Psychiatry & Psychotherapy Podcast - Borderline Personality Disorder: Common Factors In Effective Therapies With Dr. Robert Feinstein

Episode Date: February 25, 2022

In this episode, I interview Dr. Robert Feinstein, on his new book, Primer on Personality Disorders. In a chapter he authored in the book, he writes about the commonalities of effective treatments for Borderline Personality Disorder.  Dr. Feinstein states that six major types of psychotherapy achieve around 70% effectiveness in the treatment of borderline personality disorders. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. All right, welcome back to the episode. Before we start, I wanted to introduce the author, Dr. Robert Feinstein. He has no conflicts of interest. He is a psychiatrist with a ton of helpful stuff. He has been launching like psychotherapy training programs within residences. I think he has three of them so far. So it is a pleasure to

have him on. He has no conflicts of interest. I have no conflicts of interest. So if you are listening to this, you can rest assured that we do not gain anything financially by promoting any of these topics today. So here we go. I am joined today by academic psychiatrist, author, professor of psychiatry, psychoanalyst, Dr. Robert Feinstein. He is someone who has been seen patients for many years, had a number of different roles in psychiatry from senior Associate Dean of Education at the University of Colorado School of Medicine. And he was the outpatient practice director at the University of Colorado Hospital, director of the residency training for seven years in New York Medical College. He went to NYU Medical School,

Albert Einstein, psychiatry residency. He was at Columbia University for his psychoanalytic training. his CV reads like a 200-page book or so and he has a new book that came out that we will be talking about today he was the editor and wrote some chapters it is called personality disorders and has been released recently in December what's the full title of the book called Primer on Personality Disorders Oxford University Press, 2002.

Okay, very good, yeah. And so I actually, as I was reading your chapter, we're going to be talking about, it's largely on the treatment of personality disorders, which has focused largely on borderline personality disorder, and it goes through all the different types of therapies that are efficacious for this. And then some of the commonalities,

it's interesting. I actually have been working on a doctor, document going through the studies. So as I'm reading through this, I'm like, this guy beat me to it. He totally beat me to this chapter, which I'm totally happy for you. Yours is different than mine would be. Mine would be more like, this study said this, and you can see that these two therapies are pretty much the same. So I have that in the works for the future of this podcast. But what you have summarized very eloquently in this is there are a multiplicity of treatments that work for borderline personality disorder, and what are the commonalities, what are the

differences, and what can we learn from them? Because they all have something to teach us. So would you summarize it differently? Like, what would you say the thrust of your motivation for this book was? Yeah. So I guess it was for clinicians who don't necessarily work with patients with severe personality disorders, but should have some general principles of what it requires to treat personality disorders. And that's where the idea of the things that are common across all the evidence-based treatments comes from. The other part of it is that since all of the psychotherapies are about 70% efficacious, if you're trained in one form of therapy and it may not be working perfectly well, I wanted clinicians to have the ability to adapt something from a different

treatment and maybe introduce it. So for example, if you're a DBT person and it's not going that well, maybe there's a concept for mentalization-based treatment that would be useful that would improve your relationship with the patient. So I wanted people to both know about the evidence-based treatment, know the things that they all have in common, and then the ways in which they might borrow from another evidence-based treatment, some of the interventions they use, to see if they can improve outcomes when they get stuck with patients. Yeah. Yeah, that's good. So you were trained as a psychoanalyst, and so you talk a little bit about transference focus therapy as one of the modalities and mentalization, which are kind of both under that psychodynamic frame. And I think, you know,

so I did this episode on schema focus therapy for borderline per seizes disorder recently. And one person emailed me and was like, I can't believe you didn't mention DBT for borderline per seymor. and I was like, hey, I'm enthusiastic that you're a DBT therapist. You're doing good work treating this population. Don't think I'm critical of you. Nevertheless, there's good data to support. There's a multiplicity of modalities. And I think a lot of people are just like,

they haven't read the studies where they compare one modality to another. So maybe can you start with talking a little bit about how you learned that the modalities were similarly effective, Like, how did you come to grips with this in your practice or your... Sure. So, several ways. So I spent three years as the associate director of the borderline unit at Columbia Psychiatric Institute,

which was where my interest in personality disorder blossomed. That was many, many years ago. And this was a wonderful unit. It was a research unit striving to get the best treatment that was available. And in those days, patients could stay for a year. we had some patients stay three years, which doesn't exist anymore, but it was a time when there was intensive study about personality disorders in general. And obviously, while I'm analytically trained, I've had different aspects of my career where I've learned other modalities

of treatment. So I'm actually trained in six forms of treatment, realizing that in certain settings with certain goals, some treatments are better than others. And patients don't always want a long-term treatment. And sometimes patients just want to change the way they're thinking. Sometimes they want to change their behavior and that it takes more than one kind of therapy and different sets of interventions to actually help patients. So that's sort of where it started was from my own clinical experience that you can't only have one form of treatment that works well. You have to know something about the patient and figure out what's the right treatment for the right patient, for the right problem at a particular point in time.

And that concept generally brought me to thinking about, well, so what are the different ways in which you can treat patients who have personality disorder? So then I started to look at the literature, and I developed what I call the Big Six. And the Big Six are the evidence-based treatments that have significant studies that prove that they work. They work about 70% of the time.

And it turns out that all of the big six, which are transference-focused psychotherapy, mentalization-based treatment, dialectical behavioral therapy, schema therapy, good psychiatric management, which is Gunderson's treatment, and cognitive behavioral therapy all have rich data sources and multiple meta-analyses that say that these therapies work. and so that's where I started and you know that follows in general what we know about psychotherapy which is there are many ways to get to Rome it's not just one way to help patients yeah and so I think I think the first sort of like if you're listening to this and you have one approach that you're trained in

you know a lot of charismatic trainers often sort of promote their modality and so it may be there may be some initial resistance from my audience to be like, wait a minute, there's six approaches that work. Like the boards in medical school only said DBT was the thing that worked. How do we wrap our heads around that there's six different types of treatment that work here? I don't know. Anything you would say to that person? Well, yeah, what I would say is what that indicates,

and this is true for all of psychotherapy, not just for borderline, not just for personality disorders, is that it seems that it's the common factors that all psychotherapies have in common that determine the outcome. In fact, when they've actually measured it, it turns out that about 89% of outcome of psychotherapy is based on common factors, and only somewhere between 10 and 12% relates to the particular theory that you use. So what are the common factors? It's that patients need to be heard and understood. They need to be observed.

