1 00:00:00,405 --> 00:00:02,269 - Hi, my name is Yvette Esprey, 2 00:00:02,269 --> 00:00:06,002 I'm a clinical psychologist from Johannesburg, South Africa. 3 00:00:06,002 --> 00:00:08,665 In Johannesburg, I run my own private practice 4 00:00:08,665 --> 00:00:12,078 and I do some lecturing for a psychoanalytic institute. 5 00:00:12,078 --> 00:00:14,739 And I come from a background of working 6 00:00:14,739 --> 00:00:18,255 quite intensely with personality disorders, 7 00:00:18,255 --> 00:00:21,295 whilst I was head psychologist at a psychiatric hospital 8 00:00:21,295 --> 00:00:23,659 for a number of years in Johannesburg. 9 00:00:23,659 --> 00:00:27,509 And so, what I'd like to share with you in the lecture today 10 00:00:27,509 --> 00:00:30,581 is really a particular kind of treatment approach 11 00:00:30,581 --> 00:00:33,381 to working with borderline personality disorders, 12 00:00:33,381 --> 00:00:35,339 which I have found enormously helpful, 13 00:00:35,339 --> 00:00:38,492 and certainly has made sense for me in a way 14 00:00:38,492 --> 00:00:41,553 that I've been able to translate into clinical practice. 15 00:00:41,553 --> 00:00:44,504 With, obviously, varying degrees of efficacy. 16 00:00:44,504 --> 00:00:47,663 Those of you who have worked with borderline 17 00:00:47,663 --> 00:00:51,999 disorders or features will know that degrees of efficacy 18 00:00:51,999 --> 00:00:54,056 really depend on so many factors. 19 00:00:54,056 --> 00:00:56,479 But I do find that working from a particular 20 00:00:56,479 --> 00:01:00,505 theoretical base, and specifically an attachment base, 21 00:01:00,505 --> 00:01:05,337 has been enormously useful and helpful in my practice. 22 00:01:05,337 --> 00:01:08,949 So what I'd like to do in this lecture is to start off 23 00:01:08,949 --> 00:01:13,626 by giving you a theoretical underpinning to the practice 24 00:01:13,626 --> 00:01:17,060 and to really tease out, firstly, what we mean 25 00:01:17,060 --> 00:01:20,487 by "borderline", by borderline personality, 26 00:01:20,487 --> 00:01:22,722 by borderline personality disorder, 27 00:01:22,722 --> 00:01:25,471 and then to ground some of that definition 28 00:01:25,471 --> 00:01:28,003 in an attachment context and to give 29 00:01:28,003 --> 00:01:31,845 quite a detailed explanation of attachment theory, 30 00:01:31,845 --> 00:01:34,122 and the links between attachment theory 31 00:01:34,122 --> 00:01:38,522 and the presentation of borderline features and symptoms. 32 00:01:38,522 --> 00:01:40,737 I'll follow that up in the second part of the lecture 33 00:01:40,737 --> 00:01:43,661 with some comments about practice 34 00:01:43,661 --> 00:01:47,469 and some of the core treatments, factors, and tenets, 35 00:01:47,469 --> 00:01:52,243 and going into some detail around how to use attachment 36 00:01:52,243 --> 00:01:55,382 when thinking about practice. 37 00:01:56,280 --> 00:01:59,607 So, a lot of people ask me why I had a particular interest 38 00:01:59,607 --> 00:02:01,621 in working with borderline personality. 39 00:02:01,621 --> 00:02:04,772 Because, once again, as you all know, 40 00:02:04,772 --> 00:02:07,629 it's a particularly challenging and difficult 41 00:02:07,629 --> 00:02:10,836 aspect of clinical practice, and many many clinicians 42 00:02:10,836 --> 00:02:13,403 would shy away from it, enormously. 43 00:02:13,403 --> 00:02:16,225 I have to say that as I have grown in my experience 44 00:02:16,225 --> 00:02:19,394 and as I have worked longer in my practice, 45 00:02:19,394 --> 00:02:23,273 I have become far more selective about who I work with, 46 00:02:23,273 --> 00:02:26,678 but I still have a fundamental interest 47 00:02:26,678 --> 00:02:29,446 in working with those people who struggle 48 00:02:29,446 --> 00:02:33,175 at their core, with their whole way of being in the world, 49 00:02:33,175 --> 00:02:37,171 which is really, at their core, their whole personality. 50 00:02:38,412 --> 00:02:40,383 Working within the borderline spectrum 51 00:02:40,383 --> 00:02:44,897 means working with a diverse spectrum of disorders. 52 00:02:44,897 --> 00:02:49,135 No one person will ever present the same as anybody else. 53 00:02:49,529 --> 00:02:52,056 The entire system is involved, 54 00:02:52,056 --> 00:02:55,235 so we don't work with just this symptom, or that symptom, 55 00:02:55,235 --> 00:02:57,495 or just this aspect of the self. 56 00:02:57,495 --> 00:03:00,016 We are working with the entirety of the person, 57 00:03:00,016 --> 00:03:03,335 which makes it enormously interesting. 58 00:03:03,335 --> 00:03:06,870 There is something about the intensity and the engagement 59 00:03:06,870 --> 00:03:08,020 which is required when working 60 00:03:08,020 --> 00:03:10,107 with the borderline personality disorder, 61 00:03:10,107 --> 00:03:12,791 that I find very, very compelling, 62 00:03:12,791 --> 00:03:15,165 and certainly incredibly engaging, 63 00:03:15,165 --> 00:03:17,462 whilst also challenging. 64 00:03:18,323 --> 00:03:21,525 I find this work gratifying, because of 65 00:03:21,525 --> 00:03:25,071 those moments of breakthrough, and they don't happen often, 66 00:03:25,071 --> 00:03:27,712 but when they happen, they are stunning, 67 00:03:27,712 --> 00:03:30,576 and they can be life-changing. 68 00:03:30,576 --> 00:03:33,288 So that's something that I hold on to. 69 00:03:33,872 --> 00:03:36,235 Another reason for wanting to work in this area 70 00:03:36,235 --> 00:03:39,078 is that it is one of the areas of clinical practice, 71 00:03:39,078 --> 00:03:43,126 in which theory and practice correspond so well together. 72 00:03:43,126 --> 00:03:45,393 I think that often, as clinicians, we have a tendency 73 00:03:45,393 --> 00:03:48,288 to work from our intuition, from our gut, 74 00:03:48,288 --> 00:03:51,402 to feel our way into a practice, 75 00:03:51,402 --> 00:03:54,739 and often we might lack a theoretical foundation, 76 00:03:54,739 --> 00:03:57,852 or backup, to what we are doing in the room. 77 00:03:57,852 --> 00:04:00,122 Working with personality disorders gives us 78 00:04:00,122 --> 00:04:03,867 an opportunity to really marry practice and theory, 79 00:04:03,867 --> 00:04:06,981 in a very, very synchronistic way. 80 00:04:07,775 --> 00:04:11,690 In fact, Caroline Garland, who is a trauma expert, 81 00:04:11,690 --> 00:04:13,475 once commented on the usefulness 82 00:04:13,475 --> 00:04:15,642 of theory for SS clinicians. 83 00:04:15,642 --> 00:04:17,413 What theory gives us, is it gives 84 00:04:17,413 --> 00:04:19,033 us the third voice in the room. 85 00:04:19,033 --> 00:04:20,269 When we're sitting in the room, 86 00:04:20,269 --> 00:04:21,855 and we're grappling for words, 87 00:04:21,855 --> 00:04:24,738 we're grappling for ideas, we don't know what to think, 88 00:04:24,738 --> 00:04:28,089 theory is very, very often the third space 89 00:04:28,089 --> 00:04:31,309 that provides us with a moment to pause, 90 00:04:31,309 --> 00:04:35,288 and a moment to make sense of what is happening in the room. 91 00:04:35,814 --> 00:04:38,100 Theory, for me, is a tool, 92 00:04:38,100 --> 00:04:40,662 and it's fundamental to really understanding 93 00:04:40,662 --> 00:04:44,033 the particular mechanisms for change. 94 00:04:45,061 --> 00:04:49,924 And finally, understanding the theory behind 95 00:04:49,924 --> 00:04:53,127 the borderline manifestation, for me, 96 00:04:53,127 --> 00:04:55,828 certainly helps to create an empathy, 97 00:04:55,828 --> 00:04:59,243 which at other times is very, very hard to find. 98 00:04:59,243 --> 00:05:03,204 When you are sitting with somebody who is hard to reach, 99 00:05:03,204 --> 00:05:06,349 who may be being attacking, who is projecting 100 00:05:06,349 --> 00:05:10,371 everything bad that they feel about themselves into you, 101 00:05:10,371 --> 00:05:13,138 it can be incredibly hard to hold your bearings, 102 00:05:13,138 --> 00:05:17,214 and to be grounded, and to like that person. 103 00:05:17,214 --> 00:05:21,438 Theory, certainly for me, helps to create an empathy, 104 00:05:21,438 --> 00:05:22,958 and allows me to connect with that 105 00:05:22,958 --> 00:05:25,956 incredibly wounded part of the self, 106 00:05:25,956 --> 00:05:28,779 with whom I am trying to work. 107 00:05:31,114 --> 00:05:32,956 Now as I have mentioned, 108 00:05:32,956 --> 00:05:35,286 there are a great number of challenges 109 00:05:35,286 --> 00:05:37,878 when working with borderline personality disorder, 110 00:05:37,878 --> 00:05:40,063 and I just want to pause there for a moment. 111 00:05:40,063 --> 00:05:43,705 I'm always incredibly self-conscious when I use the word 112 00:05:43,705 --> 00:05:45,139 "Borderline Personality Disorder," 113 00:05:45,139 --> 00:05:48,290 knowing, very, very well, just how pejorative 114 00:05:48,290 --> 00:05:52,544 that term has become, just how stigmatized it has become, 115 00:05:52,544 --> 00:05:55,186 and I do want to say at the outset in this lecture, 116 00:05:55,186 --> 00:05:58,288 that I use that term for convenience, 117 00:05:58,288 --> 00:05:59,723 because when you are listening to me, 118 00:05:59,723 --> 00:06:00,991 you know what I'm talking about 119 00:06:00,991 --> 00:06:03,037 and we have a common understanding 120 00:06:03,037 --> 00:06:05,796 based on a common classification system, 121 00:06:05,796 --> 00:06:09,037 but I'm aware that I'm talking about individuals, 122 00:06:09,037 --> 00:06:10,927 and I'm talking about whole people, 123 00:06:10,927 --> 00:06:13,351 and I want to do that with sensitivity, 124 00:06:13,351 --> 00:06:16,563 and with empathy, and so I want to talk about 125 00:06:16,563 --> 00:06:19,433 people with a borderline personality, 126 00:06:19,433 --> 00:06:22,211 I don't want to talk about "a borderline," 127 00:06:22,211 --> 00:06:25,027 because I would hope that there can be 128 00:06:25,027 --> 00:06:27,359 some kind of a space, or some kind of a life, 129 00:06:27,359 --> 00:06:28,898 or some kind of an opportunity 130 00:06:28,898 --> 00:06:31,884 beyond the label of "borderline." 131 00:06:33,009 --> 00:06:36,650 So as I was saying, there are a great deal of challenges 132 00:06:36,650 --> 00:06:39,853 when working with borderline personality disorder. 