Introduction to Dynamic Deconstructive Psychotherapy Training: Part 4
IV. Alterity Real
The next series of vignettes illustrate experiential techniques that provide an experience of transformative healing with patient-therapist relationship. The word, “alterity”, is employed in the philosophical literature, especially by Levinas and Derrida, and is derived from an ancient Greek concept of otherness. As used in philosophy, alterity refers to the ability to see others for who they really are, instead of who we assume they are. Likewise, it refers to the ability to view ourselves from an outside or objective perspective, i.e. through the eyes of the other.
Alterity techniques are essential for supporting self-other differentiation and individuated relatedness, enhancing reflective functioning, and for restoring ruptures in the therapeutic alliance. In part, they entail adopting a basic attitude of respect for patient attitudes, opinions, goals, and plans, which may be very different from what the therapist thinks is best. They also involve providing experiential acceptance or challenge at key times in order to deconstruct undifferentiated, non-reflective “states of being” associated with a negative therapeutic alliance.
Many patients with chronic illnesses display polarized attributions of value, agency, and motivation. These attributions can interact with one another to create distinct states. The figure below summarizes the attribution configurations of four common states of being. Techniques to deconstruct states of being are very difficult to time correctly and require both self-awareness of countertransference feelings, as well as attention to the attributions of self and other that the patient may be displaying at any given moment. Chapter 6, States of Being, in the treatment manual describes these states in detail and how to deconstruct each of them.
Figure 1: Self and other attributions of four states of being
Case 1: A patient realizes that she is not differentiated from her mother
This case is of a woman who is struggling to individuate from her mother. It illustrates a lack of differentiation between self and other and the consequences for the patient’s sense of self.
Case 1: Commentary
A common occurrence in patients with chronic illnesses, and especially those with borderline personality disorder, is that they are unable to be both close and separate at the same time in relationships. In other words, patients will disown their personal and individual feelings, needs, attitudes, and opinions in order to maintain attachment in close relationships. They feel they need to give up their own individuality in order to be valued by the other person and to not be rejected or abandoned. However, the consequence of this relational strategy for the patient in the vignette is a feeling of non-existence or…a blank.
One of the goals of treatment, therefore, is to help patients to develop a close but separate relationship with the therapist, characterized by good boundaries and mutual respect of different perspectives between responsible adults. There is evidence that this new kind of relational experience in the therapy relationship can begin to be generalized to other relationships in the patient’s life.
In addition, differentiation of self from other promotes a capacity that I have labeled as “alterity.” Alterity, or otherness, incorporates the capacity for empathy, the ability to reflect on the self from an outside perspective, and an ability to perceive others as complex individuals, distinct from the self.
Case 1: Key Points
- Patients with chronic conditions often display a lack of differentiation between self and other, i.e. they feel they need to give up their own individuality in order to be valued by the other person
- One of the goals of treatment is to help support patient individuation and differentiation in the patient-therapist relationship
- Differentiation of self from other promotes a capacity for “alterity”
- Alterity, or otherness, incorporates the capacity for empathy, the ability to reflect on the self from an outside perspective, and an ability to perceive others as complex individuals, distinct from the self
Case 2: Deconstructing the angry victim state
This case is of a woman who feels everyone in her life is manipulating her. It illustrates how asking the patient about negative feelings towards the therapist and then being receptive to the criticism that follows can facilitate differentiation. A relationship cannot be authentic if one person in the relationship is always being agreeable and never criticizing or disagreeing with the other person.
Case 2: Commentary
At any given time, the therapist can choose to focus on associations, attributions, or alterity. These are each different levels of discourse. In the vignette you just observed, the patient introduces a narrative about a time when she felt that her brother-in-law was manipulating her. It would have been reasonable for the therapist to simply develop the narrative and clarify the sequence of responses and the associated affects. It would also have been reasonable for the therapist to bring in alternative or opposing attributions, for example, by asking whether the patient felt she deserved to be manipulated?
In this instance, however, the therapist chose to focus on the patient-therapist relationship because of concerns regarding a rupture in the therapeutic alliance. One sign of trouble was that the patient had missed the previous appointment. Another clue was that the patient stated that “everybody” was manipulating her. So…the therapist simply asks whether the negative feelings towards the patient’s brother-in-law also pertain to him. Even though the therapist felt the patient’s subsequent criticism was unjust, he tries to be as receptive and non-defensive as possible in order to facilitate differentiation and to deconstruct the patient’s angry victim state of being (see Angry Victim State in Chapter 6, States of Being).
This intervention of “experiential acceptance” effectively restores the treatment alliance and moves the patient to a more reflective state. By the end of the vignette, she is able to take responsibility for missing her appointments.
Case 2: Key Points
- The focus of treatment should shift to the patient-therapist relationship when there is evidence of a rupture in the therapeutic alliance
- “Experiential acceptance” is an intervention that involves the therapist attempting to be receptive and non-defensive in response to patient accusations or disagreement
- Experiential acceptance promotes self-other differentiation and helps to deconstruct the angry victim state and to restore the therapeutic alliance
Case 3: Experiential acceptance to anger at termination
This case is of a young woman who is in the process of termination after 12 months of treatment. The therapist directs the discussion towards the transference and employs “experiential acceptance” in order to help the patient to identify and acknowledge her feelings of anger and to support differentiation.
