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Dynamic deconstructive psychotherapy for substance use disorders co-occurring with personality disorders
Dynamic deconstructive psychotherapy for substance use disorders co-occurring with personality disorders
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Robert J. Gregory Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, United States
Conventional wisdom regarding substance use disorders often emphasizes the biomedical model, that is, understanding substance use disorders as resulting from a genetic predisposition kindled by the direct effects of chemical substances on the brain’s neural reward circuitry. Certainly, it is important to acknowledge the effects of external chemicals on human motivation, that is, how the chemicals can induce physical dependence through tolerance and withdrawal, as well as how they can activate the opioid and dopamine reward systems in the brain and downregulate the receptors of those same neurotransmitters, leading to increasing drug craving and dysphoria. The biomedical model usefully explains why laboratory animals will repeatedly inject themselves with certain chemicals to the point of death. This model has more difficulty explaining why addictive behavior may occur with drugs that do not induce physical dependence, such as some hallucinogens, or with nonchemical activities, such as gambling. Alternatively or adjunctively, a behavioral model for understanding substance use disorders has been proposed. In this model, chemicals and activities that are highly pleasurable are understood to be highly reinforcing of addictive behaviors. Behaviors that are reinforced tend to increase in frequency and, over time, can be difficult to extinguish. The behavioral model helps us to understand how pleasurable activities can become as addictive as certain chemicals. It also helps us to understand how environmental cues that remind us of the reinforcer, that is, are conditioned with it, can trigger cravings (think of Pavlov’s dogs). The behavioral model does not take into account mental processes, the unconscious, relationships, identity, or emotions. It has difficulty explaining why addictive behavior can persist despite strong negative consequences that should counteract the reinforcing effects of the chemical or pleasurable activity. It also cannot explain the profound personal and interpersonal aspects of addictive illness (e.g., why therapists may dread treating individuals who struggle with substance use disorders and use pejorative labels?). The present chapter aims to present a contemporary psychodynamic understanding of addiction, especially its personal and interpersonal aspects. It will also Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00011-8 © 2019 Elsevier Inc. All rights reserved.
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introduce dynamic deconstructive psychotherapy (DDP) (Gregory & Remen, 2008), a psychotherapy model that uses this psychodynamic understanding to effectively treat individuals suffering from addictive illness, especially those cooccurring with personality disorders.
Emotion processing There is evidence that the etiology of substance use disorders varies in different groups of individuals. For example, individuals with trauma histories tend to use substances in response to negative emotions and stressful situations, whereas those without trauma histories tend to use substances in response to environmental cues (Waldrop, Back, Verduin, & Brady, 2007). An interpretation of these findings is that the latter group of individuals may have a biological drive for certain substances, which is induced through continued use of the substance and is triggered by environmental cues. However, individuals with a history of trauma may use substances to self-medicate their distress, employing their addiction as a coping mechanism. An overlapping group of individuals, that is, those with personality disorders, may also turn to substances as a coping mechanism. Up to two thirds of individuals with borderline personality disorder (BPD) have cooccurring substance use disorders (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). Tragesser, Trull, Sher, & Park (2008) demonstrated that among individuals with cluster B personality disorders, drinking alcohol serves in part to cope with negative emotions. In order to understand why substances can provide important soothing functions for individuals with personality disorders, it is helpful to look at the neuroscience of emotion processing. Normal and adaptive processing of emotions involves activation of neural pathways through the prefrontal cortex, enabling identification of emotions, accurate appraisal of experiences, and selection of appropriate responses (Ochsner et al., 2004). However, studies examining emotion processing of individuals with personality disorders, especially BPD, indicate that the prefrontal areas are relatively deactivated when the individual is presented with an emotional stimulus, such as viewing upsetting photographs (New, Perez-Rodriguez, & Ripoll, 2012). When individuals are unable to use their prefrontal areas to identify their emotions and appraise their experiences, certain subcortical areas of the brain become hyperactivated in response to an emotional stimulus, especially the amygdala, which mediates anxiety and arousal, and the ventral striatum, which mediates impulsive pleasure seeking. Such individuals therefore become anxious and hyperaroused when presented with an emotional stimulus, such as rejection. They then seek impulsive pleasurable activities, such as binge eating, shopping, sex, or substance use, since these activities dampen their arousal through a negative feedback loop from the ventral striatum to the amygdala. Thus engagement in impulsive pleasurable activities serves as a primitive coping mechanism to manage the anxiety and hyperarousal that are characteristic of this population’s response to emotional stress.
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The treatment implication of this model is for therapists to find ways to strengthen the higher level neural pathways for emotion processing. A remarkable and well-replicated neuroscience finding is that when healthy individuals simply try to identify emotions in response to a stimulus, activity in the amygdala and physiological arousal decrease (Lieberman et al., 2007). Helping patients to identify specific emotions can help to reroute emotion processing from the subcortical regions to the prefrontal cortex, therefore decreasing anxiety and arousal, and decreasing the need to use substances or other impulsive pleasurable activities to self-soothe. The analogy in physical medicine is the treatment of stroke. After the first few hours the only effective treatments are physical therapy and occupational therapy. Through these treatments, patients can sometimes achieve complete or nearcomplete restoration of functioning. The reason that these treatments are effective is that they reroute neural processing from dead nerve cells to alternative neural pathways through repeated practice. There is an old adage: Neurons that fire together wire together. As these motor neuron pathways become strengthened through continued practice, neuromuscular functioning is restored. Similarly, an important mechanism of psychotherapy is to rewire the brain through strengthening of higher level neural pathways for emotion processing (see the subsection “Association” under the section “Summary of the dynamic deconstructive psychotherapy treatment model”).
