E83 - What is Borderline Personality Disorder? (with Dr. Mark Ruffalo)

Mark L. Ruffalo, M.S.W., D.Psa., is a psychotherapist in private practice in Tampa, Florida, and serves as Assistant Professor of Psychiatry at the University of Central Florida College of Medicine and Adjunct Instructor of Psychiatry at Tufts University School of Medicine. He has broad clinical experience in the psychoanalytic treatment of mood disorders, personality disorders, and psychosomatic illness, and has particular interest in the psychotherapy of schizophrenia. He is also the editor-in-chief of the Carlat Psychotherapy report.

In today's episode we discuss borderline personality disorder, the most common symptoms and problems associated with the condition, how it is treated, the pros and cons of diagnosis and much more.

His article on "double binds" in borderline personality disorder can be found here:
https://www.psychiatrictimes.com/view/double-binds-in-borderline-communication

Interviewed by Dr Alex Curmi. Watch the full podcast on youtube: https://www.youtube.com/watch?v=UDGzku4PqNQ

If you would like to enquire about an online psychotherapy appointment with Dr. Alex, you can email - alexcurmitherapy@gmail.com.

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Transcript

Welcome back to the Thinking Mind podcast. My name is Alex. I'm a consultant psychiatrist. Today we're going to be talking about borderline personality disorder. It's a serious and often stigmatized mental health condition characterized by a variety of signs and symptoms, including volatile emotions, splitting, having huge fears of abandonment, a general impulsivity, self-harming behavior, and often a pervasive sense of chronic distress. Here to talk about this condition with me is doctor Mark Ruffalo. Doctor Ruffalo is a psychotherapist in private practice in Florida, and he serves as assistant professor of psychiatry at the University of Central Florida and is an adjunct instructor of psychiatry at Tufts University School of Medicine. He has a broad range of clinical experience in the psychoanalytic treatment of mood disorders like depression and bipolar, but also personality disorder, as well as psychosomatic illnesses, and he has a particular interest in the psychotherapy of individuals with schizophrenia. Today we have a conversation about what is borderline personality disorder, what mental health professionals commonly misunderstand about it. The double bind that people with borderline personality often find themselves in the way they may behave in ways which are self-defeating. We also discussed the idea of covert contracts, whether diagnoses or labels are useful in these cases, how you would treat borderline personality disorder, and much more. If you're a listener of the podcast and you think something like psychotherapy might be useful for you, maybe you have a relationship problem, a problem at work, or maybe you just want to learn more about yourself. I am now offering private psychotherapy sessions, which can be done online or in person in the South London area, and if that's something you're interested in, you can email at Alex Karimi Therapy at gmail.com. And that same email address can be found in the description. Thank you for listening. And here is today's conversation with doctor Mark Ruffalo. 12s Thank you so much for joining me today. Thank you so much for having me. I'm looking forward to this. What is borderline personality disorder? Borderline personality disorder is a, uh, is a severe, uh, psychiatric disorder, um, marked by, um, several, uh, core symptoms, including instability in mood, uh, disturbed and chaotic interpersonal relationships, including romantic relationships, the use of, uh, sadistic defenses, including splitting projection, projective identification, identification with the aggressor. We can talk about these specifically, very often an empty, uh, sense of who one is as a person, feeling like one does not know who they are as an individual and a host of other, uh, symptoms and problems. Uh, my recent work has been on the, uh, conceptualization of borderline personality disorder, primarily as a disorder of self-contradiction, a disorder that manifests itself in very contradictory ways, self-contradictory ways and contradictory ways. And in terms of relationships to other. How do people with borderline personality normally present? How do they come to the attention of of healthcare professionals? 1s It's an excellent question. Many of my patients are self referred or referred to me by psychiatrists who believe that psychotherapy could be of benefit. Um, uh, my my experience has taught me that, that a lot of patients come within the context of relational, uh, problems, relational distress, namely, uh, romantic relationships where they've had some blowup or some problem with their partner where a partner has left or, uh, um, broken up with them. Uh, and there is intense instability and the relational dynamic, uh, between the patient and some other person or persons, uh, that that's usually what prompts the patient into treatment. Sometimes they're referred to following a brief hospitalization in which they've had in a suicide attempt or some suicidal type of behavior. Uh, and then they come to the attention of a psychotherapist. Borderline personality is it's a complex condition. It's hard to understand psychologically. Do you find that even amongst mental health professionals? It remains quite misunderstood often. And if so, what are those? What are the common misconceptions professionals have, do you think? Yeah, absolutely. I think it's a grossly misunderstood condition. It's a disorder that carries great stigma. Um, uh, and the term is often used pejoratively. It's it's used in ways that that can be rather ugly, frankly. I've heard psychiatric nurses and others talk about these patients in very negative, stigmatizing ways. Um, I think one of the best, the not best, but the most important, uh, uh, misconceptions are the most noteworthy of the misconceptions is that the patient acts in intentionally malicious ways. And, uh, really, when we're talking about that type of, uh, uh, personality structure, we're talking more about someone who may be antisocial and, uh, and not someone who falls in the borderline personality disorder, uh, range. Uh, so, so