They need empathy and validation. All therapies have in common that they all have a certain organization and a structure so that patients and therapists can follow a structure. So it turns out that having a structure, whatever it is, is somehow more important than the particular kind of structure that you have. And so this is a general principle that it's the common factors around psychotherapy that determine most of the outcome. That 10 to 12% of outcome is for patients with specific problems where some treatments are better than others. And that's what we know for certainly for borderline.

Yeah, this is something that I believe in and something that I trained. I still teach residents, and I was talking to them last night trying to convince them of this, that even within there's these studies that looking at the common factors, looking at something called Therapist Effect, that have looked at like what is, what makes one therapist better than another? It's not modality. It is more hard to train probably than a modality, right? It's like, how do you train someone?

How do you train someone to have their empathy increase, you know? Well, there are some ways to do that. But, yeah, I think you're pointing out that in many ways, the most important of those common factors is having a good alliance with a patient. Right. And the alliance is one of them. The alliance is one of the, that counts for 35% of outcomes, which means that, and I always say that to residents, hey, you don't know yet CBT or DBT or any of these other forms of treatment yet. You'll learn them as your training progresses.

But you already know how to do the common factors. And that's going to give you 80 to 90% good outcomes on your patients. Be compassionate, be empathic, work on the alliance, listen to the patient. All of those things are really what make patients better more so than the specific interventions, which will help for very specific populations under specific circumstances. Yeah. One thing that I noticed when I looked at the sort of the scientific study, sorry, I'm still like on this idea of like how they quantify whether one therapy is better than another is it seems to me that it's hard to find DBT studies by the DBT group where they're not comparing one version of DBT with another version of DBT. You know what I mean? Yes, I do. It's like, okay, we have the dominant.

sort of the dominant therapy for borderline precise order so when we study it we're not worried about challenging us compared to some other theory let's like do dbt versus dbt with prolonged exposure therapy which i was actually impressed that the addition of that like exposure therapy seemed to increase their effectiveness quite a bit i don't know any thoughts on that well that's called you know that's called the allegiance factor right that people have an allegiance to their own form of therapy. And I think that that does us all a disservice because there's so many things we can learn from multiple ways to get to Rome. So I think that's a real, that's a real unfortunate thing. And that's a real problem in psychotherapy studies in general, right? Because they compare

psychotherapy, they're not comparing two different forms of psychotherapy. They compare psychotherapy to basically a placebo-like response. And of course, you're going to do better. And, you're going to do better. But really what we want to know is, is one kind of treatment better than another. That's what we really want. And that means head-to-head studies. And in general, there's very little ability to get funding, although there are some studies, transference focused against DBT, MBT against DBT, and some studies of good psychiatric management as a alternative to DBT. And, you know, when they do, those head-to-heads comes out the same. They both work. They both work, yeah. And so, you know, I think, first of all, if you are listening to this and you're a very strong DBT therapist, then I salute

you. I really do. Like, I'm not saying that you should stop being a DBT therapist, or if you're a scheme of focused therapist. I'm not saying you should stop being a schema-focused therapist. But what I think what you're saying in this book is, like, look, all of these things work. And so can we look at some of the common threads? Or can we look at, like, maybe, some different ways of thinking about things. Like if you have that one patient that doesn't really respond to the current perspective, like can we sort of think outside the box using the other perspectives? Maybe they would be a better fit.

And we've seen that in our own, at the university I work at, like we'll have a patient who goes through DBT for, you know, six months, doesn't really get to where they need to get to. And then they'll try another partial program, which has a different psychotherapy. and it may make all the difference, you know? Yeah, I would say that's absolutely true. So it's sort of the idea that you can start with whatever expertise you have.

That's an evidence-based treatment and see how the patient does. And if the patient responds great, if you need to, you might change to another form of treatment if you have the skills or the training to do that. But I'd add one piece to that. It may also be true that people need different. kinds of treatment in sequence. So here's one example of that. So we know that DBT at the level of stopping, cutting, and suicidal behaviors may be a first-line treatment. And that may work really effectively for patients. It might be great. But at the end of one year of treatment where those behaviors have

stopped, does the patient have the life that they want? Do they have the relationships that they want? Are they able to fall in love? Are they good parents? Do they have meaningful work? Those are questions that DBT may answer in part, but for many, may not answer at all. And for patients who want to do that extra work, wouldn't it be nice to say, maybe now we should continue the work and do mentalization based treatment as the next stage to try to help you really figure out other aspects of your life that DBT didn't cover. And so it's both a switch with when one is not working, but also thinking about the sequence that some patients may need.

So I experienced this a lot with DBT patients in particular because they have a trauma history. And many of them after the DBT gets their behaviors under control need some trauma work afterwards, which DBT is trying to morph to and can, but maybe some of the trauma-specific. treatments would work better for some of those patients. Yep. That's what I'm trying to foster. That's good.

