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A manual-based psychodynamic therapy for treatment-resistant

borderline personality disorder

Article in Psychotherapy Theory Research Practice Training · March 2008

DOI: 10.1037/0033-3204.45.1.15 · Source: PubMed

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Psychotherapy: Theory, Research, Practice, Training Copyright 2008 by the American Psychological Association
2008, Vol. 45, No. 1, 15–27 0033-3204/08/$12.00 DOI: 10.1037/0033-3204.45.1.15

A MANUAL-BASED PSYCHODYNAMIC THERAPY FOR

TREATMENT-RESISTANT BORDERLINE PERSONALITY
DISORDER

ROBERT J. GREGORY AND ANNA L. REMEN

SUNY Upstate Medical University
The authors introduce a manual-based for borderline personality disorder (BPD). Dy-
treatment, labeled dynamic deconstructive namic deconstructive psychotherapy (DDP) was
psychotherapy, developed for those pa- developed for those patients with borderline per-
sonality disorder (BPD) who are likely to be
tients with borderline personality disor- treatment resistant and to have a worse prognosis,
der who are most difficult to engage including those having co-occurring substance
in therapy, such as those having co- use disorders. The second paper in the series
occurring substance use disorders. This provides 1-year efficacy data of DDP for patients
treatment model is based on the hypothe- with co-occurring BPD and alcohol use disorders
(Gregory et al., in press).
sis that borderline pathology and related Borderline personality disorder (BPD) is a
behaviors reflect impairment in specific common and severe condition with substantial
neurocognitive functions, including asso- morbidity and mortality. BPD has a point preva-
ciation, attribution, and alterity that form lence of 1% to 2% in the general population
the basis for a coherent and differenti- (Lenzenweger, Lane, Loranger, & Kessler, 2007;
ated self. Dynamic deconstructive psycho- Torgersen, Kringlen, & Cramer, 2001), but the
rate climbs to 10% to 20% in mental health
therapy aims to activate and remediate treatment settings (Widiger & Weissman, 1991).
neurocognitive self-capacities by facilitat- BPD is manifested by a wide array of symp-
ing elaboration of affect-laden interper- toms and is associated with significant functional
sonal experiences and integration of at- impairment (Skodol et al., 2002) and mortality
tributions, as well as providing novel rates approaching 10% in long-range naturalistic
studies (Paris, 2003). A central conundrum is how
experiences in the patient-therapist rela- to account for its extraordinarily diverse manifes-
tionship that promote self-other differenti- tations, including disturbances in mood, anxiety,
ation. Treatment involves weekly individ- perception, self-image, behavior, and interper-
ual sessions for a predetermined period sonal relationships (American Psychiatric Asso-
of time and follows sequential stages. ciation, 1994), within standard diagnostic catego-
ries. Broader metaphors of self or identity have
been employed to explain the multifaceted as-
Keywords: psychodynamic, borderline pects of BPD.
personality disorder, psychotherapy, Neuroimaging studies have demonstrated that
deconstruction, personality BPD is associated with metabolic dysfunction and/or
atrophy of multiple areas of the brain, including
the hippocampus, amygdala, anterior cingulate
This paper is the first in a two-part series that gyrus, and prefrontal regions (Lieb, Zanarini,
introduces a manual-based individual treatment Schmah, Linehan, & Bohus, 2004). The large
number of affected regions having diverse func-
tions, including memory, arousal, emotion pro-
Robert J. Gregory and Anna L. Remen, SUNY Upstate
Medical University.
cessing, attributions, and decision-making, sug-
Correspondence concerning this article should be ad- gests widespread impairments in neurocognitive
dressed to Robert J. Gregory, Department of Psychology, capacities that potentially impact self-structure.
SUNY Upstate Medical University, 750 East Adams Street, The authors propose that persons with BPD
Syracuse, NY 13210. E-mail: gregoryr@[Link] have deficits in three areas of neurocognitive

