Borderline Females: Victims or Predators? - Dr Karen Jacob

And when I say manipulation, it is it's not an inaccurate representation of what it's like sometimes for people to be in a relationship with somebody with BPD. If it works out, if they get what they want, then the intent was really just to control the other person to to coerce them. If you get what you want, the person responds to your text because you threaten to hurt yourself if they don't. You might get that reassurance, but there is a huge price to pay.

Welcome to the Brad Carr podcast. My guest is Dr. Karen Jacob, professor at Harvard Medical School, expert in personality pathology, and program director of the Gunderson Residence, which is named after her mentor, the late Dr. John Gunderson, who established the diagnosis of borderline personality disorder.

Dr. Karen Jacob, what is your definition of borderline personality disorder?

I describe borderline personality disorder um a little bit differently than what's been outlined by the DSM. It's far more aligned with what Marshall Lahan who wrote and developed dialectical behavioral therapy defines and describes borderline as which is five areas of dysregulation. So disregulated thoughts which may mean black and white thinking. Um it may mean extreme all ornone thinking and under more duress somebody who has borderline may actually look paranoid and so um there's often misdiagnosis because of that element of borderline. So disregulated thoughts, disregulated emotions, and what that means is um an emotional vulnerability of high sensitivity, high reactivity, and slow return to baseline. And I can talk more about that as we go. Um behavioral re activity or dysregulation, which means that people who have BPD are for far more behaviorally reactive when they're feeling high emotions. They may respond in ways that could be selfharming or suicidal. Um, disregulated sense of self, who am I? And disregulated interpersonal relationships. Somebody who has borderline and John Gunderson who developed the diagnosis for BPD would say this is actually a really core feature is somebody who has a um difficulty in interpersonal relationships where there could be dependency certainly rejection sensitivity and that fuels according to somebody like John Gunderson much of the other areas of dysregulation.

Okay. And now you're mentioning John Gunderson. As I understand, he was your mentor.

He was my mentor. Yes. Yes. And the the father of borderline personality disorder sort of codified what it is. So I'm surprised that your definition seems more based in this DBT Marshall Lahan sort of space. Um how did you come to that having learned under Dr. Gunderson?

I actually would say that um John would say would not def dismiss this definition. Um, in fact, he would probably appreciate it if he was alive and kicking right now. Um, the reason I usually describe it in terms of five areas of dysregulation is because you can have 2,000 people in a room all who have a diagnosis of of BPD and they all look really different. So, it's sometimes really helpful for clinicians to hear these areas of dysregulation when they're seeing somebody who may fall into one of these categories to sort of further ask some of the questions of is this really depression or what is the depression stemming from? Is it really related to rejection sensitivity? Huh, maybe I need to go further. So, it's it's a more userfriendly definition of which I think John would um would appreciate.

So, how is it different from his definition then?

Well, um it's not so much his definition. I would say it's the definition in the field. We usually go by the ICD or the DSM, which for borderline, there are nine nine criteria. You need to meet five out of nine for a full diagnosis of borderline personality disorder. So most clinicians likely will pull up the DSM, look through the criteria and diagnose that way, which is fine to do, of course, but um the translation to what it actually looks like in somebody sitting in front of you can be a little bit harder to translate. Um so the definition itself when you think about the uh borderline presentation in these five areas, it it it's more understandable um especially as it relates to the person sitting in front of you.

Okay. And I've heard one of your patients refer to herself as being like a turtle without a shell to get in a metaphorical level. Uh how do you think that metaphor sits with your definition?

I would say um that definition that experience by somebody who has borderline personality disorder. I think you're referring to borderliner notes. Yeah. So on borderliner notes, one of the things that the the person who runs the channel asked me to do was interview some folks who I actually had not met. So, I think you're talking about Charlotte, who um I actually didn't treat, but just did an interview to allow folks to get a sense of what does it look like to have borderline um and what's the experience like for somebody who has borderline? That idea of a turtle without a shell is that feeling of being really vulnerable. And that vulnerability can happen interpersonally, it can happen emotionally. Um, as though you have nothing to protect yourself. So, um, it's that that experience of feeling so vulnerable in a world where interpersonal relationships feel really challenging and where emotions feel really challenging can feel very exposing.

And and how does how does that metaphor fit with with your definition? Is it is it consistent or is it a manifestation? Is it one person's experience?

Um many people who have borderline will talk about feeling very vulnerable both emotionally and interpersonally. Sort of the behavioral reactivity happens as a result of those two pieces. So if you really look at some of the icons in our in our field, John Gunderson being one, Marshall Lahan being another among several others, Lahan actually describes borderline as being as the core issue being of emotional um vulnerability. This high reactivity, high sensitivity, slow return to baseline. John Gunderson would describe it as interpersonal vulnerability. Both exist and both get activated and both would be present in somebody who describes themselves as a turtle without a shell.

H I definitely understand that with the the dysregulation thing, but with the in in the personal level, but with the relational level, I'm not so sure. It seems that these people could could have lots of relationships, and when you're vulnerable, you're even sort of sympathetic and in a way uh attractive to certain people. Uh how does how does it relate to the interpersonal?

So when I think about interpersonal vulnerability in a turtle with without a shell, I I kind of think about the person um feels really protective of themselves because if they're too known, they can get too hurt, especially when you're very sensitive to rejection. So when you're somebody who really feels like you need to be accepted to be okay, um it it narrows the way in which you operate interpersonally because of the vulnerability because you're so fearful of not being accepted by other people. So in that sense you um the idea of being exposed is constantly on your mind. Um, and that shell that, you know, I I don't know exactly what Charlotte would say about this, but my guess is is that she may feel like she's trying to hold on to a shell to protect herself from not just the emotional experiences, but from the interpersonal dynamics, the inter these relationships that make her feel so um impacted, so affected.

M so if it's a a question of not wanting to be known by others or a fear maybe of being known by others then what's going on with things that seem to be patterns um lots of relationships promiscuity things like that you mean why does that happen? Yeah. If if it's an issue of being known it would seem that having lots of relationships uh would be counter to that.

So, when you see some, this is partly when I mention you have 2,000 people in a room all who have borderline, but they look really different. You'll see a group of people who have borderline. And I'm being very sort of overly generalizing for a moment because, as I mentioned, there's all sorts of shapes and sizes of what you see, and you really have to know what you're looking for. You do see a tendency of a group of people to be so protective of themselves that it's hard for them to build more meaningful relationships, more vulnerable relationships. Um, and then you see folks who want to get to know somebody right away as a way to sort of hold on to some way of connecting to somebody in order to feel a little more stable within themselves. The relationship itself sort of stabilizes the sense of self. So when you see somebody who's more promis who who's who's who's um sleeping around, right, you're seeing somebody who is trying to connect on some level and there could be a lot of reasons for that. Maybe it's the only thing they think they can connect around. That's a way they can feel needed. That's a way they can feel loved. That's and that feeling of needed, connectedness, loved is so powerful that people may end up doing all sorts of things to either forge a relationship or to maintain it.

Okay. So, what do you think is is the the root of borderline personality disorder? What what causes it? Where does it come from?

