Introduction to Dynamic Deconstructive Psychotherapy Training: Part 5
We will end this video training program with a discussion of enactment. Enactment is a central aspect of pathology and is discussed in Chapter 1 of the treatment manual. Enactment refers to the tendency for many patients to engage others in interactions that tend to reinforce patients’ distorted and polarized attributions of themselves and others. As therapists, we often feel compelled to respond to our patients in maladaptive ways. It takes an active effort on the part of the therapist to maintain a therapeutic stance and adherence to DDP methods. Our tendency to leave a therapeutic framework is the main reason why on-going clinical supervision or consultation is so essential for successful treatment of this patient population.
The treatment manual does not have a separate section devoted to enactment. However, each section in Chapter 8, Specific Techniques, is following by a discussion of common enactments. Common types of therapist enactment and/or contraindicated techniques of DDP include: directing discussion towards childhood experiences, physical symptoms, or medication; confidently completing patient narratives for them; asserting that a given feeling or action is justified/unjustified; assertively attributing a certain motivation, value or emotion to the patient or others; persuading, encouraging, reassuring, or advising in response to passivity or hopelessness; providing a rationale, denial, apology, or interpretation in response to criticism or disagreement; answering questions about therapist lifestyle or feelings; and acquiescing to patient requests to change the usual treatment parameters. These are also listed on the DDP Adherence Scale in the Appendix of the manual. The DDP adherence scale can be used to rate the overall adherence of a given therapy session.
Case 1: Difficulty in Stage IV
This case is of a young woman in Stage IV of treatment. Stage IV is an especially difficult stage for therapists to stay adherent to DDP principles as the transference intensifies and as therapists struggle with their own worries about termination (see also Case 3 Commentary in Alterity – Real).
Case 1: Commentary
In this vignette, the patient is in the Guilty Perpetrator State. She is very down on herself and feels hopeless that her marriage will ever improve.
This state tends to provoke very strong countertransference reactions on the part of therapists, who then feel an urge to rescue or to reassure. Countertransference is intensified in the context of forthcoming termination, with a strong wish to see the patient better by the time of discharge. Thus, we see the therapist in this vignette having difficulty empathically exploring the patient’s depressive state, but instead trying to fix it.
After asking whether the patient feels that she is a good mother, the therapist tries to reassure the patient that she is worthwhile. Reassurance in this situation represents an enactment of the patient’s attribution of the therapist as helpless rescuer and only deepens the patient’s depression and hopelessness. A better intervention would have been to work towards exploring and integrating polarized attributions she has towards herself as a mother and towards her relationship with her husband. Instead, the therapist enters into another enactment by attempting to validate the patient’s feelings of anger and does not allow the patient to explore the central thematic question of whether her anger is justified (in Stage II the central thematic question is, “Do I have a right to be angry?”).
Later in the interview, the therapist tries to resolve the marital difficulty by stating, “Maybe there’s some component of you being so angry at yourself and at him that that’s what makes it all blow up worse.” This is followed by a suggestion that the patient should try to be less angry at herself. Both of these interventions violate the dictum to stay neutral between the patient’s conflicts (see Association, Case 1 Commentary, and also Chapter 5, The Therapeutic Stance). The interventions enact the patient’s self-attribution in the Guilty Perpetrator State as having all the agency, and that the marriage would be fine if only she were to change. The patient ends the segment by essentially stating that she can’t change because she is irredeemably bad.
It’s very easy for therapists to enter into enactments with patients suffering from more severe chronic conditions, such as borderline personality disorder. They often make us feel compelled to respond in unproductive ways. Our immense challenge as therapists is to somehow maintain self-awareness and reflection, while remaining empathically attuned to the patient’s discourse and staying between the conflicts. Fortunately, we don’t have to be perfect…just “good enough”.
Case 1: Key Points
- The guilty perpetrator state tends to provoke very strong countertransference reactions on the part of therapists, who then feel an urge to rescue or to reassure, especially as termination approaches
- Reassurance in this situation represents an enactment of the patient’s attribution of the therapist as helpless rescuer and only deepens the patient’s depression and hopelessness
- Attempting to validate a patient’s feelings of anger can be another form of enactment since it does not allow patients to explore the Stage II central thematic question of whether their anger is justified
- Enactment occurs when therapists leave the therapeutic stance and fail to stay neutral, between the patient’s conflicts
- A therapeutic stance involves maintaining self-awareness and reflection, while remaining empathically attuned to the patient’s discourse and staying neutral between the conflicts