borderline patients, generally speaking, are not looking to inflict harm on others. They do not, uh, uh, do not receive any, um, uh, psychological, uh, benefit, if you will, from the inflicting of harm on other people. Right. Most of the time, you see that they actually have a tendency to harm themselves rather than other people. Do you see that as a kind of manifestation of an intense self-loathing? Yes. I think that's, uh, that's a good way to put it. And you're absolutely right that most often the harm is inflicted on the self rather than the other. Um, uh, it is, I think it's a manifestation of intense, uh, uh, dysphoria. Intense, uh, feelings of self-loathing, feelings of worthlessness, feelings of being unlovable and unlikable. Uh, Anna Freud would term this turning against one's own person. Uh, the the inflicting of of harm cutting and the burning and the self-injury that we see in borderline pathologies as being a manifestation of exactly what you said of of intense self-loathing and, uh, uh, and self-hatred. How does this condition develop? Do you think it's fair to say. Psychologically. The development of these processes of this personality structure begins in childhood. What might a typical life arc for someone with borderline personality look like? 1s You know, when you look at the research. Um. 1s Well, first off, that there is some evidence to suggest that genetics play a role in the development of borderline pathologies. I think that has to be noted. Um, uh, sometimes you do see a patient who meets all the criteria for borderline personality disorder, who comes from a seemingly normal and healthy environment. I will say that's the exception, not the rule. Um, there's different theories on on the, uh, on the early life of the borderline patient, uh, Marsha Linehan, who developed dialectical behavioral therapy herself, acknowledging that she, at one point in time, uh, had a borderline disorder that was effectively treated, um, uh, you know, argued that or argues that, um, that, uh, child experience, they chronically invalidating environment where a parent or parents would chronically invalidate the child regardless of, uh, successes and achievements and alike. Uh, other theorists from the object relations school of psychoanalysis might say that it's inconsistent parenting. Uh, that, um, uh, leads to the development of this type of disorder where mother is at at points in times, nurturing and loving at other points in time, malicious, hateful, uh, um, condescending and perhaps even abusive. And I'm using mother here in a generic sense that could refer to mother or father or other caregiver. But, uh, we often say mother in psychoanalysis. Uh, that's just historically the term that we use. So, um, so different ideas. Uh, we also know from the literature that there are very high rates of abuse, um, in particular sexual abuse in the early life of the borderline of the person who goes on to develop borderline personality disorder. So that has to be noted. I'm also of the belief that neglect, uh, can also be, um, something that is, um, uh, of, uh, of great importance in the backgrounds of these individuals. To me. I think love for the borderline patient, uh, is something that, uh, from the earliest days of life, is intricately tied to pain, uh, that the concept of love is, is intertwined with pain for these patients. And this is played out in their adult relationships when, uh, they enter into a loving relationship, they believe or they expect to feel pain. And when pain is not present, they may act in ways, uh, to, uh, elicit pain or act in ways that will cause pain, uh, in the interpersonal dynamic. And we can talk more about that, uh, uh, as we, uh, you know, move on in the interview. 1s Yeah, I mean, I find this. Topic of conversation. So interesting. I mean, obviously it's very important. Many patients present with this condition. It can really baffle professionals, as I mentioned earlier, when they're facing it. I remember at the beginning of my psychiatric training, when I started to deal with patients with this condition and my colleagues, it was always it always produced the most tricky scenarios, the biggest ethical dilemmas. To the outside observer. It just seems so, um. Unusual. Why would someone behave in such a self defeating way? Why would someone self-harm, for instance? And maybe you can now. Now that we've explained a little bit about the backgrounds that patients with this condition may come from, maybe you can explain why someone might act in such a self-defeating manner. Yes, yes. So, you know, I think, um. 1s I think there are two ideas that are particularly important here. Um, one goes all the way back to Freud. Uh, the father of, uh, psychoanalysis, he argued that people, um, engage in, in what he termed a repetition compulsion, um, where they will unconsciously replay early themes in life, in their adult life, with the goal of, uh, essentially achieving a different outcome. Um, um, so repetition compulsion here is, is relevant as well as what the American psychologist Paul Wachtel um, refers to as cyclical psycho dynamics that the patient unconsciously will act in ways to bring about the feared outcome, um, unconsciously. So they will elicit the outcome that they so desperately fear. So what you see so often in borderline pathologies, and it is an intense fear of abandonment or an intense fear of rejection. I've said before that the borderline patient will, despite these intense fears of abandonment, act in ways that, um, it actually make the abandonment happen. They act in ways that will lead to their eventual abandonment by partners, um, in all sorts of ways. Um, and we can talk a little bit about that. So, you know, this sort of paradoxical, self-defeating, self-contradictory way of interacting is, I think, a manifestation of inner feelings of worthlessness or feelings of being unlovable because they were rejected as a child, perhaps, um, feelings of, uh, of just being a bad person. So they act in ways that, uh, contrary to their conscious desires, which is actually love what they really wanted. The conscious level of is someone to love them. In fact, borderline patients say this all the time. All I want to do is love and be loved. But what they don't realize necessarily is that they act in ways unconsciously that are self-destructive when it comes to love, and this plays itself out in the psychotherapy relationship. Otto Cronenberg, a major American theorist, uh, on borderline disorders, um, originator of the concept of borderline personality organization. He talks about the borderline patients intention to destroy the love object, the destruction of the of the love object, um, derived from earlier, uh, wishes, uh, to destroy, uh, a, uh, the, uh, the parent rather an internalization of the process of abuse, perhaps, but, um, but this also, you know, I think it's important to note this plays itself out in the treatment relationship in which the patient may look to sabotage the treatment or destroy the therapist as a person or as a, as a provider. 