15
Gregory and Remen

functioning that form essential building blocks of co-occurring alcohol use disorder was not a sig-
a coherent and differentiated self-structure. These nificant determinant of improvement in psycho-
include the ability to form associations between pathology (van den Bosch, Verheul, Schippers, &
different aspects of affective experience, to pro- van den Brink, 2002). However, trials of DBT in
vide integrated attributions to these experiences, drug dependent populations (Linehan et al., 1999,
and to assess the accuracy of those attributions in 2002) have shown less robust treatment effects
an objective way. The three functions could be and higher dropout rates than trials of DBT that
summarized as association, attribution, and alter- excluded drug dependent patients.
ity. DDP aims to repeatedly activate these neu- DDP was developed for those more challeng-
rocognitive functions so as to facilitate the devel- ing patients with BPD, including those with co-
opment of an integrated and differentiated self. occurring substance use disorders and/or antiso-
Several other manual-based treatment models cial personality disorder. The term deconstructive
have been developed over the past 10 to 15 years. underlines a particular emphasis and perspective
Some of these include dialectical behavior therapy in the treatment representing a confluence be-
(DBT; Linehan, 1993), schema therapy (Kellogg & tween deconstruction theory and a subset of psy-
Young, 2006), cognitive analytic therapy (Ryle, choanalytic theory and technique, rather than a
1997), mentalization-based treatment (MBT; Bate- fundamental departure from accepted practices.
man & Fonagy, 2004), and transference-focused For example, the nonjudgmental and nondirective
psychotherapy (TFP; Clarkin, Yeomans, & Kern- exploratory stance of psychoanalysis is consistent
berg, 2006). The first two of these treatment models with Derrida’s definition of deconstruction as
are ostensibly labeled as cognitive– behavioral ther- “openness to the other” (Derrida, 2004, p.155).
apies, the last two as psychodynamic therapies, and Openness to the other suggests deferral of as-
cognitive analytic therapy as a blended approach. sured meaning and anticipation that new possi-
Cognitive– behavioral therapies of BPD tend to bilities will emerge during the course of treat-
be more structured and didactic, and emphasize ment that may challenge presuppositions of both
learning new coping skills and problem-solving the patient and the therapist.
strategies. On the other hand, psychodynamic ther- This paper begins by describing each of the
apies, including DDP, emphasize the development three neurocognitive functions of association, at-
of increased self-awareness through exploration of tribution, and alterity, outlining specific tech-
affect-laden interpersonal experiences and the here- niques to address them, and discussing how im-
and-now of the patient-therapist relationship. pairment in these functions contributes to the
However, there is considerable overlap between development of problematic behaviors, such as
approaches and differences are often more of substance misuse. It then summarizes the treat-
emphasis than absolutes. For example, all of these ment structure of DDP, stages of change, hypoth-
models include a structured treatment plan, identify esized mutative mechanisms, and directions for
and address maladaptive attributions and patterns of further research. The authors do not expect clini-
relatedness, and incorporate some degree of psy- cians to be able to implement the treatment after
choeducation, either implicitly or explicitly. reading this brief summary, but hope that the
Each of the treatment modalities listed above paper provides a fresh perspective on a complex
has gained empirical support through clinical tri- problem and a stimulus for new investigations.
als, especially DBT, which has demonstrated ef-
ficacy in multiple controlled trials across differ- Association
ent centers. Many of the treatment models,
however, have specifically excluded more chal- One step in generating meaning and a coherent
lenging patients from their trials, especially those sense of self is to develop the capacity to describe
with co-occurring antisocial personality disorder experiences in terms of language, metaphor, and
or substance use disorders. Treatment trials that other symbols, what Bucci (2002) has labeled as
have included these populations have had mixed moving from the subsymbolic to the symbolic
results. Ryle and Golynkina (2000) reported that level of experience. Persons with BPD often have
cognitive analytic therapy for BPD was less ef- a rich ability to employ language, metaphor, and
fective for those patients with co-occurring alco- visual symbols through poetry and art, but have
hol abuse. A post hoc analysis of a randomized difficulty consciously linking words and other
trial of DBT revealed that the presence of a symbols to their affective, bodily, or relational

16
 Psychodynamic Therapy for BPD

experiences. For example, they may have diffi- within a narrative and to clarify the associated
culty identifying, acknowledging, and describing affects. The following vignette is a segment of a
the specific affect associated with an interper- session transcript of a college student with BPD
sonal interaction (Levine, Marziali, & Hood, and alcohol abuse that illustrates these simple but
1997). important techniques.
In addition to verbalizing different aspects of
experience, it is also necessary to link sequential Case Vignette 1
experiences with one another to develop a sub-
jective sense of coherence and continuity of ex- Patient: I’m probably going to break up
perience. By linking different kinds of experi- with my girlfriend when she gets
ences based on their temporal association, it is back.
possible to form narratives. A narrative can be Therapist: Oh my goodness! What happened?
described as having three components: a wish or You were so excited about the rela-
intention, a response from the other or “RO,” and tionship the last time we met.
a response from the self or “RS” (Luborsky & Patient: (Laughs) I know. I think it was just
Crits-Christoph, 1998). Persons with BPD appear too much time to spend together on
to have difficulty making these linkages, espe- a road trip. And I realized what I
cially for particularly intense and affect-laden don’t want and I haven’t figured
interpersonal experiences. For example, patients out what I’m comfortable with.
may complain of depression that comes “out of Therapist: What happened?
the blue,” and not make the association that it Patient: Here’s the thing (pause) . . . I don’t
started right after someone snubbed them (“RS” (pause) . . . have . . .
of depression not linked to “RO” of rejection). Therapist: That’s okay; you don’t have to be
On the other hand, they may present a litany of logical. Give me an episode of
complaints about how other people have mis- something that happened between
treated them, without ever acknowledging their the two of you.
feelings of anger and shame (“RO” of mistreat- Patient: (Pause) Well, for one we both have
ment not linked to “RS” of anger and shame). the same kind of short temper, and
Impairments in describing specific affective that doesn’t help and I didn’t real-
experiences, in linking together sequential expe- ize this until we were kind of lost in
riences, and in linking experiences to context, Northampton and we both started
such as time and place, are often manifested by getting mad at the other one. It was
confusing and incoherent narrative accounts. This at the point where I was like shut-
was demonstrated in a recent randomized con- ting down and just like, “Tell me
trolled trial comparing psychodynamic therapy to where to drive!”
other treatments for BPD (Levy et al., 2006). In Therapist: You started shutting down after . . .?
that study, the Adult Attachment Interview Patient: After she got mad. And then . . . the
(Main, Kaplan, & Cassidy, 1985) was employed biggest pet peeve ever . . . she won’t
to assess narrative coherence. The authors noted ask anyone anything . . . like you
that a large percentage of the BPD study popula- know . . . if you’re trying to find
tion had great difficulty forming coherent narra- someplace and you know you’re
tives and were thus characterized as having nearby, where is such and such
unresolved/disorganized attachment. This finding café? You know? Ask then if it looks
has been replicated in other adolescent and adult like they’re local. She won’t talk to
populations with BPD (Westen, Nakash, Cannon, anyone she doesn’t know. I don’t
& Bradley, 2006). know why . . . I’m trying to drive
An important aim of DDP is to help patients to and I pull over and say, “Okay,
put words to their affective experiences and to they’re on your side. Ask them.” “I
link sequential experiences into simple narra- can’t do that.” “Fine! Sit back. I’ll
tives. This includes encouraging patients to give ask them.”
particular examples of recent interpersonal inter- Therapist: How did that make you feel when
actions. The therapist then helps the patient to she said she couldn’t do that?
link together the “RS” and “RO” components Patient: Really frustrated. It’s like you don’t