The denial system and relationships In addition to self-soothing, another important function of substance use among individuals with personality disorders is that they substances can serve as a substitute for relationships. Patients sometimes tell me that giving up smoking was like saying goodbye to their best friend. Thus soothing and comforting aspects of addiction have an interpersonal aspect. This may not be surprising, given that the attachment system and the drug reward system are mediated through the same brain region, that is, the ventral striatum, and through the same receptor system, that is, µ opioid receptors (Moles, Kieffer, & D’Amato, 2004). In other words, the brain’s reward system cannot tell the difference between a hug and a drug. The advantage of having a drug as your best friend is that a drug is a friend who will never hurt you or betray you; it is a relationship in which you are in control—or at least that is the fantasy; the denial system maintains an illusion of control. Mark Twain is said to have quipped, “Cigarettes are the easiest things to quit in the world! I’ve quit hundreds of times!” Individuals struggling with substance use disorders will use similar language, but not get the humor of the statement. The phenomenon of splitting is also part of the denial system. In splitting, individuals with substance use disorders hold in consciousness either idealized or devalued attributions regarding their substance use but not both at the same time. For example, they may describe their substance use as “a nasty habit that does me no good.” Conversely, they may describe the wonderful effects of the substance but
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split off from consciousness its negative consequences. For example, they may describe their substance use as “the only thing that helps me to relax and be myself. I don’t see any problem with it.” This tendency against psychological integration of the positive and negative aspects of substance use makes it difficult for addicted individuals to think effectively about their relationship with the substance and to gain perspective on their addictive behavior. A treatment implication is for the therapist to help patients to acknowledge both positive and negative aspects of their substance use and to hold the opposing perspectives in their consciousness at the same time. It is sometimes helpful to think of addiction as a type of transitional object, since it has many of the same features, as expounded by Winnicott (1953). Addictions, such as those to alcohol and drugs, have soothing and comforting qualities; they enable separation from real relationships, provide an illusion of omnipotent control, and bridge the boundary between internal and external reality. The denial system, with its illusion of control, accounts for why the CAGE questionnaire is such an effective screen for alcoholism. The C of the CAGE asks, “Have you ever tried to cut down on your drinking?” Often, the alcoholic will proudly provide an affirmative response, since he or she has “quit hundreds of times.” The denial system also accounts for why Step 1 of Alcoholics Anonymous (AA) is so helpful and also so difficult (Johnson, 1993). Step 1 is to “admit that I am powerless over my drinking behavior.” This step challenges the very core of the denial system, that is, the illusion of control. Finally, the denial system, including both the fantasy of control and splitting, accounts for why a motivational interviewing approach can be helpful. In motivational interviewing, the therapist respects the autonomous decision-making of the patient, thereby enabling the patient to maintain a sense of control while bringing together the split attributions involved in the addictive behavior. An important treatment implication is for the therapist to be sensitive to the patient’s sense of vulnerability in close relationships and fear of control. It is therefore especially important in this patient population to respect the patient’s autonomy. Technically, this includes avoiding asking intrusive questions, letting patients set the agenda for the session, and avoiding giving advice or instruction. It is also important to be very receptive to criticism or disagreement, providing many opportunities for patients to verbalize their ambivalence about treatment, abstinence, and/ or the patient therapist relationship. The more the ambivalence is verbalized, the less it will be acted out. Respect for autonomy does not imply that the therapist cannot provide information about substances and the potentially harmful effects of their use, but the therapist does so in the role of a consultant, letting the patient decide what to do with the information, and respecting the patient’s right and ability to choose what is in his or her own best interests. For example, a therapist might state, “It’s possible that much of your anxiety and periods of depression are due to heavy alcohol use. I am not saying that you should give up the drinking behavior, but I am sharing this so that you can be fully informed when deciding whether the positive benefits that you derive from drinking outweigh the downside risks.”
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Another clinical implication of the denial system is the importance for the therapist to check in regularly with addicted patients about any recent relapses of substance misuse and to explore these incidents. A common mistake of therapists is to ignore the addiction and instead to focus exclusively on stressors and relationships, both past and present, providing support, advice, and interpretation of these. The results of this mistake are not immediately apparent. At first, everything seems to be going well; the patient seems engaged in treatment and the therapist is feeling useful. The only difficulty is that the patient’s presenting symptoms of depression or anxiety are not getting better and actually seem to be gradually getting worse. It is eventually revealed that the addictive behavior has worsened over time, culminating in a medical, financial, legal, or family crisis. The therapist ends up feeling foolish, as though he or she has been duped and betrayed, and vows never again to treat addicted patients with psychodynamic therapy. This commonly occurring anecdote can be understood as the therapist unconsciously participating in the patient’s denial system, minimizing the central importance of the addiction, and mutually avoiding speaking of it. As the therapy progresses toward exploration of sensitive material, the patient increasingly fears and resents the therapist’s intrusive questions, advice, and interpretations. To maintain the relationship, even while distancing himself or herself from it, the patient turns increasingly to addictive behaviors, often using the substances before sessions.
Relational dynamics of shame (or why do we dread patients with substance use disorders?) The denial system is driven not only by a fear of loss of control, but also by shame. Therapists will be unable to effectively manage patients’ addictions unless they recognize the profound and often unconscious sense of shame underlying all addictive behavior. Shame can be difficult to recognize in addicted patients, since they can often appear grandiose. One way to understand this is to think of severely addicted patients as having a narcissistic self-structure characterized by a grandiose self that is conscious while their shameful and shaming internal objects are split off and projected onto others, repressed, or defended against through blame and externalization of agency (Kernberg, 1975). For example, such individuals may blame losing their job on having an unreasonable boss rather than on repeatedly showing up late or intoxicated to work. Spouses are another frequent target of externalization; for example, the patient may say, “I wouldn’t need to drink if my wife weren’t on my case all the time!” The combination of bragging about accomplishments while blaming others for negative consequences of the patient’s addictions engenders scornful, judgmental, and pejorative countertransference reactions among friends, families, and providers who interact with patients who have substance use disorders. A natural countertransference impulse is for the therapist to give the patient a reality check and say something like “I notice you are blaming everyone else for your problems. Until
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you start taking responsibility for the consequences of your addictive behavior, you are not going to get very far in recovery.” What the therapist is not understanding is that the patient’s grandiosity and externalization are intrapsychic defenses against shame, and therefore any intervention that induces further shame will be unsuccessful. Instead of breaking through the grandiosity, such an intervention will only cause the patient to become more defensive, either reacting with hostility, demanding of the therapist, “Just who do you think you are to judge me?,” or detaching from the therapist and seeking a safer, more soothing relationship with a substance. A patient once confided to me, “Every time my doctor tells me to quit drinking, I get a strong urge to drink and head for the nearest bar after the visit.” As discussed earlier, a fantasy of control is an important component of the denial system. This fantasy protects against the feelings of shame, concern, and helplessness that are engendered through an inability to control the addiction, despite repeated negative consequences. Individuals with substance use disorders are remarkably adept at unconsciously transferring these feelings and reactions onto friends, family, and providers by using projective identification. Family members typically try to control the addictive behaviors through hiding substances in the home or through threats, for example, “I’m going to leave you unless you stop drinking.” The family members have incorporated the afflicted individual’s fantasy that the addictive behavior can be controlled through willpower. A major focus of Al-Anon is to help families to realize that they are unable to control their family member’s addiction. By way of the patient’s projective identification, therapists may also incorporate the fantasy of control and will often manifest the fantasy through suggestions that their patients cut down on their use of addictive substances. As part of this fantasy, therapists believe that they can control the addiction through the power of providing insight, education, and suggestions. For example, a therapist might state, “Your excessive drinking is causing you to feel sick and feel even worse about yourself, which is causing you even more stress. If you cut down on your drinking and exercise regularly, you will feel healthier, less stressed, and will have more energy.” The patient might accept this insight and suggestion with gratitude, because the patient shares the fantasy of control with the therapist. But as the urges become uncontrollable and the behavior spins out of control again, the patients attempt to hide their addictive behavior and its severity from both themselves and their therapists. After weeks or months, the therapist finds out that the addictive behavior has worsened and then feels duped, angry, and helpless. After many such episodes, the therapist begins to feel hopeless about ever being able to be helpful to the addicted patient or to other individuals suffering from addictions and will try to avoid treating this patient population in the future. They will tell prospective patients, “First get your substance misuse under control. Then we can start the therapy.” One treatment implication of shame dynamics is to support patients’ self-esteem even when they are grandiose, to avoid control struggles, and to keep the conflict within the patient. Self-esteem can be supported by labeling the substance use disorder as an illness that is largely outside the patient’s control. The therapist can reinforce this message by reminding patients of Step 1 of AA, that is, admitting
