Robert Gregory, MD

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RESEARCH ABSTRACT

Thematic Stages of Recovery in the Treatment of Borderline Personality Disorder

Employing a case illustration and object relations theory, the author postulates that persons with borderline personality disorder have specific thematic questions that they are trying to resolve at sequential stages of their recovery. Each of the four thematic stages entails characteristic patient-therapist interactions, underlying conflicts, associated behaviors, and unique challenges and pitfalls that must be overcome in order to avoid traumatic re-enactment and move forward in recovery.

Borderline Attributions

The author explores how persons with borderline personality disorder attempt to generate meaning, eliminate ambiguity, and maintain idealizations by assigning polarized, binary attributions to their experiences.The author proposes that these binary attributions interact to form multiple, discrete self-structures or states of being. Each state is characterized by stereotyped expectations for self and other and self-perpetuating patterns of relatedness.The author delineates four common states, labeled as helpless victim, guilty perpetrator, angry victim, and demigod perpetrator, and suggests treatment strategies to deconstruct each state and to facilitate the development of an integrated and differentiated self.

Psychotherapy for Treatment Resistant Borderline Personality Disorder

A manual-based treatment, labeled dynamic deconstructive psychotherapy, was developed for those patients with borderline personality disorder who are most difficult to engage in therapy, such as those having co-occurring substance use disorders. This treatment model is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions that form the basis for a coherent and differentiated self. DDP aims to activate and remediate neurocognitive self-capacities by facilitating elaboration of affect-laden interpersonal experiences and integration of attributions, as well as providing novel experiences in the patient-therapist relationship that promote self-other differentiation. Treatment involves weekly individual sessions for a predetermined period of time and follows sequential stages.

Dynamic Deconstructive Psychotherapy for Borderline Personality Disorder and Alcohol Use Disorders

A randomized controlled trial was conducted to determine whether dynamic deconstructive psychotherapy (DDP), would be feasible and effective for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder. Thirty participants were assessed every 3 months during a year of treatment with either DDP or optimized community care. By 12 months, DDP participants showed statistically significant improvement in parasuicide behavior, alcohol misuse, institutional care, depression, dissociation, and core symptoms of BPD, and treatment retention was 67-73%. Almost all participants who received at least 6 months of DDP demonstrated clinically meaningful change. Although community participants received higher average treatment intensity, they showed only limited change during the same period. After an additional 18 months of naturalistic follow-up following termination of treatment, DDP participants demonstrated sustained treatment effects over a broad range of outcomes and achieved significantly greater improvement in core BPD symptoms, depression, parasuicide, and recreational drug use than participants who had received optimized community care. These results suggest that DDP is a cost effective treatment that can lead to broad and sustained improvement for the dually diagnosed subgroup.

Relationship between adherence and outcome in dynamic deconstructive psychotherapy

Independent raters coded video-recorded sessions on adherence to DDP techniques, as well as therapeutic alliance and standard cognitive behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent inter-rater and test-retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (rho = .64) and most secondary outcomes.

Selected References

Gregory RJ: Thematic stages of recovery in the treatment of borderline personality disorder. American Journal of Psychotherapy. 58:335-348, 2004.

Gregory RJ: The deconstructive experience. American Journal of Psychotherapy. 59:295-305, 2005.

Gregory RJ: Clinical challenges in the management of patients with co-occurring borderline personality and substance use disorders. Psychiatric Times. 23:16-18, 2006.

Gregory RJ: Borderline attributions. American Journal of Psychotherapy. 61:131-147, 2007.

Gregory RJ, Remen AL: A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training 45:15-27, 2008.

Gregory RJ, Chlebowsky S, Kang D, Remen AL, Soderberg MG, Stepkovitch J: A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder. Psychotherapy: Theory, Research, Practice, Training. 45:28-41, 2008.

Goldman GA, Gregory RJ: Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy. Psychotherapy: Theory, Research, Practice, Training.  46:480-485, 2009.

Gregory RJ, Delucia-Deranja E, Mogle JA: Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder co-occurring with alcohol use disorders: 30-month follow-up. Journal of Nervous and Mental Disease. 198:292-298, 2010.

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