Episode Transcript
[00:00:05] Amynah Dharani: You're listening to The Love Vox with psychotherapist Amynah Dharani.
Hello, everyone. I'm your host, Amynah Dharani, and I am so excited to be here. This is the podcast for people who are passionate about the human condition by people who are equally passionate voices in their feelings.
Friends, I hope you had a wonderful Labor Day weekend. I can hardly believe that summer is almost over and we are back at school.
In today's episode, we are going to dive into the highly misunderstood and highly stigmatized diagnosis of borderline personality disorder.
In very simple terms, I describe borderline personality disorder as a condition in which individuals struggle to regulate their emotions following a triggering event. Individuals struggle with intense and long lasting feelings, which makes it hard for them to return back to a stable state.
Statistically, about 1.4% of adults in the United States are believed to have borderline personality disorder, and the majority of individuals diagnosed with this disorder are women. However, recent studies show that men may also be affected at a similar rate. It's common for men to be misdiagnosed with PTSD or depression instead of borderline personality disorder.
I recently met with psychoanalyst doctor Mark Ruffalo to discuss this diagnosis. Let's go meet him.
I have here with me today Doctor Mark Ruffalo. Doctor Mark Ruffalo is assistant professor of psychiatry at University of Central Florida College of Medicine and adjunct instructor of psychiatry at Tufts University School of Medicine. In addition, he has a private practice in Tampa, Florida. Welcome, Mark.
[00:02:11] Dr. Mark Ruffalo: Well, thank you so much for having me. I've been looking forward to this wonderful.
[00:02:16] Amynah Dharani: I wanted to invite you to the show to discuss the very misunderstood diagnosis of borderline personality disorder. I feel like it's received a really bad rap socially and in social media of late, and I wanted you to help the audience understand the person behind the diagnosis. But before we dive into borderline personality disorder, if you could please explain how your being a psychoanalyst is different from a mainstream therapist.
[00:02:50] Dr. Mark Ruffalo: Yeah. So psychoanalysis was really the original form of therapy. It was developed by Freud over a hundred years ago and brought to America, and it was mainstream in american psychiatry for a good 70 years or so and is still practiced. The essence of psychoanalysis and psychodynamic therapy, or psychoanalytic therapies, which are derived from psychoanalysis, is that much of what motivates us as human beings is hidden outside of our awareness. Psychoanalytic therapies really are about uncovering, making sense of patterns that play out in a person's life, really without their understanding of why they're doing what they're doing or why they're feeling the way that they're feeling. So psychoanalysis is a depth therapy. It's different from other more directive therapies which focus on providing coping skills and changing at the conscious level the way a person thinks, such as cognitive therapy, psychodynamic or psychoanalytic therapy is more about understanding the why and how it plays out in the relationship with the therapist. So it is a bit different from other therapies which have become a bit more popular.
[00:04:07] Amynah Dharani: What is a personality disorder? How is a personality constructed? I mean, you know, we talk about personality disorder. It sounds really pejorative. You have a disorder. Can you explain that?
[00:04:19] Dr. Mark Ruffalo: Yeah, it's a great question. Personality differs from temperament. Temperament is believed to be more biologically based.
Personality is something that forms, really, from the earliest days of life.
In essence, it's the way we relate to ourselves and relate to the world. It really is something that comes to define us as a person or as it comes to represent us as an individual person in the world. So is very much influenced by early relationships with caregivers and parents.
Many of the personality traits and characteristics are believed to form in very early life, from birth to, say, age four or five, a very, very critical period of psychological development. Temperament, which I mentioned, is something that is believed to be more biologically based of that would be someone with a hyperthymic temperament. This is sometimes discussed in the context of bipolar disorder. Hyperthymia being sort of a state in which a person is always a bit elevated in their mood. They always feel a little bit euphoric, but it doesn't reach the level of mania or hypomania. It's sort of believed to be a temperament, and that is believed to be biologically based. Personality disorders are largely influenced by environmental forces, by the early childhood dynamics, abuse, neglect and the like.
