December 3, 2024 • 39 mins
In this episode of the Personality Couch Podcast, we dive into the complexities of Borderline Personality Disorder (BPD) treatment, in particular, the healing power of the invisible dynamics in therapy. We discuss the importance of motivation and insight in recovery for BPD, and the significance of the therapeutic relationship. The conversation emphasizes that while BPD is treatable, the journey is often non-linear and requires active participation from the patient. We also highlight the necessity of setting boundaries within therapy to create a safe and effective environment for healing. In this conversation, we discuss the importance of evaluating effort in therapy, the significance of attachment, and the challenges posed by boundary violations. Our conversation also explores the concepts of transference and counter-transference, the process of repairing ruptures in the therapeutic relationship, and the methods of facilitating insight and connections in therapy. Overall, this discussion emphasizes the individualized nature of treatment and the invisible dynamics that play a crucial role in the therapeutic process.
Chapters
00:00 Understanding Treatability and Recovery in Borderline Personality Disorder (BPD) 05:50 The Role of Motivation in Treatment 11:28 Which Treatment is Best for BPD? 14:08 Our Approach to BPD Therapy: Invisible Concepts 14:58 Boundaries in Therapy 21:15 The Therapy Relationship 22:51 Bad Therapy 26:51 Transference and Counter-Transference 33:35 Facilitating Insight and Connections 36:35 Summary and Conclusion
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Welcome to the Personality Couch Podcast where we discuss all things personality andclinical practice.
I'm your host, Doc Bok, and I'm here with my co-host, Doc Fish.
We are both licensed clinical psychologists in private practice, and today we will becontinuing our borderline personality disorder series.
(00:24):
So we have talked a lot about the symptoms of borderline personality disorder.
or BPD, what it looks like and the deep pain that these individuals experience.
But it's also important to talk about what professional help looks like for thiscondition.
So let's dive in.
We have learned so far that personality disorders are lifelong and pervasive.
(00:50):
So where does that leave treatment for borderline personality disorder?
Is it treatable?
Is it always treatable?
What is your take, Doc Fish?
The answer is going to be complex.
It's treatable, but like most disorders, illnesses, or even injuries, sometimes there'snot a cure.
So for example, if you break your leg, it heals, but the pain might flare up sometimeswhen it rains or if you start running.
(01:18):
Or a different example, for type 2 diabetes, severity might change.
If your sugar levels fluctuate, if variables line up, you can go back to like saferlevels.
just like borderline personality disorder.
You can go back to safer levels.
It's going to fluctuate.
Sure.
That makes sense.
Yeah.
And if I'm not mistaken, as we age, symptoms often decline, at least in regard toimpulsivity with borderline.
(01:45):
Is that correct?
Yeah.
So symptoms can remit.
Impulsivity is going to be the quickest to do so.
Any mood symptoms are going to be slower to go away.
Sure.
Sure.
Now in contrast, recovery is harder.
So symptoms can fluctuate, go up and down.
Recovery is harder because everything fluctuates and is unstable.
(02:08):
Recovery can also be hindered by external things like that are reinforcing.
So if you're reinforced by remaining sick, if it keeps an attachment because you're sick,that's reinforcing.
Or if you hold your diagnosis as an identity,
you get rid of that diagnosis, like that's painful.
(02:30):
So it's reinforcing to keep it.
So that's also going to be something that might hinder recovery.
Sure.
And sometimes these are like unconscious or subconscious things that are keeping us sickor keeping us from getting better.
It's not always a conscious, like secondary gain, but sometimes these reinforcers in ourlife, especially with borderline attachment,
(02:54):
or relationships can be a big part of those reinforcers where I'm afraid to get betterbecause of potentially losing a relationship or it disrupting a relationship.
makes sense.
This is a tricky nonlinear approach to treatment.
Like it's not a one size fits all.
it rarely is.
(03:16):
Yeah.
Okay.
So Doc Bok what are other factors to consider in treatability?
Yeah, well, there's a couple things that I think of.
that's the first one is like wanting to get better.
So similar to what you just said, like if there's other reinforcing factors, and sometimesit's subconscious, sometimes it's not.
like, does the patient actually want to get better?
(03:38):
Or are they just here to check a box?
They're here because it's what they're supposed to do.
They're here because a loved one or friend kind of pushed them into treatment.
We can't force people.
to get better, they have to want to.
Like the old saying, you can lead a horse to water, but you can't make a drink.
The same type of thing with treatment.
(03:59):
Like someone has to want to take that drink.
They want, they need to want to feel better to get better.
But one of the major hindering factors, I think of health and wholeness and just wellnessis insight.
When we don't want to go to those deep places,
(04:19):
those uncomfortable places of self-awareness and understanding maybe our motivations orwhat's behind the scenes, what's going on under the surface.
We're not willing to be self-aware of all those layers.
Then that's going to be a major hurdle to treatment because we can't address a problem ifwe don't know that the problem exists.
(04:45):
don't want to face that the problem exists.
Exactly.
And sometimes that problem is deep inside ourselves.
Yeah.
That makes me think of APA actually has a term in their dictionary called the ahaexperience or the aha moment.
And so that made me think of like insight.
Insight is when there's like reflection and you dig deep enough to have that light bulbmoment of like, I get it.
(05:10):
I'm facing this.
This exists.
And so what you're saying is like, if we are avoiding those moments, that can hindertreatment.
Sure.
And it's not uncommon because it's hard to look inward.
It's hard to look at ourselves and look at what we're bringing to the table, how we'recontributing to the distress that we're in.
(05:35):
Now that's not to say that it's all our fault, but
we have the power to make changes inside of ourselves.
So we have to be willing to have those aha moments and to look at the uncomfy things.
Right.
And you also touched on like not being motivated for treatment.
(05:55):
sure.
Sure.
So like the lack of motivation, like I said before, you can't force someone to go totreatment.
Like you can't force them to get better.
Like maybe you can get them in the door, but
the actual treatment of a condition the person has to want to get better.
And the thing with BPD is that they're in such great distress and such great pain, they'reoften willing to step foot in the door.
(06:22):
So that's the great first step.
That's step number one.
Awesome.
We're there, but that can't be the only step.
And I like to think of this in a similar way to like, you know, going to the gym or like,let's say that you have
like fitness or weight loss goals, just walking into the gym isn't going to meet thosegoals.
(06:46):
Unfortunately, there's no magic door that you can walk through.
There's no magic therapy door.
We don't come with magic wands.
Like you have to put in the work.
So just like when you are going to the gym for whatever, for whatever reason, like youhave to make lifestyle changes outside of just showing up at the gym, showing up.
(07:07):
is the first part, it's important, but it's not the only part.
So when we have people who are just checking that box, but not willing to put in theeffort for whatever reason, there can be all kinds of different reasons for that, all
kinds of internal blocks or things that maybe we're not willing to face yet.
Or we're just trying to dip our toe in the water and just not go to those like hidden,maybe ugly places.
(07:34):
we can't, we can't force
motivation.
And if someone is not motivated, and they're just coming in to check a box, let off somesteam because they're in pain, and they just want to, you know, hey, had a rough week, I
want to vent.
Yeah, that's probably not going to have as positive of outcomes as someone who's willingto put in the work and make the changes.
(07:58):
Yeah, that makes a lot of sense.
Yeah.
What about motivated people?
Like what
What does that look like in treatment and your experience?
