All right. Dr. Fu, you ready to go? I'm ready. All right. So I just want to introduce, this is Mark Ruffalo. He's a therapist based out of Tampa, Florida. Mark is a talented therapist, supervisor, teacher, educator. His primary focus is the studies of object relations, communication dilemmas, and logical reasoning deficits in psychotic and borderline states. He's known for his very clear and insightful writing. I've learned a ton from him on topics including personality disorders, history of psychiatry, and psychosis.
I think what makes Mark a great teacher is it's clear he's got diverse clinical experience from psychosis units, I believe emergency room work. I think I heard that somewhere in a podcast. And he's a psychoanalytic psychotherapist. So welcome, Mark.
Yeah, thanks so much for having me. I've been looking forward to doing this.
Yeah, just a heads up, we're very tangent-based podcasts, and we're not too, too buttoned up. So just want to encourage you to give loose, abstract answers. And we're really big on controversy. So the more controversial you can be, the better.
I know we're off the cuff, but courting controversy, that's a bit of an issue.
I'll do my best.
I'm going to say I'm a great fan of Dr. Ruffalo. He's great. I think it really comes through in your work online and your writing that you have a lot of passion for patients and that you're at what my home institution will call well-trained, kind of tongue-in-cheek. But it's a bit of a rarity in today's world.
Well, I grew up in New Jersey and I don't bite my tongue. If I have an opinion on something, I tend to share it. And I attribute that sometimes to growing up as an Italian in New Jersey. So take that as you will.
All right. Let's just start. We're going to ask some pretty basic questions. Start with the softball for you. What is borderline personality disorder? That's going to be probably the main focus of the questions that we're going to ask today. So let's start with the most basic. What is borderline personality disorder?
Sure. I see borderline personality disorder as as fundamentally being a disorder of contradiction or a disorder of paradox. And I've written a little bit about this. I think the patient is trapped in what a psychiatrist named Burnham in the 1960s called a need-fear dilemma. The patient simultaneously has needs for closeness, but once closeness is achieved with the object, the patient engages paradoxically to push the other person away.
So there's a simultaneous need for, but fear of closeness or intimacy and interpersonal relations. And I think John Gunderson's work in the 80s on BPD really shed a lot of light on this phenomenon, as well as the work of Gerald Adler, who wrote one of my favorite texts on BPD, Borderline Psychopathology and its Treatment in 1985. So I see BPD as a fundamentally a disorder of, uh, of object relations of the way the patient relates to self and other.
It's a disorder that manifests obviously most vividly in the context of relationships. Um, I tend to agree with Kernberg's sort of biopsychosocial approach to BPD. I think we're in an era in which traumatogenic theories of personality disorder have become very popular, and certainly while BPD is related to trauma, abuse, and neglect. I do think there's a biological component to BPD. I think Kernberg's notions of some genetic or an inherited aggression in borderline patients are very compelling to me.
So I think it's a complex condition, partially genetic and biological, partially environmental in its etiology, and manifesting, again, most clearly in the context of relationships marked by a paradoxical relational pattern. This sort of push-pull patterning plays out in treatment relationships as well. I think it's one of the hallmark features of borderline pathologies. leading to a great deal of confusion on the part of the other person and the patient's use of very primitive, if you will, defense mechanisms of projection, projective identification, identification with the aggressor.
sort of our central core features of this disorder. I've written a little bit with Joel Paris, who is, you know, sort of well-known in the segment of the world, yeah, about sort of... trends in diagnosis. And we're seeing this concept of complex post-traumatic stress disorder come on the scene recently. I think it's already being used as a diagnosis in Europe. I think it's taking off in some other places around the world.
The American Psychiatric Association has been a bit uh, I think ambivalent about what they're going to do with this, but I think it's a major error, uh, to, uh, to conceive of, of the entirety of what we call borderline personality disorder as simply being complex post-traumatic stress. Uh, I think this is a different condition, um, uh, One that, excuse me, I would say that much of what we call complex post-traumatic stress disorder is, in fact, borderline personality disorder.
I can get into that controversy later if you'd like.
By the way, I'm sorry. Well, I agree with that. You know, I think we all agree with that here. We got to acknowledge, I think. that we don't want to be talking too much as three people who tend to be in the same camp. So I'd like to play a little devil's advocate. Sure. What do you think of the attempts? I believe it's already in ICD-11 to rename the diagnosis.
Obviously you've covered a little bit of the complex PTSD aspect. What about something a little bit less, a little less of a paradigm shift, emotionally dysregulated personality, I believe in ICD-11, supposedly more comprehensible to patients. What do you make of that?
Yeah, yeah. I don't know if emotionally dysregulated personality or emotionally unstable personality is any more palatable of a description for the condition than borderline personality is. In fact, I think... this shifting, this ever, you know, ever changing, you know, these labels really, I think, may temporarily alleviate some stigma or improve some stigma. But I think that it's really the core essence of the pathology that creates the stigma.