[00:06:04] Amynah Dharani: And I think you really took me to the next question that I was going to ask, which is, what is the difference between bipolar and borderline personality disorder? Because they're used interchangeably, and I think a lot of the times they're misused or misunderstood.
[00:06:19] Dr. Mark Ruffalo: Yes, this is a source of such great confusion, and I think there's confusion even amongst mental health professionals. Bipolar illness used to be called manic depressive disorder, or manic depressive illness, is largely a genetic and biological condition in which a person fluctuates, usually over the period of a period of weeks to months, between intense feelings of euphoria, feeling on top of the world. I feel better than, well, racing thoughts engagement in a lot of different behavior, impulsive spending, lots of money, promiscuous sex on occasion. And just a person is sped up in their thinking and their behavior. That's a state of mania. And after a period of mania, often it is followed by a period of depression, a dark depression that may last for months. The patient, throughout their life, cycles through these different phases. Mania and depression.
Borderline personality disorder. You do see fluctuation in mood. The fluctuation in mood in borderline personality disorder, first off, is much more transient, lasting on occasion just minutes or hours. A person may wake up and feel okay, and then they feel rejected or abandoned by their partner, and now all of a sudden, they are depressed. There's no point to life anymore. And then maybe an hour later, they're singing and they're dancing to their favorite music. And the depressions that exist within borderline personality disorder are often almost exclusively within the context of some interpersonal problem, some problem that they're having with another person in their life, often their romantic partner. And then you do not see mania in borderline personality disorder. You see behavior that look a little bit like mania in terms of impulsive behavior. But another important point is that borderline personality disorder is very much influenced by the environment, by child rearing, by early object relations, whereas there's little evidence that bipolar disorder is so influenced that it's largely conceived today as a mainly a biological disease.
[00:08:42] Amynah Dharani: You speak of the environment as being such a big influence on the diagnosis of borderline personality disorder. And it takes me to understanding what are potential situations or negative environments that could have injured this individual. And I'm thinking quite early on, can you elaborate on that?
[00:09:05] Dr. Mark Ruffalo: Sure. There's different theories, there's different hypotheses. Marsha Linehandheendeh, who developed dialectical behavioral therapy for borderline personality disorder, has argued that the early environment is marked by a type of chronically invalidating parent. The environment is chronically invalidating. That's the language that she uses. No matter what the child does, he or she is going to be invalidated. Some object relations theorists in the psychodynamic world, Otto Kornberg, perhaps being the most notable, would argue that it's more inconsistent caregiving, inconsistent parenting, where at one point in time, mother is very loving and nurturing and caring. At another point in time, the mother is withdrawn, cold and blaming, and the child becomes very confused and resorts to the use of defenses, what we call ego defense mechanisms and psychoanalysis, to protect the self or the ego. And they engage in this phenomenon that's called splitting, where they split the mother basically in half. They preserve the good image of the mother in their mind, and then they disavow the bad parts of mom.
And this splitting is played out throughout life in their interpersonal relationships. And maybe we can talk about that as a phenomenon or as a symptom, but the idea would be that the patient resorts to certain mechanisms to protect themselves. The child, that is, the child, resorts to certain ways of dealing with distress to protect themselves. And as they grow older into an adolescent and into an adult, these mechanisms outlive their utility. And now they become maladaptors. And that's when we consider it a pathology. So the things that the child uses to protect themselves in early life eventually become the problems in their adult life or lead to the problems in their adult life. That's a very core, fundamental idea in psychoanalysis.
[00:11:17] Amynah Dharani: I think that borderline personality disorder is, for a large number of people, only understood as an individual that is full, emotionally volatile.
But there are higher functioning borderlines as well, clients as well, and that looks differently. Like everything, this diagnosis is also on a spectrum, and the symptoms may look different. Can you give examples of that?
[00:11:45] Dr. Mark Ruffalo: You're absolutely right, and I think this is true for many or most, or perhaps all of the psychiatric disorders that are enumerated in the diagnostic manual. They exist on some spectrum. In terms of the degree of severity. There are, without any question, very low functioning borderline people who are unable to hold a job, may have to live in assisted living facilities because of the severity. They're chronically suicidal. Every day they are hurting themselves, they are cutting themselves, they're banging their heads against the wall. These are very, very unwell individuals, unfortunately. And then you have higher functioning people with borderline disorders without any question.
