Personlighetsmysteriet

Generalistmodell for behandling av personlighetsforstyrrelser (Good Psychiatric Management) – Lois Choi-Kain

• Nasjonalt kompetansesenter for rus- og avhengighetslidelser, alvorlige samtidige psykiske lidelser og personlighetsforstyrrelser

Share episode

Trenger alle som er diagnostisert med en personlighetsforstyrrelse spesialisert behandling, eller kan en generalist-tilnærming være godt nok for mange? 

I denne episoden møter vi Dr. Lois Choi-Kain fra Harvard Medical School og McLean Hospital. Hun har vært sentral i videreutvikling av Good Psychiatric Management (GPM), en modell som gjør tilrettelagt behandling for personlighetsforstyrrelser tilgjengelig for flere.   

Du får høre mer om: 

  • GPM i praksis: Hvordan struktur, samarbeid og en aktiv terapeut gir resultater 
  • Ufarliggjøring: Hvordan vi kan møte symptomer med nysgjerrighet i stedet for frykt 
  • Veien til et selvstendig liv: Hvorfor målet er å hjelpe pasienten finne sin plass i verden, der de kan trives og fortsette å utvikle seg 
  • Håp og endring: Hvorfor ingen personlighetsforstyrrelser er «umulige» å behandle, og hvordan mestring i hverdagen skaper varig endring 

Lois Choi-Kain forklarer hvorfor det enkle ofte er det mest effektive og hvordan vi kan tilby god hjelp, selv med begrensede ressurser.  

Personlighetsmysteriet produseres av Nasjonalt kompetansesenter for rus-og avhengighet, alvorlige samtidige psykiske lidelser og personlighetsforstyrrelser

Kjetil Bremer:

Personlighetsmysteriet. En fagpodkast hvor vi utforsker personlighetens mer trøblete sider. Personlighet er noe vi alle har, og den vil være mer eller mindre på lag med oss i å leve våre liv. Ingen har en totalt uforstyrret personlighet. Det er først når personligheten blir såpass til bry for oss selv og eller andre at man ikke får til å leve et OK liv. Da kan man ha en personlighetsforstyrrelse.

Kjetil Bremer:

Velkommen til personlighetsmysteriet. Personality mystery in English. A podcast from the National Advisory Center for Substance Use and Addictive Disorders, severe concurrent mental health disorders and personality disorders. My name is Kjetil Bremmer. I'm a clinical psychologist and I'm here with my colleague Åse-Line Baltzersen, communication advisor, and we're here to interview our special guest from the United States.

Åse-Line Baltzersen:

Today's guest is someone who has been at the forefront of changing how we understand and treat people diagnosed with a personality disorder. She is director of the Gunderson Personality Disorders Institute at McLean Hospital. She is associate professor of psychiatry at Harvard Medical School. She has also written extensively and trained clinicians around the world in several specialized treatments for personality disorders. She's also known for her unique ability to bring together common factors across therapies into accessible and scalable models of care, which is what we are here to talk about today. She's edited four books on applying good psychiatric management as a public health solution to the growing demand there is for effective treatment for Borderline Personality Disorder. So without further ado, welcome to the personality mystery, Dr. Lois Choi-Kain.

Lois Choi-Kain:

Thank you for having me.

Åse-Line Baltzersen:

It's a pleasure to have you here, finally. And you have dedicated much of your career to understanding and improving the care for people diagnosed with a personality disorder. So I'm curious what led you into this field?

Lois Choi-Kain:

Well, I actually decided to go into medicine to pursue a career in psychiatry. And particularly I was interested in psychoanalysis, because understanding the way that society shapes individual psyches seemed really endlessly fascinating to me. So some of the first books I read in my college days were books by Freud that weren't about treatment but about civilization and its discontents, as well as group psychology. And in those books, he talked about how the price we paid to live in a society that's organized is to renounce our instincts, meaning that we have to learn how to somehow manage ourselves in the face of living amongst others. And we see across the globe people organize how they live amongst others in various ways. And I think now we understand that personality is at that interface of how an individual manages to incorporate themselves or not into society. So when I got into psychiatry, I actually didn't know about personality disorders, but I met John Gunderson, who then relentlessly pursued me because of my psychosocial interests in psychotherapy and people. He thought that I would be a good match for the kind of work he had done his whole career. So that's how it all started for me is that I learned that actually working with personality problems and personality disorders were the modern way of pursuing a career inspired by Freudian ideas.