Yeah.
So when there's high motivation, think, well, first we also have to consider the severity.
So even if you're motivated, if you are oceans deep in a disorder level versus only havinga toe in, like you're just over the line, you can make a ton of progress and still stay in
(08:27):
that disorder level.
Yeah.
The disorder level means there's going to be impairment in life across
settings, there's going to be instability across the board.
So you can have different outcomes, putting in the same amount of effort as someone.
So I don't want motivated people to ever think like that they're failing just becausethey're still having that impairment.
(08:51):
Like you can you can make a great movement and great progress and still have more to go.
Sure, sure.
We all we all have personality.
So
we're gonna likely have the same structure.
It's just we don't have to live in that disorder space.
External factors like stress, trauma, support, or lack thereof, that can influence whereyou're at as far as like the health continuum.
(09:20):
But I think just in general for that motivated person who is in touch with their pain, whowants to get better, who wants to put in the work, they're gonna see improvement in their
symptoms.
Sure.
And going back to what you said earlier about kind of what I like to think of like arecovery mindset.
So we all have personality structures, right?
(09:42):
That structure isn't really going to change too much over the course of our life.
Like maybe, maybe if there's like a major traumatic event or a major enlightening momentor something, but generally speaking, we're going to be at least the same structure.
It may not be at disorder level.
So just like someone who is recovering from alcoholism or recovering from some addiction,there's always a need to watch, to be careful, to be on guard because that's the
(10:17):
personality, that's the structure to go back to that addiction.
living and recovery.
And I think in a similar way with any of the personality disorders, but especially BPD,because that's what we're talking about today, is
knowing that you're probably always going to have those tendencies towards the impulsivitytowards maybe the self harm thoughts or you know, the push pool and relationships like
(10:42):
that, that internal pool is going to be there for those things because the structure isthere.
So that's not just going to go away, but there's coping skills to help quell thosesymptoms and decrease those symptoms and make them more manageable so that life doesn't
feel so rocky and so
unstable itself.
Yeah, living in kind of living in this recovery mode, but using those coping skills, Ithink is really, really important.
(11:09):
Yeah, I love that example.
Because it's every personality is going to have areas of strengths and their areas ofweakness.
And you're gonna have to know and be aware and watch out for those weakness areas.
Yeah, for sure.
So borderline personality disorder is treatable.
We got that.
Yeah, but
(11:29):
How do you know which treatment to search for?
Do all of them work?
Yeah, tell me about that.
Yeah, so that can be confusing, right?
Because in psychotherapy and in any sort of counseling, we have the alphabet soup ofacronyms of different types of treatment.
And it's like, well, where do I go?
Where do I even start to look for treatment?
(11:50):
So not all treatment is the same.
But I will say, alphabet soup aside, the therapeutic relationship
is the number one predictor of therapeutic success.
So what that means is that relationship with your therapist, if it's positive, if you feellike there's an appropriate professional connection there, you feel like your therapist is
(12:13):
in your corner.
It's just a good fit all the way around.
That above the alphabet soup is going to be a better predictor of therapeutic outcomes.
So that's number one, before we even get to the different types.
Number one.
So the gold standard for treatment is dialectical behavior therapy or DBT, which wascreated by Marsha Linehan, who also struggled with borderline personality disorder herself
(12:41):
and came up with a very specific protocol for borderline and for the treatment ofborderline.
And that is what we call kind of the gold standard of treatment for BPD.
Now there are others, there's other types of treatment too that can be helpful and we'renot going to list off all of those today, but that's kind of the one that most people
(13:07):
think about with regard to treatment.
Right.
And then I think there's also different types of DBT.
So there's like strict DBT.
which has like individual therapy, group therapy every week and like a crisis call set up.
They're usually like six months to a year programs.
(13:27):
And then there's like DBT informed treatment.
And that's like pulling from the DBT.
I think I would probably fall more in the camp of like a dabbler, like not the puristwith, you know, the six month, 12 month program.
That certainly can be helpful.
(13:47):
but kind of pulling from different tool belts, different alphabet soups that are in mytoolbox typically when I treat.
kind of moving away from that.
So what we know is that borderline is the most likely to seek treatment.
Right.
We've talked about that pretty extensively.
(14:09):
And being that we are providers, there is a pretty good chance that we have seen BPD inour practice.
So Duckfish, I'm curious what it looks like for you to treat borderline personalitydisorder and what do you focus on in sessions?
Goodness.
Okay.
See, the trouble here is that BPD is always changing.
(14:32):
It's ever shifting.
Every individual is different.
Yeah.
Treatment is individualized because there's no two borderline persons that are alike.
So it's more helpful for us to talk about broad themes and specifically invisible conceptsin therapy.
Ooh, invisible concepts.
(14:52):
Yeah, they're tricky, but they play a huge role in opportunities for growth.
Yes.
Let's start with boundaries.
Boundaries can be spoken or visible, but most of the time,
They're unspoken and invisible, but regardless, they span the entire therapeutic process.
Boundaries are extra important for personality disorders in general, but I thinkespecially important for borderline personality disorder.
(15:22):
If it wasn't invisible, I would liken boundaries to being like the frame of the therapypuzzle.
Because when you put a puzzle together, I think most people put the edges first.
you use that to contain all the other pieces because without the frame, it's hard to findform.
And you might not even notice like missing pieces or pieces on the floor that aren'tcontained.
(15:48):
Yeah, but what comes to mind with boundaries for you?
Yeah, I love what you said about the puzzle.
I'm a big puzzler myself.
And that's so true.
Like putting in the edge pieces helps give you context.
Like how big is the puzzle going to be?
Where is this really colorful patch going to go?
Like same is true for treatment as well.
(16:09):
It gives you the framework, the boundaries.
And I think within that, one of the things that I always talk about is like yourpaperwork, procedural policy stuff at the very beginning.
So paperwork, payment, communication, procedures, all of that.
There's really, there's no special cases.
Like everyone has to follow the same protocol to enter treatment.
(16:33):
And that means all paperwork must be completed before scheduling at our practice.
There's no exceptions to that.
No exceptions to that rule.
Payment must be made the day of session.
Patients aren't allowed to just accrue a balance, accrue a debt at our practice.
All communication goes through the front desk, and communication is for scheduling andpayment and insurance only.
(16:58):
Clinical information should not be shared over email.
or phone that that needs to be reserved for sessions.
Yeah, setting this really sets up therapy as a professional service and not just a chat ora chat with a friend or a stranger, however you want to think of it.
(17:20):
It's really important to set these boundaries and the framework from the outset oftreatment, just like that puzzle, right?
Like this is the framework in which treatment.
the context in which treatment is provided.
And it's professional.
It's a professional service.
Yeah.
So that's kind of like the observable pieces.
(17:43):
Are there any other pieces that you would throw in the boundary category?
Sure.
There's a few more.
These are probably still in kind of the observable camp.
And it still has to do with policies and procedures.
As a practice owner, I'm always thinking about that because it's so helpful for
all conditions, but especially personality disorders.
(18:05):
with borderline, they really need, really need those firm boundaries.
But with attendance, I think you actually have a phrase with attendance about showing up.
What is it that you tell patients?
Always tell patients the days that you don't want to come to therapy are the days whereyou probably need to.
Even if it's just to sit in silence, something's happening.
(18:29):
there's some kind of resistance.
So it's, meaningful to come.
