Personality disorders can be a real therapeutic challenge, to which it is essential to deploy maximum professional skill and human sensitivity. Only from this confluence can a formula emerge that is of benefit to the patient.

Dynamic deconstructive psychotherapy, formulated by Robert J. Gregory , aims to enable the person to connect with their own emotional experiences and develop positive relationships with those who live with them.

It is based on classic psychoanalytical models, such as object relations (the idea that one’s “self” exists only in relation to other objects) or the philosophy of deconstruction (reorganization of thoughts in the face of logical contradictions and fallacies that can condition or distort them).

Next we will see its basic characteristics , with a brief theoretical delimitation of the proposal and a detailed analysis of its objectives.

Dynamic deconstructive psychotherapy

Dynamic deconstructive psychotherapy is designed for the care approach of people suffering from Borderline Personality Disorder (BD) , with a poor prognosis due to the concurrence of other circumstances of clinical severity (drug abuse, interpersonal conflicts, etc.). It proposes a succession of therapeutic modules justified by the neurological disorders found in these patients through neuroimaging studies (on the hippocampus, amygdala, anterior cingulate cortex and prefrontal areas).

These functional and structural alterations would generate a deleterious impact on processes such as memory, affective regulation and executive functions (especially decision-making and attributional processes). In addition association, attribution and otherness would be compromised ; three facets with a key role in emotional experiences and their integration. The treatment is aimed at modifying the neurocognitive springs involved in each of them.

The program is composed of weekly sessions of 45-50 minutes duration , which extend over a year or year and a half, depending on the severity of the symptoms and the objectives achieved throughout the process. The focus is oriented towards the evocation of moments of interpersonal conflict that the patient has experienced in the preceding days, which will be explored by a therapist who takes a progressively less directive position, emphasizing individual responsibility throughout.

Next we will see an analysis of all the areas that are contemplated in the application of the procedure, as well as the techniques to be deployed in each of the cases.

1. Association

One of the fundamental purposes of dynamic deconstructive psychotherapy is to empower the person’s ability to translate their subjective experiences into words that make them more objective. The aim is to transform the symbol (or thought) into verbal contents , which will be the raw material with which we will work during the sessions. In the most difficult cases, metaphors can be used, which imply a space that borders on both sides, at the limit of what is thought and narrated.

The model suggests that people with TLP have difficulty carrying out such a transformation process, perceiving that through coding some of the most noticeable nuances of what they want to convey are lost. However, they can show their internal states with great ease by resorting to art in all its forms , so this becomes a tool in the process of association between emotion and verbalization that can be used in the therapeutic act.

What the therapist does in these cases is to recall with the patient the most recent examples (from everyday life) in which some overwhelming or difficult experience might have arisen, with the aim of dissecting them into more discrete units and weaving them in a way that is consistent with the logic of his own narrative. The underlying intention of all the possible actors involved is analysed, as well as one’s own responses and those of the rest of the participants in the situation.

The aim is to link the emotions that are experienced with acts of reality , so that these are integrated into the context of things that happen in everyday life. This task aims to eliminate ambiguity of feeling and to understand the situations through which to give meaning to the experience. That is, to interpret them in an integrated way.

The authors emphasize that patients with BPD often show a disorganized pattern of attachment, which arises as a result of abuse experiences. In this case the person struggles with the desire for closeness and the contradictory need for distance, which coexist in the same space and build the foundation from which the next step of therapy hangs: the polarization of emotions and bonds with others.

2. Attribution

The constant oscillation of mood and polarization in the way we value others generates in the person with TLP a sense of discontinuity in life experience, as if he or she had no foundation on which to build or no predictable logic. This way of living and feeling can generate a deep existential disconcert, and is one of the reasons why the individual feels a deep emptiness when he looks inside.

The person would debate in a constant ambivalence between seeking and avoiding, or between approaching and fleeing , which is rarely adequately resolved. Self-image would therefore be very unstable, to the extent that it would be very difficult to find words with which to describe what one is. One of the most relevant aspects to be dealt with in this phase of the intervention involves the secondary consequences of what has been outlined: excessive or very deficient control of impulses, and inflexible projection of all responsibility on oneself or on others (without grey areas).