In fact, the great psychiatrist and psychoanalyst Harold Searles has argued that most psychotherapists have some borderline proclivities. So it is a disorder that exists on a spectrum. We also can talk about borderline traits where a person doesn't have the full, doesn't meet the full criteria for the disorder, but they have some traits of the disorder. I will say that there are borderline patients who have what was historically described as a mask of sanity.
To the outside world, they seem quite stable and normal. Perhaps in their work relationships, they are able to maintain work relationships, they are able to achieve professional success.
But in their interpersonal life, in their romantic life, it is chaos.
[00:13:26] Amynah Dharani: An area that I feel does not get identified or understood well is the struggling of the self image, the unstable self image and the identity.
What are their feelings about themselves?
[00:13:44] Dr. Mark Ruffalo: You're spot on. This is a disorder of self, a disorder of identity. It forms, really, the core of borderline pathologies, in my opinion.
Many patients come into my office and they say, I don't know who I am.
Chronic feelings of emptiness is described in the DSM.
Many patients go from job to job, from city to city, looking for some sense of identity. And often what happens is they find a person, often a romantic partner, but it could be a friend or someone else to serve as an individual who provides a sense of identity. And they begin to adopt the interests. They begin to adopt the manner of dress or decor or manner of speech of the other person. And this other person becomes an external regulator of emotion. They depend very heavily on this other person, which in the borderline community is sometimes described as the favorite person. They attach to this individual, and it gives them a sense of identity.
So, yes, there is a lack of identity in these patients. That identity disturbance is something that Otto Koenberg talks about. There was no sense of identity that developed in early life.
And it begins to affect their adult.
[00:15:14] Amynah Dharani: Relationships in terms of how they feel about themselves and the other. The other, as in object relations, the significant other, the main person. What are the problematic ways? How are they functioning in terms of who I am in relation to this other person?
[00:15:33] Dr. Mark Ruffalo: Yes. Yes. This is the essence, I think, of the pathology. And we can look at this problem through the lens of freudian repetition compulsion. Approach avoidance repetition compulsion.
The patient will approach the other.
There will be some closeness or connection or intimacy that forms, and then they will avoid the other. Approach avoidance repetition compulsion. And I think this is fueled by the patient's anxieties, the anxiety that is most commonly discussed in the literature. What the patient most often comes in sort of complaining of, is abandonment anxiety, rejection, sensitivity.
He or she is going to leave me. Everyone always leaves me. I always get abandoned. And this is a great fear for borderline people. And they will resort to all sorts of ways to test the other person. See if you really love me, you really care about me.
But this is only one anxiety that the borderline individual possesses. The other is what is called enmeshment anxiety or engulfment anxiety, a fear of closeness and intimacy.
So what happens so often in these relationships is the development of a push pull pattern where the patient expresses feelings of love, infatuation, obsession. I can't live without you. You're all I need. You're the man of my dreams. I couldn't imagine life without you. The other idealization is talked about in the DSM and in the literature, and they may feel close to the other person, but as the other person moves in, moves closer, starts to reciprocate those feelings, then the patient unconsciously begins to push the other away and sabotage or destroy the love that was developing. Because for these patients, love is so intertwined with pain.
And where there is love, they come to expect pain.
And when there is no pain, they will act in ways to create it. And this is what the psychologist Paul Wachtel talks about when he discusses cyclical psychodynamic. The patient will unconsciously. The borderline patient will unconsciously engage in ways that elicit exactly the reaction that they seek to avoid. And I've said before, I've written before that while the borderline individual, their greatest fear is abandonment. They act in ways that virtually ensure they will be abandoned, because no healthy person is able to tolerate the roller coaster ride, the ups and the downs, the push and the pull.
I hate you. Don't leave me. Which is a title of a popular book on borderline personality disorder.
And this is the cycle. It can be a quote, unquote toxic cycle. A roller coaster ride, breaking up and getting back together again promises to get better. And then a few days later or a week later, the devaluation begins again. I don't know if I want to be with you. You're not really who I want, etcetera. So this is the pattern that plays out in borderline relationships.