So, I'm going to rely a little bit on theory here, um, which has its evidence behind it. Um, DBT is the the reason I refer to DBT is it is one of the empirically supported treatments that has a lot of evidence and while transference focused psychotherapy, mentalization based treatment, all sorts of other treatments have grown to have far more evidence, DBT um, which developed in the 80s and '9s has lots of studies behind it. And as part of DBT um there's a bio social theory um of borderline that really talks about the biological predispositions plus an invalidating environment. The biological predispositions really and this is in the DBT model but really has borne sort of true through evidence is um somebody who has a biological emotional vulnerability high sensitivity somebody who's really sensitive um high reactivity who's more reactive when they're emotional and then takes a while to return to baseline plus what Lahan would say is an invalidating environment and the invalidating environment often are very well-meaning parents parents who love their child and try and create a really stable home for their child. Um, but through different interactions between a caregiver and a par a caregiver and a child, that child may um start to doubt their internal experience and those two things combined can um create the foundation for the development of borderline. So when I say invalidating environment, it doesn't have to be a trauma. You do not have to have a trauma. It's a myth to develop borderline personality disorder. Many people don't have a trauma and develop BPD. Um, but it could be, and I give this example because it's so benign, but a child who um you're in a car car ride and you've just stopped to get gas and food for your child. They're hungry. 20 minutes later, you're back on the highway and your child says, "I'm hungry. I'm starving. And a parent may say like, "How could you be hungry? We just stopped. You just ate." And that that invalidation is a very benign example of what can happen for kids where they're like, "Am I hungry? Am I not hungry? Should I not be hungry?" That happened that happening at emotional levels can cause somebody to really doubt their internal experience.

So, this sounds like gaslighting. Is it something like gaslighting that is repeated through childhood that can be this invalidating environment?

So gaslighting is one of these terms that I think has gained so much steam. And I always say to people, what do you mean by gaslighting? Because the idea behind gaslighting is that you're offering something that isn't the person's experience. There's I I don't think it's a parent's ever intent to invalidate their child or say this isn't true. Um, so I'm not sure I would necessarily use the term gaslighting. Um, I would say that parent is using themselves as a barometer for evaluating what their child may experience without being sort of more curious. Oh, maybe my child is, you know, go has some virus that they're really hungry for food. I'm being obviously extreme by this, but um I there there's no in mal intent for the most part for many people who end up developing BPD.

Okay. So So we use the phrase invalidating to be clear that it's it's an invalidating environment. It's not an intentional sort of thing from the parent. It's not often not intentional.

Okay. And of course you have various degrees of um early childhood experiences and later experiences by children. Um sometimes it's actually an experience that child may have with friends that make them more vulnerable to interpersonal dynamics and sort of set the stage for later development of borderline. It doesn't have to be a caregiver. Um, and sometimes you only see some of the vulnerabilities that I described in a in a particular context, like intimate relationships. People will say, "Oh, everything's great with my family and friends, but romantic partners, that's a problem."

Okay. And what what I would say to that is um the the next step would then be to look at, well, was your attachment system activated? So when somebody's attachment system is activated, that's often when you see some of these vulnerabilities emerge.

Okay. And what what activates the attachment system?

Um so if somebody has a meaningful relationship with you, um where you're invested, where they're invested, where there's some um significant connection, person matters to you. Um, and depending on the nature of that relationship, that attachment system, that's that that is the development of a significant attachment for the person. Um, that's often the in those relationships where you may or will likely see more challenges for somebody to h to have a reaction um for somebody who is borderline under those circumstances.

This happens in your childhood. what happens in between then and becoming an adult who displays traits of borderline personality disorder.

Um I I wouldn't say necessarily that there's some pathway by which somebody has to go through to then develop BPD. What I would say that might be more descriptive is that when somebody has it is emotionally sort of raw in the way we've talked about Then they um have experiences where they're feeling rejected or you know whether it's by a friend group by a partner by a parent um through the natural course of their own sort of selfdoubts and wishes for acceptance there people de all of us develop strategies to manage that when somebody develops strategies that what I might call at times can hold somebody hostage age. That's sort of the quintessential challenge for somebody who has borderline. So, for example, if I need to feel connected to you and we have a relationship and I upset you for some reason, my reaction if I was borderline may be sort of desperate attempts to stay connected to you. So, I might call you a thousand times if you're not answering your phone. I might say, "I'm so upset by um hurting you. I might self harm as a communication, as a bid for connection." So, you can see how somebody over time because of their sensitivities and their need to feel connected may go to more extreme efforts to know somebody is there for them, to know somebody is connected to them.

What's the difference between that and just just being a person who sees that as an effective strategy or is is just manipulative?

Manipulative. Um that term is used not infrequently with somebody who is borderline. Um and I usually shift that word to somebody's trying to get their needs met and they're doing it in the best way that they know how without realizing the impact it has not only on them but on the relationship. So, it feels manipulative to the other person. And I think that's what you're describing. If you were the recipient, you'd feel very manipulated. Um, what often happens is as people are so desiring this connection with others they're doing what I would say the best that they can do to connect and they are learn they've learned how to do this through just natural life circumstances um of sometimes selfharming sometimes threatening behaviors that feel really tough for the other person and become unsustainable in relationships. So part of treatment is actually helping somebody realize that that hey you really want to stay connected with if I really wanted to stay connected with you I really want to stay connected to Brad but the way in which I'm doing it actually pushes somebody away and the relationship can't sustain that and that's actually part of the therapeutic process.

What's going on that would make it impossible for a person to understand that on their own? It would seem that someone who can get through life, be an adult in the world, would know if they threaten self harm to get their boyfriend to come out or something that that is a manipulative behavior that that is hurting that person and that it's going to be disastrous for their relationship even though it's going to get them a a near-term goal.

So, sometimes people do learn this over time. Um I I'll say two things to this one is sometimes people do over time life will so if you have BPD and you're displaying all the things I'm describing say in college and you don't seek treatment by the time you're my age you'll look pretty okay without a lot of the the BPD vulnerabilities life will have shaped you but the problem is is that when you're in your 20s which is often when we see people present for the first time, not always. It can present younger. Um, your 20s are the time in your life where you're building relationships, you're building friendships, you're finding a partner, you're getting it, you're figuring your career out. And when you're going through the process of learning how to relate to people, and you do it in this way, you're delaying and um missing the boat on building these relationships and the career paths. So there's a lot there's a big price to pay when you see these vulnerabilities to not attend to them when you see them and wait 10 to 20 years. It's kind of like saying if you're somebody who's fearful of flying, right? And you know, well, you don't have to fly, right? Maybe you maybe your job doesn't require you to fly. Your whole family lives nearby. But if you don't fly and you have a simple fear of flying, it's not likely that you're going to get over the fear of flying. You have to be aware that you're doing it and then confront the issue. The first part is the awareness. The second part is confronting the issue. Um most people if left to their own devices as human beings are, we do things to feel better. So if avoiding flying is going to make me feel better, I might just choose to avoid flying. Borderline is no different. I might avoid things to feel better. And so therapy um forces your hand at seeing things you sometimes don't want to see. So it would be lovely if people could be their own therapist and see the various ways that might they may have impacted their boyfriend, their friend, their family. But that pain is really significant and sometimes too much to bear. So people stay in a cycle that can be really challenging at least for the short run until the common denominator over time is me. And then often people will realize, huh, maybe this is something I need to to deal with. But it takes decades to get to that place because it requires them to confront themselves which is painful and no one wants to confront necessarily anxiety, frustration, anger or pain.

And then if if you are getting your way if if it works then why would you confront it? If if you you do manage to, you know, keep your boyfriend on a string by threatening to hurt yourself or um something like that, then then why would you change?

So, you're talking about the long-term versus short-term gains. For the short run, you might keep that guy or girl or person next to you, right? You might be successful in holding on to that person, but when you play the tape forward, just like decades go by over time, relationships are unsustainable if um operating for the most part under duress, under um threat. So um the it may serve a purpose in the short run but then you have a big price to pay in the long run. The relationships actually can't sustain that level of challenge time and time and time again.

