Russell Meares - Borderline personality disorder and the conversational model: a clinicians manual

The Norton Series on
Interpersonal Neurobiology

Allan N. Schore, PhD, Series Editor

Daniel J. Siegel, MD, Founding Editor

The field of mental health is in a tremendously exciting period of growth and conceptual reorganization. Independent findings from a variety of scientific endeavors are converging in an interdisciplinary view of the mind and mental well-being. An interpersonal neurobiology of human development enables us to understand that the structure and function of the mind and brain are shaped by experiences, especially those involving emotional relationships.

The Norton Series on Interpersonal Neurobiology provides cutting-edge, multi-disciplinary views that further our understanding of the complex neurobiology of the human mind. By drawing on a wide range of traditionally independent fields of researchsuch as neurobiology, genetics, memory, attachment, complex systems, anthropology, and evolutionary psychologythese texts offer mental health professionals a review and synthesis of scientific findings often inaccessible to clinicians. These books aim to advance our understanding of human experience by finding the unity of knowledge, or consilience, that emerges with the translation of findings from numerous domains of study into a common language and conceptual framework. The series integrates the best of modern science with the healing art of psychotherapy.

A Norton Professional Book

BORDERLINE
PERSONALITY
DISORDER

and the

CONVERSATIONAL
MODEL

A Clinicians Manual

Russell Meares

Nick Bendit

Joan Haliburn

Anthony Korner

Dawn Mears

David Butt

W. W. Norton & Company

New York London

CONTENTS

Expanded Contents

To whom this book is addressed

Lack of cohesion of self central deficit of borderline personality disorder (BPD)

Outcome studies of the Conversational Model in BPD

Some main features of treatment approach

Potentiation of the non-specific effect

Organization of the book

The problem of a manual

Early background

Essential principles of the Conversational Model in BPD

Later developments

The self system: Definition

Development of self: The metaphor of play

Doubling and Fellow Feeling

From Dyad to Triad

Analogical relatedness and two forms of human language

Trauma: The second therapeutic focus

Intrusion of unconscious traumatic memory

Transference/cotransference and the expectational field

A therapeutic approach to traumatic memory

Language and the basic defect of BPD

A hierarchy of language

Chronicles and scripts

Right-hemispheric language

Features of right hemispheric language

Cohesion, reflection and the therapeutic screen

Pronouns

Questions

The present: Moment-to-moment

The future

Naturalness

Introduction

1. Early stage

The referral

The patient

Source of referral

Nature of referral

The expectational field

The therapists countertransference

The Assessment

S ESSION 1

Suicidal ideation

Dissociation

Stimulus entrapment

Giving value to the patient

Traumatic relatedness (transference and cotransference)

The countertransference

S ESSION 2

Using what is given

A crisis

Making contact with the hospital team

The issue of medication and the third-party provider

S ESSION 3

Anxiety in the patient; anxiety in the therapist

Past experiences, current expectations

Traumatic memory

The frame, the contract, and the therapeutic relationship

Supervision, patient consent, and confidentiality

A shared moment

The Psychodynamic Formulation

A framework of understanding shared with the patient

A summary of the experience of the first three sessions

Organizing clinical data as it unfolds

Diagnosis

Creating Safety in the Therapeutic Relationship

S ESSIONS 418

Empathic attunement: Listening, understanding, and reflecting

Silences

Language: Personal pronouns and attention to the minute particulars

Coupling

Amplification

Representation

Scaffolding

Difficulty ending sessions

The therapists experiences of cotransference and countertransference

Closeness and distance

2.Middle Stage

Listening to the trauma history

S ESSIONS 1920

What happens next?

The nature of dissociation

Feeling tones and nonverbal processing

Disclosure of trauma and a reversal

Grief and loss

Continuing idealization of the therapist

Clarification, elaboration, amplification

Metaphor

S ESSIONS 2150

Pathological Accommodation

Fear of abandonment

The experience of shame and guilt

Text messages

Disjunction followed by repair

The reality of the therapists countertransference

Traumatic repetition and fears of abandonment

A separation

Processing the Trauma

S ESSIONS 5175

An improved sense of self

Changing language

A further linking

Intrusion of traumatic memories

S ESSIONS 76100

Continuing environmental conflict

A disjunction

A possible impasse

Exploring and getting past the impasse

Transformation of Traumatic Relatedness

S ESSIONS 101124

Disclosures of cumulative trauma and sexual abuse

Further grief and loss

Elaboration of early experiences

Validation

What if none of this happened?

Toward Integration

S ESSIONS 125150

Developing self-awareness and reflective capacity

Being of two minds

Further traumatic disclosures

Another overdose

The wish for therapist as a friend

What happens next

3.Late Stage

Integration

S ESSIONS 151175

Flights and perchings

A gift for the therapist

Connecting with the outside world

Separation anxiety

Intrusion of traumatic memories

Working through anxiety

Continuing motherdaughter conflict

Jealousy

S ESSIONS 176180

Change, agency, and independent living

A session with mother and daughter

A changed attitude toward medication

Separation anxiety mingling with grief and loss

Doubts indicating anxiety at ending therapy

Previous losses come to mind and are worked through

4.Ending Therapy

Further separation anxiety

S ESSIONS 181200

Therapists sense of loss

Would you miss me?

A new relationship

Working through loss, separation, and ending

A disjunction that was not really a disjunction

The therapists apology a new experience for the patient

Emergence of self-reflective capacity

The additional session

S ESSIONS 201210

Continuing to deal with loss

Increased reflective capacity and a friendly misunderstanding

A fresh approach to the future

A more mature sense of self

Review 1 (1 month later)

S ESSION 211

Improved self-regulation

Talking about ending

Flexibility of the dynamic frame

Further Sessions

S ESSIONS 212215

Coping with impending loss

The future without mother

S ESSIONS 216222

The actual loss of mother

A request for therapist to attend mothers funeral

Validating

Renegotiating the end of therapy

Recognizing self-capacities