17
Gregory and Remen

know them. They don’t know you. It the feelings exist, as opposed to just something sort of crazy that
doesn’t matter if . . . because she’s . . . may be 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
like I feel . . . or what . . . it’s like I share with people, the less I feel I exist, and there’s many days
she gets embarrassed. I’m like, where I feel sort of invisible.
“They don’t know you. You’re
never going to see them again more Attribution
than likely, so ask them where the
hell you are.” She makes no sense! People intuitively make attributions to gener-
ate meaning. Attributions of value, agency, and
In the first part of this vignette, the patient motivation help us to understand ourselves, our
offers interpretations about what went wrong in a experiences in the world, and others’ intentions.
relationship with a girlfriend. The therapist re- Stability of one’s attributions leads to a sense of
peatedly tries to bring the patient down to the continuity and consistency in expected responses
level of experience and to relate a specific inter- from oneself and others and is another building
personal encounter. The patient then struggles to block for a coherent sense of self.
coherently describe a discrete episode on a road The attributions of persons with BPD tend to
trip, but has difficulty verbalizing her experi- be distorted and to have a polarized all-or nothing
ences, providing adequate context, and making quality (American Psychiatric Association, 1994;
“RS” and “RO” connections. Kernberg, 1975). Several investigators have
As the patient relates the episode, the therapist noted that BPD attributions of self and other are
tries to help the patient clarify the “RS-RO” se- organized into poorly integrated sets, with each
quential connections. For example, the therapist set having characteristic relational patterns. The
asks the patient to describe the “RO” that precedes attribution sets and their relational patterns have
the “RS” of “shutting down.” After the patient de- been variously labeled as dialectical dilemmas
scribes the “RO” of the girlfriend refusing to ask for (Linehan, 1993), object relations (Clarkin, Yeo-
directions, the therapist asks the patient to verbalize mans, & Kernberg, 2006), schema modes
the affect underlying the consequent “RS” by ask- (Kellogg & Young, 2006), attachment represen-
ing, “how did that make you feel . . .?” tations (Bateman & Fonagy, 2004), or states of
These therapist interventions would not be un- being (Gregory, 2007).
usual in other psychodynamic treatment models. Kernberg (1975) has hypothesized that rapid
The explicit purpose of such interventions might oscillations between contradictory sets of attribu-
be to develop insight into maladaptive interper- tions, or object relations, lead to identity diffu-
sonal patterns (Strupp & Binder, 1984), correct sion. In support of Kernberg’s hypothesis,
misperceptions of others’ intentions (Bateman & Wilkinson-Ryan and Westen (2000) reported that
Fonagy, 2004), or to identify polarized attribu- the most common aspects of identity disturbance
tions (Clarkin, Yeomans, & Kernberg, 2006). In in BPD are a subjective sense of incoherence and
this vignette, however, the primary aim of help- inconsistency. Shifts between poorly integrated,
ing this patient to develop the narrative was not to contradictory sets of attributions contribute to char-
facilitate insight into maladaptive patterns or to acteristic BPD manifestations of rapidly changing
correct misattributions. Rather, verbalization of emotions, alternating neediness and rejection of
affective experience and linking-together sequen- others, unstable self-image, and alternating over-
tial responses within a narrative account can be control and undercontrol of impulses (Conklin &
therapeutic in themselves by activating associa- Westen, 2005). For example, if one’s self-
tive functions. attribution is idealized as the innocent victim of
The following statements by a patient with others’ transgressions, the emotional response will
BPD and crack cocaine addiction illustrate how be justifiable anger, and the behavioral impulse will
repeated verbalization of affect-laden experi- be hostility or detachment. On the other hand, if
ences in the context of the patient-therapist rela- one’s self-attribution is a perpetrator transgressing
tionship can foster the development of a subjec- onto idealized others, then the emotional response
tive sense of self or identity. will be guilt and fear of abandonment, and the
As I start to develop feelings surrounding certain situations behavioral impulse will be self-harm.
that I share with you . . . like I think verbalizing some of the This brief vignette of a young woman with
things that I have going on in my head sort of acknowledges BPD describing conflicts with her parents illus-