Kjetil Bremer:

You worked closely, as you say, with John Gunderson, whose legacy continues to shape how we understand and treat people with Borderline Personality Disorder. You helped develop and refine the generalist model, Good Psychiatric Management or GPM. What's Good Psychiatric Management and why was it necessary with this sort of generalist treatment?

Lois Choi-Kain:

Good Psychiatric Management basically recruits the principles that all clinicians tend to learn basically to treat patients. In our role of being therapists, clinical psychologists, or any mental health professional, we use the same common factors to attempt to listen, be curious about an individual's story, and collaborate in understanding something about how their problems originated and therefore how they might be solved. So, that's a kind of common theme among the many different flavors of treatments at work. I think that for the majority of clinicians and patients, making something that's common, maybe kind of debranded or generic, but widely available is something that we should do on a basic level. And I think in a country like Norway and in Scandinavia in general, where there's such a value system around providing something basic for everyone as a fundamental kind of goal of society, I think that a concept like a generalist approach is really suitable so that you can spread the wealth of good mental health widely and save the specialist treatment or the rare, the rarer forms of intervention for those who really seem to need it.

Kjetil Bremer:

And that sort of differentiation in treatment. Can you say a bit more about that? Who is the generalist model for?

Lois Choi-Kain:

So we really wanted to gear those ideas towards rehabilitation. And we put a lot of heart and soul into it and a lot of pressure on our patients and the families they came from. And we've realized that people could get a lot better, but it still took a lot of time. And we had the question of is more better? Because actually, even amongst the clinicians, it was like a Tower of Babel that people get confused about the many concepts. Even within Dialectical Behavioral Therapy, now there it's gone from 43 skills to hundreds of skills. And in fact, when I um gave a book jacket comment on the newer editions of DBT, I really honestly called it an encyclopedic kind of handbook of psychological skills. If you could read all the DBT skills, you would become an expert in psychology because that has every tool you'll ever need to handle emotional, psychological stressors in life. And Mentalization-Based Treatment started with a very simple idea of trying to be not-knowing, and really endeavor to be curious about the patient's point of view and help them coalesce an articulation of what that means so that other people could understand them. And over time that too became very complicated. And so this would actually sort of irritate John Gunderson, who had been practicing psychiatry and psychotherapies with patients with Borderline Personality Disorder his whole career, without so much fancy equipment. And he was very dubious that that's what it was going to require to work with patients, because in reality, people with Borderline Personality Disorder seek help. They want to be connected with other people and they'll listen to direction because they know that they would do better with that direction and the collaboration than by themselves. So he then thought maybe we should simplify this. And so luckily, Shelley McMaine in Canada had developed this very rigorous scientific study to be one of the first Dialectical Behavioral Therapy studies outside of its developer's hands, Marsha Linehan. And she took this large trial and she said treatment as usual is not a very rough comparator for a very elaborate and intense treatment. What you need is something that is actually informed, structured, and carried out most importantly by people who like working with patients with Borderline Personality Disorder. And that was actually the magic ingredient. Because at the end of that trial, at the end of the treatments of DBT and general psychiatric management, there were no statistically significant differences in outcome. And they even did two years of follow-up and they still found no differences. And this was such good news. I remember sitting in John Gunderson's office at the time as a postdoctoral fellow, and he got a call from Marsha Linehan, and she said, «Guess what? Your treatment works as well as mine.» And he was truly overjoyed. If you ever met John Gunderson, who is actually of Norwegian descent, he is a very joyful, expressive person. And he, I think, did a victory lap and was hooting and hollering, and he was kind of like um savoring his victory, even though he did not really participate in the study, other than in um supervising at times the GPM arm. So in the last part of his career, he really thought this was an important task to take the advances of all these very elegant, intensive, effective psychotherapies and just bring them down to their bare bones and to the basics, so that they would be just far more accessible to clinicians, so that clinicians could have the experience of being effective with these patients, have optimism about their capacity to work with people as they would with any other psychiatric diagnosis. And in that experience, which he would call a corrective experience, even for the clinicians, they would feel more open to and comfortable with working with people who had these emotional, behavioral, and interpersonal challenges that are the trademarks of BPD. So we started this project because there was such a gap in the field between these specialist treatments that were just not widely available and nothing. And those clinicians that didn't have the training in these specialized psychotherapies or didn't have the right setting to practice them, they felt like they were stranded and they couldn't offer any assistance. So treatments like good psychiatric management and structured clinical management, which came out of Anthony Bateman's work, those really help broaden the diverse options that both clinicians and patients have for seeking care.