So self harm is one of your research interests as I understand it. Correct. Yeah. So are there people who threaten self harm as a tactic who are not borderline?

Yes. I mean, so that would there self harm um is complicated. Okay. Um I've really focused on self harm in the context of a borderline presentation. Okay. So the function it serves in a borderline presentation usually, not always, is to shift from an emotional painful experience. So it's so hard for me to feel something. I'd rather physically feel than emotionally feel. So self harm can can can be serve that function. It can serve a function to um self-punish. I'm such a terrible person. Why did I do that? It can also serve a function of communicating one's feelings to other people. And that is a whole another area um of inquiry. Mhm. Yeah.

I'm What I'm wondering about is is your your take on intention. It seemed to be this idea that maybe people who have borderline personality disorder do this and they're not sort of aware of how it affects others. But it it seems that people would understand how this affects others or that there must be some people who do this kind of thing and do understand how it affects others. And then when you mention that it has sort of an outward signal too, it seems maybe there's this idea that the physical pain is better than the emotional pain. But at the same time, it it would be another thing that would get a lot of attention. And for a person who already seems this sort of vulnerable, sympathetic character that it that self harm could be another thing that would bring on that attention and and be another really a manipulation. You like the word manipulation in your dog.

I do. I I'm I'm curious about this this intention because it seems that if this is medicalized that the the person's intention could be neglected.

Um, I'm glad you're bringing it up. So let me just start by saying that because um you know when I say manipulation, it is it's not an inaccurate representation of what it's like sometimes for people to be in a relationship with somebody with BPD. Um, it's really striking to talk to somebody who is borderline when they when you really try and break down intent versus in impact. And that's something we talk a lot about in treatment for borderline folks that you had one intent and yet the impact is such that fill in the blank. So your intention may be to know that that person still cares about me, but the impact is it may scare the Jesus out of the person and that may actually wear the relationship down. So that impact versus intent is often learned either through therapy or through a number of failed relationships. And if the person's lucky enough to get feedback, and I really mean that because I think feedback is incredibly useful for somebody, then they begin to understand that their intent and impact may actually not be aligned.

Yeah. But if if it works out, if they get what they want, then the intent was really just to control the other person to to coersse them effectively. Like you used the word hostage earlier. It would be to take oneself as a hostage in order to make a hostage negotiation and get what you want in the negotiation. And the intent as it affects the other person doesn't really seem related to this question. Right? The the problem was that it scares say the intimate partner rather than that it denies the intimate partner say that they just need a night off from someone who is probably very emotionally taxing to begin with.

Mhm. Yeah. Um, I I cannot underscore the importance of long and short-term go gaining and loss. Okay? Because yes, if you get what you want, the person responds to your text because you threaten to hurt yourself if they don't, right? To be concrete about it. You might get that reassurance, but there is a huge price to pay. And that's often what leads people into treatment is they start seeing the way that they're trying to stay connected doesn't work in the long run. So while it may be initially reinforcing and work to get a response, if your goal is to have stable relationships over time, that is not the way to do it. It doesn't work actually.

Right. But but what about the the issue of the fact that whether it works or not, it it is harmful to that other person. You mean the person in the relationship with that other person? I mean the person who's getting that message that says, you know, hey, I'm going to hurt myself if you don't come over now.

Right. And I think the beautiful part, so I run a residential program. Yeah. At MLAN hospital. And one of the reasons um John Gunderson wanted to have a millu based treatment. It's called a millu based treatment. We integrate empirically supported treatments DBT NBT into our program. But the reason it's millu based one of the reasons I should say is because it gives people actually some im there's a lot of feedback in my program and I actually say benevolent feedback. The goal of giving feedback isn't to hurt somebody's feelings but it's to say like hey when you do that this is actually the impact it has on me. And I think what you're saying is don't people know that sometimes but sometimes actually they don't and that's the point of any therapy is to become aware of things that you might actually not be aware of both within yourself and become aware of how you operate in the world. That is that is therapy. So um seeking therapy for somebody in these circumstances part of the goal is to understand what am I doing why am I doing it and what is its impact on me and the people around me.

Okay so within this diagnosis then there's there's these many forms of dysregulation and an inability to recognize the harm that one does to others as part of the diagnosis that is not part of the diagnosis.

Okay that is Um, do people harm other people in a relationship? Um, I I don't know if I'd go so far as say other people get harmed. It may be the case that they do. Um, that's a fallout. That's an outgrowth of somebody's internal challenges. So if I'm really somebody who's rejection sens I have a a high rejection sensitivity and I really want to be accepted by other people and I'm very emotional and I'm reactive. When I feel rejection I may behave in ways that impacts other people. So the definition of the diagnosis itself is within me but it then may have an impact on other people. Now, my way of um somebody who's BPD may not actually harm anybody else. They may not hold that other person hostage. They might not threaten self harm. That's not always the case. But internally, they feel they may harm themselves and the other person may never know. Okay? Right? There may Sorry. Sorry, please. There may be all sorts of other things that happen because of those internal sensitivities that are not communications to somebody else. So the other person actually has has no idea. For example, there are people who self harm when they feel really that they've done something terrible. That's just one example. Sometimes people self harm in areas that no one would ever know about like their upper thigh, right? You would never know as a parent that your child is doing that for example. And then there are other people who might harm themselves on their arm and wear a tank top to communicate to the rest of the world. So it's there's thi this is one of the problems with the diagnosis not a problem but what makes it more challenging. So you really have to understand what is making the person more vulnerable and if they are self harming what's the function um by which they're self harming because it could mean something very different for one person and something very different for another person.

Is is self harm a hallmark of borderline personality disorder?

It's a very common um common presentation with people who have borderline, but not always. Um so self harm can come in all sorts of shapes and sizes. Um and it is not a necessary requirement. People don't have to be selfharming. They could be impulsive, quitting things, leaving things, moving places. you know, it's really that behavioral impulsivity um that often is affiliated with self harm, but not always.

Okay. So, when you're in this millubu based setting, how is a person's behavior changed by this process?

Behavioral change is one of the first things you see, right? So you start saying to somebody when you think about the sort of scenarios that I've described um you can sort of think about um oh if somebody is feeling like their partner is angry at them and they're not answering the phone they're not responding to texts right so in response to that the person with BPD may rev up and start texting and calling and then may be threatening right I use that as an example part of what we hope to do and achieve really immediately in the program is put a sort of limit or I should say um these are called target behaviors that we identify that we say to people you actually in this program we're going to ask you you may have all the urges in the world to quit to drink to cut we're going to ask you not to do that and use our staff to integrate some skills to regulate your emotions instead of regulating or getting what you need in these ways that end up not being sustainable over time or are not effective in the long run. Um, and when you stop somebody from regulating themselves or communicating in a particular way that they're used to, you're in a window of high emotion that you can help somebody sort of like calm down and then have that that is actually moments of insight. What is going on for me right now where I have such a strong urge to hurt myself or to threaten somebody? And it's in that context where we help somebody not engage in those target behaviors so that we can help them regulate and actually think. When somebody is in a high states of emotion, their prefrontal cortex shuts down. That's not a borderline problem. That's just in human beings. So if you were either one of us were in a situation where our emotions were really high and activated, we wouldn't be able to sort of think clearly. we wouldn't make good judgment calls. Um, so using skills to sort of bring it down so you can think and reflect is in part one of the very first things we help people do when they get to a program like mine or in any therapy actually.

