Perfect, perfect. That's the psychodynamic diagnostic manual. Well, we could just read it out loud.
Show it to the audience. I'm the co-editor, but... I'm not even saying disorders here, because everybody's got personality. Nope. Schizoid, paranoid, narcissistic, psychopathic, hysterical, obsessional, dissociative, it's...
arguable that that's in the hysterical category. Dependent, masochistic, hypomanic, counterdependent, sadistic, 9, 10, 11, there are 12 in the PDM. But you know there are other types that are I forgot somatizing, forgot phobic.
Personality happens usually gradually and it's a complex combination of What's your temperament? What affects were important in your growing up? What defenses did you learn to use?
Who did you identify with and counter-identify with, for that matter? How were you taught to support your self-esteem? Do you feel good when you get over on other people, or do you feel good when you do something that involves your sacrifice for the greater good?
How do you deal with disappointment? Do you blame? Were you taught to blame? Or do you try to grieve and move on and solve a problem and accept what can't be changed?
Babies differ on all kinds of measures and some kids are easy and some kids are hard and then there's an interaction between that and the family. You can have a temperament that the family appreciates and supports or you can have one that the family doesn't understand and they make you feel there's something wrong with you. And then you have On top of your temperament, developmental challenges that might be handled in one way or another by the family. You have neglect or trauma or over-control or any one of a number of different ways that your family deals with you that you then learn to accommodate to. And the Bayesian brain is a prediction machine, and it's basically saying, you know, this kept happening to me when I was young, that's how I expect the world to be.
Now, trauma at any age can disrupt personality. So can substance use. So I used to think that there must be an alcoholic personality.
There's not. Once you get somebody sober, you see what the personality was before they developed a substance use disorder. I've always been fascinated with individual differences and not just diagnostic differences, but how does it influence your therapy if you're talking to somebody?
who is an adoptee, who is a twin, who is of a different race from you, who grew up in a different class rank than you, who is a Hindu if you were brought up Christian. There are all kinds of things that go way beyond diagnosis that involve our adaptation to another person and trying to make an egalitarian, supportive, but helpful relationship with them. When I go to other countries, it's interesting on that level. They often tell me what's the common personality type in their country.
So, for example, the Swedes told me that they were schizoid. The Italians told me they were hysterical. The Poles told me they were post-traumatic. The Russians told me they were narcissistic. No, masochistic.
In Norway, they told me they were avoidant. In Australia, they told me they were counter-dependent. In Singapore, they told me they were obsessive-compulsive.
In Japan, they told me people tended to somatize. So it's very interesting how cultures will shape dominant personality styles. When I asked them, how do you think about Americans in terms of our dominant personality types, they look a little bit shy.
And they say narcissistic because, you know, we're America, we're great. There's a lot of narcissism. These days, narcissistic personality, we live in a culture that changes quickly, where we don't know who we are, we're all anxious about our status. We're in a culture that breeds narcissistic problems. And in...
American culture, we have an official kind of language about individual rights, which privileges the idea of my individual authority to whatever, commit genocide or, you know, various other things that have been done in the name of individual rights of some people. The most common kinds of personality, I would say, and there's some research on this. It's depressive personality. That's also the most common type of personality in therapists, interestingly enough.
They move toward other people. They're interested in other people. They're quite self-critical.
They're sensitive to separation. They're very sensitive to criticism. When they are criticized, they tend to assume that there is something bad about them.
In contrast, for example, to people with a more paranoid psychology, who when they're Criticized, they go right to what's wrong with you, okay? So depressive people use introjection, whereas paranoid people use projection. Introjection, turning against the self, sociophilia, sensitivity, those are all part of a depressive psychology. And you may not ever get a depressive episode with this psychology, but you have the dynamics that often go into depressive episodes. Masochistic people are not that uncommon either.
People who get in their own way. And that tends to be a depressive psychology with the additional problem of, I just don't take it out on myself. I need to keep demonstrating that I'm suffering, either to show that I'm a good person or to maintain a relationship.
I mean, there are some people who are so severely masochistic that they stay in abusive relationships because for them, It's worse to be alone than to be hit. That's a masochistic organization. And it doesn't mean you love pain.
It just means that your strategies for survival developed from a situation in which you couldn't have been separated. You had to live with your abusive parents because otherwise you'd starve to death. So it's not like they seek this, but... it's a pattern that they've learned that their attachment paradigm is that if I'm suffering, you'll pay attention to me.
They often have histories where their parents neglected them except when they were injured or sick. So that is a recognizable type of personality too. You can have all the same DSM symptoms and be either more depressive or more self-defeating. Self-defeating patients usually come in with depressive problems, but they approach therapy as an opportunity to complain about other people, you know, usually. And they put certain pressure on the therapist, you're supposed to be fixing my life, you know, I've been victimized, the bad people are out there, you know, what are you doing about it?
It's often very subtle. But if the therapist is just paying attention to their own subjective experience, you begin feeling like there's more going on here than just depression. This person keeps reenacting the idea that you've got to help me, but you're going to fail.
Some of the things that have made clinical thinking... Less popular are the pressures of drug companies who love categorical diagnosis because if you have an illness they can market a drug for it. They don't want to hear about complexity and context and dimensionality. If you're an insurance company you want to have, okay all you have to do is get rid of the symptoms. They don't do that with other illnesses but they do do it with psychiatric illnesses.