133 00:06:40,514 --> 00:06:42,477 When I was training, I remember that one of my lecturers 134 00:06:42,477 --> 00:06:46,268 said to me, "You can never have more than one person 135 00:06:46,268 --> 00:06:47,831 "with borderline personality disorder 136 00:06:47,831 --> 00:06:49,956 "in your practice at any given time." 137 00:06:49,956 --> 00:06:51,188 And I remember thinking to myself, 138 00:06:51,188 --> 00:06:52,740 "Why on Earth would she say such a thing?" 139 00:06:52,740 --> 00:06:54,589 I mean, that seems bizarre, 140 00:06:54,589 --> 00:06:58,958 until I started to work in the field and to realize 141 00:06:58,958 --> 00:07:03,519 just how much space, how much energy, how much time, 142 00:07:03,519 --> 00:07:07,911 and how much effort one person who manifests in this way 143 00:07:07,911 --> 00:07:10,552 can take from the therapist. 144 00:07:10,552 --> 00:07:13,085 And how you can have one person in your practice 145 00:07:13,085 --> 00:07:14,748 who dominates your thinking, 146 00:07:14,748 --> 00:07:17,459 both inside the room, and outside of it. 147 00:07:17,459 --> 00:07:20,138 It is taxing and demanding, 148 00:07:20,138 --> 00:07:23,219 and part of the reason for that is because 149 00:07:24,341 --> 00:07:26,699 the way of being for a person 150 00:07:26,699 --> 00:07:28,708 who lives in a borderline realm, 151 00:07:28,708 --> 00:07:32,035 is such that, whenever they encounter another person, 152 00:07:32,035 --> 00:07:35,299 and especially in the intimacy of the therapeutic space, 153 00:07:35,299 --> 00:07:39,629 it is an opportunity for them to project all sorts of 154 00:07:39,629 --> 00:07:43,636 very, very powerful affects and experiences into the other, 155 00:07:43,636 --> 00:07:44,828 which means that very, very often 156 00:07:44,828 --> 00:07:46,418 as the therapist, as you know, 157 00:07:46,418 --> 00:07:49,615 we are having to deal with incredibly primitive feelings, 158 00:07:49,615 --> 00:07:53,608 with the use of defenses around splitting, projecting, 159 00:07:53,608 --> 00:07:56,693 and we, as the therapists, are engaged 160 00:07:56,693 --> 00:08:00,816 in a long-term drama, which we must survive. 161 00:08:00,816 --> 00:08:04,316 And sometimes it does feel like survival. 162 00:08:05,586 --> 00:08:07,698 One of the other challenges in terms 163 00:08:07,698 --> 00:08:09,473 of diagnosis and formulation, 164 00:08:09,473 --> 00:08:11,903 when it comes to working with borderlines, 165 00:08:11,903 --> 00:08:14,814 is that borderline personality disorder 166 00:08:14,814 --> 00:08:16,893 is very, very often misdiagnosed. 167 00:08:16,893 --> 00:08:19,132 Certainly, I know with a lot of psychiatrists 168 00:08:19,132 --> 00:08:21,926 with whom I work, they would always prefer 169 00:08:21,926 --> 00:08:24,705 to diagnose bipolar mood disorder, 170 00:08:24,705 --> 00:08:27,187 and I think we can understand why. 171 00:08:27,187 --> 00:08:28,897 When you're working with a mood disorder, 172 00:08:28,897 --> 00:08:31,378 whose symptoms might very well mirror 173 00:08:31,378 --> 00:08:34,083 some of the borderline symptoms that we know, 174 00:08:34,083 --> 00:08:37,376 It's far easier to treat, pharmacologically, 175 00:08:37,376 --> 00:08:39,794 so we can give a mood stabilizer, 176 00:08:39,794 --> 00:08:41,496 we can give an antipsychotic, 177 00:08:41,496 --> 00:08:43,866 and we can treat the mood disorder. 178 00:08:43,866 --> 00:08:48,450 But how do we begin to medically treat a whole personality? 179 00:08:48,450 --> 00:08:50,911 And so very, very often, those patients who 180 00:08:50,911 --> 00:08:53,961 present very clearly with a borderline personality disorder 181 00:08:53,961 --> 00:08:58,961 get misdiagnosed, or the diagnosis is deferred, 182 00:08:59,786 --> 00:09:02,165 because to actually give that definitive diagnosis 183 00:09:02,165 --> 00:09:05,259 makes treatment incredibly difficult. 184 00:09:05,761 --> 00:09:08,937 We also know, of course, that patients 185 00:09:08,937 --> 00:09:11,205 can sit with the diagnosis of both 186 00:09:11,205 --> 00:09:14,138 a personality disorder and a mood disorder, 187 00:09:14,138 --> 00:09:18,514 where the hypermanic symptoms of a bipolar mood episode, 188 00:09:18,514 --> 00:09:21,427 can very, very easily mirror 189 00:09:21,427 --> 00:09:24,569 the symptoms of borderline pathology, 190 00:09:24,569 --> 00:09:26,675 and that both of those experiences 191 00:09:26,675 --> 00:09:29,631 can co-exist for the same person. 192 00:09:29,631 --> 00:09:32,352 What is extremely fundamental when 193 00:09:32,352 --> 00:09:35,584 diagnosing and formulating around personality 194 00:09:35,584 --> 00:09:38,197 is to establish a clear history 195 00:09:38,197 --> 00:09:40,844 and a clear pattern of behavior. 196 00:09:40,844 --> 00:09:45,427 We simply cannot diagnose a borderline personality 197 00:09:45,427 --> 00:09:49,019 based on one discrete episode of regression. 198 00:09:49,019 --> 00:09:51,912 Every single one of us is vulnerable to regressing 199 00:09:51,912 --> 00:09:55,553 in the face of major life stresses, or major life traumas. 200 00:09:55,553 --> 00:09:59,881 Every single one of us is capable of being reduced 201 00:09:59,881 --> 00:10:03,287 to infantile states of mind and to primitive feelings, 202 00:10:03,287 --> 00:10:06,201 when faced with overwhelming experiences. 203 00:10:06,201 --> 00:10:09,922 So in order to diagnose, accurately, a borderline pathology, 204 00:10:09,922 --> 00:10:12,131 we have to have a long history, 205 00:10:12,131 --> 00:10:15,441 where we can quite clearly see the markers 206 00:10:15,441 --> 00:10:18,215 of the development of a personality that, 207 00:10:18,215 --> 00:10:21,619 for this person, is dysfunctional in the world. 208 00:10:22,982 --> 00:10:26,366 A further challenge in working in this area 209 00:10:26,366 --> 00:10:29,495 is managing the countertransferance. 210 00:10:29,511 --> 00:10:31,883 So often our countertransferance as clinicians 211 00:10:31,883 --> 00:10:35,458 is they're a tool which we use to help us to make sense 212 00:10:35,458 --> 00:10:37,867 of what is happening in the world of the other. 213 00:10:37,867 --> 00:10:40,641 Quite often when working with personality disorders, 214 00:10:40,641 --> 00:10:42,711 it is our countertransferance that can become 215 00:10:42,711 --> 00:10:45,017 an obstacle to working with the other. 216 00:10:45,017 --> 00:10:47,393 Certainly, there are times when I 217 00:10:47,393 --> 00:10:50,741 have been working with a patient 218 00:10:50,741 --> 00:10:53,815 whose transferance is so powerful, 219 00:10:53,815 --> 00:10:56,068 and whose projections are so overwhelming, 220 00:10:56,068 --> 00:10:59,994 that I find it difficult to continue. 221 00:10:59,994 --> 00:11:03,373 At times I feel unable to continue. 222 00:11:03,373 --> 00:11:05,791 And so making sense of our countertransferance 223 00:11:05,791 --> 00:11:09,144 reactions is incredibly important. 224 00:11:09,144 --> 00:11:13,676 And making sense of how it feels to sometimes be hated, 225 00:11:13,676 --> 00:11:18,676 to sometimes experience the full force of persecutory rage, 226 00:11:19,639 --> 00:11:23,551 making sense of that is so very, very important. 227 00:11:23,967 --> 00:11:27,967 But once again, to reiterate, that the countertransference 228 00:11:27,967 --> 00:11:31,400 is really what helps us, most accurately, 229 00:11:31,400 --> 00:11:35,283 to tune in to the internal world of the other. 230 00:11:37,421 --> 00:11:40,963 Finally, the challenge of working in this area, 231 00:11:40,963 --> 00:11:45,615 is the challenge of reaching a place of intense humility. 232 00:11:46,365 --> 00:11:48,915 To recognize, in the other, 233 00:11:48,915 --> 00:11:52,236 what has to be borne, and what has to be survived. 234 00:11:52,236 --> 00:11:55,850 To recognize in the other, that in the face of overwhelming 235 00:11:55,850 --> 00:11:59,668 obstacles, internal obstacles and external obstacles, 236 00:11:59,668 --> 00:12:01,516 there is the strength of the human spirit 237 00:12:01,516 --> 00:12:03,083 and the life instinct. 238 00:12:03,083 --> 00:12:06,118 Sometimes I'm absolutely blown away 239 00:12:06,118 --> 00:12:08,752 by the circumstances of some of my patients' lives, 240 00:12:08,752 --> 00:12:11,143 by the circumstances of their early childhoods, 241 00:12:11,143 --> 00:12:13,910 bu the circumstances of their internal worlds, 242 00:12:13,910 --> 00:12:17,427 and yet they still have a life force, 243 00:12:17,427 --> 00:12:21,107 some kind of a libidinal instinct that pushes them through, 244 00:12:21,107 --> 00:12:26,085 and that gives them the courage to continue to live. 245 00:12:26,085 --> 00:12:29,490 And I find that enormously humbling. 246 00:12:31,961 --> 00:12:35,723 So, working with borderline personality disorder, 247 00:12:35,723 --> 00:12:38,551 in fact working on the personality disorder spectrum, 248 00:12:38,551 --> 00:12:42,220 we really have so many treatment modalities at our disposal. 249 00:12:42,220 --> 00:12:46,409 There are so many different ways of thinking about BPD. 250 00:12:46,410 --> 00:12:50,161 We have had Kernberg, we have had Masterson, 251 00:12:50,161 --> 00:12:53,508 we have had Linehan, we have Fonagy, 252 00:12:53,508 --> 00:12:55,737 we have countless theorists who have 253 00:12:55,737 --> 00:12:58,858 given us their treatment modality. 254 00:12:58,858 --> 00:13:00,351 Ultimately, at the end of the day, 255 00:13:00,351 --> 00:13:02,744 I think that, for each of those theorists, 256 00:13:02,744 --> 00:13:05,156 the way in which they propose we work, 257 00:13:05,156 --> 00:13:07,163 really works for them. 258 00:13:07,163 --> 00:13:08,999 So ultimately, as a clinician, 259 00:13:08,999 --> 00:13:12,895 we have to decide for ourselves what works for us. 260 00:13:12,895 --> 00:13:14,341 Of course a treatment of choice, 261 00:13:14,341 --> 00:13:16,156 certainly I think in this country, 262 00:13:16,156 --> 00:13:19,559 is dialectical behavior therapy, is DBT. 263 00:13:19,559 --> 00:13:23,394 Which really focuses on emotional disregulation, 264 00:13:23,394 --> 00:13:26,536 and I think can be an enormously effective 265 00:13:26,536 --> 00:13:30,430 way of treating the illness, and treating the disorder. 