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Jul 22, 2022

When I worked in a behavioral health hospital, all the nurses said it was because she was borderline (BPD) when there was a difficult female patient. Obviously, no one can be so easily diagnosed but it is a common belief that individuals with BPD have difficulty in relationships. How true is this and just exactly what is Borderline Personality Disorder?


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[Music] welcome into the psych with mike library this is dr michael mahon and i am here
with mr brett newcomb along one more time i'm sorry to interrupt i'll shut up on
your line we'll go ahead and introduce the our guest i brought a friend of mine with me today her name is michelle stieg
and she is a licensed professional counselor here in st louis who is so good that she hasn't accepted
any new clients in two years is that a is that a true statement uh it's no we are at two and a half years
at this point oh and over two years right i think the correction yeah right yeah one more time for the cheap seats yeah
not if you're not accepting clients for two and a half years yeah well that's awesome yeah yeah it's been
when you're good you're good say it one more time i couldn't hear you well you're good that's right you're
good okay got it yeah yeah uh i'm i got dynamic i'm telling you this dynamic
is freaking me out
all right does your wife know you're here with her yes okay
when i'm with michelle my wife is almost always with us yes so i'm feeling her energy that's this girl
is here now thank you not here oh okay except she's probably some spirit something snarky yeah she is she sending
me energy yeah snarky vibes yes yes snarky vibes i'm surprised that she
lets you hang out with the two of us unsupervised it's only because i'm here yeah exactly it's only because i'm here
yeah so did he tell you so uh we go to colorado every year
and one year he had devised this plan where he and
his friend paul brett he being brett uh
took the truck and drove around the corner and hid
so that when i got to his house uh his wife was there and and frantically
like oh my god you're you're late and they've already left and i am
freaking out there's a history here when mike was in graduate school and was one of my
students yeah he didn't turn in his assignments uh they were late too
considerably it's late yeah so much so that like a year later we had to go before the provost and work out a deal
to accept and finish the classwork sure yeah so mike has always had problems
with time management and being on time exactly and so we're going skiing and it's and you
and i are compulsively early forever absolutely if i'm not early i'm late yeah uh but we were once again
and we're gonna leave like at four o'clock in the morning and i said be on time i said matter of fact once you come up
spend the night and then we'll get you up and we'll get you in the car and we'll be ready to go now i need to be with my wife and my family because i'll
be gone for a week you know okay we'll be here on time so he was late
so i waited a few minutes and i said paul let's move the car so we already had it loaded i really appreciate it we
moved the car mike comes in we're hiding in the back room good for you mike comes in he's like where's your car they'll say oh
they left four o'clock you weren't here and he just blanched oh wait bet uh and
for the first 75 miles he didn't have anything to say done
i can't believe him you guys love me but in subsequent years
man was never late i bet yeah i thought okay so you brought it up sucker yeah yeah all right so i i don't
have a problem with it yeah i'm 60 years old now i'm do what i want and now you're on time
yeah yeah i actually i i am pretty much on time i don't think i'm late to anything anymore
but that's not what we're here to talk about what are we here to talk about what are
we here to talk about so i had sent you an article on the
difficulty that individuals who have borderline personality have
with relationships and so i actually sent this to spark the
clinical discussion i think that that is a thing that is
stereotypically believed and what i'm wondering is from because we have three
very experienced clinicians here in our experience is that a true thing or is that
something that gets hyped but really is more pop science than it is
true therapy that people who have been diagnosed as borderlines have histories of relationship problems right
and if they do why you want to deal with that
kind of but i want to hear yours first your take first and then because i have some different things yeah part of the reason that i
bring this up is because when we first met each other brett and i
you had a whether it was overt or covert a reputation for working with access to
personality disorders and in the group practice that we were in i know for a fact that it was routinely
said that if somebody had a personality disorder client they either had to do
therapy or had to do uh uh supervision with you or you had to do
the client and so you have experience in this area so i think we should define what we mean
by absolutely personality disorder uh in the dsm the diagnostic and
statistical manual whichever iteration it is 567 uh of the american psychological
association they have a
list of identified traits and the characteristics of those traits that come with a label
that's used in medical situations and for insurance coverage to say oh this person has 30928 and then everybody
knows what that means they go look it up and it's like looking at encyclopedia
there's a cluster of personality disorders and the idea is that all of us have
personality traits there are parts of us or elements of us that manifest in situations
