Dynamic Deconstructive Psychotherapy Training: Part 3
III. Attribution Techniques
Attribution methods follow naturally from a narrative sequence and provide a way to open up meaning. See section on Attribution methods and Managing Self-Destructive and Maladaptive Behaviors in Chapter 8, Specific Techniques in the treatement manual for a more complete description.
Patients with BPD have extreme and polarized attributions of value, agency, and motivation. They display black and white thinking. With Attribution techniques, the therapist inquires about alternative or opposing perspectives. For example, if the patient states, “Drinking has caused me nothing but trouble,” thereby devaluing drinking, the therapist can reply, “Are there aspects of drinking that you enjoy?” If the patient states, “My boyfriend treats me like trash,” the therapist can move the patient from external to internal agency by asking, “Do you sometimes feel you deserve to be treated like trash?” If the patient states, “I’ve felt so alone since my girlfriend left me,” thereby expressing a motivation of dependency, the therapist can bring in the opposing motivation of autonomy by asking, “Is there also some relief since your girlfriend left you?” If the patient answers in the affirmative to any of these questions, the therapist can follow with an integrative comment, e.g. “So, it seems there are some things that you enjoy about drinking, but don’t like all the negative consequences you have experienced.”
The following six cases illustrate different aspects of Attribution techniques. The first two cases are of the same patient at different stages of treatment and illustrate how the ability to integrate polarized attributions can improve over time. The next four cases illustrate how Attribution techniques help patients progress…how to help them gain a more complex and realistic perspective of themselves and others and thus develop a more integrated and coherent self.
Case 1: A patient struggles with the uncertainty inherent in opening up new meanings
The first two cases are of the same patient at different stages of treatment. In the first vignette, the patient is at the beginning of Stage III. She is now often in touch with both sides of her polarized attributions, but is struggling with how to cope with the sense of uncertainty inherent in bringing the opposing attributions together into an integrated and coherent self. Recovery is a double-edged sword, and one advantage of having polarized, black and white thinking is that one’s outlook is always very certain, simple, and clear.
Case 1: Commentary
In this video vignette, the patient is struggling with a sense of uncertainty. She has progressed in treatment sufficiently that she is now in touch with both sides of her polarized attributions. However, she finds she cannot weigh out one more than the other and characterizes this uncertainty as the hardest part about treatment. She is now faced with having to make balanced and informed decisions that may have no “right” answer. Uncertainty regarding attributions and decisions is one of the difficulties inherent in having an integrated self and moving into an adult role, and is one of the reasons for ambivalence towards treatment and recovery in Stage III.
Case 1: Key Points
- Patients often have a need for certainty
- Their polarized attribution system and black and white thinking help them maintain certainty about themselves and others
- Treatment can sometimes increase anxiety by enabling patients to develop more complex perspectives that entail seeing both sides of issues
Case 2: The patient reaps the benefits of having integrated attributions of herself and others.
This case is of the same patient as the Case 1. She is now nearing the end of Stage IV and is getting ready to leave treatment. In Stage IV, patients must come to terms with disappointments and limitations in the therapist. In the following vignette, the patient is able to acknowledge feelings of both love and hatred towards the therapist and describes how the ability to acknowledge and hold these opposing emotions and related attributions has contributed to self-acceptance and improved interpersonal relationships.
Case 2: Commentary
In this vignette, the patient has clearly become more comfortable with having more balanced and integrated attributions of self and others. I would describe her as achieving a state of reflective ambivalence, where she is able to hold feelings of love and hatred simultaneously. The patient’s ability to maintain an integrated and reflective perspective coincides with the development of self-acceptance and has clearly helped her social functioning, as evidenced by her description of encounters with another group member.
This vignette also illustrates that by the end of Stage IV, patients are better able to understand similarities and differences between past and present relationships. This patient is able to perceive the connections among the relationships with her parents, her therapist, and the other group member.
Case 2: Key Points
- In Stage IV, patients must come to terms with disappointments and limitations in the treatment and the therapist
- The ability to acknowledge complex and conflicting feelings and attributions towards self and others contributes to self-acceptance and improved interpersonal functioning
- By the end of Stage IV, patients are better able to understand both similarities and differences between past and present relationships
Case 3: Integrating opposing wishes for dependency versus autonomy
This case is of a woman who is expressing opposing motivations of dependency and autonomy in her relationships with men. The therapist attempts to help the patient clarify and integrate these opposing motivations.
Case 3: Commentary
In general, attribution interventions are most effectively applied under conditions of an adequate therapeutic alliance and after the patient has elaborated a narrative sequence. This patient is in a reflective state and ready to explore her opposing motivations for closeness and dependency, versus autonomy and control. In this vignette, the therapist simply attempts to help the patient to elaborate and become more aware of both sides of her conflict.
