Psychiatry & Psychotherapy Podcast - Borderline Personality Disorder: Splitting & Identity Diffusion with Mark Ruffalo

Episode Date: January 10, 2025

In this episode of the Psychiatry & Psychotherapy Podcast, Dr. David Puder is joined by Mark Ruffalo to dive deep into the complexities of borderline personality disorder (BPD). Together, they unpack Donald Burnham's influential 1966 paper on splitting and identity diffusion, exploring themes of self-concept, relational dynamics, and the therapeutic challenges posed by BPD patients. Learn how splitting impacts interpersonal relationships and therapeutic teams, the historical evolution of BPD from "pseudoneurotic schizophrenia" to a recognized DSM diagnosis, and the significance of psychodynamic and mentalization-based therapies in treatment. Key topics include: The history of BPD diagnosis and theory Splitting and its effects on therapy teams and relationships Identity diffusion and its manifestations in gender, sexuality, and self-worth The role of childhood trauma, attachment, and genetic factors in BPD Practical insights for clinicians working with complex personality dynamics Whether you're a mental health professional, a student of psychiatry, or someone seeking a deeper understanding of BPD, this episode offers rich insights and evidence-based approaches for navigating this challenging and often misunderstood condition. By listening to this episode, you can earn 1.75 Psychiatry CME Credits.  Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Mark Ruffalo. He is a person that I've become friends with. He's local to Florida here. I would say he drove out to be in person for this. Let me say, I met you through actually the residents who had been on the book club a couple times. And they were big fans. They were like, he is the best teacher.

You got to meet this guy. and then we met on X formerly called Twitter where I was like, man, this guy knows a lot about BPD and I've been listening to your YouTube's and I'm like, we got to get together. I know you're a fan of the history of psychiatry. And so in this episode, we're going to dive into borderline personality disorder before it was called

borderline personality disorder. Would that be fair to say? I think that's a pretty good description, yeah. And specifically a paper called the Sparterm, special problem patient, victim or agent of splitting by Donald Burnham in 1966. And let me just say to you who are listening to this, who are thinking like, really a paper from 1966? I don't think papers are written like this anymore. And this is, am I right, your favorite? This is one of my favorite papers, I think, in the history of psychiatry. I think

Burnham does such a good job of describing the syndrome in a way that you really don't see in the literature much anymore. And I don't know exactly why that is, but I really love some of the old stuff because of just how descriptive it is. I think it's almost like the new stuff has gotten so far from the practical, you know, we look at like correlations, we look at, like, correlations. We look at a point three correlation between this group and this group, or we look at, you know, a lot of statistical things, which are a little bit my isotoric or difficult to handle or difficult to understand.

This is a paper about 12 women over a 10-year period at Chestnut Lodge, age 16 to 35. It is actually, so there was a book that was written about Chestnut Lodge called The Mental Hospital that was published in 1954. So I was looking at that, and I was looking at that, And I was thinking to myself, okay, this is a place where people stayed for 18 months. Okay, this is how it used to be done.

So you can imagine like this place where nurses and doctors and you have like 30, 40 people staying for a long stay. And the kind of data you could get out of that is so much more rich than like, you know, what my experience of the psychiatric hospital was like three to four days. for most borderline patients. Same. People with borderline precise are. Yeah. And maybe someone stayed for six months if they were truly, like, in this really psychotic space.

But that was like a total exception. Yeah. Yeah. And for those who don't know, you know, Chestnut Lodge was one of the psychoanalytic hospitals that opened in the early part of the 20th century to treat mainly schizophrenic patients. There's a few notable hospitals that open during this time, Chestnut Lodge being perhaps one of the most famous. The Menninger Clinic, which is still around, obviously, Austin Riggs, which is in Western Massachusetts, and a few others. But these were places that specialized in the psychoanalytic treatment of severe psychopathology.

Virtually all of them, with the exception of Austin Riggs, have closed. And Menninger is still around. It's in Texas now, and it's changed a bit. But, yeah, it was definitely a different era in psychiatry. And many, many major names, you know, came through Chestnut Lodge, including Harold Cyrils and Otto Will and several other big names in the history of psychiatry. And so I was thinking about, like, what do you get from studying people for, like, 18 months, right? So when they talk about how they collected the data,

they talk to all the staff members. They talk to, they have recorded sessions of like these conferences. And so they're narrowing in on 12 patients that evoked the most emotion and turmoil within the teams. And so I also love this from just a team perspective. As someone who's run a partial in an IOP, like I can I can visualize the people that split the team the best. Yeah, yeah.

As someone who's been in practice, I'm reading this and I'm sweating. My head is hot. I'm imagining scenarios, situations. You know, if I would have read this as a medical student, I may have been bored. Or slightly amused or just like, uh-huh, like, uh-huh, yeah, okay. Yeah. Okay, what? But like when you're reading this, as someone who's in the,

trenches in the deep interpersonal team dynamics, right? This week, I just had a patient split, me and my therapist, and, you know, it happens, right? Yeah. I think it's hard, hard sometimes to really fully grasp the essence of splitting, unless you've really experienced it firsthand. You know, you can read all the texts in the world and all the papers in the world. and all the papers in the world. But unless you've experienced the extremes

of idealization and devaluation right before your eyes, I think it's hard to really comprehend exactly what one means when we talk about splitting. Now, yeah, you're right. I mean, this is a paper, in essence, about staff splitting,

which people use that term all the time now. I think probably one of the best contemporary scholars, you know, on this is Glenn Gabbard, whose writing is really quite extensive on splitting in hospitals and among staff members. But I think Burnham here is talking about this phenomenon before it was really fully elaborated. And I think it's one of the early papers on this concept. Yeah, and I would say Glenn Gabbard, one thing I didn't know about him as I was reading his textbooks when I was a resident, I didn't realize this is a guy who has kind of become that person that psychiatrists go.

to when there's major boundary violations. And he's kind of built his career off of this to some degree consulting with psychiatrists, physicians, therapists who end up in these ethical quandaries of situations. But here we have a paper that was written about this before even the word borderline personality disorder was really a word. Yeah. Yeah. So you see, I mean, so this is 1966.

So just a little bit of the history on borderline personality disorder. So it was John Gunderson, who in 1975 was Margaret Singer, who coined the term borderline personality disorder. But borderline states have been described in psychiatry going back at least to the 1930s with Adolf Stern, who first described sort of some condition existing somewhere in between the psychoses and the psychoneroses. So you see different terms being used. Blueler, I think, talked about latent schizophrenia, perhaps most notably as Hockinpolitans, pseudo-neurotic schizophrenia from, I believe, 1949. Psychiatrist named Peterson was talking about subclinical schizophrenia.

Kernberg in the 60s describes borderline personality organization, which is a broader concept that captures all of the personality disorders. defined by DSM. And then Gunderson really describes a distinct syndrome that we now call borderline personality disorder, which makes its way into DSM-3 in 1980. So there's been various descriptions of this condition or syndrome throughout the years,

but it was really Gunderson's work that defined it as a distinct disorder. Another influential notion was Helene Doeusie's as-if personality that's sometimes clumped together with all of the historical antecedents to BPD. Yeah, and I think, you know, it's not like it hasn't been around. It's not like it was invented. Sure. People used to call it hysteria probably met something similar to BPD.

Yeah. Yeah, yeah. And so, you know, there are some scholars, I think, Nancy McWilliams and Jonathan Shedler argue that a lot of what we call BPD is really is really histrionic personality organized at the borderline level to use Kernberg's sort of conceptualization there. Others, Gundersen, and some others see it as its own syndrome. And I think there's actually pretty good evidence to suggest that what we call BPD actually is a quite cohesive syndrome.

The symptoms are very, you know, very, that they occur together. There's a course to the illness. It begins in adolescence. You know, there's some, you know, research on genetics. So I actually do believe in the concept of BPD as a distinct psychiatric disorder. And actually, Otto Kernberg has come around, I think, to accept this notion as well. So he now incorporates BPD into his theory of personality. personality organization.

