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Dynamic Deconstructive Psychotherapy Training: Part 2

II.  Association Techniques

Association techniques are the primary treatment methods of DDP.  They include helping patients to verbalize and elaborate narrative sequences of interpersonal interactions or maladaptive behaviors, identifying underlying emotions, and exploring emotional themes of creative activities, such as artwork, poetry, or dreams.  Verbalization, labeling, and acknowledgement of emotional experiences helps to decrease the level of arousal associated with interpersonal encounters and is necessary for developing a subjective sense of self.

Patients are responsible for bringing in material for exploration.  A useful and common focus is on recent interpersonal episodes with friends, family, or coworkers.  The therapist attempts to keep the patient at the level of experience instead of letting the patient talk in generalities, e.g. “He always takes me for granted,” or instead of having the patient try to make sense of their experiences, e.g. “She just wants to use me.”  To this end, the therapist asks about specific examples and focuses on the emotional responses (see section on Association in Chapter 8, Specific Techniques in the treatment manual for a more complete description of these techniques).

The following cases illustrate different aspects of Association techniques.

Case 1 : Developing a narrative of a recent interpersonal encounter

This case represents the use of Association techniques for a young man with borderline personality disorder and alcohol abuse.  The techniques employed in the following vignette are designed to help patients to identify, verbalize, and acknowledge their emotional experiences through exploration of recent interpersonal encounters.  In this vignette, the therapist tries very hard to help the patient focus on his experiences, including the sequential connection between responses of self and of other, so as to form simple narratives. In addition, the therapist helps the patient to verbalize and acknowledge the underlying emotions.

                                                    Association: Case 1 Video

                                                                   Case 1: Transcript

Case 1: Commentary

In the vignette that you just watched, the patient is discussing recent interpersonal encounters with his boss and with his mother.  The vignette illustrates many different kinds of Association interventions, including the importance of getting down to specifics.  You may have noticed how the therapist repeatedly attempts to help the patient to elaborate the specific sequence of events, rather than gloss over details.  For example, when the patient begins to focus on physical symptoms, the therapist brings the patient back again to the narrative.

Some of the Association interventions that are employed in this vignette included helping the patient to put the narrative into a he-said, she-said sequence and clarifying the underlying emotions.  For example, when the therapist asks, “what did you say when he said, “Just give me a doctor’s note”, the therapist is attempting to help the patient to elaborate the sequence of responses between himself and his boss.  When the therapist asks, “What was it like to say that to him,” the therapist is trying to help the patient to identify and acknowledge the underlying emotion.

This vignette also illustrates some other types of interventions.  For example, the therapist makes an empathic exclamation of “My goodness!” after the patient relates significant weight loss.  An empathic, warm, and kind therapeutic stance is encouraged with DDP.  However, the therapist also remains neutral, in the sense of not taking sides when the patient is conflicted about something.  For example, the therapist makes an integrative comment by stating, “So you felt powerful on the one hand, but also worried a bit as well.”  The therapist is pointing out the conflicting emotions of power versus worry, without implying that one feeling is more appropriate than the other in this situation.

Case 1 : Key Points

  • The therapist should elicit details of specific interpersonal interactions, especially the sequence of the interaction and the patient’s underlying emotions during the interaction
  • The therapist’s stance should be warm and empathic, but also neutral, i.e. not taking sides in the patient’s conflicts


Case 2 : Exploring an incident of cutting behavior

This case describes how cutting, or other maladaptive behaviors, might be explored.  In the vignette, the therapist applies Association techniques to the behavior in order to develop a narrative.  The therapist attempts to help the patient determine the interpersonal and emotional antecedents and consequences to the cutting incident and to identify, verbalize, and acknowledge the underlying emotions.