[00:19:24] Amynah Dharani: You've spoken about the object relations theorists, the world of psychoanalysis, and of course, Marsha Lenahan's behavioral perspective on this disorder. I've often had people ask me, well, what is the attachment view on the borderline?
Can you elaborate on that?
[00:19:43] Dr. Mark Ruffalo: Yeah. Yeah. So attachment theory is a way of looking at human relationships, how people attach to another. I think that much of attachment theory is encapsulated in theory. I see attachment theory sort of as an offshoot, I think where the attachment theorists were, I think psychoanalysts were there many years before. But anyway, the idea would be that the borderline patient is prone to certain styles of attachment, anxious attachment being a style that is often associated with borderline pathologies, that the patient engages in a very anxious way with the attached individual, the individual with whom they are attached, and also in a disorganized way. We can speak also of disorganized attachment, where again, there is this pattern of push and pull. It's very confusing. It's confusing for the patient or the individual and very confusing for their partner as well.
[00:20:50] Amynah Dharani: Patients with borderline personality disorder, why do they have a problem regulating themselves?
[00:20:58] Dr. Mark Ruffalo: I think the ability to self soothe, to calm oneself in the presence of anxiety, to resort to certain ways of calming oneself. Self soothing develops when a child has been soothed by mother or by father or by a caregiver. That the ability to self soothe develops because one has been soothed. And very often what you see in the histories of borderline patients is actually quite opposite history of neglect, of the lack of nurturance and the soothing that would produce in an individual an ability to self soothe. I think that's an oversimplification, but it certainly. It certainly speaks to this difficulty with regulating one's emotions during distressing times.
[00:22:02] Amynah Dharani: And in adulthood, that soothing can be representative of perhaps over shopping, indulgence in areas like food and substances as a way to regulate oneself.
[00:22:15] Dr. Mark Ruffalo: Yes, I think that's very accurate. Again, though, the patient is looking to external sources, and when there is a lack of that object, the external regulator of the patient's emotion, then the patient may engage in these other ways of self regulating which can be quite destructive to the patient.
[00:22:44] Amynah Dharani: Like borderline personality disorder, narcissistic personality disorder has also received a bad, rapid representation in the media and social media.
But they're also known within our clinical community to be such a toxic match in a romantic relationship. Please share with the audience what is happening in a relationship between a borderline personality disorder and narcissistic personality disorder.
[00:23:14] Dr. Mark Ruffalo: This is frequently observed. What explains the appeal and the pattern that plays out of the borderline individual often seeks out a narcissistic partner. Because of the narcissistic individual's apparent self confidence.
Very often the narcissistic individual seems to have it altogether. From the outside.
They may be accomplished, and they may be a bit of a braggart about what they've been able to accomplish in life. And there are this strong presence, dominant presence in the borderline patient, so desperate to attach, to find some sense of identity, sees the narcissistic individual as an opportunity.
In the early stages of relationships, there is this idealization, this honeymoon, where the borderline individual is very expressing of love, closeness, of infatuation and obsession. I love everything about you. The narcissistic individual, so desperate, so in need of this type of treatment, becomes very, very excited, feels really good in the presence of this infatuated idealization of the borderline individual, and they end up getting together. Both are meeting each other's needs.
Borderline patient is meeting the need of the narcissistic individual in terms of inflating his ego, making him feel good about himself. And the narcissistic individual is providing that sense of strength and stability and confidence that the narcissist exudes.
And then inevitably comes a period of devaluation.
May take a week, a few weeks, a month, maybe longer. Very often some of the signs are there from the early days, but the borderline patient begins to devaluate. The narcissist.
You're actually not who you seem to be. I don't know why I'm with you. I don't like anything about you. And may say many worse things than that. And the narcissist responds with aggression, anger and hostility because what he thought was going to be an endless supply of idealization actually now is quite different.
And the borderline sort of induces in some way in the narcissistic patient this aggressive, irritable, hostile response. And the cycle begins. A cycle of push and pull and great interpersonal difficulty and. And lots of fighting and breaking up and getting back together because each individual thought that the other was going to meet all of their needs. And then all of a sudden, that's not happening anymore.