Yeah, and this is something I've covered in the past, multiple episodes. We've covered most recently medications in BPD, just in summary, a lot of the national societies are moving away towards seeing medications as helpful for BPD in and of itself. If there's comorbid issues, maybe you can treat it, but they're moving away from this idea that people are necessarily needing to be on long-term medications. Yeah, it's just a few weeks ago. The American Psychiatric Association published some new guidelines on treating BPD, and they basically said psychotherapies, the treatment of choice.

Medications, although they may be useful at times, and targeting symptoms probably are not advised long-term. And what's also noteworthy about the guidelines is that the APA acknowledged that psychodynamic treatments are effective and that there really is not, one single effective psychotherapy for BPD. I mean, for years, decades now, dialectical behavioral therapy has been talked about as being this gold standard.

And certainly it can be an effective treatment. But I think there's greater acknowledgement now that things like transference focus psychotherapy, which is Kernberg, and good psychiatric management, which was Gundersen's approach, which is still being taught and written about, and then also mentalization-based therapy, which I know that you have an interesting.

Well, I've been covering all these topics. So when this report came out, I'm like, have I somehow influenced the APA? Yeah. I'm like, probably not. But we've been talking about this. I had an episode of Feinstein where we went through the five different, you know, well-studied therapies. And, you know, like there are studies where they compare dialectical behavioral therapy with transverse-focused therapy. They both do great.

In some ways, I would say transfer-focused therapy is better because there seems to be an improvement in reflective function. I've covered that topic, and that has really helped my understanding of BPD and of severe psychopathology, which in a way that, like, I don't think it's like so much deeper than a simplistic, like, oh, therapeutic alliance is so important for psychotherapy. Yeah. I used to be a huge proponent of therapeutic alliance, but I think I've shifted more and more to like, actually what we're really trying to do is improve reflective function. Yeah.

In ourselves as therapists and in our clients. And that's a process, which is a whole lot more complex and nuanced and utilizes things like transference, countertransference. Okay, but I want to get into this paper because it's like, it's so good, and I want to read parts of it to you guys. So it starts out internal splits. The patient's divided experience and presentation of herself. And it says herself because they were all female clients in this cohort.

The typical patient in this series was very poorly integrated and in certain respects poorly differentiated. And then it's going to go through like what that like helpably means. And I want to state like it seems like these are like when you think of BPD, there are, there are, are different levels of functioning, you know, and these are probably more on the severe level of dysfunction. And I was also thinking, do these patients get dysregulated being in such intensive setting?

Sure, sure. And I wonder about that. Yeah, yeah, I wonder about that as well, and there's certainly lots of mixed opinions about treating BPD in the hospital setting, with some people arguing that really these patients should not be admitted to generally, psychiatric units. And I think there's probably some good reason for that. Now, the exception

might be if you have a unit that specializes in personality disorders such as Kernberg's unit up in New York, that may be appropriate to treat these patients in an inpatient setting. But, yeah, one has to wonder whether the length of stay, the intensity of the treatment. I mean, so, you know, years ago there was this notion of transfer in psychosis in borderline patients. And Kernberg talks about this, and he talks about having a patient once who, I believe, early in his career, the patient saw Kernberg walking down the sidewalk in New York City and hallucinated Dr. Kernberg spitting on the ground out of contempt for the patient. the patient had had a transient hallucinatory experience related to the therapy. And so it was noted that the intensity and the frequency of classical psychoanalytic treatment, where you're seeing the patient on the couch three or four or five times a week,

was not appropriate for borderline patients because they developed this sort of transference psychosis. And so one has to wonder when, patients like this are hospitalized for long periods of time, whether there's a regression that comes as a result of the hospitalization itself, and that hospitalization may, in fact, worsen these patients, even though we may not know it. We may not see it in that way today. But I think these are important ideas, you know? Yeah, I think, so when you think about most D.B.B. tracts that I've been aware of,

they'll have process group once a day, but you have a group processing. So you may be processing five days a week, but you're not the only one sharing five times a week with one person in this sort of like dyad. Yeah. The program I used to run was more for psychosomatic patients, and every group was process.

And there were a couple patients where it was too much. Every group had an element of process, I would say. would say. So there are reasons why I think DBT tracks have a lot of skills-based type of groups. You know, transfer strokes therapies twice a week. Now, mentalization-based therapy, if you look at the papers where it was very successful, they're doing these groups. It starts out five times a week. It goes three times a week and then two times a week for a year and a half. I think it was something like 500 treatments by the end of it. So it's pretty extensive and a lot of time in a lot of hours,

500, 500 hours of treatment. But if you think about like the full spectrum of someone's life and attachments, 500 hours is a blip. Sure, sure. And someone's like complete life trajectory. Yeah, definitely. Like to make such an impact in like 50 hours sometimes, right? like 75% of people get better in 50 hours of psychotherapy.

It's like, wow, that's impressive. So I don't know for certain, but I imagine that here in the 1960s at Chestnut Lodge, a lot of these patients were seeing their psychiatrist for psychotherapy probably every single day for 50 minutes or an hour, I would imagine, would be the context of this. And then also group psychotherapies and attention from nursing staff and the like. So when I looked at the book that was written about this,

and I specifically was like looking at the boundary violations. And some of the staff members, especially nurses and AIDS, became too close to certain patients. They would spend disproportionate time attending to favored patients, sharing personal details of their own lives and relying on the patients for emotional support. And that's the type of patient that we're talking about today. Yes.

It's, they would elicit in the staff this incredible bond. And through that bond, it's like the normal frame of how you might relate to a patient would dissipate. Yes. Okay. Yeah. There's a great quote from Burnham in the article that I think captures this, you know, the very, the very essence here of what you're describing, you know. He writes, no one could remain indifferent to or only mildly interested in the appeal. It's irresistible gripping, insistent demand quality evoked the most intense feelings, whether of love or of hate.

And so we're going to get to the appeal. And that's, I would say that the appeal is like this request from the patient for a special type of relationship with a particular person. And this, they hoped to obtain the ideal self. They hoped to obtain this perfect maternal role, right? And then, yeah, I wanna talk about when they looked at the commonalities of patients, I wanna go category by category and just kind of break this down.

So the first category was body image disturbances. This is page 107. And it says, she also reported such experiences as her arms swelling, her head shrinking, her body being dismembered, tenuously glued together, or suspended in midair somehow apart from herself. Other patients spoke of feeling dead, encased in cement, and uncertain whether they still were breathing. Yeah. These are obviously symptoms that, you know, point to this historic notion that that borderline personality was a, schizophrenia-like syndrome.

I mean, we're really talking about, you know, sort of psychotic symptoms here. And one has to wonder whether some of these patients included in the group of 12 did, in fact, have psychotic illness. But, yeah, I've done a little bit of writing on these types of symptoms in BPD. I think they're underestimated. I think the SM does a really poor job of appreciating the frequency and the severity of these types of symptoms in borderline patients. I mean, in the diagnostic criteria, all we see is a reference to transient paranoia, which certainly does happen in BPD. But I think if you look a little bit closer, and you really do a good job evaluating the patient, you'll see brief experiences of hallucinatory phenomena. similarities in terms of how patients use logic

and how they come to conclusions, similarities that is between BPD patients and schizophrenia patients and other commonalities, including disturbances and how one perceives one's body. When I read a lot of these, first of all, it's very visceral language,

and this is why I'm saying, no one writes like this anymore when they write about BPD. Unless they're doing a... Yeah, I just haven't read anything like this. It's, to me, it's a very dissociative phenomenon that I'm reading. It's a way that I've understood a lot of the complexity of these symptoms. Is that like when you feel tenuously glued together, suspended in midair somehow,

it's like it seems like a very dissociated state. And let me go on to depersonalization because that is the very definition of dissociation. So it says they felt like a stranger to themselves. Whose body is this? is it all mechanical and doesn't have human feeling? They refer to themselves in the second or the third person. One patient referred to her eye as the thing one sees with. She strongly implied that her use of the word I

would be criminal misappropriation of a scarce item which others deserve far more than she. These patients shared a pervasive doubt concerning what of themselves and others was real and what was false. They were enormously preoccupied with how to distinguish the genuine from pretended, most obviously in their testing of others, but fundamentally in trying to resolve their uncertainty of self-definition. Sure.

