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Borderline Personality Disorder: 12 Practical Behavioral Intervention Strategies
10 CEUs Borderline Personality Disorder: 12 Practical Behavioral Intervention Strategies

Section 18
Deconstructive Experiences in Treatment for
Borderline Personality Disorder

Question 18 | Answer Booklet | Table of Contents | Borderline CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Ms. A. was a young woman whom I treated with weekly psychotherapy for self-injury related to borderline personality disorder. As a teenager, Ms. A. left an abusive home situation to enter into a long-termUnfaithful Borderline Personality Disorder social work continuing education relationship with a physically abusive boyfriend. Ms. A.'s relationship with her boyfriend was chaotic, and at various times she would employ three different narrative descriptions of their interactions. Often, she described her boyfriend in idealized terms — thoughtful and considerate, and she imagined the perfect union with her future husband. Other times, she would angrily describe her boyfriend in devaluing terms, especially when he had been unfaithful or when she felt rejected by him. On these occasions she perceived herself as the heroic victim, putting up with his transgressions. However, this perception shifted immediately after episodes during which her boyfriend became violent towards her. Ms. A. reacted to his violence by blaming herself for provoking him or for being insufficient to meet his needs. She would become very depressed and self-injure. Each of these three conflicting narratives was accompanied by a sense of certainty or truth about her perceptions of herself and her boyfriend. She did not recall that on previous occasions she had held very different perceptions of self and other.

Ms. A.'s perceptions of me and the pattern of our interactions shifted depending on the status of her relationship with her boyfriend. For instance, during times when she idealized her relationship, Ms. A. was more detached from me in our sessions, and she had difficulty bringing up meaningful material. She would not call me between sessions, and during sessions she talked about leaving therapy because she felt she did not need it anymore. However, after each of her boyfriend's violent episodes she would reattach to me. Ms. A. would call me between sessions (telephoning more frequently than our treatment contract of up to two telephone contacts per week), expressing feelings of depression and desperation. During sessions she was emotionally involved but very passive, waiting for me to ask questions and to provide direction. 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?"

Disorganized attachment can be a useful metaphor to describe the shifts in idealization and devaluation exhibited by Ms. A. She was unable to integrate conflicting perceptions and experiences with her boyfriend or me, and so she lacked an empathic and realistic understanding of our motivations. At any given time I was either an idealized or devalued extension of her self. She was unable to see me for who I really was. When she idealized the relationship with her boyfriend, envisioning a united and perfect couple, she devalued and excluded me as an interfering interloper. I was an outsider, a contaminant, and the other. Paradoxically, I was also an essential component of her self-structure, albeit an externalized, depersonalized, and devalued component. Ms. A.'s projection of devalued aspects of the her self onto me allowed her to maintain an idealized self-image and a unified relationship with her boyfriend. That is, I was still within her hierarchical logocentric self-structure of idealized and devalued representations, even though she consciously considered me an outsider.

The challenge is that the therapist often feels compelled to act in a way that is consistent with the patient's internal representation 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, and we shared the fantasy that I was omniscient and could rescue her with sage advice. Inherent in the fantasy was the mutual perception that she was a helpless and deficient child who was unable to make reasonable decisions for herself.

The urge for the therapist to enact a particular role with the patient derives, in part, from unconscious identification with the patient's internal representations (Racker, 1957). Through identification with idealized and devalued representations of a logocentric self-structure, persons in the patient's life (including the therapist) feel compelled to enact roles that closely match the patient's expectations. Confluence between patient expectations for others' behavior and the actual behavior of others, serves to confirm patient expectations and to strengthen the representational system upon which those expectations are based and thus leads to a constricted, stereotyped, and self-perpetuating pattern of interpersonal interactions (Gregory, 2005).

A key to disrupting this interactional pattern is for the therapist to act in a manner that is contrary to the patient's expectations. It is through the patient's recognition that the therapist does not conform to projected expectations that the patient can begin to experience the therapist as a separate and unique person, instead of as a stereotyped, idealized or devalued extension of the self. Thus in order to experientially challenge a logocentric and reified self-structure, the therapist must attempt to provide a deconstructive experience, rather than an emotionally corrective experience. The deconstructive experience deconstructs the patient's constricted experience of others as mere idealized or devalued extensions of the patient's subjectivity and thus facilitates an enriched experience of interpersonal objectivity (the other as "not me").

What would have been a deconstructive experience for Ms. A.? Since her internal working model included the therapist as idealized and omniscient and herself as helpless and defective, a deconstructive experience with the therapist would necessarily challenge Ms. A.'s perceptions while retaining her relatedness to the therapist. Thus the therapist would need to refrain from advice, suggestions, or assured interpretations since these could limit ambiguity and reinforce perceptions of both the therapist's omniscience and the patient's helplessness. The specific intervention might vary depending on the therapist's theoretical orientation and yet provide a deconstructive experience. For example, a therapist employing cognitive behavior therapy might point out that Ms. A. had not been as active within sessions in identifying and modifying maladaptive cognitions or in applying the skills she learned to situations outside of sessions. Alternatively, a therapist employing a psychodynamic approach might point out how Ms. A, had not been actively bringing up material during sessions and yet had been calling frequently between sessions. The therapist may express puzzlement with the patient about the behavior and inquire whether she has mixed feelings about treatment.

With both the cognitive behavioral and the psychodynamic interventions, the therapist unexpectedly refrained from assuming either an expert or rescuer role, but instead observed that the patient chose not to participate fully in treatment. In this way the therapist challenged Ms. A.'s self-representation as the helpless victim and also challenged the representation of the other (the therapist) as the idealized rescuer.

Winnicott's description of the transitional object as the first "not me" possession (1953,p. 1) is consistent with deconstructionist attributes of being both within and outside of the self. That is, "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, 1971, p. 41).

Thus the deconstructive experience involves the use of the therapist as a transitional object who is simultaneously both part of the split and projected self and 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 see self and others more objectively.
- Gregory, RJ; The deconstructive experience; American Journal of Psychotherapy; 2005; Vol. 59 (4)

Personal Reflection Exercise #4
The preceding section contained information about deconstructive experiences in treatment for borderline personality disorder. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 18
What is a key to disrupting the interactional pattern of the therapist enacting the patient’s internal representation? Record the letter of the correct answer the Answer Booklet.

 
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