As soon as you're reduced in the symptoms that's it. It's like curing a fever and then the disease is gone. You miss a lot when you're diagnosed that way.
For example, you can't tell by the DSM description of depressive disorders, whether it's what Sidney Blatt's work suggests is an interjective depression, where the subjective experience is, I'm bad, I'm evil, I'm a terrible person. And there's a lot of guilt versus whether it's an anacletic depression where the person feels, I'm empty, I'm hungry, I need an attachment. Life is meaningless without an attachment. Those two kinds of subjective experiences of depression have exactly the same vegetative signs. They meet the same DSM criteria, but they have different implications for treatment.
There are two anxiety centers in the brain, what Panksepp calls the fear system. and what he calls the panic grief system, which is the attachment system. And people have tried SSRIs for them because SSRIs are supposed to be good for anxiety.
But if you haven't differentiated between annihilation anxiety and separation anxiety, you're not even medicating properly. They're mediated by different neurotransmitters. The fear system is the legacy of our...
Terror that a predator is going to eat us. So evolutionarily, it's the system that tells us we're going to be destroyed. Most of us don't feel annihilation anxiety too easily, but I felt it on 9-11.
Some people with paranoid psychologies feel it all the time. Separation anxiety is a different subjective experience of anxiety. It's in the panic-grief system where if...
you separate any young mammal from its parenting mammal, you get, first of all, very great anxiety and searching behavior. And if you take fMRIs of the young mammal and the mothering mammal, the same part of the brain in the mother is lighting up as lights up in the child. That system is mediated by serotonin. The fear system is not. What calms the fear system are the benzos.
And the downer drugs. So very often people we see who have a paranoid streak also have a substance use disorder based on, you know, barbiturates or benzos or the downer drugs, generally alcoholism. Let's take paranoid people.
They have the trait of suspiciousness and distrust. That's not false. They can be described that way.
But they also may have the trait of overtrusting. people that they idealize, like my cult leader is flawless, or Stalin would never have hurt anybody. It's better to think about their psychology in terms of not the trait of suspicion, but the preoccupation with trust, distrust.
Sullivan said paranoid people don't have a normal level of trust and distrust. They're on one end or the other. Same with schizoid people. They tend to have the trait of... withdrawing from closeness.
But if you get to know them, they have a lot of preoccupations with wanting to be close, feeling lonely. You know, I'm not using the DSM version of schizoid here, but the traditional idea. They may have moments of exquisite closeness with other people from which they retrieve.
So it's the closeness-distance theme that defines them. If you're a patient with a schizoid psychology. And I don't get that about you.
I may, because I have a depressive psychology, be moving toward you, trying to comfort you, trying to offer you stuff. But your experience of that is going to be, you're impinging on me. You're in my space. I'm not comfortable. So with a schizoid person, I've learned to sit back and check in on how overstimulated they may be feeling in this particular point.
So that's... A kind of gross implication. But for all the personality types, there are implications for treatment.
If they're mostly paranoid but also have elements of a lot of other things, their issue is going to be trust versus distrust, possibility of betrayal. If they're mostly obsessive-compulsive, they're going to be concerned about control, discontrol, neatness, messiness, prompt. promptness, lateness, all of those issues.
Obsessive-compulsive used to be very common in our culture. It's less so now. These are people that are very organized around what's right to do, what's timely, what's conscientious, what's neat, what's fastidious.
With obsessive-compulsive people, it's the theme of control-discontrol. You can look at the trait of fastidiousness. But most obsessive-compulsive people also have a dirty drawer because there's some place where they're out of control. If they're mostly histrionic, they're going to be interested in gender and power and sexuality and they'll have some symptoms expressing preoccupations with those areas.
And you know you can talk about those different unconscious preoccupations if you are a powerful Heterosexual male treating a female who has somewhat hysterical tendencies, you don't want to mansplain to her because her psychology is that she feels like the inferior or weaker gender. And so you want to help her find her own solutions to things. Rather than come in like you know what you should do because that's a replication of the sense that men have the power, women don't have it. If you don't have the power all you can do is try to use your sexuality to even up the power disparity and that usually goes badly.
But there are other kinds of personality in which if you simply keep asking the patient, well how have you thought about that? What would you... your solution to that be?
How do you feel about that and what implications does that have for your life? They feel like you're being evasive, you know, with a paranoid patient. They want to know what you think.
It's a very different... interpersonal environment. Narcissistic, I think we all have an image of narcissistic, not so much the more shy closet narcissistic people.
Sometimes I get patients who come to me saying, just make me popular. If I were popular or if I were rich or famous then I'd be fine. That's just the flip side of I am rich and famous and popular and I'm wonderful.
It's the same set of preoccupations, it's the same personality. narcissistic people use grandiose ideas to defend against shame. And you see both sides.
If you have an arrogant narcissistic person, the kind that the DSM describes, and they have a terrible injury, you know, they aren't promoted, they lose their job, they lose their beauty, they lose their wealth, whatever it is that they're constructing their grandiosity on, then you see the shamed. Anxious, humiliated version of it, or what some people have called closet narcissists, or Glenn Gabbard has called a hypersensitive narcissistic person. Dependent personality, I've never liked that diagnosis particularly, but that's not uncommon either.
Both men and women, it has different appearances, but where you kind of don't know who you are or what you're after. except as defined by another person, like I'm Tom's wife and Jane's mother and Sonia's teacher, and everything is defined in a complex array of connections. I don't particularly like it because I think we are all interdependent, and it becomes a problem only when there's some kind of shift where you don't have your attachments.