1s And I've also heard that what might be going on is not only does the individual have the desire to destroy the love object, but they may also have, or they may instead have the desire to merge with the love object to become one with them. In Gestalt psychotherapy, we call this confluence. So they want to become confluent with the love object. So for example, if someone is dating someone new, they essentially want to become joined at the hip to this person. And then what often happens is as soon as it becomes evident that that's not possible, because of course that's not possible. And that might be because of just life circumstances or because the person that they're in a relationship with puts up some boundaries, then that's what creates this conflict, this immediate sense of then of hatred, sometimes of anger. Often boundaries are a way of really triggering someone with borderline personality and then causing them to act out in different ways. Yes. Correct. This this merger is, is, of course, a myth. Uh, but you see this. You're absolutely right. You see this play out, I mean, practically in terms of the patient sort of adopting the interests of the love object, of behaving in ways that, uh, may not necessarily historically be characteristic of the patient, but they assume a certain manner or style of dress, uh, adopting certain interests again and the like in an attempt to merge with the love object. And then eventually they become disappointed because, uh, because such merger is psychologically impossible. We are two separate human beings who have decided to love one another, but we are not the same human being. And, um, uh, so I think that's an important point in that. And the establishment of some boundary where I and and you begin is interpreted, I think, by the patient as rejection and the idealizing feelings turn into devaluation. So the, uh, you know, the, the, the loving statements. I've never been so in love with someone before in my life. You complete me. I can't imagine living life without you turned into I hate you. You, uh, don't know, uh, you don't know me. Um. I don't know what I see in you. You've never done anything for me. I don't know why I ever got. Was you in the first place? 1s And I think this can be misinterpreted because now nowadays in the on in the culture on Instagram, you have the concept of love bombing, the idea that someone will barrage you with love and affection as a manipulative tool. And I do think some people can do that. They can intentionally do that to manipulate. But what you're talking about is more that the person really feels that way. They feel this unanimous sense of this total sense of affection for the other person. It's not an it's not an intentional thing they're doing to manipulate. It's kind of they're they're in love with the fantasy of this merger. They feel this enormous amount of affection. And little do they know that that's that's going to give way to to much more dark feelings. As soon as it becomes obvious that this sort of merger with the other person is impossible. Correct, correct. I think you're absolutely right. There's two important points here, right? Is that the what the borderline patient the person experiences is very genuine. Um, uh, these feelings are very real. When they are experienced, the person is not attempting to manipulate. When they idealize another person, they really feel, um, deeply that they have met, uh, their partner and that, uh, uh, life is grand. And I finally met the one who will be with me forever and will shower them with praise and life. Uh, the other point is that, uh, the the the patient with borderline personality disorder actually has two different anxieties. And this is, uh, very important. The American theorist, uh, Masterson, uh, talked about this right there is at once an intense fear of rejection or abandonment, uh, abandonment anxiety. And also a fear of engulfed or in measurement, fears of closeness and intimacy. And the patient, um, uh, sort of teeters back and forth between feeling too close and too distant from others. Um, so this, um, uh, this results often in a pattern of what, what has been called sort of a push and pull within the context of relationships. I'm going to pull you in close, and then once you get too close, I'm going to push you away. So after, uh, a nice evening or a vacation, uh, that is experienced in a very loving way, uh, when you get back from the vacation, the borderline patient stirs things up unconsciously and brings up old things and pushes the person away. This obviously becomes very confusing for the partner. Um, uh, but, uh, but yes, so, so we we, you know, what gets the most attention clinically, what's talked about most frequently and what the patient, most frequently complains of is abandonment, anxiety. So I'm going to be abandoned. He's going to leave me or she's going to reject me. But in reality, uh, there is not just the abandonment anxiety, but also this anxiety around intimacy and closeness and love and uh, uh, because remember, love is intertwined with pain. Um, so when, uh, when they get too close to somebody, they act in ways that, uh, are, uh, contradictory to their, uh, to to what they seem to want, which is love. Um, I think this is an important point. I think it's missed by a lot of clinicians and even by some theorists. Um, so there's at least three things going on there is the conscious, understandable longing for love and closeness and affection. There is also the fear of affection and the fear of the pain that