Case 3: Key Points
- Attribution techniques should generally be applied under conditions of an adequate therapeutic alliance, when the patient is in a reflective state, and after the patient has elaborated a narrative sequence
- Patients can have opposing and poorly integrated motivations for closeness and dependency, versus autonomy and control
Case 4: Developing ambivalence about drug use
In this case, the patient is less reflective and less aware of his attributions than the patient in the preceding case. With the therapist’s help, he begins to identify and acknowledge polarized attributions towards his pattern of Percocet misuse. When exploring incidents of substance use, or other maladaptive behaviors, a primary aim is to help patients to understand both the positive and negative aspects of the behavior so that they can make an informed decision as to whether to continue it (see Managing Self-Destructive and Maladaptive Behaviors in Chapter 8, Specific Techniques for a more complete discussion).
Case 4: Commentary
In this vignette, the patient starts off with a one-sided positive description of his experiences with Percocet. He states that it helps him to have fun when he’s all alone…and to get to sleep easily. Note that the therapist is very careful not to fall into the trap of taking the other side of the opposition by pointing out all the problems inherent in using Percocet. If the therapist had done this, it would likely have provoked a conflict between the patient and therapist regarding the patient’s drug use. By staying in a neutral position between the two oppositions, the conflict stays within the patient, where it has the potential to be explored and resolved. The patient is now in a position to begin to integrate his polarized attributions towards Percocet, so he can make an informed decision as to whether to continue using it.
Case 4: Key Points
- When intervening with maladaptive behaviors, such as substance misuse, a primary aim of the therapist is to help patients understand both positive and negative aspects of their behavior so that they can make an informed decision as to whether to continue it
- To be effective, it is of paramount importance that the therapist does not side with either the patient’s desire to continue using the substance, or the patient’s wish to stop using it
Case 5: Moving agency from external to internal
In this case, a man is struggling with attributions of agency. In DDP, the attribution of agency has to with determining who is agent of change? Within a given narrative, who has the power, responsibility, or blame? In the vignette, the therapist helps this patient to switch from an external attribution of agency to an internal attribution of agency, and then to integrate the two perspectives.
Case 5: Commentary
This vignette provides a good illustration of a type of Attribution technique called an internalizing comment. Internalizing comments can help patients get out of the victim role, and so are particularly useful for patients in the angry victim state, where agency is externalized (see Chapter 6, States of Being).
In this vignette, the patient is complaining about unjust criticism. He sees himself as an innocent victim being unfairly criticized by his supervisor. The therapist makes an internalizing comment by asking the patient who he thinks is his worst critic. The patient makes good use of this comment and begins to discuss issues of self-blame. In other words, agency has moved from other to self. The therapist follows up with an integrative comment, summarizing the patient’s polarized attributions of self-blame versus other-blame.
Case 5: Key Points
- Agency has to do with issues of power, responsibility and blame
- Patients with chronic conditions tend to either externalize agency (blame others for their problems) or to internalize agency (take on all the credit or blame)
- An internalizing comment moves agency from external to internal and can be particularly useful for deconstructing the angry victim state
- An integrative comment brings both poles of an attribution (e.g. internal versus external agency) into consciousness
Case 6: Developing integrated attributions towards drinking
The final case in this attribution series is of a woman with poorly integrated and polarized attributions towards her drinking behavior. The therapist attempts to help the patient integrate attributions of value and agency.
Case 6: Commentary
Early in this vignette, the patient’s agency is entirely externalized and she is in the victim role. It is her mother and grandmother who wish for her to enter rehab, whereas she is just going along with what they tell her to do.
The therapist then attempts to bring to consciousness her polarized attributions of agency by reminding the patient that she had previously expressed a personal desire to quit drinking and go into rehab. Following the therapist’s comment, the patient is able to regain agency and take an opposite position regarding her drinking, stating that she’s afraid of putting all that poison inside her and something bad happening to her.
The therapist then provides an integrative comment regarding the patient’s polarized agency, by stating that it must get confusing as to what other people want for her and what she wants for herself. The patient appears to benefit from these interventions and ends the vignette in a much more reflective and integrative state of mind.
Also note that the therapist does not take sides or push the patient to quit drinking, but respects that the patient will be able to make reasonable decisions regarding her drinking behavior once she is able to achieve an integrated perspective.
Case 6: Key Points
- It is common to have polarized attributions, including agency, towards drinking and other maladaptive behaviors
- The therapist should respect patients’ ability to make reasonable decisions about their substance use once they are able to achieve an integrated perspective