266 00:13:30,430 --> 00:13:32,217 But the one thing about DBT is 267 00:13:32,217 --> 00:13:35,146 that it focuses on symptom relief. 268 00:13:35,146 --> 00:13:37,744 It focuses on what manifests, 269 00:13:37,744 --> 00:13:40,445 every day, in this person's life, 270 00:13:40,445 --> 00:13:43,672 and may not get to what we believe is the 271 00:13:43,672 --> 00:13:46,837 underlying psychological deficit, 272 00:13:46,837 --> 00:13:51,417 which is born out of an early attachment relationship. 273 00:13:51,417 --> 00:13:54,665 I found that attachment makes sense, for me, 274 00:13:54,665 --> 00:13:58,580 and so does the attachment-based way of thinking about 275 00:13:58,580 --> 00:14:03,181 and working with borderline personality disorder. 276 00:14:09,604 --> 00:14:11,980 I would like to shift the focus a little bit now, 277 00:14:11,980 --> 00:14:14,295 and talk about contextualizing BPD 278 00:14:14,295 --> 00:14:15,905 as a disorder of the self. 279 00:14:15,905 --> 00:14:20,838 James Masterson was very instrumental in rewording 280 00:14:21,653 --> 00:14:24,927 the notion of a personality disorder, 281 00:14:24,927 --> 00:14:29,344 and rethinking it into a disorder of the self. 282 00:14:30,408 --> 00:14:32,834 Thinking about a borderline personality 283 00:14:32,834 --> 00:14:35,321 as being a disorder of the self 284 00:14:35,321 --> 00:14:39,316 is more nuanced, and it really focuses us on 285 00:14:39,316 --> 00:14:42,302 the self, on the development of the self, 286 00:14:42,302 --> 00:14:44,913 on the parts of the self that struggle 287 00:14:44,913 --> 00:14:46,825 to be effective in the world, 288 00:14:46,825 --> 00:14:50,481 to live an effective life, and to be functional. 289 00:14:52,388 --> 00:14:55,090 So, we might want to ask ourselves, 290 00:14:55,090 --> 00:14:58,354 "What are the characteristics of a developed self, 291 00:14:58,354 --> 00:15:01,056 "versus the characteristics of a more disordered self?" 292 00:15:01,056 --> 00:15:06,056 "What are the things that make us functional, as people?" 293 00:15:06,066 --> 00:15:09,235 And certainly, whenever I read through this list, 294 00:15:09,235 --> 00:15:12,936 I always refer to myself, and I think about 295 00:15:12,936 --> 00:15:17,599 how many aspects of the self I can relate to directly, 296 00:15:17,599 --> 00:15:18,675 and I'm sure in listening to this, 297 00:15:18,675 --> 00:15:20,998 you'll do the same for yourself. 298 00:15:20,998 --> 00:15:23,131 But one of the most important things 299 00:15:23,131 --> 00:15:25,231 that forms a coherent self 300 00:15:25,231 --> 00:15:28,727 is the ability to view ourselves, and others, 301 00:15:28,727 --> 00:15:32,504 in stable and complex and accurate ways. 302 00:15:32,504 --> 00:15:34,792 In other words, to really be able to have 303 00:15:34,792 --> 00:15:38,243 a nuanced picture of who we are in the world, 304 00:15:38,243 --> 00:15:40,498 and of who the other is in the world. 305 00:15:40,498 --> 00:15:44,265 I remember so often when working in my psychiatric hospital, 306 00:15:44,265 --> 00:15:47,333 when interviewing patients as they came in, 307 00:15:47,333 --> 00:15:49,382 and asking them to describe themselves, 308 00:15:49,382 --> 00:15:52,113 how I would be faced, quite often, 309 00:15:52,113 --> 00:15:56,463 with dumbfoundedness, with confusion, with inarticulateness, 310 00:15:56,463 --> 00:15:59,334 when I said to them, "Tell me who you are." 311 00:15:59,334 --> 00:16:01,738 "Tell me who you are as a person." 312 00:16:01,738 --> 00:16:06,628 And there was a real inability to fine-tune, 313 00:16:06,628 --> 00:16:10,319 or articulate, characteristics of the self. 314 00:16:10,319 --> 00:16:11,975 Similarly, I might say to them, 315 00:16:11,975 --> 00:16:13,036 "Tell me about your mother," or 316 00:16:13,036 --> 00:16:14,270 "Tell me about your partner," or 317 00:16:14,270 --> 00:16:18,763 "Tell me about your child," and there would be an incredibly 318 00:16:19,438 --> 00:16:22,391 striking deficit, and inability, 319 00:16:22,391 --> 00:16:24,494 to describe the other person. 320 00:16:24,494 --> 00:16:26,745 Or alternatively, the self and the other 321 00:16:26,745 --> 00:16:28,523 is described in very contradictory ways. 322 00:16:28,523 --> 00:16:31,088 So for example, a person may say, 323 00:16:31,088 --> 00:16:35,142 "Ah I really, I love people! I'm very outgoing! 324 00:16:35,142 --> 00:16:37,097 "I really really enjoy people." 325 00:16:37,097 --> 00:16:40,102 And then, to follow that up, immediately, 326 00:16:40,102 --> 00:16:42,261 with a completely contradictory statement 327 00:16:42,261 --> 00:16:44,346 about being isolated in the world, 328 00:16:44,346 --> 00:16:46,745 or about not being able to relate to people. 329 00:16:46,745 --> 00:16:50,088 And whilst those splits are so starkly obvious 330 00:16:50,088 --> 00:16:54,945 to the observer, to the person that split is not recognized. 331 00:16:54,945 --> 00:16:56,976 And it's that kind of splitting of the self 332 00:16:56,976 --> 00:16:59,154 that kind of inability to accurately 333 00:16:59,154 --> 00:17:01,080 portray the self and the other 334 00:17:01,080 --> 00:17:04,726 that is a cornerstone of a disordered self. 335 00:17:05,679 --> 00:17:08,558 Another very important aspect of a developed self 336 00:17:08,558 --> 00:17:10,859 is the ability to maintain intimate, 337 00:17:10,859 --> 00:17:13,608 stable, and satisfying relationships. 338 00:17:13,608 --> 00:17:15,680 And of course we know that that isn't only 339 00:17:15,680 --> 00:17:18,275 within the realm of romantic relationships. 340 00:17:18,275 --> 00:17:19,762 We need to ask the question, 341 00:17:19,762 --> 00:17:22,604 "Can this person relate to other people?", 342 00:17:22,604 --> 00:17:24,811 "Do they have a history of friendships?" 343 00:17:24,811 --> 00:17:26,720 One of the most very, very important 344 00:17:26,720 --> 00:17:29,867 questions to ask a person, "Do you have friends?", 345 00:17:29,867 --> 00:17:31,873 "For how long have you known them?", 346 00:17:31,873 --> 00:17:33,990 "What is the depth of that friendship?" 347 00:17:33,990 --> 00:17:36,062 Are they able to form attachments 348 00:17:36,062 --> 00:17:40,050 and relationships with their pets, for example, 349 00:17:40,050 --> 00:17:42,690 with people in their lives, or have they 350 00:17:42,690 --> 00:17:45,624 got a history of truncated relationships 351 00:17:45,624 --> 00:17:48,770 and broken friendships, and a clear inability 352 00:17:48,770 --> 00:17:52,951 to hold on, or to establish intimacy? 353 00:17:55,360 --> 00:17:59,631 Thirdly, a developed self is able to 354 00:17:59,631 --> 00:18:03,671 experience, in self, and to perceive in others, 355 00:18:03,671 --> 00:18:08,671 the full range of affect appropriate at any given moment. 356 00:18:08,864 --> 00:18:12,492 In other words, we all have the capacity to 357 00:18:12,492 --> 00:18:17,382 experience emotions in varying degrees of intensity. 358 00:18:17,382 --> 00:18:18,739 We feel strongly about things, 359 00:18:18,739 --> 00:18:20,763 we feel happy, we feel sad, 360 00:18:20,763 --> 00:18:23,403 we feel devastated, we feel joyful, 361 00:18:23,403 --> 00:18:27,962 we feel sad, lonely, hurt, angry. 362 00:18:27,962 --> 00:18:31,997 And are we able to feel those myriad emotions 363 00:18:31,997 --> 00:18:35,705 appropriately, at different times, in our lives? 364 00:18:35,705 --> 00:18:39,947 And are we able to perceive those emotions in other people? 365 00:18:39,947 --> 00:18:44,276 It's about affect tolerance, and about emotion regulation, 366 00:18:44,276 --> 00:18:48,010 which is so important to a developed self. 367 00:18:49,179 --> 00:18:54,106 Fourthly, the ability to regulate impulses. 368 00:18:56,285 --> 00:18:58,734 Can you manage impulsivity? 369 00:18:58,734 --> 00:19:02,449 How do you manage if you feel overwhelmed by a situation? 370 00:19:02,449 --> 00:19:07,130 What do you do when you feel lost, or alone, or scared? 371 00:19:07,532 --> 00:19:09,322 What do you do when you feel angry? 372 00:19:09,322 --> 00:19:11,720 Are you able to sit with those feelings, 373 00:19:11,720 --> 00:19:13,653 or do you have to do something, 374 00:19:13,653 --> 00:19:15,865 to extricate yourself from that feeling, 375 00:19:15,865 --> 00:19:18,383 because it is just too much? 376 00:19:18,383 --> 00:19:21,438 And how does that impulsivity manifest? 377 00:19:21,438 --> 00:19:25,321 So impulse regulation, capacity to manage impulsivity, 378 00:19:25,321 --> 00:19:29,061 is a very important aspect of a developed self. 379 00:19:30,439 --> 00:19:32,790 Importantly when we are considering more 380 00:19:32,790 --> 00:19:36,627 psychopathic or narcissistic personality structures, 381 00:19:36,627 --> 00:19:39,209 is the ability to function in line with 382 00:19:39,209 --> 00:19:42,129 some kind of a consistent moral code. 383 00:19:42,129 --> 00:19:46,406 In other words, to have a suitably integrated superego. 384 00:19:46,406 --> 00:19:49,386 That part of ourselves that knows what is right or wrong. 385 00:19:49,386 --> 00:19:51,939 That part of ourselves that knows 386 00:19:51,939 --> 00:19:55,141 what our actions might do to others. 387 00:19:55,141 --> 00:19:56,691 That part of ourselves that understands 388 00:19:56,691 --> 00:19:59,588 the consequences of our actions. 389 00:19:59,972 --> 00:20:03,815 And that's a fundamental aspect of a mature self, 390 00:20:03,815 --> 00:20:06,015 is to be able to differentiate that, 391 00:20:06,015 --> 00:20:09,016 and to be able to make decisions based on that. 392 00:20:10,384 --> 00:20:14,877 Is there the ability to differentiate 393 00:20:14,877 --> 00:20:16,506 what is real and what is not real? 394 00:20:16,506 --> 00:20:19,723 In other words, the capacity for reality testing. 395 00:20:21,008 --> 00:20:24,305 Is there the ability to respond to stress, 396 00:20:24,305 --> 00:20:27,360 resourcefully and appropriately? 397 00:20:27,846 --> 00:20:31,457 And is there the capacity to recover from painful events 398 00:20:31,457 --> 00:20:36,457 in a way that is mature and appropriate? 399 00:20:36,917 --> 00:20:39,669 In other words, we all struggle with painful events, 400 00:20:39,669 --> 00:20:42,941 with loss, with death, with trauma. 