So this is touching on what, you know, we would say in modern object relations theory is self and object differentiation, you know, where, where do I end and where does the other person begin? And all sorts of disturbances here in the patient's object relations. I think of this as like dissociation for me is like when all the other defenses break down, like things like sublimation, things like rationalization, humor, denial. When those break down, it kind of ends in this more dissociated state. Do you see it differently than I do?

I see it very similarly. I would say either a dissociative state or psychotic defenses at that point. So, you know, paranoid projections, hallucinations, and the like. I've had a patient that I worked through successfully who had a dissociated transference of me. So it's not that she didn't exist, although she felt like she was often in a cloud or disconnected from her body. but she went from me being this kind of like kind generative warm persona that she could bring to her mind when she was distressed to a frightful scary thing that felt like I didn't exist. Like even when I was with her in session. And it took about a year and a half.

It was the most protracted sort of dissociated transference. I'd ever been with a client. And it was a year and a half before we got to the other side of it. And to be vague, it took consistently showing up and being as present as I could. But even in session, I would start to feel dissociated. I would need to ground myself. I would need to bring myself back into my body.

I would find myself. find myself very sleepy at times. And I needed to kind of like stand up at times almost to kind of ground myself or pinch myself. Yeah, yeah. You're describing, of course, the patient-inducing a new phenomenon that's very similar to what the patient experiences,

and that's the essence of countertransference in a sense. And yeah, yeah. And of course, with these types of patients, patients, there's intense countertransference reactions that we have often. And they tell us something about the patient. I'm sure you've talked with other guests on this topic, but it's something particularly important in borderline pathologies here. Yeah. And I think it took me a while to get to this realization with this person. I think this was helpful. And this was my like interpretation to the patient. I would say, you know, like a lot of her childhood, this is what she felt of her parents.

that they were very like these ghost-like figures. And so it was really a reprocessing of that through me. And when she came to the other side, she could tolerate being around her parents more. Yeah. Okay, let's get into the next category, can we? Inside, Outside Uncertainty. She often perceived shifts in her feeling

as drastic changes in the appearance and intention of others. In the midst of all this inner outer uncertainty, she had little sense of autonomous control, but felt at the mercy of her environment. Whose thoughts are these? They must be something from a movie or a book, one patient said. People have me connected up and are putting slides in my head and make me see and say what they want.

Mm-hmm. Mm-hmm. It's a bunch of opposite paradoxes to some degree. It's like... Yes. Yes. You know, the inner, outer uncertainty, she felt like this,

at the mercy of her environment, at the mercy of other people, right? Like, where do other people stop and I begin? Mentalization talks a lot about this. Mm-hmm. They call it psychic equivalence mode where the patients are feeling like their thoughts are reality.

and that maybe other people, so when they perceive other people as thinking something, they're actually thinking it. Yeah, yeah. So it's not that Dr. Puter's angry at me, that potentially maybe Dr. Puter's angry at me, but I may be wrong. No, it's Dr. Puter is angry at me.

Yeah. It's like there's certainty there. Yeah, absolute certainty. And I think this also touches on, you know, Gunderson's notion of interpersonal hypersensitivity. These patients are, are characteristically sensitive to what's happening in the environment,

perceiving and often misperceiving things happening around them. As Harold Cyril said, the borderline patient has no symptom-free moments. He would talk about how every little thing from how you greet the patient in the waiting room to how you answer the phone if they call you to change their own. appointment, everything could be vulnerable to misinterpretation. There's this exquisite hypersensitivity. Correct, correct. And it's the interpersonal fear that I see driving it. It's like, are you and I are going to be okay? Are you, do you really care about me? Yes. Am I really your special patient? Am I someone that you really care about? Am I, I, I don't want to be, and the fear for that is so intense. And I don't know if you

heard my discussion with the mentalization based guys on narcissism. I did, yeah. But the epiphany went off in my brain

that that same level of fear for narcissists is around, is this person wounding my perception that others have of me? Yes. It's like,

it's not about the relationship, it's about this image of myself. Is this image of myself as this wonderful teacher being wounded by the slight of this person.

Yes, yeah. So I think the deficit in narcissistic patients is in the area of self-worth. In borderline patients, I think it's in the area of both self-worth and holding soothing. This was Gerald Adler's work in the 80s. So he talked about a borderline narcissistic continuum. So we see very often in borderline patients

the same deficits that narcissistic patients have, but an additional segment, of the illness when it comes to the inability to hold and soothe oneself during periods of aloneness. And so we can go into that a little bit more if you'd like about this continuum sort of idea. Yeah, help me understand that continuum. So, okay, so the people with borderline personality

sort of are really struggling to soothe themselves in their alone time. Correct. So, you know, so a lot of the therapies have, you know, when I heard Marshallineham talk about DBT, she would talk about how the borderline patients would call her patients with borderline precise order. I wanna be hesitant to say the borderline

because it puts the definition of them at their core, at the disorder. I think it's the person that struggles with borderline precise order. So they would call her. Now, I don't have this feature to my practice, right? Like, I think that there is a different way of framing. Like, the frame is all, like, very important to keep right. Therapy takes place in the session.

Yeah. So, you know, Kernberg and the transference-focused people argue that the therapy contract is essential. in work with borderline patients. It should be one of the first things that is done in working with the patient is, you know, outlining what is the role of the patient, what is the role of the doctor or the therapist, and the maintenance of the frame,

the maintenance of the contract is vitally important in the treatment of these patients. Now, Gerald Adler, whose work I really like on BPD was he argued that the goal of treatment is for the patient to come to internalize a holding, soothing object in the form of the therapist. And so Adler would recommend when the therapist goes away on a vacation to send a postcard to his patients, so that the patients have something to remember the therapist by. This is something that, you know, to other psychodynamic theorists sounds probably odd, and I doubt Kernberg would be okay with this type of model or this type of approach.

But Adler thought that the goal of treating borderline patients, at least the borderline segment of the pathology, was for them to internalize a holding, soothing interject that could sustain them when they're alone. so they no longer need to reach out to others in these frantic efforts to sustain themselves during periods of aloneness. And this gets to his idea of evocative memory, which I find such a useful concept. So I just want to talk about that for a moment. So Edler thought that borderline patients, their fundamental deficit was in the use of evocative memory. So in healthy normal functioning, if you will, we're able to conjure up a mental representation of a healthy internal object that provides us with comfort and soothes us. And so we don't have to rely on outside persons to do this for us. We can do it ourselves.

We're just fine being alone. Adler thought that borderline patients can't do this. So they rely on self-objects. They rely on other people to perform this vital psychological function for them. And when those self-objects aren't available, the patient just disintegrates. So, you know, Adler links this to developmental psychopathology and developmental theory that, you know, we talk about object constancy and the formation of evocative memory in very early life, somewhere between, you know, 12 months and two years of age, and, you know, perhaps some discerpts.

during that time is giving rise to some of the symptoms of BPD. So I think it's a powerful notion, this idea of evocative memory, object constancy, in understanding why the patient becomes so frantic when the primary object is not available to them. Interesting. Two thoughts came to my mind. One is on my episode on the prisons of Mesopotamia, which we talked about solitary confinement, it actually is toxic to everyone's brain. Like months alone in solitary confinement shrink the brain.

There's been a bunch of brain studies on this. It's very toxic to the brain. Everyone has worse mental health afterwards and increased rates of psychosis, increased rates of all sorts of things. So I think I might parse this idea that we should be okay alone. Yeah, yeah.

I was like, I'm not so sure if that's the case ever. I think there's nuance there. There's nuance there. Yeah. But it's maybe not the level of desperation of like separateness. Yes. The real painful agony. Yes.

I've had BPD patients tell me it feels like I'm dying. It feels like metaphorical death when the object is not available. Yeah. It's an absolute. Yeah. It creates a stress response in my body with the multiplicity of sort of like remembrances of the agony of this, you know?