Throughout this stage, it is important to encourage the person to engage in processes of reflection in which they avoid judging the experience , so that they can place themselves on a plane that allows for a balanced analysis of what they feel. This is because people suffering from LPD can make interpretations of their self that frame them as victims or executioners, which leads them to emotions of helplessness or self-rejection that do not fit at all with the objective parameters of the event that triggered them.

The model proposes, in short, that the perpetual lability of the spirit (and of the evaluations that are made of others) can lead to a painful dissolution of one’s own identity . Through the active search for balance, based on objectively described facts, it is possible for the person to define an adjusted image of herself and of the bonds that bind her to others.

3. Alterity

The negative interpretation of any fact depends on its outcome and on the voluntariness attributed to the hand of the person who executes it. That is, to what extent is it considered that the undesirable consequences of some adverse event could have been avoided if the triggering agent had so wished, or in what way the tort occurred in a deliberate and definitely malicious manner.

The third phase aims to strengthen the process of mentalization , or the capacity to subtract communicative elements (sender, message, receiver, etc.) to value them objectively and from affective neutrality. From this, limits are drawn between negative acts and the identity of their author, creating a distance between the signifying meaning and thus contributing to identify the presence or absence of some intentionality that connects them. If this is the case, the derived emotions must be addressed with precision.

It also seeks to adopt a position of external observer of all internal processes, so that they are devoid of emotion and can be analyzed more objectively (discriminating what is real from what is not at all). This process is very important for the assumption of fear of abandonment, since it arises without objective reasons and produces a very deep malaise.

Through the reinforcement of otherness , the person seeks to differentiate himself from others , separating his own fears from the way he perceives others, and feeling like the agent subject of his existence. The therapist should avoid any paternalistic attitude, reaffirming the identity of the person with whom he or she is interacting, since at this point it is fundamental that the person assume an active role with respect to his or her conflicts and problems of a social nature.

Managing Problem Behavior

The TLP is characterized by a concatenation of externalizing problems , beyond the complexities of the inner life of those who suffer it. These are behaviours that generate harm to oneself or others, and that eventually pose some danger to one’s life: unprotected sex, self-harm of various kinds, drug abuse, irresponsible driving or other acts in which one assumes risks for physical or psychological integrity.

The present model understands that these are behaviours associated with problems in the three areas mentioned, which can be explained by a functional alteration of the different brain systems involved in the regulation of emotions and in the perception of identity as a coherent phenomenon (which were described previously).

The deficit in the area of association leads to an unconsciousness about how negative interactions alter emotion, so that the discomfort is perceived in a vague and intangible way. This circumstance is linked to impulsive and aimless acts, since the coordinates for the causes and consequences of the affect being experienced at a given time could not be located. The behavior that would be carried out to confront stressors would be erratic or chaotic.

The attribution deficits would be related to a polarity of judgment that blocks the balanced analysis of the nuances included in the situation , which would translate into an enormous difficulty in making decisions (since the benefits and disadvantages are not contemplated simultaneously, but rather one or another in an isolated manner). There are also difficulties in inhibiting impulses, since extreme emotions tend to precipitate acts loaded with an irrepressible intention.

The difficulties in otherness would hinder the effective separation of the real and the symbolic, generating spurious associations between acts and their consequences (“I cut myself to relieve suffering”, “I drink to drown my sorrows”, etc.). The involvement of this area would also imply confusion in the processes of introspection (feeling of inner emptiness), and some of the cognitive biases that most often manifest during this disorder (arbitrary inference, generalization, etc.).

Bibliographic references:

  • Gregory, R.J. y Remmen, A.L. (2008). Una terapia psicodinámica manual para el trastorno límite de la personalidad resistente al tratamiento. Psychotherapy Theory Research and Practice, 45(1),15-27.
  • Majdara, E., Rahimian, I., Talepasand, S. y Gregory, R.J. (2018). La eficacia de la psicoterapia dinámica deconstructiva en el tratamiento del trastorno límite de la personalidad: Introducción a un modelo terapéutico basado en la evidencia. The Journal of Urmia University of Medical Sciences, 29(6), 1-19.