401 00:20:42,941 --> 00:20:45,812 But the question is, "How quickly do we 402 00:20:45,812 --> 00:20:49,559 "pick ourselves up from that place of despair?" 403 00:20:49,559 --> 00:20:51,368 And that was always one of the things 404 00:20:51,368 --> 00:20:53,561 that helped me to differentiate, 405 00:20:53,561 --> 00:20:55,688 when I was working in a psychiatric context, 406 00:20:55,688 --> 00:20:58,598 between those with a personality component, 407 00:20:58,598 --> 00:21:02,300 and those who were suffering with straightforward trauma. 408 00:21:02,300 --> 00:21:04,184 There's never a straightforward trauma, but 409 00:21:04,184 --> 00:21:06,631 nothing, I think you probably understand what I mean. 410 00:21:07,261 --> 00:21:10,561 So, somebody who goes through a trauma, 411 00:21:10,561 --> 00:21:14,303 and who is unable to pull themselves back together, 412 00:21:14,303 --> 00:21:18,885 and who is reduced to a place of absolute despair, 413 00:21:18,885 --> 00:21:20,522 where they fragment and fall apart, 414 00:21:20,522 --> 00:21:22,106 they can no longer function, 415 00:21:22,106 --> 00:21:23,396 they can't go back to work, 416 00:21:23,396 --> 00:21:25,469 they can't maintain their relationships, 417 00:21:25,469 --> 00:21:27,317 they might become suicidal, 418 00:21:27,317 --> 00:21:29,563 that is a shattering of the self, 419 00:21:29,563 --> 00:21:32,826 and an inability to pull the self back together, 420 00:21:32,826 --> 00:21:35,146 which would be a more appropriate way 421 00:21:35,146 --> 00:21:38,145 of dealing with a trauma. 422 00:21:38,542 --> 00:21:43,354 And finally, a developed self has the insight 423 00:21:43,354 --> 00:21:46,623 and the capacity to observe themselves. 424 00:21:46,623 --> 00:21:50,575 And this is, I can't stress enough how fundamental this is, 425 00:21:50,575 --> 00:21:52,605 when thinking about whether or not a person 426 00:21:52,605 --> 00:21:54,711 can be diagnosed or formulated as 427 00:21:54,711 --> 00:21:56,962 disordered in terms of their self, 428 00:21:56,962 --> 00:21:58,918 the capacity to know what is happening. 429 00:21:58,918 --> 00:22:00,864 So for many of us, we may well know 430 00:22:00,864 --> 00:22:02,513 when we're being dysfunctional, 431 00:22:02,513 --> 00:22:03,875 or when we're acting inappropriately, 432 00:22:03,875 --> 00:22:05,309 or when we're feeling something 433 00:22:05,309 --> 00:22:07,199 that perhaps we shouldn't be feeling. 434 00:22:07,199 --> 00:22:09,486 But we know it, we can observe it, 435 00:22:09,486 --> 00:22:11,631 and we can comment on it. 436 00:22:11,631 --> 00:22:14,468 Whereas with somebody who sits with a disorder of the self, 437 00:22:14,468 --> 00:22:18,261 there isn't that distance, there isn't the luxury, 438 00:22:18,261 --> 00:22:20,192 of that distance, and the luxury of 439 00:22:20,192 --> 00:22:23,566 being able to comment on their own behavior. 440 00:22:25,268 --> 00:22:28,915 Overridingly, a mature and a developed self 441 00:22:28,915 --> 00:22:32,979 has a sense of vitality, which allows for passion, 442 00:22:32,979 --> 00:22:36,135 and for meaning-making, and for creativity. 443 00:22:36,135 --> 00:22:40,244 And it's that kind of vitality, that kind of life force, 444 00:22:40,244 --> 00:22:44,335 that kind of creativity that we so seldom see 445 00:22:44,335 --> 00:22:47,927 in those people who manifest on the borderline spectrum. 446 00:22:47,927 --> 00:22:51,693 There's also the capacity to mourn, to accept, 447 00:22:51,693 --> 00:22:55,808 and to surrender to experiences in life, 448 00:22:55,808 --> 00:23:00,157 which the disordered self simply cannot bear. 449 00:23:01,078 --> 00:23:04,698 So if we step back a little bit from those capacities 450 00:23:04,698 --> 00:23:06,542 of the mature and developed self, 451 00:23:06,542 --> 00:23:07,846 and we think to ourselves, 452 00:23:07,846 --> 00:23:12,416 "Well, what are the core incapacities 453 00:23:12,723 --> 00:23:15,688 "of the borderline personality?" 454 00:23:16,719 --> 00:23:20,235 I would say that the core of a disordered personality, 455 00:23:20,235 --> 00:23:23,402 a disordered self, are the following. 456 00:23:23,402 --> 00:23:25,906 Identity distortion, a real inability 457 00:23:25,906 --> 00:23:29,385 to portray self, or other, in accurate ways. 458 00:23:30,430 --> 00:23:32,549 Inadequate relationships, or the inability 459 00:23:32,549 --> 00:23:35,455 to maintain satisfying relationships. 460 00:23:36,240 --> 00:23:38,835 Affect disregulation, really not being able to 461 00:23:38,835 --> 00:23:41,493 manage feelings, tolerate feelings, 462 00:23:41,493 --> 00:23:44,356 or express feelings appropriately. 463 00:23:44,356 --> 00:23:46,519 And impulsivity. 464 00:23:48,418 --> 00:23:51,243 In addition to this, whilst reality testing 465 00:23:51,243 --> 00:23:53,335 globally might be fairly intact. 466 00:23:53,335 --> 00:23:56,690 In other words, many of the people with whom we work, 467 00:23:56,690 --> 00:23:58,595 who present with a borderline disorder, 468 00:23:58,595 --> 00:24:00,975 are absolutely able to live in the world, 469 00:24:00,975 --> 00:24:03,368 they're able to, they're not psychotic, 470 00:24:03,368 --> 00:24:05,585 they don't present with any kind of a psychotic disorder, 471 00:24:05,585 --> 00:24:08,516 so on the face of it, they seem functional in the world 472 00:24:08,516 --> 00:24:13,195 and able to differentiate what is real and what is not real. 473 00:24:13,195 --> 00:24:16,450 But if we start to really nuance 474 00:24:16,450 --> 00:24:18,200 what we mean by reality testing, 475 00:24:18,200 --> 00:24:19,867 then we start to see that their 476 00:24:19,867 --> 00:24:21,729 sense of reality can be distorted, 477 00:24:21,729 --> 00:24:25,389 certainly when it comes to perceptions of self, or other. 478 00:24:25,389 --> 00:24:29,281 But in the main, reality testing is intact. 479 00:24:29,818 --> 00:24:31,260 However, when we are talking about 480 00:24:31,260 --> 00:24:34,034 the narcissist or the psychopath, 481 00:24:34,034 --> 00:24:38,037 a very, very important feature of their disordered self 482 00:24:38,037 --> 00:24:42,167 is the inability to distinguish right from wrong. 483 00:24:42,167 --> 00:24:47,110 There is a fundamental impairment of moral sensibility, 484 00:24:47,110 --> 00:24:50,096 which is often very, very easy 485 00:24:50,096 --> 00:24:52,718 to see, and to recognize. 486 00:24:54,090 --> 00:24:56,535 When working with a disorder of the self, 487 00:24:56,535 --> 00:25:00,608 we will frequently see that the attribution of blame, 488 00:25:00,608 --> 00:25:04,237 for experience, is almost always and inevitably 489 00:25:04,237 --> 00:25:06,080 outwards into the environment. 490 00:25:06,080 --> 00:25:07,769 In other words, 491 00:25:08,969 --> 00:25:11,321 the self will never be held responsible 492 00:25:11,321 --> 00:25:12,364 for what is going wrong. 493 00:25:12,364 --> 00:25:14,548 It will always be, "Why is the world against me?" 494 00:25:14,548 --> 00:25:16,488 "Why is this person against me?", 495 00:25:16,488 --> 00:25:18,173 "Why does this always happen to me?", 496 00:25:18,173 --> 00:25:22,321 as opposed to having a firmer internal acts of control, 497 00:25:22,321 --> 00:25:23,666 where they might say, 498 00:25:23,666 --> 00:25:25,531 "Well what is it that I might be doing?", 499 00:25:25,531 --> 00:25:27,976 or "What kind of responsibility can I bear 500 00:25:27,976 --> 00:25:30,728 "for the outcomes in my life?" 501 00:25:31,772 --> 00:25:35,551 We see a consistent pattern of dysfunctionality. 502 00:25:35,551 --> 00:25:38,881 And we see, within this consistent pattern, 503 00:25:38,881 --> 00:25:40,877 particular personality traits that are 504 00:25:40,877 --> 00:25:43,724 inflexible and maladaptive. 505 00:25:44,925 --> 00:25:48,325 Certainly inflexible and maladaptive to you and I, 506 00:25:48,325 --> 00:25:49,729 that when we observe them, 507 00:25:49,729 --> 00:25:52,152 we can see how dysfunctional they are. 508 00:25:52,152 --> 00:25:55,057 But another fundamental aspect of the disorder of the self, 509 00:25:55,057 --> 00:25:57,749 is that, for that person, the way that they are 510 00:25:57,749 --> 00:26:00,655 in the world is ego-syntonic. 511 00:26:00,655 --> 00:26:03,737 In other words, it's congruent for them. 512 00:26:03,737 --> 00:26:06,891 What's not congruent, is the way that the world, 513 00:26:06,891 --> 00:26:09,952 the way that we, respond to them. 514 00:26:11,129 --> 00:26:13,890 So finally, just to pull together 515 00:26:13,890 --> 00:26:17,646 the diagnosis and the classification of BPD, 516 00:26:18,584 --> 00:26:21,997 inevitably, it involves the whole self. 517 00:26:21,997 --> 00:26:24,748 We do not deal with discrete or separate symptoms. 518 00:26:24,748 --> 00:26:28,255 We can't take impulsivity and treat that discretely. 519 00:26:28,255 --> 00:26:31,751 We can't take self-destructive behavior 520 00:26:31,751 --> 00:26:32,879 and treat that discretely. 521 00:26:32,879 --> 00:26:36,135 We can't take that deep, dark depression 522 00:26:36,135 --> 00:26:38,454 and treat that discretely. 523 00:26:38,992 --> 00:26:43,431 We have to think about the wholeness of the system. 524 00:26:43,431 --> 00:26:47,903 And fundamental to that, is understanding the genesis 525 00:26:47,903 --> 00:26:52,328 of where this particular fractured self comes from, 526 00:26:52,911 --> 00:26:55,814 because it comes from somewhere. 527 00:27:05,015 --> 00:27:06,828 Thinking about classification systems, 528 00:27:06,828 --> 00:27:08,879 you'll all aware, of course, of the 529 00:27:08,879 --> 00:27:11,350 controversy and the debate, I would imagine, 530 00:27:11,350 --> 00:27:15,234 around BPD, that there's been a great deal of discussion, 531 00:27:15,234 --> 00:27:18,209 historically, about what it actually means, 532 00:27:18,209 --> 00:27:21,694 and how to classify it, how to define it, 533 00:27:21,694 --> 00:27:24,985 and that culminated in the atheoretical symptom list, 534 00:27:24,985 --> 00:27:27,582 which we now have in the DSM-5, 535 00:27:27,582 --> 00:27:31,104 which is commonly known, 536 00:27:31,104 --> 00:27:34,061 and it's an easy-to-tick-off checklist 537 00:27:34,061 --> 00:27:36,335 of symptom presentation, which allows us 538 00:27:36,335 --> 00:27:39,276 to give the diagnosis of a BPD. 539 00:27:39,289 --> 00:27:42,105 In contrast, however, and certainly my choice 540 00:27:42,105 --> 00:27:44,305 of diagnostic classification system, 541 00:27:44,305 --> 00:27:48,476 is the PDM, the Psychodynamic Diagnostic Manual. 