Yeah. And when I read this paper, then this next section, it talks about several of the patients had been adopted. Others had been cared for by in constant series of parent surrogates, almost all had deep doubts who their real parents were. Often they developed a compensatory family romance,

fantasies of descent from famous or royal personages. So this idea of like, you know, these are tough childhoods, you know? Like, these are not... And someone might say, well, I know someone who's BPD

who had a really good, warm family, what about them? And I would say, well, tell me, like, how much do we actually know about what that like? What was that like for that kid, you know, like in that family? Was there personality mismatch? Were there messages from the parents that you cannot show up in any way with any emotion? Because my emotions need to be fully present and, like, there's no room for you to show up. You know?

Was there a hostility or an anger? that silence to sensitive persona, right? Yeah. I see some like... Yeah, I think it's obviously... I see some expressions on your face that say you kind of are resonating with something, or you have some memories of these things? It's very complex because you're right.

There are some patients that do seem to come from normal or fairly normal childhoods who develop BPD. And Joel Paris, who's in Canada, talks a little bit about this and how he finds it quite problematic to

assert that all of BPD is the result of trauma. And this idea sort of does resonate with me. I think when we look at the genetic research, you know, it appears that roughly 40 or 50% of what we call VPD is inherited.

Whereas if you look at ADHD, it's more like 60%. If you look at height, it's more like 90%. Sure. So I agree some of it is genetic. But I would also, and you probably have more to share on this, when you look at the adverse childhood experiences, what I recently did a huge dive on this. And when you jump from one to two to three to four to five

to six different types of adverse childhood experiences, the odds ratio of BPD jumps to like 25 when you get to like five. Does not surprise me at all. And so that was, and the only two, like a lot of things are like odds ratio of two. Like pretty much everything bad has an odds ratio of two. If you get like heart disease, diabetes, all these, you know, physical issues jump up as well. but BPD and complex PTSD jumped up a whole lot more than everything else. Yeah, yeah. And I think psychodynamic theorists have known this and have talked about this for many, many decades. And I get a little bit frustrated, frankly, when I hear people, you know, talk about trauma like it's this new idea in the field.

I think, you know, if you read the historical stuff, you'll see, you know, people have been talking about things like attachment, neglect, and abuse for many decades in psychoanalysis. So it's not a new discovery. I tend to think that in terms of the psychogenic factors, I think neglect is probably a more significant or relevant factor than overt abuse in BPD, although you certainly do see overt abuse. And I think that Linnehan agrees when it comes to neglect. I think that I think Kernberg also agrees with the idea that neglect seems to be more relevant. Although there were some studies in the 90s, I believe, that showed that maybe 60 or 70 percent of patients with BPD had experienced sexual abuse. So I don't think we can, I think trauma is obviously very, very relevant in these cases. I think, but I get worried. sometimes when we go sort of on a searching expedition for trauma in the backgrounds of patients' lives. And that is a personal pet peeve of mine.

Yes. It's when I hear of a therapist with very leading questions. Yes. It's very concerning to me. Like if you have like your own journey that then becomes imprinted on all of your patients in the same way, that's an issue. Very problematic. Very problematic.

nowadays. Yeah, and I've seen this probably the worst with like, like there was one religious clergy who in one of the towns that I've lived in seemed to have this idea that certain types of people, certain issues had certain, you know, types of trauma. And he somehow became like EMD certified, but he wasn't a therapist. And so that was a bad combination. Yeah. And then there was one other person, a therapist, who had been through her own sexual, which I knew because several of our patients that told me the same stories. And so, yeah, we have to be very cognizant

to put on our own stuff. And also look at like disorganized attachment, which has been shown to be seeable at four months of age and then linked to one and a half years of age goes on to have high rates of dissociation. So there is this link from early attachment wounds as well. Undoubtedly. So we're not just looking at, we're looking at the still face experiment,

repeated over and over, right? You know, what creates a stillface experiment? For some of my patients, it was their mom was on meth and alcohol and drugs. And so their mom was just like very chaotic, not present. For some of my patients, their mom was schizophrenic. and so very psychotic, paranoid, erratic behavior, not on meds, right? For some of my patients, they moved one foster home to another. It's very erratic, chaotic.

Yeah, lots of different scenarios. Yeah, yeah. So, yeah, I think it's always good for us to put, like, please do not overly think that there's one pathway and then look for that pathway. Sure, sure. And this is, you know, Kernberg highlights this, you know, there's no single path to borderline personality disorder. You see trauma, abuse, neglect, there are genetic factors in particular innate aggression and pathology of attachment. So there's no single cause of BPD.

I think a biopsychosocial approach is vital in all of psychiatry, but especially when we're talking about BPD. One section here that was interesting was talking about gender and sexuality. And so I think we need to put like a warning label that this is like a very fluid and moment-to-moment change that they found in these types of patients. Listen to what they say. sexual identity and role also were uncertain and conflictual. These patients were tormented by questions such as

am I a woman or man, girl or boy, which do I want to be? Am I like my father or my mother? These conflicts were outwardly manifest in oscillations between masculine and feminine choices of dress, grooming activity. One patient apparently in a determined effort to deny all femininity

shared off all her hair, smoked cigars, and wore trousers. A few weeks later, however, at a hospital party, she was most decidedly feminine with a low-cut gown and evening gloves and obviously enjoyed flirtatious exchanges with many of the men present. She, like most of the special problem patients studied, also displayed feminine, masculine oscillations within the span of a few days or even hours. Yeah. touching on, you know, identity diffusion in these patients.

That's exactly what I wrote down here. I wrote distinct gender identity crisis in BPD. Yes. Like, it's a very, it's not like this person has always believed this very concrete thing. But it also has, like, as a therapist, how do we approach this in a nuanced way to not see something monolithic, but see it as like, is this an overall identity diffusion? Sure. Which I don't think we talk about that enough because we see that. We certainly don't talk about it enough when it comes to issues of sexuality.

And I think sort of wading into territory that is a bit controversial and is, you know, sort of, it's sometimes difficult to navigate when it comes to issues of sexuality in particular. But, you know, going back to the 80s at least, you know, Aktar describes the syndrome of identity diffusion and one. One of his core symptoms of it or manifestations of it is diffusion in sexual identity. So, you know, I think, like you alluded to, I think, you know, there's something about the frequency or the rapidity of the change in one's sense of self here. When it comes to sexuality here, it could occur within the course of a few days or perhaps even a few hours you're talking about in this paper. and I think there's something significant about that. Yeah, and in the next section, it talks about how age was also fluctuating. So several claimed ages older or younger than their actual ages,

and their appearances tend to fit these claims. Not infrequently, they had been encouraged to premature competence, or rather pseudo-competence in various sectors of behavior. For example, one patient described with a mixture of pride and resentment, how before the age of five, she had made her way alone around New York City subway system. Notice it's with pride and resentment. Correct. Yes. Others had been included in adult social activities at inappropriately young ages. Several had been recruited by their mothers as special confidants and companions to be leaned upon and entrusted with intimate detail.

of their mother's problems, including those of her marital relationship. The usual boundaries between generations had been blurred, and at times the usual independent axis of the mother-child relationship had almost been reversed. The daughter-father relationships had similarly been distorted with frequent, not-so-settled invitations to be a better wife than your mother is. or as patients have told me, my dad dumps on me.

There's no place for me to share my issues. Instead, he shares all his issues with me. Total blurring of the boundaries of a family relationship here. We see that very frequently. So, yeah, it's the prentification. It's role reversal, the flipping of the netherly, the flipping of the normal diet, you know, and I think about this with my kids who, you know, it's like,

I don't share, or if I share things for my day, it's like, I don't share it in a dysregulated way. Sure. But I have lots of patients who have talked about how like their mother completely disregulated, or dad completely disregulated rants for hours about this or that thing, you know, and it's like, it's so unhealthy.

Yeah, it meant many of these children grow up to become adults who work in the helping professions, actually. Oh, yeah, yeah. Oh, absolutely. Yeah. And those of us who have had such situations, you know, it comes with sometimes a mixture of pride and resentment, right? Mm-hmm.