Åse-Line Baltzersen:

I like what you say, like going back to basics in a way. And you you touched upon a few elements like informed, structured, and that those providing the care are actually interested in working with these patients. But could you take us through like what are actually the core principles of GPM? How does that look? And also for someone who are not a trained psychologist who might be listening, like what would that treatment look like?

Lois Choi-Kain:

Well, at the basic foundation, all clinicians, not just psychotherapists, but all clinicians are in a role with people seeking health care to identify what the problems are and inform the patient what they're working with. Because the patient has to be a collaborator in understanding their illness and their pathway to health. That's step one. And the easiest way to get on the same page with the patient in the medical model, and that doesn't mean you just have to be a psychiatrist. It just means you're in a healthcare model, whether you're a psychologist or nurse or occupational therapist or a psychiatrist, etc., that you work with patients based on a diagnosis. So diagnosis is necessary in healthcare to provide a treatment pathway because you then understand the origins or the etiology of the illness, and that gives you a targeted point of intervention. Like when I was in Bergen, I saw the Leprosy Museum, and Dr. Hansen, who discovered the origins of leprosy, was unlocking the key to solving the problem that epidemic posed to society. So when you diagnose borderline and other personality disorders, it unlocks a pathway forward from a serious set of problems that usually leave individuals with the disorder feeling lost, like they're broken beyond repair, and like there's no hope. And nine times out of 10, when I've sat down with a patient and said, this sounds to me like Borderline Personality Disorder because of the interpersonal sensitivities that you're describing, the emotional reactivity that you struggle with, the behavioral lack of control that sometimes leads you to do reckless things. And all of this culminates in a confused sense of thinking of reality that is like dissociation or understanding others in the form of paranoia. So if you can actually package all those problems as a palpable, manageable focus of treatment, it gives patients a sense of clarity and cohesion that enables them to partner with you more effectively in the work. Because of the interpersonal hypersensitivity and the identity diffusion, people who have borderline and severe personality disorders really struggle with relating to others in a stable fashion. So when you are in a healthcare model where people have specific roles and goals together and you have a diagnosis, it creates lanes forward in the relationship that you can stay in for guidance in the face of the usual dynamics where patients will either idealize and have high unrealistic hopes of carers or clinicians or anyone that's helping them, that inevitably kind of dips down into devaluation with the black and white thinking and feeling like they can't trust that person at all. So if you put some structure to the relationship and the collaboration, it creates markers for guidance and direction for the therapeutic team working with the patient with these problems. So that in a nutshell is kind of the foundation of good psychiatric management. That's why the term psychiatric is in it. There was a lot of challenging controversy about the nomenclature of GPM. And the whole idea behind it is not about the discipline of the person that can practice it. It's about the field and the kind of discipline of psychiatry that a lot of different professionals participate in that organizes and structures us, much like DBT does or MBT does. It's a system of care or a system of ideas that everyone already has without a specialized therapeutic approach that can create a coordination handbook for people who are working with the patient in various areas of their life, whether it's primary care or mental health or other avenues in the social world, including the legal system, because a lot of people with personality disorders end up also in the legal system.

Åse-Line Baltzersen:

The therapist is quite active as well. Is that a part of it as well?

Lois Choi-Kain:

Yes, and that level of activity of the therapist is also a principle that helps the therapist know that they should be proactive in creating a treatment plan with their patient in terms of goals that the patient has for the treatment. The patient is supposed to be an agent, and that is to counteract the passive dependency that is characteristic of some of the problematic states of the disorder. So the therapist models a level of activity and direction to inspire inpatient self-direction because some of the traditional psychodynamic approaches are more freeform and promote exploration, which for people who have identity diffusion and interpersonal hypersensitivity can be too expansive. So the kind of activity of the therapist really propels the collaboration forward. And it also calls for accountability in the individual receiving the care. Too often, in the dynamics of caretakers and people with Borderline Personality Disorder, there's a push towards dependency dynamics because the person with the disorder doesn't have a stable self-confidence in their independent abilities. So they'll oftentimes get very anxious if someone else that's capable isn't accessible to them. So GPM turns that dynamic around with the mantra in the treatment that the person with Borderline Personality Disorder has to be in charge of their care because the therapist or the clinician isn't always present. So we we actively tell patients this is not about us knowing all the answers or being the expert, but it's about you carrying forth what you learn in this treatment so that you can reach your goals independently with the help of this care.

Åse-Line Baltzersen:

Many clinicians find it quite difficult to work with people diagnosed with a personality disorder, and some even refuse to do so. I'm wondering why do you think that is, and what do you have to say to these clinicians?