And then you have to figure out where you're going. Like you retire, you don't know what to do with yourself, or you get divorced and you don't know who you are anymore. But that kind of personality has been researched.
Robert Bornstein has done wonderful research on it, and it is a useful concept and not very uncommon. I've seen a number of counterdependent people, people who have this, they're... you know, it's like the manic to the depressive. It's the polar opposite.
I need no one. I'm fine. This is not always a narcissistic thing. It's sometimes I can't depend on anybody. I'm going to depend on myself.
I never get sick. I always take care of myself. There is that version of psychology too.
I'm probably forgetting some of the big ones. Psychopathic is not too unusual. That's what the DSM calls antisocial personality disorder, but I really don't like the DSM description because it's all about the consequences and the social damage of it. And it doesn't look at the internal experience, which is I have to depend on omnipotent control everywhere. My worth is dependent only on what I can make happen.
I'm understimulated. I'm going to... Attack the world manipulatively.
I don't care about other people. I like to get over on other people. And they often are in very powerful positions. Generals, you know, presidents, presidents of countries, presidents of corporations. Because you love power, and that's what organizes everything.
And you love power even more than you love, you know, the narcissistic. gratifications of being seen as powerful, then that's an increasingly common kind of personality structure. I think in personality, it's almost always the case that people have some combinations of things.
Maybe they're a little schizoid and a little obsessional. I'm depressive and hysterical. Let me take another sip of tea here.
How are we on time? Gary? I'm still okay. I think the levels of organization are very important for people to keep in mind because if you're a beginner and you've been told that such and such a treatment, whether it's biological or psychological, is the treatment of choice for this condition, And you get a patient who's at the psychotic end of that spectrum and it makes your effort to do the evidence-based treatment makes it worse, your response is going to be, some other person could have made this work because this is the evidence-based treatment. I'm a bad therapist.
It's very different to work with somebody with, let's say, a depressive psychology who is at the healthy to neurotic range versus if they're in the borderline range versus there in the psychotic range. If, for example, you don't understand dimensionality, the fact that you can have, let's say, an obsessive compulsive disorder at a level of personality organization that's very high functioning, and the way that would present itself clinically is the person would say, I've developed this compulsion. I know it's crazy.
It's happened ever since my brother died. I want to get help with it. And they're clearly relating to you as a person who's well-meaning and intending to help them.
That kind of person is going to be a very good candidate for exposure therapy, which is an evidence-based therapy for obsessive-compulsive disorders. But if you have exactly the same symptoms, and you've had them as long as you can remember, and your parents taught you this, and you don't really think it's a problem, And furthermore, you fervently believe that if you don't carry out your compulsions, a disaster is going to happen. And you look suspiciously at the therapist as if when they tell you maybe you should move toward the objects you're afraid of contaminating you, they look like, uh-oh, you're a contaminator, and they treat you more like a persecutor. That person's going to take quite a long time in psychotherapy before they could ever do an exposure treatment. So the therapist gets demoralized, and they don't realize they've been trying to apply a technique that was developed for higher functioning people with people who are suffering much more deeply than that, and nobody's telling them that.
So it's been important to me to get the word out there that there are different levels of health, although at all the levels there are healthy as well as disordered parts of the cell. Well, at the high functioning level, almost every therapy is useful. We're talking about people who have pretty good attachment security, who can make a relationship with the therapist with the assumption that even if the therapist says something that's temporarily painful to hear, the therapist is well-intentioned.
You don't immediately go to, you were trying to hurt me. You can observe complexities in yourself and in other people. You ask a person at this level to describe the people in their family.
You get a real three-dimensional picture of a person there. At the high functioning level, it's easy to feel positive toward the patient. It's easy for the patient to feel positive toward you.
If you hurt their feelings, they'll tell you so, and so on. The patient will appreciate that you're trying to help, so you can move into various ways of trying to help them. They try to cooperate.
They don't have unrealistic goals. You can make a very realistic treatment goal framework with them. They don't test boundaries. They accept your boundaries. And if there are inevitable ruptures of the therapeutic alliance, they're easily repaired.
All you have to do is say, I'm sorry, I think I was too clumsy there. I got it wrong, and I'm sorry. That will fix it with people at this level. So they are the patients that we get very few of, but they're a delight to work with. And traditional psychoanalytic technique was test-driven on patients like that.
And those of us who've been through psychoanalysis, we were treated pretty much like that. You know, say what comes to mind. Deepen it if you can.
Get deeply into your feelings. If you do that with somebody at the borderline level, they'll get deeply into really traumatic feelings and they won't be able to put themselves back together again. At the neurotic level, they feel a catharsis and they feel at the end of session kind of relief that now they've gotten it out of their system.
Well also at the healthy level, people can acknowledge painful realities. They don't use a lot of denial. They kind of are clear about things that they're up against. That helps them with the capacity to grieve for painful realities. So, again, I would assume with somebody who's able to describe the nuances of what's happened to them that I could move pretty quickly with them toward grieving rather than blaming themselves or others.
At the healthy end of the spectrum, people use the very adaptive defenses, like having a sense of humor about themselves. Sublimation is a... Freud liked these analogies to chemistry and he talked about sublimation as the capacity to turn something that might be primitive in its origins into something socially useful. So if I'm exhibitionistic and I like to show off my body as a two-year-old that might eventually turn into my wanting to be an actress or a singer, for example.