That's good. I appreciate that. It reminds me there was one study I looked at where I think it was transference focus versus DBT, and the transfers focused had a little bit bigger improvement in reflective function, which is kind of like an attachment type of change that occurs. Do you remember this one? You're nodding for my audience. who can't see us here. So I think that's what you're kind of leaning into a little bit is like

sometimes the, so with transfers focus therapy, you're looking at what is going on between you and the patient in the here and now and quite frequently, right? You're looking at like, you are making this person feel something as the therapist. So it's much more interpersonal than like looking at behaviors. And so, so, so, Surprise, surprise, that type of work over time helps someone in their attachments with other people. Yeah, absolutely. So, you know, if you think about all these, what I call the big six, you will realize that they have different, each of them has sort of different kinds of relationships with the patients. And transference focused and MBT mentalization-based treatment and schema therapy, those three in particular, really feel that the doctor-patient relationship is,

the motivator for change and that you need the doctor-patient relationship to get the kind of change that you want. DBT and CBT sort of see those things as important factors, but for them it's teaching skills. It's do you have the skills for distress tolerance? Do you have the skills for emotional? And so the relationship in those forms of treatment is important but not essential. The skills are what's essential, and that's a different emphasis that they do. Good psychiatric management, which is basically a supportive kind of psychotherapy, says skills matter, but what matters more than any of that is just support. Do you have support to do work? Do you have support in your life for housing? Do you have support to handle medical problems? And so they come at it from even a different way,

which is where skills don't necessarily or not necessarily thing, but support is most important. So again, we just have multiple views of how to get patients better. And to me, that's so enriching because it means that we can really help a large group of patients and need to develop the flexibility to use different kinds of therapy or different kinds of interventions when we get stuck. When I've heard Marcia Lennaham talk about DBT, she has talked about specific patients she's had, how they had her phone number, how they would call her on the weekends.

It seemed to me like she had a really profound relationship with these clients. And that is something that kind of like, okay, so although you write like that the skills may be really, really important, and mindfulness and, you know, obviously these things are helpful. to some degree, but it seems to me that the relationship is pretty profound. Also, she mentioned in this lecture, if you don't do weekly countertransference sort of sessions, you know, like as a treatment team, discuss the difficult patients, process through the emotions you're having towards them, then you're not doing DBT. I remember that because she kind of like railed on people. Like, look, if you are not doing these things, you are not doing DBT. Like, you may think you're doing DBT, but you're not doing DBT. And I was, you know, there's, of course, a lot of programs throughout

the U.S. that don't give patients the therapist phone numbers. And I think at our university, we have good outcomes without doing that. But nevertheless, like, when you look at where they're doing research, often you have these sort of over-the-top, awesome, you know, connections that the patients and the therapist will have. Not that that doesn't happen in real life, but there may be some more boundaries. boundaries may be good. Anyways, any thoughts on that sort of stuff? Sure. I'll tell you an interesting story.

Many years ago, so people may not realize it. Marshall Linnehan did her initial trials at Cornell Westchester with Otto Kernberg. And he was doing what became transference focused on one unit, and she was developing the DBT skills. So she emerged with her form of treatment focused on behavior from a psychodynamic perspective, which she has said she never completely got. But I was at a conference where she interviewed a patient and Dr. Kernberg interviewed a patient. And it was a borderline patient. And then each of them talked about how they worked with the patient. But the reaction to the audience

was that each of them were borrowing heavily from elements of the other one's therapy. So Kernberg was doing behavioral things, although when you asked him what he was doing, he was saying, no, no, I'm not. And she was doing emotional transference things. And when you asked her about it, she talked about it in terms of operant conditioning and so on and so forth. So I think when you look at what clinicians are doing, there's a lot of similarities. Hearing clinicians talk about what they're doing is where the differences appear more strongly than they actually. actually are. At least that's been my experience. That's a great. That's a great observation. Yeah. And so I think in this podcast, I try to not use a lot of big words, which some people I think would prefer, you know, a little bit

more miracle, mystery and authority from me if I like used a lot of one person commented the other day. Like you need to, you know, you don't use a lot of neuroscience words. It's like, okay, so I've noticed that conferences. It's like you have a new modality. Use a lot of complicated neuroscience words. use some behavioral stuff and then you justify your like new approach right and um it's whereas like the common factors are so much more persuasive to me I guess as a

so it's like how do I how do I talk to the most people about these okay let's get into some of the some of the details of like the frame let's talk about the frame what it is what the different types of therapy do for frame so the idea

of frame is that all these therapies with patients who have personality disorders need to be well structured. And they need to be, so they shouldn't be an open-ended treatment where you're talking about whatever it is that the patient wants. So they need to be highly structured. And the way in which they're structured, almost all of them, is that if suicidality or violence or substance abuse, or eating disorders, any of these conditions or symptoms come up, that's what they address first. And that makes sense that they would want to address those first because the patients have to stay alive. They can't hurt anybody and they have to be medically stable. So all of the treatments really emphasize that as a structure. They also emphasize that it needs to be a safe space.

So the treatments have to be regular. They also emphasize that and DBT and CBT do this particularly well. They review with patients all the things that patients can do that interfere with the therapy. And this is structure. They call these treatment interfering behaviors, TIBs. And the idea is that there are things patients do that can blow up a therapy. They can act violently in therapy. they can miss sessions, they cannot do homework, they cannot do all of those things.

So these are resistances that patients put up to therapy. And in a structured treatment, you have to have a way to deal with these things which are called treatment interfering behaviors, has to be kind of structured. It's also important as part of the structure that you tell people that they have to present with a focus. What are we working on today? Right? And the focus can be different.

it can, depending on the form of treatment, it can be on interpersonal relationships, it can be on working, but they have to have a focus. It's not just an open-ended discussion. It has to have a focus and a goal that you set mutually with the patient to structure the treatment. Also important for the structure of the treatment is that patients are completely honest with the therapists. And this doesn't mean that patients necessarily lie, although some do, certainly patients with the more severe anti-social personality disorders, for example, may lie quite a bit. But more commonly is that patients withhold information. They don't share everything that's going on with them, and they do it out of shame or out of an awareness that it's not a good thing. So they withhold information.

Obviously, if they're withholding information, that makes us all worse as therapists. It can't be a good therapist when we don't know what we're treating and what information they're withholding. So therapy needs a real, a real structure. And depending on the kind of therapy, it has a particular structure. So you mentioned DBT. DBT will say that if a patient gets suicidal, they should call their therapist. There should be a conversation. They can reach their therapist.