Where it's like, like they said earlier, it's like, okay, but this, I had this sort of valuable place in the family unit. It comes with sort of a power of sorts, right? It's a special place. But at the same time, there's a suffocating aspect of it for a lot of my patients. Where it's like this was a weighty thing. And my emotional system was not ready for it, but I had to figure it out. And then my friends all found that I was the perfect person to talk to.

Sure. Probably because I had this experience. So once again, I became this like, it was like a, it allowed for the social connectedness that maybe I wanted or needed. But then it also came with the weight of like who was hearing my stuff. And sometimes they'll come to therapy and they'll be like, this is the first time I ever got, had a place where I felt like I could share. And I'm still fearing that I'm burdening you. I'm still fearing that in too much, or that. It's like, I shouldn't be sharing with you my weight or my stuff.

Sure. It's like somehow that was imprinted and then transferentially shows up in the relationship. Yeah. I think when we see it play out in the therapist who was reared in such an environment, this is sort of what, you know, what was originally called sort of a rescue fantasy or some sense of omnipotence in the therapist who is sublimating a need to rescue a broken parent through his or her work with patients.

And this can be a very helpful and effective motivator in work with patients, but it can also get the therapist into a lot of trouble in having such a need to save the patient, to be involved in rescuing the patient from the patient's problems in life. And this is where we start to talk about boundary violations and the like. But yeah, this obviously has multiple as relevance. And we can have compassion for if there are, you know, like if you get pulled away from your normal frame with a client, be curious about it.

Like, oh, what is that? There's something to learn there. And as a supervisor, as I work with therapists, it's like I'm not coming from a punitive place. It's more of like a curiosity of like, okay, like what happened there or what led to you accepting their phone calls at all times of the day and throughout the night as well. Exactly, yeah.

And then, you know, pulling that back is like the most painful thing you can imagine to do towards the patient, right? And so, yeah, this rescue fantasy is really intense. That's exactly why the contract is so important, or the frame of psychotherapy is so important. You know, you say sort of pulling that back from the patient is painful and it is. And then the patient comes to see you as depriving them of good care. of caring. You can quickly slip from this idealized persona

to completely devalued. Yes. And it's like the rage which they may be cutting themselves with, they may be doing self-harm, they may be giving them themselves bad, self-appraisals gets pointed at you. And for someone who wants

and yearns to be in this sort of place of helping, it could be exquisitely painful. Absolutely. Absolutely. It can be a very painful experience, and it can have profound effects, I think, on the therapist. You know, Harold Searles wrote a paper in 1959, which is even older than the one we're talking about today. But the title of the paper was the effort to drive the other person crazy, which is language we wouldn't use today. But I think when one is subjected to this alternating or oscillating, idealizing, and devaluing pattern,

it can have a pretty profound effect on the psyche of the other person, including the therapist. And it can contribute to a great deal of confusion on the part of the therapist. What is it that you want from me? and the patient, in essence, dumps into the therapist all of these disavowed bad parts of self and attempts to induce in the therapist a sense that is very similar to what the patient experiences himself or herself. Yeah, projective identification, right? They project these things into the therapist.

The therapist identifies with them. maybe the therapist's own sort of developmental trajectory makes them susceptible. Interestingly, we found that there was a Sanson. I used to work at a clinic that he did research out of. And he found that there are higher rates of BPD in the resident clinic than in like a normal clinic. Interesting. And I can think of a couple reasons why this might be the case.

having sent patients to resident clinic, often I would send the patients that were like really hard to refer to a lot of therapists because a lot of therapists would see them once and say like, I'm not a good, you're not a good fit, whereas the residents would just would see anyone. So sometimes that was the case maybe. But yeah, I think there's something about that.

Just beware if you're a young professional listening to this. Okay. uncertainty of self-valuation. So the typical special problem patient fluctuated unevenly between global good and bad self-appraisals. So once again, we're talking about this identity diffusion. We're talking about the sense of self- fluctuating so quickly, right? At one time regarding herself as a kind, generous, near angel, and at another as a loathsome, evil monster,

she also oscillated between opposite poles of many pairs of component attributes. Among the most salient of these was the sick well and the dependent-independent polarities. So we're seeing, again, contradiction and paradox there. And self-splitting. I think so often when splitting is taught or when we talk about splitting, we're only talking about the patient coming to see others as either being, all good or all bad. But the patient engages in self-splitting, too,

where at different points in time, the patient may find herself as very attractive and intelligent and worthy, and in other points in time as dumb and stupid and unattractive and unlovable. So self-splitting occurs as well. Yeah. They also talked about her grooming ranged from highly fastidious to totally neglectful. Her eating habits were gluttony or aesthetic, starvation and her communicativeness from lively conversation to muteness.

Sometimes she was kind and considerate at other times sarcastic and demanding. Guys, do you see why this paper is like a favorite here? You just don't see it today. I mean, you just don't see this type of writing anymore. It's beautiful writing. It's really beautiful writing. And I hate, it's like I was thinking about this coming into this. like it's so delightful to read such beautiful writing,

but at the same time, I had a stress reaction reading it, right? At the same time, I'm, like, empathizing with many patients that I've seen over the years that are caught in this. Yeah, it's very experienced near, whereas I think a lot of, especially the scientific writing today,

is very experienced far. It's intellectualization. Yeah, yeah. It's like it allows a distance. It's like operating on a cadaver. You know, it's like, yeah, yeah, yeah. They do mention here, recourse to adjectives such as mixed and borderline was frequently, frequent, in attempting to place her in a diagnostic category. So it's like borderline was used in this, even in this paper as like, they weren't quite sure what category she fit into.

Exactly, yeah. As Nancy McWilliams says, too crazy to be neurotic and not crazy enough to be deemed. psychotic. And I don't mean crazy in a pejorative way there. I mean, it's Nancy McWilliams talking about what used to be thought of as borderline cases or, you know, borderline personality cases. Okay, here's another one. Also filled with uncertainties were answers to vexing questions of her capacity for self-control and responsibility. At times, she appeared to be purposeful, even willful, active agent, at other times a helpless, passive victim. The variability of her behavior also spawned doubts about her sincerity and genuineness,

similarity to her unsureness of where her masks left off and where her real self began. How to distinguish the genuine from the pretended plagued the patient and staff alike. And so I feel like, as someone who's experienced, Like, it's almost like I want to get away from moralizing in terms of this. Like, I'm not trying to figure out what's real and not real. Like, I'm, I don't know. Did you have any thoughts on this? Yeah, yeah, yeah.

I think, you know, so often what I hear from borderline patients is I don't know who I am. I really have no idea who I am. And Burnham writes, you know, it's difficult to know where her masks left off and where her real self began. You know, but again, the variability, the shifting between seeing oneself as a competent, capable person in the world and someone who's utterly helpless, a passive victim of others. And, you know, I think victim there is important too. When we think about the victim, victimizer dynamics that we often see in the lives of borderline patients, the persecutory objects, and very often the therapist or the psychiatrist is cast into this role at various points in time, too. So, yeah, I want to get away from moralizing the behavior, too. I think we can describe the behavior and the phenomenology without moralizing it.

But I think we get into trouble when we don't even want to describe the behavior, which I think is sort of where we're headed. I think that some people get offended just by sort of talking about the behavior the patient engages in as if it's a bad thing to do. Yeah, it's like where do the identity diffusion, right? The sense of self that is like struggling to find a sense of self. It's like invasculating between extremes. Okay, so the appeal. Let's get into the appeal.