Or if I have a sadistic streak, I can turn that into very valuable social use by becoming a surgeon. You get to cut people up, but for good causes. That's the idea of sublimation. You turn something that was originally primitive into something very valuable.
So higher-level defenses like that, intellectualization and such, are characteristic of people in... this high functioning range, whereas people in the borderline and psychotic ranges don't really have a lot of those defenses. We all have primitive defenses, but they don't have the others.
So at the borderline level, you see more insecure attachment, a lot of anxious attachment, especially for the DSM-3 version and 345 version of borderline. You see sometimes type D attachment, which is based on the strange situation, you know, research with kids where kids will relate to the parenting person with these combinations of like clinging to the mother and biting her. And that's clinically very resonant.
You know, I think most of us who've practiced for any length of time have seen a number of patients who treat us as, you're the only one who can help me and I hate you, you know, both at the same time. You know, I hate you, don't leave me. It's a common phrase to describe the inner world of these people.
That's a type D attachment, disorganized, disoriented attachment. And it's usually based in traumatic experience or terrible neglect. The all good or all bad images of self or others. the patient who cannot work with me if I'm a Republican.
Maybe that's based on some realistic stuff about you and I have to have minimally similar values in order to work together. Or maybe this is a person who, you know, seeks to constantly locate problems very simple-mindedly in terms of one group that you should exterminate. Intensity is part of the borderline picture.
It doesn't always take the form of the kind of obvious, intense affects that you see in the acting out versions of borderline psychology. But certain schizoid people feel what one of my schizoid friends calls proto-affect. Like, one of the reasons they withdraw is they're just totally overwhelmed.
So intensity of affect, not being able to modulate your affect, is part of... The problem of being at the borderline level. And you rely on primitive defenses.
Let me see if I can name those without looking at my notes. Those are splitting. That's where you see all good and all bad. Denial, withdrawal, primitive forms of projection, like projective identification, where I project something on you, and I do it in a way that kind of makes it true.
What's an example? If a patient comes in to me and... and says, I'm finding myself worried that you're critical of me.
And I say to her, I wonder if because you had a critical mother, you're kind of expecting criticism and you may feel that I might be like your mother. If she's just projecting, she can see that she's projecting that on me and she'll get interested in, do I do this with other people? But another patient comes in and says, I'm worried that you're critical of me and I... Do my maybe this is about your mother thing and she says yeah it's my bad luck to get a therapist exactly like my mother you bitch. That's projective identification because when I'm on the receiving end of this I'm going to feel very critical.
You know I may not have started out critical but it's as if they project it and they're still identified with it so you're still in it with them so that's a more primitive process than being able to stand back and look at what you may have. projected. Omnipotent control, I can make anything happen, you know, is that's, you see that in psychopathic people.
Primitive forms of idealization and devaluation, you know, we all idealize and devalue, but there's a difference between I admire you because I like certain qualities you have, and you hung the moon, and if I'm exactly like you, then all my problems are solved, or, you know, you're irritating me in certain ways. Versus, you're one of the bad people. I hate people like you.
You should be destroyed. That's primitive devaluation, where you move right to blame and destruction. Because there are a lot of patients that are stuck in what Melanie Klein called the paranoid schizoid position. When something goes wrong, they want to see all good and all bad, and they want to blame. And of course, we all do that when we're under stress.
If your lover breaks up with you, the first thing you think of is not, well, I can understand why it was hard for her to stay with me because she comes from such and such a family. You just go right away to the bitch. You hate her.
She should die. After 9-11, we didn't hear people saying, we have to understand why people in the Middle East, so why there are all these young men that hated us so much that they're willing to die. What's happening in that culture? We heard about the axis of evil, and we're the good guys, and we've got to go fight them, and we heard nothing but blame.
And we all do that under stress, but some of our patients do that in every situation. And we have to help them learn how to understand, you know, the separate subjectivities of others, the fact that things aren't all good or all bad. And borderline as it arose among clinicians was, because...
An effort to talk about the dimensionality between so-called sanity and psychosis, that there was a group of people who were too troubled to be considered just neurotic, and they weren't troubled enough to be considered psychotic, so they're on the borderline between neurosis and psychosis. That's how the term arose. And then when DSM-III decided they had to include something about borderline in 1980, And they didn't want to talk about anything dimensional.
They took a type of borderline, and they, namely a more histrionic, self-dramatizing, affect-disregulated kind of borderline, and then, and they made that the definition. So we now have this hodgepodge of some people using the term in the original way, as a level of personality organization, and some people using it in the DSM way. So when I say it, I'm thinking of it in the dimensional way. Primitive forms of dissociation, like just becoming someone else, which you see in dissociative identity disorder.
Acting out. When young children are suffering emotional states that nobody helps them name and nobody helps them with, they either act out or they get sick. Both acting out to try to dramatize what's going on, because that's the only way you know how to express it, or getting sick because the body is expressing all this, are two primitive ways of dealing. At the borderline level, I've done an interesting thing in recent years of looking at all the different evidence-based approaches to borderline psychology, starting with Kernberg, but also looking at Peter Fonagy's work, Giovanni Liotti, Clara Mucci, Marsha Linehan, Jeffrey Young, Gregory and Raymond up in Syracuse.