It's a five-minute conversation. And within that conversation, skills are going to be practiced. They have a way to manage the suicidality. And each therapy has its own version of different ways to manage. consistently different problems. And that's what we mean about the structure of the therapy. Okay. Yeah, there's some, the one thing that came to my mind when you talked about,

this is going to be, we're going to review the things that get in the way of us accomplishing our goals. It's like you have different words for that in different types of therapies, of course. But then there's those, the big things that would get in the way of someone moving forward their life. Like, if you are currently intoxicated most days out of the week, then the therapy probably discussing a relationship conflict is not going to be too effective, right? Exactly. Or if you're throwing up six times a day, like, no therapy is going to be able to make you

not feel horrible inside, you know, depressed or anxious. Actually, I've had a couple of patients who it's like you get into it for like three or four months. And you're not making progress. And then I'm like scratching my head, like what is going on? And then it comes up like, this person's throwing up multiple times a day. And they didn't tell me out of shame, right? So I think one of my questions to you would be like, how do you discover, if there is a ton of shame there, what these sort of maybe hidden behaviors that are getting in the way of moving forward?

How do you go about discovering that? Well, it depends on the patient. I can't answer that globally. It really depends on the patient and what they will. So I will typically start with behaviors that are interfering with the treatment. So you know, you have to show up. You have to pay your bill on time. We have to keep boundaries. We have to have priorities. Those are the things that I'll particularly, particularly structure with patients. So it really depends on the patient and what's coming, what's, you know, what's coming at me and what the patient needs in terms of how I do that. Some patients may come to you and want to work on their interpersonal relations. And that's a different kind of work than working on why aren't you gainfully employed. Those are different kinds of works with different kinds of problems. So it's got to be tailored to the patient. Have you ever had any patients where it's like you get a couple months in and then you find something out where you're like,

oh, that's what's kept this person from moving forward? Absolutely. I'd say the biggest area for that is sort of uncovering early life trauma, which is the basis of at least a lot of the reason people have personality disorders is early life, neglect, abuse, incest, trauma, violence. So many times that's what you realize is bedrock to all. the personality disorders. I mean, everyone thinks about it in relation to borderline, but it's equally true for paranoid personality disorder. It's equally true the amount of trauma in patients who have

antisocial personality disorder, invalidating environments for patients with narcissistic. So it's trauma for this group of patients is the big thing that becomes uncovered in the process of working with them, I think, regardless of the kind of personality disorder, there's a lot of trauma out. there. Now, you talked in the book about how different types of trauma are more associated with a given personality type. So run us through that a little bit, just so I have that straight in my mind. Sure. So that's a vast literature, and I'll try to summarize it a little bit as I can and as my memory permits. So it wouldn't be a surprise that patients with antisocial personality disorder are more typically going to have violence as a part of their trauma, actual violence, people being beaten,

domestic violence is very much associated with them. So they have that kind of violence. And they also have abuse, but abuse in a physical domain. They are beaten. They are whipped. They are locked into closets, that kind of physical abuse. So that is more typical for patients who are on the antisocial spectrum. And similarly for patients who are on the paranoid personality, spectrum, that kind of direct violence. Now, there's this whole other kind of trauma that fits more with many of the other personality disorders, and that's the so-called invalidating environment. Now, an invalidating environment is where your parents basically don't see who you are. So they don't understand who you are, and they invalidate the things that you do by being critical, by criticizing you,

by raising their expectations. And environments where that's the persistent theme, the invalidating environment, they may look more like, that's typically the history you might hear more with a narcissistic person, right? You might hear that kind of invalidating. Now,

many of the patients with some of the other personality disorders come from the backgrounds where it's been neglect. So it's not necessarily abuse or invalidating, but it's absence. So the mother gets postpartum depression and in the early life of the child is sick and in the hospital. And now that young child has multiple caregivers. It's not intentional neglect, but it's functional neglect based on what's happening in the parent's life. So those are the big ones.

I look for abuse. I look for neglect. I look for histories of violence. I look for invalidating environments. Those are the matrix of the kind of traumas that set up personality disorders. So, okay, so talking about neglect, what types of personality disorders are more common with the absence, the functional neglect? Sure.

Is there a particular or is it just kind of broadly? Yeah, it's broad. Okay. There may be some data that I can't retrieve at the moment about the specificity of that and the particular personality disorders, but it's a, it's a broad one. Okay. And then, um, you are you mentioned in the book sexual abuse being more highly found in borderline personality disorder. Absolutely. That's, yeah, that's a, that's a really important. And that would be true for borderline personality disorder as well as histrionic personality disorder where sexual abuse is there. So

the, the incidence of, of incest defined as, either with parents or with close relatives in borderline women is quite high. When I worked on the borderline unit at Columbia, 50% of the women who had borderline personality disorders had repeated stories of incestual relationships. And the thing that went for that, the thing you look for clinically for that, is is there alcohol or other substance abuse in the abuse or heavy in the family? So most of them had alcoholic fathers or cocaine using cousins. Substance abuse went very high with the group that then ultimately, with the perpetrators

who ultimately delivered the sexual abuse to their unfortunate relatives. Yeah. There's a question of like, can people not remember sexual abuse that comes up from time to time with my listeners? can people like remember it later in their life can people you know like block it away from their memory what is your thoughts on that yeah i mean for sure they can uh we know this based on the example of dissociative identity disorder i mean that the whole purpose of that disorder is to block out traumatic memories or to encapsulate them so uh patients who use dissociation uh are there. Trauma induces memory changes. And if you think about it, why you'd want to not remember

something is it's so painful. So you want to put it out of your mind. And you might need to put it out of your mind to be able to function. So they may very well not remember it. And that goes both ways. So they may not remember it. And you want to allow the patients to tell their story and see if they remember more when they're in therapy. But it unfortunately sometimes goes the other way where a therapist's best intentions, they tell a patient, I think you were traumatized without that data being there, and then that creates false memories in the patients. So that's the problem on the other side sometimes that therapists get into. So you want to let the trauma history emerge from the patient's telling of the story

and not suggest it, not make that part of the ideology, but let it emerge from the patient. that's how you know that it's an important issue. Right, right. I want to reiterate that just to our, you know, like if you are suspecting sexual abuse, do not ask leading questions. You know, questions like when your parent used to give you a shower, did they touch themselves?

