For many psychotherapists, borderline clients present a professional challenge because of their frequent relational conflicts, varying developmental levels of transference, and their polarization of emotions, such as: idealization and hate, elation and despair, anger and dependency.

Attachment theory provides useful perspectives on emotionally unstable or borderline personality disorder (BPD); both in terms of how the disorder develops and in terms of therapy. Both clients and therapists may struggle with trust, high levels of negative affect, and therapeutic ruptures. Attachment needs in such clients are highly aroused and often extremely difficult to assuage. Understandably, BPD clients can not only struggle to participate in the therapeutic alliance, but can also view therapists as aloof, uncaring, antagonistic or unsympathetic.

This course will provide diagnostic perspectives on Attachment Disruptions, an understanding of the aetiology of Early Affect-Confusion and the formation of the Borderline Personality, the therapeutic use of treatment contracts, the significance of an attuned therapeutic relationship, and working knowledge of when and how to use behavioural interventions and/or supportive age regression.

This video resource pack contains two complete workshops (CPD hours: 11) that cover:

Part 1:

Dr Gwen Adshead will use a perspective based on attachment theory and the tenets of mentalisation to explore:

• How the psychopathology of emotional instability develops
• Hostile, helpless states of mind and epistemic trust
• The relationship with disorganised attachment and its sequelae
• How this understanding informs our therapeutic approaches
• How this understanding influences the way we think about families and their therapeutic needs
• Language and threat: use of why questions, silence and poor mentalising
• Preventing and managing attachment anxiety

Session 1: Attachment and personality development

In this first session we explore:

• Brief overview of attachment theory and personality development
• Attachment and Affect Regulation – developmental studies and fMRI findings
• Insecure attachment and personality disorder: with emphasis on affect dysregulation
• Mentalising and affect regulation

Session 2: Clinical implications

• Why do people with PD struggle with therapy
• Activation and deactivation of attachment systems
• Repetition of Toxic attachments and lack of Trust
• Mentalising strategies for therapists

Session 3: Psychotherapeutic implications

Our third session builds on and continues the theoretical bases considered so far and illustrates practical therapeutic implications for practitioners. Clinical vignettes will be discussed here. Specifically, we consider:

• Recognising when fragile mentalising capacities are overwhelmed by sudden surges of affect
• Helping our clients with self-soothing and other strategies needed to reduce arousal
• Self-reflection and work with co-therapists

Part 2:

Dr Richard Erskine draws on an integrative therapeutic and relational approach and specifically draws our attention to clients whose narrative is characterized by affect confusion and attachment disruptions – where the narrative alternates between blaming others and self-criticism, where the client seeks justification for felt rage and harbours explicit confusions about how others treat him/her.

In a relationship-oriented psychotherapy, the therapist’s self is focused on assisting the client’s process of developing and integrating full contact and the fulfilment of relational needs. Of particular importance is the process of attunement, not just to thoughts, feelings, behaviours and physical sensations, but also to vitality affects, such that an experience of unbroken feeling-connectedness is created.

Through case-vignettes and clinical discussions, the workshop helps us examine and identify reparative action for potentially unmet relational needs, which can include:

• Validation and affirmation within a relationship
• Acceptance by a stable, dependable and protective other person
• Confirmation of personal experience
• Self-definition
• Impacting the other person

Specifically, we consider the interpersonal needs which may often have been absent in our client’s significant relationships: for the other to be patient, calm, consistent, dependable and validating; and how the therapist can provide opportunities for the client’s self-definition and agency. We consider the unique, professional challenges that we face in such situations, when the client presents with apparent relational conflicts, varying developmental levels of transference and polarization of emotions.

Keeping in mind the therapeutic challenges we face as psychotherapists, psychologists, counsellors and psychiatrists, Richard focuses on the centrality of an involved therapeutic relationship while emphasizing the in-depth methods of a psychotherapy that integrates the client’s affect, cognition, physiology and behaviour. Emphasis will be placed on:

• Diagnostic perspectives on Attachment Disruptions
• An understanding of the aetiology of early Affect-Confusion and the formation of the Borderline Personality
• The therapeutic use of treatment contracts
• The significance of an attuned therapeutic relationship, and
• A working knowledge of when and how to use behavioural interventions and/or supportive regressions

Overall, the workshop equips us with practical methods that are effective in psychotherapy, including:

• Methods of transference resolution and countertransference identification,
• The bifurcation of therapeutically relevant challenges,
• Calibrating for juxtaposition reactions,
• Responding to oscillating relational-needs, and
• The importance of a sustained phenomenological inquiry and affect attunement

At this workshop, participants will:

• Assimilate and comprehend a series of therapeutic interventions that reflect relational, co-constructive and intersubjective sensitivity in the psychotherapy of clients with Borderline Personality traits
• Differentiate between various forms of therapeutic inquiry and apply the skills of acknowledgement, validation and normalization
• Formulate a therapeutic perspective that will include the significance of attunement to the client’s affects and rhythm while resonating with the client’s level of emotional development
• Critique a psychotherapy demonstration and describe what they think is therapeutically effective