Russell Mears in Australia. There are a lot of people who've worked on therapies for borderline psychology and what interests me is not who's right or who's better, it's what have they all found in common about dealing with this range of people. So here's my list of what they all have in common. They all first of all put their primary emphasis watching the relationship.
You can't take the relationship for granted the way you can with an erotic person who'll tell you if they suddenly feel like you did something insensitive. You have to keep monitoring it. Are you okay with what we're talking about?
Is this feeling all right to you? How's this pace for you? Are you feeling okay talking to me?
What are you finding yourself worried about? All of that here and now concern. with the alliance is important with that group. That would feel kind of infantilizing if you kept doing that with somebody in the neurotic range. They'd say, yeah, yeah, I'm fine.
Move on. Borderline patients, you expect that there are going to be ruptures, often very painful ruptures and often very early in the treatment, and that a lot of the work is going to be about repairing those ruptures. That's not just something that once in a while happens. It's the work. Right now, it seems like you can feel me only as a persecutory person.
Is it possible you can imagine that I had any other motive other than to hurt you? They know they're difficult. They know that they can have a strong impact on you. In fact, one of the implications for seeing somebody in the borderline range is not to be too neutral, because they know that they have strong.
impacts on you and they appreciate it if you acknowledge that. So if at the borderline level someone comes in and says, you know, I know we've been talking about how I shouldn't be cutting anymore but look and they start dripping blood on your carpet. You're mad at me aren't you? You know you sound like a stuffed shirt if you say well let's investigate your fantasy that I'm angry at you.
You know you have to say something like look it's my job to help you be less self-destructive. Right now you're being more self-destructive. That doesn't make me happy. What's it like for you to see the anger on my face?
That'll go a lot further than trying to treat them as if they're a neurotic level person that you can be more, you know, blank with. You want to open a space. Jessica Benjamin writes about doer versus done to formulations that we all get into, but I would say especially characterize this level.
Who's the doer? Who's the done to? And you want to open a space. A third space.
Is there another way of thinking about this that would make sense of it? They all, the second thing they all emphasize is you need to be explicit about the frame, your limits, your boundaries, your contracts. You may have to contract about self-destructive behavior, what is going to be the consequences if you attempt suicide, what are going to be the consequences if you cut yourself or do other self-damaging things.
They have to be really clear and you have to expect that the patient's going to test them. Again, at the neurotic range, if you laid out at the beginning things like, okay, we're going to meet at 10 o'clock on Tuesdays and Thursdays. If you feel bad between them, I don't want you to call me after 9 o'clock at night, and I don't take calls on weekends.
I do read texts, but I don't respond to them. You might have to go through all kinds of stuff like that with people in the borderline level. And then you have to...
And the frame isn't a magical, communally agreed upon set of rules. It's the rules that work for you in your setting that are, you know, the rules of your hospital or the rules of your private practice that allow you to do your job. So some people will let patients call them on the weekends and some people aren't comfortable with that.
And it's important as a therapist to model somebody with boundaries. So many people in the borderline range have had their Boundaries violated often by sexual abuse. They need the therapist to stick with the boundary and it's often very hard. Like one of the things that happens is the patient gets into their traumatic history and two minutes before the end of the session they're in fetal position, you know, crying, reliving some traumatic experience.
You still have to end the session on time. You can do that kindly. You can say, I'm so sorry that this came up at the very end of the session.
I am going to have to stop at the end, which is in two minutes. Please feel free to sit in the waiting room and get yourself composed, but I am going to have to stop. And then the next session, you listen for the patient coming in with all these themes of arbitrary authorities and people who don't care how you feel and people who... care more about their own scheduling. And by the 30 minutes into the session, you can say something like, I wonder if you had a really negative reaction to the fact that I ended the session on time last time.
And then they can tell you off and they can learn that it's okay to tell you off, that it's natural to be angry about limits. But you stick with the limits. The same way with a child who, you know, wants to stay out all night.
You say, I'm sorry, you got to You've got to be in by 11. Those are the rules. And then they'll come in at 11.02, and then you have to say, okay, no internet for a day or whatever is going to be the consequence that you've already set up. And I find that therapists have a very hard time with this.
We're often not trained to do this. Our training has a lot to do with making us more empathic. With borderline patients, for their safety, they need to know that we stick with our limits.
Very often what feels like a test of whether we can be flexible is really a test, are you going to rationalize changing the rules on me and all of a sudden start molesting me? So sometimes you know you're being tested, you're not sure what the test is. But usually with people in the borderline level.
the safest thing to do is keep your boundaries very clearly until you know your patient really, really well. The therapist has to be more emotionally expressive. Binary dilemmas can be expected to come up, like the patient puts you in a bind where you know if you do A it's wrong, and you know if you do B it's wrong.
You have to have a way of talking about that. And the different theorists of borderline psychology have their different ways of doing that. My way is usually to ask for supervision from the patient, you know, to say something like, look, as your therapist, because I want to remind them I'm trying to help them, as your therapist, I'm not sure what's helpful to you when you fall silent like this.
Part of me says I should be drawing you out, but then I'm the one with the agenda, and you're responding to it, and I may be drawing you in a different direction than you want to go in. So another part of me is saying, well, just wait until they feel Comfortable talking to you, but I'm afraid you'll feel that as abandonment, my not being interested. What do you want me to do when you become silent like this?
And sometimes they say, fuck you, you're the doctor, you figure it out. At least they've gotten the message that you're trying to help them and sometimes they have a solution. Why don't you ask me such and such a question? I think that would help me talk.