These patients can be, unfortunately, very, very disturbing to others. And I think that whatever we change the name to, I think that the stigma is going to remain more or less because of the nature of the pathology itself. Joel Paris has written a lot on this. So, you know, and as far as the term borderline, you know, the term most people know, you know, comes from the psychoanalytic idea that these patients are somewhere on the border between neurosis and psychosis.
I actually think there's a lot of evidence to support the idea that borderline personality disorder is similar in some ways to psychotic illness. When we look at evidence from psychological testing, unstructured psychological testing, these patients tend to evidence a lot of the same types of thought disorder that we see in psychotic patients. These patients tend to fall apart on the couch, quote unquote, in classical psychoanalytic arrangements and These patients tend to regress just like psychotic patients do.
So I'm not ready to, you know, abandon this notion of borderline as being in some way related to the schizophrenia-like or schizophrenia-like syndromes.
Yeah, you know, as an aside, too, I think it's important to recognize that borderline aspect between psychosis and neurosis, even if you're a med management clinician, because whereas a lot of the deficits can mimic psychosis, sometimes I have found in rare cases that An antipsychotic does help. And I can't explain that, you know, because phenomenologically it's different than a schizophrenia. Sure. Sometimes you see a response and there's a lot more murkiness, I think, than we're giving credit for today.
Yeah, I agree. I've actually seen patients with BPD who don't really seem complicated by other, you know, have any other comorbid condition actually get better with clozapine or at least evidence some significant improvement with clozapine. So interesting.
Yeah, you talked about how a lot of borderline states and psychosis are very similar. Can you talk about what you mean by that and where you see that?
Yeah. So, I mean, I think what most of us know and it's listed in the DSM criteria, transient psychotic episodes. That's DSM-5 TR now, criteria psychosis. BPD. Many of these patients evidence some psychotic symptoms, including transient paranoia. I've seen patients who have transient hallucinatory experiences in the context of borderline psychopathology. So this is usually evidenced under, you know, periods of intense interpersonal conflict and distress. Patient may hallucinate their partner or spouse saying someone else's name.
There may be very brief episodes where the person feels that someone is outside of the house. So the most overt psychotic symptoms, I think we're all familiar that borderline patients can evidence those transiently. But I think if we look a little closer, I think that and I've actually got a paper that is submitted to a journal right now on what Silvano Arrietty called paleologic thinking in schizophrenia.
So, you know, in quote unquote normal cognition, a person moves from making an observation about an event to to drawing a conclusion about that event. So if I walked outside and I see a cloud of smoke, that's my observation, I might draw and make an inference or draw a conclusion that there must be a fire going on somewhere, right? So that's sort of normal, rational, logical thinking.
Arrietty thought that schizophrenic patients were prone to paleologic thinking, which is marked by a reverse order of progression where a patient or a person begins with a conclusion and then looks for clues or hints to support their sort of preconceived notion about what's happening. I think we see this obviously in paranoia, in paranoid psychosis, where a person believes that they're being followed and then they hear footsteps behind them or they see a car with their lights flashing behind them and they draw a conclusion that they must be being followed.
I think that borderline patients do this as well. I think it's more subtle. It's not as overt as in as in full-blown psychotic states. But I think that borderline patients also evidence paleologic thinking, usually around themes of abandonment and rejection. So they begin with the conclusion that someone is looking to hurt them or someone's going to abandon them. And then they actually see evidence sort of retrospectively.
So my partner wants to spend time with her friends tonight. That means that she doesn't love me anymore. That means that she's abandoning me. Sort of the observation comes sort of secondary to the conclusion that the patient already has. So paleologic thinking, I think, I think there's some overlap there in terms of how borderline patients, you know, sort of come to conclusions. You know, certainly evidence, again, from psychological testing, from Rorschach testing.
But interestingly, the difference between psychotic patients and borderline patients disappears with more structured psychological tests. So on unstructured tests, the patients tend to look very similar. With structured tests, there are differences between psychotic and schizophrenic patients.
That's very interesting. You gave such a thorough answer. You basically answered a question I already had for you, but let me make sure I got it right. Basically, it sounds like Even though the paleological banking is present in both groups, and I believe we can see it in some other groups as well, patients, but we're not going to get into that right now. It seems like the core preoccupation for borderline personality may be the relationship.
And so The assumptions rise from the relationship and then the paleological thinking is applied to that. Whereas in a schizophrenia, the assumptions may be more bizarre or unrelated to relationships. And then the assumptions arise in response to whatever.
Yeah, I think that's a good summary. Right. So, you know, we've got, you know, a psychotic patient who walks outside. There's an airplane that flies overhead. And and that means that I'm the president of the United States or something along those lines. Whereas. In borderline states, the preoccupation is around, you know, typically around relationships or a more general sort of sense that people are going to hurt me, you know, sort of the persecutory object relation.
Right, right. And you were saying about the structure testing shows a difference. What happens here?
Yeah. Yeah. So and I think that we see this also in in treatment. Right. So even, you know, even psychoanalysts now sort of argue that that borderline patients require more structured treatments. Right. So even Kernberg and the transference focus people, they talk about the need for a therapy contract at the outset of treatment for for for very careful attention to the frame and the boundaries and the rules, the ground rules of psychotherapy.
