but also dependent upon continued inter-subjective
enactments with others in order to be maintained. When immersed in a state of being, persons with BPD
are unable to see other people for who they really are, as separate entities with unique wishes,
motivations, and values. Others become distorted through split-off projections of the self.
The term, state of being, was chosen to reflect the unchallenged subjectivity of these states with
no referent outside the self. This includes the inability to incorporate experiences that contradict the
attributions of self and other upon which each state is based, i.e. an inability to develop objectivity. Being
“is subjectivity itself, the immanence of self in self” (Sartre, 1992, p.17). The unchallenged subjectivity
and the ability to shift states of being is a central aspect of borderline personality disorder (Lyons-Ruth,
Melnick, Patrick, & Hobson, 2007) and contributes to an identity disturbance characterized by
 49

“incompatible personality attributes” (Akhtar, 1984, p.141) or “contradictory character traits” (Kernberg,
1975, p. 165). It is also consistent with the essential feature of instability, as outlined in the DSM-V.
Figure 6-1 illustrates how polarized attributions of value and agency interact to form the four
states of borderline personality disorder. Each of these states of being is characterized by a predominant
motivation to either attach or separate, and assignment of polarized attributions of value and agency to
self and others. These states are labeled as helpless victim, guilty perpetrator, angry victim, and demigod
perpetrator, and are reviewed below.

FIGURE 6-1: Self and other attributions of four states of being

AGENCY
SELF OTHER

SELF DEMIGOD PERPETRATOR ANGRY VICTIM

VALUE
GUILTY PERPETRATOR HELPLESS VICTIM
OTHER

The splitting of value and agency leads to stereotypical patterns of social interactions within each
state of either dependency or autonomy (Leihener et al., 2003). The corresponding fears are between
abandonment, aloneness, and rejection versus smothering, engulfment, and intrusion. There is thus a
perceived trade-off between relatedness and aloneness, leading to an inability to feel close and separate at
the same time (Fairbairn, 1941; Akhtar, 1994). To be close is to give up one’s own values, opinions, and
motivations and completely conform to the expectations of the other. To be autonomous is to withdraw
from all close relationships and to become isolated, detached, and alone.
Competing wishes for dependency and autonomy are implied within Margaret Mahler’s writings.
Mahler (1971) situated borderline personality as a developmental fixation at the rapprochement sub-phase
of separation-individuation. During this sub-phase, the toddler is torn between a pull towards symbiotic
reunification with mother, counterbalanced by fears of loss of autonomy and strivings towards
separateness (Mahler & McDevitt, 1989; Pine 2004).
Individuals tend to spend more time in certain states than others. For instance, those having
stronger dependency wishes and greater fears of separation and aloneness are more likely to stay in the
helpless victim state and the guilty perpetrator state. Others having stronger autonomy wishes or
persecutory fears and are more likely to stay in the other two states. The latter is more characteristic of
males than females, consistent with findings that men with BPD are more likely to have co-occurring
substance use disorders, as well as meet criteria for co-occurring paranoid, narcissistic, and/or antisocial
personality disorders (Johnson et al., 2003). However, it is a defining characteristic of borderline
personality disorder to fluctuate among the different pathological states, thereby appearing to have very
different personality characteristics from one moment to the next.
 50

I. HELPLESS VICTIM STATE (other is good, other is bad)

In the helpless victim state of being, both agency and value are assigned to others. Self-image is
as an innocent and helpless child, whereas other people are split into either all good and powerful or all
bad and powerful images, thereby creating a triadic attribution system analogous to Karpman’s (1968)
drama triangle of victim, rescuer, and persecutor .
The triad of helpless victim, evil perpetrator, and idealized rescuer is pervasive in popular
mythology and epitomized by the legend of Saint George and the dragon (Caxton, 1483). In this myth, a
holy knight subdues a dragon that is about to devour a princess. The princess was wearing a wedding
dress, thereby symbolizing innocence and purity, and consistent with lack of agency.
The helpless victim state allows patients to maintain self-esteem through shifting the locus of
responsibility for negative consequences from self to others. It also satisfies the patient’s need for
unification with an idealized caregiver, though at the cost of authentic relatedness and at the cost of
undercutting the patients’ autonomy and individuation.
Countertransference reactions to patients in this state are generally positive, assuming that the
therapist is the idealized other, rather than the devalued other, in the triad. Therapists find gratification in
their patients’ idealization of them and feel effective and omniscient as patients seem to hang on their
every word. At the same time, therapists feel warm, sympathetic, and protective towards the patient who
so clearly is in need of help and appreciative of their efforts. Therapists often respond to such feelings
with an impulse towards directive interventions, including sage advice, suggestions, and insightful
interpretations in the role of the wise counselor/rescuer who is going to help steer this unfortunate
person/victim in the right direction (Searles, 1961). These interventions satisfy the patient’s wish for
dependency and provide a feeling of soothing and protection, but there is an unconscious expectation of
intrusion and merger.
The helpless victim state has advantages from a therapeutic point of view. There is a strong
alliance, decreased symptoms, and improved functioning, unless too regressed. Moreover, the soothing
qualities of an Ideal Other combined with externalization of patient’s inner sense of badness allows them
to start examining and reflecting on distressing experiences and reconnecting with painful affect (Fonagy,
2000).
Although the helpless victim state offers therapeutic opportunities, there are also pitfalls. Because
this state is mutually gratifying, treatment can proceed for decades with very little progress occurring. It
seems like the patient is making use of support, advice, education, and insights, but the treatment never
ends. This is because therapist enactment of the role of an idealized parental figure protecting the patient
from a persecutory “other” reinforces the patient’s self-image as helpless, vulnerable, and dependent.
Alternatively, therapist enactment of the helpless victim state can lead to a worsening of the
patient’s condition. This state can stir up deep felt longings and frustrated rage for an idealized mother-
figure and infantile needy behaviors can escalate into a kind of feeding frenzy, especially if the therapist
has difficulty setting clear boundaries (Kernberg, 1975). As dependency wishes are activated, separation
fears and rejection sensitivity also increase, often triggering a switch into the guilty perpetrator state
when the therapist inevitably fails to meet the patient’s increasingly demanding expectations for the
idealized rescuer. For patients’ whose childhood experience suggests that relatedness must come at a
price of authenticity (Winnicott, 1955), the patient may increasingly fear a loss of autonomy and switch
into the angry victim state.
In order for the therapist to be of use to a patient in the helpless victim state, the therapist must
have the same qualities as transitional object, i.e. comforting and soothing like mother on the one hand,
but separate or not me on the other hand (Winnicott, 1953). The therapist partially gratifies dependency
wishes by a warm and soothing manner in the role of the Ideal Other, while also supporting the patient’s
independent decision-making and creative exploration of his/her unique attributes in the role of the Real
Other. This experience in the therapy runs contrary to the patient’s projected expectations of rejection or
intrusion. It is in such transitional space between merger and separateness that patients can creatively
find and explore their sense of self.
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A common challenge early in treatment comes when the patient becomes more infantile, needy,
helpless, and confused. The dilemma for the therapist is that the regression may worsen if the therapist
crosses the usual therapy parameters and starts to give excessive advice, suggestions, or reassurance. On
the other hand, if the therapist withholds advice in the face of patient’s needy demands, the therapist is
seen as cold and uncaring. The best intervention in this circumstance is often for the therapist to openly
state the dilemma. See chapter on Stages of Therapy – Stage I.
Other techniques useful in this state are included in the chapter on Specific Techniques –
Associations. The patient is generally engaged in treatment and the therapist role is mostly to
empathically listen and facilitate exploration, while avoiding the gratification inherent in advice,
reassurance, problem-solving, and interpretations. Inevitably, in the course of treatment, there will be
times when the therapist disappoints the patient in his/her role as Ideal Other. In such situations the
patient will struggle with the central thematic question of, “Do I have a right to get angry at this therapist
who has been so kind in so many ways?” These disappointments represent therapeutic opportunities.
Non-defensive exploration of the patient’s hurt and disappointment, and acceptance of the patient’s anger
runs counter to what the patient expects and can start to deconstruct the patient’s binary attributions of
value and agency. It also allows the patient to reflect on other disappointing relationships in his/her life
and address the core conflicts and central thematic questions in these relationships.
In summary, the helpless victim state’s triadic structure provides opportunities for reflection and
integration. In early stages of treatment, the therapist does not attempt to deconstruct this state, unless the
patient is regressed and dysfunctional. Rather, the therapist allows a soothing, idealizing transference to
develop while preventing regression. Regression is abetted by directive interventions and restrained by
the therapist’s strict maintenance of the parameters established at the beginning of treatment. During the
course of treatment, the therapist gradually relinquishes the role of the Ideal Other by fostering patients’
independent decision-making, facilitating opportunities for the patient to express non-hostile differences
of opinion and criticisms of the therapist, and working through disappointments in the limitations of the
treatment and in the patient-therapist relationship (see chapter on Stages of Treatment).

II. GUILTY PERPETRATOR STATE (other is good, self is bad)

The guilty perpetrator state is characterized by depression and hopelessness. Self-image is very
negative as the patient assumes total responsibility for every bad thing that ever happened. Individuals in
this state perceive themselves as inadequate, defective, evil, and/or a hopeless case, i.e. “I’m just this
crazy person who will never get better, so I might as well end things right now.” There is a significant
risk of suicide.
This depressive state is commonly triggered by separation fears and/or fears of retaliation for
attempts to differentiate the self through assertiveness (Rogers, Widiger, & Krupp, 1995). It serves to
maintain idealized attachment in a conflicted relationship by owning the blame (i.e. self-agency) for any
difficulties. The guilty perpetrator state avoids conflict over agency and the central thematic question of
“do I have a right to be angry?” It represents a last ditch effort to hold onto an untarnished image of the
Ideal Other in the context of emerging feelings of anger and resentment, but at the price of the patient’s
self-esteem. For example, this state often follows a therapist’s vacation or an incident of physical abuse
from a spouse.
Self-destructive behaviors, such as cutting or overdose, are common in this state and serve as a
form of atonement for self-perceived badness and thus relieve dysphoria. They also serve to displace
aggressive impulses that might otherwise jeopardize a relationship. However, the dependent attachment
of the guilty perpetrator state is at the cost of self-esteem, autonomy and genuine relatedness.
The guilty perpetrator state induces anxious and dysphoric countertransference reactions. The
therapist is in the awkward position of being stuck in the role of the idealized rescuer, but having no
agency and feeling very helpless and/or hopeless. For example, the patient might state, “I know you
mean well, but nothing seems to be working. I’m so depressed and need some help!” Therapists are
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impelled by an urgency to do something and so regain a sense of their own efficacy. There may be
increasingly heroic attempts at treatment, including escalating dosages of medications, multiple
suggestions, and frequent reassurance that things will get better. However, each failed intervention enacts
the patient’s attributions of the self as being bad beyond redemption and the expectations for the other to
be helpless and abandoning.
In addition to feeling desperate and inadequate, therapist may also feel a smoldering resentment
towards patients in this state for their lack of response to interventions and their negation of therapist
agency. While in the guilty perpetrator state patients may violate agreed parameters of treatment by
making increased demands for therapist time (such as multiple telephone calls) even while demonstrating
increased passivity and lack of involvement during sessions. The therapist feels victimized by the
patient’s violations of treatment parameters, passivity, and/or threats of suicide, but also feels trapped by a
sense of guilt and worries about tipping the patient into suicide by challenging or setting limits. The
therapist is unsure whether he/she has a right to be angry at the patient or whether to take responsibility
for the treatment failure. In this way the patient’s central thematic question of, “Do I have a right to
become angry?” becomes the therapist’s and self-doubt becomes a common countertransference reaction.
The guilty perpetrator state can sometimes be mistaken for the angry victim state since with both
states there can be implicit criticism of the therapist and countertransference reactions can include
irritation and inadequancy. However, in the former state the patients engage in explicit self-blame or
describe themselves as hopeless cases (having all the agency) and their mood is depressed. Moreover,
countertransference reactions to this state include self-doubt, in contrast to the common
countertransference reaction of scornful certainty when dealing with the angry victim state. Complicating
this situation is that patients can sometimes move back and forth rapidly between states in a single
session, requiring the therapist to nimbly switch techniques moment by moment.
In order to deconstruct the guilty perpetrator state, it is imperative for the therapist to avoid
enacting the role of victimized rescuer, regain agency and restore genuine relatedness so that patients can
acknowledge and bear their conflict regarding agency within themselves. One component of treatment is
simply to help patients create narrative linkages between their experiences so that they begin to
understand the triggers. “When you say depressed, what are you actually experiencing? When did you
start to feel this way? What was going on at the time? Did you have a fight with your boyfriend? Did
you talk to any of your family members?” However, insight into triggers is unlikely to bring patients out
of this state, nor are integrative comments regarding their polarized attributions. Patients in the guilty
perpetrator state have a limited ability to reflect on their experiences and therapist interventions to build
insight often only serve to deepen this state. Interpretation may represent yet another enactment of the
therapist as ineffective rescuer. This state needs to be experientially deconstructed in order for patients to
move on in recovery. However, deconstructing the guilty perpetrator state can be challenging.
Deconstructing this state involves the therapist responding in a way that is paradoxically both
within the role of rescuer, but contrary to the patient’s expectations, i.e. not “all good”, not helpless, but
confidently challenging patient passivity (see also chapters on The Deconstructive Experience and
Specific Techniques – Alterity). This can be done in a number of ways. A useful rule-of-thumb to keep in
mind is that patients with BPD are unable to be depressed and angry at the same time (i.e. depression
implies self-agency and no justification, and anger implies other-agency and total justification).

1. The therapist can regain agency by challenging patients on areas where they are not following
treatment parameters or participating fully in treatment; for example, by pointing out how the
patient may be calling frequently in crisis, but missing sessions or arriving late. These
interventions provide an experiential challenge to the patient’s expectations of the helpless
rescuer, and also serve to enable the therapist to feel more empowered and so increase the
therapist’s empathic capacity.
2. Likewise, the therapist should maintain a non-directive stance in the face of patient demands to
do more. This includes letting the patient bring up topics to explore. The message that needs to
be conveyed is, “I can’t help you unless you decide that you want to move forward in your
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recovery by being an active participant.” This also conveys hope, because it lets patients know
that there are specific actions that they can take to move on in recovery, if they so choose. If
patients then switch into the angry victim state and reply with concerns and fears that the therapist
is either uncaring or controlling, these should be non-defensively explored through experiential
acceptance.
3. Since the guilty perpetrator state is often a way of maintaining idealized attachment and
diminishing separation fears, this issue should be explored in relation to recent events. This
approach is especially relevant in Stage III. With some help, patients are often able to
acknowledge how frightening it is to begin to have a voice, a sense of self, to realize self-
limitations, and to challenge idealized authority. Many patients will wish to return to the sick
role. In Stage III, the guilty perpetrator state can serve the purpose of warding off the patient’s
anxiety regarding independent adult functioning by becoming depressed, helpless, and hopeless
once again, i.e. a depressive regression to the sick role. The conflict of moving on as a recovering
adult versus wanting to stay as a sick child can be non-judgmentally brought to consciousness.
Patients will begin to talk about how frightening it is to have hope of a future and the pressure of
meeting new expectations for themselves. They can be reminded that recovery is a choice and
that it is reasonable to elect not to proceed in such a difficult process.
4. Given that the guilty perpetrator state serves a defensive reaction to separation fears and
transforming feelings of anger into self-directed aggression, it is helpful to explore patient
reactions to recent relational situations and then to bring these into the discussion. For example,
“How did you feel when your father refused to help you on the ski slope? Do you sometimes feel
the same way here with me? So you sometimes see me as very uncaring and withholding…that
sounds important…can you say more about that?” This serves to bring the central thematic
question (“do I have right to be angry?”) into the transference, where it can be deconstructed
through providing the experience of non-judgmental acceptance of negative feelings,
disagreement, or criticisms of the therapist within the here-and-now of the patient-therapist
relationship. The therapist seeks to convey a message of acceptance (instead of
rejection/separation) for the patient’s frustration, irritation, or dissatisfaction with the therapist.
This approach is especially relevant in Stage IV, where the patient is experiencing separation
anxiety, anger, and disillusionment with the therapist and the treatment process. Successful
deconstruction of the guilty perpetrator state in Stage IV involves bringing those emotions and
perspectives into consciousness and providing empathic and non-defensive acceptance.
5. Other patients benefit from more subtle, indirect or paradoxical approaches. For example, it may
be helpful to state, “it will be a great achievement in your recovery when we can have a
disagreement or argument that doesn’t end in hostility, self-destructive behaviors, or fears that the
relationship will end over it.” With each of these techniques, the therapist is helping to put the
central thematic question and conflict where it can be resolved, i.e. within the patient.

III. ANGRY VICTIM STATE (self is good, other is bad)

In this state, agency is assigned to others, who are seen as persecutory. Patients’ self-image is
idealized as the heroic victim who endures life’s trials. Their slogan is “I can’t soar like an eagle when
I’m surrounded by turkeys.”
The angry victim state serves to enhance self-esteem and protect against feelings of shame and
fears of humiliation through externalization of responsibility/agency for negative consequences and
through idealization of the self. They have prominent paranoid and/or narcissistic traits, devaluing,
suspicious, entitled, and blaming others for their problems. If their focus is primarily on the persecutory
other, i.e. blaming others for negative consequences of their own actions, then the predominant
personality tone will be paranoid. If their focus is primarily on the idealized self, then the predominant
tone will be narcissistic, and they will appear grandiose and pompous.
 54

In this state, patients typically complain about other people, including their motivations,
interactions, and behaviors. They feel totally justified in those complaints since the locus of
responsibility is external to the self. Patients’ behavior is frequently demeaning, controlling, and intrusive
towards the therapist.
From a relational perspective, this state fulfills wishes for autonomy and mitigates merger fears.
“These patients identify themselves with their own self images in order to deny normal dependency on
external objects” (Kernberg, 1975, p.231). The cost to the patient, however, is isolation and fearfulness.
Unlike the helpless victim state, there is not the soothing Ideal Other to allow space to reflect upon the
split oppositions and begin to integrate them. Instead, the patient’s potential conflict regarding opposing
attributions of agency is externalized into control struggles, i.e. the internal conflict becomes an external
conflict. Hostility and threatening behavior also can become an issue in this state since the patients feel
totally justified in their actions towards a persecutory other. Hostility is as harmful to the perpetrator as
the victim; it ultimately reinforces a negative self-image and the embedded sense of badness, and
therefore impedes recovery.
Substances are frequently utilized by individuals in this state as a substitute for the soothing
functions of the Ideal Other (Johnson, 1993). There is evidence that attachment behavior and the use of
addictive substances are mediated through the same neurobiological pathways (Moles, Kieffer, &
D’Amato, 2004; King-Casas et al., 2005; Bartels & Zeki, 2004). Substance use facilitates patients’
toleration of separation and allows them to stay distant and in control. Patients may describe drinking or
drug use as the only way they can be themselves, i.e. authentic, and be relieved of the burden of meeting
others’ expectations in order to maintain relatedness.
Countertransference reactions to the angry victim state closely parallel those of the patient,
making this state the most contagious of the States of Being. Therapists may feel victimized and
devalued by the patient’s criticisms and whining complaints. Typical countertransference reactions are
scorn and/or irritation. There is a strong impulse to retaliate for the patient’s unjust attacks by “setting
limits” or giving the patient a “reality check”. These interventions are often rationalized by the therapist
as fully justified in order to contain the patient’s grandiosity and sense of entitlement. However, they end
up enacting the patient’s expectations for humiliation and rejection.
Winnicott (1969) posited that the key to recovery is survival of the patient’s destructive attacks
without retaliation. Acknowledging (to oneself) hateful feelings towards patients when they occur allows
the therapist to reflect, instead of retaliate, and to interact in a way that is contrary to the patient’s
projective expectations (Winnicott, 1949).
Specific techniques that may be helpful include mirroring of grandiosity, non-defensive process
exploration, and internalizing (see chapter on Specific Techniques). Mirroring is an intervention that is
diametrically opposed to the patient’s projective expectations of the other as humiliating and rejecting. It
involves going against the complementary tendency to deflate the grandiosity, but instead to express
appreciation for the apparently stellar achievements or qualities that the patient is boasting of.
Paradoxically, the response to mirroring can be a sudden and dramatic elimination of grandiosity and
defensiveness, and the beginning of genuine engagement.
Experiential acceptance is a primary tool for deconstructing the Angry Victim State (see chapter
on Specific Techniques – Alterity). The countertransference response to demeaning and suspicious
comments towards the therapist is commonly a feeling of angry resentment regarding the patient’s unjust
attacks and an urge to either go into defensive explanations or to “set some limits” and let the patient
know he/she is being hostile. For example, the patient may imply that the therapist simply wants a guinea
pig for his/her experiments, doesn’t have a clue how to be an effective therapist, and lacks genuine
concern regarding the patient’s welfare. The natural tendency is for the therapist to respond with
reassurance regarding a genuine commitment to the patient’s recovery and to indicate that the patient is
jeopardizing recovery by assuming a suspicious and hostile attitude. However, this intervention usually
sounds defensive to the patient’s critical ears and results in further testing, i.e. the therapist is an outside
other who cannot be trusted. Alternatively, the patient may take the therapist’s words to heart, become
extremely remorseful, and switch into the guilty perpetrator state. Although this switch helps the
 55

therapist feel more relaxed, confident and in control, it does nothing to aid the patient in the task of
recovery. A better response would be to empathically bring out the concerns into the open without
challenging them, as if talking about a third person. For example:

It sounds like you’re concerned that I just see you as a guinea pig. What is that like for you to
have a psychiatrist who you feel sees you as a guinea pig?

In this way the therapist is both an empathic insider, as well as a hostile outsider. The therapist’s
position as both inside and outside of the patient’s self-structure and receptivity to the patient’s efforts at
self-assertion challenges the patient’s sense of certainty regarding the attribution of the other and
challenges the expectations for the other to be humiliating and rejecting (see chapter on The
Deconstructive Experience).
Yet another effective technique for the angry victim state is internalization of agency (see chapter
on Specific Techniques – Attributions). Internalization subtly challenges the patient’s externalization of
conflict. For example, if the patient is complaining about people treating him like he’s crazy, the therapist
can gently inquire whether the patient has also had doubts about his sanity. This puts the conflict of
responsibility and self-image back into the patient, where it can be processed and worked through. Since
this technique involves an indirect challenge to the patient’s self-esteem, it should be used sparingly in the
first stage of treatment, when the patient is testing safety concerns regarding the therapist.

IV. DEMIGOD PERPETRATOR STATE (self is good, self is bad)

In the demigod perpetrator state, attributions of the other are without either agency or value. The
attribution of the self is an idealized badness. Self-esteem is derived from the ability to manipulate and
use other people and relatedness has a detached quality. Antisocial traits predominate. The mood tends to
be either elated or blunted.
Patients are likely to enter this state when fears of intrusion or persecution become very strong.
The demigod perpetrator state creates distance and a sense of empowerment in relationships. In this
state, other persons are non-entities, neither good nor bad, merely helpless pawns on a chessboard to be
used, discarded, ignored, or tormented according to the pleasure of the master. There is also gratification
from aggressive discharge and sadistic activities. Recent neurobiological research confirms that
aggression activates areas of the brain associated with anticipated rewards and pleasures (de Quervain et
al., 2004). Patients who stay in this state often engage in thrill-seeking activities and exciting
sadomasochistic dramas in order to provide a sense of “realness” or “aliveness” that they are unable to
derive from their shallow relationships.
Substances are frequently employed in this state to provide soothing functions, as well as to
enhance feelings of elation, detachment, and/or omnipotence. However, the sense of omnipotence
combined with frequent substance use and sadomasochistic engagements often lead to repeated re-
traumatization through physical altercations. They may also engage in indiscreet, impulsive or
hypomanic behaviors, which they later regret. The negative consequences challenge their sense of agency
and omnipotence. It is therefore not uncommon to rapidly move back and forth from this state to either
the angry victim state or the guilty perpetrator state.
Whereas relatedness in the angry victim state is characterized by devaluation and suspiciousness,
relatedness in the demigod perpetrator state is characterized by devaluation, detachment, and/or
intimidation. Countertransference emotions can vary from shared elation to detachment to fearfulness
and reactions tend towards appeasement. Sessions can be jovial and chatty; the therapist may share
delight in the patient’s exploits and feel relieved that the patient no longer seems whiny, angry, or
depressed. Other feelings can include boredom or detachment as the therapist struggles to elicit any
meaningful emotional response from the patient.
 56

Alternatively, the patient’s attitude may be controlling, intrusive, and intimidating. In these
circumstances, therapists may feel too frightened to set limits on the patient’s demands, like a mouse
paralyzed by a snake’s glare. By letting themselves be intimidated, however, therapists inadvertently
reify the patient’s empowered self-attribution and negation of the other.
The attributions of self and other in the demigod perpetrator state resemble Kernberg’s (1989)
description of a merged grandiose and sadistic self in antisocial personality. Kernberg differentiates
antisocial personality from malignant narcissism on the basis of an inability to idealize others in the
former case, including “a dramatic conviction of the impotent weakness of any good object relation” (p.
567).
The following example illustrates interactions within the demigod perpetrator state and the
potential for enactment. An exotic dancer in her early thirties was generally very chatty during sessions
and would dress seductively. She stated that all her former therapists became her “friends”. In fact, I
found it difficult not to chat and joke, as this was a very enjoyable mode of interaction with the patient.
She insisted that all sessions be paid in cash (the currency of her profession), which she would throw on
the table in a contemptuous fashion at the end of each session. She was displaying towards me the same
contempt that her clients showed her. It was only through repeated confrontation and clarification of this
interpersonal pattern that the patient was able to begin to relate in a genuine and open manner.
To deconstruct this state, the therapist must be able to limit the patient’s hostility and so place
himself/herself outside of the patient’s omnipotent control (Winnicott, 1969). This involves interacting in
a way that is different from the patient’s expected attributions of the other as without agency or value, and
for the therapist to feel empowered in the relationship. That can be difficult in a setting of intimidation,
but is necessary if the patient is going to successfully and meaningfully engage in therapy.
Hostility or boundary violations in the therapy can be subtle. For example, the patient might start
calling the therapist by his/her first name without being invited to do so. An important clue to the
dynamics is the therapist’s countertransference reaction. A countertransference reaction of fear,
intimidation, or appeasement suggests that the patient’s attributions of the other are without value or
agency and that the therapist is identifying with these attributions. Under these circumstances, to do
nothing represents an enactment of the patient’s expectations.
Such boundary infringements are most likely to occur in the initial stage of therapy and represent a
testing of safety concern # 3, i.e. “is the therapist able to contain my powerful aggressiveness?” The
challenge is how to set limits on patient’s hostility, demeaning attitude, or boundary violations and still
maintain an empathic attitude. Often an explicit discussion of conflicting safety concerns, i.e. needing a
therapist who is both caring and containing, can provide a helpful framework to decrease anxiety, and
also helps to define the issue as a conflict that the patient needs to resolve.
Other techniques include pointing out the patient’s detachment or chattiness and providing an
experiential challenge to the patient’s commitment to recovery (see chapter on Specific Techniques –
Alterity). Such challenges must be introduced slowly and empathically, however, given the sheer terror
that these patients have regarding emotionally close relationships. Parameters of treatment need to be
maintained, including limiting hostility and insisting on patient ownership of the treatment process. At
the same time, the therapist needs to empathically explore and empathize with the patient’s fear of
closeness and need to be in control. Problematic behaviors, such as drinking, should be explored within
this context.