the more complex and pervasive that trait is as the way we present ourselves
to the world the way other people experience us the more likely it is to be called a personality disorder if it's
dysfunctional if it if it causes us life cycle problems relationship problems
so the more it's a consistent articulated pattern as the way we and everyone else around us experiences us
the more likely it is to be a personality disorder which is an axis 2 disorder than to be just a personality
trait which might be a part of who we are but it's not all of who we are borderline personalities one of those
traits uh are that get extrapolated into a disorder
and it is a comprehensive way of being experienced experiencing self and of
others experiencing us and in my experience yes relationships are extremely problematic for people
whose central manifestation in life seems to be caught up in this complex of
traits so my introduction to borderline personality disorder was working in the hospital before i got my
graduate degree and started doing therapy i worked in a hospital from my 16th birthday until
eventually i left to go into practice with brett and [Music]
i worked on the unlocked behavioral health units and whenever there was a
female patient that was difficult and oftentimes med seeking all of the nurses
would label this person as borderline so that was my experience anybody that you
didn't want to deal with according to the nurses female specifically it's female specific right right right uh uh
was borderline and i'm like okay well what does that mean that
so anytime you so so what is this this constellation of behaviors that makes up
borderline and obviously they didn't know what they were talking about so what is the constellation that
makes up that personality you said they didn't know what they were talking about but one of the jokes in the practice over years was
that if the uh receptionist secretary hated your client female client she was
borderline yeah and she very often was i know because i really struggle because i think there's a lot of like internalized
misogyny within the dsm and all of that but you know when these difficult patients come in
and yeah they're probably borderline but the the unfortunately a lot of it is true yes right yeah so it's a it's a bit
of a frustrating topic for me well the whole idea of labeling is frustrating for me because the tendency
then is to see the label and you look up the description in the dsm and you start trying to find well how does this fit
they have to have three out of five or five out of seven and do they have these and okay then they must have these others
or just in the background let's find them and we spent all our time and energy trying to validate that in our
thinking and in our notes and in our treatment plans instead of being able to just see the
person in the room they're human here and now stuff yes and the trauma
that has led them to being a borderline i don't know ifs really changed the way
i see a lot of these like you know access to diagnoses things and
i guess as it should right yeah and you know kind of like what we were saying about sitting with a man who is who's
raging and not being activated like i don't know when i
when i work with and have worked with borderline clients it's the ifs world changed it in terms of
like being really curious about the behaviors instead of diagnostic and judgmental and
how how do we deal with the symptoms here when what we're dealing with is a wounded part of this person who has
experienced trauma and found a way to survive although it is problematic maybe now in adulthood
we need to honor that like that problematic behavior as an adult was a survival skill for them
as a child amen it deserves the respect one of the fundamental lessons you have
to learn if you're going to be a clinician is that all behaviors are in service of the self right
and so the challenge becomes when behaviors are problematic in your life
how is that in service to you what needs within you are being met by that behavior
and so then we talk about emotional economics and cost-benefit ratios do you understand that that particular
behavioral pattern whether it's emotional regulation i'd are you a sex addict are you an
alcoholic are you a workaholic how does that pay off for you right and what does
that cost you and then these labels that come with negative or pejorative
conceptualization oh you're borderline how do those behaviors manifest how do
we identify them as black is asking and how do they serve your needs and is that the most effective efficient
satisfying way to live and if it's not could we make some changes
and that's what therapy is about can we have these conversations where you're in a safe holding environment and you can
explore and experiment with identifying uh the behavioral choices and emotional
reactions that you have understanding where they come from what they cost you what how they pay
because often they're protective they're very you know i behave in a way that makes you reject me that protects me
from caring about you or having you make demands on me and i can say well you rejected me uh
can i examine that and say would it be possible to behave in a way that doesn't
require you to reject me right what would that look like and what would the cost of that would it feel like yeah what would it cost me exactly so when
you do therapy with these people who have been labeled this way those are the conversations that you try
to have something that i learned really is so we we talked in
the last episode about like how i figured out how to play the game in my masters right and
you know my auditory listening skills uh observation skills and how