Or why don't you just wait? And then they'll test you to see if you can wait. I had one guy that I did that with and he spent three sessions saying nothing. Nothing. But we had made the deal that okay, I would wait until he felt able to talk.
And then the fourth session he flooded me. with images of the ways that he was acting out sexually with men that were not using condoms and, you know, putting himself in quite great danger. So again, the sort of framing the dilemma from your perspective, not telling the patient you're trying to put me in a dilemma, but saying I find myself Not sure which way to help you. Help me with this. Help me be a better therapist, basically. You need to be more emotionally expressive.
You need to expect intense counter-transferences. That never goes away. I mean, I had the fantasy when I started this business that I would get good at working with borderline patients, and then the fact that they were difficult wouldn't bother me. I would just, you know, oh, yes, they hate me.
But it never happens. If you're really there, you're going to feel very powerfully, not always negatively. I mean, we think sometimes that the problem is that it's negative, but I've had patients where I wanted to remother them, have them move in with me.
You know, it can be loving in a kind of consuming way, too, and that's not a great thing to act out. But you should be aware of what that means if that's what you're feeling. There's something being evoked in you. And the last thing I want to say about working with people in the borderline range is, with that group, you really need consultation and supervision.
You really need to talk to other people. All the people who write about borderline psychology talk about working in a team where they present cases to each other. Kernberg still presents his own patients to the people on his team. Marsha Linehan used to do the same thing for an hour and a half with her team. It's a difficult kind of psychology, so you need help.
At the borderline level, people are still in touch with consensual reality. At the psychotic level, they get very confused by it. They get confused by the boundary between self and other. I had a patient once who I started noticing that he would cut himself off and change the subject if he began to feel his own pain. And I called that to his attention.
At this time, relevant to your previous question, I was thinking this was a person in the neurotic range. And I said, I think I'm seeing this pattern where when you start to feel sad, you change the subject. And he said, oh, yeah, I know I do that.
And I said, well, what's going on in you when you do that? And I think I was expecting him to say, I'm not ready to go there yet. I don't want to start crying or, you know, I just want to move more slowly. But what he said was, well, I can see I'm hurting you. He saw sympathetic sadness on my face when he was starting to get sad, and he felt he was damaging me.
He couldn't imagine that I was a separate person able to feel compassionately for his suffering. He had to stop damaging me. That is a psychotic level confusion between... His mind and my mind, that's a very subtle version of it.
I mean, some patients come in and say, I know you're the devil because I can see the horns and the tail, and that's not too hard to figure out. But there are a lot of people who have never been diagnosable as schizophrenic or psychotically manic or depressive, but who are very confused about what's inside and what's outside. and who have peculiar beliefs that they're very invested in.
And those people are fragile. They also have primitive defenses, but the defenses aren't working for them in any way. And they are often in a state of terror.
So the main thing to understand about that group is that they're terrified. They probably need some medication for the terror, and it's probably annihilation anxiety, so it... You know, whiff of Haldol is probably better than some of the more addictive benzos, for example. But, and I'm not a psychiatrist so I'm talking a little bit beyond my competence, but that's my clinical experience.
And they also need a therapist who's constantly in touch with the fact that they may be making profound misinterpretations. I had a patient, for example, who was late. I'd worked with her for about five years and I thought she was pretty much in the low borderline range. But I said, it's not like you to be late to a session.
She said, oh yeah, it took me longer than usual to boil all my sheets and towels. And I said, you boil all your sheets and towels? And she suddenly looked at me with grave distrust and she said, of course I boil all my sheets and towels.
Haven't you ever heard about germs? What kind of mother doesn't boil all her sheets and towels every morning? And I could feel myself having gone from, you know, somebody she idealized who was sympathetic in her mind to somebody she was profoundly afraid of because maybe I was one of the contaminators. So that goes beyond borderline.
And, and... That requires the therapist always to have a focus on safety. With people at the psychotic level, it's somewhat different.
You have to put the emphasis on safety, and that may mean deviating from your usual style. It may mean that the patient needs the door to be open because they're afraid that they're going to be trapped in there with you. Or you may have to say, if you want to look around the... office to be sure that there are no bugging devices here. It's okay with me.
And you have to ask them periodically, are you feeling reasonably safe just trying to be open about your inner life? There's a tone that's important with people in the psychotic range that I've had a lot of trouble trying to capture. I know a number of people who are really good with this population, whether they are diagnosed schizophrenic or whether they're simply the crazier end of the personality spectrum.
And they have this wonderful capacity to be very egalitarian, very respectful, I'm just another human being trying to help, and at the same time being authoritative enough that the patient feels, okay, I'm working with somebody who knows what to do, because people in this range are so... terrified. They need to feel like they're with someone competent, but not with a competent person who talks down to them.
Respect has to be the primary attitude in this kind of... So the way that would look is Bertram Caron, who was great with this population, used to say to delusional patients, oh, that's brilliant, the theory that you came up with, to understand what happened to you. It's brilliant.
And the patient would say, so you agree with me? And Karen would say, well, actually, I don't. But that's only because, you know, I come from a different angle of vision of you than you did.
I'm older than you were at the time you came up with this brilliant idea. And I've had certain kinds of training. If you want to hear how I would make sense out of what you describe, I'd be glad to tell you.