Okay. So then there seems to be this issue of a difficulty in understanding how one's behavior affects oneself along with how it might affect others. regardless of outcomes. um regardless of outcomes, meaning regardless of whether or not you get what you want from the from another person that maybe there's a difficulty in seeing not only how it might affect them negatively, but also how this is affecting you because there there seems to be this emotional uh haze that you're you're describing where it sounds like the patient can't really recognize what's going on in themselves and has to be sort of worked through a process that that may in fact be the case that They're they're understanding themselves and they're understanding where those vulnerabilities lie and the ways in which they may either soo themselves, get their needs met, stay connected to other people in the world, um manage themselves when they're alone. So that process is partly self-standing and then partly as just human beings in the world who have natural desires to be related to other people, we also very much want to help the person understand how they do relate to other people and whether those ways of relating are sustainable over time.

H okay. I'm I'm still curious about intent. Is is there anything to to neuroscience with this sort of disorder? When you hear about things like psychopathy, there's discussion that there there's different brain structures, that maybe there's a lack of conscience because of the way that brain structures involved in empathy may be different. Um what what do you think?

Um I I will cite one study that may be particularly useful which came out I want to say maybe eight years ago by Martin Bohas and his group in Germany. And what what they could do in Germany is what they um did was they had folks who were diagnosed with borderline versus controls. They put them in an MRI and they cut they they cut them. And I don't know if it was the subjects cutting themselves or what, but if you look at somebody in somebody's brain who has a diagnosis of BPD, they actually look calmer when they are are during this study very differently than somebody who is not does not have a diagnosis of borderline. So when people who have BPD say cutting actually regulates me, there is data supporting that. What would be going on in a person's brain to make a person who has a diagnosis that is as you've described built on several forms of dysregulation actually more regulated by cutting or being cut. We don't know exactly with this study compared to a person who is considered otherwise healthy. I I I can't give you the neurological data on that one which I think would answers most if not all of your question. Um, but I can tell you experientially people report feeling many people not all people report feeling like a sense of relief emotionally through self harm. And you know, having seen hundreds if not thousands and thousands of people who have borderline over the many years that I've worked with this population, um, the two main things I often hear is it's easier to feel physical pain than emotional pain for me. like it's actually relieving if it's physical rather than emotional. Um, and it another um thing people often say to me is it refocuses my attention away from all the things that really are so emotionally or interpersonally upsetting.

Okay. So, it sounds like the the easier to feel physical pain than emotional pain would be verified by this study from Germany that you've mentioned.

Yes. I mean that would be one, you know, theory that we would throw out there. And then the refocusing of attention it because it might seem at first, well, if I have emotional pain and then I had physical pain, now I have both. But it sounds like your experience suggests that actually it's one or the other that the physical pain sort of blinds to the emotional pain. It's a shift of attention. And in fact, when you look at some of the um DBT skills that folks use to regulate themselves, when I talked about those high levels of emotional intention intensity, one of the skills is distress tolerance. It's called the crisis survival skills. And part of distress tolerance part is how to reorient, distract yourself from an emotional experience and give yourself some space to bring the intensity down. So there DBT part of DBT is providing skills to actually shift emotion to give people a chance to bring the intensity of emotion down.

Okay. And in your millu treatment, the the DBT is part of that process. And then is is there constant access to some sort of therapist? I've I've heard of programs where people going through DBT uh can have the phone number of their therapist call them at all hours. Is it something like that?

So a as a residential program, we have staff 24/7. Okay. And um all of our staff who are not the clinical team. So we have clinical team that sort of designs um and um and participates in the actual delivery of the clinical care. Um our what's called a clinical residential counselor CRC their job is to actually help skills coach. So, if somebody comes down at 2:00 in the morning, there is a staff person saying, "Let's do a scale to get you back to bed." If somebody's really emotionally sort of um at that 10 out of 10, there is always a staff person to say, "Why don't you try this? Why don't you share that?" and help that person build a repertoire of distress tolerance skills so that they they can have them in their back pocket when they leave the program.

Okay. So when someone leaves that program, it seems regular life would be very different from this. How do they do in in the long run? Do they maintain these skills? Do they fade over time?

So you know um a program like mine which is not unique a residential program very intense lots of groups lots of support lots of self exploration self- understanding a lot of efforts to help change um I helped open the program in 2009 and what we found was when people left our program and even if they continued with their clinical team with less structure became more challenging like so less structure not not surprisingly so um what often helps people what I would say generalize their gains is to have a slower transitional process I'm referring to folks who are really struggling to the degree they need residential treatment by the way many people have borderline and don't need residence they can do this on an outpatient basis but if somebody is in a situ situation where it's life-threatening enough or they need that much support for whatever reason that they come to a residence like mine. Um the sort of ideal scenario is to transition slowly by um structuring some sort of period where there might be some if we're doing MBT and DBT some groups around these things at a lighter touch um and to continue either with their team or a team that has similar skills to continue reinforcing what was learned in the program as they start living their life.

Okay. So this intensity of a program, this is something like a suicide intervention then and sometimes not always not always not always and then it's phased down ideally.

So different levels of care. If somebody's had a suicide attempt, they may end up actually at the emergency room. Mhm. then to an inpatient unit and then to various levels of care depending on the problem and what they might need. If they land in in a residential program, the hope is and depending on were they diagnosed 10 years ago, have they had other treatment, is this their first episode, is their first diagnosis, is was it a misdiagnosis, whatever is going on with that person, they come to a program that's a residential program. The hope is if they are able to navigate that program to create a transitional process. So for example, we require everyone to have a job before they discharge from our program for all sorts of reasons. That was a very big tenant for John Gunderson for all sorts of reasons that I can get into. But what we would do is support not just the therapy, ongoing therapy that they started in the program, but then now they have different um contexts to practice. What happens when my boss um disciplines me and I want to impulsively quit? Things like that. Um, how do I navigate my friendships outside of this program? And over time, maybe I'm in a romantic partnership. How do I navigate those things? um ideally using uh a a treatment team or a therapist that's knowledgeable of the diagnosis but also of you.

Okay. So this kind of intervention not always a suicide intervention but but very intense. Um what is the connection between borderline personality disorder and suicide? I hear stunningly high numbers sometimes attributed to rates of suicide. Um what do you think about that?

It is um the the attempts um some so so having some um let me say this. So yes there is a high correlation to just answer your question between suicidality and BPD. Um suicidality what caused me to pause is sometimes people make an attempt and they really don't want to die. Um, and sometimes they really don't want to die and don't and that may be their entrance into therapy at that point. And sometimes people are very suicidal and they really do want to die. And you can have different outcomes there. And those people who really don't want to die but feel so terrible that they're starting to sort of manage their emotions in very selfharming and risky ways can by accident die. That does happen. So these so there are all sorts of reasons why people get suicidal and for somebody who has BPD it's almost always in the context of relations. So a loss, grief, um disconnection, rejection. Um, and so you're the person is and I I said this before and I do think it's a a benevolent way of seeing the problem that I that I do support is the person's trying to do the best that they can to regulate themselves and to figure out how to be in relationships, but it's clearly not working if they're suicidal or they're self harming.

Okay. So, it sounds like there's there's more nuance on behavior that we might call suicidal that it could be more of just reckless behavior, dangerous behavior to distract oneself, uh like the like the cutting and things that then ends up putting someone's life in risk.

Exactly. Or for example, we started this conversation where we talked about promiscuity, right? somebody's desperately needing to connect and so the way in which they know how to stay related to people is by through these kinds of behaviors and they may end up in a really risky situation.

Okay. And that would be enough to put someone in u in this residence.

Um, it could be definitely. Okay.