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powerlessness over the addiction. If substance misuse is outside the patients’ control, the patient no longer needs to feel ashamed about it. Although these patients cannot control their substance misuse, they can control and accept responsibility for getting into treatment and staying in treatment. That’s a powerful message for individuals struggling with addictions. Self-esteem can also be supported through mirroring. Mirroring is a paradoxical technique developed by Kohut (1995) for the treatment of narcissistic personality disorder. Kohut described mirroring as “the gleam in the mother’s eye, which mirrors the child’s exhibitionistic display” (p. 116). Thus the therapist acts as a mirror to the grandiosity, reflecting it back to the patient instead of challenging it. For example, when a patient begins to brag about the many textbooks he or she has read and how much more psychology he or she knows than the therapist, the countertransference impulse is for the therapist to provide a reality check and ask, “So what graduate school in psychology did you attend?” This is a shaming response that only ends up strengthening the patient’s grandiosity in order to defend against shame. Instead, a mirroring response would be to state, “Wow! You are well read and know a lot about psychology.” In my experience, the stronger the countertransference impulse toward a reality check, the more effective a mirroring response will be. Often, the results can be immediate and dramatic as the patient begins to identify and acknowledge shame about substance misuse and to take responsibility for his or her actions. Another treatment implication of shame dynamics is to avoid control struggles and to keep the conflict within the patient, that is, to change the conflict from an interpersonal phenomenon to an intrapsychic phenomenon. This can be very difficult to achieve, since addicted patients will attempt to engage the therapist in a control struggle in order to maintain the denial system and avoid an intrapsychic conflict. A good general rule is that if therapists find themselves in a control struggle with their patients, they are likely involved in an enactment, and the session is heading in the wrong direction. I am reminded of a severely addicted patient who presented to me stating, “Doc, you got to do something about my drinking. It’s killing me!” My countertransference emotion was hopelessness, given the severity of his addiction and repeated unsuccessful attempts at rehabilitation. Nevertheless, I proceeded to run through a list of treatment options and facilities, stating, “Just because prior attempts at rehab were unsuccessful doesn’t mean that future ones will be too. Usually it takes more than one attempt at rehab before a lasting recovery can be achieved.” The patient responded, “But I don’t want to quit drinking!” So there we were, only 2 minutes into the interview and already in a control struggle. The patient was attempting to transfer his concerns about drinking onto me through projective identification. Fortunately, in this instance I was able to recognize the defense and respond therapeutically, stating, “But that is the question, isn’t it? What do you want? When you entered the room, you asked me to help you with your drinking, but now you’re not so sure you want to quit. Your drinking must do some very good things for you if you are still wanting to continue using it despite the many negative consequences you have sustained. If you would like, we can explore together the good and bad aspects of drinking so that you can weigh these
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together and decide what you’d like to do. I’m in no position to judge what is best for you. Only you can decide that.” Through this intervention, I was able to avoid the control struggle that the patient was unconsciously attempting to create and instead put the conflict about whether or not the patient should drink back onto the patient, where it could be resolved.
Dynamic deconstructive psychotherapy DDP is a treatment that takes into account the emotion processing, denial system, and shame dynamics of addiction as outlined above and presents an organized, systematic approach (Gregory & Remen, 2008). It incorporates findings from neuroscience research and object relations theory, especially emphasizing the ideas of Winnicott, Kernberg, and Kohut. The overarching treatment philosophy is deconstructive in orientation. Derrida defined deconstruction as “openness to the other” (Derrida, 2004, p. 155). This philosophy suggests a deferral of assured meaning and an openness to different perspectives. DDP therapists try not to make authoritative interpretations about the meaning behind their patients’ actions or how patients should best live their lives. Instead, therapists work toward facilitating the development of a complex and integrated self through creating a safe space for patients to put their experiences into words, to explore new perspectives on their experiences, and to risk authenticity in their relationship with the therapist. DDP was originally developed for treatment-resistant BPD, especially for cases complicated by cooccurring substance use disorders, but has since been used with many different disorders, especially those involving impulsive behaviors and suicide risk. Both process and outcome researches have been performed on DDP, as summarized below.
Empirical research on DDP Empirical research supporting the effectiveness of DDP is based primarily on two clinical trials. The first was a 12-month randomized controlled trial for individuals suffering from cooccurring alcohol use disorders and BPD (Gregory et al., 2008), with a 30-month naturalistic follow-up (Gregory, Delucia-Deranja, & Mogle, 2010). Participants in the study were severely ill; almost half (43%) met criteria for antisocial personality disorder, and 83% met criteria for other substance use disorders. Because of ethical concerns, participants in the control group were not assigned to just a minimalist treatment but were instead referred to the best alternative treatment available in the community, depending on availability and the participant’s willingness to engage in such treatment. The control treatments, labeled optimized community care (OCC), included drug and alcohol rehabilitation facilities, dialectical behavior therapy (DBT), case management, pharmacotherapy, and therapists of an eclectic orientation specializing in the treatment of BPD. When both individual and group contacts were added together, the OCC participants actually received
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greater treatment intensity than those receiving DDP. DDP was carried out primarily by psychiatry residents, who had received 3 6 months of weekly training and supervision prior to treating study participants. By the end of the 12-month trial, individuals who had received DDP achieved significantly greater reductions in symptoms of BPD, depression, and heavy drinking than those who had received OCC. These differences were even greater at 30-month follow-up. Clinical response rates for BPD were 90% for individuals receiving 12 months of DDP, as compared to only 40% for those receiving OCC. Moreover, illicit drug use markedly decreased during treatment with DDP, completely remitting by 12 months and sustained at 30-month follow-up. Those receiving OCC, however, steadily increased their use of illicit drugs throughout treatment and follow-up. The second clinical trial was a quasirandomized observational study examining 12-month outcomes of patients treated at a medical university BPD specialty clinic by therapists who were expert in DDP or DBT (Gregory & Sachdeva, 2016). All patients met criteria for BPD, and most had a cooccurring alcohol or drug use disorder. Three treatment modalities were compared: DDP, comprehensive DBT (individual and group components), and a control treatment of weekly eclectic individual psychotherapy with or without DBT skills group. The outcomes of this study were remarkably consistent with those of the prior trial. Patients who received DDP were significantly more likely to achieve reductions in symptoms of BPD and depression than the control recipients; 90% of those receiving 12 months of DDP achieved a clinical response, compared to 40% of those receiving the control treatment. Patients receiving DBT had an intermediate response rate of 67%. In the intent-to-treat analysis, patients receiving DDP had significantly greater reductions in BPD symptoms, depression, and self-harm than those receiving DBT and experienced greater improvement in social and occupational functioning. Other research on DDP has focused on mechanisms of change. When video recordings of DDP sessions were rated by observers who were blinded to outcome, therapist adherence to the DDP treatment model was found to correlate strongly with outcome (r 5 0.64), suggesting that DDP works primarily through specific mechanisms rather than through common factors, such as therapist warmth and attentiveness (Goldman & Gregory, 2009). After an independent review of the evidence supporting its effectiveness by a US federal agency, the Substance Abuse and Mental Health Services Administration, DDP was included in the National Registry of Evidence-Based Programs and Practices (www.nrepp.samhsa.gov).
Summary of the DDP treatment model In a nutshell, the overall aim of DDP is to help individuals to connect to themselves and to others. In other words, DDP creates a safe space to help individuals to identify, acknowledge, and bear their interpersonal experiences and emotional pain, instead of using avoidance maneuvers, and to take the risk of relating to others in more authentic ways, beginning with the patient therapist relationship. DDP involves weekly individual therapy sessions, each lasting 45 50 minutes. It is
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time-limited treatment (12 months), with the end date set at the beginning of treatment. There are four stages of treatment and recovery, each with a specific task and underlying thematic question; successful negotiation of each stage is important for a lasting recovery (Gregory, 2004). In negotiating each stage, DDP employs three basic sets of techniques: association, attribution, and alterity.