542 00:27:48,476 --> 00:27:51,517 In the PDM, what is considered 543 00:27:51,517 --> 00:27:53,710 is the whole range of functioning, 544 00:27:53,710 --> 00:27:57,802 which presents within the BPD spectrum. 545 00:27:57,802 --> 00:28:00,976 Consideration is taken of developmental factors. 546 00:28:00,976 --> 00:28:04,277 Consideration is taken of environmental factors, 547 00:28:04,277 --> 00:28:06,985 and current context, and support systems, 548 00:28:06,985 --> 00:28:10,121 and so that if you use this particular classification system 549 00:28:10,121 --> 00:28:12,891 in diagnosing or formulating around your patients, 550 00:28:12,891 --> 00:28:15,766 you are really getting a much more multi-dimensional 551 00:28:15,766 --> 00:28:19,801 picture of this person, of this individual. 552 00:28:20,694 --> 00:28:23,609 And really, it is only over time 553 00:28:23,609 --> 00:28:27,146 as we get to know a patient more and more intimately, 554 00:28:27,146 --> 00:28:29,864 that we can really comprehensively 555 00:28:29,864 --> 00:28:34,178 formulate and understand their particular manifestation. 556 00:28:34,178 --> 00:28:35,624 Certainly I've had people, with whom 557 00:28:35,624 --> 00:28:38,127 I've been working for many, many years, 558 00:28:38,127 --> 00:28:40,126 five years, I've got somebody I've 559 00:28:40,126 --> 00:28:42,157 been seeing for seven or eight years, 560 00:28:42,157 --> 00:28:46,265 where getting to know them has really happened over time. 561 00:28:46,265 --> 00:28:48,725 So my initial formulation 562 00:28:48,725 --> 00:28:51,934 of borderline personality disorder, 563 00:28:52,856 --> 00:28:56,024 whilst it was accurate, it certainly wasn't 564 00:28:56,024 --> 00:28:58,776 nuanced enough for me to fully comprehend 565 00:28:58,776 --> 00:29:01,453 the way that this particular person manifests. 566 00:29:01,453 --> 00:29:05,424 Over time, we are more able to do that. 567 00:29:06,227 --> 00:29:08,818 The PDM really draws largely 568 00:29:08,818 --> 00:29:11,783 on Otto Kernberg's psychoanalytic structural theory, 569 00:29:11,783 --> 00:29:15,104 which I'm going to go into a little bit, later on, 570 00:29:15,104 --> 00:29:18,621 where broad areas of functioning are taken into account. 571 00:29:18,621 --> 00:29:23,123 And so what the PDM suggests, and as Kernberg suggests, 572 00:29:23,123 --> 00:29:26,233 is that there is a borderline organization, 573 00:29:26,233 --> 00:29:28,811 there is a spectrum of borderline functioning. 574 00:29:28,811 --> 00:29:31,658 There is not one borderline personality disorder, 575 00:29:31,658 --> 00:29:34,858 rather there is an organization, there is a spectrum, 576 00:29:34,858 --> 00:29:37,862 there is a range of functioning, 577 00:29:37,862 --> 00:29:39,734 and within this range of functioning, 578 00:29:39,734 --> 00:29:42,484 there are particular manifestations. 579 00:29:42,484 --> 00:29:45,174 And so if you look at the PDM diagnostic system, 580 00:29:45,174 --> 00:29:48,368 they have named a number of 581 00:29:48,368 --> 00:29:51,284 manifestations of the borderline organization, 582 00:29:51,284 --> 00:29:54,084 depending on the specific defenses used, 583 00:29:54,084 --> 00:29:57,348 and these will include the schizoid personality, 584 00:29:57,348 --> 00:29:59,912 the paranoid, the psychopathic, 585 00:29:59,912 --> 00:30:02,222 the narcissistic, the sadistic, 586 00:30:02,222 --> 00:30:04,486 the masochistic, the depressive, 587 00:30:04,486 --> 00:30:07,107 the somatizing, the dependent, 588 00:30:07,107 --> 00:30:11,050 the phobic, the anxious, the obsessive-compulsive, 589 00:30:11,050 --> 00:30:12,940 and the histrionic, and I'm sure that 590 00:30:12,940 --> 00:30:16,384 as I'm saying this to you, some of you are thinking 591 00:30:16,384 --> 00:30:21,384 to yourselves, "Ah, that particular patient or client, 592 00:30:22,350 --> 00:30:24,571 "sounds like they've got that particular 593 00:30:24,571 --> 00:30:26,169 "manifestation of defenses," or 594 00:30:26,169 --> 00:30:28,091 "Ah, that particular label makes sense 595 00:30:28,091 --> 00:30:29,691 "to me for somebody else." 596 00:30:29,691 --> 00:30:32,318 And so the PDM really gives us an opportunity 597 00:30:32,318 --> 00:30:35,165 to fine-tune, and to refine our way 598 00:30:35,165 --> 00:30:36,540 of understanding this person. 599 00:30:36,540 --> 00:30:38,181 And of course, the more that we can 600 00:30:38,181 --> 00:30:40,842 refine our formulation, the more able we are 601 00:30:40,842 --> 00:30:44,414 to really attend to this person with 602 00:30:44,414 --> 00:30:47,144 a treatment that is going to be the most adequate 603 00:30:47,144 --> 00:30:49,743 for them and most appropriate for them. 604 00:30:50,263 --> 00:30:53,528 But I do want to pause a little bit now and step back, 605 00:30:53,528 --> 00:30:58,528 and look at Kernberg's structural diagnosis of personality. 606 00:31:01,204 --> 00:31:02,971 Some years ago Kernberg suggested 607 00:31:02,971 --> 00:31:04,157 that we need to be looking at the 608 00:31:04,157 --> 00:31:06,834 diagnosis of personality disorders 609 00:31:06,834 --> 00:31:08,251 from a different perspective, 610 00:31:08,251 --> 00:31:10,551 that we need to shift away from specific 611 00:31:10,551 --> 00:31:12,736 behaviors and symptoms, to considering 612 00:31:12,736 --> 00:31:14,756 what is happening intra-cyclically. 613 00:31:14,756 --> 00:31:17,293 And of course, we are referring to 614 00:31:17,293 --> 00:31:19,276 a psychoanalytically oriented theorist, 615 00:31:19,276 --> 00:31:21,536 and so he is interested in what is happening 616 00:31:21,536 --> 00:31:23,987 in the internal world, as am I. 617 00:31:23,987 --> 00:31:25,865 And so rather than seeing 618 00:31:25,865 --> 00:31:30,163 a borderline personality disorder as a personality type, 619 00:31:30,163 --> 00:31:32,942 we rather look at a borderline level of functioning. 620 00:31:34,741 --> 00:31:37,265 And at that borderline level of functioning, 621 00:31:37,265 --> 00:31:39,527 all of these different manifestations, 622 00:31:39,527 --> 00:31:41,557 the paranoid, the phobic, the anxious, 623 00:31:41,557 --> 00:31:44,097 the histrionic, the narcissistic, 624 00:31:44,097 --> 00:31:49,093 they all function with weak ego strength. 625 00:31:50,186 --> 00:31:54,291 Their overall adaptive functioning is impaired. 626 00:31:55,366 --> 00:31:57,797 It's more impaired than we see in neurotic patients, 627 00:31:57,797 --> 00:32:01,682 but it is less impaired than we see in psychotic patients. 628 00:32:02,351 --> 00:32:04,578 At this level of impairment, 629 00:32:04,578 --> 00:32:07,764 we understand that there is a fundamental arrest 630 00:32:07,764 --> 00:32:10,822 of ego capacity, and of the self. 631 00:32:11,698 --> 00:32:14,749 And so he proposed an intrapsychic structural approach 632 00:32:14,749 --> 00:32:16,626 to diagnosis, and he proposed 633 00:32:16,626 --> 00:32:19,785 three broad structural organizations. 634 00:32:19,785 --> 00:32:23,699 So if you can imagine that there is the neurotic level 635 00:32:23,699 --> 00:32:26,380 in the higher end of the hierarchy, 636 00:32:26,380 --> 00:32:28,319 right at the bottom end of the hierarchy is 637 00:32:28,319 --> 00:32:31,585 the psychotic level, and then in between the two, 638 00:32:31,585 --> 00:32:34,046 that's the borderline range. 639 00:32:34,046 --> 00:32:37,132 And it is within that borderline range 640 00:32:37,132 --> 00:32:41,567 that we see a massive fluctuation of functionality. 641 00:32:42,136 --> 00:32:45,308 So certainly, you can have some highly functional 642 00:32:45,308 --> 00:32:49,066 individuals, who are operating within the borderline range, 643 00:32:49,066 --> 00:32:51,184 but you are tending towards a more 644 00:32:51,184 --> 00:32:53,767 neurotical level of functioning. 645 00:32:53,767 --> 00:32:57,034 And then you have those indviduals 646 00:32:57,034 --> 00:32:59,159 who are operating at a much lower level 647 00:32:59,159 --> 00:33:00,642 within their borderline range, 648 00:33:00,642 --> 00:33:03,491 in fact, virging on the psychotic, where sometimes 649 00:33:03,491 --> 00:33:07,883 they might even dip into more psychotic waves of relating. 650 00:33:08,703 --> 00:33:11,544 But there is a broad range available 651 00:33:11,544 --> 00:33:15,679 in which to diagnose and formulate each individual. 652 00:33:16,555 --> 00:33:20,723 But in each case, the psychic structure, 653 00:33:21,401 --> 00:33:24,501 which is present for the individual, 654 00:33:24,501 --> 00:33:27,240 performs a very, very important function, 655 00:33:27,240 --> 00:33:30,513 and that function is to stabilize the mental apparatus. 656 00:33:30,513 --> 00:33:32,792 That function is to stabilize the self. 657 00:33:32,792 --> 00:33:34,993 And I think this is a point that I can't 658 00:33:34,993 --> 00:33:37,213 express often enough and emphasize enough 659 00:33:37,213 --> 00:33:39,198 and I'm going to repeat it a number of times 660 00:33:39,198 --> 00:33:42,667 in this lecture, which is to say that the ways in which 661 00:33:42,667 --> 00:33:46,013 the BPD presents, the ways in which 662 00:33:46,013 --> 00:33:50,666 these individuals present, are all adaptive. 663 00:33:50,666 --> 00:33:53,669 They are all ways of trying to stabilize 664 00:33:55,005 --> 00:33:58,734 an unbalanced internal situation. 665 00:33:58,734 --> 00:34:00,757 The defenses that they use, 666 00:34:00,757 --> 00:34:03,354 the ways in which they act in the world, 667 00:34:03,354 --> 00:34:06,987 they are all attempts, and often desparate attempts, 668 00:34:06,987 --> 00:34:11,761 to stabilize an unstable internal experience. 669 00:34:12,331 --> 00:34:14,835 And so this particular psychic structure, 670 00:34:14,835 --> 00:34:17,766 this borderline psychic structure, 671 00:34:17,766 --> 00:34:21,667 becomes this particular individual's matrix 672 00:34:21,667 --> 00:34:24,839 from which behavior springs. 