most of my work is like a very sensory experience of just knowing when to push the gas knowing
when to downshift it's very sensory for me and at the beginning of my career i was
not very skillful in catching um some of those cues that i might be
working with a borderline client or whatever what started to happen to me is
my body would have a physiological reaction when i was in the presence
and one day i just like put the puzzle pieces together
that when you are with these you know this person here this person here
my body like would shut down i'm smiling because i remember a few months back you called me yes about a client that you
had that you were suddenly having this epiphany right i'm dealing with this borderline situation right because the
clinical issues were about boundaries right and these
people are so skilled at getting beyond or behind your boundaries and i am a master of better
having boundaries like it is like the foundation of what i teach with
people and and she got me you know she got me and at the same time well done you know what
i mean so i had this conversation with y'all and i said okay you need to do this and this and this and this and this
and she said i think you need to come out of retirement and take this claim
just once
so let's go to our break and then when we come back um i want to maybe kind of uh
set up a foundation for what we understand borderline to be from our clinical
perspectives hey everybody dr michael mahon here from psych with mike and i couldn't be more
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friday it's psych with mike okay we're back and so
i think well let me ask the question
probably the single most significant clinical
presentation of borderline is a profound
fear of abandonment would we all agree with that yeah okay and so then that
fear of abandonment creates a dynamic of behavior where the individual may
approach these kinds of interpersonal relationships because that's what they
desperately desire but will ultimately do things to undermine and even to
destroy those relationships and so it's an approach avoidant kind of behavioral
pattern and that's what makes their ability to be in interpersonal relationships complex do we all agree
with that yes and it's intensely repetitive yeah they cycle through relationships where
different persons same issue different person same issue different person same issue same behavior
they are incredibly seductive and i don't mean the sexual sense although they can be what they do
um in their neediness i need you to love me to accept me to help me
but i'm going to test it do you really love me do you really need me and so i'm going to constantly test it if you get
frustrated with me if you reject me if you punish me then i was right all along and you didn't love that self-fulfilling
prophecy yes the reason why that's so hard is because the vacillation of the affects so their moods will change
rapidly and unpredictably so you may think that you're in this really intense
relationship and all of a sudden this individual does something out of left field and then you react to that in a
negative way and then that confirms their world see what you made me do yeah i knew you were gonna do this well and i
think as a clinician you have to be acutely aware of your parts right when it comes to
because it is a constant dance right so like oh and they're so subtle and their
productiveness they want to be your first client or your last client they want to walk you to your car they
want to bring you donuts first thing in the morning to have with your coffee they want to be special they want to be
different uh they will study your office when they will study you yes
they find out what tv shows you watch they'll find and they look you up on the internet they find out where you live they drive by your house i love your
roses they look so good you're like wait a minute you don't know where well they do know they do and so i
think it's imperative that you be aware of the shifts that happen inside your system and your own internal
system will tell you yes if you listen yes because they as a borderline client will pick up on
the shift before you even do and they will call you on it which then puts you
into or can like um into a defensive position where then you're trying to scramble
and make up and be like no it's not like this when they can read you so you're aware your self-awareness
is imperative because they will know you when that when a new part steps in with
you they're on it well and they they know the buzzwords to use to to push your
buttons they'll say you don't really care about me you're just a paid friend you're just doing it
for the money and you have to say i'm not your friend at all right i'm not a paid friend i'm not a friend right that's not my role in
your life i care about you i'm your clinician i'm your therapist i'll pay attention to you
as long as you pay your bill yep right i am paid right but you're buying a
professional service and you're not buying friendship right i don't actually think about you over the weekend when
you're not here although they will try to get you to they'll send you letters they'll call you they'll have a crisis
call yes you have to so working with these individuals borderline is about borders
you have to have boundaries you have to have lines you have to say this is not the way it works right so i
used to teach my students who wanted to be clinicians if you have one of these clients that send you a 10 page letter
during the week because they can't hold you from week to week session they don't remember what you said they can't they
can't hear your voice they become terrified that you don't really exist so they write your letter you're supposed