Association Association techniques aim to help patients link their experiences to their symbolic verbal capacity. Most commonly, this involves helping patients to put their recent emotionally laden social interactions into words, but can also involve exploration of creative activities, such as dreams, artwork, or poetry. As explained in the “Emotion processing” section, individuals with addictions and personality disorders commonly have an extraordinarily difficult time verbalizing specific interpersonal interactions and their emotional responses. They may be very glib when it comes to speaking generally about their experiences with other people, but when the therapist asks them to share specific instances, to put the events in sequence, and to label their emotional responses, they struggle to find the words to describe their experiences. Within DDP, symptoms of anxiety and arousal are viewed and framed as evidence of unprocessed underlying emotions, such as anger or shame, which patients are not able to identify, acknowledge, and bear. The therapist helps patients to recognize, verbalize, and tolerate such painful emotions. Through remediating emotion-processing pathways, association techniques help with the symptoms that are caused by subcortical activation and prefrontal deactivation. For patients who are well engaged in treatment, anxiety markedly improves within 2 3 months of beginning treatment. As the levels of anxiety and arousal settle down, craving for substances also diminishes. And as patients become better able to identify their emotions, they develop a greater sense of self and a more stable identity. DDP has been found to be an effective treatment for dissociative identity disorder (Chlebowski & Gregory, 2012), with association techniques being particularly helpful (Goldman & Gregory, 2010).
Attribution Whereas association techniques help patients to verbalize their interpersonal experiences, attribution techniques address how patients make meaning of those experiences. Attributions of individuals with addictions, as well as those with borderline or narcissistic traits, tend to be rigid and polarized, a phenomenon that has been referred to as splitting (see section “Denial system and relationships”). Two kinds of splitting have been noted in the literature. Most commonly, splitting refers to attributions of value in which self and other (or substances) become either idealized or devalued, with little in between. The second form of splitting is one of agency rather than value. I am using the term agency to refer to the agent of change, that is, the person responsible for the consequences. Patients may sometimes see themselves as an innocent victim of others’ actions, bearing no responsibility for their
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present circumstances; the opposite may also occur, when patients see themselves as the perpetrator and the cause of all their troubles. One way in which DDP aims to deconstruct this rigid and polarized attribution system is by asking about opposite or alternative meanings within interpersonal narratives and then helping patients hold both sides of the split in their consciousness at the same time. For example, when patients are explaining how soothing and helpful cannabis is for them (idealization of the drug), the therapist might bring in the other side by asking, “In addition to its helpful aspects, do you also have concerns about your use of cannabis?” As another example, when patients are complaining about how others are criticizing their drinking (having a self-attribution as victim), the therapist might point out, “But I can guess who is your harshest critic,” and the patient usually responds by saying, “Me” (now having shifted into a self-attribution as perpetrator).
Alterity Splitting involves more than a polarized attribution system. It also encompasses an intersubjective matrix in which therapists’ “buttons are pushed” by patients’ projective identifications, which can lead to therapists responding to patients in ways that reinforce the patient’s polarized attributions. For example, therapists may feel compelled to make shaming remarks to their addicted patients, which end up reinforcing patients’ devalued attributions of themselves (see section “Relational dynamics of shame”). The term alterity refers to otherness, that is, an outside and more objective perspective. Alterity techniques break through the patient’s self-reinforcing and polarized attribution system and open up new possibilities for relatedness within the patient therapist relationship (Gregory, 2005). Techniques within this category are experiential and relational in nature, involving deconstructive aspects of the patient therapist relationship in the here-andnow. Patients with severe personality pathology, including those having substance use disorders, are unable to find space for themselves in relationships. They tend to believe that in order to maintain relationships, they must conform totally to the other person’s values, motives, and opinions. Their expectation is that to do otherwise will inevitably result in being rejected and ejected from the relationship. The patients thus act as chameleons, making themselves invisible in relationships. They may also experience difficulty differentiating their own values, motives, and opinions from those of individuals with whom they are in relationship, a phenomenon that Kernberg has labeled identity diffusion (Kernberg, 1975, p. 165). When disagreement or resentment builds up within the patient toward others, it either is quelled through the use of substances; is turned against the self in the form of depression, cutting, and suicide ideation; or spills over into hostility. Alterity techniques provide a sense of safety within the patient therapist relationship by balancing caring and respect with maintenance of clear boundaries, roles, and expectations. Alterity techniques also provide space for patients to feel close to the therapist, while also being authentic, a phenomenon that can be called individuated relatedness. In order to facilitate individuated relatedness, the therapist
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attempts to be a soothing and warm presence while supporting autonomous decision-making, withholding judgment regarding the patient’s decisions (either positive or negative), and encouraging the patient to voice criticism of and disagreement with the therapist. For example, when patients are complaining about other people judging them for their use of substances, an Alterity technique is to ask the patient, “Do you ever feel that way here?” Even if the answer is no, the intervention is still therapeutic, since it gives patients the message that they do not have to play the “good patient” in their relationship with the therapist; they have space to be themselves. The question also deconstructs the patient’s expectation that the therapist will be harsh and judgmental and thus opens up new possibilities for relationships, strengthening the patient’s sense of trust. In process research, the use of alterity techniques has been found to be strongly correlated with improvement in social functioning (Goldman & Gregory, 2010).
Conclusion As can be understood from the above summary of DDP, this treatment model can be considered as having both unique and common elements with other psychoanalytically oriented therapies, differing more in emphasis than in absolutes. The overall treatment philosophy of DDP is less authoritative and interpretative than most psychodynamic therapies, leaving it to the patient to be the final arbitrator of meaning and direction. There is a strong emphasis on helping patients to identify their emotions while recounting the details of specific social interactions, to create complex meanings to their experiences, to mourn their own and others’ limitations, and to experience a novel and deconstructive relationship with their therapist as important components of the healing process. Each of the three sets of techniques, that is, association, attribution, and alterity, helps to treat different aspects of the psychopathology and dynamic underpinnings of addiction and personality disorders, synergizing to build selfawareness and integration toward a long-lasting recovery. An updated version of the DDP treatment manual is available (at no cost) at www.upstate.edu/ddp. Other training materials are also available on the website, including video-recorded lectures and an interactive web-based training module.
References Chlebowski, S. M., & Gregory, R. J. (2012). Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy. American Journal of Psychotherapy, 66, 165 180. Derrida, J. (2004). Deconstruction and the other. In R. Kearney (Ed.), Debates in continental philosophy (pp. 139 156). New York: Fordham University Press. Goldman, G. A., & Gregory, R. J. (2009). Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 46, 480 485.