Lois Choi-Kain:

I think it's really unfortunate that people shy away from working with personality disorders because in the mental health profession, we're all in this to connect to people, to understand humanity better, and to help people who are in a difficult place in life. However, as human beings, we all have tendencies to avoid things that scare us or threaten us, including high degrees of anger as well as self-destructive behavior. Those two things just tend to trigger clinicians and other people in the same way that might promote some fear and aversion, so that clinicians end up feeling both incapable and not motivated to work with patients with this kind of severity in their clinical profile. But in my experience, in promoting GPM amongst clinicians who weren't out there to be specialists, what I've really loved most is how empowered people feel, that they feel like it's okay to just be themselves and do what they know how to do well and have patience for people who had the symptoms of BPD. They're expectable. That's why the patients are there. You don't need to take it personally. And the more you can look at it together instead of it being a problem between the clinician and the patient, the more you can actually find it really interesting, like a mystery to be solved.

Kjetil Bremer:

That's nice. Waking up curiosity and mastery, probably also in the clinicians. And what what's the frame of the course or the training program for this uh GPM model?

Lois Choi-Kain:

Well, it's by design very short. So the training is actually only eight hours. And this was intentional because John Gunderson, I think, felt that sometimes we'd get in the weeds as clinicians working with personality disorder into the minutia of the different techniques, and we'd get very perfectionistic and preoccupied with what the books say, which made us totally miss out on the person in front of us. So he wanted to trim it down to something that most people could feasibly do. And that's one day of training. And if it could sustain his attention, it could sustain anyone's attention. So we wanted to give people just a kind of refresher on things they already do in a general everyday way, but kind of personalize it or tailor it towards the special needs of people who have Borderline Personality Disorder, just like you would for any other diagnostic category. So just being sensitive to the thing that you're actually treating is a big part of what good clinicians do, keeping an eye on that as a treatment target. But then around that, trying to help the person gain some mastery of their life beyond that by managing their symptoms. So that's really the basic starting point. We're not trying to solve all the person's life issues. We're not trying to resurrect the developmental deficits or problems on their journey in life. We're just trying to help them be a little bit less reactive and understand their job in trying to think first and accept reality as it is in front of them so that they can get on a path of developing their personalities. Because we all develop our personalities by pursuing things in the world like work, whether that's in school or in some community activities or in a vocation or profession, as well as in developing the many relationships you have in those activities. And that's where personality forms. It I think we have misunderstood that personality somehow stabilizes and forms in these fancy psychotherapies, which help a great deal to navigate the world, but they're not a substitution for the school of life.

Kjetil Bremer:

And what's what's the typical requirements? Is it the one that goes to wants to learn this? Is it therapists, clinicians in private practice working on their own? Is it organizations? Is it what what what does it take to implement it? Is like the you can have a course one day and then feel more secure on what to do and

Lois Choi-Kain:

Yes.

Kjetil Bremer:

Yeah.

Lois Choi-Kain:

Everybody starts somewhere with everything they learn how to master eventually. So I think GPM has this mindset that this is a a bit of a toolkit that you go out and start practicing with. And in the process of sticking to basic principles of good care, with a little bit of knowledge, up-to-date knowledge about BPD, you can really then get more intimate experiential knowledge of how you work best as a clinician with people with personality disorders. Because we all tend to kind of hone our styles over time with just experience. So GPM is meant to be just a starting point, and it is expressly designed for each individual clinician to do what feels authentic to them while following the principles. So we're low on telling people exactly what to say, although we have a little bit of a cheat sheet on what you can say in the absence of not having your own phrases yet. And then as you get more comfortable with having these really important conversations with people that you fear are volatile or too sensitive to handle what you have to say, then you just feel more empowered to just talk. So it's about being professional with the basic principles of good care, but being real. And these two things interact that having a professional kind of ground to stand on helps you stay steady in the ups and downs of being in a relationship with a person with a severe personality disorder. And then that helps you then be real with them. And it's in that real connection that a lot of the therapies accomplish in different ways that I think is really the healing ingredient. Because when the patient feels understood and like there's someone that they can go to when they need the help. And by the way, their skill that they need to learn in GPM is asking for the help they need, which is not always easy for everyone, whether you have BPD or not. But it's about helping that person feel kind of remoralized and have a corrective experience of just close relationships that don't have to be exclusive or the end all or be all, but just reasonably good enough help. Because actually it's just in that good enough state that propels people to be more self-reliant. Because if you're too good, why then get independent from that person?

Kjetil Bremer:

Yeah, nice point.