And there's consequences when you don't come that with the policies, if you're not goingto show up, there's a fee.
Like we've set aside our professional time for this hour for you.
And if you're not going to show up, then there's most likely going to be a charge.
(18:50):
And if there's a pattern of not showing up, then I mean, potentially that's grounds fortermination.
If you know,
you're not showing up to treatment.
And certainly if you're accruing a balance, we don't allow patients to accrue a debt.
those things can be really, really important and just establishing the professionalrelationship.
(19:11):
As I said before, a couple other things that I think of like in, in the actual sessionsare going to be, we can talk about anything, but you can't necessarily act on it.
Yes.
Right.
And we can talk about how angry you are, but
I won't tolerate disrespect towards me.
(19:31):
We can talk about how you're feeling.
We can talk about that you feel angry towards me, but if you're up in my face beinghostile, that's unacceptable.
If you're destroying things in my office, that's not acceptable.
And I think you have a phrase for that too, Doc Fish.
Yeah.
Yeah, it's similar.
(19:51):
We can talk about anything.
Can be angry with me.
You can yell at me.
Can't knock over the lamp.
Right.
So you can't be destructive in the anger and behave on it.
But we can let's talk about anger.
You want to yell, let's talk about it.
Is it helpful?
Because I'm not reacting to your yelling.
Sure.
(20:11):
It's probably not helpful.
I think the last thing in treatment that's maybe more overt is like, I'm not doing thework for you.
And what I mean by that is I'm not going to work harder.
than the patient is working.
And that can be hard because certain personality structures can really pull for us to domore than we're supposed to do.
(20:33):
And as I'm talking about this, maybe this is more of an unspoken dynamic that's not asovert.
if we're spending more time outside of sessions, like preparing for the session, thinkingabout what we're going to talk about in session, if we're spending more time than the
patient on those things, hmm.
(20:54):
it's time to reevaluate, like who's actually putting in the effort.
We can't compensate if there's a lack of motivation, just like we talked about at thebeginning.
Like we can't fill up or make up for that lack of motivation to get better.
You also mentioned earlier that the therapeutic relationship is the most important factor.
(21:15):
Absolutely.
think attachment is a huge one.
So attachment is a relational connection or avoidance between client and therapist.
Now in BPD, there's often a quick attachment, which kind of stems from that pain, thatneed for help or a helper, and therefore that need for relationship.
(21:36):
And also with BPD, there tends to be like a push-pull of idolization or devaluation.
Idealization is when the therapist is like the hero, the rescuer, best thing ever.
Providers have to be careful because that feels good to hear.
We can accept it, but not reinforce it.
(21:58):
Devaluation is kind of the opposite.
It's where the therapist is viewed as the villain, persecutor, worst thing ever.
Been there.
Yep.
It's less, less common still possible.
And it can even be fleeting.
Like they can have moments where it
But it's the same thing, accept it, but don't reinforce it.
That can be challenging.
(22:19):
I can see how, I mean, we're using a kind of villain, persecutor, rescuer, like, I'mseeing how the drama triangle might come into play with some of these personality
disorders and with attachment in particular.
Yeah.
And I'm also just thinking of like the interaction between boundaries.
(22:41):
and attachment.
like you're saying, like, you're not going to react, don't reinforce it.
That's a boundary.
We're talking about attachment, but it's a boundary.
I'm not going to reinforce that.
And I'm just thinking about like, like bad therapy is often boundary violations.
It's often violations with the attachment relationship.
(23:05):
And I'm,
curious.
We're taking a little side tangent, but I'm curious if you have seen that like kind ofviolations of the attachment or boundaries in the therapeutic relationship.
Yes, unfortunately, my absolute biggest pet peeve is when the therapist has too much selfdisclosure.
You do not want to know who your therapist is dating, or for breakfast, their owndiagnosis.
(23:30):
Therapy is the client space.
It's not the therapist space.
Client space, client space.
gosh.
So that's, that's my biggest pet peeve.
Super passionate about that.
But there's other things too.
I've heard of some providers socializing with their clients outside of therapy becauseafter so much time, their friends not okay.
(23:54):
It's just not okay.
What about you?
Have you seen, heard anything?
gosh.
I, I have not been fully insulated from that either.
But yeah, I mean, I had a situation where I was seeking therapy and it was a newappointment and the therapist wanted to exchange business cards with me once I shared what
(24:14):
my profession was.
And so like we can't, we can't hold that this is like a therapeutic space.
Like now, now this is a marketing meeting.
You just switch that.
yeah.
So that's just a personal example.
And then I think,
As a testing psychologist, I work with other providers in a different capacity.
(24:37):
usually if the therapist is the one that's kind of encouraging the patient to get tested,then I'm going to be talking with a therapist, trying to understand what's going on in
treatment, having a very collaborative relationship with therapists in our area.
And out of that, I've definitely seen a lot of dynamics that are concerning.
(25:00):
And I hate to say a lot of dynamics because most therapists are good enough.
However, we can get tangled up, especially if there's personality pathology, being thatthat's what we often treat at our practice.
We're going to probably see more of that.
And sometimes therapists can be blindsided or get tangled up in it.
That can be like getting too involved in the patient's story and wanting, maybe wantingthe testing psychologist to rescue.
(25:28):
I need this diagnosis to fix, to rescue something or someone.
Or then on a different plane is the clients maybe wanting the therapist to meet all theirneeds and kind of getting wrapped up in that.
Like, tell me what to do.
Fill me up.
I need to know constantly.
And then sometimes that can get like passed through to the testing psychologist too.
(25:51):
Like, well, you need to do this.
It's like, did you get that from the patient?
Are we holding those boundaries?
Being possessive or controlling, like the therapist being possessive or controlling whenit's time to end therapy, or perhaps they're not, they're outside of their competency and
it's time to end but they can't break the attachment because of their issues.
(26:12):
Yikes.
Yes, that's not a good one.
Yeah.
And probably the most severe kind of in the camp of attachment and boundary breaks isgoing to be like physical contact or intimate.
relationships with patients outside of session or it just, just no, just no, don't dothat.
Don't do that.
(26:32):
This is grounds to find a new therapist.
If that's happening, report, find a new therapist.
in the boundaries, I'm going to contain us and take us back to invisible concepts thathappen in therapy.
Yes.
So we were talking about attachment.
(26:52):
Part of the attachment relationship in therapy is what's called transference and then alsocounter-transference.
Yeah.
So let me explain.
Transference is when, because the client doesn't have a full picture of who you are, theyunconsciously perceive you to be in a role that they're already familiar with, that they
(27:13):
already have a mental map for, for example, like their mother.
So then counter-transference is on the therapist's end.
It's the therapist's own reaction to that transference, which often is gonna mirrorwhatever that proposed figure is.
like whatever the mom felt, that might be what the therapist feels as well.
(27:35):
So like it could be frustration or rescuing.
So if you had a critical mother as a client, you might come in, you don't know who yourtherapist is.
Like you have to learn all those dynamics.
their favorite color is, what they eat for breakfast, because you shouldn't.
Okay, so if you had a critical mother, you're going to go into therapy and you're, youmight think like the therapist is going to judge you or therapist is going to be critical.
(28:01):
And you might act defensively, or in a passive over compliant manner.
And whatever that reaction is, that's going to trigger the therapist's own reaction thatcountertransference.
Wow.
to most likely react like mom did.