Case 3: Commentary
There are obvious similarities between the vignette you just witnessed and the previous one. In both, the therapist redirects the discussion to the patient-therapist relationship after the patient had been speaking of being mistreated by others. In this vignette, the therapist suspects that the patient harbors negative feelings towards him because the patient had brought up feelings of being hurt and abandoned by her boyfriend in the context of a forthcoming termination. The therapist provides “experiential acceptance” of the patient’s negative feelings towards him. Even so, the patient is only able to be indirect about her feelings, expressing them in a detached and playful manner. The patient needs to get more in touch with her feelings of anger, hurt, and disappointment, and to mourn the loss of the fantasy that the therapist will always be there to nurture and protect (see Stage IV in Chapter 4, Stages of Therapy).
Experiential acceptance can be particularly difficult for therapists to implement during the termination process. Therapists commonly have strong countertransference reactions about termination, including worrying about whether the patient is going to be okay, self-doubt about whether this is the right thing to do, relief about ending the treatment, guilt about leaving the patient in the lurch, and so on. Because of these strong reactions, therapists may be particularly reluctant to facilitate their patients’ ability to talk about their worries about the transition, their worsening symptoms, their gratitude towards the therapist, or how angry they are about being abandoned. And yet this is precisely the kind of dialogue that is most likely going to ensure a successful termination.
Case 3: Key Points
- During the termination process in Stage IV of treatment, patients need to identify and acknowledge feelings of anger, hurt, and disappointment, and to mourn the loss of the fantasy that the therapist will always be there to nurture and protect
- Experiential acceptance makes it easier for patients to acknowledge negative feelings towards the therapist during termination and promotes self-other differentiation
- Experiential acceptance is difficult to implement during termination because of the therapist’s strong countertransference feelings
Case 4: Managing countertransference with a patient in the angry victim state
This case is of a young woman in the angry victim state, displaying a markedly negative transference right from the beginning. The therapist attempts to deconstruct this state through experiential acceptance.
Case 4: Commentary
In this vignette, the patient is accusing the therapist of being a cold scientist, merely using the patient as a specimen. The patient’s attribution of self is the heroic victim and motivation is autonomy. Her attributions of the therapist are as being bad and also having all the agency. These attributions are consistent with the angry victim state and can be deconstructed through experiential acceptance (see Angry Victim State in Chapter 6, States of Being).
The patient is feeling betrayed by the therapist. The therapist has a concordant countertransference and is also feeling betrayed. The therapist is impelled to respond, “How can you say I don’t care? Don’t you remember all the things we went through and all the telephone calls?” Instead, the therapist provides a deconstructive experience by responding in a different and unexpected way, in a way that connotes receptivity and acceptance. The therapist non-defensively rewords the patient’s unjust accusations as conflicting images of the therapist as either a cold and callous researcher versus someone genuinely motivated to help.
In response to these interventions, the patient moves to a more reflective state and the therapeutic alliance is restored. The patient admits to no longer having negative perceptions of the therapist and is able to reflect that her accusations are a protective mechanism. She then goes on to free associate to her relationship with her parents and concerns about putting them on a pedestal, only to be blind-sided later.
Case 4: Key Points
- In the angry victim state, the patient’s attribution of self is the heroic victim and motivation is autonomy. Attributions of other are as being bad and powerful
- In the midst of an intense interaction, both the patient and therapist may be experiencing the same emotion
- By responding in a different way from what the patient expects, the therapist can provide a deconstructive experience that suggests new possibilities for relatedness
Case 5: Deconstructing the guilty perpetrator state in a suicidal patient
The next 3 cases illustrate an experiential technique called: Experiential Challenge. Experiential challenge is most useful in circumstances where therapists find themselves “walking on eggshells” and need to regain agency. Such circumstances include, for example, the Guilty Perpetrator State, where patients view themselves as being hopelessly and irredeemably bad and the therapist as an ineffective rescuer. In the vignette you are about to see, a woman in the guilty perpetrator state is presenting with suicide ideation.
Case 5: Commentary
This vignette is a window into a larger pattern of interaction that invites other persons in to rescue and reassure, but ends in bitter disappointment. This pattern is typical of the Guilty Perpetrator State. The trap here is that the more the therapist tries to intervene, the more clear it becomes how futile these interventions are and what a hopeless case the patient is. For instance, on the one hand, the patient states that she is here asking for help. On the other hand, she implies that any help is going to be ineffective and that she might as well kill herself. The therapist’s countertransference reaction is helpless frustration.