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Goldman, G. A., & Gregory, R. J. (2010). Relationships between techniques and outcomes for borderline personality disorder. American Journal of Psychotherapy, 64, 359 371. Gregory, R. J. (2004). Thematic stages of recovery in the treatment of borderline personality disorder. American Journal of Psychotherapy, 58, 335 348. Gregory, R. J. (2005). The deconstructive experience. American Journal of Psychotherapy, 59, 295 305. Gregory, R. J., Chlebowski, S., Kang, D., Remen, A. L., Soderberg, M. G., Stepkovitch, J., & Virk, S. (2008). A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder. Psychotherapy: Theory, Research, Practice, Training, 45, 28 41. Gregory, R. J., Delucia-Deranja, E., & Mogle, J. A. (2010). Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder cooccurring with alcohol use disorders: 30-month follow-up. Journal of Nervous and Mental Disease, 198, 292 298. Gregory, R. J., & Remen, A. L. (2008). A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training, 45(1), 15 27. Gregory, R. J., & Sachdeva, S. (2016). Naturalistic outcomes of evidence-based therapies for borderline personality disorder at a medical university clinic. American Journal of Psychotherapy, 70, 167 184. Johnson, B. (1993). A developmental model of addictions, and its relationship to the twelve step program of Alcoholics Anonymous. Journal of Substance Abuse Treatment, 10, 23 34. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. Kohut, H. (1995). The analysis of the self. Monograph series of the psychoanalytic study of the child, No. 4. Madison, CT: International Universities Press. Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18, 421 428. Moles, A., Kieffer, B. L., & D’Amato, F. R. (2004). Deficit in attachment behavior in mice lacking the µ-opioid receptor gene. Science, 304, 1983 1986. New, A. S., Perez-Rodriguez, M., & Ripoll, L. H. (2012). Neuroimaging and borderline personality disorder. Psychiatric Annals, 42, 65 71. Ochsner, K. N., Knierim, K., Ludlow, D. H., Hanelin, J., Ramachandran, T., Glover, G., & Mackey, S. (2004). Reflecting upon feelings: An fMRI study of neural systems supporting the attribution of emotion to self and other. Journal of Cognitive Neuroscience, 16, 1746 1772. Tragesser, S. L., Trull, T. J., Sher, K. J., & Park, A. (2008). Drinking motives as mediators in the relation between personality disorder symptoms and alcohol use disorder. Journal of Personality Disorders, 22, 525 537. Waldrop, A. E., Back, S. E., Verduin, M. L., & Brady, K. T. (2007). Triggers for cocaine and alcohol use in the presence and absence of posttraumatic stress disorder. Addictive Behaviors, 32, 634 639. Winnicott, D. W. (1953). Transitional objects and transitional phenomena; a study of the first not-me possession. International Journal of Psycho-Analysis, 34, 89 97. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2004). Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry, 161, 2108 2114.
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Robert J. Gregory Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, United States
Conventional wisdom regarding substance use disorders often emphasizes the biomedical model, that is, understanding substance use disorders as resulting from a genetic predisposition kindled by the direct effects of chemical substances on the brain’s neural reward circuitry. Certainly, it is important to acknowledge the effects of external chemicals on human motivation, that is, how the chemicals can induce physical dependence through tolerance and withdrawal, as well as how they can activate the opioid and dopamine reward systems in the brain and downregulate the receptors of those same neurotransmitters, leading to increasing drug craving and dysphoria. The biomedical model usefully explains why laboratory animals will repeatedly inject themselves with certain chemicals to the point of death. This model has more difficulty explaining why addictive behavior may occur with drugs that do not induce physical dependence, such as some hallucinogens, or with nonchemical activities, such as gambling. Alternatively or adjunctively, a behavioral model for understanding substance use disorders has been proposed. In this model, chemicals and activities that are highly pleasurable are understood to be highly reinforcing of addictive behaviors. Behaviors that are reinforced tend to increase in frequency and, over time, can be difficult to extinguish. The behavioral model helps us to understand how pleasurable activities can become as addictive as certain chemicals. It also helps us to understand how environmental cues that remind us of the reinforcer, that is, are conditioned with it, can trigger cravings (think of Pavlov’s dogs). The behavioral model does not take into account mental processes, the unconscious, relationships, identity, or emotions. It has difficulty explaining why addictive behavior can persist despite strong negative consequences that should counteract the reinforcing effects of the chemical or pleasurable activity. It also cannot explain the profound personal and interpersonal aspects of addictive illness (e.g., why therapists may dread treating individuals who struggle with substance use disorders and use pejorative labels?). The present chapter aims to present a contemporary psychodynamic understanding of addiction, especially its personal and interpersonal aspects. It will also Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00011-8 © 2019 Elsevier Inc. All rights reserved.
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introduce dynamic deconstructive psychotherapy (DDP) (Gregory & Remen, 2008), a psychotherapy model that uses this psychodynamic understanding to effectively treat individuals suffering from addictive illness, especially those cooccurring with personality disorders.
Emotion processing There is evidence that the etiology of substance use disorders varies in different groups of individuals. For example, individuals with trauma histories tend to use substances in response to negative emotions and stressful situations, whereas those without trauma histories tend to use substances in response to environmental cues (Waldrop, Back, Verduin, & Brady, 2007). An interpretation of these findings is that the latter group of individuals may have a biological drive for certain substances, which is induced through continued use of the substance and is triggered by environmental cues. However, individuals with a history of trauma may use substances to self-medicate their distress, employing their addiction as a coping mechanism. An overlapping group of individuals, that is, those with personality disorders, may also turn to substances as a coping mechanism. Up to two thirds of individuals with borderline personality disorder (BPD) have cooccurring substance use disorders (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). Tragesser, Trull, Sher, & Park (2008) demonstrated that among individuals with cluster B personality disorders, drinking alcohol serves in part to cope with negative emotions. In order to understand why substances can provide important soothing functions for individuals with personality disorders, it is helpful to look at the neuroscience of emotion processing. Normal and adaptive processing of emotions involves activation of neural pathways through the prefrontal cortex, enabling identification of emotions, accurate appraisal of experiences, and selection of appropriate responses (Ochsner et al., 2004). However, studies examining emotion processing of individuals with personality disorders, especially BPD, indicate that the prefrontal areas are relatively deactivated when the individual is presented with an emotional stimulus, such as viewing upsetting photographs (New, Perez-Rodriguez, & Ripoll, 2012). When individuals are unable to use their prefrontal areas to identify their emotions and appraise their experiences, certain subcortical areas of the brain become hyperactivated in response to an emotional stimulus, especially the amygdala, which mediates anxiety and arousal, and the ventral striatum, which mediates impulsive pleasure seeking. Such individuals therefore become anxious and hyperaroused when presented with an emotional stimulus, such as rejection. They then seek impulsive pleasurable activities, such as binge eating, shopping, sex, or substance use, since these activities dampen their arousal through a negative feedback loop from the ventral striatum to the amygdala. Thus engagement in impulsive pleasurable activities serves as a primitive coping mechanism to manage the anxiety and hyperarousal that are characteristic of this population’s response to emotional stress.
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The treatment implication of this model is for therapists to find ways to strengthen the higher level neural pathways for emotion processing. A remarkable and well-replicated neuroscience finding is that when healthy individuals simply try to identify emotions in response to a stimulus, activity in the amygdala and physiological arousal decrease (Lieberman et al., 2007). Helping patients to identify specific emotions can help to reroute emotion processing from the subcortical regions to the prefrontal cortex, therefore decreasing anxiety and arousal, and decreasing the need to use substances or other impulsive pleasurable activities to self-soothe. The analogy in physical medicine is the treatment of stroke. After the first few hours the only effective treatments are physical therapy and occupational therapy. Through these treatments, patients can sometimes achieve complete or nearcomplete restoration of functioning. The reason that these treatments are effective is that they reroute neural processing from dead nerve cells to alternative neural pathways through repeated practice. There is an old adage: Neurons that fire together wire together. As these motor neuron pathways become strengthened through continued practice, neuromuscular functioning is restored. Similarly, an important mechanism of psychotherapy is to rewire the brain through strengthening of higher level neural pathways for emotion processing (see the subsection “Association” under the section “Summary of the dynamic deconstructive psychotherapy treatment model”).