Wow.
Does that make sense?
(28:21):
It does.
There's so much more that goes on in therapy versus just active listening.
We each have these kind of like maps from childhood, and they guide us in relationships.
They guide us in attachments.
So there is so much more that goes on in the therapy relationship versus just activelistening.
(28:45):
There's so many dynamics, not just that the patient is bringing in, but that the therapistis bringing in.
And that's why we've got to know ourselves and contain ourselves and be boundary.
It's so that we can just work on the client stuff, the clients maps from childhood, notour own.
Let's not bring our own stuff into that because it just gets way too messy.
(29:09):
If we're just now just triggering each other and we're not really
engaging in treatment.
But those unspoken dynamics and those kind of like attachment maps, that informs a lot oftreatment.
I think one of the most important things in my opinion for those maps, like you'reprobably going to therapy because those maps aren't helpful.
(29:31):
Exactly.
The maps you learned are not, are no longer working.
And so we have to find different paths and corrective experiences is something that I findsuper valuable, invisible though too.
It's hard to explain because it has to be really individualized.
for example, if you have somebody who turns anger towards themselves, so instead of beingangry with someone else, they're like, I'm bad.
(29:58):
I'm not good enough.
I'm filling the blank.
Whenever they are able to express anger for someone else or even admit that they're angryfor someone else, that might need to be celebrated.
Sure.
Because it's different than what was on the map.
But in contrast, if you have someone who is outwardly destructive in anger, you're notgoing to want to celebrate that for them.
(30:21):
You're going to want to celebrate taking accountability or self-containment for theiranger.
Another good example of this is if someone has been parentified, so in childhood beingforced to take the role of a supportive adult within the family, I see this all the time.
I can set boundaries so that I'm the parent.
(30:43):
So for example, I'll be the one who takes like the authoritative roles of paying attentionto the time, making sure that we're scheduled, making sure that we fit in the frame.
Oppositely, if I have a client who is more childlike in their regression, not where theyneed to be developmentally, I can then set boundaries to make sure they pick up their own
(31:08):
responsibilities.
It's like not.
calling if they're late or missing sessions, not playing into any tantrums.
So it really, really depends on who that person is.
But a corrective experience is essentially going against whatever's not helpful from thatchildhood map.
And that's where taking the time to get to know the client's history as well can be reallyhelpful.
(31:35):
time.
Yeah.
And it's not necessarily even verbalized.
It can be later, but in the moment, oftentimes it's just a dynamic.
It's invisible.
Right.
Right.
And again, these invisible dynamics is where we have to be on the lookout for the dramatriangles too, especially with personality stuff.
(31:56):
But if we're disrupting those reinforcers, like you're saying, like we're doing adifferent, we're going about the map in a different way.
We're taking a different route.
Like that's disrupting those reinforcers and
potentially not kind of going along with the drama triangle.
If that's a part of the mapping dynamic.
(32:17):
I think oftentimes it can be.
Let's see.
So along those lines, and we also have repairing ruptures.
any conflict or potential for conflict in the therapeutic relationship can lead tofocusing on the attachment between myself and a client.
So for me specifically, I want to validate without judgment.
(32:39):
because I want client to be upset.
But I need to do that in a way where they also understand I'm not gonna abandon them.
Sure.
So sometimes this can look funny.
I get excited on my part and I celebrate it.
So client might come in and they're like, I'm so mad at you.
And I'm like, good, yes, awesome.
(33:00):
Okay, let's talk about it.
Let's get into it.
I'm so glad you brought it up.
By doing that and going through that process, you can repair the relationship, continuethe relationship, take accountability.
I need to take accountability for my part, only my part though, and resolve the conflictinterpersonally.
Wow.
(33:21):
Yes.
So before I go on big bunny trails, because I get so passionate about this stuff,invisible dynamic, what about you?
Sure.
It's another one.
My goodness.
So.
One of the ones that I like to use probably more than anything else is facilitatinginsight and making connection.
(33:42):
So this ideally is client led, especially after, after some time.
And I think Doc Fish, you had a great example that I've heard you use about like teachinga kiddo to like put away their toys.
Kiddos need to learn, right?
And adults, we also need to learn.
So
If we are teaching a kiddo colors, for example, right?
(34:05):
Like put the orange ball in the orange bin.
Let's put the blue ball in the blue bin.
It's not gonna be helpful to do it for them.
Right.
It's just not like they're not gonna learn.
You can model for them at first, because they have to learn like what the process to dothat is.
But client led connections or kiddo led
(34:28):
activity, right?
That's so much more powerful and helpful.
Yeah, yeah.
And that's, that's the types of connections that I enjoy making.
And of course, we have to model sometimes first, like making those connections, like, yousaid this back here, and then you said this over here, wonder if that means this, like
modeling, so that eventually, the patient can start coming up with thoseconceptualizations and those connections as well.
(34:56):
But then there's another part of that that's a little different that I use a lot, and it'scalled immediacy, which is basically calling out the dynamic in the room.
So we're naming the elephant.
So let's say, for example, Doc Fish, you come into my office, we're talking aboutsomething from childhood that's distressing or something from, it doesn't have to be
(35:20):
childhood, could be yesterday, and you start picking at my couch cushions.
while you're talking about it.
I might use immediacy by saying, Doc Fish, I noticed that when you started talking aboutthis thing that happened yesterday, you started picking apart my couch cushions.
What's going on there?
And so by naming it, like there's there's no way we can be 100 % self aware all the time,right?
(35:46):
But if we are helping facilitate that self awareness, like, gosh, I didn't even realize Iwas picking apart your couch cushions, like
We're helping facilitate those insights by calling out the third dimension or the thirddynamic in the room that's happening.
And that can look like a bunch of different things.
Yeah.
I wonder too.
I think it could maybe also be directed towards the connection between client andtherapist of like, you seem a bit angry with me right now.
(36:15):
Okay.
So that makes sense.
So making connections, facilitating insight includes self-reflection, awareness, looking.
deep into yourself and then being able to verbalize it in treatment.
Yeah.
Yeah.
Exactly.
a lot of it can be like how childhood affects your current functioning.
(36:36):
So all of this is part of treatment.
This kind of behind the scenes, what's going on, what are we actually doing when we go towork, when we're treating borderline personality disorder.
These unspoken dynamics are what you and I
Doc Fish, what we like to focus on as personality disorder specialists, because that's thestuff that's tricky, that like third dimension, bird's eye view stuff, the stuff that's
(37:01):
unconscious sometimes, or attachment based, it's not overt, it's not just what's happeningin the room, the dialogue that's being exchanged, it's the under layers of that.
And that in conjunction with the therapeutic relationship is highly impactful fortreatment.
And those are the approaches that you and I typically take when we're treating BPD.
(37:25):
Yeah.
And I love this.
I'm so excited about talking about this because it's literally the unspoken stuff.
Exactly.
one's talking about it.
Exactly.
So we learned a lot today and we learned specifically that BPD is treatable, but you haveto put in the work and want to grow.
(37:46):
So
Treatment for BPD is extremely individualized and contains, as we've said, a lot ofinvisible dynamics.
And sometimes this can feel frustrating too for clients because they're not like checkingoff the boxes like in some manualized treatments, but they're often finding the healing
over time without even realizing it.
(38:08):
And that's because we target that attachment piece in treatment.
The stability then.
that therapy brings is another big part of the healing process.