closeness can bring. And then complicating it even further. There is kind of a strange unconscious desire for pain, because pain might have been familiar in the early life environment. And you can see how if you're caught between all these three, you can can cause some really difficult life situations. Most definitely. And I think you encapsulated it very well there in just a few sentences. It can be confusing for the, the, the, the, the partner, uh, the love object, if you will. Also very confusing for the patient because often when they do push someone away, they become very regretful and they feel an immense amount of guilt and they don't understand why they've done it. Uh, why why why am I hurting this person that I love? And, uh, eventually it's going to lead to them, to them leaving. And I know that. And so. Yes, but the but the the unconscious appeal of pain, if you will, is something that, uh, is, uh, is interesting, uh, because remember, love intertwined with pain. Very often this plays out in other ways, uh, in, in the relationship, particularly in the sexual realm where you see, uh, very often in my clinical experience, at least, a desire for pain during sex, um, or painful experience during sex, not the pathologize, uh, all of, uh, all of this, but, uh, but yes, they will act in ways that seem, uh, that make it seem like they actually do desire pain in interpersonal relationships. Some some patients have even said he treats me too nice. He's too kind to me. He he or she, uh, you know, I actually want someone who's who's who's last night. It's nice who is actually more, uh, uh, more aggressive towards me. Um, and this may actually play out in the selection of partners where they actually eliminate partners who are going to treat them well, who are emotionally available or psychologically stable and the like. Uh, so, so selection of the partner is something else. I think that, uh, you know, sort of is, is noteworthy. And I think this is so useful to talk about because this applies the concepts we've been talking about so far really apply to everyone. In my experience, the good thing about learning about personality disorder in depth is that it just gives you a really good insight as to how personalities work. In general, we all unconsciously long for things which can be a little bit destructive, and we have these conflicts between what we may want consciously and what we want unconsciously. We can all behave in a self-defeating manner or be self-critical. And then as a result of that self-criticism, do things which are a bit destructive for ourselves. Do you think there's any truth in the idea that an individual with borderline personality may select a partner that is particularly bad for them, that may be used them in adulthood? Is that something you've observed in your clinical work? I do believe that that that can be true. Uh, again, you know, going back to this notion of repetition, compulsion, cyclical psycho dynamics that that in part a selection that there may be some disturbance in the selection of appropriate partners. But to to your earlier point, uh, you know, the way that we conceptualize this now, as I'm sure you know, is that the personality disorders, at least many of them exist on a spectrum with normality. In fact, you know, this is the way we conceptualize a lot of psychiatric disorders now. So, yes, we all at times may engage in some of the defenses that the borderline patient utilizes. You know, uh, for those who, um, you know, are interested in politics or sports, you know, I know, uh, we call it soccer here. Football in the UK. Uh, right. You you idealize your team, you devalue the other team. Right? And, uh, you know, same thing with politics. We idealize this particular party or candidate. We devalue the other one. Right. So we all may utilize these defenses to some degree. When we talk about personality disorder, as it is, when the defenses are used to the exclusion of healthier defenses, the pathological defenses are utilized, uh, more frequently. They, uh, are utilized again, more frequently, and then to the exclusion of healthier defenses like humor and the like. So, uh, so, yes, I think that's a very important point, in fact. One heuristic I like to use to elucidate this, one that I've been using lately, is the dichotomy between sensation and perception, which many people don't think about. That much sensation being the raw data we take in from our environment, what we see, what we hear, the stuff that actually happens, whereas the perception is the meaning making that we make from a given set of data, and particularly the meaning we make, the meaning we make from the data we emphasize and the data that we under emphasize and don't focus on at all. So with someone with a borderline personality structure, what you would expect because they they're going in with a mindset that they're likely to be abandoned, for example, is that the the sensation, the data they take in might be fairly straightforward. The normal mix of data they may get from a new romantic partner, the things that go well, the things that go badly, the positive signs, the negative signs. What they'll do is they will perceive, overemphasize the negative, overemphasize all the signals that perhaps they are going to be abandoned and they may under emphasize all the stuff that's a lot more reassuring. And again, easy to easy to isolate people with borderline personality and almost pathologize them because that's what's happening. But everyone is doing this. We're all generating flawed perceptions based on a kind of incomplete filtering of the data, based on what our beliefs are, what our mindset is. And that's why it is so, so important to to be conscious of what your beliefs are and then to consciously override them when they're not reality oriented. Yes, yes, I agree with that conceptualization. I think the problem is one with borderline patients. The these, you know, inaccurate perceptions are exaggerated. They do it more often. And, and and the theme is rejection and abandonment. Right. And then number two, it is very hard in the moment to override these inaccurate perceptions of of of of other and how people treat me and the like. Right. So you said something very important there. I agree, you know, that there is almost a discounting