Lois Choi-Kain:

And some of these therapists that are specialists are just too good. Why would you ever want to end a therapy with the likes of Anthony Bateman or Marsha Linehan or Shelley McMaine? They're just captivating people. I would just want to stay with them forever. But in GPM, we aim to be a little bit more mediocre so that people can move on from us and they won't miss us too much.

Åse-Line Baltzersen:

Maybe that's good for the patients. As well to meet like you can put people on a pedestal, right? And then, like you said, be real and every human being has a flaws, right?

Lois Choi-Kain:

Exactly.

Åse-Line Baltzersen:

Being real in that.

Lois Choi-Kain:

I found it shocking that John would actually act so human on purpose. He would like forget people's names and just make mistakes and put his foot in his mouth all the time. Because he was really trying not to be idealized in a way that promoted excessive dependency. And he really wanted clinicians to know if you make mistakes, that helps patients feel like they too can make mistakes. It's not the end of the world. And things can be repaired or restored, or you can learn from those mistakes. So, really, the GPM therapists are also taught to not exempt yourself from humanity and try not to be too perfect or too helpful, or else you don't give the patient enough space to find themselves as very useful and maybe capable of doing a better job than you in figuring out how to live their life.

Åse-Line Baltzersen:

So the last place we need an instagram filter is in therapy? Just a thought.

Lois Choi-Kain:

Exactly.

Åse-Line Baltzersen:

But I do have a question though, when it comes to kind of the most of these different specialized models, and from what I understand, GPM as well has as a part of its structure that you have support, either from a team and or organizational support. Do you have any advice to clinicians who are working alone in private practice and who might not have that support but still have patients who have severe personality disorder or Borderline Personality Disorder?

Lois Choi-Kain:

Absolutely. I think that people who are on their own in practice, whether they're in private practice or they live in an area where they're the only clinician around, even as a primary care provider or as a solo practitioner, as a psychologist, those folks will need something that can be accessible in a broad variety of contexts for a lot of different patients. And what they will need is their own support system. And whether that is more interpersonally dense, like something like supervision, you can get supervised by someone who's more experienced in doing any treatment, but particularly GPM, because it becomes a shared point of focus. And when there's these usually very complex, severe cases where you don't know which end is up or where to start, it's just a kind of organizing approach to start with: okay, what are the diagnoses at hand here? In which order should we treat them? Does the patient know what these diagnoses involve and how to how they should know whether or not they're getting more ill or getting better? And then once you figure out the diagnosis and the psychoeducation, we look at something called the interpersonal hypersensitivity model that is the key foundation of GPM. All manualized therapies that have been proven to be effective have a model of how the problems of borderline and other personality disorders evolve. And in GPM, we focus on something called interpersonal hypersensitivity, which means for people with BPD, they over-rely on having some trusted other there in order to feel secure so that they can explore the world. So it's like having just one tool in your toolbox that is dependency on this other person that may make you feel comfortable when it's available, but the minute that's threatened, whether it's in your imagination or really truly threatened, that brings out a stress reactivity that we know as fight or flight. So you know how fight or flight is an important mechanism for all animals to escape imminent danger. Now, for a zebra running from a lion, that doesn't involve a lot of thinking or planning. They just bolt away. But us humans, we're plagued by things that cause us anxiety, like mortgages and bills, and we hyperactivate our fight or flight responses in these ways that can be really self-defeating. So people who have Borderline Personality Disorder, when they feel like their attachment is threatened, they either get in a fight and get devaluing and feel like the source of the problem is the other person because the person who they're dependent on has all the power. Or they go into flight and feel like maybe they weren't good enough and they start beating themselves up, or maybe they'll deliberately self-injure. And those behaviors are not pro-social. Fight or flight was not built to be pro-social. So that ends up pushing other people away inadvertently, and the very thing that a person with Borderline Personality Disorder fears happens, which is abandonment. And that's when they become unanchored. So the security that they kind of overrelied on just dissipates and their bearings to reality become loose. So they become more dissociative, they become more impulsive, not appreciating the realistic consequences of their behavior, and they also become more paranoid, so that actually reconnecting with other people, even when you were spending so much time being preoccupied by them, becomes impossible. And that's when people with BPD might become more seriously hopeless and suicidal. Now the story doesn't end there. What happens then is that's the stage where everyone starts to try to help. And they intervene in a unilateral, one-sided way and rescue the person, and then the person is reconnected and feels important and cared for, and the cycle just starts all over again. So in GPM, we teach clinicians about this and we use this model to work with patients to understand what happened that caused this oscillation of symptomatic states that we know to be fundamental to BPD. And that's also what we do in the supervision of clinicians is let's look at what triggered this and then understand how to intervene better. Because actually, if you're too dependent on other people, the magic solution is actually self-reliance. And that might propel motivation forward to look at one's own kind of using that hammer for every problem. Because this, after all, I think all of these therapies work by generating reappraisal of reality. So if we think, wow, that strategy failed, relying on my therapist when they're on vacation all the time in Norway, then they might reappraise. Maybe I shouldn't rely on my therapist so much because they're not a good solution to every problem. And that's where the beginning of change can re can occur.