It seems so much of this is about emotion. um what is done to help people with borderline personality disorder deal with their emotions?

So emotion when when we were talking about emotional vulnerability and that sort of biological predisposition um first thing is understanding your emotions. You might be surprised at how few people stop to say what am I feeling? People who don't have borderline often don't know what they're feeling. Um, it's kind of like a pandemic if you ask me. Um, I actually just wrote a story book um for children so parents can just start talking about feelings literally because of this like stop. What are you feeling inside? Is there language for that? Can you talk about it? Is it okay to talk about your feelings? There are lots of homes where feelings are talked about all the time. There are lots of homes where we never talk about feelings. Mhm. Ever. So the first thing is let's actually stop and pay attention to what's going on inside of us. And then to understand how we understand emotions. Emotions are not just physiological experiences. They're not just your heart racing. My heart could race. Your heart could race. I could be really excited for this podcast. You could be really anxious that I might say something terrible during this podcast. Both of our hearts are racing. the emotion that we label is based on also our perspective. So it's not just a physiological thing. So all of these teaching points um we help people understand like what's going on inside of you? How do you know? What do you feel? What's your physiology? What is what are you thinking? What's your action urge? What do you have the desire to do? You know, if I'm anxious, as I said, many people who are anxious, they avoid. That's a natural reaction to anxiety is um you know to either fight or flee, anger, anxiety, that kind of thing. Um, if you're shame, feeling shame, you hide. That's just a natural reaction. So what's your action urge? And then we sort of help people understand what's going on with you. And then how do how can we help you put words to those feelings and communicate them not just to yourself so you know what's going on within you but to somebody else. Like have you ever had um um an experience where you're driving to work and you just get to work and you're like how did I get here? Sure. Right. That's not really people I dissociated. Well I mean dissociation is a whole clinical thing. You're probably thinking about something else and maybe you have a big like an emotional experience. Now, what you're feeling, you might have to say, you have to make you might have to get to the parking lot and say like, "What was I just thinking about? What am I feeling that is causing me to be so distracted that it was like I was transported from home to work?" Mhm. Um, so it's really slowing down a process that happens so quickly for all of us. And depending on your culture or your environment or your home or all sorts of things, um, you may not have learned to slow down enough. It might not have been okay to have feelings. Um, you know, parents will often say to me, I was raised in an environment where feelings were not okay. You went to your room, you cried it out, and you came back. Right? And so parents who don't have an experience of of allowing emotional expression have a hard time parenting somebody to have emotional expression. So part of it is just learning all these pieces of how to name an emotion, how to know what you're feeling, how to communicate what you're feeling.

Okay. A lot more on emotions and things, but but first

Let's plug the children's book. What's it called? Where can people get it?

Well, it's so I so actually this was born out of um co um so I used to get calls from people all the time about themselves, a partner, parent, child, um, how do I get help? And unfortunately, you know, my feeling about the mental health field is it's not as accessible as going to your pediatrician for a physical problem, and there's still unfortunate stigma attached to it. So, um, the number of calls I was getting during CO just blew me away. It wasn't like every week anymore. It was like every day. And I was trying to think of how I can just help parents, have to begin with, have some resources. And I started actually writing a book for parents. And I just scrapped it. It was like, this is not what I want to do.

Um, and then I was thinking, actually, the the maybe the biggest bang for my buck, and I don't mean that financially. I mean that in terms of helping people, um, is through prevention, through not h not treating the people who have already been identified, but when they're little, is there language in their house? How can parents start talking about sad, happy, um, how do they learn some basic skills to ground, to regulate? And so in the GR, in in my program, we give folks, um, we talk about cop, copaheads, and stress tolerance and emotion regulation and what tools they can use to ground themselves and things like ice dives, which activate your parasympathetic nervous system. It's called the diver's reflux, and it's like an immediate activation from, um, your sympathetic nervous system, um, to your parasympathetic nervous system. So your, so your fight or flee response to your rest and digest response, and that is a very, very grounding experience. People don't know about it. They just don't know about it.

And so, um, this, the book I wrote is really just like a Dr. Seuss-like book about emotions that comes with a set of distress tolerance tools, you know, like little fun ice patches that parents can put in the freezer and, um, teach kids a little bit about some basics that I honestly hope all families eventually know. So when their kid is having a hard time, it's not like they're 15, 18, and they're at that place where it's a really big problem, that it's just part of the language of home. Yeah. So it's, it's to answer your question, it's called The Feelings Toolbox. Um, it's right now, I am actually finalizing the project. It should be ready to rock in about a month. Um, and right now, you can get it really only online. It's the very baby. We're at the sort of fetal stages of it. Um, but it's, it's a formed, it's a formed thing. And, um, I, if anything, hope that people can invite language for emotions into their world, into their lives, into their kids' lives and learn some really simple interventions that may end up being really important later on for them in life.

Okay. Well, when it is ready, let me know and we'll, we'll update the description. So if people are watching this after it comes out, they'll be able to find it. Um, with these emotions, anger seems like a very important one with borderline personality disorder. And I think I've heard you say that it's kind of about learning to not fear anger, but rather to allow it. Um, how do you work with people around anger?

So, anger is an interesting thing, I think, for a lot of people. Anger can be really scary for people. And when you have BPD, one of the things that we will see fairly frequently is anger is a really tough emotion for somebody to experience for all sorts of reasons. So I described the person who really wants to be accepted. Well, if you see yourself as a monster and anger is part of being a monster, you're going to take all that anger. You're going to try and have it just disappear. Um, anger doesn't go away just because you want it to. It's a natural emotion. We all have it. You can't just poof make it disappear. So for a lot of people, learning that anger is a basic emotion across cultures, little, little babies, you see signs of some basic emotions, joy, disgust, sadness, anger, fear, those kinds of things, surprise. Um, so to, to sort of embrace anger, learn how to experience it in your body and learn how to, um, have it exist within you and your relationships, and then it won't destroy you or your relationships. It may, if it becomes rage. Um, but rage happens when anger is kind of pushed down.

What do you think is the toughest emotion for, for the people you work with? I would say shame and anger.

Okay. Can we talk about shame? Yes. What's going on? Shame is a tough emotion, I think, for most people. Mhm. Um, so there's what I would say, justified shame and unjustified shame. So, if I, um, so shame is when you do something that really is, so I'm going to use some terms that really aren't mine, but I'm going to use them regardless. So, when shame is, you've done something that's socially like unacceptable, un, you know, you've broken a the law, for example, and you might, maybe you cheated off your friend and you got caught, and you feel a lot of shame. That's justified shame. That's good news that you're feeling that shame. It's still really hard to feel, but you've done something, um, that really has broken a social norm and you feel badly. If you didn't feel badly, I'd be a little more worried because we'd be talking about somebody who might look a little more antisocial. Well, I wanted to do well on that exam. It didn't really matter how I got there, but if I have to lie and cheat and steal, I'm cool with that as long as I get what I need. Um, so there's the justified shame and then there's the unjustified shame. Like, um, um, I told my friend that they really hurt my feelings, and now I'm really ashamed for telling them that. Um, of course, there may be a lot in that example, but actually sharing with somebody how you feel, especially if it's in a sort of balanced way, is good news. So if somebody says has unjustified shame, that's, that is an area to help somebody work on. Um, why do you feel so badly about yourself for having, um, done something that seems actually kind of reasonable?