OTHER PERSONALITY TRAITS

The states of being do not account for co-occurrence of histrionic obsessive-compulsive, schizoid,
or schizotypal traits. These traits can occur within or outside any of the states and thus are not amenable
to experiential deconstruction. Patients having schizoid or schizotypal personality traits are especially
challenging since they have more muted and less emotionally engaged transference to the therapist and
thus are unable to benefit as much from experiential techniques (See Chapter 5, The Therapeutic Stance).
 57

They may therefore require a prolonged period of treatment in Stage I in order to develop a trusting,
soothing relationship with an idealized other.

SUMMARY OF TREATMENT IMPLICATIONS FOR THE STATES OF BEING

The term enactment refers to those occasions when there is confluence between the patient’s
expectations of the other (based upon polarized attributions of self and other in any given state) and the
actual behavior of the other. Although some theorists argue that enactment is an inevitable component of
countertransference, I am distinguishing between countertransference as a feeling and enactment as an
action. Whereas countertransference is a helpful compass to guide the therapist’s interventions,
enactment reinforces patients’ pathological expectations of themselves and others.
The term countertransference is employed in a broad sense in this manual to describe any feelings
that the therapist may have towards the patient for whatever reason. These can also be either positive or
negative. What is most important is for the therapist to learn to recognize and acknowledge such feelings,
particularly when the therapist feels compelled to initiate an intervention. Because of inherent tendencies
towards enactments in the treatment of BPD, the therapist’s countertransference feelings provide an
important clue regarding the moment-by-moment process within the patient-therapist relationship and for
patient expectations for others’ behavior. Negative feelings towards a patient are not bad in and of
themselves. It is only when those feelings turn into an enactment that they become harmful.
If the supposition is correct that persons with BPD have logocentric self-structures characterized
by a need for certainty and for unified understanding between speaker and listener, then it follows that the
therapist should, to some extent, accommodate these needs in order to decrease anxiety and maintain an
alliance. For example, the logocentric need for a unified understanding with the Ideal Other can be
accommodated through reflective listening and empathic statements that convey understanding (see
chapter on Specific Techniques – Ideal Other). Numerous clinical investigators have highlighted the
importance of reflective listening and empathy, and have noted that such interventions serve to decrease
anxiety (Rogers, 1992).
In addition, providing explicit treatment expectations and contingencies can accommodate the
patient’s need for certainty, including what is expected of the patient and what the patient can expect from
the therapist. Other investigators have noted that formalized written treatment expectations improve the
therapeutic alliance and allay anxiety, and have incorporated this strategy into their treatment methods for
borderline personality disorder (Bateman & Fonagy, 2004; Clarkin et al., 2006; Linehan, 1993).
However, as patients progress through treatment, logocentric needs, idealizations, and
devaluations must begin to be challenged in order to maintain a therapeutic alliance and promote
differentiation and individuation (Gregory 2004, 2005). Because each state of being is maintained by
interpersonal enactments, therapists’ responses can either reify the attributions and expectations of a given
state, or begin to deconstruct them. By interacting in a manner that contradicts the patient’s one-sided
attributions and expectations of the other, the therapist is able to challenge the patient’s attribution
system, and open up new perspectives and possibilities. A change in the patient’s expectations of the
other necessarily challenges the expectations for the self.
The therapist therefore tries to find a balance between experientially signifying the Ideal Other
who satisfies the patient’s logocentric needs for certainty, understanding, and idealization; and the Real
Other or not me object (Winnicott, 1953) who signifies “a displacement that indicates an irreducible
alterity” (Derrida, 1981, p. 81). The patient’s realization of a not me object in the person of the therapist
leads to differentiation of self from other, and the opportunity to reflect upon and define the self from a
position exterior to the self (see chapter on The Deconstructive Experience).
In addition to experiential interventions, the therapist can also deconstruct states of being through
a play with patients’ descriptions of their polarized attributions (see chapter on Specific Techniques –
Attributions). The therapist attempts first to open up new meaning through inquiring about alternative or
opposing attributions, and then to bring together opposite attributions simultaneously. For example, a
therapist utilizing this technique might state to Mr. R, “I notice that you either blame others and see
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yourself as a victim, or blame yourself for all your difficulties and see yourself as the perpetrator. When
you are the victim, it is your girlfriend who is the perpetrator and vice versa.” Kernberg (1991, p.197)
described this type of intervention as an atemporal transference interpretation, serving to neutralize
splitting and build ego strength.
Such an intervention is also consistent with deconstruction theory. Derrida proposed that a
deconstructive reading of a text involves trying to “find out how their thinking works or does not work, to
find the tensions, the contradictions, the heterogeneity” (Derrida, 1997a, p. 9). It then involves bringing
together the “two poles of an opposition…each challenging, perverting, and exposing the impurities and
contradictions in their neighbor; and at some point…give rise to something else” (Derrida, 2004, p. 153).
Derrida (1981) employed the term différance to describe the potential for new meanings and possibilities
to emerge through this process of binary analysis, i.e. différance is “that which produces different things,
that differentiates” (p. 9).
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7. THE DECONSTRUCTIVE EXPERIENCE

The organ thus welcomes the difference of the stranger into my body: it is always the organ of my ruin
(Derrida, 1978, p. 186)

Deconstruction theory was developed by Jacques Derrida as a reaction to classical Western

philosophy’s assertion of essential meanings or truths and delineation of definite identities. An essential
meaning or identity implies a degree of certainty, lack of ambiguity, and exclusion of opposing ideas.
Derrida referred to this phenomenon as logocentrism, i.e. the “ideal of perfect self-presence, of the
immediate possession of meaning” (Derrida, 2004, p. 147).
In his later work, Derrida extended the concept of logocentrism to societal values and group
identity. For example, Derrida argues that exclusion and devaluation of others is an inherent part of
logocentrism and creates a sense of unified identification and belonging among the insiders – the valued
group. Derrida is referring here to the other as representing the devalued and excluded group, the
outsiders, the contaminants. For example, the identity and coherence of Nazi Germany as a pure and
superior Arian race depended on the devaluation and exclusion of the Jews and other ethnic groups. “The
rapport of self-identity is itself always a rapport of violence with the other…dependent on an oppositional
relation with otherness” (Derrida, 2004, p. 149).
The following case illustrates how this aspect of logocentrism can be relevant to the clinical
situation.

Case
Ms. A was a young woman who was seeing me in weekly psychotherapy for treatment of self-
injury related to borderline personality disorder. As a teenager, she had left an abusive home situation to
enter into a long-term relationship with a boyfriend who was also sometimes physically abusive. The
relationship was chaotic and her perception of self and other would radically differ at various times.
Often she would describe her boyfriend in idealized terms, as being thoughtful and considerate, and she
would imagine the perfect union with her future husband. Other times, she would angrily describe her
boyfriend in devaluing terms. On these occasions she perceived herself as the heroic victim putting up
with his transgressions. This perception would shift, however, immediately after episodes during which
he would become violent towards her. Paradoxically, Ms. A would react to his violence by blaming
herself for provoking him or for being insufficient to meet his needs, and would enter into a very
depressed state accompanied by self-injury. Each of these three situations was accompanied by a sense
of certainty or truth about her perceptions of herself and her boyfriend. There was no recollection that
she held very different perceptions of self and other on previous occasions.

This case ties into the concept of logocentrism in that idealization of self was dependent upon
devaluation of other, and vice versa. Another aspect of logocentrism was that in each of the three
scenarios, the patient manifested certitude, lack of ambiguity, and inability to self-reflect. There was no
integration of previous experiences or perceptions that contradicted her present belief system. This is
consistent with the previous discussion on states of being . Ms. A was manifesting a different state of
being in each of these scenarios. Each state has characteristic attributions of self and other guiding
patterns of interactions with no integration of alternative self and other attributions.

Case (continued)
Ms. A’s perceptions of me and the pattern of our interactions would shift depending on her
relationship with her boyfriend. For instance, during times when she would idealize her relationship with
her boyfriend, Ms. A would be more detached from me in our sessions and have difficulty bringing up


This chapter is based on a previously published paper: Gregory RJ (2005). The deconstructive experience,
American Journal of Psychotherapy, 59, 295-305.
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meaningful material. I would not hear from her between sessions and during sessions she would talk
about leaving therapy and not needing it anymore.
However, she would reattach to me after each of her boyfriend’s violent episodes. Ms. A would
call me between sessions expressing feelings of depression and desperation (even calling more frequently
than our treatment contract of up to two telephone contacts per week). During sessions she was
emotionally involved but very passive, waiting for me to ask questions and to provide direction. None of
my suggestions, however, seemed to help. While in the midst of one of these depressive episodes she
stated, “ I can’t believe I drove him to do that. Now he’s going to leave me. I just feel like dying! What
should I do?”

Ms. A was unable to integrate conflicting perceptions and experiences with her boyfriend or me
and so lacked an empathic and realistic understanding of our motivations. At any given time I was just an
idealized or devalued extension of her logocentric self-structure. She was unable to see me for who I
really was. Thus when she idealized the relationship with her boyfriend as a united and perfect couple, I
became devalued and excluded as an interfering interloper. I was an outsider, a contaminant, and the
other. Paradoxically, I was also an essential extension of the self, albeit an externalized and devalued
aspect, that allowed Ms. A to maintain an idealized view of herself and a unified relationship with her
boyfriend. I.e. I was still within her hierarchical logocentric self-structure of idealized and devalued
attributions, even though I was consciously considered an outsider.
When Ms. A became depressed, the state of being shifted to the guilty perpetrator state but
remained logocentric. I became idealized in the role of rescuer and the boyfriend became the idealized
victim, even though he had been physically violent. Ms. A now devalued herself as an outsider who was
going to be excluded, i.e. abandoned by her boyfriend and/or myself. Paradoxically, but consistent with
the guilty perpetrator state (see chapter on States of Being), she retained the agency as being
irredeemably bad. I was the helpless rescuer who was unable to make positive suggestions.
What is the most helpful intervention for the therapist to make in this situation, other than
ascertaining and assuring safety issues? Ms. A is depressed and asking for help. One option is to advise
the patient to leave her boyfriend. Assure Ms. A that no one has the right to be violent, that she is not to
blame, and that the stress of trauma is causing her depression. The difficulty with this strategy is that
even if the advice succeeds and Ms. A leaves the relationship, her self-structure remains unchanged, and
the idealized and devalued attributions of self and other merely exchange places. The therapist becomes
the idealized and effective rescuer, the patient is now the innocent victim, and the boyfriend becomes the
devalued perpetrator who is now excluded from the relationship between patient and therapist. If the
advice fails, then Ms. A reverts to the previous state where the therapist is the excluded interfering
interloper. Whether or not Ms. A follows the advice, the self-structure remains the same.
An alternative intervention is for the therapist to interpret or point out Ms. A’s pattern of
alternating idealizations and devaluations. Kernberg (1975) developed this intervention for the treatment
of borderline personality organization. Treatment involves bringing both poles of idealized and devalued
attributions into consciousness simultaneously, thereby neutralizing the splitting. For example, the
therapist could state, “right now you have a need to see me as all-good and yourself as all-bad. But
yesterday the roles were reversed and I was the all-bad, interfering therapist. For you there is no in-
between.” Such an intervention is consistent with the aims of deconstruction to make explicit both the
idealizing and devaluing aspects of a supposition and can be useful for that purpose.
A risk to interpretation of splitting, however, is that interpretation given with assurance can
sometimes reinforce logocentrism within the patient-therapist relationship. Interpretation is an act of
translation that potentially limits ambiguity in order to determine a certain meaning. In striving to
achieve a definite meaning, interpretation therefore risks colluding with the patient’s exclusion of
alternative perspectives and complexities of meaning.
In addition to limiting ambiguity and complexity, assured interpretation also risks reinforcing the
perception of the therapist as the all-wise, idealized conveyer of meaning and of the patient as helpless
and child-like, thereby experientially confirming the splitting of the underlying self-structure into
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idealized and devalued attributions. Risks inherent in authoritative interpretations have been debated
extensively and are reviewed elsewhere (Kernberg, 1998; Schafer, 1998). Derrida warned to “avoid both
simply neutralizing the binary oppositions of metaphysics and simply residing within the closed field of
these oppositions, thereby confirming it….To deconstruct the opposition , first of all, is to overturn the
hierarchy at a given moment” (Derrida, 1981, p. 41).
If authoritative assertions run the risk of experientially reinforcing logocentric self-structures,
what kinds of relational experiences might challenge or disrupt a logocentric self-structures, instead of
merely switching states? This question is closely related to the concept of the corrective emotional
experience and to other therapy modalities that rely on experiential aspects of the patient-therapist
relationship. The corrective emotional experience is a term employed initially by Franz Alexander (1950)
to describe innate healing aspects of the patient-therapist relationship. He posited that healing does not
result solely from insight or interpretation, but instead from the way in which the therapist interacts with
the patient. The patient-therapist relationship can provide healing insofar as it differs from, corrects or
repairs earlier traumatic childhood interactions, instead of reenacting them. Alexander may have
answered Ms. A. with suggesting an increase in the frequency of sessions or telephone calls as a way of
assuaging her fears of rejection and preventing reenactment of abandonment.
The therapist role as substitute parent is concordant with Ms. A’s wish for merger with an
idealized all-loving parental figure. Patients can feel enormously soothed and relieved through such an
idealized relationship (Kohut, 1971). As with the previous interventions, however, the therapist runs the
risk of reinforcing the patient’s self-attributions as child-like, helpless, and defective. By staying within
the logocentric hierarchy the therapist inadvertently fosters dependency, repeating the pattern of
idealization and devaluation with different configurations or different players in “an interminable
analysis. The hierarchy of dual oppositions always reestablishes itself” (Derrida, 1981, p. 42).
Can deconstruction theory help provide an alternative experiential model to parental substitution?
The application of deconstruction theory to treatment would emphasize deconstructing Ms. A’s
pathological logocentric self-structure, rather than adding what is missing. How can the therapist
experientially disrupt the patient’s self-structure and still retain relatedness?
The challenge is that the therapist often feels compelled to act in a way that is consistent with the
patient’s polarized attributions of the other. In Ms A’s case, I felt compelled to advise her to leave her
boyfriend. I enjoyed Ms. A’s idealization of me, but felt helpless to offer anything of value, and thus was
compelled to do more. However, every directive intervention I made was ineffective and only reinforced
the patient’s self-attribution of being irredeemably bad and of the patient’s attribution of the other as
meaning well, but lacking agency to effect change.
Therapists’ identification with their patients’ polarized attributions provokes counter-therapeutic
interventions that are consistent with expectations, and which form the basis for enactment (Racker,
1957). Enactment may or may not be traumatic, but is always stereotypical and reinforces the state of
being derived from those attributions. When therapist interactions do not conform to expectations, states
of being can begin to deconstruct into more integrated, complex, and differentiated self-structures. In
order to experientially challenge a pathological and polarized self-structure, the therapist attempts
therefore to provide a deconstructive experience, rather than an emotionally corrective experience.
In philosophical terms, the therapist is attempting to create a différance from the duality of
signified and signifier (Derrida, 1981). In other words, the therapist must not only be signifier for the
patient’s idealized and devalued attributions, but must also create a différance or space between the
patient’s attributions and the actual behavior of the therapist. The patient must experience the therapist’s
position as within the conflict, as well as outside of it (Derrida, 1981). “Deconstruction is not a method or
some tool that you apply to something from the outside. Deconstruction is something which happens and
which happens inside” (Derrida, 1997a, p. 9). An experience whereby the signifying extension of the self
(the therapist) behaves differently from expectations provides an opportunity for the self to “appear to
itself as other than itself, so that it can interrogate and reflect upon itself in an original manner” (Derrida,
2004, p.140).
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The deconstructive experience is a technique that can be employed to disrupt negative enactments
within the patient-therapist relationship or to support patient individuation and differentiation (see chapter
on Specific Techniques – Alterity). In brief, the deconstructive experience is informed by paying attention
to the patient’s emotional themes within their narratives and the therapist’s own countertransference
responses, and assessing the patient’s current stage of recovery and state of being. This information
together can help the therapist understand the underlying dynamics of the process so as to determine the
most suitable intervention to disrupt this process.
What would have been a deconstructive experience for Ms. A? Since her attributions included
the therapist as idealized but lacking agency, and the patient as irredeemably bad, the experience with the
therapist would necessarily challenge those perceptions while retaining relatedness. For example, the
therapist might point out how Ms. A has not been actively bringing up material during sessions and yet
has been calling more in-between sessions. The therapist may express puzzlement with her about the
behavior and inquire whether she has mixed feelings about treatment. The therapist has thus refrained
from assuming either an expert or rescuer role, but instead is observing that the patient is choosing to not
fully participate in treatment. The therapist is regaining agency by challenging Ms. A’s self-attributions
of being irredeemably bad and deconstructing her expectation that the therapist would try to rescue her,
but would be ineffective. A deconstructive experience can broaden attributions to include new
possibilities for the self and move patients into a more reflective and differentiated state.
Of course, several theorists have already incorporated aspects of the deconstructive experience
into their frameworks employing different nomenclature. Of the major theorists, Roger’s (1992) has
perhaps been most explicit regarding his attempt to overthrow the usual hierarchy of the patient-therapist
relationship. His client-centered treatment model emphasizes a therapeutic stance of mutual openness,
authenticity, acceptance, and equal authority between therapist and client. A potential risk, however, is
for the therapist to be devalued and excluded (since the therapist is refusing to be idealized) thus making
it harder for the client to engage in treatment. Alternatively, the therapist who combines mutual openness
with directive interventions risks blurring boundaries of self and other, and may be perceived as an
idealized extension of the logocentric self-structure.
Winnicott’s description of the transitional object as the first not me possession (Winnicott, 1953,
p. 1) is consistent with deconstruction qualities of being both within and outside of the self. I.e. “the
transitional object is never under magical control like the internal object, nor is it outside control as the
real mother is” (Winnicott, 1953, p. 10). It is a symbolic object that is both united with mother and apart
from her, i.e. “its not being the breast (or the mother), although real, is as important as the fact that it
stands for the breast (or mother)” (Winnicott, 1953, p. 6). Finally, Winnicott discusses transitional
phenomena, such as play, as being “not inside by any use of the word…. Nor is it outside, that is to say, it
is not a part of the repudiated world, the not-me, that which the individual has decided to recognize (with
whatever difficulty and even pain) as truly external, which is outside magical control” (Winnicott, 1999,
p. 41).
Thus the deconstructive experience involves the use of the therapist as a transitional object who is
simultaneously both part of the split-off and projected self, and who is also a separate person standing
outside the self. Therapy itself becomes a transitional phenomenon that allows the patient to “weave
other-than-me objects into the personal pattern” (Winnicott, 1953 p. 3) and thus develops a capacity to
differentiate between self and others and to gain more realistic appraisals. The ability to maintain an
outside perspective towards oneself and others I have labeled as alterity (see chapter on
Conceptualization of Borderline Personality Disorder).
Other clinical theorists have also incorporated deconstructionist elements. Buie and Adler (1982)
have described disillusionment in the idealized image of the therapist as a necessary stage in the treatment
of borderline personality disorder. I.e. it is necessary for the therapist to first be idealized as an extension
of the patient’s self-structure. However, the therapist must eventually be de-idealized through
disappointments in the patient-therapist relationship and be seen as a separate person in order for the
patient to develop a sense of self.
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Searles (1961) emphasized similar stages in psychotherapy of schizophrenia. Searles describes

the patient-therapist relationship evolving from out of contact to an idealized symbiosis to resolution of
symbiosis, characterized by relinquishment of symbiotic modes of relatedness and the ability to relate to
others as separate persons with their own needs and wishes apart from those of the patient.
In his treatment model for narcissistic personality, Kohut (1971) argued that the therapist must
become an idealized or mirroring self-object of the patient in order to maintain a cohesive self-structure.
In Kohut’s model, however, it was not the creation of an idealized self-object that was transformative.
Rather it was graded, non-traumatic disappointments and disillusionment in the self-object that built ego
strength, the so-called experiences of “transmuting internalization”.

Conclusion
Idealizations and devaluations, a high degree of certainty, simplicity, lack of ambiguity, and an
inability to consider alternative perspectives, are indicative of a logocentric self-structure and often
characterize the narratives of patients with BPD. Logocentric self-structures, or states of being, consist of
poorly integrated, polarized, rigid, and stereotypical attributions of self and other. A consequence of this
self-structure is a limited capacity for empathy and an inability to realistically appraise complex attributes
of self or others.
Patient-therapist interactions have the potential to either reinforce or to deconstruct logocentric
self-structures, regardless of the overarching treatment model that is employed. Therapist interventions
that rely on advice, suggestion, or assured interpretation run the risk of reinforcing patients’ logocentric
self-structure through limiting ambiguity of choice and meaning. A deconstructive experience is a
therapeutic intervention that aims to disrupt logocentric self-structure through providing experiences
within the patient-therapist relationship that challenge stereotyped attributions and expectations, broaden
perspectives of self and others, and support the development of a differentiated self.
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8. SPECIFIC TECHNIQUES

The following chapter summarizes each of the central techniques employed in DDP. The first
four sections, i.e. Association, Attribution, Ideal Other, and Alterity, organize techniques by the particular
neuroaffective function that is being remediated or the type of relationship that the therapist is trying to
build. Proscribed techniques are delineated at the end of each of these sections. The chapter wraps up
with a fifth section outlining specific management strategies for self-destructive and/or maladaptive
behaviors. There are a host of other techniques not included in the manual, which are not central or
proscribed, but may sometimes be helpful, e.g. clarifying patient’s attributions.
Adherence to appropriate technique can be rated on a standardized scale (see Appendix) by the
therapist or outside observer employing video recordings of sessions. This scale includes both the central
techniques, as well as proscribed techniques, and is scored as percent adherence.

I. ASSOCIATION METHODS

In emerging from itself, hearing oneself speak constitutes itself…Thus it differs from itself in order to
reappropriate itself (Derrida, 1978, p. 166)

1. Verbalization and Elaboration of Narrative Sequences

When starting a session, the therapist should allow the patient to pick the focus for discussion.
The therapist attitude that “whatever topic is important to you is also important to me” helps patients feel
accepted and respected. It also provides the patient with a sense of ownership and responsibility for the
treatment, and so discourages regression. The primary role of the therapist is therefore to support the
patient’s exploration and reflection of narratives and attributions.
As patients become more comfortable with the therapist and more reflective, they will bring up
recent interpersonal encounters. This tends to be the most fruitful area of discussion for most patients as
it provides opportunities to enhance awareness of feelings, to begin making basic connections in their
sequential experiences with others, and to link these experiences to their emotions.
The role of the therapist is simply to help patients to verbalize narratives of recent interpersonal
encounters and elaborate their emotional experiences. However, this simple intervention can be very
difficult in practice. Patients with BPD have an enormously difficult time getting down to the level of
specific experiences. Instead, they are much more comfortable talking about general patterns of
interaction, e.g. “He is always criticizing me”. Or they will talk at length about the meaning of their
experiences or others’ intentions and attributions, e.g. “she’s just trying to get rid of me”. The therapist
practicing DDP continually asks, “Can you give me an example of that?”
A complete narrative can be described as having three components: a wish or intention, a
response from the other or “RO”, and a response from the self or “RS” (Luborsky & Crits-Christoph,
1998). For example, the statement, “I hoped my mother would have baked me an apple pie, but instead
she baked me a cherry pie and I was very disappointed,” is an example of a complete narrative. The wish
is for an apple pie, the RO was baking a cherry pie, and the RS was a feeling of disappointment. In
applying DDP, the therapist helps the patient to connect the RS and RO components within narratives and
to clarify the associated affects. For example, the therapist might ask, “What did you say to your mother
when you found out she had baked you a different pie from what you had hoped for?” “What did she say
back to you?” “Were you feeling anything else at that moment, other than disappointment?”
The following vignette is a fairly typical segment of a session transcript of a young man with
BPD in Stage II that illustrates these simple but important techniques:

P(atient): My regional manager called and harassed me three times when I was sick; so, the day after
that happened I told my Mom I do not stand for harassment; it’s not something I’m willing to take; so I’m
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going to go ahead and quit. And she was telling me not to, which went against what I believe in. If I went
back to work for them, it would be saying that harassment is all right, and I don’t stand for that.