Because especially with BPD, these individuals, their lives are often so marked withinstability that the therapeutic relationship and that therapy hour is like the one thing
(38:33):
that's stable and that is inherently healing.
But we also have to be contained and boundaried in order to keep that stable place forpatients.
All right.
so we could talk forever about treatment of BPD and our own approaches, but it is time towrap up for now.
(38:53):
So thank you for joining us today on this episode of The Personality Couch.
Make sure to check out our blogs that coincide with each episode for more in-depthinformation at www.personalitycouch.com.
And as always, don't forget to give us a thumbs up or rate and review us on your favoritepodcast app.
(39:15):
Be well, be kind, and we'll see you next time on the Personality Couch.
Welcome to the Personality Couch Podcast where we discuss all things personality andclinical practice.
I'm your host, Doc Bok, and I'm here with my co-host, Doc Fish.
We are both licensed clinical psychologists in private practice, and today we will becontinuing our borderline personality disorder series.
(00:24):
So we have talked a lot about the symptoms of borderline personality disorder.
or BPD, what it looks like and the deep pain that these individuals experience.
But it's also important to talk about what professional help looks like for thiscondition.
So let's dive in.
We have learned so far that personality disorders are lifelong and pervasive.
(00:50):
So where does that leave treatment for borderline personality disorder?
Is it treatable?
Is it always treatable?
What is your take, Doc Fish?
The answer is going to be complex.
It's treatable, but like most disorders, illnesses, or even injuries, sometimes there'snot a cure.
So for example, if you break your leg, it heals, but the pain might flare up sometimeswhen it rains or if you start running.
(01:18):
Or a different example, for type 2 diabetes, severity might change.
If your sugar levels fluctuate, if variables line up, you can go back to like saferlevels.
just like borderline personality disorder.
You can go back to safer levels.
It's going to fluctuate.
Sure.
That makes sense.
Yeah.
And if I'm not mistaken, as we age, symptoms often decline, at least in regard toimpulsivity with borderline.
(01:45):
Is that correct?
Yeah.
So symptoms can remit.
Impulsivity is going to be the quickest to do so.
Any mood symptoms are going to be slower to go away.
Sure.
Sure.
Now in contrast, recovery is harder.
So symptoms can fluctuate, go up and down.
Recovery is harder because everything fluctuates and is unstable.
(02:08):
Recovery can also be hindered by external things like that are reinforcing.
So if you're reinforced by remaining sick, if it keeps an attachment because you're sick,that's reinforcing.
Or if you hold your diagnosis as an identity,
you get rid of that diagnosis, like that's painful.
(02:30):
So it's reinforcing to keep it.
So that's also going to be something that might hinder recovery.
Sure.
And sometimes these are like unconscious or subconscious things that are keeping us sickor keeping us from getting better.
It's not always a conscious, like secondary gain, but sometimes these reinforcers in ourlife, especially with borderline attachment,
(02:54):
or relationships can be a big part of those reinforcers where I'm afraid to get betterbecause of potentially losing a relationship or it disrupting a relationship.
makes sense.
This is a tricky nonlinear approach to treatment.
Like it's not a one size fits all.
it rarely is.
(03:16):
Yeah.
Okay.
So Doc Bok what are other factors to consider in treatability?
Yeah, well, there's a couple things that I think of.
that's the first one is like wanting to get better.
So similar to what you just said, like if there's other reinforcing factors, and sometimesit's subconscious, sometimes it's not.
like, does the patient actually want to get better?
(03:38):
Or are they just here to check a box?
They're here because it's what they're supposed to do.
They're here because a loved one or friend kind of pushed them into treatment.
We can't force people.
to get better, they have to want to.
Like the old saying, you can lead a horse to water, but you can't make a drink.
The same type of thing with treatment.
(03:59):
Like someone has to want to take that drink.
They want, they need to want to feel better to get better.
But one of the major hindering factors, I think of health and wholeness and just wellnessis insight.
When we don't want to go to those deep places,
(04:19):
those uncomfortable places of self-awareness and understanding maybe our motivations orwhat's behind the scenes, what's going on under the surface.
We're not willing to be self-aware of all those layers.
Then that's going to be a major hurdle to treatment because we can't address a problem ifwe don't know that the problem exists.
(04:45):
don't want to face that the problem exists.
Exactly.
And sometimes that problem is deep inside ourselves.
Yeah.
That makes me think of APA actually has a term in their dictionary called the ahaexperience or the aha moment.
And so that made me think of like insight.
Insight is when there's like reflection and you dig deep enough to have that light bulbmoment of like, I get it.
(05:10):
I'm facing this.
This exists.
And so what you're saying is like, if we are avoiding those moments, that can hindertreatment.
Sure.
And it's not uncommon because it's hard to look inward.
It's hard to look at ourselves and look at what we're bringing to the table, how we'recontributing to the distress that we're in.
(05:35):
Now that's not to say that it's all our fault, but
we have the power to make changes inside of ourselves.
So we have to be willing to have those aha moments and to look at the uncomfy things.
Right.
And you also touched on like not being motivated for treatment.
(05:55):
sure.
Sure.
So like the lack of motivation, like I said before, you can't force someone to go totreatment.
Like you can't force them to get better.
Like maybe you can get them in the door, but
the actual treatment of a condition the person has to want to get better.
And the thing with BPD is that they're in such great distress and such great pain, they'reoften willing to step foot in the door.
(06:22):
So that's the great first step.
That's step number one.
Awesome.
We're there, but that can't be the only step.
And I like to think of this in a similar way to like, you know, going to the gym or like,let's say that you have
like fitness or weight loss goals, just walking into the gym isn't going to meet thosegoals.
(06:46):
Unfortunately, there's no magic door that you can walk through.
There's no magic therapy door.
We don't come with magic wands.
Like you have to put in the work.
So just like when you are going to the gym for whatever, for whatever reason, like youhave to make lifestyle changes outside of just showing up at the gym, showing up.
(07:07):
is the first part, it's important, but it's not the only part.
So when we have people who are just checking that box, but not willing to put in theeffort for whatever reason, there can be all kinds of different reasons for that, all
kinds of internal blocks or things that maybe we're not willing to face yet.
Or we're just trying to dip our toe in the water and just not go to those like hidden,maybe ugly places.
(07:34):
we can't, we can't force
motivation.
And if someone is not motivated, and they're just coming in to check a box, let off somesteam because they're in pain, and they just want to, you know, hey, had a rough week, I
want to vent.
Yeah, that's probably not going to have as positive of outcomes as someone who's willingto put in the work and make the changes.
(07:58):
Yeah, that makes a lot of sense.
Yeah.
What about motivated people?
Like what
What does that look like in treatment and your experience?
Yeah.
So when there's high motivation, think, well, first we also have to consider the severity.
So even if you're motivated, if you are oceans deep in a disorder level versus only havinga toe in, like you're just over the line, you can make a ton of progress and still stay in
(08:27):
that disorder level.
Yeah.
The disorder level means there's going to be impairment in life across
settings, there's going to be instability across the board.
So you can have different outcomes, putting in the same amount of effort as someone.
So I don't want motivated people to ever think like that they're failing just becausethey're still having that impairment.
(08:51):
Like you can you can make a great movement and great progress and still have more to go.
Sure, sure.
We all we all have personality.
So
we're gonna likely have the same structure.
It's just we don't have to live in that disorder space.