The borderline patient requires, requires structure and treatment. Otherwise they, they fall apart. They fall apart on the couch as the old stuff goes. Um, so, um, and, and I, I think there are some other, um, there are others, other similarities there between the two groups of patients as well. Um, So I'm not ready to abandon this notion that there is, you know, abandon the terminology borderline. I actually think that it sheds some light on the nature of the condition.
And actually, I think there's some reason why many of the big names in the history of borderline personality disorder got their start researching schizophrenia. So John Gunderson was a schizophrenia researcher and clinician. Harold Searles began his career working with schizophrenics at Chestnut Lodge. And then he began to write about borderline patients. So I think there's something to this idea that there is some similarity here between the two disorders.
I kind of want to keep us moving on some of the things that I know you speak really well on. What what are the core anxieties in borderline personality disorder?
Yeah, so what gets the most attention and what the patient most frequently complains of is abandonment anxiety. So, you know, intense fears of abandonment and rejection, usually in the context of romantic relationship, but sometimes friendships and family relationships, and certainly the treatment relationship. We see these patients become very preoccupied with with the therapist, you know, if the therapist leaves to go on a vacation, there's a sense that the therapist has completely abandoned the patient.
If, you know, if I don't reply to an email that comes in at 10 o'clock at night or at two o'clock in the morning, it's because I don't really care about the patient or my other patients are more important than the patient, right? So, so, anxieties around abandonment and rejection. Most people are well aware of those anxieties. But psychodynamic theorists talk about another core anxiety. And I sometimes call this sort of the twin anxieties phenomenon, where we've got abandonment anxiety on the one hand, and then we have enmeshment or engulfment or anxiety or annihilation anxiety.
And this is the flip side. This is a sense that in interpersonal relationships, the patient is going to be swallowed up, engulfed. They are going to lose their sense of who they are. That produces this paradoxical effect that I mentioned earlier. So the patient, in the words of Roy Grinker, teeters back and forth like a yo-yo in relationships where they Again, there's this push-pull where neither closeness nor distance is tolerable for the patient.
So they basically teeter back and forth between, you know, this intense abandonment anxiety And then this enmeshment anxiety, which could be conceptualized as really a fear of intimacy and closeness in relationships. So very often what happens is a borderline patient might come in and start talking about how they just had a wonderful trip with their partner, And it went really well. And it was, you know, we had such a nice week or such a nice week on a vacation.
But we get back on Monday. And I started to bring up something from the past. And I started to sort of create some conflict in the relationship after a period of intimacy or a period of closeness. So when we look at this psychodynamically, what we see is, well, the patient was probably feeling very, very uncomfortable with by the degree of closeness and intimacy that had been achieved, and then unconsciously acted in such a way to push the object away.
So, you know, and this can happen in psychotherapy as well, which is really sort of a microcosm, a little petri dish for what happens in the borderline patient's interpersonal world. So we talk about that, we talk about the transference and and the countertransference in the psychodynamic world as sort of mirroring what happens in the patient's broader object relations. But this push-pull, abandonment anxiety, engulfment anxiety, patient moving back and forth like a yo-yo, I think these are all important themes in understanding how the borderline patient's mind works.
I'm curious in terms of what you're describing with the push-pull, abandonment, investment anxiety, where does splitting fit into all of this? Does it help us to understand this? Is it related? Is it somehow not related?
Yeah, I think splitting is obviously a fundamental concept in understanding borderline personality disorder. It comes from the work of Melanie Klein, but it was really Otto Kernberg that really teased out what we mean by splitting. So we see splitting play out sort of in the context of this paradoxical sort of tendency. So splitting means in essence that the person has a very difficult time integrating one's sense of self and sense of the object as a whole entity or as a whole person.
So, you know, in normal, quote unquote, object relations, we're able to say, you know, person X has good qualities. They have some not so good qualities, but all in all, they're a pretty decent person, right? We have an integrated, you know, vision or representation rather of that person in our minds. what happens in severe personality disorders is, uh, is that the patient lacks this ability to integrate.
So at different points in time, they feel that the object is either all good or all bad. So in psychotherapy, you know, I'm either the best therapist they've ever had the most empathic, warm, you know, most understanding. Uh, I'm so lucky to, you know, to be treated by you. And then, you know, at, you know, uh, often in the context of some minor slight or what's perceived as a minor slight, then it all changes.
Then I become all bad. I don't know why I'm coming here every week. I don't know why I'm paying you all this money. You haven't helped me at all. You never say anything nice to me. All you are critical of me. You're a bad character. In fact, you're the bad person. And so, you know, so splitting, you Very important concept. It's a defense mechanism that is employed by patients, both with borderline and narcissistic pathologies, most notably, but also very, very central to understanding what happens.