of the positive things that have happened, uh, and, um, a selective attention to what the partner hasn't done. Uh, you know, uh, partner gives ten compliments, but because he didn't compliment me the 11th time, well, that's what I'm going to focus on. My partner wants to take me out to eat at a fancy restaurant, and, uh, brings me a small gift or a card, but because he didn't bring me flowers, well, then, you know, he doesn't really love me. Uh, so if someone with borderline personality comes to you, if you're working with them, what's what's your therapeutic approach? Yeah. So, you know, I practice general psychodynamic therapy with, uh, with borderline patients with the particular, uh, focus on, uh, what we call the transference reaction, uh, which is how the patient comes to relate to me in the treatment arrangement. And, um, you know, I think first, uh, as Kornberg notes, um, uh, once a diagnosis has been established, it's it's my belief, I believe, uh, that we we have to inform the patient of the clinical diagnosis. Um, uh, historically, that wasn't always done in psychoanalytic psychotherapy and psychoanalysis, but I believe it is important we have something that we're treating and something that we're working on together, um, over time, you know, to to, in a nutshell, what what occurs is the interpretation of defenses, how the patient utilizes these defenses. Um, their psychological origin, why they developed. So for instance, splitting, which is this alternating between idealizing and devaluation as, uh, an attempt by the child to split the mother, uh, or a caregiver into all good or all bad parts, to preserve a good image of the mother in the child's mind. And this at once was an adaptive mechanism. It outlives its utility. And now the person engages in splitting, uh, in their day to day life as an adult. So an understanding of the psychological origin of the of the symptoms or of the defenses and then, uh, pointing out how the patient comes to relate to me in ways that are very similar to the way the patient relates to others. And then we openly talk about it. I will share my own reactions or my own counter transference, if you will, with the patient in a way that is open and honest, uh, and in a way perhaps that they have never experienced this, uh, before. Um, um, so this I think it has to be said, you know, this is a process that can take many months, in fact, in some cases, many years, the treatment of a borderline individual in psychotherapy, um, uh, but, uh, but the foundations can, can get better. Um, uh, um, and often do get better. Can you give me an example? So you mentioned transference. Transference is, you know, the reaction that. A patient would have told the therapist that perhaps there there is coming from their psychological origins or it's coming from an old relationship. It's being transferred onto the therapist. Counter transference is, of course, what the reaction that that the therapist is having towards the client. Can you give me an example of a really common transference reaction that a patient might have towards you, what your counter transference might be, and then how you would work through this? Sure, sure. So yeah. So you know, I think, uh, the perception that the therapist is rejecting the patient or is abandoning the patient may come out in several ways. You know, as an example. Uh, the the ability to maintain a psychotherapy frame, uh, which, you know, for your listeners are basically the boundaries of the treatment relationship we agreed to meet these days. And from this time to this time, um, so the patient may experience, uh, the ending of the session at the time at which it is supposed to end as a rejection. You're not going to spend more time with me. I'm completely unraveled here in your office, and you're not going to give me extra time. Um, and that is perceived as some rejection of the patient. The therapist travels for a vacation, has to miss a week of work. Um, and the therapist and the patient rather experiences that as an abandonment. You've abandoned me. And not so uncommonly, if you read the literature, um, the patient may go into crisis. They may end up in the emergency department. They may end up hospitalized while the therapist is on vacation. Um. Uh. So, uh, so, so this is sort of an example, you know, the push pull pattern that I mentioned earlier, um, may play out, uh, when there is, uh, what I perceive as a particularly productive session where we seem to be addressing some important material in the treatment, um, and the patient may have that sensation as well. They may miss the next appointment. They may just not show up. Uh, right. Oh, I'm getting too close to the therapist. The therapist is getting too close to me. The therapist is really starting to get to know me. I'm going to have to put my, uh, guard up, and I'm not going to come next time. You know, I'm. I'm too. I'm too anxious about what's happening here in the relationship. And then counter transference in terms of what the therapist feels, uh, uh, can range from, uh, from, uh, disappointment, uh, to, uh, feeling angry towards the patient or even hateful towards the patient. Uh, when the, when the patient is devaluing you and saying things such as, well, you know, I'm paying you all this money, you're not helping me at all, or you're no better than my last therapist, or you have this good reputation. I don't know why you have this good reputation. You've never done anything for me. I've been coming here for a year and a half, and you've done nothing for me, you know? You know, uh, while, you know, the last session, they were praising me for helping them better than they've ever been helped in more caring and and, uh, you know, more understanding than anyone who's ever treated them before. And this creates, of course, in the therapist these very confused feelings and feelings sometimes of of hate or dislike for the patient. Right. In very much the same way that the partner of the patient or the favorite person or the family member may experience very confused feelings. Uh, um, and importantly, this is talked about in The treatment, you know. You're telling me this today? But last week or a few weeks ago, you were telling me something completely different. How do you make sense of that? And how do you think it