[00:26:18] Amynah Dharani: In order to progress in life and in treatment, what is the borderline needing?
[00:26:28] Dr. Mark Ruffalo: I think the borderline patient needs a caring, supportive environment, a partner who is going to be patient and understanding, but at the same time not smothering.
Right? Because we have to realize these twin anxieties, abandonment, rejection on the one hand, closeness, intimacy, engulfment, and enmeshment on the other. They need someone who's going to be able to realize that I'm going to give love and I'm going to give support, but I have to, at times, keep a little bit of distance. I can't get too close.
This may eventually allow the patient within their romantic relationship to stabilize. Now, in terms of treatment, I practice general psychodynamic psychotherapy with these patients, informed by an object relations perspective.
In therapy, the patient needs to understand how these patterns play out, often in the context of the treatment relationship. And we talk about how the push and the pull, the idealizing and the devaluing plays out with me in the therapy office.
And this formalized form of this treatment is called transference focused psychotherapy, developed by Kernberg and colleagues in New York. And it is an evidence based psychotherapy, a psychodynamic therapy for borderline personality disorder.
So it's about the relationship. It's about understanding the development of the origin of the problem and then how it plays out in real time with the therapist arise in many different ways in the treatment relationship itself. Now another type of treatment which we've mentioned before is dialectical behavioral therapy, which is largely a skills focused therapy providing the patient with ways to tolerate distress, ways to handle the difficult emotions when they arise. And it is derived in some way from cognitive behavioral approaches where I the focus is very much on what's happening consciously and how to regulate self soothe. So DBT is much about the provision of skills. DBT has been shown to reduce suicide in borderline patients. Psychodynamic therapies such as transference focused psychotherapy tend to be better when it comes to the development of insight and awareness, self awareness about patterns of behavior. Both transference focused cytodynamic therapy and DBT are evidence based approaches to borderline personality disorder.
[00:29:24] Amynah Dharani: If someone were to say, well, what am I doing? I have a loved one, what should that loved one, what sort of treatment should they go to? You and I are both practicing psychodynamic therapists. We understand the cognitive world. That's probably how we had our foundations. But the lay public, what should they know about what type of therapy might be suitable or starting place for a loved one?
[00:29:52] Dr. Mark Ruffalo: It's a great question and it does depend a bit on the severity of the condition. Now if you have someone who is suicidal all the time, has had multiple attempts cutting themselves, really unable to function in day to day life, that patient may be better off in a dialectical behavioral therapy skills group in doing individual therapy with a person trained in DBT, someone who specifically is trained in this work, and I think group therapy as well is very helpful multiple times a week for patients who are on the more severe end the spectrum now for patients who may exhibit a lot of problems interpersonally, but they're more or less able to function and they're able to go to work and they're not chronically suicidal, and they're not always hurting themselves, then a psychodynamic approach may be more helpful. And in that case you may want to look for someone who is trained in psychodynamic psychotherapy or psychoanalytic psychotherapy. The American Psychoanalytic association has a directory on their website on psychology today. You can search by specialty or modality. Psychology today is probably the largest of therapists in the US. A lot of patients come to me after DBT where they've learned the skills and they've learned the techniques to self regulate and their emotions are not as intense as they were before DBT, but they want more, they want understanding and for those individuals, a psychodynamic approach is also useful.
[00:31:44] Amynah Dharani: So, yeah, one thing that concerns me, and that's why I wanted to have borderline personality disorder as a topic on this show, is, again, the shaming part of it. And a lot of clients that are coming to me are coming for relationship issues.
If you could wrap up this show by explaining, what can a client expect in your clinical room?
What should they expect with a psychodynamic, psychoanalytic oriented therapist like yourself?
[00:32:16] Dr. Mark Ruffalo: Even within the psychodynamic or psychoanalytic world, there are many differences in approach and different schools of thought. So it's not a uniformed therapy, really. But for me, the diagnosis of the condition is very important, and Koenberg talks about how the patient ought to be informed of the diagnosis. Historically, this wasn't done that many psychoanalysts would not tell the patient what he or she believed was going on in terms of psychiatric condition. But Koenberg says it's best to tell the patient, this is what you have.