The denial system and relationships In addition to self-soothing, another important function of substance use among individuals with personality disorders is that they substances can serve as a substitute for relationships. Patients sometimes tell me that giving up smoking was like saying goodbye to their best friend. Thus soothing and comforting aspects of addiction have an interpersonal aspect. This may not be surprising, given that the attachment system and the drug reward system are mediated through the same brain region, that is, the ventral striatum, and through the same receptor system, that is, µ opioid receptors (Moles, Kieffer, & D’Amato, 2004). In other words, the brain’s reward system cannot tell the difference between a hug and a drug. The advantage of having a drug as your best friend is that a drug is a friend who will never hurt you or betray you; it is a relationship in which you are in control—or at least that is the fantasy; the denial system maintains an illusion of control. Mark Twain is said to have quipped, “Cigarettes are the easiest things to quit in the world! I’ve quit hundreds of times!” Individuals struggling with substance use disorders will use similar language, but not get the humor of the statement. The phenomenon of splitting is also part of the denial system. In splitting, individuals with substance use disorders hold in consciousness either idealized or devalued attributions regarding their substance use but not both at the same time. For example, they may describe their substance use as “a nasty habit that does me no good.” Conversely, they may describe the wonderful effects of the substance but
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split off from consciousness its negative consequences. For example, they may describe their substance use as “the only thing that helps me to relax and be myself. I don’t see any problem with it.” This tendency against psychological integration of the positive and negative aspects of substance use makes it difficult for addicted individuals to think effectively about their relationship with the substance and to gain perspective on their addictive behavior. A treatment implication is for the therapist to help patients to acknowledge both positive and negative aspects of their substance use and to hold the opposing perspectives in their consciousness at the same time. It is sometimes helpful to think of addiction as a type of transitional object, since it has many of the same features, as expounded by Winnicott (1953). Addictions, such as those to alcohol and drugs, have soothing and comforting qualities; they enable separation from real relationships, provide an illusion of omnipotent control, and bridge the boundary between internal and external reality. The denial system, with its illusion of control, accounts for why the CAGE questionnaire is such an effective screen for alcoholism. The C of the CAGE asks, “Have you ever tried to cut down on your drinking?” Often, the alcoholic will proudly provide an affirmative response, since he or she has “quit hundreds of times.” The denial system also accounts for why Step 1 of Alcoholics Anonymous (AA) is so helpful and also so difficult (Johnson, 1993). Step 1 is to “admit that I am powerless over my drinking behavior.” This step challenges the very core of the denial system, that is, the illusion of control. Finally, the denial system, including both the fantasy of control and splitting, accounts for why a motivational interviewing approach can be helpful. In motivational interviewing, the therapist respects the autonomous decision-making of the patient, thereby enabling the patient to maintain a sense of control while bringing together the split attributions involved in the addictive behavior. An important treatment implication is for the therapist to be sensitive to the patient’s sense of vulnerability in close relationships and fear of control. It is therefore especially important in this patient population to respect the patient’s autonomy. Technically, this includes avoiding asking intrusive questions, letting patients set the agenda for the session, and avoiding giving advice or instruction. It is also important to be very receptive to criticism or disagreement, providing many opportunities for patients to verbalize their ambivalence about treatment, abstinence, and/ or the patient therapist relationship. The more the ambivalence is verbalized, the less it will be acted out. Respect for autonomy does not imply that the therapist cannot provide information about substances and the potentially harmful effects of their use, but the therapist does so in the role of a consultant, letting the patient decide what to do with the information, and respecting the patient’s right and ability to choose what is in his or her own best interests. For example, a therapist might state, “It’s possible that much of your anxiety and periods of depression are due to heavy alcohol use. I am not saying that you should give up the drinking behavior, but I am sharing this so that you can be fully informed when deciding whether the positive benefits that you derive from drinking outweigh the downside risks.”
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Another clinical implication of the denial system is the importance for the therapist to check in regularly with addicted patients about any recent relapses of substance misuse and to explore these incidents. A common mistake of therapists is to ignore the addiction and instead to focus exclusively on stressors and relationships, both past and present, providing support, advice, and interpretation of these. The results of this mistake are not immediately apparent. At first, everything seems to be going well; the patient seems engaged in treatment and the therapist is feeling useful. The only difficulty is that the patient’s presenting symptoms of depression or anxiety are not getting better and actually seem to be gradually getting worse. It is eventually revealed that the addictive behavior has worsened over time, culminating in a medical, financial, legal, or family crisis. The therapist ends up feeling foolish, as though he or she has been duped and betrayed, and vows never again to treat addicted patients with psychodynamic therapy. This commonly occurring anecdote can be understood as the therapist unconsciously participating in the patient’s denial system, minimizing the central importance of the addiction, and mutually avoiding speaking of it. As the therapy progresses toward exploration of sensitive material, the patient increasingly fears and resents the therapist’s intrusive questions, advice, and interpretations. To maintain the relationship, even while distancing himself or herself from it, the patient turns increasingly to addictive behaviors, often using the substances before sessions.
Relational dynamics of shame (or why do we dread patients with substance use disorders?) The denial system is driven not only by a fear of loss of control, but also by shame. Therapists will be unable to effectively manage patients’ addictions unless they recognize the profound and often unconscious sense of shame underlying all addictive behavior. Shame can be difficult to recognize in addicted patients, since they can often appear grandiose. One way to understand this is to think of severely addicted patients as having a narcissistic self-structure characterized by a grandiose self that is conscious while their shameful and shaming internal objects are split off and projected onto others, repressed, or defended against through blame and externalization of agency (Kernberg, 1975). For example, such individuals may blame losing their job on having an unreasonable boss rather than on repeatedly showing up late or intoxicated to work. Spouses are another frequent target of externalization; for example, the patient may say, “I wouldn’t need to drink if my wife weren’t on my case all the time!” The combination of bragging about accomplishments while blaming others for negative consequences of the patient’s addictions engenders scornful, judgmental, and pejorative countertransference reactions among friends, families, and providers who interact with patients who have substance use disorders. A natural countertransference impulse is for the therapist to give the patient a reality check and say something like “I notice you are blaming everyone else for your problems. Until
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you start taking responsibility for the consequences of your addictive behavior, you are not going to get very far in recovery.” What the therapist is not understanding is that the patient’s grandiosity and externalization are intrapsychic defenses against shame, and therefore any intervention that induces further shame will be unsuccessful. Instead of breaking through the grandiosity, such an intervention will only cause the patient to become more defensive, either reacting with hostility, demanding of the therapist, “Just who do you think you are to judge me?,” or detaching from the therapist and seeking a safer, more soothing relationship with a substance. A patient once confided to me, “Every time my doctor tells me to quit drinking, I get a strong urge to drink and head for the nearest bar after the visit.” As discussed earlier, a fantasy of control is an important component of the denial system. This fantasy protects against the feelings of shame, concern, and helplessness that are engendered through an inability to control the addiction, despite repeated negative consequences. Individuals with substance use disorders are remarkably adept at unconsciously transferring these feelings and reactions onto friends, family, and providers by using projective identification. Family members typically try to control the addictive behaviors through hiding substances in the home or through threats, for example, “I’m going to leave you unless you stop drinking.” The family members have incorporated the afflicted individual’s fantasy that the addictive behavior can be controlled through willpower. A major focus of Al-Anon is to help families to realize that they are unable to control their family member’s addiction. By way of the patient’s projective identification, therapists may also incorporate the fantasy of control and will often manifest the fantasy through suggestions that their patients cut down on their use of addictive substances. As part of this fantasy, therapists believe that they can control the addiction through the power of providing insight, education, and suggestions. For example, a therapist might state, “Your excessive drinking is causing you to feel sick and feel even worse about yourself, which is causing you even more stress. If you cut down on your drinking and exercise regularly, you will feel healthier, less stressed, and will have more energy.” The patient might accept this insight and suggestion with gratitude, because the patient shares the fantasy of control with the therapist. But as the urges become uncontrollable and the behavior spins out of control again, the patients attempt to hide their addictive behavior and its severity from both themselves and their therapists. After weeks or months, the therapist finds out that the addictive behavior has worsened and then feels duped, angry, and helpless. After many such episodes, the therapist begins to feel hopeless about ever being able to be helpful to the addicted patient or to other individuals suffering from addictions and will try to avoid treating this patient population in the future. They will tell prospective patients, “First get your substance misuse under control. Then we can start the therapy.” One treatment implication of shame dynamics is to support patients’ self-esteem even when they are grandiose, to avoid control struggles, and to keep the conflict within the patient. Self-esteem can be supported by labeling the substance use disorder as an illness that is largely outside the patient’s control. The therapist can reinforce this message by reminding patients of Step 1 of AA, that is, admitting