And I've also heard people talk about how shame is sort of a social emotion. So even if say you didn't do anything, but people are talking about you, suggesting that you did, or you you sense maybe an ambiguity as to whether or not people would believe that you did something or didn't, that people feel shame too. Is it, is it that nuanced? I, I mean, it can be. It usually, so when you think somebody's talking about you, and that there is the, remember I mentioned cognitive dysregulation and paranoia early on? Sometimes people aren't talking about you, and fear they are because you're really, really sensitive to other people, and you assume they're doing something they're not. So, um, mentalization-based treatment, another empirically supported treatment that I shared with you earlier, that is about learning how to hold on to a perspective, but others at the same time. So I might really believe this, and I might think this is going on, but there may be another perspective that coexists that's completely different than mine. Um, so it's hard to, when somebody sort of describes shame related to something like, "Oh, somebody's talking about me. Maybe they are." And is it accurate? Is it inaccurate? That opens a whole another, um, area of sort of inquiry. But if it isn't accurate, then you're talking about feeling hypervigilant to rejection.

Okay. Ultimately, are people who are like this feeling lonely? You're, you're asking some freight questions, Brad. Um, I would say it's more the feeling of alone-ness, being alone, because somebody can be in the, in the presence of lots of people and still feel incredibly alone. Yeah. Um, so to refer back to John Gunderson, who's done a host of work in, obviously, in this field, one of the last things he did in his career was he developed a treatment called Good Psychiatric Management, GPM. In that treatment, there's a diagram that I love, and many people who have borderline can relate to it. And in the diagram, this sort of cascade of describing why the interpersonal connection is so important. And at the very top of the diagram, it's when somebody feels held and harmonious and connected with somebody, they're good. You wouldn't know they struggle with BPD and these vulnerabilities because they're feeling very stable in the context of a relationship. If the relationship were to disappear, that's when you start seeing the problems. And if somebody, despite best efforts to remain connected, feels that, um, feels like they're unable to sort of, um, feel held or connected, they're in what I would call a despairing place, feeling alone. And that's actually when people get hospitalized. It's when there's a disconnection despite their best efforts. They continue to feel very alone in the world. They get more despairing, they get self-harming, and the hospital is sort of introduced as a containment to re-regulate.

So what would happen for a person in a relationship who wants to be that regulating force for a borderline partner? They're, they're signing themselves up for that. Yeah. You know, they, they know, oh, um, you know, girlfriend has borderline personality disorder, but she seems to do better when, uh, I'm, I'm really there. Maybe I can sort of love her through this, and we're going to, we're going to, you know, figure it out and I'll keep her stable. Is there, is there that attitude? How does that go? That doesn't go well over time because there, I don't know of a human being that could always be there for somebody else in the way that that person wants to. So, it's just a matter of time. And it's that extreme that it's, it's got to be always there in the way that the person wants. It can be. It doesn't have to be to the letter of the law in that way, but, um, regardless if it's exactly as the person wants it, if that person feels disconnected, like the other person's giving a, is in a podcast, right? Um, and say it's a patient of mine, and they really need to reach me, and I'm not responding. That can be enough for somebody, that window of time, to feel really alone and really despairing because, remember, somebody has BPD is exquisitely interpersonally sensitive. So as a therapist, what I would hope therapists, you know, take a stance of is not only psychoeducation, which alone is therapy. Part of GPM describes psychoeducation as being a really important part of treatment, like getting this information, um, but also helping people learn how to be more independent. So, um, I wrote a paper in the Harvard Review of Psychiatry probably about a decade ago around intersession contact, right? You mentioned DBT and intersession contact. And there's a lot of pros to that, right? You're, the likelihood of you getting activated and feeling really alone if you're held in, in session with a therapist that you really feel connected to, it's probably not that likely. But you go out in the world, and you have all these interactions with people, and you actually may start feel, likely will have experiences and where you, where you get triggered, is what I might say. And so DBT coaching is intended to help somebody integrate skills, really to regulate themselves so they don't fall back on self-harming behaviors. That's one really important reason people use skills coaching. Um, it can also be destructive to a treatment. So, if you're a therapist that is always available at all times, and the person learns that they can't manage in your absence, you're just reinforcing the very problem they came into therapy for. You're not meaning to, yeah, but you are. So, um, my hope is that therapists actually empower somebody to use skills. So John Gunderson would say this, and I agree, that if somebody over time can't take in what you're, you're doing in therapy to generalize it outside of therapy, the therapy should be re-evaluated. Okay. So that's, that's the, the sign. If it's not working outside of therapy, then, then something has to change. If somebody's, what I would say, continues to be in behavioral discontrol after three to six months of DBT treatment, I would actually get some consultation on the case. What's going on here? Mhm. And so then even the most self-sacrificing boyfriend, if he is still the, the sort of necessary buffer, um, then it's not really working, and, and that person needs something else. The patient needs something else. They may. And so, like for example, this self, what did you call it with this? Like a self-sacrificing, like a guy who just says, like, I'm going to, I'm going to be the best. I'm going to be the savior. I would call that, that is actually, there's a name for that. It's called the white knight syndrome. Okay. There is a name for it. And, um, we do see people who have that white knight syndrome. Yeah. And it's really helpful for that person to understand why they feel like they have to be a white knight in the first place. That might be soul-searching and therapy for them, but, um, also to play a different part in the person's life so that they're not inadvertently reinforcing the very problem that the person who has BPD struggles with. Mhm. Yeah. Yeah. It seems like you could get into a, a very dangerous dyad where if, if you have that sort of white knight inclination, and then you find someone who seems really vulnerable and seems to need you all the time, that it would, it would spiral. Um, what do you, what do you think about those sort of dynamics? How, how can people recognize when that's happening? Well, sometimes it's recognized, um, by somebody else. M. It could be recognized by the person who has BPD themselves, although less likely because they may be getting their needs met. Um, but over time, if you're in that white knight syndrome place, it becomes, and I say this, unsustainable over time. You could be in it for a decade, two decades, but over time, that wears on a relationship, and eventually, it just is, it becomes unsustainable. And if you decide you want to still be with this partner, and maybe through that, I've had partners say, if you don't get help, I can't stay in this relationship, and it's a limit that that person sets that forces the hand of the other person to seek treatment. So it's not because they're like, oh, I'd like to, you know, pursue really intensive either outpatient or residential care. It's, I really want to be with this person, and they can't be in a relationship with me as it stands. Okay. So, this, this white knight syndrome, other people can see it in someone maybe more easily than someone can see it in themselves. How could someone know if, if they are acting that way? If you mean, if you're a partner and you're, um, you're, you're perhaps embodying this white knight. Yes. Yes. I'm imagining someone who finds this video because they're starting to think, you know, my girlfriend sounds like she's got some of these things, and I want to know more about borderline personality disorder, and then they say, "Wait a minute. Am I the white knight instead? What's going on?" What, how do you reflect on what is that white knight syndrome? Um, it's usually, and I want to just plug, um, one thing. While BPD has predominantly been a problem for most females, women, um, we see it across genders and, um, more and more. And I was just talking to a family whose son is really struggling with borderline and wishing more residential programs like a program like mine existed for, um, for a broader, you know, population of folks. So, I just want to put that out there because we're learning more and more that the people who present to treatment may be predominantly female, but that's not always the case. Um, so what you would look for is, is do I feel like I am somebody's, I'm going to use a little psychobabble, regulating sort of tool? Am I their emotion regulation, um, skill? Um, without me, how would they do? And if you feel like you have to stay in this relationship, have to respond to this person in a certain way at a certain time, that's a sign to say, wait a second, what's happening here? What, what purpose is my ongoing support in this way doing to this relationship? How, what, what is the impact it's having on my partner? What impact is it having on me? And that's, that's a, that's a litmus test then to, to ask yourself those questions. Absolutely. Okay.