External factors like stress, trauma, support, or lack thereof, that can influence whereyou're at as far as like the health continuum.
(09:20):
But I think just in general for that motivated person who is in touch with their pain, whowants to get better, who wants to put in the work, they're gonna see improvement in their
symptoms.
Sure.
And going back to what you said earlier about kind of what I like to think of like arecovery mindset.
So we all have personality structures, right?
(09:42):
That structure isn't really going to change too much over the course of our life.
Like maybe, maybe if there's like a major traumatic event or a major enlightening momentor something, but generally speaking, we're going to be at least the same structure.
It may not be at disorder level.
So just like someone who is recovering from alcoholism or recovering from some addiction,there's always a need to watch, to be careful, to be on guard because that's the
(10:17):
personality, that's the structure to go back to that addiction.
living and recovery.
And I think in a similar way with any of the personality disorders, but especially BPD,because that's what we're talking about today, is
knowing that you're probably always going to have those tendencies towards the impulsivitytowards maybe the self harm thoughts or you know, the push pool and relationships like
(10:42):
that, that internal pool is going to be there for those things because the structure isthere.
So that's not just going to go away, but there's coping skills to help quell thosesymptoms and decrease those symptoms and make them more manageable so that life doesn't
feel so rocky and so
unstable itself.
Yeah, living in kind of living in this recovery mode, but using those coping skills, Ithink is really, really important.
(11:09):
Yeah, I love that example.
Because it's every personality is going to have areas of strengths and their areas ofweakness.
And you're gonna have to know and be aware and watch out for those weakness areas.
Yeah, for sure.
So borderline personality disorder is treatable.
We got that.
Yeah, but
(11:29):
How do you know which treatment to search for?
Do all of them work?
Yeah, tell me about that.
Yeah, so that can be confusing, right?
Because in psychotherapy and in any sort of counseling, we have the alphabet soup ofacronyms of different types of treatment.
And it's like, well, where do I go?
Where do I even start to look for treatment?
(11:50):
So not all treatment is the same.
But I will say, alphabet soup aside, the therapeutic relationship
is the number one predictor of therapeutic success.
So what that means is that relationship with your therapist, if it's positive, if you feellike there's an appropriate professional connection there, you feel like your therapist is
(12:13):
in your corner.
It's just a good fit all the way around.
That above the alphabet soup is going to be a better predictor of therapeutic outcomes.
So that's number one, before we even get to the different types.
Number one.
So the gold standard for treatment is dialectical behavior therapy or DBT, which wascreated by Marsha Linehan, who also struggled with borderline personality disorder herself
(12:41):
and came up with a very specific protocol for borderline and for the treatment ofborderline.
And that is what we call kind of the gold standard of treatment for BPD.
Now there are others, there's other types of treatment too that can be helpful and we'renot going to list off all of those today, but that's kind of the one that most people
(13:07):
think about with regard to treatment.
Right.
And then I think there's also different types of DBT.
So there's like strict DBT.
which has like individual therapy, group therapy every week and like a crisis call set up.
They're usually like six months to a year programs.
(13:27):
And then there's like DBT informed treatment.
And that's like pulling from the DBT.
I think I would probably fall more in the camp of like a dabbler, like not the puristwith, you know, the six month, 12 month program.
That certainly can be helpful.
(13:47):
but kind of pulling from different tool belts, different alphabet soups that are in mytoolbox typically when I treat.
kind of moving away from that.
So what we know is that borderline is the most likely to seek treatment.
Right.
We've talked about that pretty extensively.
(14:09):
And being that we are providers, there is a pretty good chance that we have seen BPD inour practice.
So Duckfish, I'm curious what it looks like for you to treat borderline personalitydisorder and what do you focus on in sessions?
Goodness.
Okay.
See, the trouble here is that BPD is always changing.
(14:32):
It's ever shifting.
Every individual is different.
Yeah.
Treatment is individualized because there's no two borderline persons that are alike.
So it's more helpful for us to talk about broad themes and specifically invisible conceptsin therapy.
Ooh, invisible concepts.
(14:52):
Yeah, they're tricky, but they play a huge role in opportunities for growth.
Yes.
Let's start with boundaries.
Boundaries can be spoken or visible, but most of the time,
They're unspoken and invisible, but regardless, they span the entire therapeutic process.
Boundaries are extra important for personality disorders in general, but I thinkespecially important for borderline personality disorder.
(15:22):
If it wasn't invisible, I would liken boundaries to being like the frame of the therapypuzzle.
Because when you put a puzzle together, I think most people put the edges first.
you use that to contain all the other pieces because without the frame, it's hard to findform.
And you might not even notice like missing pieces or pieces on the floor that aren'tcontained.
(15:48):
Yeah, but what comes to mind with boundaries for you?
Yeah, I love what you said about the puzzle.
I'm a big puzzler myself.
And that's so true.
Like putting in the edge pieces helps give you context.
Like how big is the puzzle going to be?
Where is this really colorful patch going to go?
Like same is true for treatment as well.
(16:09):
It gives you the framework, the boundaries.
And I think within that, one of the things that I always talk about is like yourpaperwork, procedural policy stuff at the very beginning.
So paperwork, payment, communication, procedures, all of that.
There's really, there's no special cases.
Like everyone has to follow the same protocol to enter treatment.
(16:33):
And that means all paperwork must be completed before scheduling at our practice.
There's no exceptions to that.
No exceptions to that rule.
Payment must be made the day of session.
Patients aren't allowed to just accrue a balance, accrue a debt at our practice.
All communication goes through the front desk, and communication is for scheduling andpayment and insurance only.
(16:58):
Clinical information should not be shared over email.
or phone that that needs to be reserved for sessions.
Yeah, setting this really sets up therapy as a professional service and not just a chat ora chat with a friend or a stranger, however you want to think of it.
(17:20):
It's really important to set these boundaries and the framework from the outset oftreatment, just like that puzzle, right?
Like this is the framework in which treatment.
the context in which treatment is provided.
And it's professional.
It's a professional service.
Yeah.
So that's kind of like the observable pieces.
(17:43):
Are there any other pieces that you would throw in the boundary category?
Sure.
There's a few more.
These are probably still in kind of the observable camp.
And it still has to do with policies and procedures.
As a practice owner, I'm always thinking about that because it's so helpful for
all conditions, but especially personality disorders.
(18:05):
with borderline, they really need, really need those firm boundaries.
But with attendance, I think you actually have a phrase with attendance about showing up.
What is it that you tell patients?
Always tell patients the days that you don't want to come to therapy are the days whereyou probably need to.
Even if it's just to sit in silence, something's happening.
(18:29):
there's some kind of resistance.
So it's, meaningful to come.
And there's consequences when you don't come that with the policies, if you're not goingto show up, there's a fee.
Like we've set aside our professional time for this hour for you.
And if you're not going to show up, then there's most likely going to be a charge.
(18:50):
And if there's a pattern of not showing up, then I mean, potentially that's grounds fortermination.
If you know,
you're not showing up to treatment.
And certainly if you're accruing a balance, we don't allow patients to accrue a debt.
those things can be really, really important and just establishing the professionalrelationship.
(19:11):
As I said before, a couple other things that I think of like in, in the actual sessionsare going to be, we can talk about anything, but you can't necessarily act on it.
Yes.
Right.
And we can talk about how angry you are, but
I won't tolerate disrespect towards me.