So this push-pull that I describe, the need-fear dilemma, if you will, often what prompts the push away or is associated with the push away is a period of devaluation of the object. So splitting idealization and devaluation, that's DSM-5, criteria, right? And so splitting is utilized, if you will, unconsciously to push the object away or devaluation rather is utilized unconsciously to push the object away. And then what often happens is there's a period of guilt and then via manipulation, if you will, emotional blackmail, there's an attempt to pull the object back in.
So threats of suicide, threats of, you know, of other things to pull the person back in and left untreated. This is a pattern that goes on, you know, indefinitely.
Now, you mentioned that splitting is also present in NPD, narcissistic personality, sort of tangentially related to things that we see in multiple conditions. Are you a lumper or a splitter of diagnosis? You know, some people, they'll put everything under one umbrella. Some people, they want to get very specific. How do you feel about some of the older and still sometimes included personalities, personality disorders, such as, of course, histrionic and maybe passive aggressive personalities, those sorts of things?
Yeah, I tend to be a clumper. When it comes to borderline personality disorder in particular, I'm very fond of Gerald Adler's conceptualization of a borderline narcissistic continuum in which narcissistic personality disorder is the less severe condition and borderline personality disorder is the more severe condition. And Adler thought that as borderline patients get better in treatment, they actually look more narcissistic. So there's a narcissistic sector of the pathology and then a borderline sector of the pathology.
And borderline patients, what we call borderline personality disorder patients, have both. sectors, if you will. So I actually think there's a lot of compelling evidence to support this notion. Sometimes we hear people talk about how the borderline patient is a failed narcissist. I don't know if you've ever heard that, but sometimes people use that language. And there's certainly, even if we look at the SM criteria, there's certainly a narcissistic element to borderline personality disorder.
When we're talking about self-idealization of the self, so self-splitting, the person may have a very grandiose sense of self that's only short-lived, but may feel and think very highly of themselves. Um, so, um, um, so yes, I, I mean, I think that, uh, um, uh, I think there's, there's a lot of overlap between the personality disorders. I think there's a lot of overlap between borderline and narcissistic disorders.
Um, and in general, I'm, I'm pretty much a clumper, uh, when it comes to psychopathology.
Yeah, I think that's prudent. As you bring that continuum up, I do wonder about it. I wonder if that's a matter of more overt, overtly borderline seeming patients may be undiagnosed narcissists who have been rendered unstable by their life circumstances. And if you stabilize them, they tend to start to present the narcissistic pathology versus the more quiet borderline types where the deficit's more in the identity and self-direction.
I generally don't see them get too narcissistic when they get better, but that might just be my patient population.
Yeah. Yeah. Yeah. It's, it's, uh, um, it's complex obviously, but I, I think that, um, uh, it was Roy Grinker who, uh, who first described four different subtypes of borderline patients, ranging from sort of the neurotic end of the border to the psychotic end of the border. And then he described back in the 60s sort of the core borderline syndrome, which is what it sort of looks like BPD as currently defined in the DSM.
But there's widespread variability in the presentation i mean obviously we have very very severe uh borderline patients who are you know these are the patients who you know are are hitting their head against the walls they live in assisted livings they can't hold a job and then you have higher functioning patients who adler would say look more narcissistic but have a core uh borderline pathology
This is a great conversation, but we have limited time, and there's too many things I want to get to. One thing I wanted to cover is I think – I imagine a lot of our listeners are medication prescribers. Mark, I know you don't prescribe medications, but I'm curious – what advice you would give to those responsible for medication management in those at borderline? Not in terms of medications, just like, what do you think the role is?
What do you think should be communicated? Yeah, I guess like from an outsider, what would you say?
Yeah, I mean, I think that, yeah, I'm gonna borrow from Nasir Gami here. I mean, I think that a lot of, a lot of what is done pharmacologically with, with BPD is, is just merely symptomatic treatment, you know, much like treating, you know, a fever with aspirin or something. Um, I think that, um, um, You know, I don't really think there's anyone who believes that medication treats the core of the pathology, which I think is largely psychosocial.
And I think even hardcore biological psychiatrists would acknowledge that. I think that certainly I've seen some patients get better to some degree with medication treatment as an adjunct to psychotherapy. Yeah. Hard to say exactly why, but I imagine there is some benefit from the drug itself. But I think what's most important to me to keep in mind if you're a prescriber is that we often see transference and countertransference issues play out around medicine.
Where the prescriber... if he doesn't or she doesn't agree to prescribe something as seen as a withholding persecutor, as someone who says he wants to help me, but really wants to hurt me. We often see a lot of splitting around issues of medicine. And this is in part a byproduct of the split treatment model, which has become so popular where the patient sees one person for therapy, another person for medication.
So, you know, meds are, you know, the issue of meds with borderline personality disorder, it's just an issue that's ripe for all sorts of transference distortions and counter transference reactions. Very often in supervising residents, what I find is that even though they know that medicine really isn't going to solve the patient's problems, they may feel compelled, sometimes even coerced into prescribing something that they know really isn't going to work.
It's pretty powerful.