Like, when this happened, did this happen? You know, those types of leading questions are, they put an image in your patient's mind when the patient is in a distressed state often. And just even thinking about that image can be distressing. I think it's one of my pet peeves. I catch it once in a while. Like a patient will get referred to me.

And, you know, I can just, it's like, yeah, anyways, any more thoughts on that? Things that you would, you, thinks that therapist should never say to patients. Yeah. You don't, you don't want to create a false memory because then the patient adopts it as their identity and it may not actually be true. So you have to let patients tell their story of their trauma, let it emerge in the relationship. And the way it typically emerges is you'll see trauma in their current life. And as you work through the trauma in their current life, that's the setting in which the

memories will emerge of similar kinds of trauma that occurred earlier in their lives. And, you know, our memory is not great. We don't, you know, most of us don't remember a lot of details about what went on in our early. life. So that's just the way brains work. Yeah. Yeah, so we've been talking about trauma. You also talk a little bit about how some of this is genetic. And I think it's important to kind of balance that. I think there's some people who are on one spectrum where they think it's all genetic. There are some people on the other spectrum who think it's all environment. So for the different disorders, you know, like how genetic is,

for example, narcissistic personality disorder? Sure. So in general, all of the personality disorders have a genetic component and an environmental component that's usually largely based on trauma or one of the forms of trauma. Those are the two things that need to sort of work together. And the genetics are modest, almost all the personality disorders, perhaps with the exception of narcissistic personality disorder.

I'll come back to that. all of them have modest to moderate heritable traits. And the three traits that are often inherited that lead that come from genetics are a genetic tendency towards negative emotionality, that's one, a genetic tendency towards high impulsivity or low agreeableness. These are things we can see in early life of infants, and a tendency towards introversion. So those three factors are the ones that we've tracked the most on all the personality disorders because they have genetic links that we can understand. So those are the three traits. And so they all have genetic inputs. Now, narcissistic personality is the one where

there's the least evidence for genetic input, although there's some emerging evidence that maybe there is some for that one. That one's the least genetic as far as. as we know. And that's because that seems to be more of a parenting issue for these folks, the way they were raised and the way they were parented that led to the formation of the narcissistic character, although there's still some debate about that. There may be some genetic inclination for narcissistic PD as well, and that remains to be determined. Okay. Yeah, I'm wondering, do you, do you like sub-categorize narcissism in the way that you think about it? I've sometimes thought, okay, there's some narcissists that are more linked to, for example,

psychopathy, where they have the low affective empathy, they have more of that psychopathic personality. So they're kind of more of the dark triad, psychopathy, Machiavellianism, and narcissism versus there's some that seem like they're more weak egos, you know, like underneath, right? Do you have any, like, in your mind subcategories that you think about? Yeah, so I would say there's actually a literature on some of this. So at the most severe and worst is what we might call the malignant narcissist. These are the people who are prone to sadism. These are the people who are cruel.

These are the people who will hurt and exploit others. And typically have a lot of both narcissistic features, meaning I'm the one who can fix everything. I'm the one all-powerful, but they also have a lot of antisocial features. And that malignant narcissist is a group of patients that we don't know how to treat. Now, if you move down on that, you might say that there are some narcissists that have some paranoid trends. These are the ones that are kind of suspicious of other people's intention. That one is a little less severe. on the edge of treatability. We may be able to treat those

on the edge of treatability. And so antisocial features on the first one, paranoid features, maybe a little bit easier to treat. And then if you move down, you get to the one that you were talking about, David, which is the sort of the more healthy narcissist who doesn't have a sense of themselves,

doesn't know what their identity are. Those are a very treatable group within the spectrum of narcissism. And you could think about these patients. Another way we think about them, are they more on the psychotic level of personality organization, which would be malignant narcissism?

Are they more in the borderline organization level, which would be more the paranoid? Or are they on the more neurotic level of narcissism, which would be the person who doesn't have a strong identity? So there is that spectrum, and a real spectrum of treatability. Yeah, I think for those of you who, that's like new vocabulary,

in more of the psychodynamic, psychoanalytic tradition, there's those three categories, you know, psychotic, borderline, which is different than borderline per seymor disorder and neurotic. And I think it's, yeah, anything else you want to say on that

just to kind of educate people who may have never heard those three categorization levels. So what they are, are ways to think about how people function. And what category you're in is determined by your relationship to reality is the main one. So if you think about that one, if you have a psychotic personality disorder, you're having hallucinations or delusions. If you have a borderline personality disorder, your relationship to reality is you're not,

for the most part, psychotic, but you might have disturbances in the sense of reality, a little dissociation, maybe a little unreality, a little confusion as to who you are. And if you're at the neurotic level, you're basically in touch with reality and context. So those are the levels. That's one way to differentiate these three levels. And another way, which I won't go into much, is to look at the kind of defenses, this makes it very psychodynamic, to look at the kind of defenses that are used, the idea being that psychotic patients use primitive defenses, borderline patients.

use splitting defenses, and neurotic patients use more repressive-based defenses. That's a very psychoanalytic view of these different levels. And the concept is that patients at different points in time will function at different levels. So it's not like you get assigned a level and you stay there. A patient who's psychotic may be psychotic for a period of time, and when they're better, they function more in the borderline range. And a patient who has some disturbances in reality functioning in the borderline rain when things are going well may look more neurotic. So that's the idea is that people move up and down these levels depending on their environment. But you don't usually see a psychotic person functioning at a neurotic level. That's usually too far reach. They don't

usually get there as a way to sort of, I hope that's not too confusing. No, I don't think it's too confusing. Okay, so, okay, we talked about Frame. We talked a little bit about early childhood and therefore, like, things that you might need to treat. So let's talk a little bit about, like, the therapeutic alliance and how it differs between the Big Six that you talked about. Sure. So this is really interesting, and they all have sort of different approaches

to thinking about how they should relate to the patient. So I'll start with the one that's most controversial. So schema therapy, they believe that the therapist's role is kind of to be a good parent. it's limited reparenting. And that that's your relationship. You're being a good parent with boundaries, so you don't do everything a parent does.