Experiential challenge is potentially a life-saving intervention that can disrupt this kind of destructive enactment. The heart of experiential challenge is to clearly and authoritatively point out the fork in the road and to help the patient figure out which path they want to choose, while remaining neutral between the two choices. In this vignette, instead of jumping in with suggestions, interpretations, or false reassurance, the therapist regains agency and, paradoxically, instills hope by pointing out the many ways that the patient is choosing not to participate fully in the treatment process. For example, the therapist points out that the patient is not keeping her commitment to stay safe, she is skipping treatment sessions, and she is not bringing in meaningful material to explore. By pointing these out, the therapist is helping the patient to deconstruct her self-attribution as a hopeless case and her attribution of the therapist as a helpless rescuer.
One caveat to this vignette is that if the therapist had felt that the patient was an immediate danger to herself, the focus would have shifted to the need for hospitalization and pointing out the patient’s prior commitment to keep herself safe (see Psychiatric Hospitalization in Chapter 11, Special Situations).
Case 5: Key Points
- “Experiential challenge” is an experiential technique that involves the therapist challenging patients regarding choices they are making.
- Experiential challenge is most useful in circumstances where therapists find themselves “walking on eggshells” and need to regain agency, such as when the patient is in the guilty perpetrator state or demigod perpetrator state
- In the guilty perpetrator state, patients view themselves as being hopelessly and irredeemably bad and the therapist as an ineffective rescuer
- Experiential challenge is a potentially life-saving intervention that disrupts patient attributions of self and other and, paradoxically, instills hope by pointing out the many ways that the patient is choosing not to participate fully in the treatment process
Case 6: Deconstructing the guilty perpetrator state in a regressed patient
This case presents another example of experiential challenge of a patient in the Guilty Perpetrator State. The difference is that in the forthcoming vignette, the patient’s depression comes at a later stage of treatment and represents a regression back to the sick role after having made significant progress.
Case 6: Commentary
At the beginning of the vignette, the patient is very down on herself for eating chocolate and skipping school, and seems frightened, confused, and helpless. She had previously been making progress in treatment and improved her level of functioning sufficiently that she could return to school.
One way to view her relapse is that it provides a solution for her ambivalence about recovery and her unconscious wish to return to simpler times of the sick role. Ambivalence about treatment and recovery is common in Stage III. As awful as it is to be sick with borderline pathology and drug addiction, one is at least free of the expectation of self-reliance and the responsibility of having to make difficult decisions. Paradoxically, there is some comfort in loss of hope. When there is no hope, there is no pressure.
The therapist attempts to deconstruct this depressive regression with experiential challenge. He challenges the patient’s self-attribution that she is doing the best she can but is simply too sick to succeed. He points out that she has been missing psychotherapy sessions, and so is making a choice to stay sick and dysfunctional.
The patient responds to these interventions by moving from the guilty perpetrator state to the angry victim state. She tells the therapist to just shut up and be quiet. In response, the therapist then shifts techniques to experiential acceptance of the patient’s anger. The patient responds by becoming more reflective and confident, admitting that she is not allowing herself to acknowledge her emotions and is turning her anger on herself.
Case 6: Key Points
- Ambivalence about treatment and recovery is common in Stage III of therapy and may be manifested by a depressive regression
- Experiential challenge can be used to restore patient motivation for treatment during a depressive regression
- Experiential challenge sometimes moves patients from the guilty perpetrator state to the angry victim state, which then requires experiential acceptance to deconstruct
Case 7: Experiential challenge to intrusive behavior
This case illustrates a different indication for experiential challenge. In addition to deconstructing the guilty perpetrator state, experiential challenge is useful for containing boundary violations stemming from excessive neediness or hostility (see section on boundary intrusions in Chapter 11, Special Situations). Boundary violations disrupt the treatment frame and jeopardize the therapeutic alliance. The context for the vignette is that the patient has been leaving very long messages on the therapist’s voicemail about quarrels the patient had been having with his girlfriend. The therapist has feels intruded upon by this behavior and attempts to set limits.
Case 7: Commentary
Patients with borderline personality disorder commonly cross boundaries in relationships, including the patient-therapist relationship, and this tends to evoke very negative reactions in other people. Although the long messages were only a minor annoyance, the therapist felt that he was at risk of losing his sympathy for the patient, as well as his empathic attunement, and thus decided to confront this behavior.
The therapist begins the vignette by requesting that the patient stop leaving such long messages. The therapist then explains that the messages make him feel used, like a garbage can, implying that they represent a form of hostility.
The patient responds by becoming somewhat embarrassed and apologetic. He then free associates to his relationship with a friend. The friend apparently also felt intruded upon by the patient’s neediness and told the patient not to call anymore. The therapist applies an Association technique by asking, “How did that make you feel?” The patient gestures that he feels downcast.
What is lacking in this vignette is an experiential acceptance following the challenge. After the patient described feeling downcast due to his friend’s rejection, the therapist should have asked whether the patient felt downcast after the therapist’s limit-setting. This intervention would have restored the therapeutic alliance, while supporting self-other differentiation.
Case 7: Key Points
- In addition to deconstructing the guilty perpetrator state, experiential challenge is useful for containing boundary violations stemming from excessive neediness or hostility in the demigod perpetrator state