Dynamic Deconstructive Psychotherapy Training: Part 1
I. Strengthening the Alliance
This section deals with techniques that are used to foster a therapeutic alliance with the therapist. A strong alliance is essential for dampening patients’ arousal and helping them to work through the insights and challenges of the treatment and recovery process. Hence these techniques are employed primarily in the early stages of treatment.
The aim of the first stage of treatment is to establish a strong therapeutic alliance. In order to establish an alliance, therapists must satisfy their patients’ safety concerns for caring, respect, and containment. These three concerns are largely unconscious and poorly integrated, and often at odds with one another (see Stage I in Chapter 4, Stages of Therapy). For example, a patient with BPD can demand admission to the hospital, expressing a need to be taken care of, and then just as adamantly demand discharge two hours later because of intolerable ward restrictions. In order to meet patients’ safety concerns, the therapist must combine qualities of warmth, empathy, respect and non-judgmental acceptance, with strength, reliability, and limit-setting.
In addition to maintaining a therapeutic stance, there are specific methods and techniques that therapists can employ to enhance the alliance. During the evaluation process, this includes providing a collaborative formulation and treatment goals, and making explicit the minimum necessary commitments for successful treatment (see Chapter 3, Establishing the Frame).
During the early treatment process, techniques for establishing and maintaining the alliance include repeating back patients’ narrative connections, repeating back patients’ assertions of positive attributions, recognizing and questioning patients’ emotions in the moment, and repeatedly framing the treatment tasks, central thematic questions, core conflicts, and safety concerns (see section on Ideal Other in Chapter 8, Specific Techniques in the treatment manual for a more complete description of these techniques and when to use them).
The following two cases illustrate some of the Ideal Other techniques.
Case 1: Repeating back a narrative sequence and making a framing comment
This case is of a man who is describing a recent conflict with his girlfriend. The therapist primarily employs Association techniques in order to develop the narrative, but then sums up the narrative sequence and provides a framing comment.
Case 1: Commentary
In this vignette, as the patient begins to relate his encounter in the movie theater, the therapist initially applies an Association technique to develop the narrative by asking, ‘what were you feeling at the moment?’
The therapist then repeats back the sequence of events, linking together responses of self and responses of other. This simple intervention of repeating back a narrative sequence can help to strengthen a therapeutic alliance. Patients have a need to be understood by an idealized other and this intervention helps the patient to feel understood. In addition, patients with emotion processing deficits often have difficulty hearing what they just said and may express delighted surprise at hearing it back and state, “Yes, that’s exactly how it was!” This intervention serves to not only build the alliance, but to reify experience.
The vignette also demonstrates Attribution techniques as the therapist attempts to explore alternative meanings and emotions, and makes an integrative comment. In addition, it demonstrates a framing intervention as the therapist points out the Stage II central thematic question of “Do I have a right to be angry?” Framing interventions are employed primarily in Stages I and II. They provide a framework for the patient’s experiences that pays homage to the patient’s need for certainty and thus helps to decrease arousal and strengthen alliance (see under Attribution, Case 1 Commentary).
Case 1: Key Points
- Patients have a need to be understood by an idealized other
- The simple intervention of repeating back a narrative sequence can help to reify experience and help the patient to feel understood, thus strengthening the therapeutic alliance
- Framing interventions are employed primarily in Stages I and II.
- Framing techniques provide a framework for the patient’s experiences, thus providing the patient with a sense of certainty and helping to decrease arousal and strengthen alliance
Case 2: Repeating back assertions of positive attributions
This case is of an older man who has prominent narcissistic traits. The therapist uses “mirroring” to repeat back the patient’s assertions of positive self-attributions, instead of challenging them. Paradoxically, mirroring serves to diminish grandiosity and improve the therapeutic alliance
Case 2: Commentary
The technique of mirroring is derived from Heinz Kohut’s Self Psychology and I use it primarily for patients who have prominent narcissistic traits. Kohut described mirroring as “the gleam in the mother’s eye in response to the child’s exhibitionistic display” (The Analysis of the Self, 1971, p. 116). With this technique, the therapist repeats back the patient’s assertions of positive self-attributions. In this vignette, the therapist states, “It sounds like you are very well read in very many areas.” In response to the therapist’s mirroring, the patient paradoxically drops his grandiosity and begins to describe his bragging as a defense mechanism.
This technique kind of rubs us the wrong way, since our first impulse with a narcissistic patient, such as the one we just observed, is to give him a reality check. But, paradoxically, reality checks tend to increase grandiosity and mirroring allows patients to drop their grandiosity and become more genuine and reflective by supporting their underlying fragile self-esteem (for further information on mirroring, see section on Ideal Other in Chapter 8, Specific Techniques).
Note that mirroring is not about trying to point out areas of self-worth to depressed patients. Trying to do that represents an enactment that comes across to the patient as unempathic and is generally ineffective.
Case 2: Key Points
- The technique of mirroring is employed in patients with prominent narcissistic traits and involves repeating back the patient’s assertions of positive self-attributions
- Mirroring allows patients to drop their grandiosity and become more genuine and reflective by supporting their underlying fragile self-esteem