18
 Psychodynamic Therapy for BPD

trates how attributions can rapidly alternate stated you felt abandoned by your girlfriend
within a session. when she left, but were you also relieved? In
Case Vignette 2, a reasonable intervention for the
therapist at this point in the session would have
Case Vignette 2
been to state, “Do you notice how you just
Patient: I asked my father, “Why do you switched from blaming your parents for your
allow Mom to talk to me like that conflicts with them to blaming yourself? Is it
. . . call me a psycho and idiot, and sometimes difficult for you to know if your feel-
everything else?” I’m not a psy- ings are justified in a situation like that?”
cho. She called me that one time. Other psychodynamic treatment models for
Now she’s on a kick where, “It’s BPD, including MBT (Bateman & Fonagy, 2004)
my house!” I don’t do anything to and TFP (Clarkin, Yeomans, & Kernberg, 2006),
bother them whatsoever. They just also employ interventions targeting patient mis-
want to have control over the sit- attributions. MBT posits that a core deficit in
uation. mentalization leads to misattributions regarding
Therapist: So you feel your parents are trying the intentions and motivations of self and others.
to control you? With this treatment, the therapist initially con-
Patient: No . . . they probably thought I was veys understanding of the patient’s attributions
out of control because I was very emo- (thereby providing an experience for the patient
tional. I was crying hysterically. I of accurate mentalization by the therapist), and
wanted them to answer me, but I then attempts to correct the misattributions.
shouldn’t have gotten that mad be- In contrast to MBT, TFP posits a defensive po-
cause it was just me venting. larization or splitting of attributions into all-good or
all-bad. Using this model the therapist nonjudg-
At the beginning of this segment, the patient’s mentally points out polarized attributions of self
self-attribution is as an innocent victim of her and other, especially as they pertain to the patient-
parents’ verbal abuse and control. Badness and therapist relationship, so that the patient can work
agency are attributed entirely to the parents. toward integrating them (Clarkin, Yeomans, &
However, when the therapist repeats back the Kernberg, 2006). The TFP approach is consistent
patient’s attributions, she suddenly switches to with DDP in its aim to integrate misattributions,
the opposite extreme. The parents are now instead of attempting to correct them.
viewed as innocently trying to do what’s best for
their daughter and the patient becomes the per- Alterity
petrator, the hysterical troublemaker who is mak-
ing mountains out of molehills. In addition to reflecting upon experiences and
An aim of treatment with DDP is to help attributing meaning to them, it is also necessary
patients to identify and integrate polarized attri- to have some degree of objectivity (“how realistic
butions of self and others so as to improve their are my attributions?”). Alterity is a word bor-
subjective sense of coherence and consistency. rowed from the philosophical literature meaning
The patient’s attributions at any given time can a reference point outside the subjectivity of the
be deciphered through observation of the pa- self, what Derrida described as “an absolute out-
tient’s affect, the narrative themes, and the ther- side” (Derrida, 1978, p. 106). An analogy would
apist’s own affective responses to the patient. The be a lighthouse as an outside reference point that
therapist then attempts to open up new possibil- provides an objective perspective on the ship’s
ities of meaning and to help the patient to move location and direction. An important consequence
from the simplistic certainty of polarized attribu- of alterity is the ability to reflect on the self and
tions (Akhtar, 1998; Gregory, 2007) to reflection others from an outside or “objective” perspective.
and tolerance of the rich and complex ambiguity Alterity is, therefore, a function that moves be-
of diverse perspectives. yond the establishment of a coherent identity, to
To this end, questions that a DDP therapist the development of realistic and reflective self-
might pose include, “What else did you feel?” awareness, a differentiated self.
“Even though you think he treated you poorly, The concept of alterity is related to mentaliza-
does part of you also feel you deserved it?” “You tion (Fonagy & Target, 2000), which involves the

19
Gregory and Remen

ability to accurately perceive others’ intentions autonomy and independent decision-making, by