T(herapist): Mm…so she said…

P: …That I should quit.

T: How did you feel about that when she said…

P: That I should just confront my manager. I’m like, ‘I’m sick in bed and you make me call you three
times to get out of bed. That’s just rude and it’s unhealthy for me.’ I get even sicker with the flu than
other people and that’s why my doctor was very cautious about it. He was going to give me medication,
but he decided not to. He said to stick by my ibuprofen.

T: So in that last conversation with your regional manager, what happened during that last time, the
third time he called?

P: He was still going on about the doctor’s note. He was like, ‘Have you gone to the doctor today yet?’
And I was like, ‘No! I’m sick in bed with a 104 fever. What do you expect from me?’ He was like, ‘just
give me a doctor’s note.’ And I was like, ‘I’m not going to take this.’ So two days after that…

T: What did you say when he said, ‘Just give me a doctor’s note?’

P: I said, ‘Okay sir, I will do that.’ And next morning he called again, which was the fourth time.

T: Oh!

P: And I just had enough of it and told him not to disturb me again because I was sick and if I really
wanted to, I could file harassment charges against him.

T: That’s what you said, huh?

P: Yeah, I told him I’d file harassment charges because I was in no condition to even go out in the
weather. I was in really bad shape. I lost 11 ½ pounds.

T: My goodness!

P: My body just would not eat.

T: Well, what was it like to say that to him?

P: It felt powerful and I was worried that he might fire me for it.

T: So you felt powerful on the one hand, but also worried a bit as well.

P: Yeah, and then on Friday I…

T: But what did he say after you said that you might file harassment charges?

P: He hung up on me.
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T: And were you more nervous after he hung up?

P: I was a little bit. But I thought about it hard and then the next morning I called in to the local
manager and said, ‘I’m sorry to do this to you, but I quit.’

T: What did she say?

P: She said, ‘That’s fine. See you tomorrow.’

In this vignette the patient offers three discrete interpersonal episodes, the first with his mother,
the second with his regional manager, and the third with the local manager. The sequence, “He was like,
‘Have you gone to the doctor today yet?’ And I was like, ‘No! I’m sick in bed with a 104 fever. What do
you expect from me?’” is an example of a complete but simple narrative. The statement by the regional
manager, “Have you gone to the doctor today yet?” is the RO. This RO is followed by an RS of, “No!
I’m sick in bed with a 104 fever. What do you expect of me?”
Throughout the vignette, the therapist attempts to develop the narratives by asking about links
between RS and RO and helping the patient to identify and verbalize the associated affects. For example,
the therapist helps the patient to narrate the RS that follows the RO of, “Just give me a doctor’s note” by
asking, “What did you say when he said, ‘Just give me a doctor’s note?’” On the other hand, the therapist
helps the patient to narrate the RO that follows an RS by asking, “But what did he say after you said that
you might file harassment charges?” The therapist also attempts to clarify associated affects at various
points in the interview. For example, “How did you feel about that when she said…?”
These therapist interventions would not be unusual in other psychodynamic treatment models.
The explicit purpose of such interventions might be to develop insight into maladaptive interpersonal
patterns (Strupp & Binder, 1984), correct misperceptions of others’ intentions (Bateman & Fonagy,
2004), or to identify polarized attributions (Clarkin et al., 2006). In this vignette, however, the primary
aim of helping this patient to develop his narratives was not to facilitate insight into maladaptive patterns
or to correct misattributions. Rather, verbalization of emotional experience and linking-together
sequential responses into a narrative account can be therapeutic in themselves by activating associative
functions and fostering a subjective sense of self.
Notice in the vignette that the patient repeatedly gets sidetracked away from the interpersonal
episode into discussion of other issues. The therapist repeatedly redirects the conversation back to the
level of experience to verbalize and elaborate the narratives that the patient started.
Also notice that the patient is preoccupied with issues of justification throughout the vignette,
consistent with the Stage II central thematic question of, “Do I have a right to be angry?” For example,
he provides several reasons why he was too sick to return to work so as to feel sufficiently justified to
finally assert himself with his regional manager. The patient relates feeling powerful about his self-
assertiveness, but this is also accompanied by fears of abandonment (i.e. getting fired). Thus the patient
feels obligated to either be in total conformity with the wishes of the manager (“okay sir. I will do that),
or to totally leave the relationship by quitting his job. The patient is illustrating the difficulty in being
close but separate in relationships.
With more disorganized patients, a common error that therapists make in working with patient
narratives is to repeatedly try to clarify the context, instead of asking about RS, RO, and associated
affects. This is understandable given how confusing these narratives can be. Disorganized patients can
suddenly switch pronouns or switch scenes jumping through time so that it becomes impossible for the
listener to discern who is speaking to whom at any given moment. The therapist must learn to tolerate a
certain degree of confusion and uncertainty rather than continually interrupting the flow of the narrative
to clarify context. Otherwise, the therapist runs the risk of cutting off the affective connections to
experience and creating a passive and dependent enactment.
Acknowledgement of feelings and verbalization of narratives begins to create a separation
between patients’ here-and-now consciousness and their emotional experiences, between observing and
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experiencing. Thus a space is opened up for reflection on experiences, for ownership of them, and for the
beginning of a subjective sense of self. The following statements by a patient with BPD and crack
cocaine addiction illustrate how verbalization of emotional experiences in the context of the patient-
therapist relationship can foster the development of a subjective sense of self.

As I start to develop feelings surrounding certain situations that I share with you…like I think
verbalizing some of the things that I have going on in my head sort of acknowledges the feelings
exist, as opposed to just something sort of crazy that…maybe like if I don’t share them, like no
one knows…and I don’t know how much they exist. And honestly, I think the less I share with
people, the less I feel I exist, and there’s many days where I feel sort of invisible.

Note that this therapist had not tried to validate the patient’s emotions, but simply had provided
an opportunity for the patient to verbalize them. An essential component of a subjective sense of self is
the ability to form a dialogue with an internal or external other. In the above example, the patient is able
to discern that her sense of existing as a person derives from her ability to acknowledge to herself feelings
about certain situations and to share these feelings with other people.
Although Association techniques appear to be simply and easy, patients find them extraordinarily
difficult. They are much more comfortable speaking about general patterns of interaction and will avoid
speaking about specific encounters and labeling specific emotions. The therapist must therefore gently
redirect the patient back to specific examples, while avoiding the temptation of over-structuring the
session and setting the agenda (see Chapter 5, The Therapeutic Stance). Between sessions, it is helpful
for the patient to continue the work of therapy through application of Daily Connection Sheets (see
Chapter 3, Establishing the Frame, and Appendix D, Daily Connection Sheets).

2. Exploring emotional themes of creative activities

Encouraging creative endeavors and helping patients to link them to emotional experiences is
another aspect of DDP that fosters a sense of self. Creative endeavors can include drawing, pottery,
sculpting, creative writing, poetry, or exploration of dreams. Even allowing the patient to choose topics
for discussion is a form of creative exploration whereby the interpersonal experience between patient and
therapist can take on characteristics of play. Creativity provides an avenue for the flow of unconscious
wishes, fears, and conflicts into a tangible symbolic expression that allows space for reflection. The
patient will most be able to benefit from these techniques after safety concerns are addressed in Stage I
and the therapist is in the role of the Ideal Other.
Artistic explorations tend to work best for patients who already have inclinations in that direction.
I will encourage patients to draw, write, or paint between sessions, especially during times when they are
feeling overwhelmed. Sometimes I will also encourage patient’s to draw or paint within a session if they
appear to be struggling with some emotion but are having difficulty putting it into words. When drawing,
it is helpful to instruct patients to draw whatever comes to mind, instead of simply copying a design. The
patient’s associations to the drawing can be explored. It is then helpful for the therapist to share his/her
associations and feelings about the figures. Pay particular attention to the affect that the various figures or
parts of the drawing evoke. Look for polarized attributions of self and other (see chapter on States of
Being). A similar process can be used to explore poetry and prose.
Much has been written about dreams and their exploration and interpretation. I tell patients that
dreams have many possible meanings, rather than just one, and that there are many ways to explore them.
In my work, I have found it more helpful to focus on affective themes and associations in the exploration
of dreams, rather than on dream symbolism and double entendres. For example, the therapist can inquire
about the particular emotion that the patient was experiencing at a particularly intense moment in the
dream. This question often leads to the patient’s free association of a similar affective theme in other
relationships. Depending on the particular dream, the therapist may also want to inform the patient that
“one way to interpret dreams is that all the characters within the dream are different aspects of yourself.”
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The following example is regarding exploration of a dream of a patient in Stage IV of treatment.

The patient has been discussing how angry she felt at the therapist for not fully informing her about
aspects of a group therapy he had referred her to. The therapist feels that the criticism was unjustified,
but does not explain away the misunderstanding and therefore invalidate her feelings. Instead he
continues listening. The patient then associates to a dream she had the previous night:

I was walking through a garden and there are colorful, poisonous snakes intertwined with one
another. I was trying to get away from them. Just then my Mom came along and caught one of
the snakes by the neck so it couldn’t bite me. But the snake was still hissing at me. I was like,
‘Thank God! Thank God! She protected me.’ And then, [pause] she took the snake and threw it at
me. In my dream I was like, ‘I knew I couldn’t count on you.’

The therapist then asks the patient to label the emotions she was feeling at the moment her mother
threw the snakes. The patient states, “It’s a feeling of anger and betrayal. People have betrayed me my
whole life.” The therapist associates to the earlier discussion they had had regarding the group therapy
and attempts to provide experiential acceptance by asking whether she had the same feelings towards the
therapist, which the patient affirms. The patient then thanks the therapist for acknowledging how his
actions made her feel and goes on to explore some of the profound disappointments she had experienced
in her relationship with her parents.

3. Proscribed Techniques
There are certain areas of discussion that will cause excessive anxiety for most patients,
particularly in Stage I. When patients become very anxious, they are no longer able to engage in
productive exploration. Three problematic content areas include:

1. Details of traumatic experiences

2. Acknowledgment of feeling angry
3. Challenges to the sustaining fantasy of the idealized parent.

Gentle probing of these areas to leave the door open for exploration is generally helpful, but
insistent questioning is likely to be viewed as intrusive and traumatizing. Some patients will even need to
be constrained from excessively dwelling on traumatic experiences. Sometimes patients get the idea that
if they can somehow they can get all the traumatic memories out of their system by vomiting them into
the lap of the therapist (figuratively speaking) then everything will be better. For the BPD patient,
however, such “behavioral desensitization” often leads to clinical deterioration because of an inability to
process the experiences, particularly in Stage I. By late in Stage II, patients will usually have sufficient
capacity to gradually bring forth repressed memories without prompting from the therapist and usually
without dissociating or regressing.
Likewise, many patients will attempt to divert discussions into elaborations of their physical
symptoms or their need for medication. Diversion into these topics subtly shifts the role of the therapist
from mirror to rescuer or authority figure, and also serves to avoid exploration of emotional interpersonal
experiences. For these reasons, such discussions should be brief and deferred to the end of the session.
Assured interpretations are to be avoided, especially interpretations linking patient-therapist
transactions to earlier child-parent experiences (so-called genetic interpretations). Assured interpretations
can create the perception that the therapist is imposing his/her own “reality” and way of structuring the
world onto the patient, and so undermines the patient’s need for autonomy. See chapters on The
Therapeutic Stance and The Deconstructive Experience for a more complete discussion. Genetic
interpretations can also create overwhelming anxiety in Stage I or II if they challenge the idealized image
of parental figures. However, there is a role for this kind of interpretation in Stage IV, as both therapist
and parental figures are de-idealized.
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In general, listening techniques do not include advice, suggestion, and reassurance. Their
absence is one of the defining characteristics of DDP, as opposed to supportive or CBT treatments.
Paradoxically, the patient may strongly press the therapist for these interventions because of strong
dependency wishes. However, the patient’s sense of autonomy is sacrificed in the process with resultant
regression and control struggles (see chapter on Stages of Therapy – Stage I for further discussion of this
topic).

II. ATTRIBUTION METHODS

1. Asking About Alternative or Opposing Attributions

Its force is a certain pure and infinite equivocality, which gives signified meaning no respite, no rest, but
engages it in its own economy so that it always signifies again and differs. (Derrida, 1978, p. 25)

As outlined in previous chapters, BPD is characterized by poorly integrated polarized attributions

of value, agency, and motivation regarding self and others. Thus patients with BPD have difficulty
holding in their consciousness two opposing attributes simultaneously. People are seen in black or white,
all one way or all another. DDP helps patients consider alternative perspectives to their experiences and
to be able to tolerate consideration of conflicting viewpoints. In this way, patients move from a state of
logocentric certainty to one of reflective ambivalence.
Neuroscience research supports the effectiveness of attribution techniques for adaptive emotion
processing. Reappraisal of emotional experiences has been shown in multiple studies to be more effective
than distraction or emotion suppression in decreasing distress associated with emotional stimuli and in
dampening physiological arousal (Kalisch, 2009).
The therapist should suspect poorly integrated polarized attributions when:

 The patient exhibits a sudden shift from a previous point of view

 There is denial of a previous viewpoint and marked certainty regarding the current viewpoint
 The patient’s viewpoint appears extreme, either devaluing or idealizing
 The patient is arguing forcibly a given viewpoint, as if trying to convince the therapist (or
himself/herself)
 The therapist is experiencing strong countertransference wishes to rescue, direct, or condemn.

The first step in helping the patient to develop more complex and integrated attributions is simply
to ask the patient about alternative or opposing viewpoints. For example, the therapist can ask, “Although
you are sad that your girlfriend broke up with you, are you also relieved?” Or, “Despite saying that you
hate your ex-boyfriend, I wonder if you also still care for him?” Or, “So you feel you need to go in the
hospital? Do you have any reservations about it? Or, “It seems that you enjoy having power over your
parents by getting them to behave as you wish, but the fact that you keep bringing up this issue makes me
wonder whether you also have some mixed feelings about your actions. Do you think you do?”
A related intervention is to make an internalizing comment in response to patient’s use of
externalization. Externalization is a common defense employed by BPD patients and refers to a shift in
agency from self to other. Attribution of self-agency is not only disowned and dissociated from
consciousness, it is also projected onto another person. Agency is externalized to the other in the helpless
victim state and the angry victim state (see chapter on States of Being). By shifting responsibility onto
others, externalization provides a means of transforming internal conflicts into external conflicts and
avoids underlying feelings of shame (Freud, 1965; Novick & Kelly, 1970). Thus, in the case of
alcoholics, externalization allows them to avoid feeling conflicted about their drinking and instead
maintain the fantasy that “I want to drink and would be fine if I didn’t have my wife, children, therapist,
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etc. hassling me all the time about my drinking. They treat me like an imbecile!” A helpful and
internalizing comment that the therapist could make in return is, “I get the sense that you sometimes
wonder if you are an imbecile regarding your drinking. Is this how you feel sometimes?”
Internalization represents one of the most simple and effective techniques that can be applied for
patients in the angry victim state to open up meaning, bring in opposing attributions, and move patients to
a more reflective and integrated mind-set. This technique can be employed when patients excessively
complain about how others are mistreating them. Internalization serves to transform a conflict from
external and interpersonal to internal and inside the person, where it can be acknowledged and worked
through. This technique is most effective in Stages II, III, and IV and should be applied only sparingly in
Stage I, i.e. before there is a solid therapeutic alliance.
Below is a transcript where an internalizing comment was made:

P(atient): The person in the business office required all this I.D. before she would take my request
seriously. I needed to prove to her that I was a legitimate person.

T(herapist): She didn’t believe that you are a legitimate and competent person?

P: That’s what I felt like. I don’t think most people do see me that way. Even my friends sometimes say
“God has one hand on (patient) and one hand on the world.”

T: But you know, of course, your harshest critic?

P: Is moi?

In this example, the internalizing question of, “Are you your harshest critic?” allowed the patient to
realize that her primary problem was not others’ perceptions of her, but how she perceived herself.
Another type of internalizing comment can be made for patients who are trapped in want/should
dilemmas. For example, “I really want to drink, but know I shouldn’t.” Or, “I don’t want to attend my
classes, but know I should.” In these cases, patients are in a control struggle, but it is with a harsh part of
themselves that is not well integrated and feels external to who they really are and to what they really
want. There is no way for patients to resolve a want/should dilemma. It feels like endless torment of
continuous self-shaming. In this circumstance, the goal for the therapist is to transform the want/should
dilemma into a want/want dilemma. Patients must come to acknowledge that the “should” represents a
part of them that is concerned about their behavior and wants something better. In this way patients take
ownership for having conflicting desires over the behavior and are in a position to resolve the conflict.
The conflict becomes, “I know there are pros and cons to the behavior, but what do I really want?”
In later stages of treatment, internalizing comments can also be helpful when patients project
shaming and judgmental aspects of themselves onto the person of the therapist. For example, a patient
may assert, “You just think I’m crazy and want to get rid of me.” A good internalizing response would be
to state, “By asking me that I wonder if you are questioning whether you’re crazy and whether you
deserve to be kicked out of treatment? Do you sometimes ask yourself that?” If this intervention is
ineffective and the patient responds with, “No, this is about you not about me,” then the therapist can
apply experiential acceptance and ask, “What is it like to have a therapist who you feel just wants to be
rid of you?” See section on Alterity in this chapter for more information on this technique. A response of
defensive reassurance, such as “You are certainly not crazy and I’m not going to leave you,” would likely
be met with disbelief, mistrust, and need for more reassurance.

2. Integrative Comments or Questions

The next step beyond suggesting alternative or opposing attributions is to bring both poles of the
oppositions into consciousness simultaneously through integrative comments or questions. So, for
example, when a patient is in the angry victim state, his or her spouse may be perceived as horribly
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abusive (see chapter on States of Being). When a patient is in guilty perpetrator state, the same spouse
may be viewed as kind and loving. An integrating comment would point out these two opposing
viewpoints. By becoming aware of one’s divergent and conflicting attributions, an integrated self can
develop. It is important to keep in mind that the two sides of an opposition can be integrated, but not
necessarily resolved. For example, issues of how to balance responsibility between self and other and
how to preserve autonomy in close relationships are inherent aspects of the human experience and can
never be resolved completely satisfactorily. However, opposing attributions move from being split-off
and poorly integrated, to conscious internal conflicts within a whole person.
Integrative comments are very similar to internalizing comments. In both types of intervention,
split-off attributions are brought into consciousness. In the following example, a patient is demonstrating
poorly integrated attributions towards her mother, her favored sister, and her husband:

Patient: I don’t know why I’m so jealous of my sister and am thinking it’s really immature of me. I’m just
thinking I need to get over this because we’re going to the same church, she’s going to be her and I’m
going to be me, and I’m going to need to find my place in this world regardless of my sister and all her
fan club. It’s just that I don’t like the fact people don’t acknowledge all I’ve gone through, but give
sympathy and assistance to her. It makes me mad. At a party my mother was telling me, ‘it’s so awful
what (my sister) went through with her husband, thank God she’s away from him.’ And I was like, “and
thank God I’m away from my husband!” And then she spoke of how my ex-husband is on the worship
team and ‘maybe he’s changed.’ Like my sister’s could never change! I just wanted to deck her.

Therapist: It’s definitely a sensitive spot, because that’s exactly what you are struggling with. Is my
husband just this nice earnest guy who is trying to reform? Is it just my attitude that’s the problem? Do I
have any right to be angry and any value in myself? And so, it’s a very sore spot.

Patient: I think I’m coming to terms with it though.

In the above example, the patient starts out with attributing all agency or responsibility to herself,
i.e. “I’m so jealous….” She quickly moves to the other pole by attributing all agency to others, i.e.
“people don’t acknowledge all I’ve gone through….” The therapist attempts to bring both poles of her
attributions into consciousness with an integrative comment.
Polarized attributions also often manifested in attitudes and behaviors towards the patient-
therapist relationship. Patients may sometimes believe that they are being rejected or victimized by the
therapist, and other times believe that the therapist is their savior. Likewise, they may sometimes wish for
the therapist to tell them what to do and take care of them. Other times, patients might rebel against
therapist recommendations in an effort to assert autonomy.
Among patients with co-occurring alcohol dependence, there are often polarized attributions
regarding self-image related to drinking. For example, there may be polarized self-images of an
omnipotent he-man who can hold his liquor and of a foolish drunk who can’t control his drinking and the
raging consequences of the drinking. Pointing out both sides of patients’ self-attributions in relation to
their drinking allows them to have a more realistic and integrated self-image and to weigh the pros and
cons of their behavior.
The challenges to making effective integrative interventions include recognizing polarized
attributions when they occur and overcoming countertransference reactions. When these challenges are
not met, the therapist often takes one side of the ambivalence thereby allowing the patient to take the
other. For example, when the therapist’s countertransference reaction is a wish to rescue and comfort the
patient, the therapist may make a reassuring and hopeful comment, such as “don’t worry…it will all work
out. You just have to be patient.” Paradoxically, however, such reassuring and hopeful comments are
often perceived by the patient as unempathic. The patient may believe that the therapist does not
understand the depths of his/her despair and will remain stuck feeling hopeless and unlovable. The
patient may be thinking, “I’m glad you think things are so rosy. I wish I did.” Inherent in the successful
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integrating comment is the recognition that the patient must be the one to resolve his/her ambivalence, not
the therapist. In the above example, the patient must resolve that question of whether or not he/she is a
hopeless case. Reassuring comments from the therapist will not magically persuade him/her otherwise.
Integrating comments are often less useful for patients in Stage I who have very poor reflective
functioning. Such patients may have opposing attributions that are so completely polarized that
integrative comments come across as unempathic or critical. The patient then feels misunderstood and
the therapeutic alliance is threatened. In the early stages of treatment, such patients are more likely to
benefit from listening techniques, such as repeating back what the patient has just said in the therapist’s
own words, or from experiential techniques (see sections in this chapter on Ideal Other and Alterity).

3. Proscribed Techniques
The essential error in exploring attributions is for the therapist to seek definite meaning, instead
of opening up new possibilities and tolerating uncertainty and ambivalence. This is an easy error to slip
into since BPD patients have a strong desire for certainty and will push therapists to make black and white
categorizations. For example, a patient might rail against a family member and seek justification from the
therapist for feelings of anger or hostile reactions. The therapist will be tempted to “validate” the
patient’s point of view by acting in the role of judge in deciding who was right and who was wrong in any
given situation. It is important for the therapist to stay neutral in exploring attributions to keep open both
sides of the oppositions (see chapter on the Therapeutic Stance).
Another common error is for therapists to spend an excessive amount of time clarifying
attributions or general patterns of interaction, instead of bringing the level of discourse to specific
interpersonal experiences. BPD patients can spend a great deal of time trying to make sense of their
interactions with other people. They may come up with elaborate but simplistic explanations about
motivations of themselves or others. Such discussions tend to be non-productive and only serve to
reinforce a distorted and stereotyped world-view. Instead of encouraging patients to elaborate their
viewpoints and the reasons behind them, therapists applying DDP need to either open up new meaning by
asking about alternative explanations, or to redirect the conversation to the detailed sequence and
associated affects of specific interpersonal incidents.

III. FACILITATING THE IDEAL OTHER

For in its representation of itself the subject is shattered and opened (Derrida, 1978, p. 65).

A discussion of the importance of the Ideal Other is outlined in the chapter on The Therapeutic
Stance. This stance includes satisfying logocentric needs for certainty and perfect understanding. It also
includes finding balance between competing safety concerns. How are these accomplished?

1. Mirroring – Affective Attunement

As mentioned previously, persons with BPD often are unaware of their feelings. There is a
disconnection between stressor/event, evoked emotion, and subsequent action taken. Instead, stressful
events are likely to create a state of generalized hyperarousal characterized by anxiety, vigilance,
confusion, and/or feeling overwhelmed.
One important technique for helping patients to become aware of their emotions and for
maintaining the soothing functions of the Ideal Other is mirroring. Mirroring is a term first applied by
Lacan (1949) and later modified by Winnicott (1999) to describe the function of the mother in fostering
her infant’s sense of self. According to Winnicott, “the mother is looking at the baby and what she looks
like is related to what she sees there” (p. 112). In other words, the infant finds him/herself by scanning
the mother’s face during interactions with her. If the infant is happy, the smile on the mother’s face tells
the infant that he/she is happy and has been recognized as such.
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Thus, an important function for the mother, and ultimately for therapist as idealized mother, is
empathic attunement. This involves simply questioning patients about their present emotions when they
seem to be displaying some affect, such as tearfulness, that they are unable to verbalize. For example, the
therapist can state, “I notice you seem to be struggling with some emotion right now, can you tell me
what you are experiencing?”
Note that tearfulness is very common among patients with BPD and therapists commonly assume
that tears are an indicator of sadness. However, patients with BPD are often unable to experience genuine
sadness until later in treatment, and tears are more often expressions of anxiety, anger, fear, shame, or
feeling overwhelmed.
Often the most accurate way of gauging the underlying feeling state of the patient is for therapists
to monitor their own countertransference responses. Persons with BPD universally evoke strong
emotions in their therapists at various points in their treatment. Like their patients, however, therapists
are not always aware of what emotion they are experiencing at the moment or why.
As a general rule, the emotional responses of therapists to their BPD patients derive from
unconscious identifications. Thus, very often the therapist and patient may be experiencing the same
emotion. In subtle ways, the patient’s feelings can be transferred onto the person of the therapist. For
example, therapists may find themselves becoming angry, but are not sure why. There has been no direct
provocation and the patient does not appear to be angry. The therapist can explore whether this feeling is
emanating from the patient by stating, for example, “I somehow sense that you might be angry right now.
Are you feeling that way?”