to read that letter that makes you think about them when they're not there so the way you handle that is you bring
them in the office and say read this to me you don't have have not read it
they get really rattled and that's not the objective is to get them rattled the objective is to say
you exist and i exist in separate planes when we come together it's predictable it's
consistent i'm available i'm available for you now whatever you needed me to hear share it with me now so
what is the feeling of the room here because everybody obviously is a
well-trained experienced clinician as to whether or not these individuals
can make because what you're talking about brett is you're setting boundaries yes
can that individual then understand those boundaries accommodate them can
they move beyond the borderline kind of insecurity to
have a secure interpersonal relationship okay theoretically
no okay most of them right and from our training so we
grew up with the whole kohut kernberg kind of access to understanding and from
our training what we have been taught is that it would be extremely difficult for
an individual who has this personality disorder to move past they can learn
compensatory behaviors the theory is that you can provide benefit by doing supportive expressive psychotherapy
i support you i let you express your feelings i'll let you experience your feelings in a safe holding environment
but i don't fix you i don't change you you may be able to do that yourself but
the theories that i've read say you can't do it until you're in your late 40s right 50s
only then if you intensely want to and have a supportive environment to work on it and i want to be clear that
from our kohut kernberg kind of psychodynamic education that's what we've been taught
if there are other people out here who have different ideas we're not saying you're wrong we're not saying that we
know everything we're saying that from our clinical perspective that's what we've been taught i would be interested
from an internal family systems perspective is that different yeah so i think again
a common thing for me you'll always hear is that awareness and so when we work with you know trauma backgrounds or
did um borderline dissociative identity disorder yes um
so it's a really interesting approach when it comes to the ifs work because what
we're doing is creating awareness of when a a part steps in and blends with the
client or when a client becomes hijacked with a part triggers triggers and then you know prior to learning about ifs and
how parts work um they're just functioning right like they're just going through their day and
they don't understand why why they're getting triggered or why they're repeating the same patterns of
putting pushing people away or feeling abandoned or feeling like nobody loves them and so our our job in internal
family systems is to um map the different parts of them that hijack
them right so it's a constant awareness of of parts
stepping in and swooping in and me saying to them like mike it seems like
your suicidal part has really stepped in because i've learned the tone of the voice that your suicidal part has
um so then we work directly are you aware that that part's here in the room right
yeah probably talking with me yeah it's here well so from my union perspective
that would be my animus part and yes i'm very aware of but most clients aren't yeah i mean
that's part of what you tried by that invitational oh to invitation to awareness what you were talking about our first episode you asked them get in
touch with that and you're trusting your own radar i am sensing it
i'm wondering if i'm getting that accurately are you aware of it can you feel it but so when they when you teach
them when you map the parts and then you work directly with the protective parts and you understand so
we always say like all parts of us are welcome because all parts intentions are honorable they show up in really messed
up ways though sometimes but their intention is honorable even suicide even self-harm
that part gets to be here because its intention is honorable it loves and cares about you so much it will do
whatever it has to do to take care of you even kill you yeah 100 because the only
way for you to not be harmed in this way is to die it's to be taken out which is the ultimate loving act as seen
by this part of that part and so we teach people because we're we're walking around fats
i'm unhappy i don't know why i keep doing this i don't know why i keep ending these relationships and this is anybody who comes to therapy right and
so when we map the parts and we learn the parts and we understand the intention of the part and the fear
i am afraid if i don't make mike suicidal x y and z can
happen so we learn their narratives so then we learn how to negotiate and we work with them and we heal the trauma that's
underneath the protective part the trauma that that part is protecting so that extreme part of
their personality like a borderline for example that extreme part of their personality
doesn't have to hijack them or get so activated because we are working with the trauma that it's protecting does
that make sense yes it does to draw to me yeah right right um what i'm thinking is though
again the importance of not identifying a diagnosis and seeing a label correct
seeing a person and the awareness that there are traits
that can become developed to the point that they take over the personality and then you have a
personality disorder but lots of people have the traits and so the
at different times when i'm out of balance one trait is stronger for me than at other times and if i come to
therapy and they see this trait i don't want them throwing a big whole label on