and is derived from theory of mind (Premack & tolerating disagreement and criticism, and by pro-
Woodruff, 1978). However, alterity is a broader viding unexpected, paradoxical acceptance or chal-
concept that incorporates facets of several other lenge at key times that deconstruct attributions of
psychoanalytic terms, including observing ego, self and other associated with a negative therapeutic
empathy, self-other differentiation, and the third alliance (Gregory, 2005, 2007). DDP outlines spe-
(Britton, 2004). A common aspect of these con- cific sets of borderline attributions that can inter-
cepts, and the essence of alterity, is a movement fere with the therapeutic alliance and delineates
beyond personal subjectivity or interpersonal in- strategies to experientially deconstruct them
tersubjectivity, to a perspective that is more real- (Gregory, 2007), and thus may be particularly
istic, differentiated, and objective. helpful at engaging challenging patients.
Unlike functions of association and attribution, Schema therapy, MBT, and some models of
alterity has less to do with integration than with short-term dynamic psychotherapy (Strupp &
differentiation. Alterity includes, for example, Binder, 1984) also include experiential compo-
differentiating the signifier from the signified, the nents to their treatments and describe innate heal-
symbolic from the real, or the particular word ing aspects of the patient-therapist relationship.
from the aspect of experience it represents. As an Unlike DDP, however, these models advocate
example of the latter difficulty, a patient asked, that the therapist provide positive elements miss-
“Why do words . . . especially my own frighten ing in the patient’s childhood through limited
me? As if when I say the word water, I’ll get wet? reparenting, mentalization, positive role model-
Why does my brokenness scare me if I make ing, or corrective emotional experiences. As dis-
mention of it?” cussed in a previous paper, it may be problematic
Persons who have difficulty differentiating the for a therapist to assume the role of a substitute
symbolic from the real may be prone to employ parent in this patient population since it may
objects or behaviors as a symbolic substitution experientially reinforce the patient’s self-image
for what is missing in reality (Winnicott, 1953). as a helpless and defective child, and foster long-
For example, patients with BPD may fill their term dependency toward the idealized therapist
hospital room with teddy bears as a symbolic (Gregory, 2005).
substitution for soothing attachment with an ide- The following transcript is from a session with
alized other (Mack & Viederman, 2000). a woman in her early 20s having a history of
In addition to this type of differentiation, alter- BPD, alcohol dependence and major depressive
ity also incorporates differentiation of self from disorder. The context of the present session is that
other. One reason why the narrative in Case Vi- the patient made a late cancellation to the previ-
gnette 1 was so confusing was that the patient ous session. The therapist identifies and experi-
continually switched pronouns so that it was un- entially deconstructs the patient’s paranoid attri-
clear at any given time who was doing what to butions of the other through paradoxical
whom. Differentiation of self from other allows receptivity to the patient’s accusations.
empathic appreciation of others as separate and
unique individuals, forms a basis for realistic and Case Vignette 3
complex comparisons between oneself and oth-
ers, and provides for self-reflection and realistic Patient: Everybody’s manipulating me. Ev-
self-assessment. erybody. My parents take this tone
Each of the previously described DDP inter- with me to get me to fix their car.
ventions for building associative and attribution Therapist: I notice you said everybody. How do
capacities also supports the development of alter- I manipulate you?
ity. By becoming more aware of one’s experi- Patient: I was talking to a guy the other day
ences and attributions, one gains a more realistic and I asked, “I know I’m in the
appraisal of them. An innovative aspect of DDP research study, and is my therapist
is that it explicitly attempts to develop alterity by here to help me or am I here to help
providing experiences of self-other differentia- him with the study?” And the guy
tion in the patient-therapist relationship. Thera- said, “You’re even less than a pa-
pists applying DDP experientially promote self- tient. You’re more of a specimen.”
other differentiation by respecting patient So it’s kind of foolish for me to think

20
 Psychodynamic Therapy for BPD

that you even care. Maybe I idealize from present narratives support the development
this situation. Do you think I do? of alterity.
Therapist: Well, that’s an important question.
Do I have any genuine caring or are Management of Problematic Behaviors
you just a specimen in the labora-
tory to be used or discarded? Impulsive and self-destructive behaviors com-
Patient: And that’s why I was thinking I re- monly occur with BPD and can include substance
ally need help, and he is just going misuse, binge eating, unsafe sex, unconstrained
to provide what the study allows and shopping, reckless driving, and parasuicide behav-
doesn’t care if I need more. ior (American Psychiatric Association, 1994). DDP
Therapist: So different images you have of me posits that deficits in association, attribution, and
is being a cold and callous re- alterity contribute to the employment of these be-
searcher versus someone who cares. haviors as maladaptive coping mechanisms.
Patient: I think it’s a kind of protection. Because of their associative deficits, patients with
Because I don’t really see you like BPD are often unaware of stressful interpersonal
that now when we’re in our ses- interactions or the negative affects that are gener-
sion, but when I’m not with you, I ated through these interactions. Instead, they may
sometimes think like that. I want to experience only a vague tension or discomfort from
think the worst in case if that’s which they seek relief through substance use, self-
what you really were, I would be injury, binge eating, compulsive shopping, and
less hurt. But with my parents I other problematic behaviors. Thus, these behaviors
can’t do that. I think that they’re can be viewed as maladaptive and impulsive mech-
so good, and I am so wrong to anisms for affect regulation (Trull, Sher, Minks-
question them, but then I get blind- Brown, Durbin, & Burr, 2000).
sided. On the other hand, deficits in attribution make
it more difficult to stop the behaviors. Because of
At the beginning of the transcript, the therapist their poorly integrated, polarized attributions, pa-
screens for negative feelings toward treatment tients may be unaware and unable to acknowl-
when the patient expresses negative feelings to- edge simultaneously both the harmful conse-
ward other people, stating, “Everybody’s manip- quences of problematic behaviors and the
ulating me.” The therapist had been alert to the possible benefits of the behaviors, including relief
possibility of a tenuous treatment alliance given from negative affects (Johnson, 1993). Thus, they
the previous missed session. The therapist tries to are unable to make an informed choice, weighing
convey openness and receptivity to the patient’s pros and cons of discontinuation.
negative feelings, thereby deconstructing the pa- However, to understand how these behaviors
tient’s expectation for an invalidating and defen- may relieve negative affects, it is necessary to
sive response. For example, the patient may ex- turn again to alterity. As mentioned above, an
pect the therapist to respond, “Don’t you aspect of alterity is differentiating the symbolic
remember how I had completed those forms for from the real. Just as teddy bears can function as
you and responded to so many of your phone a symbolic substitute for soothing attachment
calls? How could you say I don’t care?” The with an idealized other, problematic behaviors
therapist also tries to integrate the patient’s po- can also serve symbolic substitutive functions.
larized attributions of the other as either totally For example, patients with BPD have stated that
caring and accommodative or as cold and manip- cutting “helps relieve the emotional pain by re-
ulative. The patient responds to these interven- placing it with physical pain,” or that “my hurt is
tions by becoming more allied with the therapist let out by tears of blood.” Likewise, they may
and more reflective. She is now able to get in talk about their “relationship with the bottle,” or
touch with her fears of vulnerability in relation- describe achieving sobriety as “losing my best
ships and associates back to the relationship with friend.”
her parents, thereby differentiating past from In addition to symbolic substitution, evidence
present narratives. Each of these three interven- from animal studies suggests that substance use
tions: deconstructive experiences, integration of may provide a direct neurochemical substitution
polarized attributions, and differentiation of past for the soothing functions of attachment. For