makes me feel? Yeah, those are really good examples. And what I found very commonly with my colleagues, with people who are new, new mental health nurses, psychiatrist, therapists, because most of us come to the profession with a very agreeable nature, with a strong tendency to want to help people. When we get these reactions, like being really idealized one moment and then devalued the next, what it produces is what I've seen. It produces intense feelings of guilt, of unworthiness, of inadequacy, as as a professional. And it's so counterintuitive. Again, if you don't understand psychodynamic work or transference, it's so counterintuitive to think of a feeling as being produced in you because of someone else's disposition. We kind of over identify with our feelings quite naturally, and it's even more counterintuitive to then decide that the best way to work through it is actually voice it to the patient, and to actually shed more light on it. Usually, if you feel these feelings of inadequacy, the first thing we want to do is not tell anyone at all, because it's almost like a sign of shame and so cathartic to be able to air that out in the relationship in a in a gentle way, obviously. No, I agree with that. It is in some ways very counterintuitive. But you know what you said? The feeling of inadequacy. Sometimes I term this, you know, the patient is making you feel impotent, you know, in terms of your work. Um, and, uh, and, uh, like, nothing is sticking, nothing is working. Your interpretations have not had any effect. And uh, uh, but uh, but yes, I think, uh, voicing it, talking about it in the room is actually what helps the patient because they're likely not getting this from anywhere else. And within the, the confines of the treatment relationship, that can be very productive. Mhm. And there is, of course, a kind of therapy designed by Marsha Linehan who you mentioned called dialectical behavior therapy, which is specifically designed for patients with this condition. And you know, if you're someone if you think you may struggle with emotional regulation, if you think you're a friend or a relative of someone with borderline personality, definitely look that up because there's loads on YouTube, loads of little techniques you can start to use straightaway. Do you use any techniques like that? Any techniques from DBT in your work with these patients? Actually, a lot of patients come to me after, um, after DVT. Um, uh, I will just take a step back. So dialectical behavioral therapy, uh, developed by Linehan, is a very skills based approach. Um, learning techniques for the patient to use in the moment when they are feeling, um, distressed. Um, uh, very effective when you look at the literature are very helpful in terms of suicidality. Um, there is another approach which is derived from a psychodynamic approach, which was pioneered by Otto Kornberg, uh, in New York with his work with borderline patients called transference focused psychotherapy, which is a modified psychodynamic treatment that, when you look at the literature, seems to be as effective as DVT. I think that treatment selection, uh, we have to remember that not all patients are are suitable for particular treatments. We have to do a good job of selecting which patients may benefit more from DVT, which benefit patients may benefit from the psychodynamic approach. Um, so I don't know whether TFP transference focus therapy has made it across the pond of the UK, but it is starting to take hold here in the United States with more and more practitioners training in it. And we're seeing more and more research being done on it, uh, which is more or less the way that I practice. I don't practice formal transference focused psychotherapy, but I utilize a lot of the concepts. So, um, uh, so, uh, so, uh, yeah, DVT is, is often, you know, the treatment to which most, uh, borderline patients are referred, um, and it has its strengths and, and can be quite effective and helpful in helping the person manage the day to day distress that they feel. A psychodynamic approach is, um, is more toward, uh, geared more toward understanding of the self, of the patterns that play out in relational, uh, life. Um, and then, um, uh, you know, uncovering the psychological origins and the meaning of the symptom. So, uh, yeah. Yes, absolutely. And and there is there are transference focused psychotherapy training programs. In the UK and the way I. The way I integrate all of this is. I like to think that, you know, with any problem that someone comes to you with for therapy, you can approach it from two angles, the more superficial angle. And I don't mean superficial in a derogatory way, but superficial in terms of the behaviors, the the major behaviors, but also the micro behaviors. The more obvious conscious thoughts, they're more obvious conscious emotions. So you can approach it from that angle, but then you can also approach it from that, from the depth. That being more the early life, the beliefs that they may have about themselves, the world or others that are more unconscious. So I like to think that therapies like DBT obviously tend to look at things from that more superficial, if you like angle and can be incredibly helpful. Transference focus therapy looks at that depth. You know, all the things that you described. But I would also say that because I've sat in on a few DBT groups and I've got to read the DBT manual. There are some aspects of DBT which can be very deep, and those would be the mindfulness components, where you can really see how much the therapy was influenced by Buddhism, not in a superficial sense, but very much embracing some of the deepest aspects of Buddhist philosophy, like what should your attitude be towards suffering and having attitudes, for example, of radical acceptance even towards the bad things that happen in our lives. So I personally, based on my experience, I wouldn't say DBT has is just about those behavioral things. But obviously, you know, a lot of the skills are centered around that. Yeah, I think that's very well said. And again, not to disparage some of the more superficial treatments, um, which can be very helpful. And again, they've been shown to reduce rate of suicide in these patients. I just think it's important to add, you know, 10% of patients with