2. Mirroring -- Repeating Back Narrative Connections

Attending to affect-laden interpersonal experiences can help the patient to develop a subjective
sense of self. “When I look I am seen, so I exist” (Winnicott, 1999, p. 114). Patients with BPD often
have difficulty making sequential narrative connections, and when they do, the connection may not be
acknowledged to themselves. For example, a patient may state, “When he said that, I got so mad that I
just left the room.” However, if the therapist then were to ask, “What got you so angry?” it is not
uncommon for the patient to deny having experienced any feelings of anger whatsoever and end up
feeling misunderstood.
Paradoxically, therapists working with BPD patients cannot assume that the patient’s own words
are registering with the patient. A simple technique to help reify experience is to simply repeat back the
narrative sequence that the patient has just stated. This technique not only helps patients feel understood,
but also helps them to acknowledge their experiences. Using the above example, the therapist can state,
“So when he said that, you got angry?” The process of patients linking their experiences into narratives
and having these narratives heard and restated by the Ideal Other (the therapist), allows patients to extend
the range of their subjectivity and to develop a sense of self or being in the world.

3. Mirroring -- Repeating Back Assertions of Positive Self-Attributions

Mirroring responses may support not only a sense of self, but also may build self-esteem for
patients with prominent narcissistic traits. Kohut (1971) used the term mirroring to describe “the gleam
in the mother’s eye, which mirrors the child’s exhibitionistic display” (p.116). With this technique the
therapist acts as a mirror to the patient’s grandiosity, i.e. repeating back the patient’s positive self-
attributions instead of challenging them. Therapists may be reluctant to mirror a grandiose, demeaning,
and entitled patient, but paradoxically, this technique allows the patient to give up his/her grandiosity and
to meaningfully reflect on experiences and attributions. So, for example, if the patient challenges the
therapist’s expertise and goes into a discussion of psychoanalytic theory, a suitable response would be to
state, “I guess you really know a lot about psychodynamics.” This technique is most likely to be helpful
for the angry victim state and can often help to experientially deconstruct that state and move the patient
into a more reflective and engaged stance.
The intervention of mirroring, as defined by Kohut, is closely related to another intervention in
the psychological literature labeled self-affirmation. Self-affirmation seeks to restore self-image after a
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threatening event by helping patients to remember their personal values and priorities. Self-affirmation
has been shown to improve mood and self-esteem (Koole, Smeets, van Knippenberg, & Dijksterhuis,
1999), enhance the mind’s ability to suppress unwanted thoughts (Koole & Knippenberg, 2007), and gain
more realistic perspectives of visual images and social interactions (Whitson & Galinsky, 2008).

4. Framing – Circumscribed Education

The word, framing, in this manual encompasses a need to establish a starting point in therapy, a
location of definite meaning. It is an educative intervention that defines the nature of the treatment,
acceptable behaviors and the patient-therapist relationship. The nature of the treatment encompasses the
goals and tasks of treatment and why it may be helpful for the patient’s condition. It also encompasses
delineation of the three basic safety concerns, the two core conflicts of victim vs. perpetrator and
autonomy vs. dependency, and the central thematic questions.
Because framing is educative, it involves imposing basic meanings and rules for the patient.
Thus it is not a deconstructive intervention that opens up meaning to allow full reign to the patient’s
creative impulses. Instead, framing is a way of setting a boundary for those impulses…a line that cannot
be crossed or a steppingstone to build upon. The artist needs a frame for the painting as well as materials
and a setting in order to begin a creative endeavor. Framing is used primarily in Stage I and feels
containing to overwhelmed, fragmented, and frightened patients. Framing is sometimes used in later
stages as a containment tool when necessary. However, if framing is being used extensively in later
stages, it commonly reflects enactment of therapist urges to rescue in the role of the omniscient parent and
patient wishes to regress to earlier stages, and thus can be counterproductive.
Framing does not incorporate psychoanalytic terms of clarification or interpretation. These
terms are usually defined as interventions that clarify unconscious feelings and relationship patterns so as
to provide insight. In so doing, they necessarily impose the therapist’s construction of meaning onto the
patient. In this manual, those terms were avoided both to de-emphasize the role of insight and also to
delimit the therapist role as conveyer of meaning. In DDP, the therapist shares his/her associations and
potentially useful metaphors and may offer alternative or opposing meanings, but care is taken not to
impose them on patients or to state them with religious conviction.
Common types of framing can be summarized as follows:

 education about the treatment process, including goals and expectations

 education about the respective roles of patient and therapist and why these boundaries are important
 education about the connection between feeling and action, e.g. how unprocessed feelings of anger
can turn into either self-harm or hostility
 description of the core conflicts, stages of recovery, states of being, and the central thematic questions

In the following example, the patient had difficulty responding to an innuendo made by her ex-
husband. Framing is made regarding themes and conflicts in order to create a language and to offer a set
of metaphors for the patient’s experience.

P(atient): My ex saw somebody in church with me and he was like, ‘Who was that, your boyfriend?’ I am
like, ‘No’. And I had wanted to say something to him and I wondered why does it take me so long to
register when it comes to communication?

T(herapist): It was hard to stick up for yourself?

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P: It always has to do with sticking up for myself. Always. That’s where the hole is. That’s where the
missing link is and I get so angry with myself because it comes later. It does eventually come together. I
get it eventually. You know what I mean.

T: Mm hm. It’s a fundamental question for you, “do I have rights?” Do I have a right to exist? Do I
have a right to have my own opinion? Do I have a right not to be abused? Is that something I deserve?

P: Yeah. Then I thought about my court battle with my ex and my mom. This voice just said, ‘what is the
point in calling her since she’s not going to stick up for you?’ And it just added to my anger because I
was thinking of all the times she hasn’t stuck up for me. I was just so angry. I wanted to leave or kill
myself.

T: The question you’re struggling with is ‘Do I have a right to be angry?’

P: Do I have a right to be angry? I know the answer…on some level.

In the above example, the thematic question of “do I have a right to be angry?” dominated the
discourse. Underlying this question is a polarized self-image of victim vs. perpetrator and polarized
wishes for dependency vs. autonomy. Bringing the question into consciousness allowed the patient to
have a framework and to develop a set of metaphors for further exploration.
The most common countertransference feeling driving a framing response is a feeling of
helplessness and the need to rescue or “do something for the patient.” The challenge for the therapist is to
not immediately jump into rescue action in order to relieve his/her own feelings of helplessness. When a
therapist is using multiple framing responses or interpretations within a session, it usually indicates that
the therapist is enacting the role of rescuer. Other such actions within that role can include changing
medications, hospitalization, increasing the frequency of sessions or phone calls, or giving advice or false
reassurance. Many of these interventions may be indicated in a crisis, but the therapist must think
through whether he/she is simply reacting to an uncomfortable feeling or is doing what’s best for the
patient. Raising this question in supervision can be essential to answering this question and deciding
upon an appropriate intervention.
Another situation that frequently provokes inappropriate framing is when the patient shares
idealized or eroticized transference feelings, wishes, or fantasies. The countertransference impulse in this
situation is usually to create distance, sometimes through intellectualization. In this way, the patient is
consciously taking one side of the dependency vs. autonomy opposition, i.e. wish for idealized merger
with the therapist, and the therapist is taking the other side, i.e. wish for distance and autonomy.
Maladaptive but common reactions are for therapists to relieve their own discomfort by either clarifying
boundaries or by defensively explaining them away as part of the transference, i.e. “you don’t really wish
I would move in with you, but instead you actually wish you had a more loving mother.” A better
approach is to empathically explore, accept, tolerate, and contain positive transference feelings.
Boundary clarification should be reserved for situations where positive feelings, wishes, and fantasies
towards the therapist become replaced by actions.
Note that framing does not include supportive psychotherapy interventions of advice, suggestion,
skills training, reassurance, or problem solving. The therapist needs to empathically understand and
accept patient feelings, fantasies, and motivations, without telling them how they should think or act.
Similarly, therapists walk a fine line in exploring and framing patient conflicts and dilemmas, without
suggesting how to resolve them.

5. Proscribed techniques
A danger in adopting the role of the Ideal Other is the difficulty in giving it up. It feels wonderful
to be idealized and to be seen as all-caring, all-knowing, or all-loving and it can be very difficult to
maintain a neutral position between polarized attributions and watch your patient struggle. Therapists as
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Ideal Other cross the line when they begin to assertively attribute a certain motivation, value or emotion
to the patient or others, e.g. “That must have made you angry.” Paradoxically, such comments can come
across as intrusive and unempathic. A danger signal is when therapists find themselves starting sentences
with, “It sounds like…” or “You must have….”
Another proscribed technique is to persuade, encourage, reassure, or advise in response to the
patient’s passivity or hopelessness. These responses cause the therapist to assume a parental role.
Patients have often told me that when their therapist would reassure them, e.g. “Don’t worry, you’ll get
through it,” they end up feeling like their therapist just doesn’t understand them.

IV. ALTERITY – Introducing the Real Other

Only pure absence—not the absence of this or that, but the absence of everything in which all presence is
announced—can inspire (Derrida, 1978, p. 8)

Like many terms, enactment is employed in different ways in the psychoanalytic literature. For
the purposes of this manual, I am defining enactment as patient-therapist interactions that reinforce the
patient’s polarized attributions of self and others. I do not necessarily mean that patient and therapist are
reenacting a traumatic relationship from the past, though this is sometimes the case. Instead, I am
suggesting that enactment reinforces character pathology and the patient’s polarized attribution system.
The opposite of enactment would be a deconstructive experience, i.e. the therapist in the role of
the Real Other interacts with the patient in a way that is inconsistent with the patient’s polarized
attributions. The Real Other represents the other that is not me or not within the subjectivity of the self.
The Ideal Other represents a projection of positive self attributes and the Devalued Other represents a
projection of negative self attributes, but the Real Other is an unreachable reference point beyond the
projections of the self, the absolute outside. It moves the perspective on the self from subjective to
objective and introduces a new relational element, the differentiation of self from other.
In order to prevent enactments and maximize differentiation, it is necessary for the therapist to
pay attention to the process of patient-therapist interactions and to attempt to understand at any given
moment the patient’s expectations for self and other (See chapter on States of Being). It is also necessary
to pay attention to how the patient is defining himself/herself within a given state and what is possibly
being split off from consciousness in order to maintain the self-attributions of that state, e.g. recognition
of maladaptive behaviors. Thus simply checking in about maladaptive behaviors can represent an
intrusion of the Real into the patient’s subjectivity.
Persons with BPD often provoke intensely negative feelings in people with whom they interact.
Others then react to those feelings in ways that end up reifying the patient’s negative expectations. This
kind of negative enactment is a key mechanism for the stereotypical patterns of maladaptive relationships
seen in this population. For example, a patient of mine with strong dependency needs expected others to
be rejecting and abandoning of her, and this was the story of her life. Her typical pattern in a telephone
conversation with a friend or relative was to keep that person on the telephone as long as possible. If the
other person were to delicately hint that it was time to go, the patient would ignore the hint and begin a
new and urgent topic of conversation. Eventually the person on the other line would be forced to be rude
and hang up the telephone, leaving the patient feeling rejected and abandoned yet again. Unconsciously,
the patient had created an enactment, which reinforced her expectations for rejection and the polarized
attributions of self and other that formed the basis for those expectations.
A way to begin to disrupt this relational pattern is to learn to recognize unfolding enactments and
to introduce new, unexpected elements into the relationship. Unfolding enactments may be signaled by
patterns of interaction (such as passivity), relational themes in the patient’s narratives (such as being
misunderstood by others), patient actions (such as missed sessions), or by strongly positive or negative
countertransference reactions accompanied by a compelling urge to intervene in some manner. Thus, a
therapeutic intrusion of the Real that disrupts unfolding enactments requires moment-by-moment
empathic attunement to the patient, as well as self-awareness and acceptance of the therapist’s own
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emotional reactions (Winnicott, 1949). Ultimately, a task of treatment is for patients to be able to
experience a new way of relating, one that is close, but is also respectful, non-destructive, and non-
traumatic. Specific interventions that introduce alterity and support patient individuation and
differentiation are outlined below:

1. Questioning possible negative or mixed feelings towards the therapist, the treatment, or recovery
in response to indicative behaviors or comments
An important intervention to disrupting a negative transference is to check in and openly explore
with the patient what is transpiring here-and-now in the patient-therapist relationship. Exploration of the
transference relationship can sometimes serve to clarify the reasons for deterioration in the relationship.
But, more importantly, it gives an experiential message to the patient that it is okay to bring up
disagreements or criticisms, i.e. the patient does not have to give up his/her own values and opinions in
order to have a relationship with the therapist and is allowed to differentiate from the therapist as a unique
individual.
In Stage I, the patient is primarily concerned with safety within the therapeutic relationship.
During this stage patients are very sensitive to perceived rejection (safety concern #1) and can react with
rage over a seemingly minor off-hand comment made by a therapist. Patients with BPD are unable to
assert themselves in a healthy way, e.g. they are unable to state, “It really hurt and angered me when you
made light of my recent overdose.” Patients are usually very reluctant to acknowledge either to
themselves or to their therapist that they are angry. Instead, they are likely to express outrage indirectly
through actions, i.e. a missed session, tardiness, increased use of profanity, increased cutting, etc., or
alternatively through turning their rage into depression. It is always helpful to ask in these circumstances,
“Was there something I said last session that upset you?”
Missed sessions or tardiness can also be an indicator of ambivalence about the treatment process,
rather than anger or dissatisfaction with the therapist. For example, it may be difficult for patients to
acknowledge certain feelings or conflicting attributions and the patient may wish for simpler solutions,
such as finding the right pill or magic potion that will make everything better. Greater emotional distance
often follows an intense session, particularly if the patient brought up feelings of anger, traumatic
experiences, or denigration of parental figures. This possibility needs to be gently but directly probed. It
is important to keep in mind that in Stage I, patients with BPD are unable to assert themselves in verbally
appropriate ways with the therapist, i.e. they are unable to be close and separate at the same time. So
ambivalence is almost always manifested by actions rather than words. The following intervention
suggests how the therapist can probe the patient’s ambivalence without forcing the patient to directly
express dissatisfaction or criticism:

I’ve noticed you have had difficulty getting to sessions lately. You mentioned it’s been hard to
find rides and sometimes you’ve forgotten. You also mentioned that you have found our sessions
helpful and that you want to come. But sometimes things that we know are good for us can be
difficult or unpleasant. For example, I find myself sometimes forgetting appointments to the
dentist or find that things come up that prevent me from getting there. On the other hand, I
always remember to go the candy store and am always able to get there. And I’m wondering
whether coming here feels more like coming to a dentist’s office or a candy store?

This intervention stays in the middle of the patient’s ambivalence about treatment and allows the
patient to regain a sense of ownership for the treatment. It also disrupts the emerging enactment of the
helpless patient being interrogated by the intrusive therapist.
In Stage II, patients are more directly involved in the process of self-other differentiation,
including challenging the authority of others and questioning their own legitimacy. Are my needs, values,
and opinions legitimate, or must I subjugate myself to conform to the needs, values, and opinions of the
other person in order to maintain a relationship? Characteristically, BPD patients assume that any efforts
towards self-assertiveness will be met with rejection and/or abandonment.
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Of course, this also pertains to the patient-therapist relationship. The therapist as Real Other can
deconstruct those expectations and promote self-other differentiation by being very receptive or even
encouraging to efforts by the patient to disagree with or criticize the therapist. For example, if patients
are discussing how someone is controlling or mistreating them, the therapist can ask, “Do you sometimes
feel that way here?” Sometimes encouraging patient self-assertiveness or differentiation can take a
playful tone, as in the following example, “I’m a bit disappointed that you are saying you are not angry
with me. It will be a sign of progress when the two of us can have an argument and you can leave the
office at the end of the session without worrying about being kicked out of my practice, or without having
to go into depression or punish yourself in some way.”
In Stages III and IV, patients tend to be very ambivalent about the whole recovery process as they
face the realities of moving into an adult role and feel overwhelmed by responsibilities. Mild
ambivalence usually takes the form of the patient stating that he or she doesn’t know what to bring up for
discussion or missing sessions. Stronger ambivalence may be expressed through regression to earlier
modes of functional relatedness and maladaptive coping.
Ambivalence can be addressed in a number of ways. If it seems likely that the ambivalence is a
temporary reaction to a previous discussion of an intense and overwhelming topic, it may be best just to
allow the patient to keep things light, thereby respecting the patient’s need for some space. If the
ambivalence persists, a gentle inquiry about the process is indicated. For example, “You seem to be
having a difficult time engaging in therapy since our session a couple weeks ago. Was there something we
discussed at that session that was upsetting to you?” Or, “You seem reluctant to explore topics in depth
today. Why do you think that is?” If repeated attempts to help the patient verbalize ambivalence are
failing to engage the patient and the patient is frequently missing sessions, more direct confrontation and
containment efforts are needed. The following example indicates how a therapist might address frequent
missed sessions in a later stage of recovery:

I realize that it’s hard to get to sessions with so much going on. On the other hand, with many of
my patients, missing sessions or coming late is often due to mixed feelings towards treatment and
the recovery process. Change is always hard. Becoming more aware of experiences and moving
into an adult role can be difficult and scary. When you first came to me, you were looking for
help with low self-esteem and wanting better relationships. The question is whether you feel you
have achieved those goals sufficiently or whether you would like to continue moving forward. It’s
a matter of weighing pros and cons and only you can make that choice. But being half in and
half out of treatment is the worst of both worlds. It means you still have to endure these difficult
psychotherapy sessions, but aren’t able to get much benefit from them since you don’t come often
enough. Maybe it’s just a bad time in your life to make such a commitment toward recovery. I
can respect that. But if you are unable to make every session on time, then it’s like making a
decision not to be in treatment at all, because I’m not going to be of use to you in meeting your
treatment goals unless we meet for the full time every week. So it’s really up to you and what
makes sense for you at this time in your life. I would like to continue working with you towards
recovery, but I can also respect your choice of holding off treatment at this time.

The therapist as Real Other does not try to reassure or persuade the patient to persevere, instead
the therapist should ask about ambivalence towards recovery, allow the patient to reminisce about simpler
times of being the sick child, be receptive to anger towards the therapist for not doing more to rescue, and
help the patient weigh risks and benefits of moving forward.

2. Experiential acceptance
Experiential acceptance is a key therapeutic technique, especially during Stage I and II of
treatment. If patients are in a very non-reflective state, they may be unable to make use of any other kind
of therapeutic intervention because their level of reflective functioning is so low. Experiential
acceptance serves to deconstruct the angry victim state through paradoxical non-defensiveness in
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response to patient accusations. It can also sometimes help to deconstruct the guilty perpetrator state by
promoting self-other differentiation (see Chapter on States of Being).
In the angry victim state, the patient’s self attribution is the idealized victim and the patient
expects to be humiliated or persecuted by the therapist. This expectation puts the therapist in a precarious
situation. For example, the patient may accuse the therapist of being uncaring and simply wanting to get
rich at the expense of patients who desperately need help. If the therapist denies the accusation in as nice
and caring a voice as he/she can muster, the patient’s doubt, contempt, and suspicion merely increase. On
the other hand, should the therapist try to attack back by making the patient submit to an interpretation,
e.g. “You are projecting your bad object into me so that you can feel all-good and all-powerful,” this will
also often make the situation worse. In response to this interpretation, patients in angry victim state tend
to either become more contemptuous and suspicious, or (if the interpretation is subtle and well-timed) will
“get” the interpretation and go into a state of marked self-condemnation, i.e. the guilty perpetrator state.
Therapists generally feel very good about themselves for moving patients from angry victim to guilty
perpetrator. There is a feeling of omnipotence and elation at their cleverness for having transformed the
patient through interpretation, i.e. the therapist identifies with the patient’s idealized attribution of the
other, but the patient remains just as fragmented.
A better way for the therapist to respond to the patient in the above example is to not challenge
the patient’s attributions directly, either through disavowal or interpretation, but instead to non-
defensively explore them through an experiential acceptance. For example, the therapist can ask, “What
is it like for you to have a therapist who you think just wants your money, and doesn’t give a hoot about
you?” If the patient responds by making another accusation, the therapist should respond with another
experiential acceptance. This response undermines and deconstructs the attributions of the angry victim
state far more effectively than disavowal or interpretation and rapidly moves the patient to a state of
greater reflection and relatedness.
Often patients will not directly criticize the therapist, but instead may be complaining about other
people. The therapist can provide a deconstructive experience by bringing the victimization into the
transference and asking, “Do you sometimes feel that way here?” Even if the response is denied, i.e. “No,
I don’t feel that way about you,” at least the therapist has implicitly given the patient the message that it’s
okay to criticize or disagree and we can still maintain a relationship. Thus regardless of whether the
patient responds in the affirmative, self-other differentiation is supported.
In Stage II patients are trying to answer the central thematic question, “Do I have a right to be
angry?” Although patients will try to sort this out mainly through explorations of current relationships
outside the therapy, at some point patients will try to resolve this question within the therapy relationship.
Commonly, the patient may express dissatisfaction or anger over something the therapist said or did in a
previous session. If the therapist is able to react non-defensively to such a comment and frame it as an
attempt to answer the central thematic Stage II question, the patient receives a deconstructive experience
and gains new perspective and an improved ability to tolerate self-other differentiation.
On the other hand, if the therapist reacts defensively, including denying the validity of the
accusation by providing a reasonable and rational explanation, the patient experiences an enactment of
expectations to be humiliated and invalidated, as if their own perspective cannot be trusted. Patients in
Stage II are likely to suppress feelings of anger or rage at the therapist or direct it onto themselves as the
guilty perpetrator until they suddenly explode over some seemingly trivial matter. This explosion may be
followed by more self-remorse, urges to punish themselves via self-destructive behaviors, and finally
attempts at humble and apologetic reconciliation with the therapist. At this point the therapist can still
salvage the treatment by reviewing the previous events (this time non-defensively with an experiential
acceptance) and framing them as related to the central thematic question, “Do I have a right to be angry?”
The following is an example of experiential acceptance of a patient expressing hopelessness in
the guilty perpetrator state, Stage II. In this state, patients become depressed, hopeless, and/or self-
destructive as a way of avoiding acknowledging anger towards the therapist. Thus they are able to
maintain attachment to the therapist as Ideal Other, but at the expense of their own self-esteem. The
intention of the therapist’s interventions in the following example was to use humor and acceptance of the
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patient’s anger to support self-other differentiation. In this way, the patient no longer would feel that she
had to take total responsibility for problems in the therapy relationship in order to maintain attachment.

P(atient): I feel frustrated with myself. I cut myself again right after we spoke on the telephone.

T(herapist): What frustrated you about that whole situation?

P: About cutting again and what I did to you.

T: You feel you’ve done something to me? What did you do to me?

P: I just feel bad when I inconvenience you by calling.

T: Are you telling me that you felt so frustrated for inconveniencing me that you had to cut yourself for
it? Is that the main thing you’ve done to me is inconvenience me? What else?

P: I guess I just didn’t keep my promise fully not to cut. I feel bad about that.

T: Well I kind of like bad people. You know, I think you really haven’t been bad enough, to be frank. I
think you need to be a little more bad. If anything, you should be angry or frustrated with yourself for not
being bad enough. So you need to think of some other ways you could be bad.

P: I could cut again [laughs].

T: Well that’s just bad to yourself. What bad thing can you do to other people? What can you do to me?

P: I wouldn’t want to do anything bad to you.

T: And I really wouldn’t want you to. But you can fantasize about bad things you could do to me without
actually doing them, like hanging me up by my thumbnails. What else? You need to stretch your
imagination a bit here.

P: I can’t [laughs].

T: Well, that will be your homework assignment then to come up with different bad things you could do
to me. That way you won’t need to feel frustrated with yourself for just making things inconvenient for
me. Inconvenience won’t seem as big after all the other things you’ve done to me in your imagination.

P: But I don’t feel angry with you, I feel frustrated at myself.

T: I think that’s the problem. This discussion really touches on that central question for you. You know,
do you have a right to be angry with me? Are you always to blame? Here I am trying to help you, how
dare you be angry with me? So when things go wrong in our relationship, it creates a big dilemma for
you. Are you to blame or am I?

This session marked a turning point in the patient’s treatment. She became more engaged in
therapy and seemed less stuck in guilt and hopelessness.