So there are boundaries around it, but you're modeling what a good parent would be. Many of the other therapies are really against this idea that we as therapists should be good parents. But I think it operates at some level on all the treatment. So that's one idea of the nature of how the therapist should be. To contrast to that, the DBT therapists in general tend to take a coaching approach. So they're coaching people,

and it's a very non-judgmental approach. So they don't judge patients, but they coach the patient, and they may be very warm towards the patient, but the idea is to coach the patient to use the skills that DBT wants to teach them, the mindfulness-based skills, the distress tolerance skills, into personal skills. So they're coaches. And that's how they respond to suicidality, right? They coach the patients to learn how to use those skills so that they're not so suicidal. So that's a kind of coaching relationship.

Now, the CBT people, they're not so strong on the relationship. And they say that their relationship is what they call collaborative and trial and error. So you try to collaborate with the patient. but you experiment with what behavioral techniques work best for the patient. So it's not your personal relationship, but it's the empiricism, the experimenting with what knowledge and skills a patient needs to get better. So they're not so focused on a warm and caring relationship because they believe that skills manage carry more.

Again, I'm characterizing it. I think CBT therapists, plenty of them are warm and they borrow from the other forms of treatment as well. Now, there is an interesting distinction between transference-focused psychotherapy and mentalization-based treatment. So the TFP, transference focus group, they take a role that's much more expert. And their role, as they see it, is not particularly to have a warm, caring relationship, although that happens, and it is important. But they see their role as to contain the emotional storms of the patient so that the patient doesn't get destroyed and that the relationship is maintained. Now, mentalization-based treatment is a little different. They're much,

they're less expert and they're more egalitarian. They say, you know, people's mental states are opaque. We don't know what other people think. So they take what's called a not knowing stance. And what that simply means is they're very, very curious about what the patient is thinking and very, very curious about their own thoughts. And they're talking a lot about that. So they don't take an expert position. TFP takes a much more, I'm an expert position. I'll tell you through interpretation, what's going on with you. They take a little more of an expert position. Again, I'm characterizing them to draw some of the distinctions. And good psychiatric management is really just a supportive relationship. They just try to be really supportive. What do you need? How can I help you? What are the

services we can give? They're trying to be supportive. They lean a little in the psychodynamic direction, but it's basically just a very supportive relationship, as you would be with a very good friend or a good family member, and that's what they emphasize. So some variation in the relationships that each of the therapies have with their patients. That's good. Yeah. I think the most interesting one for me to learn about was when I got to that sort of the mentalization, the kind of the not knowing stance. And I was at a conference and I watched Transfer Focus Therapy with Kernberg. Was it Kernberg, right? He's the guy that. Yeah. He was the young or yeomen. He was the guy giving the talk. And it seemed almost a little bit adversarial at times. And Dr. Tar, one of my mentors, he talks about how. he tends to think of transference work a little bit more with the intersubjectivist's approach that you can be responsible for aspects of it, whereas it seemed like Kernberg was putting all the responsibility on the patient. Do you have any thoughts on that? Sure, sure. So I think

another way to frame that question, which is what I think you're asking, is, you know, there are different relationships to countertransference, right? And so countertransference is one of two things. It's either the stuff you bring as a therapist from your own history that interferes with work, with your work. That's your, based on your history, you have problems and you bring them into the therapy and that causes problem in the relationship. People call that the classic countertransference. But the one for personality disorders that we talk about is the one. that's called global transference. And the idea for a global transference is that if I put a patient in the room with 50 therapists and then let the 50 therapists interview the patient and then went

around the room afterwards and asked the therapists, how did you feel about that patient? There would be an enormous similarity in all the therapists feeling the same way about that patient. So that's telling you that your reactions to the patient are coming from the patient, not from your own history. That's the totalistic one. And transference focused in particular is really focused on the idea that much of what therapists feel are coming from the patient. They're not coming from the therapist. And I'd say for the severe personality disorder, that's generally true. so, you know, but maybe it's 95% coming from the patient and 5% coming from the therapist, or maybe at different times it's 50-50, sometimes from the therapist, sometimes from the patient,

sometimes for the both of them together. So, and that's why sometimes transfer and focus can be very assertive about what the patient is doing to you with the idea that what they're doing to you is the same thing they've done to the people in their outside life. They're bringing in their transferences, if you will, from their outside life into the therapy relationship, and they're treating you the same way they've treated other people in their lives. And often that happens. And that's a useful learning environment to learn how to do something different. I like how Yalom talks about this just to kind of bring it down to a lay level. He talks about in one of his books, he talks about how he always gives directions to his office the exact same to every person.

yet every person seems to respond differently to the directions. And I'm reminded of this recently. I had a new patient and just the amount of sub-questions on the frame to me prior to engaging the first session were like astronomically higher. And it turned out this person had untreated OCD and was having intrusive thoughts, leading to behaviors about four to six hours a day. So it's like that, just how people respond to you

in things that you do the same exact way every time, right? And the differences in that response says a lot about the person, more than it does about you, right? Exactly. That's a great way to put it. Yeah, and if you're a barista listening to this, you know, and you do the coffee the exact same and you get that grumpy person coming up, it's probably them, it's probably not you, right?

For some reason, like, it's so hard for people to get out of that mindset that it's the other person. Right. I don't know. Does that make... That makes sense. Yeah. And then that's what the therapists are trying to decide, is it me, is it you?

You know? Right. And so I think that, you know, therapists in general tend to be more sensitive. It's like, how do we receive negative feedback? It hurts. Right? And so transfer focus therapy kind of allows a way of understanding negative feedback in a way that you could use that to help the other person. Absolutely. It's like a practical. So if you have a really hard time receiving negative feedback from patients, now if every patient gives you the same feedback, it might be you, right?