673 00:34:24,839 --> 00:34:27,377 The particular behavioral symptoms that we see 674 00:34:27,377 --> 00:34:31,061 comes from an intrapsychic matrix. 675 00:34:31,061 --> 00:34:34,347 And there are three ways of really trying to think about 676 00:34:34,347 --> 00:34:37,353 what this intrapsychic matrix looks like, 677 00:34:37,353 --> 00:34:39,578 and how it functions. 678 00:34:39,578 --> 00:34:43,737 Firstly, we look at degree of identity integration. 679 00:34:44,062 --> 00:34:47,909 Secondly, we look at types of defensive operations. 680 00:34:47,909 --> 00:34:51,655 And thirdly, we look at capacity for reality testing. 681 00:34:52,117 --> 00:34:53,725 So for example, if you were looking 682 00:34:53,725 --> 00:34:57,139 at the neurotic individual, 683 00:34:57,447 --> 00:35:00,194 somebody who presents as neurotic, 684 00:35:00,194 --> 00:35:04,138 is going to present with an integrated sense of identity, 685 00:35:04,138 --> 00:35:08,800 where the primary defense is based on repression, 686 00:35:08,800 --> 00:35:13,319 and there is very, very strongly intact reality testing. 687 00:35:14,412 --> 00:35:15,652 If you look at somebody from the 688 00:35:15,652 --> 00:35:17,612 psychotic end of the spectrum, 689 00:35:17,612 --> 00:35:19,969 obviously there, we have a complete 690 00:35:19,969 --> 00:35:23,821 fragmentation of identity, we have identity diffusion. 691 00:35:23,821 --> 00:35:27,885 We have very, very, very primitive defenses, 692 00:35:28,746 --> 00:35:32,917 and often times, we have a complete lack of reality testing. 693 00:35:33,502 --> 00:35:37,173 But for the borderline, somewhere in between, 694 00:35:37,173 --> 00:35:41,186 we have a relative degree of identity diffusion. 695 00:35:41,186 --> 00:35:43,378 We have primitive defense structures 696 00:35:43,378 --> 00:35:46,526 which are primarily based on splitting. 697 00:35:46,526 --> 00:35:50,315 And we have relatively intact reality testing. 698 00:35:51,715 --> 00:35:53,848 But let's tease this out a little bit further 699 00:35:53,848 --> 00:35:56,693 and I want to take you into each of these three dimensions 700 00:35:56,693 --> 00:35:59,526 so that we can fully understand how they might 701 00:35:59,526 --> 00:36:02,566 present themselves in different individuals. 702 00:36:04,302 --> 00:36:07,467 Starting with identity integration. 703 00:36:07,467 --> 00:36:09,528 The lack of an integrated identity, 704 00:36:09,528 --> 00:36:12,527 which leads to diffusion, is seen in a 705 00:36:12,527 --> 00:36:15,542 very, very poor concept of self and other, 706 00:36:15,542 --> 00:36:17,477 as I spoke about earlier. 707 00:36:18,077 --> 00:36:20,315 The subjective manifestation of us, 708 00:36:20,315 --> 00:36:24,381 in other words,the way that a person feels 709 00:36:24,381 --> 00:36:27,376 in the context of identity diffusion, 710 00:36:27,376 --> 00:36:30,255 is a feeling of chronic emptiness. 711 00:36:31,378 --> 00:36:35,058 And so often, when I say to somebody, 712 00:36:35,058 --> 00:36:37,311 "How do you feel inside?" 713 00:36:37,311 --> 00:36:41,564 they might say, "I feel empty, I feel dead," 714 00:36:41,564 --> 00:36:44,538 but often that word empty has a resonance 715 00:36:44,538 --> 00:36:48,120 which is quite powerful, and it really communicates 716 00:36:48,120 --> 00:36:50,805 that sense of internal hollowness, 717 00:36:50,805 --> 00:36:53,970 with which they live, every single day. 718 00:36:55,170 --> 00:36:58,680 Within this identity diffusion there are 719 00:36:58,680 --> 00:37:02,433 contradictory self-perceptions and contradictory behavior, 720 00:37:02,433 --> 00:37:04,535 that can't be properly integrated 721 00:37:04,535 --> 00:37:07,409 in any kind of emotionally meaningful way. 722 00:37:07,409 --> 00:37:10,289 They are shallow, and often 723 00:37:12,411 --> 00:37:16,578 lacking in authenticity, relatedness, 724 00:37:16,578 --> 00:37:18,609 and relating to others. 725 00:37:18,609 --> 00:37:20,712 There is a real inability to gain 726 00:37:20,712 --> 00:37:24,312 a clear picture of self and of others. 727 00:37:26,297 --> 00:37:29,818 And there's a real lack of engagement. 728 00:37:30,509 --> 00:37:35,310 Certainly, often when I first meet patients who come to me, 729 00:37:35,525 --> 00:37:39,423 in the initial sessions, I find it very, very hard 730 00:37:39,423 --> 00:37:43,053 to truly connect with that person, to find that person, 731 00:37:43,053 --> 00:37:47,638 and I can feel the way in which they have used their mind 732 00:37:47,638 --> 00:37:51,400 to protect themselves from real, authentic engagements. 733 00:37:51,400 --> 00:37:54,879 So there can be the display of engagement, 734 00:37:54,879 --> 00:37:57,191 there can be a pseudo-engagement, 735 00:37:57,191 --> 00:37:59,478 but to really access that person 736 00:37:59,478 --> 00:38:02,951 feels incredibly challenging and very, very difficult. 737 00:38:02,951 --> 00:38:05,754 So there is very, very often superficial relating 738 00:38:05,754 --> 00:38:09,199 that goes with this kind of identity diffusion. 739 00:38:11,722 --> 00:38:15,056 To move on to the defenses, as I said earlier, 740 00:38:15,578 --> 00:38:17,088 the kind of defenses that the 741 00:38:17,088 --> 00:38:20,275 borderline organization will resort to 742 00:38:20,551 --> 00:38:24,073 are incredibly primitive defenses. 743 00:38:25,212 --> 00:38:28,737 The more neurotic individual is going to use repression 744 00:38:28,737 --> 00:38:31,059 to literally push down, 745 00:38:31,521 --> 00:38:34,124 to literally keep away, 746 00:38:34,416 --> 00:38:36,444 experiences or feelings that are going to 747 00:38:36,444 --> 00:38:39,090 overwhelm daily functioning. 748 00:38:39,551 --> 00:38:41,690 But repression is different to splitting. 749 00:38:41,690 --> 00:38:45,827 Splitting is a literal dissociation of experience, 750 00:38:45,827 --> 00:38:49,485 a literal cutting off of feeling, 751 00:38:49,485 --> 00:38:53,065 of experience, of self and of other. 752 00:38:53,572 --> 00:38:57,330 And these defenses are absolutely fundamental 753 00:38:57,330 --> 00:39:00,183 to the survival of the ego, and I always find 754 00:39:00,183 --> 00:39:04,728 this notion incredibly painful and sad to consider, 755 00:39:04,728 --> 00:39:06,838 because if we think about the genesis 756 00:39:06,838 --> 00:39:09,861 of splitting defenses, splitting originates 757 00:39:09,861 --> 00:39:12,987 in early infancy, all of us, going through infancy 758 00:39:12,987 --> 00:39:16,045 and toddlerhood and childhood, used splitting 759 00:39:16,045 --> 00:39:19,029 to help us, to ward off experiences that were 760 00:39:19,029 --> 00:39:21,957 too challenging or too overwhelming or too painful. 761 00:39:21,957 --> 00:39:24,999 And that was a very adaptive function as a child. 762 00:39:24,999 --> 00:39:28,324 Infants and children need splitting defenses 763 00:39:28,324 --> 00:39:31,092 in order to help them to negotiate 764 00:39:31,092 --> 00:39:33,418 the growth of the self, 765 00:39:33,418 --> 00:39:35,471 and the negotiation of the external world. 766 00:39:35,471 --> 00:39:37,695 So quite often, for example, you will see 767 00:39:37,695 --> 00:39:41,608 an infant or a toddler who suddenly gets overstimulated 768 00:39:41,608 --> 00:39:43,908 if they're being tickled or teased or they're laughing, 769 00:39:43,908 --> 00:39:45,685 they're suddenly being overstimulated, 770 00:39:45,685 --> 00:39:48,310 they might just turn away, in a very literal way, 771 00:39:48,310 --> 00:39:52,100 as if to say, "You don't exist anymore.", 772 00:39:52,777 --> 00:39:54,014 "You're not there anymore." 773 00:39:54,014 --> 00:39:58,203 That's a very literal illustration 774 00:39:58,203 --> 00:40:01,400 of splitting, of pushing aside, 775 00:40:01,400 --> 00:40:04,060 and in that moment, that little one 776 00:40:04,060 --> 00:40:07,023 needs that, fundamentally, in order 777 00:40:07,023 --> 00:40:10,759 to get through that overwhelming stimulation. 778 00:40:10,759 --> 00:40:14,315 But with the development of the robustness of the self, 779 00:40:14,315 --> 00:40:16,219 that kind of need for splitting 780 00:40:16,219 --> 00:40:19,060 should ideally fall away, 781 00:40:20,152 --> 00:40:23,531 because the individual is then able to negotiate 782 00:40:23,531 --> 00:40:27,154 extreme feelings of distress or overstimulation. 783 00:40:27,154 --> 00:40:31,135 But for the borderline personality patient, 784 00:40:31,703 --> 00:40:35,041 that splitting is still the primary way 785 00:40:35,041 --> 00:40:37,582 of managing overwhelming affect, 786 00:40:37,582 --> 00:40:40,635 of managing overwhelming experiences. 787 00:40:40,635 --> 00:40:44,514 And of course, within those key defenses 788 00:40:44,514 --> 00:40:47,510 are things like primitive idealization, 789 00:40:47,510 --> 00:40:51,393 where people are seen as all good or all bad, 790 00:40:51,393 --> 00:40:55,595 where parts of the self are seen as all good or all bad. 791 00:40:55,595 --> 00:40:59,213 And as a clinician, certainly I've had this experience, 792 00:40:59,213 --> 00:41:02,463 they can be the experience of being completely idealized. 793 00:41:02,463 --> 00:41:04,264 And it's wonder to bask in that glow 794 00:41:04,264 --> 00:41:05,850 of being the good object, 795 00:41:05,850 --> 00:41:07,898 but of course we have to remind ourselves 796 00:41:07,898 --> 00:41:09,920 that it is an absolute experience, 797 00:41:09,920 --> 00:41:12,233 and not based on reality, 798 00:41:12,233 --> 00:41:15,627 and equally, it is absolutely appalling 799 00:41:15,627 --> 00:41:20,018 to have bear the brunt of being the all bad object, 800 00:41:20,018 --> 00:41:25,018 or to witness the patient seeing themselves, 801 00:41:25,167 --> 00:41:29,364 and holding themselves, in that all bad way. 802 00:41:29,364 --> 00:41:33,444 So primitive idealization and primitive devaluing 803 00:41:33,444 --> 00:41:36,385 is one of the core defenses. 804 00:41:36,385 --> 00:41:40,170 Projection, and most notably, projective identification, 805 00:41:40,170 --> 00:41:44,069 where difficult or overwhelming experiences 806 00:41:44,069 --> 00:41:48,237 are thrust out psychically into the other. 