3. Experiential challenge in response to passivity or hopelessness

There are times when it is necessary for the therapist to point out recent patient-therapist
interactions in a more confrontational or challenging manner. Like experiential acceptance, the purpose
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of an experiential challenge is to move the patient to a more reflective state. It is a higher risk maneuver
that potentially may lead to enactment, so it should be employed sparingly. A good rule of thumb is
never to use experiential challenge when the therapist is feeling irritated or frustrated with a patient.
Ironically, these are the very times when therapists will be most tempted to use it. For example, when a
patient is constantly complaining about being mistreated by others, it is very tempting for the frustrated
therapist to state, “I’ve noticed that you seem to be able to talk a great deal about others and what they
have been doing to you, but never about what you are trying to do to change yourself. What do you make
of that?” A countertransference feeling of irritation or frustration indicates that the therapist is likely
identifying with attributions of other as perpetrator (see chapter on States of Being). In this context,
“setting limits” or “giving the patient a reality check” enacts patients’ negative expectations and polarized
attributions.
Experiential challenge is most likely to be helpful in situations where the patient is in a non-
reflective state and self-attributions have all the agency. This situation is most common when the patient
is in the demigod perpetrator state or the guilty perpetrator state. When patients are in the guilty
perpetrator state, they present with passivity, depression, and hopelessness. The therapist’s worry is
often about tipping the patient into suicide. The therapist is in the role of ineffective rescuer and feels
trapped by a sense of concern for the patient’s well being while also frustrated by the patient’s passivity
and lack of involvement in recovery. By remaining stuck and helpless, the therapist is enacting the
patient’s attribution of other as being without agency, attributions of self as being irredeemably bad, and
expectations that the patient will overwhelm the rescuing capacities of the therapist. By challenging the
patient’s passivity and by pointing out concrete steps that the patient can undertake for recovery, the
therapist deconstructs the paradigm of victimized rescuer/hopeless case and helps move the patient to a
more reflective stance (see chapter on States of Being – Guilty Perpetrator State for a summary of helpful
interventions). The following is a transcript of a therapist employing experiential challenge for a suicidal
patient in the guilty perpetrator state.

T(herapist): How close have you come to doing something?

P(atient): Not very close, but I think if I had a gun I would do it. It’s not that I could get one, but…

T: You would do it?

P: I think so.

T: Well, then you shouldn’t be in treatment here with me. Our work together is about becoming
integrated and differentiated as a person. Depression is an important part of the work and if you are not
committed to the treatment then you shouldn’t be here.

P: Well, I don’t have a gun.

T: But that’s not making a commitment to keeping yourself safe and I said at the beginning of our
treatment that one of the expectations of therapy is that you keep yourself safe. That means if you have a
gun and feel like shooting yourself, you get yourself to the hospital and get admitted.

P: What are they going to do?

T: They’ll keep you safe.

P: Would you want to live like this?

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T: You have to decide that for yourself. I’m not here to see you into a completed suicide. I’m here if
you’re serious about recovery. In the last few weeks I’ve seen you not working towards recovery, I’ve
seen you much more constricted. And I know you come up with all sorts of reasons as to why you can’t
do it… ‘I’m afraid, I’m this, I’m that.’ You have been going to your group therapy, which is wonderful,
but then you didn’t show up last Friday and are stating you want to attend less frequently. And you know,
you can do that or you can work towards recovery. It’s that simple. You could be bringing in your
dreams; you could be exploring your drinking. There are all sorts of things you could be bringing up.
You are making a decision not to make use of…[interrupted].

P: I’m coming here asking you for help.

T: That’s not the therapy. Remember one thing we talked about was that you have to be an active
participant. The one thing that doesn’t work is for you to sit back and say, “Cure me”.

Experiential challenge may appear to be a strange intervention for someone on the edge of death
and already obsessed with self-loathing. Paradoxically, however, this technique can be lifesaving. By
disrupting the enactment of therapist as ineffective rescuer and pointing out ways that the patient has not
been fully engaged in treatment, experiential challenge instills hope into the recovery process. This
particular patient had a history of severely refractory depression prior to treatment and multiple serious
suicide attempts, including one requiring ICU care. She required many experiential challenges during the
course of treatment, but made no further suicide attempts during this time and did not require
hospitalization. About halfway through treatment, she described feeling relieved from depression and
hopeful about her future for the first time in her life.
Experiential challenge is also useful for patients in the demigod perpetrator state. It can be
employed when patients are hostile, intrusive, or detached in sessions. See section below on Alterity –
Real Other Techniques, Managing Self-Destructive and Maladaptive Behaviors.

4. Proscribed techniques
The difficulty implementing experiential methods is in the timing. Our own unprocessed
countertransference feelings drive us to intervene at the worst possible moments. We are urged to rescue
or reassure at the very time that the patient needs to be challenged and we are urged to challenge or
confront at the very moment when we should be receptive, mirroring, or accepting. Therapists should
therefore attempt to identify and process any feelings they have towards the patient that arise in the course
of therapy to help identify the particular enactment that is developing and the state of being that the
patient is entering. This is most easily accomplished by sharing those feelings with a psychotherapy
supervisor or in a consultation group.
As a general rule, it is not recommended that therapists share their countertransference feelings or
details of their private lives with their patients. These interventions almost always represent an
unconscious enactment whereby therapists unburden themselves of feelings that are too difficult to
contain or accommodate an intrusive patient. In response, patients may feel burdened to take care of the
therapist, feel guilty that they provoked anger, or believe that the therapist is unable to contain their
intrusiveness. In any of these scenarios, the net result is inhibition of creative exploration and the
individuation process (Gill, 1983).

V. MANAGING SELF-DESTRUCTIVE AND MALADAPTIVE BEHAVIORS

The supplement occupies the middle point between total absence and total presence. The play of
substitution fills and marks a determined lack (Derrida, 1997b, p. 157)
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Therapeutic Stance for Behaviors

The most important principle of treatment is to maintain a therapeutic stance that keeps the
conflict within the patient (see chapter on The Therapeutic Stance). Self-destructive or maladaptive
behaviors generate conflict because they are so helpful on the one hand, and yet so shameful on the other
hand. They can elevate mood, reduce distress, and satisfy attachment needs (see Chapter 10). On the
other hand, maladaptive behaviors eventually undermine self-esteem through an inability to control the
behaviors and through negative consequences and personal failures stemming from the continued use of
the behaviors. In order to avoid this conflict, patients will attempt to provoke therapists into taking on
one side or the other.
The most common enactment is a mutual fantasy that the therapist can control the drinking,
cutting, etc. with some sage advice, keen insight, or magic potion. What should be an internal conflict
regarding the behavior, i.e. “Should I drink or shouldn’t I drink?” becomes an external conflict with the
therapist. This conflict can take two forms depending on the patient’s state of being. In an autonomous
state, such as the angry victim state or the demigod perpetrator state, the external conflict becomes, “I
want to drink and would be fine if I didn’t have the therapist on my back all the time about it.” Less
commonly, in a dependent state, such as the helpless victim state or guilty perpetrator state, the external
conflict becomes, “I don’t want to drink anymore, so why doesn’t my therapist do more to help me?” In
both situations, instead of giving advice to cut down the behavior, the therapist should help patients
explore their positive and negative attributions about their behavior so they can develop an internal
conflict about whether to continue it.
Addicts are especially likely to externalize conflict due to enormous shame regarding their
behaviors. This shame is often covered over by a grandiose or entitled manner, but is nevertheless still
present. It is particularly important therefore for the therapist to support self-esteem when addressing
substance misuse. The stance should be completely non-judgmental, neither explicitly approving nor
disapproving of maladaptive behaviors, not encouraging or congratulating patients when they abstain.
Instead, the therapist can empathize with the many negative consequences and suffering that patients are
going through because of them. A non-judgmental stance also helps move the behavior out of the moral
realm and into the medical realm and serves to keep the conflict within the patient.

Association Techniques for Behaviors

Therapeutic interventions for maladaptive and self-destructive behaviors are essentially the same
as for other types of experiences. The therapist attempts to help patients fit their behaviors into narrative
sequences and also helps them to identify their polarized attributions regarding the behaviors. The only
exceptions to this overall treatment strategy are that the therapist must periodically check-in regarding
relapse of the behaviors due to avoidance (see section below) and the therapist must check for whether the
patients are able to keep themselves safe and assess need for hospitalization (see chapter on Special
Situations).
Behaviors can substitute for the “response of other” when helping patients to fit together an RS-
RO sequence (see section on Association in this chapter). For example, the therapist can help the patient
to identify an interpersonal event (e.g. RO of rejection) to a particular emotional reaction (e.g. RS of
shame and anger) to a behavioral response (e.g. RO of cutting) to a subsequent emotional response (e.g.
RS of release of tension, along with shame and fear of loss of control).
Helping patients to fit their maladaptive and self-destructive behaviors into narrative sequences
can be challenging since patients will often experience their relapses as coming “out of the blue”.
Because of aberrant processing of emotional experiences, patients are often unable to recall recent
interpersonal encounters and identify associated feelings. Thus a major task for a therapist is to help
patients to connect specific encounters, events, and emotions with their behavioral relapse. Common
triggers include recent traumatic events, a rejecting response from another person, anticipated rejection,
and transference feelings that emerged in response to a recent session. There may be a strong
concomitant fear of separation or abandonment. The therapist should explore with the patient links
between stressors, feelings, and behaviors.
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Usually patients will attempt to construct simple explanations for their relapses, and these should
not be taken for face value without further exploration. The most common explanation that patients will
provide is that their sudden impulse “came out of the blue.” Other common explanations include, “My
medications aren’t working any more” and “It’s just been a hectic week.” For example, I had a patient
who would repeatedly become suicidal and engage in self-harm when her husband would hit her, but was
consistently unable to connect the two events on her own. She would even neglect to mention the abuse
and didn’t realize the impact it was having. I had to explicitly ask whether her husband had recently hit
her since the patient would not volunteer that information. Helping this patient establish conscious links
between her episodes of suicide ideation and traumatic events eventually motivated the patient to take the
necessary steps to protect herself.
Aspects of maladaptive or self-destructive behaviors that need to be explored include:

1. Context of the behavior/traumatic event. “When exactly did you first notice wanting to self-harm
this week?” “When did it start getting worse again?” “What else was going on?” “Were you
drinking at the time?” “Where were you when it happened?”
2. Antecedents. “What was going on right before you cut?” “What were you feeling at the time?”
“Had anything stressful happened to you that day?”
3. Consequences. “What were you experiencing while you were cutting into your arm?” “What did
you feel afterwards?” “What was the feeling of drinking like for you?” Did something bad
happen to you while you were intoxicated?” “Did you go to the emergency room?”
4. Connections. “Have you had any upsetting experiences this week?” “I notice your mood swings
have been getting worse since the time you say you started drinking again. Is that something you
noticed too?” “Do you think the suicidal thinking that you’ve been experiencing lately is
connected with getting beat up by your boyfriend?” “What was the last session like for you?”
5. Metaphors. Very often self-destructive and maladaptive behaviors can serve as symbolic
substitutes for what is missing in relationships or self-structure, and it is sometimes helpful for
patients to become more aware of this. Some behaviors can promote a sense of autonomy and
control, e.g. food restriction. Others can provide a substitute for the soothing functions of
attachment, e.g. addictions. Still others can sometimes allow the patient to displace feelings of
anger in order to maintain attachment, e.g. cutting and purging. See Chapter 10 on Psychiatric
Comorbidity for a fuller discussion.

Attribution Techniques for Behaviors

The process of exploring a behavior helps patients to fashion words for it and so creates a space
for reflection between the subject and the behavior. The patient is then in a position to reflect on the
meaning of the behavior and to integrate polarized attributions they may have regarding the behavior.
Denial is often integral to self-destructive and maladaptive behaviors. An essential aspect of
denial is a splitting of consciousness. That is, persons who use denial are able to discuss either the
positive aspects or the negative aspects of their behavior, but not both simultaneously. They have
polarized attributions of value towards their behaviors, seeing the behaviors in either idealized or
devalued terms. Thus they are unable to weigh the pros and cons of a behavior in order to make an
informed choice as to whether or not to continue it. A role of the therapist therefore is to help bring both
sides of their polarized attributions of towards the behavior into consciousness. For example, patients
may talk about their drinking as a nasty habit that doesn’t do anything for them, but they just can’t stop.
In this case, the therapist could state, “for you to continue drinking despite all the problems it is causing
you indicates that drinking must do something really terrific for you. Let’s explore the drinking and find
out what it does for you.”
Alternatively, patients may take the other pole of their attributions and only be able to discuss
positive aspects of the behavior, while blaming the negative consequences on other things. For example,
“Pot is the only thing that calms me down when I feel really stressed. It works better than any of the
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medications. The only reason I’m thinking of quitting is that my girlfriend gets on my case about it, but I
don’t want to give it up.” In this situation it is necessary for therapists to bring to consciousness the
negative consequences while trying to maintain balance between the opposing attributions, i.e. to neither
encourage nor discourage the behavior. For example, the therapist can state, “

It sounds as if pot is incredibly helpful for you and you really rely on it to calm things down. On
the other hand, there is research evidence that pot causes memory problems and worsens
disorganized thinking. I notice that every time that you start using it heavily again, your thinking
becomes more disorganized and you forget what we talked about in sessions. So you need to
decide whether continuing to use pot is worth the negative consequences of interfering with
treatment and your relationship with your girlfriend and possibly delaying your recovery. It very
well may be worth it, and if so, you should definitely continue using it. On the other hand, if
you’re sick of the negative consequences and want to move forward in recovery, then we’ll need
to figure out how else you are going to feel soothed when you feel really stressed.

In addition to polarized attributions of value, very often patients will have polarized agency
regarding their behaviors. In other words, they may get very down on themselves for the behavior, e.g. “I
should be able to control this. I’m just a weak person”. Alternatively, they may externalize agency and
blame their behaviors on others, e.g. “I only cut because there’s no one there to support me.” Motivation
for change is also often externalized, e.g. “I’m only going to rehab because my wife wants me to.”
Therapists can help explore and integrate both poles of the patient’s attributions of agency. For example,
“I notice you alternately either blame yourself as having a weakness for drinking or blame it on your
husband.” Another example, “Does it sometimes get confusing as to what you want for yourself and what
others want for you?”
It is most helpful for the therapist to avoid control struggles over maladaptive behaviors by
employing a more non-directive approach, helping the patient weigh risks and benefits. A striking
example of this principle was with a patient who was developing increasing cutting behaviors. She would
often call me prior to cutting, but my exhortations and listing of alternative coping strategies would never
decrease her urge to cut. Finally, I recognized that I might be engaged in an enactment of a mutual
fantasy that I could control her cutting. From another perspective, the patient was avoiding an internal
conflict regarding her cutting by getting into a control struggle with me. The next time she called
complaining of an urge to cut, I stated,

I hear you saying that you don’t want to cut anymore because of the disfigurement and because it
makes you feel like you are crazy. On the other hand, I understand that cutting does great things
for you. It’s able to take away the feeling of guilt through self-punishment like nothing else can.
And I’m beginning to realize that I haven’t been as respectful as I could have been regarding how
important cutting has been to you. In fact, you may decide that cutting is the best solution for
how you’re feeling at this stage of your treatment, and I have to respect that.

This was the gist of a more extended conversation. For once, the patient did not cut immediately
after our conversation. Remarkably, the patient never cut again over the course of our treatment together.

Ideal Other Techniques for Behaviors

The primary component of this set of techniques for managing behaviors is the treatment frame
itself. A clear treatment frame serves to contain problematic behaviors and helps keep them from
disrupting the treatment or from leading to serious harm. It is imperative that at the beginning of
treatment, the therapist makes clear to the patient those behaviors that are acceptable and those that are
not. Behaviors are frequently used to test the limits of the patient-therapist relationship by expressing in
action what cannot be put into words. For example, a patient may test the limits of the therapist’s caring
by losing more and more weight. A test of the therapist’s respect for autonomy may be to tell the
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therapist about a recent drinking binge. Patients may test the ability of the therapist to contain their
neediness by calling more and more frequently. However, if the expectations are clear from the
beginning, patients have less of a need to test the boundaries (see chapter on Establishing the Frame for
instructions on how to set up a clear treatment frame).
The therapist can tailor treatment expectations to the needs of a given patient. For example,
patient with eating disorders should be told at the beginning of treatment to keep their weight above a
certain minimum, to get regular follow-up with a primary care physician, and to allow open
communication between the therapist and physician. Patients who are very needy should be carefully
informed about duration of sessions and limitations on telephone calls. Patients with drinking problems
should be told that they cannot come to sessions intoxicated. Patients with frequent cutting should be told
that they need to agree to go to the emergency room to evaluate their cuts when their therapist
recommends it. Patients with frequent aggression should be told very explicitly about unacceptable
hostile behaviors during sessions. And all patients should be told to keep themselves safe. This includes
patients taking responsibility for getting to an emergency room when they feel they are no longer in
control of their suicidal impulses.
Another important Ideal Other technique for managing behaviors is framing. For managing
behaviors, framing involves providing education about the behaviors based on research evidence or
clinical experience. An example of a framing response regarding benzodiazepines is to state:

Although patients often find benzodiazepines enormously helpful for decreasing anxiety, there is
research evidence that they actually worsen the course of borderline personality disorder and
can prolong recovery. In particular, they can worsen mood swings and increase self-destructive
behaviors. So even though they are incredibly helpful to you, I am not able to prescribe them
because of their harmful effects. I’m kind of stuck with the ethic, ‘First do no harm.’

A similar kind of framing response can be made with heavy drinking. For example, the therapist
can state:

T. From what you are saying, it seems that the drinking helps you feel relaxed when you’re
under a lot of stress. However, I want you to make an informed choice as to whether to
continue it. Because one of the negative aspects of drinking that it has a prolonged
withdrawal syndrome that often worsens symptoms of borderline personality disorder for
1 to 2 days after drinking even relatively modest amounts. And I’ve noticed that pattern
with you as well. You seem to get more depressed and moody for 1 to 2 days almost
every time you drink.
P. But drinking is the only thing that helps me to relax.
T. Yes. It sounds very helpful to you. I just want to let you know that there are negative
consequences in terms of your recovery. It’s up to you to decide whether the positive
aspects outweigh the negative consequences.

Although management of behaviors is a primary concern, management is going to be ineffective

without an adequate therapeutic alliance. Patients with addictive tendencies are especially challenging to
form an alliance with. In addition to the control struggles referred to earlier, a related challenge is that
patients with addictions are often in one of the autonomous states of being, such as the Angry Victim
State or Demigod Perpetrator State, instead of the dependent states (see Chapter 6, States of Being). In
the autonomous states, patients have negative attributions of others and a desire for autonomy. They
avoid getting close to their therapists because of fears of intrusion, control, or humiliation. Moreover,
their substance use serves as both a chemical and symbolic substitute for attachment, so they often are
less driven to bond with their therapists than patients without addictions. Authoritative assertions,
judgments, or directions may be extremely well received by patients in dependent states and even serve to
strengthen the alliance. However, for patients in autonomous states, these interventions cause increased
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anxiety or resentment. Even an overly warm and empathic manner can be perceived by some patients as
cloying and intrusive. It is thus particularly important when engaging with this subgroup of patients for
the therapist to intervene in a non-directive and non-judgmental manner, maintain a highly respectful
stance of patient autonomy, and support self-esteem through mirroring and framing addictions as an
illness.

Alterity – Real Other Techniques for Behaviors

1. Checking. A very important aspect of managing behaviors is to periodically check in with the
patient about these behaviors. There are many times during the course of treatment when patients will not
admit maladaptive behaviors because of underlying shame about them. Typical topics that are avoided
include substance use, traumatic incidents, treatment non-compliance, and self-injurious behaviors. If
these are not directly addressed, they tend to slow down the course of recovery. For instance, a patient
may deal with conflicted feelings towards a friend, relative or therapist by going home and cutting every
night. The self-destructive behavior is never brought up for exploration and the conflicted feelings are
never addressed.
When checking in, the therapist must bear in mind that patients have underlying shame about
each of these topics and so they must be approached in a gentle manner. Because of the shame, patients
may not fully acknowledge the extent of their behavior or the consequences. They also may not mention
the behaviors to the therapist because of expectations of a condemning response from him/her. The
expectation of a condemning response is present because at some level patients have already strongly
condemned themselves for their behaviors.
Any unexpected deterioration in clinical condition should raise cautionary flags about one of
these hidden behaviors. Simply asking the patient about each of these is usually sufficient to bring them
into discussion. For example, the therapist can ask, “Have you been drinking lately?” “When was your
last drink?” For patients with a history of cutting behaviors, the therapist could state, “You seem to have
had a stressful week. Did you end up cutting yourself? Did you want to end your life at the time?”
Because avoidance and denial can be so powerful, therapists should ask about self-destructive and
maladaptive behaviors on a periodic basis and anytime there is deterioration in clinical condition. Once
the behavior is identified, it can then be explored further in a non-judgmental manner.

2. Experiential Acceptance. Experiential acceptance has a circumscribed but important role in

managing maladaptive behaviors and is used for those occasions when the discussion about behaviors
begins to take on a moralistic tone. This is particularly the case with addictions, but can also occur with
cutting and other self-destructive behaviors. Patients have a great deal of shame about their behaviors and
tend to see themselves as morally weak. In their minds, they would be able to quit if they were a strong
and good person. The addicts’ notion of being morally corrupt is reinforced by recollecting all the times
in their life that they lied about their behavior and even stole money to continue it. Even some of the
language used in addictions, e.g. “I’ve been clean 5 months” or “you have a substance abuse problem”,
lends credibility to the moral argument. Someone who abuses drugs is an abuser and, by implication,
abusive.
Therapists and other providers often find themselves adopting a moral tone when talking with
patients about their behaviors. A danger signal is when therapists find themselves using the word
“should”, e.g. “You should really stop drinking.” Such a statement reinforces the patient’s attribution of
self as a naughty child who should be able to control his/her behavior. The statement also reinforces the
patient’s attribution of the other as moralistic and judgmental, and reinforces an expectation of
humiliation.
In general, the more strongly a therapist feels compelled to make a judgmental statement about a
patient’s behavior, the more therapeutic it is to remain neutral, emphasizing both positive and negative
aspects of the behavior. Experiential acceptance deconstructs patients’ pathological attributions and
expectations of humiliation, thereby helping patients to move to a more reflective state where they are
able to be conflicted about their behavior and to engage in treatment.
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3. Experiential Challenge. When problematic behaviors are treatment-related, i.e. either

directed towards the therapist or occur during a psychotherapy session, they need to be dealt with through
experiential challenge. Treatment-related behaviors can be directed either towards self or other and
should be addressed directly and clearly through verbal exploration and/or limit-setting.

a. Challenging self-directed behaviors

Self-directed behaviors during sessions usually involves some kind of cutting or scratching,
though head-banging and other types of behaviors can also occur. Patients are typically in the Guilty
Perpetrator State or Helpless Victim State during these episodes, but occasionally patients in the Demigod
Perpetrator State will test the therapist’s containment abilities in this way (see Chapter 6 on States of
Being).
As a general rule, any self-destructive behaviors occurring during sessions should be strictly
forbidden. They should be framed as hostility directed towards the self and thus a violation of one of the
written treatment expectations, i.e. “no hostile behaviors”. If self-destructive behaviors during sessions
are allowed to continue, they tend to escalate over time as the patient seeks to test how much the therapist
cares and is able to contain. Instead, the therapist should address behaviors promptly as they come up,
e.g. “You can’t do that. Cutting during sessions is not allowed. It’s a form of self-directed hostility and,
as we discussed at the beginning, hostile behaviors during sessions will limit my ability to be helpful to
you.” Patients generally respond very well to this intervention and feel less need for further testing.
Should the behavior continue, however, the therapist should end the session early after assuring that the
patient is not an immediate danger to himself or herself.
After the behavior is contained, the therapist can then explore the behavior in the same way as
he/she would explore behaviors outside of session. The therapist can ask about the emotion associated
with the behavior and attempt to link it to the topic of discussion or thoughts that the patient had had prior
to the incident.