And I think ultimately that's detrimental. Um, uh, and, uh, so, I mean, this is because I don't, because I don't prescribe, I don't write a lot and frankly, don't think a whole lot about these issues, um, other than when they come up in supervision. But, um, but I, I think it's a, it's a topic that's probably been underappreciated. Um, uh, and, and I will just note because last week the, the APA, uh, revised their guidelines for, for BPD.
They, they did note that, um, that, that, you know, medication treatment of BPD should, um, generally be short-term, you know, alleviation of the most acute symptoms, and the topic of medicine should be revisited. I think in the guidelines, I think they say every six months about whether we should continue with pharmacotherapy for these patients.
I like those guidelines. Now, you know, it sounds like when you're talking about those experiences of the residents, you know, knowledge is not enough. to guard you against the enactments and the misbehaviors that may happen in complex treatment. Uh, you gotta be aware of your feelings. It sounds like, uh, because people are feeling compelled to act even when they know better reflection of the patient's experience. You also mentioned the split treatment thing.
I think, um, most psychiatrists have a, uh, a lot of experiences where they've been triangulated, uh, against a therapist. I wonder if there's anything different experientially about the therapist's experience. Do you get triangulated against, let's say, a psychiatrist?
No, it never happens. Yeah, it happens all the time. And this is part of the patient's pathology. They try to if I may speak frankly, they try to rope you in. But, you know, we ought to be wary of being the patient's hero. You know, it's a very short-lived experience in working with a treating borderline patient. So Very often the patient will try to get me to comment on, well, do you think Dr.
So-and-so prescribed the right drug here? And I have to say, well, I don't really know. That's not what I do. Why don't you talk to Dr. So-and-so about that? Why don't we see how it makes you feel? Why don't we see if it helps you? But again, I mean, this is ripe for all sorts of manifestations of the patient's disorder coming right out before your eyes. And I think it's something we have to pay more attention to.
Now, you know, how I've heard you talk about and I've heard other people talk about communicating the diagnosis of borderline personality disorder to a patient. And usually I hear, you know, somewhat vague comments in terms of like, you know, be empathic. How how do you think is the best way to go across it? And can you like almost give me an example of what you see as like a really productive way to talk about it with a patient?
Yeah.
I take the approach that the diagnosis ought to be communicated to the patient, that we should not withhold the diagnosis or mentioning the diagnosis. First off, I mean, it's hard to comment sort of broadly about this because I do... I do think it's very individual specific about when is the patient ready to hear this. Some patients may respond very poorly to receiving a formal diagnosis. But I think in general, the way that I like to go about it is, well, you've told me about all these experiences that you have, and they're obviously very distressing to you.
And they've caused a lot of problems in your life. That's why you're sitting here with me in this office. And I can tell that you suffer a great deal. I know it hasn't been easy. We have a name for this thing. And this is what we call it. And I think this captures what you experience pretty well. And then we might have a discussion about what is meant by a diagnosis.
Is it a disease that you're born with? Is it a way of describing experience? And when it's presented in this way, that there are other people who suffer like this, maybe not in the same exact way, but in ways that are very similar. And we have a way of understanding it. We have a way of making sense of it. There's models that have been developed about how to work with and to help someone who has these experiences in life.
then very often the patient is receptive. You know, so I'm not sure if that adequately answers your question, but I mean, I think it's delicate. It's a delicate issue. I've seen patients who, when they receive a diagnosis of BPD, you know, they start to feel finally there's a way to make sense of what has been so confusing for me and basically everyone around me for years. And then there are patients who feel unfairly labeled.
But if it's done carefully, delicately, with a good explanation of why I think this is what's happening, then I think often it's either well-received or it's received well enough to continue with treatment.
I mean, I thought that was a wonderful, uh, encapsulation of how to. Describe communicated diagnosis, especially your emphasis on what you've drawn together with the patient in terms of the clinical evidence, the history and focusing on the suffering and the despair that comes with that as a way to move forward. Um, sounds like a great way to build an alliance. So yeah, listen up listeners. That's really how we should be doing things.
But I'm going to challenge you here. I'm going to say, at gunpoint, how would you respond to a layperson or a patient without being able to know anything about them, having to create one size fits all description, answering the question, is this disorder my fault? Where does it come from? Why do I have it?
Well, if I were held at gunpoint, ask that question. I would say... Well, it may not. It surely it surely was not your fault that you developed this condition. Now, there may be certain things about your biology that contributed. And most certainly there were certain things about what you experienced in life that contributed to developing this condition. But as for the question or as to the question of, you know, are you responsible for it?
Well, that's an interesting philosophical, moral, ethical question. I think that we always have to look at how the patient contributes to their own pathology, to their own suffering. I think that's a hallmark of good psychotherapy. If we get into a pattern in therapy where all we're doing is supporting and validating the patient especially the patient with borderline personality disorder, what ends up happening is their defenses just become reinforced.
You're right. All of your problems are because of other people in your life. You have just been involved in a series of relationships with bad people. They're all the problem. And you just need to find the right person. this obviously becomes very problematic. And I think that it leads to a dependency on the therapist that is pathological. I think it reinforces the unhealthy defenses. It encourages splitting, unfortunately, because frankly, we don't really do a good job anymore of training therapists and basic psychodynamics.