807 00:41:48,237 --> 00:41:50,615 Is another core experience, which is precisely why, 808 00:41:50,615 --> 00:41:54,558 as clinicians, we will feel things in our bodies, 809 00:41:54,558 --> 00:41:58,416 we will feel things in our system 810 00:41:58,416 --> 00:42:02,186 which are a direct missile 811 00:42:02,186 --> 00:42:06,252 thrown out by the person in the room with us. 812 00:42:06,252 --> 00:42:09,600 And in that moment, what is happening for the individual 813 00:42:09,600 --> 00:42:12,849 is that they cannot tolerate whatever the experience is, 814 00:42:12,849 --> 00:42:15,657 and they have to rid themselves of it 815 00:42:15,657 --> 00:42:18,140 in a very, very direct way, 816 00:42:18,140 --> 00:42:20,843 and locate that in you, 817 00:42:21,551 --> 00:42:25,359 in you as the clinician, in you as the other. 818 00:42:26,389 --> 00:42:30,642 Another common defense is that of denial, 819 00:42:30,642 --> 00:42:34,143 where the person might exhibit 820 00:42:34,143 --> 00:42:36,104 quite extraordinary lack of concern 821 00:42:36,104 --> 00:42:37,745 about people and their lives, 822 00:42:37,745 --> 00:42:41,247 or about loved ones, people who they are close to. 823 00:42:41,247 --> 00:42:44,261 There might be an absence of anxiety 824 00:42:44,261 --> 00:42:47,580 or an absence of appropriate emotional reaction 825 00:42:47,580 --> 00:42:51,223 to hearing news about important things. 826 00:42:51,747 --> 00:42:54,831 And this is what happens when denial sets in 827 00:42:54,831 --> 00:42:58,853 once again, as a way of protecting self from feelings 828 00:42:58,853 --> 00:43:03,390 that are just too, too, too painful, too difficult. 829 00:43:05,666 --> 00:43:07,260 And I suppose the reality is that, 830 00:43:07,260 --> 00:43:10,681 if we can really, truly comprehend 831 00:43:10,681 --> 00:43:13,853 that when an experience of pain, for example, 832 00:43:13,853 --> 00:43:17,613 or of fear, or of sadness, is experienced 833 00:43:17,613 --> 00:43:21,262 as a concrete object internally, 834 00:43:22,032 --> 00:43:25,104 we can understand how frightening that is, 835 00:43:25,104 --> 00:43:29,504 and how important it is to try to get rid of that feeling, 836 00:43:29,504 --> 00:43:31,617 by throwing it out, and hoping 837 00:43:31,617 --> 00:43:34,543 that somebody else will catch it. 838 00:43:35,637 --> 00:43:37,121 So those are the core defenses 839 00:43:37,121 --> 00:43:39,864 that really center around splitting. 840 00:43:41,173 --> 00:43:44,780 The third aspect along which Kernberg suggests 841 00:43:44,780 --> 00:43:47,816 that we diagnose and formulate our patients 842 00:43:47,816 --> 00:43:50,604 is along the line of reality testing. 843 00:43:50,604 --> 00:43:53,726 And included in this, it's not only understanding 844 00:43:53,726 --> 00:43:56,618 what's real and what's not real in the perceived world, 845 00:43:56,618 --> 00:43:58,657 but it's also about the capacity 846 00:43:58,657 --> 00:44:02,178 to differentiate self from non-self, 847 00:44:02,178 --> 00:44:05,451 so "What is me?" and "What is not me?" 848 00:44:05,451 --> 00:44:08,333 And this often manifests itself in relationships, 849 00:44:08,333 --> 00:44:09,936 "Where do I begin and end and 850 00:44:09,936 --> 00:44:12,164 "where does the other begin and end?", 851 00:44:12,164 --> 00:44:15,403 which is why so often we see in 852 00:44:15,403 --> 00:44:19,753 borderline relationships either a complete merging, 853 00:44:20,276 --> 00:44:23,548 or a complete splitting-off or complete separation, 854 00:44:23,548 --> 00:44:27,334 and the ability to maintain appropriate boundaries 855 00:44:27,334 --> 00:44:29,720 is extremely compromised. 856 00:44:30,044 --> 00:44:33,242 Part of reality testing is the capacity 857 00:44:33,242 --> 00:44:37,353 to realistically evaluate one's own affect, 858 00:44:37,353 --> 00:44:42,057 to realistically evaluate one's own behavior, 859 00:44:42,626 --> 00:44:44,556 or thought content. 860 00:44:44,556 --> 00:44:48,942 So, for example, if I'm feeling absolutely furious 861 00:44:48,942 --> 00:44:51,419 because this bank manager is not doing 862 00:44:51,419 --> 00:44:53,900 what I have asked him to do, which is to 863 00:44:53,900 --> 00:44:56,810 change my account to another account, 864 00:44:56,810 --> 00:45:00,089 and in this moment, he is the target of all of my rage, 865 00:45:00,089 --> 00:45:02,875 it is absolutely fine to take my cup of coffee 866 00:45:02,875 --> 00:45:05,459 and throw it over him, isn't it? 867 00:45:06,104 --> 00:45:09,677 It's that kind of reality testing that falters, 868 00:45:09,677 --> 00:45:13,397 because, for that person, and I'm describing a real event, 869 00:45:13,397 --> 00:45:17,198 for that person, in that moment, that behavior is justified, 870 00:45:17,198 --> 00:45:21,197 because that experience is compartmentalized, 871 00:45:21,197 --> 00:45:24,869 and split off from the norms of society, 872 00:45:24,869 --> 00:45:27,410 and the norms of interpersonal relating. 873 00:45:29,087 --> 00:45:31,299 And so whilst, in our borderline patients, 874 00:45:31,299 --> 00:45:35,509 we may not see a gross breakdown of reality testing, 875 00:45:35,509 --> 00:45:38,458 such as we would see in a psychotic person, 876 00:45:39,351 --> 00:45:43,174 if you start to fine-tune, it then becomes possible 877 00:45:43,174 --> 00:45:47,275 to recognize those moments of reality breakdown, 878 00:45:47,275 --> 00:45:50,979 particularly in relation to self-perception, 879 00:45:50,979 --> 00:45:53,203 perception of others, and the perception 880 00:45:53,203 --> 00:45:57,283 of what is appropriate between self and others. 881 00:45:58,560 --> 00:46:01,410 Now Kernberg has, what I find, a very useful 882 00:46:01,410 --> 00:46:03,601 structural interview that he suggests 883 00:46:03,601 --> 00:46:05,834 we apply when we first meet a person, 884 00:46:05,834 --> 00:46:10,186 but I quite like to just have these three aspects 885 00:46:10,186 --> 00:46:14,717 of intrapsychic experience sitting in the back of my mind 886 00:46:14,717 --> 00:46:17,220 when I meet a person, and as I get to know them, 887 00:46:17,220 --> 00:46:19,858 so that I start to get an idea 888 00:46:19,858 --> 00:46:22,415 of how they are in terms of their identity integration, 889 00:46:22,415 --> 00:46:25,299 how they are in terms of the defenses that they use, 890 00:46:25,299 --> 00:46:29,781 and how they are in terms of their reality testing. 891 00:46:31,181 --> 00:46:33,899 But if we then think to ourselves, 892 00:46:35,730 --> 00:46:38,996 "What actually happens in the room?" 893 00:46:40,396 --> 00:46:43,077 So we've got all this theory, all these notions 894 00:46:43,077 --> 00:46:45,381 of what might be happening internally, 895 00:46:45,381 --> 00:46:50,305 but what am I going to see when I meet a person, 896 00:46:50,322 --> 00:46:52,975 and they're sitting in the room with me 897 00:46:52,975 --> 00:46:55,079 and I start to work with them? 898 00:46:55,079 --> 00:46:57,850 What am I going to be able to recognize 899 00:46:57,850 --> 00:47:00,432 both in the way that they relate to me 900 00:47:00,432 --> 00:47:03,086 and in the way that they relate to others 901 00:47:03,086 --> 00:47:06,945 in their lives, that they describe to me? 902 00:47:06,945 --> 00:47:11,808 And I think that there are three core symptom clusters 903 00:47:12,607 --> 00:47:17,607 that we will see, no matter what particular manifestation 904 00:47:17,815 --> 00:47:21,189 of borderline organization we have in our rooms. 905 00:47:21,189 --> 00:47:25,788 The first symptom area is that which centers around affect, 906 00:47:26,464 --> 00:47:29,061 that we are always going to see 907 00:47:29,061 --> 00:47:31,568 intensity of affect in some way. 908 00:47:32,153 --> 00:47:35,368 Very, very often that intensity of affect 909 00:47:35,368 --> 00:47:38,369 will manifest as anger or aggression, 910 00:47:38,369 --> 00:47:40,718 and it may not be the overt aggression 911 00:47:40,718 --> 00:47:43,328 that is channeled outwardly, 912 00:47:44,467 --> 00:47:48,472 anger against the other, anger against me as the clinician. 913 00:47:48,472 --> 00:47:51,443 It may well be anger that is internalized, 914 00:47:51,443 --> 00:47:55,046 anger against the self, anger that implodes 915 00:47:55,046 --> 00:47:58,399 inside the self, but nonetheless 916 00:47:58,399 --> 00:48:02,211 they are powerful anger affects. 917 00:48:02,642 --> 00:48:05,629 We see also affect of instability, and so 918 00:48:05,629 --> 00:48:09,528 from one minute to the next, sometimes in a 50 minute hour, 919 00:48:09,528 --> 00:48:12,896 we can see a rollercoaster of emotions, 920 00:48:12,896 --> 00:48:16,420 from absolute joy to the depths of despair, 921 00:48:16,420 --> 00:48:19,216 from one session to the next. 922 00:48:19,523 --> 00:48:21,536 In the accounts that the person gives 923 00:48:21,536 --> 00:48:23,434 of their daily interactions, 924 00:48:23,434 --> 00:48:26,972 we see a real affect of instability, 925 00:48:27,648 --> 00:48:30,436 and we also see, and quite often as a 926 00:48:30,436 --> 00:48:33,812 consequence of the affect of instability, 927 00:48:33,812 --> 00:48:37,601 unstable relationships, we also see 928 00:48:37,601 --> 00:48:40,719 incredibly intense relationships, 929 00:48:41,688 --> 00:48:44,425 just as we experience an intense relationship 930 00:48:44,425 --> 00:48:46,571 in the therapeutic context. 931 00:48:46,571 --> 00:48:48,419 So that's affect. 932 00:48:48,803 --> 00:48:53,355 The second main symptom area is around identity. 933 00:48:54,909 --> 00:48:58,556 The chronic emptiness that we will see, 934 00:48:58,556 --> 00:49:03,398 abandonment fears, because if the self is not seen as whole, 935 00:49:03,398 --> 00:49:05,946 and if the other is not seen as whole, 936 00:49:05,946 --> 00:49:08,201 and if it's not possible to understand 937 00:49:08,201 --> 00:49:10,993 the relationship between self and other, 938 00:49:10,993 --> 00:49:14,762 then the possibility of being left, of being abandoned, 939 00:49:14,762 --> 00:49:18,978 becomes terrifyingly real, and so whenever 940 00:49:20,594 --> 00:49:24,390 a BPD comes into the context of a relationship, 941 00:49:24,390 --> 00:49:28,222 so, too, comes the possibility of abandonment, 942 00:49:28,222 --> 00:49:31,454 abandonment anxiety, abandonment depression, 943 00:49:31,454 --> 00:49:33,454 abandonment fears. 