(19:31):
We can talk about how you're feeling.
We can talk about that you feel angry towards me, but if you're up in my face beinghostile, that's unacceptable.
If you're destroying things in my office, that's not acceptable.
And I think you have a phrase for that too, Doc Fish.
Yeah.
Yeah, it's similar.
(19:51):
We can talk about anything.
Can be angry with me.
You can yell at me.
Can't knock over the lamp.
Right.
So you can't be destructive in the anger and behave on it.
But we can let's talk about anger.
You want to yell, let's talk about it.
Is it helpful?
Because I'm not reacting to your yelling.
Sure.
(20:11):
It's probably not helpful.
I think the last thing in treatment that's maybe more overt is like, I'm not doing thework for you.
And what I mean by that is I'm not going to work harder.
than the patient is working.
And that can be hard because certain personality structures can really pull for us to domore than we're supposed to do.
(20:33):
And as I'm talking about this, maybe this is more of an unspoken dynamic that's not asovert.
if we're spending more time outside of sessions, like preparing for the session, thinkingabout what we're going to talk about in session, if we're spending more time than the
patient on those things, hmm.
(20:54):
it's time to reevaluate, like who's actually putting in the effort.
We can't compensate if there's a lack of motivation, just like we talked about at thebeginning.
Like we can't fill up or make up for that lack of motivation to get better.
You also mentioned earlier that the therapeutic relationship is the most important factor.
(21:15):
Absolutely.
think attachment is a huge one.
So attachment is a relational connection or avoidance between client and therapist.
Now in BPD, there's often a quick attachment, which kind of stems from that pain, thatneed for help or a helper, and therefore that need for relationship.
(21:36):
And also with BPD, there tends to be like a push-pull of idolization or devaluation.
Idealization is when the therapist is like the hero, the rescuer, best thing ever.
Providers have to be careful because that feels good to hear.
We can accept it, but not reinforce it.
(21:58):
Devaluation is kind of the opposite.
It's where the therapist is viewed as the villain, persecutor, worst thing ever.
Been there.
Yep.
It's less, less common still possible.
And it can even be fleeting.
Like they can have moments where it
But it's the same thing, accept it, but don't reinforce it.
That can be challenging.
(22:19):
I can see how, I mean, we're using a kind of villain, persecutor, rescuer, like, I'mseeing how the drama triangle might come into play with some of these personality
disorders and with attachment in particular.
Yeah.
And I'm also just thinking of like the interaction between boundaries.
(22:41):
and attachment.
like you're saying, like, you're not going to react, don't reinforce it.
That's a boundary.
We're talking about attachment, but it's a boundary.
I'm not going to reinforce that.
And I'm just thinking about like, like bad therapy is often boundary violations.
It's often violations with the attachment relationship.
(23:05):
And I'm,
curious.
We're taking a little side tangent, but I'm curious if you have seen that like kind ofviolations of the attachment or boundaries in the therapeutic relationship.
Yes, unfortunately, my absolute biggest pet peeve is when the therapist has too much selfdisclosure.
You do not want to know who your therapist is dating, or for breakfast, their owndiagnosis.
(23:30):
Therapy is the client space.
It's not the therapist space.
Client space, client space.
gosh.
So that's, that's my biggest pet peeve.
Super passionate about that.
But there's other things too.
I've heard of some providers socializing with their clients outside of therapy becauseafter so much time, their friends not okay.
(23:54):
It's just not okay.
What about you?
Have you seen, heard anything?
gosh.
I, I have not been fully insulated from that either.
But yeah, I mean, I had a situation where I was seeking therapy and it was a newappointment and the therapist wanted to exchange business cards with me once I shared what
(24:14):
my profession was.
And so like we can't, we can't hold that this is like a therapeutic space.
Like now, now this is a marketing meeting.
You just switch that.
yeah.
So that's just a personal example.
And then I think,
As a testing psychologist, I work with other providers in a different capacity.
(24:37):
usually if the therapist is the one that's kind of encouraging the patient to get tested,then I'm going to be talking with a therapist, trying to understand what's going on in
treatment, having a very collaborative relationship with therapists in our area.
And out of that, I've definitely seen a lot of dynamics that are concerning.
(25:00):
And I hate to say a lot of dynamics because most therapists are good enough.
However, we can get tangled up, especially if there's personality pathology, being thatthat's what we often treat at our practice.
We're going to probably see more of that.
And sometimes therapists can be blindsided or get tangled up in it.
That can be like getting too involved in the patient's story and wanting, maybe wantingthe testing psychologist to rescue.
(25:28):
I need this diagnosis to fix, to rescue something or someone.
Or then on a different plane is the clients maybe wanting the therapist to meet all theirneeds and kind of getting wrapped up in that.
Like, tell me what to do.
Fill me up.
I need to know constantly.
And then sometimes that can get like passed through to the testing psychologist too.
(25:51):
Like, well, you need to do this.
It's like, did you get that from the patient?
Are we holding those boundaries?
Being possessive or controlling, like the therapist being possessive or controlling whenit's time to end therapy, or perhaps they're not, they're outside of their competency and
it's time to end but they can't break the attachment because of their issues.
(26:12):
Yikes.
Yes, that's not a good one.
Yeah.
And probably the most severe kind of in the camp of attachment and boundary breaks isgoing to be like physical contact or intimate.
relationships with patients outside of session or it just, just no, just no, don't dothat.
Don't do that.
(26:32):
This is grounds to find a new therapist.
If that's happening, report, find a new therapist.
in the boundaries, I'm going to contain us and take us back to invisible concepts thathappen in therapy.
Yes.
So we were talking about attachment.
(26:52):
Part of the attachment relationship in therapy is what's called transference and then alsocounter-transference.
Yeah.
So let me explain.
Transference is when, because the client doesn't have a full picture of who you are, theyunconsciously perceive you to be in a role that they're already familiar with, that they
(27:13):
already have a mental map for, for example, like their mother.
So then counter-transference is on the therapist's end.
It's the therapist's own reaction to that transference, which often is gonna mirrorwhatever that proposed figure is.
like whatever the mom felt, that might be what the therapist feels as well.
(27:35):
So like it could be frustration or rescuing.
So if you had a critical mother as a client, you might come in, you don't know who yourtherapist is.
Like you have to learn all those dynamics.
their favorite color is, what they eat for breakfast, because you shouldn't.
Okay, so if you had a critical mother, you're going to go into therapy and you're, youmight think like the therapist is going to judge you or therapist is going to be critical.
(28:01):
And you might act defensively, or in a passive over compliant manner.
And whatever that reaction is, that's going to trigger the therapist's own reaction thatcountertransference.
Wow.
to most likely react like mom did.
Wow.
Does that make sense?
(28:21):
It does.
There's so much more that goes on in therapy versus just active listening.
We each have these kind of like maps from childhood, and they guide us in relationships.
They guide us in attachments.
So there is so much more that goes on in the therapy relationship versus just activelistening.
(28:45):
There's so many dynamics, not just that the patient is bringing in, but that the therapistis bringing in.
And that's why we've got to know ourselves and contain ourselves and be boundary.
It's so that we can just work on the client stuff, the clients maps from childhood, notour own.
Let's not bring our own stuff into that because it just gets way too messy.
(29:09):
If we're just now just triggering each other and we're not really
engaging in treatment.