borderline personality disorder will end up dying by suicide. I believe about 75% of those will attempt suicide at some point. Um, so, you know, this is a psychiatric disorder that, uh, uh, is is really in some ways a lethal one. Um, yeah. So that's, that's very important. And moving on from that to like the idea of diagnosis, the idea of diagnosis, I think is still quite controversial in psychiatry. And it becomes more controversial the more you move away from more biological conditions like bipolar and schizophrenia, the more diagnosis seems to become controversial. Do you think that in general, using a diagnosis like borderline personality disorder is helpful for the for the patient? Or do you think it's mixed? Do you think it depends on that patient's disposition and their personality, or do you think it's actually too stigmatizing? What's been your experience? I mean, it's it's a great question. You know, this is a problem that from my, uh, time on Twitter, I've noticed is a little bit of a bigger problem in the UK than it is in the United States. It seems that UK psychology is very anti diagnosis and in some ways anti-psychiatry, whereas psychology here in the United States is very much aligned with American psychiatry in many ways. But I do your question about diagnosis, which is very important. Um, I think uh. First off, um, when we when we think of the concept of disease historically, and I've written a little bit on this, right. Disease, you know, dis ease disorder, something is out of order and characteristically or historically, rather, the concept of disease is much more intricately tied to some combination of functional impairment and suffering than it is to known biological pathology. Right. So there are a whole host of medical diseases that we have no problem calling diseases, and we have no idea what is going on in terms of the underlying pathophysiology. Migraine disorder is probably the best example. Lou Gehrig's disease, or ALS, is another disorder in which the underlying pathophysiology is unknown. Right? So when it comes to psychiatric disorders, I have no problem referring to them as disorders or diseases because they cause some characteristic combination of functional impairment and suffering, often intense suffering when it comes to borderline personality. Of course, there have been other suggestions, um, in terms of renaming the disorder, but I think because of the nature of the condition itself, whatever we rename it, uh, to, will at some point carry, uh, very similar type of uh, of, uh, social, uh, view or social stigma. Um, I, I think that, um, uh, you know, while there are important discussions to be had around what is a disorder, what is a disease and the like, I think borderline personality disorder. Um. Uh, is a condition that, uh, you know, at this point in time has been very well researched. Um, you know, it it certainly describes a unique set of patients or people who struggle in very similar ways. Um, you know, it was Gunderson who John Gunderson at, at Harvard who, uh, operationalized the criteria for BPD in the 1970s. And it was added to the diagnostic manual, the APA's diagnostic manual, the DSM, in 1980. Um, and so I think diagnosis is important. I think it very often gives the patient some, uh, idea of what what is going on with me. Uh, and there are other people who suffer in ways that are very similar to the way I suffer. And there's a name for this, and there's a name for it. Not only is there a name for it, but there are treatments that can help me. Um, and thus I, you know, I think this argument about Pathologizing is, is something that you encounter more frequently in the UK, but, uh, is also something that I think people, you know, they they don't have a good sense of, of diagnosis in medicine, uh, that, that many, many medical conditions are, you know, uh, are less than, uh, clear in terms of the, the etiology and the and the pathology of what's going on. Yes. And we are more divided about this in the UK. And I know because I've been in both a psychotherapy training program which is completely detached from medical psychiatry, and I've been in a psychiatric program. And the attitudes, the attitudes are very different. Now, I wouldn't say in the psychotherapy context it's totally dismissed, but it's certainly a lot more controversial and there's a lot more room for debate. I do my ultimate feelings about it is. 1s It does depend. And I've mentioned this on a podcast a couple of weeks ago with Rose Cartwright. It depends a lot on how the diagnosis is delivered. I think the. The case can be made that diagnoses like borderline personality disorder are often delivered clumsily and badly by clinicians. Sometimes, I'm sorry to say, even psychiatrists who don't have a sophisticated understanding of the condition, and they may be correct in terms of their diagnosis. The patient's symptoms may match that diagnosis, but in my experience, it's a diagnosis that needs to be delivered in a very skillful way. For example. All the things you mentioned, you know, letting the patient know this is a way of understanding the whole collection of problems, problems where it's not obvious that they're actually related to each other. It's a it's an explanation that can that help that can help them find community and help them connect with other people. It can also help them understand their past, because you might come to understand you have this set of problems because you've had a series of adverse issues in your life. And in many ways, these these problems were originally coping strategies to deal with an early life environment that was very difficult. I think these are all important points. And there are points which I see not mentioned often enough in the diagnostic process. Often, for example, when a patient has come in after a suicide attempt with an overdose and. Frustratingly often, the attitude in inpatient and hospital settings can be, um, they have borderline personality disorder. This is not really a legitimate mental health condition like bipolar disorder or schizophrenia. And the irony is, it can lead them to feeling even more invalidated by the very people that are supposed to help them. So I definitely onboard with you. I think diagnosis is important. The concern is I see it often not being