                                                    Association: Case 2 Video

                                                                  Case 2: Transcript

Case 2: Commentary

In the vignette you just watched, the therapist attempts to help the patient to develop a narrative of her maladaptive behaviors by asking about the emotions, events, and thoughts that precede and follow the patient’s desire to scratch herself and to have a drink of alcohol.  The patient displays enormous difficulty putting words to her emotional experience, and instead describes a kind of confusion and numbness. 

This vignette is a good example of what it is like working with a subgroup of patients who provide markedly incoherent narratives.  Patients in this subgroup may require extensive use of Association techniques and a sometimes longer course of psychotherapy.

Case 2: Key Points

  • The therapist should help patients to put maladaptive behaviors, such as cutting and drinking, into a narrative sequence
  • Some patients convey disorganized and confusing narratives


Case 3 : Exploring a dream

This case is of a woman who has made considerable progress, but is now becoming ambivalent about continuing treatment and recovery.  The vignette illustrates how dreams that patients bring to sessions can be usefully explored.  In general, dream work involves narrative elaboration of the dream sequence, asking about the patient’s emotional responses to particularly intense situations in the dream, and exploring possible meanings.  Two ways of thinking about dreams within DDP is either that it’s a transference dream in that one of the characters represents the therapist, or that all the characters in the dream represent different aspects of the patient.

                                                   Association: Case 3 Video

                                                                   Case 3: Transcript

Case 3: Commentary

In the preceding vignette, the patient relates a dream about a helicopter ride.  An important context for this dream is that the patient is far along in treatment and is roughly between Stage III and Stage IV of recovery when she shares it.  Stages III and IV are characterized by ambivalence towards treatment and recovery as the patient begins to face the hard realities of limitations of self and other, and the difficulties inherent in transitioning from a child-like sick role to the often overwhelming adult world of responsibility, heartache, and disappointment.

In this vignette, the dream is fairly detailed, so the therapist does not need to spend a lot of time elaborating the narrative sequence, but instead focuses on the patient’s emotional responses.  For example, the therapist asks, “Are you scared a lot these days?”  Towards the middle of the discussion, the therapist also provides a framework for further exploration by suggesting that one way to interpret the dream is that all the different characters in the dream represent different aspects of the patient.  This framework allows the patient to get more fully in touch with her ambivalence about treatment and recovery, which is a central issue for this particular patient.

Case 3: Key Points

  • Exploring a dream involves narrative elaboration of the dream sequence, asking about the patient’s emotions in response to particularly intense situations in the dream, and exploring possible meanings
  • Stages III and IV of treatment are characterized by ambivalence towards the recovery process as patients begin to face the hard realities of taking responsibility for their life and the limitations of self and other
  • Dream exploration is sometimes facilitated by providing a framework for the different ways that dreams can be interpreted


Case 4 : Patient describes developing a subjective sense of self

This vignette is a monologue of a young woman who is in Stage II of treatment.  She is reflecting on her treatment and what she feels has been helpful to her.

                                                     Association:  Case 4 Video

                                                                    Case 4: Transcript

Case 4: Commentary

This vignette was taken from a clip of a session about 3 months into treatment, when the patient was early in Stage II.  Up to this point in treatment, the therapist had applied mainly Association techniques, helping the patient to put her experiences into narrative sequences and to identify, verbalize, and acknowledge her emotions. 

The reason I have included this vignette is that it’s such a great illustration of how important and life-changing it can be for patients to simply have an opportunity to verbalize their emotional experiences with an empathic therapist.  Note that the therapist did not attempt to validate the patient’s feelings by suggesting that they were appropriate or inappropriate, nor to make meaning of her experiences.  The therapist had simply listened and asked questions.

As the patient so clearly states, Association interventions aimed at helping the patient to articulate her emotional experiences, have facilitated the development of a subjective sense of self.  The patient now has a sense of existing or being and no longer feels invisible.

Case 4: Key Points

  • Simply providing patients an opportunity to verbalize their emotion-laden experiences using Association techniques can lead to the development of a subjective sense of self