So the appeal is made by the patients. and it's um let me let me read it here it comprised requests for healing rescue and protection from suffering the themes of intense need was communicated variously i need you you are my lifeline you make me alive complete and real you are absolutely essential to me um obviously such poignant statements readily evoked wishes to help in persons who had elected healing roles. More than this, they prompted in many listeners a profound sense of being chosen as the needed person, a response which Maine termed the arousal of omnipotence. Now, this is one of my favorite passages in the entire paper,

because Burnham is talking about how vulnerable the therapist or the doctor or the nurse here is to this appeal and the feelings that it evokes in the other person to be needed so desperately, to be wanted, to have the patient communicate to you that without you, I will fall apart. you are essential, evokes, especially in people who have chosen to help others as a matter of their livelihood, a profound reaction. And this is often sort of the source of a lot of the problems and the conflicts that we see into personally is that, you know, Burnham emphasizes the needed person being chosen as a the needed person. And I think there's something significant about that. The arousal of omnipotence. What do you think about that phrase? I don't know exactly what Maine is referring to there, but I imagine that it's a sense in the helper that I'm the only one who really can understand this patient. I'm the

only one who has the training or the knowledge or the experience to help this person. Oh, yeah. It's a hero type of fantasy, right? When you go back, you mentioned victim, abuser, and hero. And this is why when I talk about the hero's journey, I like to pose the therapist not as the hero, but as the guide. If anything in the story, you're going to be the guide, which is kind of like this, you know, in the hero's journey, it's like the common mythological structure of the hero. venturing into foreign land, needing to overcome obstacles, encounters a guide to equip them in some way

to overcome the obstacles. They go then, separately, overcome the obstacles, and come up against maybe malevolence or evil, overcome it, and then go back home, and then bring back home some of the gifts that they learned along the way. Yeah, yeah, it's a good metaphor. Yeah, I think in therapy, this plays out

with the therapist assuming this, role of, you know, sort of, of boundless help, or I'm going to come in and I'm going to swoop the patient up and I'm going to rescue him or her. And it will be because of me that I've saved this patient. And this, you know, this results, I mean, just to bring it down to a clinical level, it results in all sorts of problems in treatment where, you know, where if you're a psychopharmacologist, you may be prescribing medication that's not indicated. you may decide not to hospitalize a patient when the patient really needs to be hospitalized because only you can really understand the patient.

I'm the only therapist or I'm the only psychiatrist that will really get the patient. And then, of course, it can evolve into bigger boundary problems as well. In the article, they talk about the origins of the appeal. In this, the patient's urge for a very special relationship, tantamount to rebirth into the good mother's self-union was rooted in her conviction that herself was directly and currently shaped by proximate persons. She experienced her good self as resulting from current contact with good persons and her bad self from contact with bad persons and her uncertainties and variations of self-definition from the inconsistencies within

and among others. Yeah. I think this is, you know, 10 or 15 years later, we see Gunderson talking about the same thing about how sensitive the patient is to relationship with others. I mean, he really defines the syndrome

as an interpersonal problem at its core and how, you know, how the patient feels is very, very intricately tied to what's going on in this relationship with the, to use Gundersen's term, with the major object, right? So if I feel good today, it's because things are going well with the major object.

If I feel depressed, it's because my, there's some problem in that relationship. And my sense of goodness, my sense of how good I am in the world, is shaped by proximate persons, to use Burnham's term, right? So very, very, very, one sense of self, one sense of goodness, one's sense even of wanting to, go on living in certain cases is very, very much linked to whether one is appreciated by, cared for by, loved by the major object. So they talk about how some of the nursing staff were noticing that they were the good objects.

And so then they tried to rally others to also be good objects. And then the patient would identify someone else that's like, this is a bad, object and so they would try to insulate themselves away from the bad objects right and in addition she attempted to purify herself by projecting bad self elements onto objects defined as bad so now the patient is projecting as well onto the bad objects all of the badness yes and and this is where this this kind of unique splitting takes place and now you have factions yes on the unit some, you know, thinking, we just need to love,

this is a special person, we need to love them more, we need to give them more of what they want. And other factions, thinking like this person's manipulative, this person is lying, they're using the system where we should be stricter. Yes. And then the, you know, members of the former group start accusing members of the latter group

of being too punitive or too authoritarian or lacking in compassion, not caring. narrowing enough about the patient. And it can get really ugly. And Gabber does a good job of talking about this, too, in some of his writings about staff splitting. But intense divisions sometimes. Sometimes it falls along professional lines where there are differences between, say, nurses

and social workers and psychiatrists, and sometimes it depends on the individuals. But, yeah. Another related paper that touches on some of these themes is another great piece. I think it was from the 80s. The title of it is The Patient Who Can't versus the Patient Who Won't, or treating the patient who can't versus treating the patient who won't. And it talks about splitting around this issue as well, with some staff members asserting that the patient just isn't trying hard enough.

They really can do something. and then other staff members saying, no, the patient has a disease, they have an illness that prevents them from being able to do thing X or thing Y. And so you see divisions along that take that form as well. But yeah. I love how you integrate all these other papers into this, man. That's so good. Okay. So furthermore, the urge for all good self participating, In all good relationships runs counter to normal integration of both good and bad within the self and within the particular relationships. These points of contrast are important in understanding the nature of the appeal. Yeah, so touching again on just fundamental object relations theory,

integration in the sense of self and other as being a part of normal and healthy development, that, you know, I'm able to say that the other person is comprised of both good qualities and bad qualities, but, you know, overall they're a pretty decent person. That's sort of a healthy integration of the object. When one has not achieved that developmentally, then we talk about splitting, where you can't see the object in its totality. You can't see nuance.

Things are either all good or all bad. So she's either comprised of all good elements and good parts or all bad parts and bad elements. So integration is being a vital developmental achievement in object relations theory. So the appeal starts often with the call from the referring agency. When I read this, I was like, oh, my. Right? So you can imagine, it says often the initial referral was made through a special channel and contained a mixed plea and warning that the patient required and deserved special treatment.

The referring person would emphasize how vital it was that the patient be met by sensitive understanding, lest the basis for the treatment be undermined at the onset. His advanced briefings would include warnings of others' failures at this task and invitations to rectify their insensitivities and mishandlings of the patient. I love how they kept records of this. Yes, yes, this is great. So good. Requests for the assignment of the especially skillful and experienced therapist of a specified age and sex were common. Mm-hmm.

Yeah, we see. this all the time now. I don't know if you follow, you know, on social media, but I'm a member of certain local groups that post, you know, looking for a referral for this type of patient. And very often you'll see this sort of phenomenon, the one that you just read about in a short little description of the patient. I have this very vulnerable patient who has special, as really special needs to really be sensitively cared for and I think they need a therapist

who is a female or a male between this age and this age who is inclusive and this and right. So a very, I think this is a very common phenomenon that Burnham was describing, you know, 50 plus years ago now. Yeah, from the onset, the typical problem patient engaged in a quest for persons who might fit the good mother magic helper mold. So, you know, this patient is searching for this person.

Yes. You know? Yes. They're searching. And I would say there's some that are just better at cultivating and like getting this type of relationship, you know? poignant depictions of the theme of love deprivation in her life was outstanding. This was conveyed by a myriad of subtle hints as well as full descriptions. She vowed that her parents had been so troubled, insensitive, or otherwise preoccupied, that they neglected her needs.

And potentially that really happened. Sure. Yeah. And so it's potentially, I'm like, am I, what side am I on right now? not really I'm not really the magical helper right now. In the way I frame that.

Yeah, I think that, Byrne, I'm talking about the theme of love deprivation is very interesting to me. I think clinically this plays out often when the patient comes in and they start to talk about how their other therapists have failed them. That no one has ever really been

able to understand me. No one has ever really got me. And I've been deprived of good treatment by my past providers. Now, you and I both know that there's a lot of good therapy out there, and there's a lot of bad therapy out there, too. So you certainly can't diagnose a patient on the basis of this sort of thing. But this theme that I've been deprived by all of my past treaters, all of my past love partners, is very common in borderline psychopathology. Yeah. It's a mixture.

It's complicated, like you said, because there are some, you know, and this is where, if it's a one-off, like I know this provider well, I've had many patients with this provider, and this person says this, it's like, oh, wow. Whereas if it's like the 10th story about that provider, which being a psychiatrist, I'll sometimes hear the 10th story about a specific provider.

It's like, oh, take no to that too. But inevitably, most providers, I can kind of figure out who they work well with and who they don't work well with. And so, I don't know, but yeah, it's like, it's also how they cultivate certain stories about the provider. It's like they're splitting from the very get-go. Yeah. Yeah, okay.