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powerlessness over the addiction. If substance misuse is outside the patients’ control, the patient no longer needs to feel ashamed about it. Although these patients cannot control their substance misuse, they can control and accept responsibility for getting into treatment and staying in treatment. That’s a powerful message for individuals struggling with addictions. Self-esteem can also be supported through mirroring. Mirroring is a paradoxical technique developed by Kohut (1995) for the treatment of narcissistic personality disorder. Kohut described mirroring as “the gleam in the mother’s eye, which mirrors the child’s exhibitionistic display” (p. 116). Thus the therapist acts as a mirror to the grandiosity, reflecting it back to the patient instead of challenging it. For example, when a patient begins to brag about the many textbooks he or she has read and how much more psychology he or she knows than the therapist, the countertransference impulse is for the therapist to provide a reality check and ask, “So what graduate school in psychology did you attend?” This is a shaming response that only ends up strengthening the patient’s grandiosity in order to defend against shame. Instead, a mirroring response would be to state, “Wow! You are well read and know a lot about psychology.” In my experience, the stronger the countertransference impulse toward a reality check, the more effective a mirroring response will be. Often, the results can be immediate and dramatic as the patient begins to identify and acknowledge shame about substance misuse and to take responsibility for his or her actions. Another treatment implication of shame dynamics is to avoid control struggles and to keep the conflict within the patient, that is, to change the conflict from an interpersonal phenomenon to an intrapsychic phenomenon. This can be very difficult to achieve, since addicted patients will attempt to engage the therapist in a control struggle in order to maintain the denial system and avoid an intrapsychic conflict. A good general rule is that if therapists find themselves in a control struggle with their patients, they are likely involved in an enactment, and the session is heading in the wrong direction. I am reminded of a severely addicted patient who presented to me stating, “Doc, you got to do something about my drinking. It’s killing me!” My countertransference emotion was hopelessness, given the severity of his addiction and repeated unsuccessful attempts at rehabilitation. Nevertheless, I proceeded to run through a list of treatment options and facilities, stating, “Just because prior attempts at rehab were unsuccessful doesn’t mean that future ones will be too. Usually it takes more than one attempt at rehab before a lasting recovery can be achieved.” The patient responded, “But I don’t want to quit drinking!” So there we were, only 2 minutes into the interview and already in a control struggle. The patient was attempting to transfer his concerns about drinking onto me through projective identification. Fortunately, in this instance I was able to recognize the defense and respond therapeutically, stating, “But that is the question, isn’t it? What do you want? When you entered the room, you asked me to help you with your drinking, but now you’re not so sure you want to quit. Your drinking must do some very good things for you if you are still wanting to continue using it despite the many negative consequences you have sustained. If you would like, we can explore together the good and bad aspects of drinking so that you can weigh these
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together and decide what you’d like to do. I’m in no position to judge what is best for you. Only you can decide that.” Through this intervention, I was able to avoid the control struggle that the patient was unconsciously attempting to create and instead put the conflict about whether or not the patient should drink back onto the patient, where it could be resolved.
Dynamic deconstructive psychotherapy DDP is a treatment that takes into account the emotion processing, denial system, and shame dynamics of addiction as outlined above and presents an organized, systematic approach (Gregory & Remen, 2008). It incorporates findings from neuroscience research and object relations theory, especially emphasizing the ideas of Winnicott, Kernberg, and Kohut. The overarching treatment philosophy is deconstructive in orientation. Derrida defined deconstruction as “openness to the other” (Derrida, 2004, p. 155). This philosophy suggests a deferral of assured meaning and an openness to different perspectives. DDP therapists try not to make authoritative interpretations about the meaning behind their patients’ actions or how patients should best live their lives. Instead, therapists work toward facilitating the development of a complex and integrated self through creating a safe space for patients to put their experiences into words, to explore new perspectives on their experiences, and to risk authenticity in their relationship with the therapist. DDP was originally developed for treatment-resistant BPD, especially for cases complicated by cooccurring substance use disorders, but has since been used with many different disorders, especially those involving impulsive behaviors and suicide risk. Both process and outcome researches have been performed on DDP, as summarized below.
Empirical research on DDP Empirical research supporting the effectiveness of DDP is based primarily on two clinical trials. The first was a 12-month randomized controlled trial for individuals suffering from cooccurring alcohol use disorders and BPD (Gregory et al., 2008), with a 30-month naturalistic follow-up (Gregory, Delucia-Deranja, & Mogle, 2010). Participants in the study were severely ill; almost half (43%) met criteria for antisocial personality disorder, and 83% met criteria for other substance use disorders. Because of ethical concerns, participants in the control group were not assigned to just a minimalist treatment but were instead referred to the best alternative treatment available in the community, depending on availability and the participant’s willingness to engage in such treatment. The control treatments, labeled optimized community care (OCC), included drug and alcohol rehabilitation facilities, dialectical behavior therapy (DBT), case management, pharmacotherapy, and therapists of an eclectic orientation specializing in the treatment of BPD. When both individual and group contacts were added together, the OCC participants actually received
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greater treatment intensity than those receiving DDP. DDP was carried out primarily by psychiatry residents, who had received 3 6 months of weekly training and supervision prior to treating study participants. By the end of the 12-month trial, individuals who had received DDP achieved significantly greater reductions in symptoms of BPD, depression, and heavy drinking than those who had received OCC. These differences were even greater at 30-month follow-up. Clinical response rates for BPD were 90% for individuals receiving 12 months of DDP, as compared to only 40% for those receiving OCC. Moreover, illicit drug use markedly decreased during treatment with DDP, completely remitting by 12 months and sustained at 30-month follow-up. Those receiving OCC, however, steadily increased their use of illicit drugs throughout treatment and follow-up. The second clinical trial was a quasirandomized observational study examining 12-month outcomes of patients treated at a medical university BPD specialty clinic by therapists who were expert in DDP or DBT (Gregory & Sachdeva, 2016). All patients met criteria for BPD, and most had a cooccurring alcohol or drug use disorder. Three treatment modalities were compared: DDP, comprehensive DBT (individual and group components), and a control treatment of weekly eclectic individual psychotherapy with or without DBT skills group. The outcomes of this study were remarkably consistent with those of the prior trial. Patients who received DDP were significantly more likely to achieve reductions in symptoms of BPD and depression than the control recipients; 90% of those receiving 12 months of DDP achieved a clinical response, compared to 40% of those receiving the control treatment. Patients receiving DBT had an intermediate response rate of 67%. In the intent-to-treat analysis, patients receiving DDP had significantly greater reductions in BPD symptoms, depression, and self-harm than those receiving DBT and experienced greater improvement in social and occupational functioning. Other research on DDP has focused on mechanisms of change. When video recordings of DDP sessions were rated by observers who were blinded to outcome, therapist adherence to the DDP treatment model was found to correlate strongly with outcome (r 5 0.64), suggesting that DDP works primarily through specific mechanisms rather than through common factors, such as therapist warmth and attentiveness (Goldman & Gregory, 2009). After an independent review of the evidence supporting its effectiveness by a US federal agency, the Substance Abuse and Mental Health Services Administration, DDP was included in the National Registry of Evidence-Based Programs and Practices (www.nrepp.samhsa.gov).