Kjetil Bremer:

Then you talk about the the reconnection, uh the re-establishment of social connection and the uh the establishment of agency and the establishment of socializing and work and the corrective experience of getting a life.

Lois Choi-Kain:

Exactly.

Kjetil Bremer:

Can you say some more about that? Because that is that that is really a huge point as we see it, and we see it in research, psychotherapy research also for these patients. That we we help them by getting remission from a lot of symptoms, but the getting back to life is u where it's uh sort of is the the missing part in a way.

Lois Choi-Kain:

Exactly. Exactly. I think the interesting thing about personality is that all our personalities develop in a niche. We find a place in the world and we learn about our own habits and our tendencies, how we react to different challenges in life, how we rely on other people or not, and that's how all our personalities develop. So you're exactly right. Trying to manage symptoms so you can get back into finding your niche in the world to develop yourself is really the goal of any treatment in all of healthcare. And once you find that niche, what happens is a sense of belonging and a sense of feeling settled or anchored in the world, having a place for yourself. And that's psychologically stabilizing for all of us. So some people have more unique qualities that require a very specific niche. So they have to keep looking for that niche and be actually more resilient and more psychologically minded than someone who's just not very selective about the niche they need to grow up in. So, you know, having just a corrective experience that remoralizes you, that's the goal of GPM, is to just help people feel like they have a problem that's common. Other people have it. They have a problem that's well understood by a lot of researchers and clinicians. It's not something that means that they're an outsider or an outlier or someone that doesn't belong in society. And then they learn that they can figure out a way to master their makeup so that they manage their vulnerabilities and put forward their strengths and apply them. Because what happens for people with personality disorders is that they kind of too broadly manage their vulnerabilities by just avoiding the world. And then they don't develop any niche for themselves, and then they become stunted in their own growth. So they're kind of in an arrested development, and then that just feeds into their identity diffusion because they're not doing anything to be an agent in life by which they can define themselves.

Åse-Line Baltzersen:

Seems like you're making it quite clear that change is possible.

Lois Choi-Kain:

Change is possible for everybody. And I think that's the belief that we want to promote, that actually there are no personality disorders that are beyond repair. I think the recent finding by Fonagy and Bateman that MBT works for Antisocial Personality Disorder has kind of recatalyzed a sense of hope and interest and curiosity in understanding people with that disorder. So I think that if we have the attitude that any personality disorder can be helped and any individual with a personality disorder can do the work of getting better, all we can do as clinicians is offer good mental health care. And then it's up to them to decide what to do with it. And that's what John Gunderson really, this is very American, but John Gunderson was fond of saying, here's what I think, do with it what you will.

Åse-Line Baltzersen:

I think it's I really want to make like a clip of this for anyone who's ever been told like no, change is not possible when you get that diagnosis and just clip it on there and add your credential under it.

Lois Choi-Kain:

I think exactly. And you know, we've been wrong in all of healthcare and the history of medicine and psychiatry, we've been wrong about a lot of things. So even when there's a sense of hopelessness, which is really helplessness amongst those in the field, that is always subject to change. And I think we should continue to answer these questions of how to solve the problems that we know exist for different strands of personality disorder. So far, we have some good solutions for BPD, and that's a huge banner of hope. And now Antisocial Personality Disorder, which was just a few months ago thought to be completely untreatable. So I think that being wrong actually provides us a lot of opportunity to understand that we should question our own beliefs. This all started, this work in BPD, by John Gunderson wondering: are these patients really untreatable? Are they really treatment resistant? Or are we applying the wrong treatments? And I think that was the million-dollar question that opened up this arena for all of us to work in.

Kjetil Bremer:

That has been a lot of the focus on BPD and uh some on uh other uh types of personality problems, but there's a lot of uh work to do and uh a lot of treatments to develop.

Lois Choi-Kain:

Absolutely.

Kjetil Bremer:

But you but you've also been uh involved in that part, haven't you? Would you say something about that, about treatment for other personality problems?