Up to you. So you hear the combination of, I know what I'm doing. You know, this is a delusion from my perspective, but I'm so admiring. I'm learning something from you. I think the core of a respectful attitude is looking up at somebody, not necessarily in an admiring or idealizing way, but in a way of, you have something to teach me.
I can learn something from you. That's absolutely primary with this group because they have such histories of humiliation. If you're a little bit crazy, you're going to get humiliated by your peers growing up. And being humiliated is a terrible risk factor for developing psychotic psychology. If you're bullied, you are much more likely to have a psychotic diagnosis later on.
So you want to be an anti-humiliator when you're with these people. You have to normalize. More?
I mean, psychotic people often have fusions of perception and meaning or fusions of affect with behavior. They'll feel terrible about a thought. And you might have to say, you know, thoughts themselves aren't dangerous. You should be able to think any thought you have. sadistic, envious, greedy, whatever.
And then you make the choice whether you want to act on that in any way. But you crucify yourself for the thought. So you're teaching the person there's a difference between what's inside and what's outside.
There's a certain amount of educating that goes on with people in this level. And you can do it not by heavy-handed didactic stuff, but for example, I had a woman in this range who came to me really upset at herself, felt she was a horrible person, I think she used the phrase the spawn of Satan, because she had found herself having the fantasy of strangling her teenage daughter. So I was just about to go into this lecture about how, well, you know, most parents have fantasies of strangling their oppositional teenage kids now and then.
But I realized she was so sensitive to humiliation that if I took that stance, it would sound like I was coming from one up, talking down to her, what most parents feel. So I said, oh, tell me about it. When my daughters were that age, I wanted to strangle them three times a day.
That made us equal. That imparted the lesson without my being a heavy-handed educator. Two other things about working with people at the psychotic end of the spectrum.
It's really important for them to feel like you appreciate that they're trying to solve a problem with their symptoms, that there's a health-seeking aspect to whatever crazy thing they've come up with. And if you can appreciate that. Then they're willing to look at how this might also be maladaptive under the current circumstances.
And finally, you want to be conversational and active with that group, even more than with borderline patients. You might want to talk about yourself. You might want to chat about things that are important to the person. You don't worry about not being blank with this group. If you're blank, you just make them crazier.
So let's... Yeah, let's break. How do you do first session? The patient comes in, and my main concern in a first session is to make a relationship with the person. The empirical literature shows that the relationship is the most important element of therapeutic progress.
I had one patient who told me I was too warm. And I said, I'm sorry, I can't do a personality transplant, but what's the problem with my being warm? He said, I'm afraid I'll get all crying and regressed. You have to be yourself in this role.
You can't seem like you're following a script. Patients want to meet a real human being. So the first question I ask them is, you know, what brought you here or how can I help you?
Because I want to find out. What brought them here at this particular time? Then I ask them how they understand their suffering. I mean, what is their own theory of why they've gone off the deep end or however they describe what they're suffering?
You know, relational issues, family issues. Occasionally they don't know. You know, they just suddenly got depressed or they suddenly got anxious.
And then I'm thinking about, well, what might have unconsciously kicked them out? this off. Maybe it's the anniversary of the death of somebody.
Maybe their child got to the age that when they were sexually abused. Maybe it's an anniversary reaction of some kind. I usually ask patients if I remember, do you mind if I write it down?
It helps organize me. And I find most people appreciate that. They appreciate being listened to as opposed to the more contemporary rushed psychiatric interview where you try to just you know, check off what are the DSM signs that you might have.
So if I'm taking notes about things like what happened to them, I explain that this is just for my use. This doesn't go into the actual record. So, you know, if anybody doesn't want me to take notes, I won't.
But it helps me, you know, I'm always anxious at the beginning of meeting a new person. And it It gives me something to hold on to and something to do with my hands. So it's helpful for me to make me at ease.
And if I'm at ease, then I can help the patient be at ease. But what I'm trying to do in the first hour is make a relationship. I always ask in the first hour, is there anything you want to know about me?
Sometimes people want to know, what are your credentials? Or occasionally they ask a question that's too intimate, like, have you ever had a lesbian affair? At which point, you know, I'll say, you know, that just feels a little too intimate, but tell me why that's really important for you to know.
Two or three times in a 50-year career, I've had people ask me a question that I thought was too private to answer. Usually they ask me questions that I do answer, because the first meeting is about... Trying to make a relationship. So if they ask me, you know, are you a Republican?
Lately, some people have been asking me that because they really don't want to work with a Republican. Some people ask me if I have kids, and fortunately I do. If I didn't have kids, that would make me a little self-conscious, but I think I would have to answer it.
Actually, I don't, but it seems that's very important to you, and you're wondering whether you can trust. somebody who doesn't know what it's like to be a parent from personal experience. So I do answer what questions they ask me in the first interview.
I try to draw out the patient for at least half an hour, and then I try to make some intervention that tells the patient that I'm listening and trying to figure out a way to think about this problem. So I try some kind of intervention. boy, it sounds like you've had an awful lot of loss in your history and not too many opportunities to grieve. Is that right? And then I will say something like, so it looks like we'll be working on turning your depression into normal grief, which is a process you will get over, unlike depression, which can just sink you for a long, long time.
At the end, if they want to work with me, I say, what I'd like to do is next session. I'd like to take a really full history from you. You know, your childhood, what your parents were like, who were the main people in your life, what's your work history, your sexual history, your social history, anything you don't want to answer, just tell me, but I'm going to be really intrusive for this meeting because I need a context to understand what you've come to me about today.