I mean, you know, most therapists go through graduate school nowadays at the master's level, and even at the doctoral level, many of them really having no basic introduction to, you know, to psychodynamic or object relations theory. What ends up happening is, you know, it becomes this very supportive, validating type of treatment that I think in the end is potentially harmful to patients with borderline personalities or
Yeah. And the beginning was a great answer. We should do a segment where me and Dr. Fu imitate people with personality disorders and ask you questions and you answer them.
I suppose that would have been more popular on TikTok.
It comes much more natural to us to... Yeah, we covered a lot there. I'm looking, I guess we have like 15 minutes. We did want to talk about some trends that we see in regards to diagnosis and mental health in general. I think what Dr. Poo was just asking there had a lot to do with personal agency when it comes to these disorders. And I'm curious, broadening from personality disorders, do you think the mental health today is is moving towards or away from personal agency and what impact has that had?
Yeah.
Well, I, I, I, I think, I think there's probably a core set of psychiatric disorders. I I'm, I'm in agreement with, with Gami again on this. I think, I think the number is pretty small. But I think these disorders really do represent mostly biological diseases. And I think, you know, Kreplin sort of made a distinction between I believe what he called disease processes and clinical pictures. So, you know, I think when it comes to schizophrenia, although you can use psychotherapy to help the schizophrenic patient, and I've been an advocate of that, and I see a lot of psychotic patients, I think more or less what we're looking at with schizophrenia is a biological disease.
I think it's also true that manic depressive illness or what is now more or less bipolar disorders, probably a biological disease, um, you know, pure, you know, obsessive compulsive disorder, uh, probably in this category and, and, you know, severe depressions, melancholia, you know, in, in those conditions, I, I think it's really hard to talk about, um, um, you know, sort of personal agency. It reminds me of this paper from the eighties.
I forget the author of it now, right now, but it was, he was a, I believe he was a psychoanalyst at Harvard, if I remember correctly, treating the patient who can't versus treating the patient who won't. And yeah. And it wasn't Les Havens. It was, it was someone else, but in essence, I mean, I think we all have to make this distinction early on in the treatment.
of what is it that the patient can't do versus what is it that the patient won't do? And even if we don't think of it in these terms, ultimately we have to, you know, as the clinician, we have to come to some determination about this. You know, the patient with a really severe chronic schizophrenia disease you know, who wants to go on to medical school or to become an astronaut or something.
And, you know, it's probably true that that patient in the vast majority of cases, you know, can't do that because of the severity of their illness, right? So, I mean, that's a pretty... pretty simple example. But, you know, in other cases, it's much less clear. What is it that the patient can't do versus what is it that the patient won't do? And we get into trouble when we say the patient can't when in reality they won't or vice versa in psychotherapy and probably psychiatric treatment as well.
And so, you know, this distinction is so important to make. And it's one that we don't realize, I think, that we're doing, but we do it in virtually every treatment. And it touches on agency, right? You know, since we're talking mostly about borderline personality disorder today, you know, I like to make it clear at the outset of treatment with patients that the expectation is that you're going to get better.
that many patients with this disorder actually get a lot better in time.
It sounds too basic, but it is absolutely crucial to communicate.
Absolutely. Yes. Yes. And we chuckle because, you know, it's, it's, it's true, but a lot of people don't communicate it. Yeah. And I think it, you know, can be really harmful sometimes when, when we don't communicate that expectation. Uh, uh, but, uh, but yeah, you know, so, you know, agency, uh, you know, responsibility is sort of a dirty word in psych and I've written a little bit about, yeah.
Um, but I mean, I think good therapy ultimately is, leads to the patient feeling more responsible for their choices in life, a greater degree of freedom in the world, a greater sense of self-responsibility. And I think therapies that sort of move the patient, if you will, in the opposite direction are potentially quite dangerous and quite harmful.
So what would you do, magic wand? if you could influence today's broader training programs in mental health. I'm not just including, of course, psychiatry residencies, psychology programs, psychoanalytic institutions, but, you know, the bread and butter of today's therapists, right? Social work, counselors, LMFTs, everything.
I actually think that incorporating more history of psychiatry and history of psychotherapy material into training, even early on, is really important. Because when you read history and you know history, you realize that the fields have been prone to so many fads over the years. Mm-hmm. And things come and go. There's, you know, major, you know, pendulum swings in psych. And if you live long enough and you stay around long enough, you see old things come back in fashion or so I understand.
And so I think, you know, you know, I actually just said something about this on social media yesterday about the APA guidelines on BPD, right? When I was in school and training in the 2000s and early 2010s, dialectical behavioral therapy was the gold standard for BPD. And if you didn't do that, If you were trying to apply psychodynamic therapies to treating BPD patients, you were probably going to be ineffective or worse.
You might actually do harm the patient. Well, now we see the APA saying, well, there's good evidence for transference-focused psychotherapy and mentalization-based therapy and Gunderson's good psychiatric management, right? So, you know, there's a faddish sort of propensity in our field. So that, and then also... read the old school stuff. You know, you know, read, read some, of the stuff that was written 50 or more years ago.