b. Challenging therapist-directed behaviors

Maladaptive behaviors directed towards the therapist can be intrusive, detached, controlling, or
intimidating. Many persons with BPD have difficulty acknowledging feelings of anger, but persons in the
angry victim state or demigod perpetrator state are more likely to express anger or hostility since they
feel totally justified. It is important to distinguish between the two states since the optimal therapist
intervention is going to be very different. Experiential challenge should never be used for patients in the
angry victim state since it will reinforce negative attributions of the other as bad and powerful and an
expectation to be humiliated. The countertransference response to patients in the angry victim state tends
to be irritation or devaluation.
On the other hand, patients in the demigod perpetrator state can be frightening. The patient’s
attribution of others is that they are without agency. Often patients will make subtle twists in the
conversation to reveal what has happened to other people who have crossed their paths. There may also
be a subtly threatening tone of voice or body language, such as where patients position themselves in the
room, intruding into therapist’s personal space or blocking the exit. There may be vague and veiled
threats. The therapist has an overall sense of foreboding and worries of tipping the patient “over the
edge”.
This situation needs to be quickly and directly addressed by the therapist. A fearful or hesitant
response enacts the patient’s attribution of the other as being without agency and will result in escalating
more overt transgressions. Experiential challenge is essential to both maintain safety and to provide a
deconstructive experience. For example, the therapist can state, “When you talk about how you have
harmed other people who have given you a hard time, it kind of implies that if I say the wrong thing you
might become violent. Is that what you’re saying?” If the patient gives any response to that question
with anything but a resounding no, the therapist can follow up with, “I want to be very clear on this
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point…violence or threats of violence are totally unacceptable here. Even an indirect threat of violence is
a form of hostility and will destroy any potential I might have to be of help to you.”
Hostility invariably harms the therapy relationship and the patient’s recovery, and so must be
contained (Bion 1967). Hostility can take many forms, both direct and indirect. Some of these include
use of profanity in session, missed sessions, indirect threats of malpractice lawsuit, multiple telephone
calls at inconvenient times, telling stories of violence towards persons who disappointed them, not paying
bills on time, etc. Of course, there are other reasons for some of these behaviors and these must be
explored before labeling the actions as hostile.
As a prophylactic step towards containment of hostility, it is helpful to set the parameters and the
contingencies of treatment at the beginning. This was more fully discussed in the chapter, Establishing
the Frame. Patients feel less anxious when they know what to expect and what is expected of them.
Likewise, they are less likely to test limits through hostile behavior if they know in advance what the
limits are.
When clear hostility is demonstrated in sessions, the first step is to label it as such. For example,
at the end of a session a patient refused to leave my office until I agreed to have a physical relationship
with her. She also stated that unless I agreed to her demands, she would stay put until security dragged
her out of my office. However, when I labeled her behavior as hostility directed towards me, she
immediately got up from her chair, apologized, and left. The patient later telephoned me concerned that I
would terminate because of her hostility. In the subsequent session we explored the sequence of events
and reactions leading up to the crisis.
It is also helpful for the therapist to provide a framing response clarifying the difference between
anger and hostility. Anger is a feeling and hostility is here defined as a threatening or aggressive action.
The therapist can emphasize that anger is a useful feeling and that it signals something wrong in a
relationship. However, the patient should be told that when anger spills over into hostile action, it is then
universally destructive to the relationship. The patient at that point may need to be reminded of the
written treatment expectations and why those are necessary.
After the hostility has been contained, the therapist should explore the sequence of events leading
up to the hostility. Reasons for hostility vary and depend in large part on the particular stage of treatment
and state of being. Stage-related causes for hostility can include testing of safety concerns in Stage I,
perceived negative responses from the therapist to the thematic questions in Stages II, distancing from
treatment and recovery in Stage III, and fuller realization of the limits of the patient-therapist relationship
in Stage IV.
Beginning therapists are often afraid to directly confront the patient or label hostility, having the
mistaken impression that they are always supposed to be gentle, nice, and “supportive” to patients. Firm
but empathic limit-setting for patients in the demigod perpetrator state can provide a deconstructive
experience by the therapist acting in a way that is inconsistent with the patient’s attribution of the other as
lacking agency, and by promoting the idea within the patient that his/her aggression can be contained.
In one case, after I had provided written treatment expectations and maintained careful boundaries over
several sessions, a patient told me, “You have it too easy here.” She then proceeded to make it really
difficult for me over the next couple months by misusing my prescriptions. When I finally set limits on
the behavior she appeared relieved and increased her engagement in the therapy process. Sometimes
persistent hostility and subsequent limit-setting will necessitate ending the therapy relationship, especially
in Stage I. But this is rare if the limits and expectations for patient behavior are clear from the beginning
and adequate framing and explanation is provided.
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9. PSYCHOTROPIC MEDICATIONS

Every major class of psychotropic medication (i.e. antidepressants, mood stabilizers,

antipsychotics, and anxiolytics) has been tried in the treatment of borderline personality disorder and its
varied manifestations. Each class appears to be partially beneficial for some patients, but almost never is
there a strong and sustained response and it is impossible to predict which patient is going to respond to
which treatment.
A common strategy is to treat the comorbid disorders and symptoms with the corresponding class
of medication (Soloff, 2000). For example, symptoms of depression would be treated with an
antidepressant, paranoia with an antipsychotic, mood lability with a mood stabilizer, etc. However, there
is little evidence to support this strategy (see chapter on Psychiatric Comorbidity). Different classes of
medication appear to have broad and overlapping, albeit modest, benefits. Patients often end up on
multiple psychotropic medications since there is usually multiple Axis I comorbidity and patients tend to
be very reluctant to remove a medication. At best, many patients will describe having some of the edge
taken off of their distress and symptoms, so that they feel less overwhelmed.
More recent meta-analyses have supported modest efficacy of anticonvulsant medications and
antipsychotic medications for treatment of mood symptoms (anxiety, depression, irritability, and mood
reactivity), but have generally found little support for the use of antidepressant medications (Lieb, Vollm,
Rucker, Timmer, & Stoffers, 2010). Anticonvulsant medications demonstrated an additional benefit of
reducing self-harm behavior, that was not demonstrated for antipsychotic medications. However, no class
of medications was found to reduce overall severity of BPD, or to target symptoms of abandonment,
emptiness, identity, or dissociation. Moreover, the quality of medication studies is often marginal, with
low sample sizes, short-term follow-up, small treatment effects, and selective reporting of methods and
results. So psychotherapy is still by far the most effective treatment modality for this disorder.
Many patients prefer benzodiazepines to any other class of medications, stating that it is the only
medication that reduces their anxiety. Even thought they may help with anxiety, benzodiazepines will
worsen behaviors, such as outbursts, assaults, self-harm, and/or suicide attempts, in most patients with
BPD (Cowdry and Gardner, 1988) and may increase the risk of suicide attempts and self-harm in
depressed adolescents (Brent et al., 2009). The mechanism is likely through dampening of cortical
inhibition, thereby deregulating mood and releasing impulsive, self-destructive urges (Deakin, Aitken,
Dowson, Robbins, & Sahakian, 2004). In an effort to first do no harm, benzodiazepines are
contraindicated for patients with BPD. However, often a substantial effort at psychoeducation is required
for patients to understand and agree with this rationale.
Although anticonvulsants, such as lamotrigine, topirimate, and valproate, have modest efficacy
for some of the symptoms of BPD, there are a number of factors that militate against their use for BPD.
Individuals with BPD can be highly impulsive, which impedes their ability to maintain steady blood
levels, increases risk of overdose, and increases risk for unprotected sex. Only lamotrigine and
oxcarbazepine are Category C for risk of fetal abnormalities; topirimate, valproate, and carbamazepine
are Category D. Moreover, carbamazepine, oxcarbazepine, and topiramate can lower levels of birth
control pills, thereby increasing the risk of pregnancy. Furthermore, anticonvulsants may increase suicide
risk, according to FDA analysis, though the evidence for this is not strong. For all these reasons,
anticonvulsants should not be the drugs of first choice for most patients with BPD. If one is going to be
used, the risk/benefit profile of lamotrigine is probably the most favorable.

Suggested Guidelines
 Provide psychoeducation about the limited efficacy of medications, even if co-occurring Axis I
disorders are present; keep expectations low and emphasize the importance of involvement in
DDP, or other evidence-based therapies, as the best hope for recovery.
 Start with a low-dose antipsychotic medication, e.g. 2-10 mg aripiprazole, 25-100 mg of
quetiapine, or 0.5-2 mg of risperidone per day. The dose can be increased if psychotic symptoms,
such as auditory hallucinations or ideas of reference, are present.
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 Use an anticonvulsant medication if intensive self-injury or bipolar I or II disorder is present.

Lamotrigine has the most favorable risk/benefit profile for most patients.
 Try an SNRI or SSRI if a severe major depressive disorder is present, or if there is marked
difficulty with impulsive aggression. Impulsive aggression is a potentially inheritable trait that
has been linked to low serotonin levels in the central nervous system (Kendler et al., 2008).
 Consider naltrexone if there are marked difficulties with impulsive pleasure seeking. Although
there are no trials of naltrexone in BPD populations, this class of medications has been shown to
be helpful for a range of impulsive activities including pathological gambling, binge eating,
kleptomania, and alcohol misuse. Studies using it for self-harming behavior have been mixed.
 Avoid PRN medications since they give patients an implicit message that anytime they are
distressed, they should take a pill or a substance.
 Prescribe no more than three psychotropic medications at any one time to minimize potential for
harmful interactions. For patients who are more impulsive or at higher risk for suicide,
medications should be dispensed in relatively small quantities and medications with greater
potential for lethality should generally be avoided.

Psychological Factors
Medications can have important psychological significance. Many patients hope for a “magic
bullet” that will relieve their distress and explain their suffering. A “chemical imbalance” and medication
cure provide a much easier explanation and solution to their difficulties than going through the anguish of
self-awareness, conflict resolution, and exploration of relationships. Excessive time and effort spent in
sessions finding the best medication shifts the focus from where it needs to be for recovery to progress.
If the therapist has prescribing privileges, medication can also serve the function of a transitional
object. Medication can represent a tangible gift from the therapist and token of caring. Non-compliance
with medication can reflect ambivalence towards the therapist. Often it is the medication prescribed by
the therapist with which the patient chooses to overdose in an unconscious angry and defiant gesture.
As a general rule, if medication management is being discussed every session, regardless of
comorbidity, then there is likely an enactment in the patient-therapist relationship that needs to be
deconstructed. Most often this sort of enactment occurs early in treatment and involves a patient who is
in an extreme state of arousal or dysphoria and there is a shared fantasy that the therapist should be able to
make everything better with a magic potion. In this circumstance, when the patient asks, “Doc, you got to
give me something to help with this anxiety!” the therapist can provide a reframing response, such as:

You are clearly extremely anxious and I can understand you wanting some relief. As we
discussed earlier, however, we know that medications have very limited benefits for persons with
your condition, so the best we are going to achieve is to take the edge off. What can help more
substantially, however, is for you to continue to explore your recent interpersonal experiences,
particularly how you respond to them emotionally. As you start to be able to identify and
acknowledge your emotional responses, you will find your level of anxiety will decrease
substantially. However, it’s a difficult and long-term process, and in the meantime, you are going
to be anxious. The anxiety won’t kill you, but it can be extremely uncomfortable.”

Note that this intervention disrupts the typical medication enactment of the sick helpless child
waiting passively for the powerful therapist to provide a cure. The interpersonal dynamic is now changed
to one of mutual responsibility shared between two adults.
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10. PSYCHIATRIC COMORBIDITY

General Management Considerations

Comorbidity with other Axis I and II disorders is the rule, rather than the exception, for persons
with BPD and sometimes requires minor modifications of the usual treatment frame, depending on the
particular symptom or syndrome (see below). Patients with BPD can sometimes meet the diagnostic
criteria for several Axis I disorders and these disorders appear to be interrelated with BPD. The DSM
system from the third edition onwards has emphasized phenomenology of diagnoses over etiology. This
system has served to enhance diagnostic reliability, sometimes at the expense of validity. Evidence
suggests that the pathophysiology, course, family history, and treatment outcomes of Axis I disorders may
be different for persons with co-occurring BPD. In the co-occurring population, remission of Axis I
disorders is dependent on remission of BPD and not vice versa (Webber et al., 2015, Zanarini et al.,
2004). Moreover, when Axis I conditions co-occur with BPD, they tend not to respond to standard
treatments (Feske et al., 2004). These studies provide strong support for the hypothesis that Axis I
disorders in the presence of BPD, with the possible exceptions of bipolar disorder and schizophrenia,
should be considered as complications of the underlying personality disturbance and that diagnosis and
treatment efforts should primarily be directed towards the BPD instead of co-occurring Axis I symptoms
and syndromes.
Figure 10-1 illustrates common co-occurring symptoms and syndromes. These symptoms and
syndromes often have defensive functions and/or symbolic significance when they occur in persons with
BPD. Many of them are also more likely to occur in a particular state of being and result from deficits in
processing of emotional experience, including intolerance of internal conflict and a need to dissipate
dysphoric affects.
The principal role of the therapist is to help the patient explore the linkages between various
behaviors, triggering emotions, interpersonal experiences, and symbolic meanings. The therapist
generally tries to avoid suggesting a meaning, unless the patient is hyperaroused and fragmented and thus
could benefit from such framing as a containment technique. It is better for the therapist to point out and
raise questions about possible meanings while suspending presuppositions. This facilitates creative
discovery of the self and avoids the intrusive and logocentric role of the therapist as the all-wise conveyer
of meaning.

Figure 10-1. Common associated symptoms and syndromes

• Depression, suicide attempts, self-mutilation

• Bingeing, purging, dietary restriction

• Compulsive cleaning or checking
• Hypochondriasis, phobias, panic attacks, flashbacks
• Pleasure or thrill-seeking impulsive activity or hostility
• Substance misuse

Depression
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Consistent with DDP theory, research findings support the conceptualization of depression in
persons with BPD as a reflexive reaction to separation anxiety (see chapter on States of Being). Three
studies have compared the quality and phenomenology of depression with or without co-occurring BPD
(Rogers et al., 1995; Westen et al., 1992; Wixom, Ludolph, & Westen, 1993). These studies indicated
that when BPD is present, major depressive disorder is accompanied by feelings of emptiness, loneliness,
and longing for attachment figures. These characteristics have a negative correlation to depression
severity in patients without BPD (Westen et al., 1992).
Research suggests that the pathophysiology of major depressive disorder (MDD) may also differ
when it co-occurs with BPD. For example, the sleep EEG of patients with co-occurring BPD and mood
disorders is not usually accompanied by shortened rapid eye movement sleep latency that typically is a
biomarker for mood disorders (Benson, King, Gordon, Silva, & Zarcone, 1990). Likewise, in a study of
50 patients with co-occurring BPD and MDD, only 26% had non-suppression on the dexamethasone
suppression test (Korzekwa, Steiner, Links, & Eppel, 1991).
In addition, treatment studies suggest some differences in MDD when it co-occurs with BPD. A
meta-analysis by Newton-Howes, Tyrer, and Johnson -Howes (2006) indicated that depression was half
as likely to respond to treatment with medications and/or psychotherapy when co-occurring personality
disorders were present. Joyce et al. (2003) reported a poor response to nortriptyline for patients with
MDD and co-occurring BPD. Another study indicated that MDD does not respond to electroconvulsive
therapy when there is co-occurring BPD (Feske et al., 2004). A two-year prospective naturalistic study
reported that MDD accompanied by BPD takes a significantly longer time to achieve remission than
MDD without Axis II (Grilo et al., 2005). In a large epidemiological survey, BPD was a strong
independent predictor of persistence of MDD over 3 years (Skodol et al., 2011). In a 3-year longitudinal
study of 161 persons with BPD, Gunderson and colleagues (2004) reported that improvement in BPD
preceded improvement in MDD, but improvement in MDD did not precede improvement in BPD.
Remission rate from BPD was not affected by presence of co-occurring MDD. The results of longer term
treatment studies suggest that depression gradually improves over a period of years, rather than weeks in
the co-occurring subgroup (Bateman & Fonagy, 1999; Korner, Gerull, Meares, & Stevenson, 2006).
Nevertheless, short-term treatment studies indicate good responsiveness of co-occurring
depression. Hilsenroth and colleagues (2007) reported that a short-term psychodynamic approach with a
focus on emotion and affect-laden interpersonal experiences was highly effective in reducing depression
severity for patients with co-occurring major depressive disorder and BPD, but the time to response was
longer than for patients without co-occurring BPD. Some short-term studies of antidepressant
medications with weekly medication management visits indicate no effect of BPD on treatment response
for patients with major depressive disorder (Mulder, Joyce, Frampton, Luty, & Sullivan, 2006). Alliance
and allegiance effects in the first few months of treatment may account for the discrepant findings.
According to DDP theory, most BPD patients with severe depression are in the guilty perpetrator
state and respond to therapeutic strategies appropriate to that state (see chapter on States of Being).
Antidepressant medication trials should also be pursued, but are unlikely to lead to sustained remission.
Excessive time and effort spent on pharmacological solutions is an error that can often impede recovery
by encouraging a passive patient attitude that waits upon rescue from the therapist.
Self-destructive behaviors, including suicide attempts and self-mutilation, commonly accompany
depression in persons with BPD. They can serve multiple purposes, including a redirection or
displacement of aggression from the other towards the self in order to maintain connectedness in a
conflicted relationship and so avoid separation anxiety. They also serve to mitigate the dysphoria
associated an internal sense of badness through decreasing dissociation and through symbolic atonement
or discharge. In general, the therapist can manage such behaviors through non-judgmental exploration of
associations and attributions (see chapter on Specific Techniques). However, dangerousness must also be
assessed and appropriate actions taken to ensure safety.

Eating Disorders
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Eating disorders often co-occur with BPD and are found in approximately 50% of BPD patients
admitted to psychiatric wards, with binge eating disorder being the most prevalent of these (Zanarini,
Reichman, Frankenburg, Reich, & Fitzmaurice, 2010). Among patients with bulimia or anorexia nervosa,
the rate of BPD is approximately 26% (Sansone, Levitt, & Sansone, 2005). Co-occurrence of BPD is an
important consideration in treatment of eating disorders since BPD has been shown to negatively correlate
with treatment outcome of bulimia (Steiger & Stotland, 1996).
The various symptoms of eating disorders can have magical symbolic significance. For example,
bingeing can serve as a self-soothing activity like substance use (see below). Patients also sometimes
describe it as symbolically representing filling up their emptiness. Purging, by contrast, can sometimes
magically represent a removal of an embedded sense of badness and thus is most often employed when
patients are in the guilty perpetrator state, whereas dietary restriction can serve to maintain a sense of
autonomy and control.
In general, eating disorders can be managed in a similar manner to other self-destructive and
maladaptive behaviors. However, some special modifications apply for anorexia and/or bulimia (also see
chapter on Establishing the Frame). Foremost among these is a close collaborative relationship with a
primary care physician who is familiar with some of the medical complications of this group of disorders.
The patient’s weight, hemoglobin, and electrolytes should be regularly monitored. An electrocardiogram
should be obtained to screen for QT prolongation and arrhythmias. In addition, modifications to the
written treatment expectations may be made to include regular primary care visits and weight or
behavioral parameters that would trigger referral to an inpatient unit or partial hospital. I recommend
relatively short stays at eating disorder units since, in my experience, many facilities have difficulty
recognizing and appropriately managing patients with BPD. Nevertheless, when a patient’s weight falls
below 15% of ideal, not only is there an increased risk of dangerous arrhythmias, but patients can become
more confused, detached, and less able to identify and label emotions in themselves and others, thereby
slowing the recovery process (Oldershaw, Hambrook, Tchanturia, Treasure & Schmidt, 2010).

Anxiety disorders
Anxiety is a nearly universal phenomenon in persons with BPD and is a manifestation of
hyperarousal stemming from aberrant processing of emotional experience through the amygdala. Patients
will usually meet criteria for discrete disorders, most commonly generalized anxiety disorder and
posttraumatic stress disorder, but panic disorder, obsessive compulsive disorder, and phobias also
frequently co-occur. Posttraumatic stress disorder (PTSD) occurs in 60% of inpatients with borderline
personality disorder and in 30% of individuals with BPD in the general population (Pagura et al., 2010;
Zanarini et al., 2004). Obsessive compulsive disorder occurs in about 25% of inpatients with BPD and
co-occurrence is associated with a worse response of OCD to usual treatments (Baer et al., 1992; Hansen,
Vogel, Stiles, & Gotestam, 2007).
In general, anxiety disorders tend to markedly improve using standard DDP interventions without
the therapist having to focus specifically on the anxiety disorders or to add medications. As patients are
increasingly able to process their emotional experiences, levels of arousal come down, usually within 2-3
months of beginning therapy. However, if anxiety is severe and distressing, it is useful to add a one-time
brief modification early in therapy, including teaching relaxation techniques and/or behavioral
desensitization. Because these are more directive interventions, they have the potential to disrupt the
nature of the patient-therapist relationship and must therefore be used sparingly. For example, I save
relaxation training for the last 10 or 15 minutes of a session as I do for medication management, and
introduce it with a caveat that it will only take the edge off the anxiety and that further involvement with
DDP is needed for more definitive symptom control.
In PTSD, persons struggle unsuccessfully to keep traumatic recollections or flashbacks out of
consciousness. There is a battle between one part of the mind or brain connected with the memory
system that is continually pushing the past into the present, and the conscious self that is trying to
suppress it. PTSD in patients with BPD can often exacerbate polarized, split-off attributions of agency
into victim vs. perpetrator. Recollections may be accompanied by a theme of victimization that,
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paradoxically, can provide a sense of meaning and support identity, i.e. “I was victimized, I am a victim.”
Alternatively, recollections may be accompanied by a theme of shame and guilt, i.e. “I got what was
coming to me.” Similarly, PTSD touches on the central thematic question of “do I have a right to be
angry?” and “are my needs legitimate?” Very often the fear of acknowledging their own feelings of anger
and hatred can be transformed by patients into a severe and refractory fear of their perpetrator. In
summary, PTSD can serve to connect people with their past, as well as to reinforce polarized attributions,
resolve the central thematic questions, and to solidify a passive and child-like self-image as innocent
victim or guilty perpetrator.
For patients in Stages I and II, simply facilitating the process of integrating opposing self-
attributions of victim vs. perpetrator through DDP is usually sufficient to manage PTSD symptoms.
Often a framing comment that the patient’s fear of the perpetrator also represents fear of the patient’s own
feelings of anger and hatred is very helpful and makes intuitive sense to most patients with BPD. For
patients with marked social withdrawal, I will also spend a few minutes at the end of a session providing a
framework for their avoidance and suggesting that they desensitize themselves to feared situations by
getting out more in public.
PTSD symptoms can sometimes emerge later in treatment, in Stages III and IV. In these
instances, PTSD often signifies ambivalence towards moving forward into an adult role and an
unconscious wish to regress back to simpler times when self-attributions were clearer and free of
responsibility in the sick role. Sometimes letting go of the recollections of PTSD can feel like letting go
of an essential part of the self and the connectedness with important past relationships (Nadelson, 2005).
Resolving PTSD through DDP in later stages of recovery involves the therapist attempting to bring into
consciousness the patient’s ambivalence about recovery and about moving into often overwhelming adult
roles and responsibilities.

Bipolar Disorder
Manic-like mood and activity can sometimes appear when patients are in the demigod perpetrator
state and needs to be differentiated from bipolar disorder. In the demigod perpetrator state, there is a
sense of euphoria accompanied by idealization of the self. There is a high likelihood of impulsive
activities having a high likelihood for negative consequences, including spending sprees, promiscuity, or
intoxication. During manic-like activity, patients can appear, domineering, threatening or arrogant.
Threatening or hostile behavior can also occur in the angry victim state as patients feel justified in
retaliating for perceived persecution.
Patients with BPD who display manic-like symptoms and activities may meet diagnostic criteria
for bipolar disorder if the period of activity is of sufficient duration. However, diagnosing bipolar
disorder is extremely challenging in borderline patients due to overlap in symptoms. It is quite common
for patients with BPD to be misdiagnosed as having bipolar illness, particularly bipolar II (Zimmerman,
Ruggero, Chelminski, & Young, 2010). Borderline patients have greater mood reactivity than bipolar
patients and tend to describe low moods following negative events and high moods following positive
events. But because of the borderline’s limited range of subjective awareness, they often describe their
mood shifts as coming “out of the blue”. There is also a danger of under-diagnosing bipolar disorder. In
bipolar disorder, the duration of mood shifts lasts longer, mood shifts are more autonomous, impulsivity
is restricted to high mood states, and there is usually a family history of severe mental illness. Impulsive
behaviors of BPD are present in periods of both low mood, as well as high mood states.
A good general treatment guideline is to treat bipolar disorder and borderline personality disorder
fairly independently of one another. Co-occurring bipolar disorder does not appear to affect the course or
prognosis of BPD (Gunderson, 2006) and may benefit from adjunctive treatment with a mood stabilizer.
On the other hand, there is evidence that bipolar disorder may have a different pathophysiology and
treatment course when it co-occurs with BPD. For example, bipolar disorder co-occurring with BPD
responds relatively poorly to mood stabilizers in comparison to bipolar disorder without BPD (Swartz,
Pilkonis, Frank, Proietti, & Scott, 2005). Furthermore, I have had cases where psychotherapy for BPD
led to resolution of bipolar disorder. For example, I previously described a patient with a history of
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postpartum depression and two very clear manic episodes with psychotic features that required
hospitalization (Gregory, 2004). She began a course of DDP and was able eventually to come off all her
psychotropic medications. Seven-year follow-up after discontinuing her medications demonstrated no
recurrence of major depression, psychosis or mania. In summary, the model of independent disorders for
co-occurring BPD and bipolar disorder is a reasonable model for management, but is also insufficient to
explain clinical observations and deserves further research.