Very, very often. often in the initial stages with this type of patient, you will be cast in the role of, you know, of white night. You know, you're the best doctor I think I've ever seen. You know, you have all these great reviews on the internet and I'm so thankful that you've accepted me as a patient and, you know, the idealization often begins pretty early. But as Jonathan Shedler says, you know, if you're cast as a white knight in Act 1, you're almost certain to be cast as a villain in Act 2.

And, you know, he's talking, of course, there about splitting. And the inevitable devaluation that ensues in the treatment of these patients. I think it's worth going through, like, this one little part that talks about her sufferings took on the form of intense loathings and accusations of herself, using such epithets as dirty, disgraceful thing, monster, horrible monster, disgusting piece of garbage. She experienced some of these accusations as arising from within, others from outside, episodic self-mutilation was also frequent.

Her violent self, no, her violent hatred and rejection of parts of herself had multiple meanings, several of which will be discussed later. Here I wish to focus on the meaning of self-hatred as a form of suffering. And I would say, like, there is a lot of suffering in these patients. And so as we're talking about this, I don't want us to, I don't want us to miss the heart of it, which is like we study this so that we can help. And hopefully, not. over-idealize ourselves as they idealize us and not over-devalue ourselves as they devalue us.

But have some thick skin to ride through it and see ourselves with the constancy that they don't necessarily see. Yes. Yeah. I think that that point about suffering in these patients is so important. And, you know, when we, you know, when I was in graduate school and when I was doing my internship and psychotherapy training, you know, we certainly talk about the suffering of schizophrenic patients, the suffering in bipolar illness and the severely depressed patient. I think that the suffering that we see in borderline personality disorder is amongst the most severe. if not the most severe type of suffering in all of the psychiatric illnesses as I've grown to work with borderline patients. I think it's different in some ways

than how, say, the patient with psychotic illness suffers, but it's profound. And I think that, I think some people interpret talking about the nature or the essence of the psychopathology and the symptoms that the patient presents with as somehow like missing the suffering of the patient or neglecting how much the patient suffers or what the experience is like for the patient and I don't see that at all.

I think that talking about the nature of the psychopathology is a way to understand the depth and the severity of the suffering in a way that if you don't talk about the nature of the psychopathology you just miss. And so I think there's room for both. we can understand the pathology, and we can also appreciate the intensity and the severity of the suffering that exists in these patients.

Yeah, and I would add, as someone who's led a team, in the partial I op that I ran, I've stepped down from that role this year, I would sometimes see the splitting. And being able to point that out to the team, put words to it, get both sides to talk about it,

was some of the most important work that I did. And it was my psychodynamic understanding of transference, countertransference, projective identification that helped me do that. So when I imagine talking to you, you know, the people that listen to this, it's about keeping the team together as well. Because I imagine most people,

as they go on in their profession, they become team leaders, you know, whether it's a small community or people work for you. And it's like having this, and this paper kind of stowed away as like a tool, you know? Yeah. I wonder if you could speak to this. It says, the present series of patients also presented evidence of childhood experiences

which had taught them the power of displays of suffering and the threats of self-harm to influence others. Frequently, one or both parents had used such methods of appeal or coercion. In other instances, strong self-destructive urges while not manifest in the parent's overt behavior had featured prominently in their fantasies and dreams. Yeah, I think it just makes sense that in the context of neglect, a child might learn to resort to all sorts of means

to garner love and attention and sympathy. And so I think this is often the seeds or the root of some of what we describe as manipulation. And I think this is an important way of understanding the patient's extreme. And I think when we think of manipulation, we think of like someone's manipulating us to get money from us. someone's manipulating us to get sex, someone's manipulating money to control us. This is not necessarily what we're talking about. We're talking about manipulation for the goal of you being this love object.

Yes, yes. This stabilizing force internally for them, this all-soothing mother. Yes. And I think that can give us some more compassion around, like, the ploys. A lot of this stuff is not happening consciously. They don't know. That's a vital point.

That they're doing this type of thing. I'm also brought back to stories of like sociopathy and where it's like someone was born into a family where the dad was a con man and they ended up doing similar stuff to dad. Right. Maybe their parent used illness as a weapon. of regaining connection. And so they saw this, maybe mother threatened suicide

when she needed something. So it's like maybe some of this stuff was kind of caught. Sure. Not that we should shame that from happening, but to understand it. Yeah, I think of somatic or hypochondriical symptoms

often developing this way. If a child's emotional needs were not attuned to, if a child wasn't listened to emotionally, but for instance a parent would bring the child to a doctor at the first sign of a cough or a fever, then unconsciously the child may develop some pattern of exhibiting physical symptoms to garner emotional attention and love. And so I think that's a powerful idea.

Yeah, and I think the skillfulness determined how well they probably, were able to achieve that. Correct. And, yeah. They talk about how she often exemplified the care she desired by ministering to substitute objects, including live pets or cuddly toy animals. For instance, she would embrace and rock one of these saying,

she is frightened and wants to be held. I had one attending who said, who told me, like, you know someone like, as borderline precise, sort of they come in to the office with a stuffed animal. Yeah, I mean, I heard the same thing at Pitt. I mean, it was very commonly said. And I think there's truth, at least to some degree, to these notions that have been around for decades. They talked about how they described their room.

One patient even tacked on the wall pelts of pets that had died. You can think about these as like transitory objects, love objects from the past, you know? Yeah. Again, to sustain the patient, right? These, you know, in the failure of evocative memory to go back to Adler, right, the patient needs some tangible representation of a good object, right? So, you know, I've heard of patients who will hold on to something

that reminds them, say, of their partner when their partner is gone, to remind them that their partners still exists in the world. Either it's a small gift or something that they hold in their pocket, some type of souvenir that the patient can use to conjure up the mental representation of the partner in the absence of the other person. And so I think in this, you know, here, the pets on the wall, you know, I think maybe something akin to that. Yeah. A staff member once commented, going into a room is like going inside her.

The urge to create an all-good world or perfect constancy was clearly evident. Oh, here we go. The quality which she most desired in the supplies was genuineness. again and again, she sought proof that they were real, not pretended. But her doubts never seemed quite fully allayed. Repeatedly, she explicitly and implicitly. You don't really care. If you did, you would do something to prove it more tangibly.

Yeah, this touches on what the psychiatrist Grotzstein sort of talked about when he was talking about a black hole. They used this metaphor to describe the futility of satisfying a patient plagued or beset with this type of problem. It's sort of like pouring into a glass with no bottom. There's nothing that can be said or done that really allays the patient's abandonment, anxiety.

And the patient always really, requires more and more proof from the object that you're not going to leave me, right? And sometimes this will be asked explicitly. In therapy, I have patients who ask me, you know, sometimes weekly, you know, you're not going to, you're not going to retire or you're not going to move or you're not going to fire me, are you? Yeah. And that may allay their concerns for a short period of time, but as well, Scrotstein's would say it's sort of a black hole phenomenon.

Sometimes I recently did an episode on OCD, and they talk about not reassuring the patient, but sitting in the doubt. And I wonder if that's how we should approach that type of anxiety. That's interesting, yeah. It's almost like it's really distressing, I think this is what Dr. Tar would say, what he taught me. It's so distressing to think that I might leave.

and I just want to sit with you in that distress. And then I'll keep reading from this article. If you really cared, you would give me more than talk. She spoke of earlier experiences in which actions of others had bellied their words. Her word wariness and seemingly insatiable desire for something more, of course, presented difficult problems in psychotherapy.

Yes, words are not enough. you need to show me. I think that's a pervasive communication in these patients. Sharing secrets. They go on to sharing secrets. So you can start to see where like, this is where there's some, you know, slight boundary violations.