But if it's like that one in 10 person and it's like this is a different type of reaction, instead of just going straight to blaming yourself, it's like how do we look at the patient's transfers? I had a patient who came into me and said, after at the beginning of the second session, he said, you are such a moron. You're an idiot. You don't know anything. I don't, you went to, you went to, you went to you went to medical school to learn how to do this, you're really terrible, he said to me. So I'm sitting there, that hurts, that doesn't feel so good. And I said to the patients, we just met, is it possible you could know me this well, such that those statements could be true? Yeah.

That really rattled the patient. Yeah. Just giving them back a little bit that their way of seeing me was grossly distorted because they didn't know me that well, right? Right. Right. Yeah. I think, let's see, I'm thinking what would I have said? If I wasn't rattled, so I think sometimes we're, it's like you get rattled by a comment like that and you want to defend yourself, right? You want to like, if I was you, I'd be like, have you been on a, my website, you can download my CV, buddy. There's nothing in that CV that says incompetent. If I'm incompetent, good luck finding someone who's competent. But, you know, because probably you're listening a lot, you're taking in the story, it's like maybe this person wanted something, right? So, okay, so the non-defensive part of me, like if I was, if I was in my,

my own therapeutic stance, I probably would say to them, like, okay, I hear that you're upset, and there's something about our last interaction where you feel like I'm not understanding you in the way that you want to be understood. Can you help me, like, understand what happened last session that you did not feel understood? That you feel like maybe if I was smarter, I could grasp, you know? I think I'd probably, that's probably where I would be if I was in a kind of a therapeutic stance. Sure. That's a great intervention because what you're doing is realizing that the patient's attack is coming from feeling hurt by something you said or didn't say. So that's a great, that's a great response. Or like you talk in your chapter about like these therapeutic ruptures, right? Like how do we mend the therapeutic rupture?

You know, can we capture that moment where they felt unheard? Can we rewind it back to that moment and have them walk me through? Because if they were, like, okay, you talked about how a lot of these patients had a very invalidating environment. And so, you know, it's not you, the clinician, that's being the invalidating person. It's like they're projecting this invalidating. persona onto you. And so it's like, can we rewind to that moment where they felt that invalidation

and see if we could get them to talk about the distress and then empathize with the distress? You know, like, oh, it's so awful that you felt like I was preoccupied with something else that I was not thinking about what you were going through. Yeah, those interventions are exactly what a DBT person would do, and they would call that chaining, right, going backwards, to find out where the problem was. Or an MBT therapist would say that you're mentalizing the patient. You're mentalizing, you're understanding their intentions, their feelings at a deeper level.

Yeah, or maybe you're getting, yeah, and you're getting them to mentalize, or you're asking probing questions to get them to mentalize your internal world as well. Exactly. Like when, a question might be like, okay, when that went on and you were talking about that, what did you imagine I was thinking or feeling towards you? Exactly. Well, Robert, you were thinking, and notice that the patient uses your first name, right? Well, Robert, what you were thinking was you were thinking that, I don't know,

I'm thinking if the patient was that narcissistic patient that I'm imagining you spoke about, would be thinking something like, well, you were thinking, I have no idea what this guy's talking about because he is, he's, he's on another level that I am. You know, he's, he's processing things at a speed that are much faster than my own puny speed of processing. And so I'm just, I'm just not following with him. And I could just, I just was re-enraged that you would be, so willing to charge me for that hour, despite your lack of ability. Right. Well, what you're bringing to is that patients can make us feel very defensive.

And we don't have anything to defend. You know, we do our work, and sometimes they'll see us with distortions. And a good way to do that is exactly what you describe. What were you feeling before you said those awful things to me? what did I say or do that made you feel that way? What did I say that made you feel I was stupid? What did I say that made you feel I was incompetent? Let's rewind that and go back over that so I can understand what I did.

Take a non-knowing stance so I can understand what I did that made you feel that way. Obviously, it's not a good thing if you feel that way. I don't know how we're going to work together if you feel that way. So I want you to feel better. And the way to do that is to really. rewind that and say what did, you know, and then that helps you understand how they were seeing you and how they were seeing themselves, which is the critical part of all work with personality disorders, how each of these patients see themselves and how they see others and the distortions in the way

in which they see themselves and the distortions in the way they see somebody else. Yeah, really well put, really well put. I think, you know, the earlier, we can talk about this kind of stuff with patients, the better, I would say, because if they're having some negative transference, and I think it's pretty normal for the average person have some sort of negative transference, but especially when you get into the personality disorders,

they're going to have more transference towards you. And so the earlier that we can get them to talk about their fears of what you may be thinking or feeling and empathize with their distress, look at it, I think that it can be, it can help the work move forward. Absolutely, absolutely. I always tell patients, especially if really all patients,

I say, look, if you're having any negative reactions to anything I've said or done or not done, would you feel comfortable talking with me about that? Because it's important that you feel really comfortable and that we can talk freely with each other. Would you be comfortable telling me that even if it's negative thoughts? And you're right, if you address those things early on, then patients will stay in treatment. And if you don't address them, they drop out.

Yep. Yep. And, you know, it's not unusual when I have someone with like some of these personality types, is that they haven't lasted long in a lot of different therapies. And I think it's largely because we've, clinicians are not getting trained in this type of work a lot of the time, transference focused work, mentalization. I think both of those really work at the interpersonal level.