Substance Use Disorders

Approximately 50-70% of psychiatric inpatients with BPD also meet diagnostic criteria for
substance use disorders (Dulit, Fyer, Haas, Sullivan, & Frances, 1990; Zanarini et al., 2004; Zanarini et
al., 2011). The prevalence of BPD among patients being treated for drug dependence is variable
depending on the sample. In studies employing structured diagnostic interviews, the prevalence of BPD
has varied from 18-34% in patients receiving treatment for cocaine dependence (Kleinman et al., 1990;
Kranzler, Satel, & Apter, 1994; Marlowe, Kirby, Festinger, Husband, & Platt, 1997) and 5-45% in
patients treated for opiate dependence (Brooner, King, Kidorf, Schmidt, & Bigelow, 1997; Cacciola,
Alterman, Rutherford, McKay, & Mulvaney, 2001; Cacciola, Rutherford, Alterman, McKay, & Snider,
1996; Darke, Ross, Williamson, & Teesson, 2005). The prevalence of BPD among persons in treatment
for alcohol use disorders appears similar to those in treatment for drug dependence, ranging from 16-22%
in samples of patients undergoing detoxification, inpatient or outpatient rehabilitation (Martinez-Raga,
Marshall, Keaney, Ball, & Strang, 2002; Morgenstern, Langenbucher, Labouvie, & Miller, 1997;
Nurnberg, Rifkin, & Doddi, 1993).
There is evidence that co-occuring BPD worsens the outcome of alcohol and drug rehabilitation.
In the study by Marlowe et al. (1997) of cocaine-dependent persons, BPD was the only Axis II disorder
diagnosis that was consistently associated with a negative outcome, including measures of both treatment
compliance and drug abstinence, and this relationship was independent of measures of anxiety,
depression, or initial severity of drug dependence. Cacciola et al. (1996) examined 7-month outcomes of
197 men admitted to a methadone clinic. In that study, BPD had no significant effect on drug use, but
was associated with negative outcomes on other measures, including alcohol use, medical and psychiatric
symptoms, and relationships. Darke et al. (2005) examined the impact of BPD on 12-month outcomes of
495 heroin users treated in a variety of settings. They reported that BPD did not affect remission from
heroin or other drugs, but it was associated with higher levels of needle sharing, worse global
psychological health, and almost four times the rate of attempted suicide.
Two studies have looked specifically at the impact of BPD on the severity or course of alcohol
use disorders. In the retrospective study cited above by Martinez-Raga et al. (2002) patients at a
detoxification program who had BPD or antisocial personality disorder were significantly more likely to
have an unplanned discharge from the facility than those who did not have those personality disorder
diagnoses. In the study by Morgenstern et al. (1997), BPD uniquely predicted multiple measures of
problem drinking, even after controlling for the effects of gender and other Axis I disorders. The
measures included: lifetime severity of alcohol dependence, psychological problems related to drinking,
earlier age of onset of drinking, worse adaptive coping, and suicide ideation. BPD symptoms were
sustained during times of abstinence and were predicted by measures of maladjustment in childhood and
adolescence. These results suggest that persons with BPD represent a distinct subgroup among patients
receiving treatment for alcohol dependence, with unique clinical variables, etiology, and treatment course.
Likewise, studies examining persons treated for BPD have demonstrated that co-occurring
substance use disorders adversely affect outcome on measures of psychopathology. Ryle and Golynkina
(2000) reported that cognitive analytic therapy for BPD was less effective for those patients with co-
occurring alcohol abuse. According to a study by Miller, Abrams, Dulit, and Fyer (1993), BPD
complicated by an alcohol use disorder is associated with unemployment, poor school performance, and
promiscuity, as compared to BPD without a co-occurring alcohol use disorder. A study by van den
Bosch, Verheul, and van den Brink (2001) compared 29 subjects with BPD to 35 subjects who had co-
occurring BPD and substance use disorders. The latter group was found to have greater levels of anxiety,
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antisocial behavior, and suicide attempts. In a large psychological autopsy study of substance-related
suicides, female victims were noted to have high rates of borderline personality disorder (Pirkola et al.,
1999). In a large longitudinal cohort study of 193 borderline patients interviewed 15 years after
residential treatment, co-occurring substance misuse was the single largest predictor of completed suicide
(Stone, 1990). In a prospective study of 290 subjects diagnosed with BPD who had been hospitalized at
McLean, Zanarini et al. (2004) reported that co-occurring substance use disorders strongly and negatively
correlated with remission from BPD at 6-year follow-up. The presence of a substance use disorder had a
greater effect on outcome than the presence of any other co-occurring Axis I disorder, including
posttraumatic stress disorder, bipolar disorder, eating disorders, or major depressive disorder. Similarly, a
7-year prospective study of 88 psychiatric inpatients diagnosed with BPD indicated co-occurrence of
substance use disorders was associated with increased suicide thoughts and behaviors and persistence of
BPD diagnosis at follow-up (Links, Heslegrave, Mitton, Van Reekum, & Patrick, 1995).
DDP posits that persons with co-occurring BPD and substance dependence have strong feelings
of vulnerability in relationships and so tend to remain in the autonomous states of being. In these states
there is a splitting off and denial of the wish for closeness in relationships. Substances serve as a magical
substitute for interpersonal attachment and so help to maintain distance.
This model is supported by animal and human studies indicating that the neural network
underlying the drug reward system of the brain is the same neural network that maintains attachment. In
several animal studies, administration of opioids has been shown to attenuate separation anxiety and this
phenomenon has been linked to the μ-opioid receptor (Nelson & Panksepp, 1998). Moles et al. (2004)
reported that mice who were lacking the μ-opioid receptor gene displayed both reduced reward
dependence to nonopioid drugs of abuse, as well as reduced attachment behaviors towards their mothers.
Studies have also linked benzodiazepines and the benzodiazepines receptor complex to separation anxiety
(Nelson & Panksepp, 1998). Likewise, Macaques monkeys raised apart from their mothers develop
higher levels of ethanol preference (Barr et al., 2004).
Human studies support a common link between the drug reward system and attachment. In large,
prospective studies in Denmark, early weaning from breast-feeding has been associated with the
development of alcoholism in adulthood (Goodwin et al., 1999; Sørensen, Mortensen, Reinisch, &
Mednick, 2006). King-Casas and colleagues (2005) measured neural correlates of trust using functional
magnetic resonance imaging of events in a single-exchange trust game. The authors reported that
intention of trust was mediated through dopaminergic activity within the head of the caudate nucleus, the
same neural region implicated in the drug reward system.
For the most part, co-occurring substance use disorders can be managed with standard DDP
techniques. See chapter on Specific Techniques—Managing Self-Destructive and Maladaptive Behaviors
for a summary of these. Because of the strong autonomy needs of this co-occurring subgroup, it is
particularly important to maintain a non-directive stance and avoid control struggles. For severe addicts,
however, I strongly recommend to them that they be involved in concurrent rehabilitation programs or 12-
step groups.
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11. SPECIAL SITUATIONS

1. Psychiatric Hospitalization
Deciding when to admit a patient to a psychiatric ward is probably the single most vexing
dilemma with which therapists are faced when treating patients with BPD. It is challenging to accurately
assess potential lethality in this population and difficult to determine the best disposition.
Although patients having BPD are at significant risk for completed suicide, the degree of lethality
can be difficult to assess at any point in time. Many patients have chronic suicide ideation (Sansone,
2004). Others have markedly fluctuating mood, and ideation about suicide can vary moment by moment.
Borderline patients with antisocial traits and/or substance use disorders may be at higher risk (Runeson &
Beskow, 1991). For those patients who have substantial dissociative symptoms, there may be split off
aspects of the self that want to die and other parts that want to live. Different parts of the self may come
to the forefront at different times. Self-destructive behaviors can similarly run the gamut from cuts that
are barely visible, to overdoses of a few pills, to behaviors that necessitate care in the ICU or result in
death. Which mood, aspect of the self, or behavior should the therapist pay attention to when determining
need for hospitalization?
It is also challenging to determine the benefits versus risks of hospitalization in any given patient.
BPD is one of the few conditions that can often be made worse by hospitalization (Paris, 2004; Stone,
1993). The hospital is a very regressive environment. All basic necessities are provided and there is little
need for patients to make independent decisions. Staff are always available and potentially can provide
continual warmth and support. In these conditions, patients’ merger and dependency wishes become
strongly activated (Bornstein, Becker-Matero, Winarick, & Reichman, 2010). Similarly, patient fears of
loss of autonomy and rejection/abandonment are heightened. The interactions with staff become more
intense as these wishes and fears translate into attention seeking, control struggles, and efforts to prolong
discharge. Some staff will react with rescue fantasies and will change medications, add diagnoses, or
cross usual patient-staff boundaries. Other staff will react negatively to the patient’s help-seeking
behaviors and patients may make suicide gestures or threats on the unit to demonstrate the legitimacy of
their needs (Main, 1957). When discharge or transfer inevitably ensues, patients can feel rejected,
depressed, confused, and abandoned, and are often at greater risk of completed suicide after
hospitalization than before it.
The other risk of hospitalization is that hospital providers will sometimes recommend a radically
altered formulation and treatment plan to the patient. Often comorbid Axis I disorders become the focus
of inpatient treatment with the implied message, “If only we can find you the right combination of
medication, all your problems will be resolved.” This message can undermine the therapeutic alliance
with the outpatient therapist and discourage patients from facing the arduous task of recovery.
Because of both the difficulty in assessing lethality and the relatively low benefit to risk ratio of
hospitalization, the threshold for hospitalization should be higher for patients with BPD than for those
with other disorders. On the other hand, some patients can benefit from brief stabilization in a hospital
environment. The entire clinical condition needs to be considered when making a decision whether to
hospitalize, including:

 Whether the patient’s overall condition is stable or deteriorating

 Whether there has been a change in the patient’s support system
 Whether there have been unusual or extreme recent stressors
 Whether the therapist has a good working relationship with the inpatient providers
 Whether prior attempts at hospitalization have been generally helpful or harmful
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Therapists need to ask themselves whether it is truly in the best interest of a given patient to
hospitalize him/her, even if the patient is expressing strong suicide ideation. Often it is more helpful to
explore with patients the antecedents of the suicide wishes so that they can process their emotional
experiences instead of seeking immediate discharge of their aroused state through destructive action. If
the patient is in the guilty perpetrator state, an experiential deconstruction may also be indicated (see
chapters on States of Being – Guilty Perpetrator State and Specific Techniques – Alterity).
Early in treatment, complaints about suicide may represent a test of safety concerns for the
patient-therapist relationship. This is particularly true when the patient is refusing hospitalization. So if
the therapist doesn’t involuntarily hospitalize the patient, the patient believes that the therapist doesn’t
really care what happens and feels rejected and abandoned. If the therapist does hospitalize the patient,
the patient feels controlled and manipulated by the therapist. In this situation, the therapist can point out
the conflicting safety concerns and also remind patients of their commitment to keep themselves safe.
When psychiatric hospitalization is employed, it is generally better for it to be of brief duration,
usually less than a week to minimize regression. In my experience, one week is a useful rule of thumb for
when regression is likely to get out of control. It is very important to coordinate care with the inpatient
treatment team, but not for the outpatient therapist to go into the hospital daily to see the patient. This
leads to conflicts and boundary issues between the therapist and staff. If the therapist goes in to visit the
patient, it should be with permission of hospital staff and a one-time brief encounter.
Useful strategies for the inpatient team include minimizing medication interventions, setting the
discharge date at the beginning of the hospitalization, and reversing the usual incentives for discharge.
For most other psychiatric patients with behavioral problems, it is helpful to tell them that they can be
discharged when they are able to demonstrate reasonable judgment and control over their behaviors. For
patients with BPD, however, this strategy gives them the message that they will no longer be cared for
once their behaviors or thoughts of suicide improve. It is generally more helpful to warn borderline
patients about the regressive danger of prolonged hospitalization and potential worsening of symptoms.
Inform them that deteriorating behavior or suicide ideation will be an indication that hospitalization is
starting to have a detrimental effect and that earlier discharge is warranted when these signs appear.
All too often the focus of inpatient care becomes the search for a quick and definitive cure and an
exclusive focus on their comorbid conditions. This frequently involves starting new medications or
radically changing the outpatient treatment plan before consulting with the outpatient therapist. Staff
members sometimes make denigrating comments regarding the outpatient therapist, other staff members,
or the treatment plan. A more helpful focus of inpatient treatment is collaborative consultation with the
patient and outpatient therapist. It is important for the inpatient team to carefully evaluate recent
stressors, maladaptive behaviors, and especially how the patient perceives the outpatient therapist. An
unfolding negative enactment or feelings of rejection and abandonment are common triggers for
hospitalization. There may also be stressors or behaviors that the patient did not share with the therapist.
The inpatient team should also meet with the outpatient therapist, paying careful attention to the
therapist’s countertransference reactions to the patient and to what actually goes on during sessions. Has
the therapist been able to maintain appropriate roles, boundaries, and parameters of treatment? Is there an
enactment within the therapy? Where is the treatment getting stuck? Gentle but direct feedback to the
outpatient therapist regarding these issues can sometimes be critical to overcoming a therapeutic impasse
and facilitating continued recovery after discharge.

2. Severe Dissociation
Most patients with BPD have significant dissociative symptoms and some meet criteria for
dissociative identity disorder. There are times when patients will dissociate within a session. This may
be manifested by episodes of spacing out or blank stares. Alternatively, the patient’s thoughts and
associations may become more disorganized than usual or cut off from affect.
Dissociation is a complex phenomenon with multiple determinants. For example, although
dissociation is most often associated with early childhood abuse, recent drug or alcohol use may increase
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tendencies towards dissociation. The same may be true of certain diseases of the central nervous. Once a
person has a tendency to dissociate, it may be precipitated by anxiety or severe stress, and so may be seen
as a primitive and maladaptive defense against anxiety. Part of the management strategy therefore is to
monitor patients’ level of anxiety and attempt to keep it within a manageable limit so that they can
continue to be reflective and make use of the treatment. This includes avoiding topics early in treatment
that can often trigger overwhelming anxiety, such as childhood trauma, acknowledgment of anger, and
devaluation of parental figures.
There are also interpersonal aspects of dissociation. An anxious and dissociating patient tends to
create a large countertransference response within the therapist of anxiety, helplessness, and a desire to
rescue. Therapists may be tempted to go outside of a therapeutic stance during these times and attempt to
direct, re-focus, or reassure the patient. As the therapist steps out of neutrality in these ways, the conflict
of autonomy vs. dependency is often intensified. The patient feels gratified that the therapist is finally
showing that he/she is genuinely concerned in taking definitive actions to soothe and rescue. At the same
time that dependency wishes are being activated, the patient may be resentful at the loss of control and
vulnerability entailed in dissociation and the therapist taking advantage of that by becoming more
directive. The net result can be increased dissociation and regression to a helpless, confused, child-like
state.
Bearing these factors in mind, it is most important for therapists with dissociating patients to
support the patient’s role as an autonomous decision-making adult, rather than a dissociating and
dependent child. Therapists should control their urges to rescue and reassure, but should instead
encourage exploration of the dissociative phenomena. When did it first start? What were the patient and
therapist talking about at the time it developed? Had the patient taken alcohol or drugs (including
benzodiazepines) the day of the appointment? Framing to provide an explanation for the experience and
to decrease anxiety can also be helpful. As anxiety decreases, dissociation will also decrease. If there is a
repetitive pattern of dissociation within sessions, the therapist should consider an unfolding enactment
and can ask, “What is it like when you dissociate in sessions? Do you feel more vulnerable with me when
that happens? Does it feel like I’m taking your concerns seriously?”
For patients who come to treatment with a pre-established diagnosis of dissociative identity
disorder, the disorder should be framed as a manifestation of a poorly integrated self-structure. Very
often patients with this disorder refer to themselves by the names of their various alters and speak of the
alters as if they are separate persons, e.g. “Sam is angry right now.” Therapists applying DDP should
discourage this behavior, viewing it as regressive, and address patients by their proper name, regardless of
how bizarrely they are behaving. When patients begin to speak about characteristics of their alters as
separate people, as in the above example, the therapist can attempt to reframe the problem and define the
internal lack of integration, e.g. “But, of course, Sam is simply a part of you.”

3. Deterioration in Clinical Condition

Deterioration in clinical condition is often manifested by increased self-destructive behaviors or
maladaptive interactions. As with ambivalence about treatment, it can sometimes follow a difficult
session. Self-destructive behaviors can provide a primitive and maladaptive way to deal with
overwhelming feelings. For example, when a patient acknowledges feeling angry with a parent or a
therapist, he/she may become flooded with shame about having such feelings and worry about rejection
from the therapist. Cutting becomes a means to relieve tension associated with unprocessed emotions, to
atone for the “sin” of anger, thereby alleviating the sense of shame, as well as to maintain the relationship
by re-directing aggression towards the self. A gentle exploration regarding the previous session and
underlying feelings can be extremely helpful. Using the above example one could ask, “What was the
previous session like for you? You had touched upon some difficult topics.”
On the other hand, clinical deterioration may have nothing to do with what was discussed in the
therapy. Often it will follow a traumatic event or perceived rejection by family members. The patient
may be reluctant to share these factors because of shame or anxiety, so the therapist has to be alert to
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them and ask screening questions, e.g. “Was your boyfriend or anyone else violent towards you this past
week?”
Alternatively, even small quantities of alcohol can sometimes trigger worsening depression and
irritability and therapists should routinely ask the patient about recent drinking behavior or drug use when
there is other evidence of fluctuating mood. See chapter on Specific Techniques—Managing Self-
Destructive and Maladaptive Behaviors for a complete discussion of intervention strategies once this
problem is identified.
In later stages of therapy, clinical deterioration most commonly represents regression and an
unconscious wish to return to the sick role. The therapist needs to gently probe this area since patients are
often reluctant to acknowledge to themselves ambivalence towards recovery. Helpful screening questions
include, “What has the treatment been like for you?” “What’s been the hardest aspect of treatment and
recovery?” “Do you sometimes wish that things were back the way they were before you started this
process?” See chapter on Stages of Therapy—Stage III for a more complete discussion of this area and
recommended interventions. In summary, there are many possible causes for clinical deterioration and
the therapist must specifically screen for each of these causes to gain a full understanding and apply the
appropriate treatment interventions.

4. Boundary Intrusions
Boundary intrusions can take many forms, from difficulty leaving the office at the end of the
session, to frequent telephone calls, to seductive or flirtatious behavior, to requests for therapist
disclosure. These behaviors are most common in Stage I and open exploration can strengthen the
treatment alliance. For example, “I notice that it takes us a long time to finish discussions when the
sessions are ending. Do you find it hard to leave here when the time is up?” This inquiry is likely to lead
into discussions regarding unmet dependency needs and the conflict between divergent wishes for
dependency and autonomy.
Frequent telephone calls, letters, e-mails or other indirect efforts to increase time with the
therapist may be dealt with in a similar manner. Exploration of the behavior, however, should be
accompanied by a reminder of the agreed parameters of therapy and why they are essential. For example,
after exploring a patient’s need for more frequent telephone calls, the following framing is helpful:

I understand and agree with you that one hour per week and a couple phone calls doesn’t cut it.
Unfortunately though I have certain limitations in what I’m able to provide without getting
burnout. If I go beyond those limits, I’m not going to be able to be of much help to you as a
therapist. If you are feeling you need more, we should consider adding some other kind of
treatment, such as group therapy.

Flirtatious behavior, chattiness, seduction, or other attempts to engage the therapist in a type of
relationship other than the patient-therapist relationship is one of the more insidious forms of boundary
intrusions. This is most likely to occur when patients are in the helpless victim state or demigod
perpetrator state. Therapists often enjoy the interactions and patients usually deny the behavior when
directly confronted. A gentle exploration of the process is helpful in most situations. For example, “I
notice that the past few sessions you’ve been bringing up a lot of material for discussion, but you also
seem to be having difficulty bringing up more sensitive topics or feelings. Would you agree with that?”
Another difficult area is that of disclosure. Patients often question their therapists’ habits,
interests, and family life. In part, this reflects natural curiosity and a desire for a closer connection.
However, repeated personal questions also are intrusive and threaten patient-therapist boundaries. They
force the therapist into enactments of either rejecting the patient by refusing to disclose or by crossing
boundaries by full disclosure. It is helpful therefore to gently refuse disclosure, reinforce the importance
of boundaries, and explore patients’ feelings and fantasies underlying the questions, as well as their
reaction to the therapist’s refusal to disclose.
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5. Vacations or Absences
Therapist vacations and other absences have a large symbolic significance in the treatment of
BPD. If the treatment is going well, the patient has formed a strong idealizing transference. The
fantasized wish is that the therapist is an all-loving, all-caring, and all-giving parent. Vacations directly
challenge this fantasy. The patient’s unconscious reasoning is, “If the therapist truly cared about me, the
therapist would never leave me knowing how much I need him/her.” Feelings of anger, rejection,
betrayal, deprivation, and even shame may follow. The patient may even make a suicide gesture prior to
departure to show the therapist how much he/she is needed. Other times, the patient may show little
emotion, but develop increased suicide ideation as anger regarding the therapist’s actions is redirected
towards the self. Hospitalization is sometimes indicated during these times.
Process explorations are always indicated before and after vacations, i.e. “what are your thoughts
on the news that I’ll be gone for those two weeks?” “What was it like for you while I was gone?” The
goal is for patients to become more aware of their feelings about the absence, so they can process them
instead of entering into a state of arousal, regression and fragmentation.
For patients who are unable to describe any feelings associated with my pending vacation, but
who have strong dependency needs and self-destructive tendencies, it is helpful for the therapist to make a
negative prediction. Therapists can state, “Even though you are not aware of any feelings about my going
on vacation, I’m going to make a prediction. I think that at some level you have anger about my going
away and that you will turn that anger on yourself rather than acknowledge it to me.” Paradoxically, this
intervention often prevents clinical deterioration for a number of reasons. It offers experiential
acceptance of the patient’s anger. It conveys the message that the therapist understands how difficult the
absence will be. And it gives the patient an incentive to prove the therapist wrong and stay safe.
It is natural also for therapists to have strong feelings about their departing on vacation. There is
usually a mixture of relief, excitement, and guilt. Therapist guilt about vacations or other absences can
sometimes present a major obstacle to useful process exploration. Therapists want to be able to enjoy
vacations without worrying about their patients. They may provide their patients with false reassurances
or try to find someone else willing to see them in their absence (as if someone else could be an equal
substitute). The last thing they want is to encourage their patients to tell them how difficult it is going to
be for them. And yet, paradoxically, this is the key to their patients’ safety and toleration of therapist
absence. If patients can be helped to be made aware of their feelings and also believe that their therapist
understands how difficult it is going to be for them, patients will be much less likely to search for ways to
discharge those feelings. Therapist vacations are often actually helpful and strengthening for patients.
Patients become stronger when they discover that they are able to survive the therapist’s absence, that the
therapist does eventually return, and that the therapist still cares about them.
A similar type of exploration and discussion needs to take place if there is a premature
termination due to the therapist moving to a different region or finding another job. The key again is for
the therapist to be able to tolerate his/her feelings of guilt, empathically listen to the patient’s feelings and
fears about termination, and refrain from giving false assurances.
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12. MEDICAL CARE

1. Somatization
Borderline personality traits are common in patients with somatization disorder, factitious
disorder, or high utilizers of health care. It is easy for enactments of the core conflicts of BPD to get
played out in medical settings. The covert message of the medical setting is, “we only care for you when
you are sick.” Borderline patients may unconsciously or consciously create symptoms of illness in order
to convince health care providers that they are sick enough (i.e. worthwhile enough) to be cared for. The
central question regarding justification, “Are my leads legitimate?” gets played out here. Likewise, safety
concerns are also being tested. In medical settings, BPD patients can present with multiple physical
complaints and excessive demands of physician and nursing time and attention. This neediness can create
numerous altercations with overworked office staff.
Typically, an initial encounter with a primary care physician may be characterized by the
patient’s describing unusual but distressing symptoms. The patient complains that previous physicians
did not adequately evaluate the symptoms. The physician empathically senses the very genuine distress
of the patient and is moved by his/her child-like attributes. Atypical presentations of various syndromes
(e.g. lupus or multiple sclerosis) come to the physician’s mind and a comprehensive work-up is initiated.
The patient senses the empathic response of the physician and idolizes him or her, while denigrating
previous health care providers, consistent with the patient’s polarized attribution system. A typical
comment made to the physician is, “you’re the first doctor who has actually listened to me and taken my
problems seriously.” The physician feels good about the encounter as he or she identifies with the
projected idealization and begins to have fantasies of a heroic rescue via a savvy diagnosis and rapid cure.
The physician notes that visits with this particular patient take an inordinately long time, but feels okay
about this sacrifice since he/she is going to be the doctor that finally finds out what’s wrong with the
patient and institutes a cure.
This honeymoon period between the patient and physician inevitably starts to unravel. As
laboratory tests come back negative, physician hopes for a heroic cure become dimmed and interventions
become more cautious. The patient senses the physician’s withdrawal and begins to exaggerate current
symptoms or come up with new ones in order to regain the nurturing concern of the physician and
reestablish legitimacy. However, the new complaints seem less credible to the physician and he/she
begins to feel duped and made a fool of. The physician starts to resent the length of the visits and his/her
tone of voice is now somewhat abrupt. The patient senses the physician’s withdrawal of concern, feels
rejected, and makes more frantic maladaptive efforts to regain the relationship and demonstrate that
his/her needs are legitimate. This often includes frequent telephone calls, numerous questions, new
distressing symptoms, and even sometimes threats of suicide if nothing more is done to alleviate
symptoms. Soon after this, an angry confrontation between patient and physician ensues and/or a referral
is made for psychiatric treatment. The patient ends up feeling profoundly rejected, abandoned, depressed,
and hopeless, thereby repeating a recurrent pattern of traumatic abandonment. If the patient is in the
angry victim state, he/she can also become hostile. The cycle begins again as the patient seeks a “more
caring and competent” physician.
If the outpatient therapist is not cognizant of these issues, he/she may inadvertently foster the
enactment by sympathizing with the patient over the poor quality of medical treatment received. Often
the therapist steps out of role to try to become an advocate for better care and encourages patient
assertiveness. However, it is generally more helpful for the therapist to try to establish a close and
collaborative relationship with the primary care physician and receive written consent from the patient for
frequent and free communication of concerns. Assisting the primary care physician to understand the
patient’s behaviors can greatly increase empathic bonds between them.
In longitudinal studies, the primary care intervention that has been shown to be most helpful for
somatizing patients is for physicians to subtly shift their behaviors. This includes shifting the focus from
curing symptoms to coping with illness (to allow discussion of psychosocial determinants), withholding
tests and procedures unless there is objective evidence of illness (thereby avoiding iatrogenic harm), keep
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visits and phone calls brief (to minimize burn-out), and to make visits frequent and regular, rather than
contingent on patient symptoms or distress. Decoupling the amount of attention from the amount of
complaints gives patients the message that they do not have to be sick to be cared about.