Lois Choi-Kain:

Sure, sure. You know, when I was running that residential treatment and there was no limit to the the intensity or the amount of treatment we could apply, what I realized is you can't actually treat one disorder at a time. That was a fallacy. We thought, okay, we'll first treat the BPD, and maybe a lot of the other things will go away, and whatever's left over, then we'll treat that. But that becomes a 10-year process of treatment that I just really wondered if that was necessary. And I really thought it wasn't good enough because who wants to put their life on hold for 10 years to go through different manualized treatments? And so, you know, one of the wonderful things about good psychiatric management is that it's managing different disorders together at the same time using the best standards of care for each disorder. Now, it is true that treating Borderline Personality Disorder has a huge bang for the buck. So the new research that indicates that Borderline Personality Disorder is a general kind of factor of personality psychopathology, that work that Carla Sharp and her team and Aidan Wright and his team kind of contributed to our field really changed our minds about how to understand the different personality disorders. And the way I read that is that Borderline Personality Disorder is that kind of gateway diagnosis that if you have problems of emotional lability, problems of interpersonal reactivity, problems of behavioral discontrol, including self-destructiveness, and problems of identity and thinking, if you can treat those things first to stabilize someone, to then work on their different variations on personality traits, I think you can further refine the approach in a sequence of priorities. Because obviously, like Marsha Lynnihan said, if the person is trying to end their life, they have to be alive to work on the other problems. And so you have to settle that first. And in fact, Aidan Wright's work that used the collaborative longitudinal personality study data that John was the PI on, found that the decreases in Borderline Personality Disorder, the general factor of personality psychopathology, tracked with the most change in the other functional areas. But the personality trait domains, like things like dominance, obsessionality, impulsivity, compulsivity, those things don't change that quickly. So I think in order to help clinicians and patients really feel the reward of the treatment, you can focus on the things that BPD treatments brought to the table, like emotion regulation and interpersonal effectiveness or interpersonal management, which a lot of the treatments focus on, and then focus on the various strands of problems. So for people who have narcissistic difficulties on top of Borderline Personality Disorder problems, they have prominent problems of self-esteem regulation and identity concerns. And I think this is actually a really interesting direction because honestly, who doesn't have self-esteem regulation problems and identity concerns? So it's brought into focus that personality disorders are not just about relationships, it's about self-pathology and self-management, because so many people that don't have personality disorders will have some sort of identity crisis. So the tools we then develop for treating narcissistic problems become more broadly relevant. Now, we don't know if any of the adaptations for Narcissistic Personality Disorder yet work. None of them have been subject to randomized controlled trials, but I think it gives us a different lens with which to understand human problems that people do have problems of their self-image, how to cultivate it, how to be connected with it, how to be authentic, and how to feel good enough about your self-image. That's a project that everybody in the world should be concerned about in terms of their psychological growth and development. Then there's the arena of obsessive-compulsive personality problems, which I have to admit, this list appeals to many of us professionals. It's a culture and a way of life to be rigidly perfectionistic and want to get things just right. And I think that disorder represents the dilemmas we all have about mastering our realities. So some of us go a little bit too far about having to have too much control to feel good about ourselves and our efforts. And we do that at the expense of feeling our life experience. Everything is external and we don't pay enough attention to what happens behind the scenes of our minds. And then there are personality disorders like Antisocial Personality Disorder, which I think are about problems with authority. And when people have been, for example, really deprived from getting their needs met, they will opt to just disregard authority and be instrumental about getting what they want. And this is an adaptation. And so helping people who have that condition learn how to modulate themselves so that they can follow the rules of living in society so that they can then find their niche safely in life. That is really a concern that a lot of people will have broadly at different times for different reasons. And those are, I think, the major categories that I think become very salient for a lot of people who come to the table who have had major life arrest, arrested development. They need to work on these various areas of dependency, self-image, mastery, and kind of dealing with the rules of society. But then there are these other concerns like avoidance. I think all of those disorders are subject to varying degrees of avoidance. And they're all subject to varying degrees of paranoia. So those are like the that's the major breakdown that I'm working on now to make Good Psychiatric Management relevant across a more dimensional way of thinking about personality disorders.

Åse-Line Baltzersen:

You're bringing this kind of you started with it going back to basics, but you're kind of bringing this also back to basic. And just the way you're speaking about narcissistic people who struggle with those difficulties is quite different from well, I saw on LinkedIn you went after the American Psychological Association saying calling saying narcissists.

Lois Choi-Kain:

Yes.