21
Gregory and Remen

example, studies of attachment behavior in labo- so that they can make an informed choice as to
ratory animals suggest that the neural network whether to continue the behavior.
underlying the drug reward system of the brain is The following vignette is of a patient in her
the same neural network that maintains attach- late teens with alcohol dependence, obsessive–
ment. Moles, Kieffer, and D’Amato (2004) re- compulsive disorder and BPD who is considering
ported that mice who were lacking the ␮-opioid entering an alcohol rehabilitation program.
receptor gene displayed both reduced reward de-
pendence to nonopioid drugs of abuse, as well as Case Vignette 4
reduced attachment behaviors toward their moth-
ers. Macaques monkeys separated from their Therapist: I think that’s an important insight
mothers developed higher levels of ethanol pref- when you say, ‘I’m not sure I want
erence (Barr et al., 2004). to do recovery.’ Can you tell me a
Likewise, the results from human studies sug- bit more about that?
gest that disruptions in early infant-mother at- Patient: Truthfully, the only reason I’m do-
tachment can predispose to substance depen- ing it right now is ‘cause everybody
dence later in life. In large, prospective studies in wants me to. My mom, she’ll hate
Denmark, early weaning from breast-feeding has me if I don’t go into the rehab place
been associated with the development of alcohol- . . . the same with my grandmother.
ism in adulthood (Goodwin et al., 1999; Sø- They don’t know what to do with me
rensen, Mortensen, Reinisch, & Mednick, 2006). anymore.
The supposition that substances can serve as a Therapist: Do you remember our conversation
symbolic and neurochemical substitute for the on the phone? You said, ‘I really
soothing functions of attachment has treatment need to go into rehab because I
implications. One would expect patients with drank again and don’t want it get-
concurrent substance dependence to be more de- ting out of control.’
tached and more difficult to engage in a treatment Patient: Because part of me doesn’t want to
relationship. Treatment studies of patients with keep drinking . . . putting all that poi-
co-occurring BPD and substance use disorders son inside of there, and plus, when I
demonstrate relatively high dropout rates (Line- drink I do stupid stuff. Something bad
han et al., 1999, 2002) thereby supporting this could happen to me.
prediction. DDP attempts to build alliance Therapist: It sounds like it gets confusing as to
through establishing a clear and collaborative ‘what other people want for me and
framework for treatment during the initial ses- what I want for myself.’
sions, by a nonjudgmental and nondirective stance Patient: Well, I know what’s best for me
(Karno & Longabaugh, 2005), and by delineating “cause all I’ve got is trouble from
specific techniques to deconstruct negative attribu- drinking, but sometimes I don’t feel
tions of self and other that may interfere with main- like putting in the effort to give it up.
I just want to keep drinking and
taining a positive patient-therapist relationship
drinking.
(Gregory, 2007).
Therapist: So What you are saying is that
Management of problematic behaviors, includ-
there’s a big part of you that doesn’t
ing substance misuse, involves helping patients to
want to keep drinking . . .
verbalize their affective and bodily experiences
Patient: And another part of me that does.
before, during, and after the behavior, link to-
gether antecedent and consequential interper- This vignette illustrates how a patient’s polar-
sonal responses into a narrative sequence, and ized attributions and poor self/other differentia-
integrate polarized attributions that they might tion can contribute to continued drinking behav-
have regarding the behaviors. Except for those ior. The therapist tries to help the patient identify
occasions when they jeopardize safety, the ther- and integrate her polarized attributions toward
apist neither encourages nor discourages mal- drinking and recovery. The therapist begins the
adaptive behaviors, but instead facilitates explo- integration process by attempting to clarify the pa-
ration of them. The aim is to help patients to tient’s present motivation to stop drinking. The pa-
develop an integrated and objective perspective, tient attributes no motivation to herself to quit and