2. Medical hospitalization
Many of the same concerns and management principles apply when a patient is hospitalized for
medical reasons as for management of somatization. Patients with BPD can feel frightened, alone, and
confused on a medical ward. On the other hand, nursing care and medical attention can increase the pull
towards regression to a child-like state with attention-seeking or demanding and entitled behavior. The
covert message of the medical setting remains the same, i.e. “we only care for you when you are sick.”
Patients with BPD get the message that they must remain sick to stay in the hospital and that greater
symptomatic distress leads to greater engagement with nurses and physicians.
Many of the patient’s regressed behaviors can be irritating to staff. For instance, patients may
misread intentions and become unduly suspicious. On the other hand, because of their high anxiety levels
and regressed dependency wishes, they may frequently call on staff and need continual reassurance. As
staff members begin to respond with irritation, the patient feels rejected or abandoned and then may
regress further. Some patients will start to escalate complaints or behaviors in order to prove to staff the
legitimacy of their concerns.
Hospitalization also plays on patient fears regarding loss of autonomy. There is little sense of
control when staff comes to take blood samples, activity is restricted to bed, and various procedures are
endured, including intrusive interviews and physical examinations. Regressed, hospitalized patients with
BPD sometimes try to regain a sense of control by refusing procedures and demanding changes in
medical regimens.
There are some helpful strategies to prevent escalation of tensions. These include keeping the
hospitalization as brief as possible and providing frequent but regularly scheduled nursing attention,
regardless of how many or few complaints the patient has. Decoupling the amount of empathic attention
from the amount of complaints undermines medical settings’ covert encouragement of the sick role.
Physicians and nurses should explain as clearly as possible the goals of hospitalization and expectations
for patient and staff behavior. Staff should maintain adequate boundaries and interact in a manner that is
neither excessively warm, nor cold and rejecting. Likewise, visits to the patient by the outpatient
therapist should be infrequent and brief while the patient is in the hospital. As much as possible, the
patient should be involved in treatment decisions to foster a sense of autonomy. Collaboration between
the outpatient therapist and the medical team to institute a plan of care can sometimes make all the
difference between a regressive or progressive hospitalization.

3. Medical complications
Patients with BPD usually require more medical care than other persons the same age. Some
common comorbidities include chronic fatigue syndrome, fibromyalgia, temporo-mandibular joint
syndrome, and obesity or obesity-related conditions, i.e. back pain, diabetes, hypertension, osteoarthritis,
or urinary incontinence (Frankenburg & Zanarini, 2004). The co-occurrence of obesity, especially
increasing weight over time, has been found to be an especially poor prognostic factor for BPD, including
symptoms, social and occupational functioning, and healthcare utilization (Frankenburg & Zanarini,
2011).
Those patients having eating disorders, such as bingeing, purging, and/or restricting, have a
special set of medical problems. The electrolyte disturbances, nutritional deficiencies, and hormonal
changes associated with eating disorders can lead to numerous physical problems, which require careful
monitoring. This is best done through close coordination with a primary care physician, even if the
therapist is also a physician (see chapter on Psychiatric Comorbidity). The therapist should not perform
physical examinations, except to assess vital signs. Any form of physical contact between therapists and
patients with BPD in general should be avoided.
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Self-destructive behaviors, such as overdosing and cutting, may also require urgent medical
attention. Any reported overdose is an indication for emergency medical evaluation since patients
sometimes minimize the seriousness of the overdose or underestimate the quantities of pills taken.
Deeper cuts also require emergency medical evaluation for cleansing and suturing in order to prevent
infection and permanent disfigurement or disability. This can sometimes create a control struggle as
patients are frequently reluctant to go to the emergency room to get sutured because they fear getting
committed to inpatient care. Even superficial cuts can sometimes become infected and require medical
attention if they don’t readily heal.
Impulsive behaviors, such as drinking, drug use, or sexual promiscuity, also entail medical risks.
Sexually active patients should be asked about contraception (including barrier protection). Periodic
screening for sexually transmitted diseases may be necessary.
All of these potential problems point to the need for regular follow-up with a primary care
physician. Preferably, this should be someone who is sensitive to psychosocial issues and willing to take
on challenging patients. Coordination of care between primary care physician and therapist is essential
and written consent should be obtained for free communication. It is also helpful to have “obtaining
appropriate medical care” as a component of written treatment expectations (see chapter on Establishing
the Frame).
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13. DEVELOPING A DDP PROGRAM

1. Training Considerations
As alluded to briefly in the preface, DDP can be readily integrated into clinical, training, and
research programs. The techniques are fairly simple and easy to learn for therapists at all levels of
experience. However, it can be difficult for therapists to stay within the treatment frame due to strong
countertransference pulls towards enactments.
There are three levels of proficiency that can be achieved: basic, advanced, and master. In order
to achieve basic competency, the therapist must demonstrate an ability to move a patient from Stage I to
Stage II and successfully apply all the major DDP techniques. Achievement of basic competency
suggests that the therapist is able to apply effective DDP treatment provided the therapist receives on-
going weekly case supervision. This basic level can be attained within 6 months of initiating training for
most therapists. A few therapists will achieve proficiency in a much shorter period of time and a few will
never achieve proficiency for a variety of reasons. These include a strong allegiance to other treatment
paradigms, an inability to tolerate ambiguity or self-awareness, and/or a reluctance to give up
gratifications inherent in idealized therapist roles of sage, prophet, or teacher.
In order to achieve an advanced level of competency, the therapist must demonstrate an ability to
move at least two patients through all four stages of recovery. Achievement of advanced competency
suggests that the therapist is able to independently provide effective DDP, to train other therapists in this
modality, and to certify whether they have achieved basic or advanced competency. The time
commitment for training to this level involves seeing 3-4 patients on a weekly basis over 12-18 months
(since 1 or 2 may drop out), along with weekly case supervision. Thus this level can be achieved as part
of a two-year psychotherapy training program in graduate school or residency, or as a part-time
postgraduate fellowship.
In order to achieve master level competency, the therapist must already be at an advanced level.
In addition, the therapist must have extensive experience practicing DDP after advanced competency
training as well as experience teaching and/or scholarly work involving DDP. A master level therapist is
able to certify other therapists at all three levels of competency.
In addition to reading the manual and/or working through the web-based module, training in DDP
involves on-going weekly individual and/or group case supervision/consultation with an advanced or
master level therapist. Therapists should bring audio or video recordings of sessions to the supervisor to
ensure continued adherence with the treatment approach and to manage countertransference. I
recommend that audio or video recording be a precondition for treatment with this patient population,
particularly during therapist training so as to optimize patient outcomes. At SUNY Upstate’s residency
training program, a webcam video recording system feeds directly onto a dedicated shared drive in a PC.
This is an inexpensive system that provides relatively high quality video and audio and does not require
excessive time or technical expertise for supervisors and trainees.
During clinical supervision sessions, therapists in training take the lead in selecting a particular
case or issue to discuss. Generally these involve situations within sessions that provoke strong
countertransference reactions, such as frustration, helplessness, or fear. The therapist and supervisor then
examine together a segment of video to delineate the dynamics of the interaction and determine whether
there is an unfolding enactment that needs to be deconstructed. The supervisor will suggest whether the
predominant level of intervention for a particular clinical situation should be on associations, attributions,
or alterity and make specific recommendations for technique.
Once therapists begin to develop familiarity and proficiency with techniques, they often benefit
from periodically reviewing the video of a complete session they had with a given patient and
independently rate their own treatment adherence. The DDP Adherence Scale can be used for this
purpose (see Appendix). The supervisor may then independently rate the same session on the scale and
compare results with the trainee. This exercise, albeit time-consuming, greatly helps improve therapist
awareness of patient-therapist process and deepens proficiency with the treatment model.
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Even advanced and master level therapists benefit from periodic consultation with colleagues in
order to maintain an outside perspective and a therapeutic stance. Weekly meetings of group consultation
with other experienced therapists provide a very helpful, enjoyable, and functional model. Although the
treatment techniques are fairly simple and straightforward, maintaining adherence in the face of strong
countertransference reactions can be a major challenge.

2. Clinical Considerations
In addition to establishing a training structure for DDP, treatment effectiveness can be optimized
through developing a system of care that includes an intake protocol, a referral network, and outcome
measures. The clinical program at SUNY Upstate sends out an intake packet to prospective patients that
includes a brief letter, various forms, the patient-rated SCID-II checklist for symptoms of BPD, some
standardized self-rated outcome measures, and an information sheet on BPD. The prospective patient
then meets with a clinical coordinator (not the therapist) to receive structured diagnostic interviews, IQ
testing, and other measures. All testing is then incorporated into a summary sheet and given to therapist
to review with the patient at intake. Self-rated outcome scales are re-administered every 6 months and the
results entered into a clinical database.
The use of standardized self-rated outcome measures entails minimal time and effort and serves a
number of purposes. Firstly, it provides accountability for the treatment program and for the clinicians
providing care. Standardized outcomes allow meaningful quality assurance and monitoring of
effectiveness. This information can also be used to negotiate with insurance companies and government
bodies for appropriate coverage or to meet regulatory requirements. At an individual level, the use of
standardized outcomes can provide useful feedback to clinicians and patients regarding progress towards
treatment goals. Two self-report measures that I have found particularly sensitive to change include the
Beck Depression Inventory (Beck et al. 1961) and the Borderline Evaluation of Severity over Time (Blum
et al. 2002).
Although employment of self-rated measures and a clinical database are useful for clinical and
training purposes and assessing quality assurance, they are inadequate for developing a research program.
It is beyond the scope of this manual to describe all the components of a research program in DDP. But,
in brief, it would require institutional approval, written informed consent, a thoughtful research design,
and a far more comprehensive battery of measures, including a combination of both self-rated and
observer-rated intake, outcome, and process measures. Because of the time-intensive and meticulous
nature of outcome research, it generally requires external funding.
A final consideration in establishing a clinical program in DDP is a referral network. Patients
with BPD generally require multimodal care, often including general medical care, group therapy,
medication management, case management, drug and alcohol rehabilitation, and/or inpatient psychiatric
care. Types of useful adjunctive treatment are discussed in the chapter on Establishing the Frame. The
most important guideline is to keep open lines of communication and to have a close, collaborative
relationship with other clinicians. This includes providing brief education to other providers about the
nature of the patient’s condition and treatment structure and goals. It also necessitates patient release of
information to facilitate free flow of information between providers.
As discussed above there are many essential ingredients to an effective training and/or clinical
program in DDP and developing a program entails considerable effort. However, for those therapists
committed to this population, there are few things in life as gratifying as helping patients on the brink of
despair to discover themselves and transform their lives, and having the opportunity to witness the
personal and professional growth of those training in this treatment model.
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APPENDIX A -- DDP Adherence Scale

Therapist:______________________________ Date:______________________________

Rater: ______________________________ Patient:______________________________

Instructions to rater: Count the number of times that the therapist performs each of these interventions
in a 30 minute interval. Intervals begin from 10 minutes into the session to 40 minutes into the session.

Rating
Associations

1. Asks about the wish/RS that precedes or follows an RO _____

2. Asks about the RO that precedes or follows an RS _____

3. Asks about the RS or RO that precedes or follows maladaptive behaviors _____

4. Clarifies the affect underlying an RS in a narrative _____

5. Clarifies the affects in the patient’s art, poetry, or dreams _____

Subscale Score: _______

Attributions

6. Asks about alternative or opposing attributions of emotion, value, agency, or motivation _____

7. Makes integrative comments or questions regarding patient attributions _____

Subscale Score: _______

Ideal Other

8. Repeats back the patient’s affective RS-RO narrative connections _____

9. Repeats back the patient’s assertions of positive self-attributions _____

10. Recognizes and kindly questions the patient’s emotions in the moment _____

11. Points out the treatment tasks, central thematic questions, core conflicts, or safety concerns _____

Subscale Score: _______

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Rating
Alterity – Real

12. Inquires whether patient participated in recent self-harming behaviors or substance use _____

13. Questions possible negative or mixed feelings towards the therapist, the treatment,
or recovery in response to indicative behaviors or comments _____

14. Receptive comments or questions in response to criticism, disagreement, praise, or desire _____

15. In response to patient’s passivity or hopelessness, therapist points out ways that patient
could decide to be more fully participating in treatment or recovery _____

16. Points out intrusive, controlling, or intimidating behavior/comments towards therapist _____

Subscale Score: _______

Negative Enactment

17. Directs discussion towards experiences in childhood _____

18. Directs discussion towards physical symptoms or medications _____

19. Confidently completes patient narratives for them _____

20. Asserts that a given feeling or action (by self or others) is justified/unjustified _____

21. Assertively attributes a certain motivation, value or emotion to the patient or others _____

22. Persuades, encourages, reassures, or advises in response to passivity or hopelessness _____

23. Provides rationale, denial, apology, or interpretation in response to criticism or disagreement _____

24. Answers patient’s questions about therapist lifestyle or feelings _____

25. Acquiesces to patient’s requests for changing the usual treatment parameters _____

Subscale Score: _______

Adherent (A+A+IO+AR) _______

Total (A+A+IO+AR+E) _______

% ADHERENCE (Adherent/Total X 100) %

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Instructions for Scoring the DDP Adherence Scale

Sessions are scored from minute 10 to minute 40 of the therapy session for a total of 30 minutes.
To score each item, the rater simply places a mark next to an item every time a given intervention
represented by that item occurs within those 30 minutes. The beginning and end of sessions are not scored
since these times may be appropriately used for supportive interventions, such as reviewing symptoms
and medications, assisting with disability forms, or rescheduling appointments.
Sessions may be scored from session transcripts, audiotapes, or videotapes. However, the latter is
preferred so that the rater can determine whether the therapist is attending to signs of emotions, such as
tears or agitation.
Raters should be somewhat familiar with treatment principles and have read the section on
“Specific Techniques” in this book. They should have had some clinical experience in psychotherapy,
but do not have to been supervised in DDP. Training of novice raters should involve repeated attempts to
rate practice videos until a consistently high inter-rater reliability is achieved with an expert rater for at
least 5 different patients.
Therapist interventions fall into one of three categories, i.e. adherent, non-adherent (enactments
that have the potential to worsen pathology), and neither adherent nor non-adherent. The latter category
most commonly includes empathic comments and efforts to clarify patients’ meaning or attributions.
Such interventions are often useful and necessary, but are not one of the core techniques of DDP and are
not rated on the scale.
The first category of adherent interventions is Associations. This category includes interventions
by the therapist that attempt to develop a narrative sequence of a specific interpersonal interaction and
related affects (items 1-3), e.g. “how did you respond after she said that?” or to get patients in touch with
their affective experiences (items 4), e.g. “how did that make you feel?” This category can include
narratives within dreams, e.g. “what were you feeling when the stranger walked closer”(item 5)? It also
includes narrative sequences involving maladaptive or self-destructive behaviors, e.g. “what was going
through your mind just before you cut?” “How did that first drink make you feel” (item 3)?
This category does not include attempts by the therapist to clarify how the patient makes sense of
an interaction, including possible motivations. For example, the questions “why do you think he said
that?” or “why did you do that?” would not be DDP interventions. For the most part, therapist questions
beginning with the word, “why”, are not consistent with DDP principles. In addition, this category does
not include either hypothetical narratives, e.g. “What would you have done if she had hit you?” or
narratives regarding patient-therapist interactions, e.g. “How did you feel when I said that?” This
category also does not include therapist clarification of feelings regarding general patterns of behavior.
For example, the question, “How does it make you feel when he does that?” would not be scored.
The second category of adherent interventions is Attributions. This includes efforts by the
therapist to open up new meaning by asking about alternative or opposing attributions or affects (item 6),
e.g. “Is there a sense of relief in your loss in addition to your sadness?” or “I wonder if you’re actually
more angry at yourself than the other person?” If the therapist is assertively suggesting a new meaning,
e.g. “although you’re blaming the other person, you’re actually more angry at yourself,” it would be rated
as an enactment (item 21).
The Attributions category also includes interventions to integrate opposing attributions (item 7),
e.g. “I notice just now that you went from totally blaming yourself for the accident to totally blaming the
other driver.” Assertive integrative comments are not marked as enactments.
The third category of adherent interventions is fostering the Ideal Other. These interventions
help to decrease anxiety and increase reflective functioning by facilitating an idealized, soothing
transference with the therapist. These include reifying narrative connections (item 8), mirroring
grandiosity (item 9), empathic attunement to patient affect in the here and now (item 9), and educative
comments called framing responses (item 10). Note that framing is limited to the listed types to be
marked as adherent. These include pointing out the goals and tasks of DDP; the central thematic
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questions, e.g. “do I have a right to be angry?”; the core conflicts of victim vs. perpetrator or dependency
vs. autonomy; or pointing out the three safety concerns of the patient-therapist relationship.
The final category of adherent interventions brings in elements of the Real. Most of these
categories involve bringing the discussion to the patient-therapist relationship, but may also involve
checking avoidance about behaviors. For example, checking in with the patient about recent maladaptive
or self-destructive behaviors (item 12), asking whether the patient has mixed feelings about the therapist
or the treatment (item 13), or providing experiential acceptance or challenge when appropriate (items 14-
16).
The Negative Enactment items are clearly non-adherent and count against the overall adherence
score. If the therapist initiates a discussion about childhood experiences (item 17), physical symptoms or
medications (item 18), then these are marked as enactments. However, if the patient initiates these topics
and the therapist continues the discussion by asking further questions, then these items should not be
marked.
For item 19, the therapist completes the narrative sequence or states how the patient presumably
was feeling in response to others’ actions, e.g. “That must have made you feel angry.” This example
could alternatively be marked on item 21.
For item 20, the therapist makes a judgment regarding blame, responsibility, or agency for an
interpersonal episode or a maladaptive behavior, e.g. “He had no right to say that to you” or “Your
parents were just trying to help” or “You should have found a different way to cope with that situation.”
Item 21 represents the largest category of enactment for most therapists we have rated. It
involves taking an extra step beyond clarifying or rewording what the patient has said to the making of
new meaning, i.e. putting words in the patient’s mouth, making authoritative interpretations, or
assertively assigning a meaning or experience. For example, after a patient describes yelling at
somebody, the therapist may be tempted to state, “Sounds like you were feeling angry.” This kind of
enactment can also include asserting a given motivation, e.g. “You wish your mother loved you more”, or
of value, e.g. “Seems like you don’t think much of him.” If the therapist had posed these examples as
questions, they would not be marked as enactments. In general, interventions that begin with the words,
“sounds like”, “you must have”, or “seems like” are likely to be enactments. Exceptions to this general
rule are if the therapist is essentially restating what the patient just said, is making an integrative
comment, is providing a framing intervention, or is attempting to be receptive to criticism, e.g. “You must
feel disappointed in having a therapist who doesn’t fully understand you.” The latter comment would
best fit under item 14.
Directive or supportive interventions can be enactments of a parental therapist with a childlike
and helpless patient, and certain types of these interventions are prohibited in DDP (item 22). Examples
include, “Perhaps it would be better for you to cool down before confronting your wife.” Or, “Don’t
worry, things will get better if you just hang in there.”
Item 23 is marked when therapists make defensive comments that absolve them of responsibility
in response to patient criticism or disagreement. This can include a rational explanation in response to
seemingly unjust attacks by the patient. For example, if the patient states, “You never listen to me,” item
23 is marked if the therapist responds; “I can understand how it seems that way when you’re upset.”
Items 24 and 25 represent difficulties with patient-therapist boundaries. For both items, the
therapist displays an inability to set limits on the patient’s controlling or intrusive behavior.
In order to calculate overall therapist adherence, each of the marked responses on items 1-16 are
summed and the total is put in the space labeled Adherent. Then this number is added to the sum of the
marks on items 17-25 and put in the space labeled Total. To be valid for scoring, the interview should
have at least 10 interventions in Total. To obtain the percentage of adherent interventions, the number of
Adherent interventions is divided by the Total number of interventions and multiplied by 100. This
number is placed in the space labeled % ADHERENCE, and is used in estimating therapist adherence to
DDP methods and technique.
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APPENDIX B – Upstate Borderline Questionnaire (UBQ) – © Robert Gregory v.6.1.13

INSTRUCTIONS
Circle “YES” or “NO” if the question completely or mostly applies to you. If you do not
understand a question, leave it blank.

In the PAST YEAR:

1. Have you often become so preoccupied with fears of abandonment or separation from important
people in your life that it’s been hard to think about or do anything else?
NO YES

2. Have you often found with people you are getting to know, that they seem at first like the most
special and understanding person you have ever met, but then later they do something to
disappoint you?
NO YES

3. Have you often wondered who you really are as a person, or noticed that you seem like a different
person around different people?
NO YES

4. Have you often done the following activities? (circle all that apply)
1. Spent a lot of money on things that you later regretted? NO YES
2. Driven a vehicle well over the speed limit? NO YES
3. Had 5 or more drinks containing alcohol, or used drugs to get high? NO YES
4. Binged on food? NO YES
5. Had sex with someone you hardly knew? NO YES

5. On at least two occasions, have you tried to hurt yourself or kill yourself (e.g. choking, cutting,
burning, overdose, etc.) or threatened to do so?
NO YES

6. Have you often had mood swings or noticed that your mood can suddenly shift from happy or
angry to depressed, and then back again?
NO YES

7. Have you usually felt empty inside?

NO YES

8. Have you often had anger outbursts, during which you say things or do things that you later
regret?
NO YES

9. At times when you have been stressed, did you ever develop any of the following reactions?
(Circle all that apply)
 Become very suspicious of people around you? NO YES
 Feel detached from what is going on around you, as if it isn’t real? NO YES
 Feel disconnected from your body or as if you are floating above it? NO YES
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Scoring Instructions (for therapist)

Each of the nine items matches the DSM-V criteria for borderline personality disorder. Thus the
range of possible scores on the UBQ is 0 to 9. In order to score item 4 as positive, the patient
must endorse at least two of the five questions under that item. In order to score item 9 as
positive, the patient must endorse at least one of the three questions under that item. If there is a
positive score of at least 5 of a possible 9, the patient can be said to have borderline personality
traits and is likely to be a candidate for DDP. In an unpublished study, a score of six or greater
has a positive predictive value of 90% for borderline personality disorder. In other words,
patients who score six or greater on this questionnaire are very likely to meet DSM diagnostic
criteria for borderline personality disorder.
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APPENDIX C – Upstate Behavior Inventory-9 v. 1.1.14 © Robert Gregory

In the PAST 30 DAYS: (for each item, please fill in the number of days)

How many days did you spend in the emergency room or CPEP? ____

How many days did you spend on a psychiatric hospital ward? ____

How many days were you paid for working (employment)? ____

How many days did you go on eating binges during which

you ate so much that you felt uncomfortably full? ____

How many days did you force yourself to vomit, exercise excessively,
use laxatives, or go on strict diets? ____

How many days did you try to harm yourself by cutting, puncturing,
burning, overdose, or smothering? ____

How many days did you physically harm or threaten to harm another person? ____

How many days did you have 5 or more drinks containing alcohol (wine, beer, liquor, etc.)? ____

How many days did you use an illegal drug or use

a prescription medication for nonmedical reasons? ____
118
 119

APPENDIX D – Daily Connection Sheet v. 3.1.14 © Robert Gregory

Interaction: For each day of the week, briefly describe a specific interaction you had with another
person that day. Choose the single interaction that caused you to have the strongest reaction, either
positive or negative, regardless of the time of day. As time permits, elaborate on this interaction in a
journal.

Specific emotions: Rate each of the emotions that you had during that interaction from 0 (emotion did
not occur) to 4 (very strong emotional reaction). Also, list any other emotions (see back of sheet).

Specific emotions
Interaction Shame Relief Fear Anger Other
Day 0-4 0-4 0-4 0-4 (list)

Mon

Tue

Wed

Thu

Fri

Sat

Sun
 120

Emotions List

Accepted Honored Abandoned Humiliated

Affectionate Hopeful Afraid Hurt
Alive Humorous Alone Impatient
Amused Interested Angry Inadequate
Attractive Joyful Annoyed Incompetent
Beautiful Lovable Apprehensive Indebted
Blameless Loving Ashamed Indecisive
Brave Loyal Betrayed Inferior
Calm Passionate Bitter Inhibited
Capable Peaceful Blamed Insecure
Caring Playful Contempt Intruded
Cheerful Pleased Defeated Irresponsible
Cherished Powerful Dependent Irritated
Comfortable Proud Despairing Jealous
Comforted Quiet Desperate Let down
Competent Relaxed Disappointed Lonely
Concerned Relieved Disbelief Mad
Confident Respected Discouraged Misunderstood
Content Safe Disgust Needy
Courageous Satisfied Distrust Rage
Curious Secure Embarrassed Rejected
Delighted Self-reliant Empty Responsible
Desirable Sexy Exasperated Sad
Eager Silly Evil Scared
Excited Special Fearful Sleazy
Flattered Strong Foolish Sorry
Forgiving Supportive Frantic Touchy
Friendly Surprised Frustrated Trapped
Fulfilled Sympathetic Furious Ugly
Generous Tender Guilty Unappreciated
Glad Trusted Hateful Uncertain
Good Trusting Helpless Unfulfilled
Grateful Understood Hesitant Unsafe
Great Warm Hopeless Worried
Happy Welcomed Horrified Worthless
 121

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