I mean, there may be some places for sharing stories from your own life, right? But for her, the appeal was sharing secrets and receiving secrets. as Maine termed the precious little jewels of information while telling each other that this information was something she had been unable to tell anyone else

and extracting from each a promise that the secret would be revealed to no one else. The secrets were offered and frequently accepted as if valuable tokens of trust and esteem. It created a two-person secret society. This idea of secrets was later a bit dismantled when the staff would come together

and have these sessions where they would realize, like, oh, multiple of the staff members had received the same secrets. And so this was a way of connectedness that was common. Yeah, yeah. Yes, I'm gonna tell you something I've never told anybody else,

but in reality, I've told multiple other persons this thing, but yeah. Okay, so another side to the patient's bestow of secrets was her encouraging her confidants to reciprocate by confiding in her. She implied that this would go far toward proving their trust and esteem of her. She further encouraged confidences by remarkable, though uneven capacity for empathic reading of the innermost thoughts of the others.

And these patients are very sophisticated in reading the room, reading small grudges that might exist between two individuals, exploiting those grudges, gathering secrets about the staff members, and then using those as a weapon, potentially. Sort of talking about, you know, what is sometimes called triangulation. And, again, a lot of this is motivated by unconscious forces. but attempts to divide and conquer

as the manifestation of the pathology yeah so with the the next thing was the bargain okay

and the special feature of the appeal was the bargain which as offered by the patient and accepted by the staff was largely unspoken and perhaps largely unconscious it involved the patient

offering the implicit promise, not only that her needs were temporary and satiable, but that if they were met, she would become well. If you will temporarily be a good mother to me, I will then become strong and self-sufficient, even to live up to my potentialities. And so you can see where this becomes difficult for the provider because it it's like if you break your normal frame if you collude with me in a special type of relationship then that is what will be healing yes yeah and and this is where i think as providers we need to be um very like sure that our normal way of doing things is sufficient yeah yeah and i mean i think i you know i think what is

in essence, communicated is, I need you to bend the rules for me, or I need you to break the rules for me. That's really what will help me, in so many words. That if you really cared about me, you would. If you really wanted to help me, and you don't just say that you want to help me, then you'd be willing to deviate from your established way of doing things. So in practical terms, what ends up happening frequently is texting or communicating outside of sessions, phone calls, requests to meet outside of the office, for instance, in a park or at a restaurant, or over coffee, that, you know, I'm going to make a bargain with you. Mm-hmm. Yeah. And, you know, I'm thinking like, well, is it behavioral therapy to go to a park with someone who's anxious about going to the park?

You know, maybe for someone with OCD, but maybe not this type of patient, right? Sure. I mean, I think this is why diagnosis is so important. Yeah. Is that we don't treat every patient in the same way. And I think that, you know, there's so much anti-psychiatry stuff out there that I think this is really one of the most important aspects of diagnosis when it comes to psychotherapy is that the way you would treat a personality disordered patient is different. You know, I was just reading Kernberg yesterday, and he talks about how, you know, there's, in less severe pathologies, there's a sort of blurring. between psychodynamic and supportive psychotherapy.

But when we're dealing with severe personality pathology, it requires a different approach. I think one thing that we, that maybe we may not fully get to, is how then through this special relationship, they can turn you against some other staff member. And how because of the other staff, remember there's this intense self-hatred, the cutting, the self-harm,

this has to get pointed somewhere. And so it's like they want you to collude with them with the same level of anger and vitriol towards this other person. Yeah. And so the others go all bad. They self-harm, and it comes out in their dreams as well, right? This badness.

Yeah. I think Gabbert has commented on, you know, the patient's projection of their own internal conflicts is in some way it alleviates the conflicts existing within the patient when they see the conflict between the staff. And then there's a projection of this inner conflict as a means of resolving in some way these unconscious forces within the self. the paper the paper kind of

it goes on to talk about more of the splitting talk about how team meetings became a way of kind of like overcoming this and I think a commonality of mentalization based therapy DBT that I've seen Marshall and had at a conference once said

if you're not meeting as a team frequently to discuss these patients you're not doing DBT and I think as leaders, as you all are, all of my listeners are leaders, you are in the team helping facilitate that, right? And helping the splitting. I want to kind of bring this to a close

pretty soon because we're going to go get some dinner here. Probably the best rabbi I think I've ever had in my life. Oh, it's going to be the best room. And my stepdad on the butcher shop, so it's saying something. Okay. Yeah, this is one that you have to order a couple days in advance. And if you ever come to Orlando, send me a message on Instagram, and I'll tell you where to go. One of the things that kind of jumped out at me is that you may enlist colleagues to meet the patient's needs.

And so your own internal regulation gets to a place where you start to not be able to meet the patient's needs. And so it gets to this point where then you seek more and more support for yourself to help regulate. And I would say I remember a colleague coming to me who was completely disregulated from one of these types of patients. He didn't even know she was borderline personality disorder. He had been through a whole counseling degree and never heard how to treat it. Yeah, yeah. So, you know. It's such a failure of education.

just even saying this person has borderline persiazzarriess owner, he looked at me with this like look of like, huh? Yeah, yeah. Like, what is that? And how do I treat that? It's very unfortunate. Very unfortunate. And so he got some books on different ways of treating it.

And he's doing good work now. It's multiple years later. And the person's thriving last time I spoke to him. So one of the things they comment towards the end of this paper was that sometimes the group meetings were not enough.

And so have some compassion for yourself as a future provider, as someone who's going to be part of teams, that sometimes the groups were still not enough. Sometimes they floundered or even totally collapsed. The special meetings.

Yeah. So, wow, this was awesome. I feel like if we had another hour, we could do the justice to the end of the article, but you all will have to, you could, you know, on my website, Psychiatrypodcast.com, we'll link the full article, and you can go on there and read the whole thing. Yeah, definitely encourage your listeners to read it. It's, you know, again, I guess it's, what, 49 years old now, 1966. Am I doing my math right? Yeah.

Jesus. 1966, okay. Yeah, so, you know, your initial sense might be always outdated, but no, there's gold in this article. Yeah. Yeah, and I think also there's gold in, and this is what I appreciate about you, is like, not neglecting to read old good articles. And I hope to have you on, and maybe we'll go through some one at a time kind of like this, and really give it justice, right? because there's so much wisdom to be heard. And I can almost see like, you know,

you can get CME for this, you can go on my Psychiatrypodcast.com and get like a couple units of credit probably because this is super long. And I was thinking, you know, like, okay, what's the justification that this is good CME? Right? This is a 50-year article, you know? And it's like, no, like there's such wisdom in history.

And I was thinking about like how history is, what really happens. You can't have a philosophy or an idea that's not rooted in actually looking at historical facts. And I believe

that this author and this research team did a good job of encapsulating 12 patients that effectively split the unit over a course of 10 years. Yeah.

And summarizing the details of that in a not a quantifiable way, right? There's not like a lot of statistics here. It's a qualitative. So this is early qualitative research, which is what a lot of good papers were. Definitely.

I mean, this is the foundation of psychiatry and psychopathology, and psychotherapy was qualitative work and case studies. And, you know, if you don't know history, you will think that you've invented something that's been talked about in psych, at least, you know, in many cases for many decades, and sometimes, you know, a century or more. Yeah, and that's the grandiose naivety, right?

It's like why you and Shether probably won't create your own therapy schools because you're like, no, like, we're not better than these greats that came before us. Why I probably will not have my own psychotherapy school is because there's, There's just so much goodness to repeat. Okay, we'll leave it there for today. Thank you so much for coming on. I really appreciate it. Now we're going to go have some good steak.

And yeah. Thanks so much for having me. Been looking forward to this and appreciate the opportunity. And I heard you're thinking about writing a book where you actually like try to compile a lot of these good papers. We're in the early stages of that right now. But yeah, I think it's going to be an essential papers sort of book. on BPD where I write an introductory chapter and sort of try to weave all the theory together.

And I might just plug you. Now, you didn't ask me to do this, but you can find Mark at Mark L. Ruffalo, RUFF, A-L-O, on Twitter, X. That's probably the best place to kind of see a lot of his thoughts, follow him. I think he's one worthy person to follow. And you'll learn a lot from articles he'll talk about throughout your time. Okay. We'll leave it there. Thanks, David.