Åse-Line Baltzersen:

It's it's a different language. And we're getting close to the end, but I'd love like a few moments over time on that because we don't see much of that in social media. The nameless narcissist, as he calls himself, said to me once the term narcissist narcissist has become a business model. And also among more and more clinicians who go on YouTube to front that.

Lois Choi-Kain:

Absolutely. Absolutely. I you know, one of the interesting things that we see in the history of personality disorders treatment is the repetition, compulsion of all the mistakes we made with BPD. We're making again with NPD or narcissism in general and antisocial personality disorder. And so there's a kind of still covert but obvious stigma that clinicians bear towards people with narcissistic problems. And I think it's because we don't have a well elaborated cohesive toolkit for modulating our treatment of individuals with these complex problems. So we see it as something to be feared and problematic, and we have these kind of silent judgments that ironically get conveyed to the very people who are sensitive to how they're being seen by others. So it's this real paradox. And I've actually been very reluctant to over-diagnose narcissistic personality disorder because actually, in the large epidemiologic study done in the US with over 30,000 individuals, the NESARC study, they found that 6-7% of all Americans met criteria for NPD. I think those of you outside of the United States might not be surprised by that. But actually, when they subjected that data to the distress and impairment criteria, they found that only 1% of people actually met the diagnostic requirements if you look at distress and impairment. A nd so what that means is that a lot of people will be living in this world with the same personality configuration as someone with narcissistic personality disorder, but not have a personality disorder. And I think it has to do with finding the right niche. Some people with these personality styles will find the right niche to be productive for themselves and in their relationships with others. Nobody's perfect, but they have a good enough way of managing their endowment. But I think the problem is part of the disorder is that people with narcissistic makeups tend to diminish the importance of other people. And there's usually some reason for that. It's adaptive. And then clinicians, as those other people, feel kind of wounded by that. And a lot of clinicians will go on YouTube and have like a whole kind of um approach to helping people who have been hurt by narcissistic people, which I find very um interesting, but also very pejorative. So, in true style of Good Psychiatric Management, one of the biggest lessons John Gunderson taught me as a clinician was to detoxify things that people tend to overreact to. So people being self-centered or dominant or kind of grandiose detoxify it. That's a part of humanity. And it's not all a bad thing. A lot of people who can be like that are quite successful and well-suited for certain kinds of endeavors in life, but not all of them. So finding a way to manage that and have different sides of yourself. You know, you can be more narcissistic or self-promoting and aggressive in a certain area of your life, but not be that way in a different area of your life where it might require more mutuality and collaboration. And that's what personality is all about. It harkens back to Freud, who talked about the ego. The ego is the central captain of the ship that decides how to manage the demands of reality and one's drives and one's sense of morals. And now I think personality really assumes that role where the ego was really emphasized, or some people still call it that. And I think if you can find a way to manage the different aspects of your personality in a way that syncs up with the world, that is the whole point of working on yourself. Whether you have a bona fide personality disorder or you just have the normal occasional personality problem that we all have in life.

Åse-Line Baltzersen:

We might close with it's my favorite question to ask. It came out of the responses I got when I did my master's. So what's your favorite thing about working with people with a personality disorder?

Lois Choi-Kain:

I think my favorite thing about working with personality disorders is just the genuine, raw authenticity of it. So people are at their most true form of self when they are symptomatic of personality problems, whether you have a personality disorder or not. When we all kind of let down the mask and we act more in terms of who we really are, unfiltered, so to speak, I think that's when you make real contact with people. And I think that's sort of true test of trying to really understand people in a more holistic way. That when you fall in love with someone, you might just focus on their idealized qualities. But really staying in love is about the whole package, accepting that with those great attributes everybody has, it are some liabilities. And whatever makes you fall in love with person also is what's most irritating about them. And when you come to some acceptance of that, I think you have a better grip on having more stable relationships in life. You know, in psychoanalysis, they called this the depressive position, is seeing things as having two sides. And I think if you can think about personality in that way and really make true contact with all these characteristics that personality disorders represent that are like frowned upon in society, then I think you can have a more genuine, broad experience of what it means to be human. And that's what I love about personality disorders. It really teaches us what it means to be human.

Kjetil Bremer:

Okay, so thank you very much. It's uh has been so great to have you here and uh been talking to you.

Lois Choi-Kain:

Thank you for having me. I really enjoyed this time together, and I'm really enjoying Norway.

Kjetil Bremer:

You're welcome.

Åse-Line Baltzersen:

Thank you.

Lois Choi-Kain:

Thank you.