You'll realize that they were seeing the same patients with the same types of problems. And just because something is old doesn't mean that it's no longer valuable. In fact, I actually think that a lot of the writings from 50 years ago or so are much richer in what they capture than the stuff in the psych journals today, which just seems so watered down and the like.
Yeah, it's unfortunate. I mean, my guess is that it's just a matter of the publication expectations, right? You have to sort of follow almost a cargo cult of how you write an article. What's more important is that you detailed every aspect of your systematic review rather than the quality of your synthesis of what has come before. Exactly. Now, if I can get my trainees to read anything, I'll take your advice.
It's a little hard these days.
Yeah, I think it's talking about – there's just so many circles, like things – like I'll read a paper. I'm going to get the details wrong. But I read a paper from like 1860s that said like we are on the cusp. We're a decade away from understanding all the biological aspects of mental health. And it's like that was over 100 years ago. Yeah. Yeah. Yeah. And I see people on social media saying like, oh, that paper is from 10 years ago.
I want to do you have a more up to date paper? And it's really got to be reframed that, no, this paper has lasted 10 years. Sure. The newer stuff is not the better stuff.
I'm actually more skeptical of the newer stuff. I feel like there's. Yeah, I. Yeah. I always recommend starting, you know, starting with with some of the older stuff, you know, Freud, Kreplin and the like.
Yeah, that does annoy me. Right. It's not as if it's purely a bench research issue where we're identifying genomes or. Drug targets that I can understand why. Or histology, pathology. If you want more paper, I got it. But for example, this year, submitting a presentation for the American Psychiatric, they had a rule that your citations had to be in the last four years. You know what ended up happening?
We'd have to get review articles that would cite the actual important papers that were relevant to the presentation. It was just arbitrarily in the last four years.
Sure, sure. And I think sometimes rules like that are just to increase the number of citations on newer papers, you know, that sort of thing.
I'm noticing we only have, you know, I want to make sure we end early so you can move on to, I think you have a patient afterwards. Is there anything else that we haven't talked about? There's a bunch of stuff in the beginning that we brought up that we didn't quite finish. Anything else you want to close a loop on before, you know, before the end?
Well, I'm not so sure. I've written a little bit on anti-psychiatry and defending psychiatry from a lot of criticism that's out there now. And so if anyone's interested in some of that work, I've written some stuff with Ronald Pies, who's become a good friend. Ron was the editor-in-chief of Psychiatric Times. But, you know, I think in closing, you know, there's a lot of room for informed criticism of what happens in psychotherapy and psychiatry without you know, without aligning yourself with anti-psychiatry.
And I think sometimes these labels just get thrown out and, you know, and they become sort of meaningless. You know, there's a lot good with psychiatry and psychotherapy, but there's a lot wrong with it too. And I think when you read the brightest minds in the field, I think you see that they're willing to be a bit critical to question things about why we do things and why we think about things the way we do and that sort of thing.
So I guess I'll close with that. A healthy skepticism I think is important.
Absolutely. Right. The criticism makes us stronger. Well, I will say I'm looking forward to reading more of your work, especially anything that you will have in the future to further describe the psychotherapy of patients with psychosis. I think it's a very exciting area that's been understudied, especially of late. Thank you for coming on and talking to us. It was a real pleasure.
Yeah, absolutely. Thank you, guys. This has been great.
Yeah, we really appreciate it. If you ever want to come back, you're always welcome. Absolutely. Let's do it. All right. I'm going to, we'll close it there.
All right. Well, here we are. Uh, some final thoughts before we totally wrap up your impressions, Dr. Malzberg.
Dr. Phil, you know, I'm not good at that. I'm not, I don't think of my feet.
Well, you gotta, you gotta, you gotta do it. We're pushing you along.
All right. Uh, that was incredibly helpful. Um, we, I feel like he packed so much in an hour. Um,
Yeah, when you get a good thinker like that, you want to do re-listens. That's what I'm going to say. I sympathize with people who want to rename borderline because I know they're well-intentioned and they want to fundamentally treat people. Here's the problem. I think it's actually a very complicated area of psychiatry and pathology. you can't describe it in one name. It's got too many parts, moving parts, variable parts.
And one umbrella term like borderline, I think is just fine. The real problem that I see is that clinicians don't do enough work to really understand recognition, diagnosis, and treatment of borderline conditions. And what they do is that they reserve, I think I've said this before a previous episode, They reserve the diagnosis to patients they don't like, and that corrupts the practice of mental health treatment.
So, yeah, can you come full circle? What did you mean by that in regards to renaming?
Well, they want to rename because they think that the name hurts patients because it's stigmatizing. But the reason why it's stigmatizing is because the clinicians themselves are the ones reserving the diagnosis for patients that they dislike. They withhold the diagnosis when they have patients that they like. I'm reminded of a time where I was discussing a patient with another clinician, and in my opinion, extremely clear borderline personality disorder.