22
 Psychodynamic Therapy for BPD

the motivation for change is entirely attributed to mended guidelines (American Psychiatric Asso-
others (the mother and grandmother). During the ciation, 2001). However, concurrent individual
remaining portion of the transcript, the therapist treatment with another psychotherapist is prohib-
tries to nonjudgmentally help the patient acknowl- ited as this can enhance polarization of attribu-
edge the opposing extremes of her attributions to- tions and increase anxiety as different therapists
ward recovery. The patient responds to these inter- may provide conflicting frameworks.
ventions by becoming more reflective and After the first few sessions, the stance of the
integrative, weighing both sides of her ambivalence, DDP therapist is generally nondirective and non-
and thus developing the ability to look at her drink- judgmental to facilitate exploration of experience
ing behavior from the more objective perspective of and promote self-other differentiation. For exam-
alterity. ple, some explicitly proscribed therapist interven-
Occasionally, therapists applying DDP are tions include asserting that a given feeling or
forced to take a more directive stance when per- action (by self or others) is justified or unjusti-
sistent suicide or homicide ideation, or out-of- fied; assertively attributing a certain motivation,
control behaviors pose a substantial risk of seri- value, or emotion to the patient or others; or
ous harm to the patient or others. Under these employing encouragement or reassurance. The
circumstances, patients may need to be reminded patient is treated as an adult having autonomous
of their commitment on the treatment plan to decision-making authority within the parameters
keep themselves safe, including hospitalization of the treatment contract. Psychoeducation aimed
when necessary. On rare occasions, patients may at helping patients better understand their condi-
refuse measures needed to ensure safety, and tion or treatment options is occasionally em-
involuntary hospitalization may be necessary ployed, but unlike cognitive– behavioral treat-
along with a reevaluation of whether the patient ment models, such as DBT (Linehan, 1993) or
is sufficiently committed to recovery to continue schema therapy (Kellogg & Young, 2006), is not
the difficult work of exploratory psychotherapy. a major emphasis and does not include training or
advice.
Treatment Structure The primary area of discussion and exploration
during sessions involves patients’ recent interper-
DDP is manual-based (Gregory, unpublished sonal encounters. The therapist also encourages
manuscript) and involves individual weekly ses- exploration of dreams, artwork, and creative writ-
sions lasting 45 to 50 minutes. The treatment ing. Like other psychodynamic treatments for
model was designed to be relatively easy to learn BPD, uncovering or exploring past trauma is
and well defined. de-emphasized in DDP, especially in the initial
Treatment is limited to 12 to 18 months dura- stages of treatment, because it can destabilize
tion. The specific termination date within the 12 patients through overwhelming anxiety (Gregory,
to 18 month time frame is collaboratively estab- 2004).
lished at the beginning of treatment as part of a
comprehensive treatment plan and takes into ac- Stages of Treatment and Hypothesized
count the severity of pathology as well as extra- Mechanisms of Change
neous factors, such as affordability and therapist
availability. The treatment is divided into four distinct
Adjunctive treatments, such as group therapy stages, each characterized by specific narrative
with an interpersonal focus, 12-step groups, art themes (Gregory, 2004). In the first stage, pa-
therapy, and medications, are encouraged, but not tients are typically attempting to assess the safety
required within this model. Different kinds of and limits of the patient-therapist relationship.
treatments can bring different perspectives to The initial task is to collaboratively establish a
bear on issues, can diffuse the intensity of the formulation of the patient’s difficulties and then
patient-therapist relationship and can also help to outline the goals, tasks, and written expecta-
with symptom management. Most patients re- tions for treatment, including an agreement that
ceiving DDP also receive medications, including the patient will keep him or herself safe. The
antidepressants, mood stabilizers, and/or antipsy- establishment of a comprehensive treatment
chotic agents, either prescribed by the therapist or framework is a common feature of both psy-
by another provider in accordance with recom- chodynamic and cognitive– behavioral models of

23
Gregory and Remen

treatment for BPD (Bateman & Fonagy, 2004; bringing up termination directly, patients fre-
Clarkin, Yeomans, & Kernberg, 2006; Kellogg & quently bring up themes of rejection and aban-
Young, 2006; Linehan, 1993). donment in recent and past relationships. The
During this stage, the therapist helps patients to task of the therapist during this stage is to help
verbalize recent interpersonal experiences, link establish links between relational themes in the
“RS” and “RO,” and identify underlying affects. present and the past while remaining receptive to
The therapist also attempts to rapidly recognize anger and disappointment in the therapist and the
and provide experiences that deconstruct a nega- limitations of the patient-therapist relationship.
tive therapeutic alliance. The combination of The fulfillment of these tasks leads to more real-
these techniques and a comprehensive initial istic appraisals of self and others, and often, im-
framework facilitate rapid resolution of this proved social and occupational functioning, in-
stage. By the end of the first stage, the patient- terspersed with episodes of regression.
therapist relationship should optimally be fairly The authors hypothesize that the establishment
stable, idealized, and have soothing qualities. of a stable, idealized, and soothing patient-
The task for the second stage of treatment is therapist relationship is the primary mechanism
for the patient to develop more complex narra- leading to rapid improvement in affective lability
tives that incorporate opposing attributions of and diminution of maladaptive behaviors early in
motivations (“When she said she was leaving me, treatment. However, for this improvement to con-
I felt both horrified and relieved”) and of value tinue during the course of treatment and to be
and agency (“I don’t know whether he was being sustained after termination, and for substantial
abusive when he hit me, or whether I provoked gains in social and occupational functioning, the
him to do that”). Patients tend to bring up recent authors posit that patients must develop improved
interpersonal conflicts during this stage and to neurocognitive functions in the areas of associa-
ask, “Do I have a right to be angry” and “Are my tion, attribution, and alterity. Verbalization and
needs legitimate?” Instead of providing validat- integration of experiences and attributions, and
ing answers to these questions, the therapist at- deconstructive experiences in the patient-
tempts to maintain a nonjudgmental stance so as therapist relationship are essential interventions
to foster simultaneous acknowledgment of op- needed to activate these functions. The authors
posing attributions toward self and others and hypothesize that there is an association between
move the patient toward a reflective ambivalence. implementation of these therapeutic interven-
As patients gain a more realistic appraisal of tions, improvement in neurocognitive self-
themselves and others, their sustaining idealiza- capacities, improvement in symptoms and func-
tions begin to be threatened. Acknowledgment tioning, and normalization of the metabolic
and mourning for the loss of these idealizations activities in the affected areas of the brain.
marks the transition into the third stage. A preset duration of treatment may help to
During the third stage, the task becomes facilitate involvement in the treatment process,
mourning and acceptance of self-limitations, and move patients more rapidly through the stages,
of the limitations of important relationships. In- develop self-efficacy, prevent long-term depen-
stead of discussing recent interpersonal conflicts, dency on the therapist, and reduce treatment
narrative themes tend toward disappointments in dropout rates (Sledge, Moras, Hartley, & Levine,
idealized relationships and fears of personal in- 1990). The supposition that patients with BPD
competence. The therapist can foster movement can make clinically meaningful progress after
through this stage by helping the patient to ver- only 12 months of treatment is supported by a
balize these disappointments and to mourn. Dur- recent controlled trial of DDP (Gregory et al., in
ing this stage, patients are often more dysphoric press). However, therapists applying DDP do not
and may become more ambivalent about treat- expect their patients to be completely recovered
ment and recovery. They may reminisce about by the end of treatment. Patients are told at the
simpler times and display periods of regression. beginning that recovery from BPD is lifelong
However, they may also describe a newfound and continues outside of treatment, and that the
sense of self and capacity for empathy. development of a coherent, and differentiated
The final stage involves mourning and accep- self-structure is a graded process, rather than
tance of the limitations of the patient-therapist all-or-nothing.
relationship as termination approaches. Instead of The downside of a time-limited treatment is