But those unspoken dynamics and those kind of like attachment maps, that informs a lot oftreatment.
I think one of the most important things in my opinion for those maps, like you'reprobably going to therapy because those maps aren't helpful.
(29:31):
Exactly.
The maps you learned are not, are no longer working.
And so we have to find different paths and corrective experiences is something that I findsuper valuable, invisible though too.
It's hard to explain because it has to be really individualized.
for example, if you have somebody who turns anger towards themselves, so instead of beingangry with someone else, they're like, I'm bad.
(29:58):
I'm not good enough.
I'm filling the blank.
Whenever they are able to express anger for someone else or even admit that they're angryfor someone else, that might need to be celebrated.
Sure.
Because it's different than what was on the map.
But in contrast, if you have someone who is outwardly destructive in anger, you're notgoing to want to celebrate that for them.
(30:21):
You're going to want to celebrate taking accountability or self-containment for theiranger.
Another good example of this is if someone has been parentified, so in childhood beingforced to take the role of a supportive adult within the family, I see this all the time.
I can set boundaries so that I'm the parent.
(30:43):
So for example, I'll be the one who takes like the authoritative roles of paying attentionto the time, making sure that we're scheduled, making sure that we fit in the frame.
Oppositely, if I have a client who is more childlike in their regression, not where theyneed to be developmentally, I can then set boundaries to make sure they pick up their own
(31:08):
responsibilities.
It's like not.
calling if they're late or missing sessions, not playing into any tantrums.
So it really, really depends on who that person is.
But a corrective experience is essentially going against whatever's not helpful from thatchildhood map.
And that's where taking the time to get to know the client's history as well can be reallyhelpful.
(31:35):
time.
Yeah.
And it's not necessarily even verbalized.
It can be later, but in the moment, oftentimes it's just a dynamic.
It's invisible.
Right.
Right.
And again, these invisible dynamics is where we have to be on the lookout for the dramatriangles too, especially with personality stuff.
(31:56):
But if we're disrupting those reinforcers, like you're saying, like we're doing adifferent, we're going about the map in a different way.
We're taking a different route.
Like that's disrupting those reinforcers and
potentially not kind of going along with the drama triangle.
If that's a part of the mapping dynamic.
(32:17):
I think oftentimes it can be.
Let's see.
So along those lines, and we also have repairing ruptures.
any conflict or potential for conflict in the therapeutic relationship can lead tofocusing on the attachment between myself and a client.
So for me specifically, I want to validate without judgment.
(32:39):
because I want client to be upset.
But I need to do that in a way where they also understand I'm not gonna abandon them.
Sure.
So sometimes this can look funny.
I get excited on my part and I celebrate it.
So client might come in and they're like, I'm so mad at you.
And I'm like, good, yes, awesome.
(33:00):
Okay, let's talk about it.
Let's get into it.
I'm so glad you brought it up.
By doing that and going through that process, you can repair the relationship, continuethe relationship, take accountability.
I need to take accountability for my part, only my part though, and resolve the conflictinterpersonally.
Wow.
(33:21):
Yes.
So before I go on big bunny trails, because I get so passionate about this stuff,invisible dynamic, what about you?
Sure.
It's another one.
My goodness.
So.
One of the ones that I like to use probably more than anything else is facilitatinginsight and making connection.
(33:42):
So this ideally is client led, especially after, after some time.
And I think Doc Fish, you had a great example that I've heard you use about like teachinga kiddo to like put away their toys.
Kiddos need to learn, right?
And adults, we also need to learn.
So
If we are teaching a kiddo colors, for example, right?
(34:05):
Like put the orange ball in the orange bin.
Let's put the blue ball in the blue bin.
It's not gonna be helpful to do it for them.
Right.
It's just not like they're not gonna learn.
You can model for them at first, because they have to learn like what the process to dothat is.
But client led connections or kiddo led
(34:28):
activity, right?
That's so much more powerful and helpful.
Yeah, yeah.
And that's, that's the types of connections that I enjoy making.
And of course, we have to model sometimes first, like making those connections, like, yousaid this back here, and then you said this over here, wonder if that means this, like
modeling, so that eventually, the patient can start coming up with thoseconceptualizations and those connections as well.
(34:56):
But then there's another part of that that's a little different that I use a lot, and it'scalled immediacy, which is basically calling out the dynamic in the room.
So we're naming the elephant.
So let's say, for example, Doc Fish, you come into my office, we're talking aboutsomething from childhood that's distressing or something from, it doesn't have to be
(35:20):
childhood, could be yesterday, and you start picking at my couch cushions.
while you're talking about it.
I might use immediacy by saying, Doc Fish, I noticed that when you started talking aboutthis thing that happened yesterday, you started picking apart my couch cushions.
What's going on there?
And so by naming it, like there's there's no way we can be 100 % self aware all the time,right?
(35:46):
But if we are helping facilitate that self awareness, like, gosh, I didn't even realize Iwas picking apart your couch cushions, like
We're helping facilitate those insights by calling out the third dimension or the thirddynamic in the room that's happening.
And that can look like a bunch of different things.
Yeah.
I wonder too.
I think it could maybe also be directed towards the connection between client andtherapist of like, you seem a bit angry with me right now.
(36:15):
Okay.
So that makes sense.
So making connections, facilitating insight includes self-reflection, awareness, looking.
deep into yourself and then being able to verbalize it in treatment.
Yeah.
Yeah.
Exactly.
a lot of it can be like how childhood affects your current functioning.
(36:36):
So all of this is part of treatment.
This kind of behind the scenes, what's going on, what are we actually doing when we go towork, when we're treating borderline personality disorder.
These unspoken dynamics are what you and I
Doc Fish, what we like to focus on as personality disorder specialists, because that's thestuff that's tricky, that like third dimension, bird's eye view stuff, the stuff that's
(37:01):
unconscious sometimes, or attachment based, it's not overt, it's not just what's happeningin the room, the dialogue that's being exchanged, it's the under layers of that.
And that in conjunction with the therapeutic relationship is highly impactful fortreatment.
And those are the approaches that you and I typically take when we're treating BPD.
(37:25):
Yeah.
And I love this.
I'm so excited about talking about this because it's literally the unspoken stuff.
Exactly.
one's talking about it.
Exactly.
So we learned a lot today and we learned specifically that BPD is treatable, but you haveto put in the work and want to grow.
(37:46):
So
Treatment for BPD is extremely individualized and contains, as we've said, a lot ofinvisible dynamics.
And sometimes this can feel frustrating too for clients because they're not like checkingoff the boxes like in some manualized treatments, but they're often finding the healing
over time without even realizing it.
(38:08):
And that's because we target that attachment piece in treatment.
The stability then.
that therapy brings is another big part of the healing process.
Because especially with BPD, these individuals, their lives are often so marked withinstability that the therapeutic relationship and that therapy hour is like the one thing
(38:33):
that's stable and that is inherently healing.
But we also have to be contained and boundaried in order to keep that stable place forpatients.
All right.
so we could talk forever about treatment of BPD and our own approaches, but it is time towrap up for now.
(38:53):
So thank you for joining us today on this episode of The Personality Couch.
Make sure to check out our blogs that coincide with each episode for more in-depthinformation at www.personalitycouch.com.
And as always, don't forget to give us a thumbs up or rate and review us on your favoritepodcast app.
(39:15):
Be well, be kind, and we'll see you next time on the Personality Couch.
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