So irrespective of your primary modality to be able to think in terms of transfers, what's the best way to learn about this, do you think? Like, if you had like someone, let's say they were a psychiatry resident, they were like, you know, I don't know if I have enough time to do six years of psychoanalytic training like you did,

how do I go about learning this, how to do this type of. work? So you don't need 300 years of training to do all of these, all of these things. Each of the different modalities has training courses that they offer. So transference focus, there's a group at Columbia that offers training in that mentalization based. There's Peter Fonagy's group at Anna Freud Center that offer training. In fact, for my own education, I just completed a three-day training in mentalization-based treatment, which is something I wanted to know more about. It was three days. I learned an awful lot. I can borrow some of the techniques that were taught in that session and

use them. I'm not a mentalization-based treater at this point, because I haven't been through the rigorous aspect that it takes to do that. But I learned a whole bunch of things that were useful to me in the way in which I work. And so every one of them has that. Some of the problem is that, because they stay so pure to their model, they often require an enormous amount of training, usually on the order of a year, sometimes two, where you're both reading about it and treating patients and being supervised. That's the triad that they use for training. The one exception to that, which is really worth talking about, is good psychiatric management. And it turns out this is a training you can get in one day. It's one day of training. Because

basically we all know how to be supportive to patients. We know how to do that. That's not a new thing for clinicians. And what they teach you is how you frame the personality disorder. And then what are the interventions you should be using to support those patients? Should the patient be in partial hospitalization? Should the patient be an intensive outpatient treatment? How do you go about getting them employed? They're very much focused on the here and now. And for that kind of treatment, which takes one day of training is probably the most accessible, most quickly of any of these forms of treatment. And these specialized forms of treatment are very useful for the really disturbed severe personality disorders where general psychiatric treatment and management really just

won't work for them. Yeah, I think key in my mind is to get a good supervisor. Like, if you feel well connected to your supervisor, if you feel like he or she can empathize with your distress, create a therapeutic alliance. Actually, this is a paper I just got it, accepted academic psychiatry. I was first author. It's on looking at connection and supervision. And I created a tool to measure that. And what I found was that burnout, like emotional exhaustion, dropped considerably if someone was really, really well connected to their supervisor.

And so it even helps with burnout. And so having that sort of ongoing supervision. And now in the age of Zoom, you can find people all around the world. You can go and Robert, I saw on your website, you have the ability for people to reach out and get supervision from you. Absolutely. Or I do coaching internationally. as well. So it's like, you know, if you have a modality that you're working on, you can find someone who's maybe not the name brand person, but someone who's experienced in it and you can

seek them out. And I highly recommend that. Any other things that you wish to cover during this hour on your chapter, your sort of big topics that we missed that you feel passionate about? Sure. I would say, if there's one thing I would I would say is we need to stop the wars and the battles that go on about what therapy is superior to what other one. And we see this all the time. CBT, you know, right now of this decade, we're in a mode where if therapy is being offered, it's CBT as though it's the right treatment. and there was a period of time where psychodynamic was the right treatment, right? So there is no right treatment.

That's the main thing that I feel passionate about. There are multiple ways to do that. We should be thinking about how we can use what other people have taught us to improve our own responsiveness to patients. We can be more responsive if we're working in one way and the patient doesn't like it. and understand some of these other theories, we can work in a different way. We can change the way we work with patients. So if we have more therapist responsiveness to the patient using evidence-based treatments as guidelines, we'll get much better outcomes.

So I would say, let's stop the psychotherapy wars. I don't care. And the data says we all do pretty well, but we all don't do great. We all do about, you know, all of the forms of psychotherapy have about approximately about a 70% efficacy. That means 30% of our patients are not going to be helped by whatever form of treatment we're using. So what do you do for that group?

Well, hopefully, you learn and go to a different form of treatment or you refer to somebody else who can do that treatment, but you don't give up on the patients just because we've had a failure of one kind of treatment without going through the many different approaches. So I'd say that of all of the things, that's what this looking at the big six has reinforced with me more than anything else is learn from your colleagues. And also, you alluded to this, use language that's not so technical. You know, as you said, every therapy uses the kind of language which sort of makes it seem like it's so special. But actually, if you track the concepts, they run in different language across many of the therapies.

They say the same thing. They just use different language to describe similar processes. Yep. I was giving a history of psychiatry class to the residents, and one of them was like, why do we need to learn all this stuff that happened pre-Froyd? And I'm like, well, because Freud is repackaging it, and then modern therapies are repackaging it now, you know? So we look a little bit at, you know, Stoic philosophy and Aristotle, Plato, all these ancients, because all of them are using different words to describe something that's, sometimes, you know, like repackaged in a new brand. And then, you know, you go to these conferences and each brand leader will give an hour lecture and then recruit you to their weekend seminar. And there, they may upsell you to the next level of training and, you know, which is good. I mean, you should go to those. You should experience them if you're a new clinician. But just realize that like there are some commonalities and that what is it like after you read a

couple articles you'll feel like an expert after you read a thousand articles you'll feel like maybe some of the interconnectedness of all of them out of it and any concluding thoughts on this sort of way of thinking about things well i would maybe just make a comment about training um it it it's very easy to come sort of eclectic where you take a little bit from this therapy a little bit from that therapy and you kind of slap it together however you feel and that's very problematic in its own right. So for those who are training, I say, if you want to learn CBT, then with a subset of patients, do just CBT and learn what CBT can bring you and learn what CBT can't do, but stay with that model. And then if you want to learn transference focused, stay with that model until you

learn the limitations. And then once you have one or two models in your mind and can figure out the structure, then you can borrow things from one form of therapy than another. But the idea of just sort of borrowing randomly interventions from wherever they come from, the problem with that is that you then don't have a structured treatment. And that's really what's most important to patients is that you have a structured treatment and you're making sure that you're handling the problems they have in a systematic way. There can be many different systematic ways, but it has to be systematic for patients to get better. Yeah, I like that. That's good. That's good advice for beginning professionals here. Okay. Well, I have really appreciated your time. Thank you so much,

Robert Feinstein, for coming out and for sharing your knowledge. I will put a link in the show notes to your book. And if you leave them a good review, put that you heard them here so that we can rejoice that someone came from the podcast and got the book and read it and appreciate it. and appreciated it. And yeah, if you want to track Robert Feinstein down, I will put a link to his website as well. And, you know, in the age of Zoom, he could come lecture you wherever you're at. And so, yeah, any other final remarks?

I will also add that I will post a couple of handouts that people can get on my website, or you can post on yours however you want to do it, that we'll give them some of the information in our discussion today. Great. Okay. Thank you so much. Thank you very much. Pleasure talking with you. I really appreciate it.