When you're working with someone, how do you know when treatment is finished, or is it ever finished? Um, so treatment can finish in a lot of different ways. Um, we just had a case conference and we're having this conversation because people can be in treatment. People can be in treatment because they just want to learn more about themselves. Forget about borderline aside. And people may just really feel like therapy is a self-discovery over time. So I would say that there's a lot of reasons people enter treatment, but if you're entering treatment for a certain reason, like borderline, like self-harming behaviors, like suicidality, like unstable relationships, like, you know, um, discovery of sense of self, those kinds of things, you'd have some clear markers of what your goals are in therapy, and they may change over time. Um, but what you may start out doing in therapy may look different over time. So, you may learn more about yourself over time that actually may require ongoing therapy or not. I, I usually say to people, the point of therapy is to not be in therapy anymore, or at least not need it. You may want it, and it might be a very, um, helpful, um, opportunity for ongoing growth, but wanting it and needing it are really, really different things. Um, what I will also say is often people who seek treatment for borderline are not just struggling with one problem. So to see somebody with just BPD is like a unicorn. There are a lot of comorbid diagnoses, and sometimes once you treat the, like somebody who has BPD, um, other problems actually stabilize. Like what we know in our program is somebody who has PTSD and borderline, when we look at our data, that without actually doing PTSD treatment, because we're a, a personality disorder program, you see improvements in PTSD from admission to discharge, and you've never actually done specific PTSD treatment. So treat other symptoms can stabilize through just borderline treatment. It's also the case that once borderline sort of stabilizes, that you see other problems that have been masked, like narcissism. We often see somebody who, you know, again, we get people who are often treatment-resistant in a program like mine. So I'm talking about a percentage of folks who have borderline, but this is not exclusive to just the folks that we might see. But when somebody who stabilizes around the borderline treatments, borderline symptoms, you might see a real issue of self-esteem, which is more of a narcissistic problem that is sort of hidden or masked because the interpersonal and sense of self are so active.

Okay. So now we're starting to touch on some overlap here. Um, earlier I think you'd mentioned that if you, you saw someone who presented with a lack of shame, that you might start to wonder if they have something like antisocial personality disorder. Now we're talking if borderline gets treated, perhaps we see narcissism. Narcissism, you didn't say narcissistic personality disorder. But it seems the cluster B's sort of blur together. What do you think about the distinction between the cluster B's and, and how important is that distinction? Um, so this is a hot topic in the field right now. Um, and what I would, and it's shifting. So the field is really shifting to more of a sort of seeing personality disorders on a continuum rather than categorical. Mhm. And if you look at, so Otto Kernberg, who was the sort of father of Transference-Focused Psychotherapy, if you look at his, um, BO, borderline personality organization, what he looks at is personality disorders on a continuum, and antisocial being on one end, malignant narcissism, narcissism, borderline, and so on, to sort of least to most severe.

Could you walk us through the rest of that? So on? I, I think people would really like to know what that full set is. Oh, you're going to test. Um, I, I don't know if I have all of them memorized because you have dependent, avoidant, histrionic. Okay. Um, I don't think I'm missing any, but I could be. OCPD, obsessive-compulsive. That's great, just to have a sense of it. Thank you. But the, I think the, the part that we genuin, generally see in our population are folks from the borderline, dependent, borderline, point, antisocial, because those are the folks who often are the ones seeking treatment. And I actually see a lot of, we, anecdotally and clinically, see a lot of overlap. So what we often talk to families and patients about is borderline personality organization, where these certain traits exist, and the field is sort of shifting in that direction too. Okay. Toward this Kernberg model? Toward, yeah. Kernberg's model. Mhm. What would be the, uh, the argument against that? Um, it's a great question. You know, I think if John was alive and kicking, he'd really want to keep more of a categorical, preserving borderline as a unique, um, disorder. And I think one of the things that can, can be really helpful when you, when you have these clear-cut diagnoses is, to me, I will actually just say for me, the reason diagnosis matters in the first place is because it informs treatment. So, if I see something that I can clearly say is borderline, it's going to inform what I do in treatment. Um, and that's actually a big plus. I also think it's really helpful for people to know what their diagnosis is. We get a lot of people who say, "I didn't, I don't know if my therapist didn't see the border, like borderline as a diagnosis, or whether they just didn't want to tell me." And unfortunately, half the time they might have seen the diagnosis but not informed the person. So it can be really helpful to ground somebody in their understanding of themselves, and also, you know, for practitioners, it informs what you do. Mhm.

So Karen, I'm curious about this spectrum. You said at one end we have the antisocial personality disorder, and then if we walk back from that, we get to borderline personality disorder. And earlier, I think you said that the distinction that you start to see around people who don't have shame would start to make you question whether they're borderline or antisocial. The, the behavior like threatening self-harm just to get someone to do what you want seems to be something that there would be a shame for. But there there isn't, it sounds like with the borderline patient. So where does the shame level become relevant? I would say there's actually a lot of shame for somebody who's borderline. Even if they, they are doing something that is going to push another person to do what they want against their will, they're sort of taking themselves as a hostage, they, they still feel shame about doing that, but they keep doing it.

Tell me more. Absolutely. So if you actually, when you sit down with somebody who has BPD and they've learned how to get their needs met through these ways that actually feel really hard for the other person, right? Um, we talk about intent and impact. When there's ongoing revelations around the other person's experience, I have yet to really try to think about this before I make any profound statements. Uh, it would be, I would be hard-pressed to say that that person, if they really are either narcissistic or borderline, I'm not talking about malignant narcissism or antisocial, doesn't have profound feelings about this, profound, whether it's guilt, shame, sadness, anxiety, profound feelings about it. If somebody's doing this to get their own needs met and there's no remorse, there's no shame, there's no guilt, and that happens, that's when you're looking at somebody who's more antisocial.

The shame being internal, though. The shame isn't expressed in a change of behavior. The shame can be. So the natural reaction for somebody who feels shame is to hide. Okay? So they may get really avoidant, and you don't know that they feel terrible because they're not responding to you, right? They're avoiding you because the shame is so profound. So, like for example, um, I can think of many people I've treated who feel really, um, might have threatened something and then retreat and don't answer their phone, and it feels like they're sadistic, right? Yeah. Um, in some way, when you start understanding the psychology behind it, it may be that they're sadistic. It may be that they're so profoundly upset with themselves that they can't bring themselves to say, "Yeah, I really had a negative impact on you."

Okay. It does sound sadistic. And, and you, you pointed me out earlier, I use the word manipulation. I've talked with some of the best experts in manipulation in the world. And that's the silent treatment. That is, I did something you didn't like. So now I'm going to give you the silent treatment to punish you. Yeah. Um, I mean, what is the distinction between what is textbook manipulation and just a crippling shame? I would say, um, two things to better understand the function of what's going on. You know, why is somebody doing what they're doing? Is a really critical question. Is it to torture somebody else? Right? Is it to punish somebody else? It may be a punishment, and you may be completely right. Um, so is the function to torture you, or is it because you feel so terrible that you're punishing yourself, essentially? You're taking yourself out of the game. So you can see it from both sides, and you can see why, for, by the way, for therapists, it's really hard work because the therapeutic relationship is, you know, a very intense relationship, especially when you're dealing with somebody who's so interpersonally sensitive, that you can just imagine how this may play out in the therapy. Oh, yeah. Right. And so a lot of people, you hear this, and it makes me actually really sad on inpatient units, around in the hospital, saying, "Oh, you know, she has BPD, or they have BPD, or he has BPD, or whatever," as a way of like, red flag. And that really, I, I see so many patients who then actually have gone through treatment and are incredibly stable and want borderline taken off of their epic record because they're treated differently when they go into an emergency room, and they're actually quite stable and fine. Um, and that is stigma. That is part of the unfortunate place we are right now in, in, um, personality disorder work.