Is that all right with you? And then I do that the second meeting. Some people, you know, they are pretty...
Terse and I can go to taking some history in the first meeting but usually the first meeting is more feeling out the problem itself. There are certain things I always ask about in that interview. One is substance use, another is any history of eating disorder.
These are things that people are ashamed about but in the beginning they're willing to tell a mental health professional. Later on when you matter a lot to them. They're even more ashamed, but they remember they told you about it.
Same thing with sexual history. I sometimes ask them about stories about them as a kid, any family anecdotes about what they were like as a kid. I try to get a feel for their temperament.
I always ask them their earliest memory, because like a good psychoanalyst, I do believe that that's very organizing to how they experience the world. At the high-functioning level, we're talking about the neurotic to healthy range, you can observe complexities in yourself and in other people. You ask a person at this level to describe the people in their family, and you get a description something like, well, my father, he was a military guy, and he sometimes ran the house like, you know, a barracks.
And I was a bit afraid of him because he was... really strict, but he went to every game I ever played. He cheered me on. He supported me through my college education.
He came to every graduation. I know he loved me. You get a real three-dimensional picture of a person there.
But some people will say, well, my father was a monster, or my father was just a useless alcoholic, or my father, he was, he is the best. You know, I want to be just like him. Well, what do you admire about him?
Everything. You know, and you don't get any nuance. Or sometimes you get, tell me about your father.
I don't know. He was just my dad, you know, where they can't bring this person to life. So one of the reasons for asking in the first or second interview to describe people in your life is to see whether the person thinks in all good, all bad categories or blanks out. or whether they can really bring a person to life. The same is true for their self-description.
Well, if I do hear that they have only, you know, stereotypes of themselves and other people, I try to drill down on that a little bit, as the CBT people say, and see if they can mentalize at all, meaning that's Peter Fonagy's word for really getting the separate subjectivity of other people or what philosophers call theory of mind. I say, do you have any sense why your mother behaved that way? What do you know about her history?
Identity integration is an important concept because you know that if the person has it, you can assume a pretty good relationship as long as you're trying to do your job well. You know you're going to screw up, but you know that they're going to be able to say, ouch, I didn't like what you said. I think that's wrong.
or they're capable of that anyway. There are a lot of implications of whether the person has identity integration or not. It's pretty similar to Kohut's idea about identity diffusion as being a problem. Yeah, it's the person feels easily fractured and confused about who they are. You say to a patient with identity diffusion, how are you experiencing me right now?
You look troubled. Well, I don't know, I'm just very confused. Are you calling me a bad person?
They can't stay with, you and I are working together on a part of myself that's been giving me trouble. It's like, uh-oh, you just fractured me into a million pieces, and I have to pick them up. It does orient me toward not necessarily spending a lot of time, at least early in treatment, talking about their difficult past.
Because very often they think about that past in terms of heroes and villains and persecutors and victims, and it's hard for the therapist to know exactly what happened. It's better to work in the here and now when you get this. It's like, how are you feeling toward me right now? When I said that you looked like I had really criticized you. Do you get that I was trying to give you something helpful even if I did it clumsily?
And you can work with that. But if you work with somebody who doesn't have that, they could, you know, decide you're a persecutor and walk out of treatment, or they could get really compliant because they don't want to get on your bad side. And a lot of therapists are not trained to feel the difference between a patient who's being compliant and a patient who's really working with them as a collaborator in this process. When we work with a borderline patient, we make them a much more competent, adaptable...
Self-soothing person with a very intense psychology that's never going to be easy for them. At the psychotic level, you know, if it were just a developmental thing, you'd think that they would start looking borderline when they're starting, because that's the next step up, but that isn't what happens. What happens is they become a very well-compensated person who is dealing with a lot of, you know, annihilation anxiety, but doesn't have to be. delusional anymore to do so. So in terms of the levels, you want to help people become a better version of somebody at that level.
In terms of the types, there's an old psychoanalytic chestnut, you can change the economics but not the dynamics, meaning you can help an obsessive-compulsive person find much better ways to deal with anger than. Let's say rituals or various kinds of intrusive thinking. But you're not going to turn that person into a hysterical person or a depressive person.
They're still going to be obsessionally organized. They're just going to be much more flexible, have much more range, be able to use a much wider group of defenses, not feel quite so rigid. I think if you approach a patient with the idea, oh, we can get this completely eradicated, whatever it is, they wouldn't believe you. It's realistic.
But it may feel like it doesn't match with the therapist's fantasies of total transformation of somebody else. But for example, with a traumatized person, you're never going to be able to make them a person who wasn't traumatized. But you can help them become not so much self-defined as a trauma survivor, as a person who happens to have had trauma in their history and who's coping with the consequences of that very well. I think we all wish we could turn them magically into somebody who'd never had a trauma, but that's not going to happen, and they know that. I think I would recommend that they read all the stuff and then forget it.
You don't have to have all this in your head in order to be a good therapist. Basically, you have to care about other people, be humble, be interested in them, want to help them, set a tone where they can correct you when you stumble. The process is going to move forward.
And if it doesn't, then you get a consult with somebody who can help you figure out whether you... I have made a misdiagnosis and missed something or whether you're a bad fit with this patient or whether it's just taking a long time. You're very welcome this was fun. It's fun to just mouth off about things that are important to me for a long time.