Summary of the DDP treatment model In a nutshell, the overall aim of DDP is to help individuals to connect to themselves and to others. In other words, DDP creates a safe space to help individuals to identify, acknowledge, and bear their interpersonal experiences and emotional pain, instead of using avoidance maneuvers, and to take the risk of relating to others in more authentic ways, beginning with the patient therapist relationship. DDP involves weekly individual therapy sessions, each lasting 45 50 minutes. It is
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time-limited treatment (12 months), with the end date set at the beginning of treatment. There are four stages of treatment and recovery, each with a specific task and underlying thematic question; successful negotiation of each stage is important for a lasting recovery (Gregory, 2004). In negotiating each stage, DDP employs three basic sets of techniques: association, attribution, and alterity.
Association Association techniques aim to help patients link their experiences to their symbolic verbal capacity. Most commonly, this involves helping patients to put their recent emotionally laden social interactions into words, but can also involve exploration of creative activities, such as dreams, artwork, or poetry. As explained in the “Emotion processing” section, individuals with addictions and personality disorders commonly have an extraordinarily difficult time verbalizing specific interpersonal interactions and their emotional responses. They may be very glib when it comes to speaking generally about their experiences with other people, but when the therapist asks them to share specific instances, to put the events in sequence, and to label their emotional responses, they struggle to find the words to describe their experiences. Within DDP, symptoms of anxiety and arousal are viewed and framed as evidence of unprocessed underlying emotions, such as anger or shame, which patients are not able to identify, acknowledge, and bear. The therapist helps patients to recognize, verbalize, and tolerate such painful emotions. Through remediating emotion-processing pathways, association techniques help with the symptoms that are caused by subcortical activation and prefrontal deactivation. For patients who are well engaged in treatment, anxiety markedly improves within 2 3 months of beginning treatment. As the levels of anxiety and arousal settle down, craving for substances also diminishes. And as patients become better able to identify their emotions, they develop a greater sense of self and a more stable identity. DDP has been found to be an effective treatment for dissociative identity disorder (Chlebowski & Gregory, 2012), with association techniques being particularly helpful (Goldman & Gregory, 2010).
Attribution Whereas association techniques help patients to verbalize their interpersonal experiences, attribution techniques address how patients make meaning of those experiences. Attributions of individuals with addictions, as well as those with borderline or narcissistic traits, tend to be rigid and polarized, a phenomenon that has been referred to as splitting (see section “Denial system and relationships”). Two kinds of splitting have been noted in the literature. Most commonly, splitting refers to attributions of value in which self and other (or substances) become either idealized or devalued, with little in between. The second form of splitting is one of agency rather than value. I am using the term agency to refer to the agent of change, that is, the person responsible for the consequences. Patients may sometimes see themselves as an innocent victim of others’ actions, bearing no responsibility for their
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present circumstances; the opposite may also occur, when patients see themselves as the perpetrator and the cause of all their troubles. One way in which DDP aims to deconstruct this rigid and polarized attribution system is by asking about opposite or alternative meanings within interpersonal narratives and then helping patients hold both sides of the split in their consciousness at the same time. For example, when patients are explaining how soothing and helpful cannabis is for them (idealization of the drug), the therapist might bring in the other side by asking, “In addition to its helpful aspects, do you also have concerns about your use of cannabis?” As another example, when patients are complaining about how others are criticizing their drinking (having a self-attribution as victim), the therapist might point out, “But I can guess who is your harshest critic,” and the patient usually responds by saying, “Me” (now having shifted into a self-attribution as perpetrator).
Alterity Splitting involves more than a polarized attribution system. It also encompasses an intersubjective matrix in which therapists’ “buttons are pushed” by patients’ projective identifications, which can lead to therapists responding to patients in ways that reinforce the patient’s polarized attributions. For example, therapists may feel compelled to make shaming remarks to their addicted patients, which end up reinforcing patients’ devalued attributions of themselves (see section “Relational dynamics of shame”). The term alterity refers to otherness, that is, an outside and more objective perspective. Alterity techniques break through the patient’s self-reinforcing and polarized attribution system and open up new possibilities for relatedness within the patient therapist relationship (Gregory, 2005). Techniques within this category are experiential and relational in nature, involving deconstructive aspects of the patient therapist relationship in the here-andnow. Patients with severe personality pathology, including those having substance use disorders, are unable to find space for themselves in relationships. They tend to believe that in order to maintain relationships, they must conform totally to the other person’s values, motives, and opinions. Their expectation is that to do otherwise will inevitably result in being rejected and ejected from the relationship. The patients thus act as chameleons, making themselves invisible in relationships. They may also experience difficulty differentiating their own values, motives, and opinions from those of individuals with whom they are in relationship, a phenomenon that Kernberg has labeled identity diffusion (Kernberg, 1975, p. 165). When disagreement or resentment builds up within the patient toward others, it either is quelled through the use of substances; is turned against the self in the form of depression, cutting, and suicide ideation; or spills over into hostility. Alterity techniques provide a sense of safety within the patient therapist relationship by balancing caring and respect with maintenance of clear boundaries, roles, and expectations. Alterity techniques also provide space for patients to feel close to the therapist, while also being authentic, a phenomenon that can be called individuated relatedness. In order to facilitate individuated relatedness, the therapist
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attempts to be a soothing and warm presence while supporting autonomous decision-making, withholding judgment regarding the patient’s decisions (either positive or negative), and encouraging the patient to voice criticism of and disagreement with the therapist. For example, when patients are complaining about other people judging them for their use of substances, an Alterity technique is to ask the patient, “Do you ever feel that way here?” Even if the answer is no, the intervention is still therapeutic, since it gives patients the message that they do not have to play the “good patient” in their relationship with the therapist; they have space to be themselves. The question also deconstructs the patient’s expectation that the therapist will be harsh and judgmental and thus opens up new possibilities for relationships, strengthening the patient’s sense of trust. In process research, the use of alterity techniques has been found to be strongly correlated with improvement in social functioning (Goldman & Gregory, 2010).
Conclusion As can be understood from the above summary of DDP, this treatment model can be considered as having both unique and common elements with other psychoanalytically oriented therapies, differing more in emphasis than in absolutes. The overall treatment philosophy of DDP is less authoritative and interpretative than most psychodynamic therapies, leaving it to the patient to be the final arbitrator of meaning and direction. There is a strong emphasis on helping patients to identify their emotions while recounting the details of specific social interactions, to create complex meanings to their experiences, to mourn their own and others’ limitations, and to experience a novel and deconstructive relationship with their therapist as important components of the healing process. Each of the three sets of techniques, that is, association, attribution, and alterity, helps to treat different aspects of the psychopathology and dynamic underpinnings of addiction and personality disorders, synergizing to build selfawareness and integration toward a long-lasting recovery. An updated version of the DDP treatment manual is available (at no cost) at www.upstate.edu/ddp. Other training materials are also available on the website, including video-recorded lectures and an interactive web-based training module.
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