And the response from the clinician was, I don't like to jump to borderline. Well, what does that mean? Would you ever say, I don't like to jump to bipolar disorder? I don't like to jump to schizophrenia. I don't like to jump to major depression. No one says that. You go off the clinical evidence. But clinicians are perpetuating an environment where it's a stigmatizing diagnosis because they themselves have an unacknowledged hatred of patients with borderline personality.
And yes, the treatment can be difficult, but it's unfair to the patients.
I feel like I'm going to move to defend that person who said, I don't like to jump. There is the concept of the diagnostic hierarchy, which the personalities disorders fall below a mood or psychotic disorder where you should be treating and making sure that those are treated before giving someone that diagnosis. So there is some validity to what that person said.
We can debate on that. I'm against that. I'm not Alan Francis. I think that it's ludicrous to think, The presence of axis one rules out the presence of axis two, or the presence of axis two rules out the presence of axis one. Comorbidity exists, right? And if personality is something that is present in everybody and present from an early stage, you can make that diagnosis if you have the data.
If you have the data. Well, that's what I'm saying. I'm saying the data was there. The axis one was already well identified and treated. You have to consider alternative explanations.
Yeah, so I think you're agreeing with what I'm saying, but to clarify, what you're saying is the axis one was well treated, and you had the data to see what the axis two was. What I'm saying is... Kind of, but I don't believe in the hierarchy.
I don't believe in the hierarchy. I believe that you have to weigh each possible diagnosis and find which ones are supported. There's no hierarchy. There's a hierarchy if there's obviously sufficient symptoms of certain conditions, right? Mania, hypomania, acute psychosis, OCD, that would impair your ability to elicit or observe the diagnostic features of another condition. That I agree with.
Yeah, and that's kind of the main point is the hierarchy, even if it's simplified and not perfect, makes sure that you don't diagnose conditions that are secondary to another condition, that you're not diagnosing ADHD before treating mood symptoms, which are leading to difficulty with concentrating. You're not diagnosing a personality disorder before treating mood symptoms that could be exacerbating personality aspects. Yeah.
In a well-trained, intelligent clinician, I totally agree.
Yeah, none of us are well-trained, intelligent physicians. How many do you know?
Exactly. So I think what really happens in practice is people go like, I've identified what looks like major depression. Therefore, I can't make any other diagnoses, nor do I need to. And so people really should be longitudinally observing, re-diagnosing, re-testing it.
Yeah, and the flip side that's wrong is I've just met this person. I'm seeing primitive defense mechanisms. Therefore, I'm diagnosing personality disorder when it could possibly be.
Yeah, I mean, we weren't agreeing with that. I think we covered that in an earlier episode, too. But that's, again, because clinicians are, I think, reserving those diagnoses for the patients they don't like, and they don't understand how to diagnose personality actually, right? They go off their countertransference rather than digging up and evaluating the clinical data across the lifespan.
um yeah so i guess this is you know we have to remember we're capping off our our dr ruffalo interview i feel i feel bad should we always have a segment where we get to give our opinions without the the guests well i mean is that is that so wrong we
love the guy I mean, even if we didn't like the guy, I think that's our right as hosts, I think. I don't know. I don't see it as bad. No, I agree. It's just a little fun.
Yeah. What did you take away? What do you think was, what did you enjoy about Dr. Ruffalo's comments?
Well, I think they were all really great. He's got such a command of the area, and he's so well read. I'm a pessimist. I feel like he's right. And I don't think that the field, you know, in general is going to carry through that stuff. Like I mentioned, um, nobody reads and you kind of need to read. And I don't think technology is going to make that any better.
People are going to think that asking chat GPT for a summary of an article is the same thing as reading and rereading it and letting it kind of sit with you and letting yourself apply it to your clinical encounters. You know, it's just different.
Yeah. Um,
I say as we are recording new media, a podcast.
Reading and listening. Reading and listening are the two things. Sure, sure. Yeah, I made a joke, but I think it would be cool to do a segment of... Because one thing I particularly enjoyed with mentors is having them answer as if they're in the clinical space and having them answer questions from patients. I always found that so helpful because a lot of times you'll get responses like, how do I communicate this diagnosis?
And you'll get guidelines, be empathic, be thorough, all these things. And hearing someone give an example of how they communicate it, I... We should do a segment where, yeah, we're just patients. Yeah, that's that's a good idea.
And, you know, great tip for the trainees. Right. Ask for specifics. Ask for role play and also ask multiple supervisors, even supervisors that you don't like. You will find that you'll probably learn something even if you disagree.
Yeah, I remember I would always have to pin them down and make them answer because a lot of supervisors would get away with answering vaguely. And I would demand that they give direct answers. And I thought it was super helpful.
I got a little secret for you. I got a little secret for you. It's because the more senior you're attending, the less direct patient care you do. And so you may not have done that for a while.
All right. Well, that caps up our episode. Anything else you want to close off on?
Oh, no. I think it was a good one. Looking forward to the next one. Like and subscribe, et cetera, et cetera. And we'll see you guys next time. All right.
Thanks a lot for listening.