me right because that's dangerous in a lot of different ways right so i think clinicians need to be super
tentative and cautious about access to labeling well and i also would say i
mean whether it's borderline or i think women get diagnosed borderline men get diagnosed narcissistic
and whether or not that's a different set of constellations or not
the truth is that there should be an even distribution of those disorders right so
there should be just as many men who are borderline as there are women even though there's a tendency to identify
women that is something that has developed in the zeitgeist of the practitioners
it shouldn't be a real thing in the population yeah and so that's for me that's why
because you taught us early brett don't label people there's no reason unless they need to get reinsured
reimbursement from reins from insurance what what value is there in the label
well they're true potentially a reason if they're going to go to other therapists or be in the hospital other professionals
will if you look at that label have a certain data transfer to say okay
i know what i'm dealing with as long as it's an accurate label as long as they don't have a bias though yeah right
because when i was in the hospital like i said you know every woman who was hard to get along with was borderline well
clearly that then i should be able to then i should be borderline don't you think i'm pretty hard to get along with
yeah crickets look at that i don't have a problem with this
but but obviously you're more sociopathic but yeah
now we got to tell people what sociopathy is no we're not going to do that so uh
but uh what i'm hearing though from you michelle is that your
clinical perspective is much more optimistic about how these individuals could
learn new adaptive behaviors than what brett and i have been taught to believe
ish so um i'm more optimistic at the potential
and the um [Music] i think there's more potential
for healing from this angle from this model and and where we have always been
taught that this is an age-related thing like you have to be later in life to really approach these issues from an ifs
perspective that age restriction wouldn't be a part of it right you could do that at 18 as well as
you could do it at 58. correct but i but there's a part of me that does but still buy into the the age yeah you know what
i'm saying like from a realistic standpoint from what you've seen i mean people have to have i think you have to have the life experience yeah yeah yeah yeah
exactly because otherwise you don't if you don't have the life experience you don't have the perspective to understand you sabotage more quickly it's an empty
it's an empty container and so well and i think that the ifs standpoint
allows for you know if we're talking about like like a cancer diagnosis right if we
provide these therapeutics it gives you a longer better quality of life and ifs i feel like offers that in a sense when
it comes to trauma and and the personality disorder access like i think we can offer better quality of
life throughout the lifespan if you learn this at a particular spot they have the awareness
learn about the parts and and we can go in and heal specific traumatizing events so
parts don't have to get so activated and if nothing else it gives you the
opportunity to see the behavior in real time like when you
say oh i see your your self-destructive part has come in well now that
individual can say oh okay i see that exactly yeah that's exactly it so they can start to
identify it within themselves and when they're so we can take it outside of the petri dish of the the office they
can i catch it possibly i see that with all clients yeah in
terms of identifying the behavioral matrix that they experience
to i mean people that are dissociative that have uh they have the ability to
disconnect or go away and if you're talking to them and you're trained you can see them go away you can see when we
start to talk about grandpa there's something shifts right and their expression in their eyes sometimes in
their bodies they cross their legs or whatever and so then as a clinician you start to
point that out to them and show them you say well you just went away somewhere no no i'm right here it's creating the awareness yes back to the awareness yes
it's everything it's crucial yes because you you see so you don't muscle up and say i'm the brilliant
person in charge here you say okay it's really important for me to understand
not supposed to can i point this out to you again just so that you can clarify for me that i'm wrong one more time i'm okay with
hearing that because i want to learn to hear you accurately and if if if i think red and you think blue then i need to know that so then they're like yeah okay
and you just keep doing it and keep doing it and keep doing it if you're right if you're on target with what
you're seeing there will come a point where they will laugh and go oh i just did that didn't i
exactly awareness awareness consistency yes of the message from the theory
i'm not attacking you i'm just saying i think i see this i think i'm feeling this it's just an observation am i out
of balance here yeah you are and when you do that consistently then it creates
a less threatening opportunity for the client to then allow it to boil up into
their own internal awareness yeah exactly exactly yeah okay hopefully that was beneficial for people um we
may be get kind of heady in some of these clinical discussions so if anybody ever has any questions or would like a
clarification of anything i'll share real therapy somewhere go see a real therapist you can also send us questions
you can get us at as always the music that appears in psych with mike is
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me [Music]