So after diagnosis is rendered, we proceed, usually in twice weekly psychotherapy. Patient comes in and begins to talk about his or her life. And I may not be, I may not ask many questions. I'll try to get the patient to just talk about what's going on in their world and in their inner world, and they may have to prompt them a little bit, and I may ask some questions. So the initial sessions are really listening. What's going on in your life? Who are you as a person sitting in this room?
And then once, once I gather that information, then we begin to focus.
Usually something occurs early in the treatment between the patient and myself. The patient may ask to schedule an extra session, for instance, or the patient may miss an appointment. Or the patient may say something to me that warrants sort of discussion, warrants some sort of examination of what happened. And then it opens the door to a discussion of our relationship, how the patient relates to me and how I feel in relation to the patient, which is the transference and the counter transference in the psychoanalytic jargon.
And then over time, I begin to point out the patient's defenses and how they play out with me, how the patient engages in splitting and projection and projective identification in the treatment relationship with me. Those are fancy words, but basically they are ways that the patient utilizes to protect themselves that cause interpersonal damage. And so at one point in time, the patient may idealize me and say, I've never seen a therapist as good as you. I've read everything you've written. You're going to save me. You're going to help me. And I know that you're the one. I love how your office is decorated. I love coming here. You're the best thing in the world.
[00:35:10] Amynah Dharani: Those are usually alarm bells for me. Or at least.
[00:35:14] Dr. Mark Ruffalo: Yes, yes. The patient's idealizing me, right? Maybe a counter transference reaction is it kind of feels good, right?
And then sure enough, within a matter of time, the patient comes in and devalues you.
I don't know why I come here every week. I don't know why I'm spending money on this. You haven't helped me.
You're not as good as my last therapist. And they begin to triangulate. Meaning bringing in a third party in the relationship and comparing me.
You've never done anything to me. I don't know why you have such good reviews on the Internet. You're not a good therapist. I don't know why I'm coming here. Right.
And then once that devaluation subsides, if the patient has not left treatment, because there's a real risk that after a period of intense devaluation, the patient will leave and never come back to therapy. But if the patient comes back and they're not devaluing me anymore, then we begin to talk about what happened and how this process is playing out with me and how it reflects how the patient relates to others in their daily life.
And then eventually, perhaps, we make what's sometimes called a genetic interpretation. We make some connection to the past and what is replaying from the past in the here and now.
And over a period, usually of a few years, patient may get better. In fact, many patients do get better. That's one of the myths of borderline personality disorder. And so this is, in essence, how I work.
[00:36:56] Amynah Dharani: Dr. Mark Ruffalo, thank you so much for attending. I hope you will come back.
[00:37:02] Dr. Mark Ruffalo: I would love to. Thank you so much for having me. This was wonderful.
[00:37:07] Amynah Dharani: Welcome back, friends. So what did you take away from my discussion with Doctor Mark Ruffalo?
As a psychotherapist, I do work with personality disorders in my private practice as a clinician. I believe that within the communities of mental health providers, there's not enough clinical training around this diagnosis and other personality disorders and definitely not enough providers who agree to treat such cases.
I do understand that individuals with borderline personality disorder stir up negative stereotypes based on their inability to control their behaviors. Yet it surprises me how mainstream this stigmatization of borderline personality disorder has become. I feel sad about that.
What I do encourage people is that if you do come across someone with these tendencies, it may be helpful to reflect on the root of your own fears or thoughts regarding mental health.
Developing empathy is key for people suffering with this disorder and other mental health conditions so that they can get care and necessary support.
If you'd like to learn more about my private practice, you can go to thelifeinterrupted.com. in the meantime, please connect with The Love Vox on Facebook, Instagram, and X. And if you'd like to contribute to the show, please visit the show's website, thelovevox.com, where you can leave voicemails that can be featured on the show, and you can also contribute to stories we are looking to feature. Until next time, stay passionate. Stay curious.