24
 Psychodynamic Therapy for BPD

that there are some patients who make only mod- ● Providing novel experiences in the patient-
est gains within the predetermined timeframe and therapist relationship that challenge distorted
may have benefited from a longer duration. At the expectations and promote self-other differenti-
time of termination, therapists applying DDP ation.
may advise such patients to try a different form of ● Facilitating mourning for the loss of idealiza-
treatment or to begin longer-term psychodynamic tions as the patient develops increasingly real-
therapy with a different therapist. Other patients istic appraisals of self and others.
choose to leave the mental health system at ter-
mination or engage in less intensive forms of An important direction for further develop-
treatment. Further research is needed to deter- ment of this treatment will be empirical testing of
mine which patient characteristics predict a good mechanisms of action, including the role of the
response to DDP, how its efficacy compares to therapeutic alliance as a mediator or moderator of
other manual-based treatments, and whether pa- outcome. Elucidation of mechanisms will also
tients continue to improve after termination. require the development of paradigmatic markers
for each of the three neurocognitive functions,
Summary and Directions for Future Research and assessment whether improvement in these
markers with treatment leads to changes in gene
The last few years have heralded a new and expression, neurotransmitter activity, and neuro-
exciting phase of research on borderline person- nal metabolism and remodeling in the affected
ality disorder, including improved understanding brain regions.
of epidemiology, etiology, and prognosis, and the The authors hope that the present model of
development of many new treatment options. In borderline pathology will not only help to de-
the present paper, the authors have attempted to velop more effective treatments for this disorder,
integrate diverse theories of borderline pathology but will also facilitate future research delineating
with empirical findings, philosophical concepts, essential aspects of the self and its relationship to
and clinical observations to propose a model that the brain. Because BPD is characterized by spe-
highlights three neurocognitive functions, includ- cific deficits in functional neuroanatomy and in
ing association, attribution, and alterity, that form self-capacities, it presents an admirable model for
the building blocks of a coherent and differenti- study of interactions between these two domains.
ated self. For example, recent neuroimaging studies sug-
DDP is a time-limited treatment that aims to gest that the capacity for alterity may be mediated
remediate deficits in neurocognitive self- in part through the medial prefrontal cortex, as
capacities. The authors hypothesize that repeated evidenced by studies locating mentalization (Gal-
activation of the three neurocognitive functions lagher et al., 2000), empathy (Shamay-Tsoory,
of association, attribution, and alterity, through Tomer, Berger, Goldsher, & Aharon-Peretz,
the targeted interventions outlined in this paper 2005), moral judgment (Greene & Haidt, 2002),
leads to improvement in BPD psychopathology. differentiation of self from other (Uddin, Kaplan,
This hypothesis is supported by a recent con- Molnar-Szakacs, Zaidel, & Iacoboni, 2005), and
trolled trial of DDP in patients with co-occurring self-awareness (Gusnard, Akbudak, Shulman, &
BPD and alcohol use disorder that demonstrated Raichle, 2001) to this region. Thus, the medial
clinically meaningful changes in BPD symptoms prefrontal cortex may be a promising region to
and alcohol misuse (Gregory et al., in press). The develop as a neuroimaging paradigm marking
major principles and techniques of treatment improvement in alterity function with targeted
could be summarized as follows: treatment in BPD populations.
● Establishing a comprehensive framework of
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