delivered skillfully enough, and also with enough humility that even though this diagnosis has validity, there is kind of mystery still still mystery to the biology as well. Things along those lines, I think that's beautifully said. And I think that that way of delivering the diagnosis, what ends up happening is the patient may avoid psychotherapy, they may avoid treatment for the rest of their lives because the diagnosis was delivered in such an inhumane and maybe hurtful way. Um, and, and I think that's, that does real damage not only to patients but to the field as well. Um, uh, and I think that has to be mentioned. Yeah, I agree with all of that. 1s One idea I saw you alluded to in your writing is the idea of covert contracts. And I find this idea so interesting, and I think it would be helpful for so many people telling me about covert contracts. Yeah. So the covert contract, uh, is a means of communication. It was first described, I believe, in the 90s by a psychologist. But covert contract exists when person A expects person B to do something, but they don't express what it is that they want person B to do. So when person B does not do the thing, that person A. 1s Um, expects them to do has made a contract in their mind for person B to do person A turns around and says, well, I know you don't care about me, or I know you don't love me. You didn't do this for me, right? Uh, and this is the the the nature of the covert contract is making a contract in your mind with another person, without revealing to that other person what it is that you expect from them. And what I've outlined in the article to which you refer is, uh, um, is, uh, is that this is a method of communication that we often see in borderline pathologies, uh, the, the use of the covert contract. And consciously and not, it's not a deliberate attempt to, to, to hurt the other person, but uh, um, but, uh, but yes, the covert contract. I like to think of it as a form of a double bind, uh, method of of communication in which, uh, you choose A or B, it doesn't matter. You're still going to lose in the in the interaction. Something I see really commonly in my practice is. 1s People pleasing and people pleasing presents a very interesting kind of covert contract whereby a person will say, I will do this, this and that for you. And in return, without telling you, as you mentioned, I would expect you to do something in particular and in return, if as long as I'm nice to them or I help them out with their groceries, or to do do the laundry without having to mention, God forbid, what I need or my vulnerabilities, they will then do the thing that I need them to do, and that's something I see. So it's a way of avoiding asserting actually who you are and what you want. Yes, yes, yes. I think that, uh, I think that's well said. I think that's a good example of, uh, of of a covert contract in action. Can you comment a bit on the value of. Taking a bit of a philosophical approach to mental health, I feel that I can't help but feel that mental health is unique in that, because we're dealing with people in the full complexity of their lives, their choices, their life trajectories, dealing with suffering and how they should deal with suffering. I can't help but feel that a philosophical approach is often warranted. Can you comment on that? Is that something that you found to be important in your work? Absolutely. And I think all of the greatest. Psychological and psychiatric theorists. Um, you know, going back to Karl Jaspers. 1s Uh, have been philosophically informed. Uh, we're dealing with, you know, uh, in the mental health professions and by psychiatry and psychology and social work and others in this, um, we're dealing, you know, not. 1s Simply with the pathology of, say, the heart or pathology of the lung. And those are very complex, too. I'm not meaning to disparage those fields, but we're dealing with the human mind, which is, um, uh, something so vastly, uh, um, a different I think in many ways, uh, uh, has been attempted to be understood for centuries. And so I, I, I think that philosophy is so vital, uh, to, to our work, uh, it's underappreciated. I think it's under taught. We don't focus much on it in training. And there are many philosophical assumptions that we make in our work that we're not aware of, um, that really guide and, and, and determine how we conceptualize and work with the people with whom we work. And, um, uh, so, yeah, I agree with that. Uh. 1s And what would you say is a good example of how, let's say, your clinical philosophy has changed or matured over the years since you started. 1s Now, that's a great, uh, question. I, you know, I. My clinical philosophy. Um, uh, when I entered the field, um, was in some ways, um, uh, very much aligned with some of those critics in the UK. Uh, I didn't, uh, I didn't particularly appreciate the notion of categorizing human beings into these different, uh, boxes or categories, uh, and labeling them with illness that we can't demonstrate on MRI or, you know, objective testing. And then I learned that, uh, uh. 1s My thinking evolved, and particularly in work in psychiatric emergency departments, which really allowed me to see, uh, most clearly severe psychopathology and the idea that these people weren't sick in any way or these people were not ill, uh, that they were not, uh, metaphorically ill. These patients were literally ill, um, and, uh, and so my thinking evolved in that way. And then I began to see the, um, the usefulness, the utility of, of diagnosis and of conceptualizing these different human problems, uh, uh, in a diagnostic way. 1s Yes, that makes a lot of sense. 1s Doctor. I'm aware we're out of time, but thank you so much for coming on. There's lots more I want to talk to you about, so we're going to have to have you back, I'm afraid. Well, let's do it. I really appreciate you having me on. Uh, thank you so much. 9s Thanks so much for listening this week. If you've got any feedback, as always, do get in touch. If you enjoyed the episode, why not give us a rating on Spotify or Apple Podcasts? Because it really helps other people to find us. If you want to get in touch, you can find us on Instagram or Twitter, or you can drop us an email. And if you value the show more generally, why not bias coffee? Thanks so much.