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Mental Disorders

by Russell Meares
W. W. Norton, 2012
Review by Kamuran Elbeyoğlu on Jul 9th 2013

Borderline Personality Disorder and the Conversational Model

The diagnosis and treatment of borderline personality disorder have been a problematic issue among clinical psychologists, health professionals working with BPD and psychiatrists as they are greatly varied in their training and experience in dealing with BPD. Russell Meares together with a host of co-authors who are all well trained professionals and have significantly contributed to the development of conversational model for BPD put forward a unique form of therapeutic approach for the treatment of BPD.

The proposed conversational model is based on two assumptions, one of which is that the primary disturbance in BPD is a failure of cohesion of the sense of self, and that this disconnectedness among the elements of psychic life is a reflection of disconnectedness between areas of brain that usually operate together. The principal assumption is that a certain kind of mental activity, found in reverie and underlying symbolic play, is necessary to the generation of the self. Since childhood traumas play a central role in forming BPD, the main issue to address in the book is the role of trauma; drawing upon William James’ conception of self, and especially his pertinent statement: “thoughts connected as we feel them to be connected are what we mean by personal selves. The worst a psychology can do is to interpret the nature of these selves as to rob them of their worth” (James, 1892: 153-154), they describe the therapeutic conversation as being dominated by two forces. While the positive conversation is toward well-being, health and the sense of selfhood, the negative conversation is traumatic, destructive, intruding into or overthrowing the emergent self.

Developing the conversational model as a scientific theory of treatment for BPD, the task confronting them, therefore, seems to be twofold; firstly, the need to define self and understand how it develops, and secondly, to explore and differentiate the features of systems of traumatic memory. Conversational model is based on failure of cohesion of the sense of self, which is the main disturbance of BPD. The model engages a certain kind of non-linear, associative and affect-laden mental activity through conversation, which is direct, emphatic and attuned to the patient’s own mode of expression, instead of jargon, intellectual and theory-based language as found in “treatment as usual” therapies. It incorporates data from the fields of neurophysiology, child development, linguistics, memory research, trauma studies and most importantly, accounts of personal experience.

This manual, in which all contributors who mainly share their experience with patients with borderline personality disorder, recounts how conversation comes alive with the verbal and non-verbal communications that form the foundation of human relatedness and the individual’s coherence and cohesion of self. The authors have found a conversational rhythm based on “analogical responsiveness” constitutes the most effective way of working with borderline patients. During childhood, the small stories being told analogically are the atoms out of which that larger organism, the individual’s own symbolic narrative self is eventually created. The relationship between the mother and the child during symbolic play can be conceived as analogical. She shows in her face and in the contours of her voice, the shape of her baby’s immediate experience. What she exhibits is the baby’s first analogue. In symbolic play this analogical relatedness is partly internalized. It is a principal aim of the therapist in the Conversational Model to find, in the bits and pieces of the other’s experience, as it is selected and recounted, a shape, an analogical resemblance, which gives it coherence. Even though the conversations they engage with the patients seem deceptively simple, the conversations of the model can and do touch the patient’s dissociative sense of self as powerfully as a mother acknowledges her baby: I know you, and through my knowing, you will come to know yourself. An analogue is the primordial form of the symbol. Analogical linking is the means toward the development of symbolic thought, which is so deficient in BPD.

As Russell Meares explicitly announces, this manual is prepared as a practical guide for health professionals interested in using the conversational model in the treatment of BPD. Since “analogical relatedness is the principal therapeutic agent in the treatment of BPD by the conversational model” (p. 28), it aims for the reader to learn how a deep understanding of traumatized self emerges from the analogic links and metaphoric connections the method promotes. The arrangement of the book therefore, follows this strategy. An introductory chapter is followed by a chapter dealing with the theoretical bases of conversational model. Since language is a therapeutic instrument, third chapter is devoted briefly sketching some key aspects of the language that is used in the therapeutic conversation.

Chapter four titled as The Story of a Therapeutic Relationship aims at giving a sense of feeling and flavor of conversational model by describing a 2-year treatment in which therapist works with her first patient with BPD: a woman, Bella, severely disabled by her condition, repeatedly hospitalized after suicide attempts, and despairing of her particular health–care system. The story of Bella beautifully illustrates some of the difficulties of BPD and how it might be approached by the use of the audiotaped conversations between Bella and the therapist, who has given Bella a written and informed consent for her case material to be used in the guidebook.

After the chapters dealing with theoretical underpinnings and the actual applications of the conversational model, the fifth chapter outlines general practical issues in the psychotherapy of patients with borderline personality disorder. It describes the general characteristics of a coordinated system of mental health care for dealing with BPD. Even though in many cases of BPD a single therapist is involved, in more severe cases there needs to be a team of health professionals working together with a number of facilities. This chapter illustrates how effective management of this network is an important element in the total therapeutic approach.

Chapters six and seven are complementary chapters dealing with the “nuts and bolts” of the conversational model approach; one is dealing with general principles of the conversational model, while the other is dealing with particular issues and situations. Chapter six focuses on the therapeutic field and how positive and negative forces dominating the therapeutic conversation play a role in the generation of self. Chapter seven concerns the actual language and therapist attitude that arise in particular situations, around certain issues and forms of presentation that can be seen in day-to-day clinical practice.

Last chapter titled Discourse Correlates of Therapeutic Methods and Patient Progress is written by the team of linguists working with Russell Meares and his colleagues to develop conversational model, and gives a short account of an approach to the study of mental process that moves beyond, but complements, such research instruments as neuroimaging. It draws upon the idea that “though we cannot view psychic life, the way words are used gives us a window through which we can ‘see into’ the mind” (p. 10).

What makes this guidebook really useful and valuable both to practitioners and to those undertaking future research in this field is a suggested adherence scale for the conversational model, Russell Meares added in the Appendix. This manual will be a valuable tool for clinicians and practitioners working with BPD patients in their effort to help patients recover their very sense of self, integrating the unconscious traumatic memory systems that repeatedly intrude into healthy mental function or if needed, overthrow it. This guidebook provides essential reading not only for clinicians working with borderline patients and interested in using the conversational model, but also for any practitioner in the field interested in rethinking the structure of the way they talk with their patients.

 

© 2013 Kamuran Elbeyoğlu

 

Kamuran Elbeyoğlu, Toros University, Department of Psychology, Mersin, Turkey