Okay. But how, but how do you know? How do you know that someone is just feeling shame when their behavior from the outside fits just so good on on a manipulation plan? I mean, to say, I'm going to hurt myself if you don't do what I want. Okay, you didn't do what I want. Now I'm going to give you this silent treatment. Uh, I mean, that, it's just, it's just, and it's got to be devastatingly effective. So how, and then there should be shame on doing silent treatment as well. Yeah. Yeah. Because, because to give someone the silent treatment who, say, was very close to you in your life, is going, you know, it's going to hurt them again, um, over, you know, emphasizing that over time, especially in therapy. So I have to sort of come back to therapy as being a really important part of this, where you start to begin to understand your impact on other people. That impact is, you might think it's really obvious. It's not. It's often not obvious as obvious as we'd like to think it is. I hope it becomes more obvious through therapy. And if somebody continues to do something knowing the impact they have on somebody else, because it's that their needs are more important than somebody else's needs, right? My needs are more important than your needs. So I'm going to do what I need to do. You're, you're moving into less borderline and more along that continuum. That's why I sort of say the continuum is there. It, it's good news in my opinion if somebody is behaving in these ways to remain connected, and then they feel really badly, but they don't know any better, and they need to learn different ways to stay connected and to regulate themselves. That's great news. And that is the case when you see somebody who's really got the core issue is BPD. You see that more often than not. When somebody's needs are just unimportant to the other person, or their needs are more, they're more self-serving. That's actually a little less borderline than you might imagine. You're now going into other personality problems. Yeah.

I spoke with a psychiatrist yesterday from Zurich, and her philosophy, and it's something to question for sure, is that a lot of what we're seeing in borderline personality disorder is women who are actually antisocial and then they are looking for some sort of feminized way to manipulate. They're not going to do it by force. They're not like these guys who are going to end up in prison, um, because they're antisocial men and they're aggressive. Uh, and that it's a, it's sort of a masking to, "I'm so vulnerable, I'm so needy," whatever, but really they have no concern for others. Um, I would wonder what you think of of something like that. I would say that's not somebody who's borderline. Mhm. But it, but can it, can it be mimicked? Can a, can a person who is antisocial present like that? Uh, so, you know, we see people all the time who come into a program like mine, and you, it, it does not take long to be able to differentiate those two things, but it may be through experience, like as a therapist, experience with that person, where you get a, a flavor of that differential. Um, but somebody who is doing something without regard to somebody else's feelings, I would say that's not somebody who is really purely borderline. Okay. Okay. That's, that's not what we would see.

What's the distinction for you that that trips the switch? Some of the questions you're asking, you know, um, am I disregarding somebody's thoughts and feelings? Are my needs really the only needs in the room? Do I feel shame? Do I feel remorse? Do I feel guilt? What's my priority? To get my needs met or to be related to somebody else? Okay. Right. These questions, these questions are answered by a person who, if they, they're antisocial, we would expect would use deception. Correct. Um, they may, they may use deception. That's true. Um, they may not be so skillful. Okay. To use deception. Sometimes it's just clunky and obvious through behavior, through experience. Okay. And then you're hearing these, this isn't self-report on some sort of checklist. Your intuition as a therapist is also kicking in, you can follow up. I, I would actually say this is less through self-report, although we do in a program like mine, we do do assessments throughout their stay, but clinically, you will see these things both within the relationship. And if you are lucky enough to observe them in a community-based situation, like a milieu, um, it becomes more a benefit of a residential program like mine, is that you can see everything play out in real time. Mhm. Just by virtue of having a community-based program. Okay. Yeah.

Karen, I think in, in general, people are afraid of getting into relationships with people who are going to hurt them. Um, and unfortunately, relationships with people with borderline personality disorder can be hurtful. Um, what advice or suggestions or observations do you have just about in general, um, getting into good, healthy relationships? I would say actually, the person who identifies as borderline is a lot, um, is a lot a safer bet to get into a relationship with somebody like that than somebody that has no idea about their own psychology. Okay? Because there are many people who, so John Gunderson would say, everybody has a little bit of BPD. Everybody's a little socially, you know, sensitive. Everybody's like, likes to be accepted. Everyone has emotions. Everyone has behavioral reactivity, you know, at some level. The problem is when you hit the extreme levels, and it's, um, impairing your functioning either at work or in relationships, right? Those are the times where you're like, "Uh, I need to go seek help." So he would say, "Everyone's got a little BPD." I'm going to put that out there. Um, but I think the, if you're somebody who of course wants to be in a safe relationship, it's helpful for you to know your own psychology first. And if you see these tendencies in a relationship, um, my, a, a big thing that we talk about in, in my program, and also that I would share in any clinical setting, any, um, patient I would see or family, is to talk about it and to talk about what your experience is, what that impact is like, and see how available and open somebody is to look at themselves, to see their own contribution and willingness to change. Because if you have those things there, it's actually a, a very good recipe for, um, ongoing improvement and stability in a relationship. It's when it's, it's, you need to change. You have to do this. I'm not, I am all, I'm fine. Um, then you're stuck. There's nothing to actually, there's no traction. There's no investment. There's no motivation. And we've come full circle back to gaslighting. Very good. So, the looking at the self, the willingness to change, and looking at the contribution that you make to a relationship, if you find someone like that, um, that's a good starting place. It's a great starting place. Great.

Well, Dr. Karen Jacob, before we get to our last question, where is the best place for people to look for you online? Um, so I'm at McLean Hospital. They certainly can find me there. Um, um, and then, you know, there's this, my, my, my side gig, this project that I'm really hoping, um, can, can be welcomed by families, um, in order to help get a head start on emotional conversations, some interventions that are based on some of these empirically supported treatments that I referred to. So some distress tolerance skills, things like that. Um, it's actually at a site called, and I won't get into why, but, um, no.com. Um, okay. We'll put a link in the description for everyone to check out.

All right. And Dr. Karen Jacob, last of all, we've talked a lot about John Gunderson, and you're in that lineage. I'd just like to know what's it like for you to be sort of carrying the torch in this field of borderline personality disorder. Um, so, um, during the last year of John's life, um, he really dedicated his life to understanding actually a disorder that he would say, and I quote him, scared the Jesus out of him. Um, so if you go into borderline notes, there's one of John's clips where he talks about how he got into this, and he's did tremendous work to get the field to where it is now. And one of the things he said to me was, "It's really important to continue, um, teaching people how to diagnose, how to identify, and how to treat people with BPD. It's a very treatable disorder. It's a very treatable problem." And so I feel like, um, my, the program itself is very oriented to training and teaching. One of the things I welcomed about, um, this podcast is a real opportunity to destigmatize BPD, to humanize BPD, and to, um, get the message out there for somebody who might be struggling with BPD or know somebody that, while treatment could be really scary, if you can allow yourself an opportunity to pursue therapy, um, it can be really life-changing for you. There's, there's a lot of really good treatments out there. So I feel strongly to carry that torch to the next generation post me. Yeah.

Well, Dr. Karen Jacob, for, for doing that work and for, for having the courage to, to educate and for taking this interview with me. Thank you so much. Thank you for having me. I really appreciate it. Thanks for watching my interview. To go even deeper on these ideas, you can watch my episode with Dr. Hannah Spier using the link in the description or the box on the