944 00:49:33,454 --> 00:49:37,751 And so we see clinging, we see merging, 945 00:49:37,751 --> 00:49:41,522 we see desperate attempts not to lose the object, 946 00:49:41,522 --> 00:49:45,305 which forms part of the identity component. 947 00:49:46,412 --> 00:49:50,450 And the third core symptom is around impulsivity. 948 00:49:51,250 --> 00:49:53,463 So, just because you've got somebody in your room 949 00:49:53,463 --> 00:49:57,595 who's never cut themselves, or never hurt themselves, 950 00:49:57,595 --> 00:50:01,239 in a literal kind of way, doesn't mean that they don't 951 00:50:01,239 --> 00:50:04,863 show, in some way, the impulsivity that is so 952 00:50:04,863 --> 00:50:09,178 characteristic of this particular type of patient. 953 00:50:09,178 --> 00:50:13,293 Self-harm will almost inevitably manifest in some way, 954 00:50:13,293 --> 00:50:17,612 and it may not always be overtly evident at the outset. 955 00:50:17,612 --> 00:50:20,673 Reckless behavior, substance abuse, 956 00:50:20,673 --> 00:50:23,689 and once again, substance abuse may not be 957 00:50:23,689 --> 00:50:28,214 gross alcohol abuse, 958 00:50:28,214 --> 00:50:31,277 or gross recreational drug abuse, 959 00:50:31,277 --> 00:50:36,004 it may be consistent use of pain medication, 960 00:50:36,004 --> 00:50:37,551 it may be the consistent use 961 00:50:37,551 --> 00:50:40,979 of over-the-counter sleep medication, 962 00:50:40,979 --> 00:50:44,582 where, somehow, this person is turning to substances 963 00:50:44,582 --> 00:50:47,691 to help them to manage their everyday existence 964 00:50:47,691 --> 00:50:50,727 and to get through their everyday lives. 965 00:50:51,896 --> 00:50:55,076 So we have consensus 966 00:50:55,076 --> 00:50:58,940 around the core affect areas. 967 00:51:00,723 --> 00:51:04,009 We have consensus around 968 00:51:05,117 --> 00:51:08,856 how we experience those patients 969 00:51:08,856 --> 00:51:12,352 who present with a BPD in our rooms. 970 00:51:12,352 --> 00:51:14,911 But there is not consensus 971 00:51:14,911 --> 00:51:17,952 about the underlying psychological mechanism 972 00:51:17,952 --> 00:51:22,001 that informs this particular disorder. 973 00:51:22,263 --> 00:51:26,649 What is it that creates 974 00:51:27,988 --> 00:51:31,866 this particular manifestation of the self in the world? 975 00:51:32,620 --> 00:51:34,603 And this is where I want to talk, 976 00:51:34,603 --> 00:51:37,500 a little bit, about attachment theory, 977 00:51:37,500 --> 00:51:40,317 attachment theory as the foundation, 978 00:51:40,317 --> 00:51:42,642 attachment theory in terms of helping us 979 00:51:42,642 --> 00:51:47,074 to understand what goes wrong. 980 00:51:50,440 --> 00:51:52,824 I'm certainly not saying that it's the only explanation, 981 00:51:52,824 --> 00:51:56,228 but certainly it's an explanation that makes sense for me, 982 00:51:56,228 --> 00:51:58,461 and as I said earlier, it's an explanation that certainly 983 00:51:58,461 --> 00:52:02,541 helps me to be in the room in a particular kind of way. 984 00:52:04,997 --> 00:52:08,505 Now, thinking about the etiology of BPD, 985 00:52:08,505 --> 00:52:10,237 there has been some current research 986 00:52:10,237 --> 00:52:12,526 which has looked at genetic components. 987 00:52:12,526 --> 00:52:15,873 In other words, is it an inheritable disorder? 988 00:52:15,873 --> 00:52:18,914 And there is some evidence that suggests that, 989 00:52:19,483 --> 00:52:21,504 but there's also increasing evidence 990 00:52:21,504 --> 00:52:25,510 that there is an environmental component 991 00:52:25,510 --> 00:52:30,138 to creating BPD that we simply cannot ignore. 992 00:52:30,730 --> 00:52:32,054 And what is, I mean, coming back to 993 00:52:32,054 --> 00:52:34,006 the age-old nature-nurture debate, 994 00:52:34,006 --> 00:52:37,401 what is probably most likely the answer 995 00:52:37,401 --> 00:52:41,220 is that there is some kind of a coming together, 996 00:52:41,220 --> 00:52:44,237 a marrying, of what the individual brings 997 00:52:44,237 --> 00:52:47,250 constitutionally into the world 998 00:52:47,250 --> 00:52:51,919 and the way in which that constitutionality matches, 999 00:52:51,919 --> 00:52:56,544 or meets up, with their particular environmental context. 1000 00:52:57,379 --> 00:53:00,289 So certainly, and once again, having worked 1001 00:53:00,289 --> 00:53:02,800 with a diverse range of people, 1002 00:53:02,800 --> 00:53:07,077 I do believe that some people are born with 1003 00:53:07,077 --> 00:53:11,225 a clearer propensity to aggression, for example. 1004 00:53:12,164 --> 00:53:15,044 And if you take that clearer propensity for aggression 1005 00:53:15,044 --> 00:53:17,194 and you match it with with a particular 1006 00:53:17,194 --> 00:53:19,362 early attachment environment, 1007 00:53:19,362 --> 00:53:23,467 you can create a volcano 1008 00:53:23,467 --> 00:53:25,500 of anger and rage and aggression 1009 00:53:25,500 --> 00:53:27,881 that is going to spew out and spill out 1010 00:53:27,881 --> 00:53:30,855 all the way through the lifespan. 1011 00:53:30,855 --> 00:53:33,121 Similarly, you might have people 1012 00:53:33,121 --> 00:53:36,587 who are born with less constitutional aggression, 1013 00:53:36,587 --> 00:53:39,476 and yet still they come up against 1014 00:53:39,476 --> 00:53:42,015 an early environmental context that is 1015 00:53:42,015 --> 00:53:45,398 problematic for many ways that I'm going to go into, 1016 00:53:45,843 --> 00:53:48,766 that then creates the foundation for the growth 1017 00:53:48,766 --> 00:53:51,019 of an anger, of a frustration, 1018 00:53:51,019 --> 00:53:52,214 and of an aggression, that then 1019 00:53:52,214 --> 00:53:55,296 is going to manifest throughout the lifespan. 1020 00:53:56,689 --> 00:54:00,544 Attachment, that relationship between the infant 1021 00:54:00,544 --> 00:54:03,638 and the primary caregiver or caregivers, 1022 00:54:03,638 --> 00:54:06,315 can be understood to be the mediator 1023 00:54:06,315 --> 00:54:10,684 between the environment and the constitution. 1024 00:54:10,684 --> 00:54:13,492 So how do those two things lock together? 1025 00:54:13,492 --> 00:54:14,966 They lock together through the 1026 00:54:14,966 --> 00:54:18,416 interpersonal context of self and other. 1027 00:54:18,416 --> 00:54:22,584 And as we know, human beings are not one of the species 1028 00:54:22,584 --> 00:54:25,593 that can be born into the world and fend for themselves. 1029 00:54:25,593 --> 00:54:28,663 Fundamentally, we need, not only 1030 00:54:28,663 --> 00:54:30,602 at a physical and a biological level, 1031 00:54:30,602 --> 00:54:32,990 but at an emotional level of attachment, 1032 00:54:32,990 --> 00:54:36,704 we need the other to help us to survive 1033 00:54:36,704 --> 00:54:38,841 and to help us to grow. 1034 00:54:39,934 --> 00:54:44,639 So the underlying premise of attachment theory is that 1035 00:54:44,639 --> 00:54:49,437 the adult personality is the outcome of development, 1036 00:54:50,297 --> 00:54:54,830 and that a personality disorder, or a disorder of the self, 1037 00:54:54,830 --> 00:54:59,619 is the consequence of an environmentally-induced 1038 00:54:59,619 --> 00:55:02,089 distortion of psychological functioning. 1039 00:55:02,089 --> 00:55:05,604 In other words, the way that the psyche functions 1040 00:55:06,280 --> 00:55:08,558 is a consequence of something 1041 00:55:08,558 --> 00:55:12,047 that has been distorted environmentally. 1042 00:55:12,047 --> 00:55:13,477 So to back up just a little bit, 1043 00:55:13,477 --> 00:55:16,352 and to think about attachment theory more broadly, 1044 00:55:16,352 --> 00:55:19,075 we know, for example, that Bowlby introduced us, 1045 00:55:19,075 --> 00:55:22,448 most fundamentally, to different 1046 00:55:22,448 --> 00:55:25,234 kinds of attachment styles, and broadly speaking, 1047 00:55:25,234 --> 00:55:28,536 he spoke about secure versus insecure attachment, 1048 00:55:28,536 --> 00:55:30,373 and we know that those can be broken down 1049 00:55:30,373 --> 00:55:31,752 into different kinds of attachments, 1050 00:55:31,752 --> 00:55:36,153 such as anxious, avoidant, or disorganized attachment. 1051 00:55:37,274 --> 00:55:40,083 Most importantly, in the context of BPD, 1052 00:55:40,083 --> 00:55:44,859 we are looking at the possible existence 1053 00:55:44,859 --> 00:55:48,402 of a disorganized early attachment, 1054 00:55:48,402 --> 00:55:50,513 so the early attachment relationship 1055 00:55:50,513 --> 00:55:54,443 created a sense of internal disorganization. 1056 00:55:54,828 --> 00:55:56,562 And this is why, for those people 1057 00:55:56,562 --> 00:55:59,743 who have to live with and survive BPD, 1058 00:56:00,511 --> 00:56:03,527 they have to live with and survive an ongoing 1059 00:56:03,527 --> 00:56:07,922 internal experience of chaos and disorganization. 1060 00:56:10,367 --> 00:56:13,926 What is fundamental to secure attachment? 1061 00:56:14,552 --> 00:56:18,597 So secure attachment is about proximity. 1062 00:56:18,997 --> 00:56:21,660 It's about closeness. 1063 00:56:21,660 --> 00:56:24,348 It's about mental closeness. 1064 00:56:25,501 --> 00:56:30,343 It is about evoking an experience of safety. 1065 00:56:30,729 --> 00:56:34,208 And that's not just pockets of safety, 1066 00:56:34,440 --> 00:56:37,562 it's an experience of consistent 1067 00:56:37,562 --> 00:56:41,393 and reliable and ongoing safety. 1068 00:56:41,393 --> 00:56:45,957 And this experience of safety results in the development 1069 00:56:45,957 --> 00:56:50,906 of psychological processes that are robust and flexible. 1070 00:56:53,261 --> 00:56:55,932 An experience of safety within the context 1071 00:56:55,932 --> 00:56:57,977 of a close, emotional relationship 1072 00:56:57,977 --> 00:57:01,879 is absolutely essential, it is fundamental, 1073 00:57:01,879 --> 00:57:05,177 it is cornerstone for the development 1074 00:57:05,177 --> 00:57:07,814 of an autonomous sense of self, 1075 00:57:08,583 --> 00:57:10,744 and for the development for all of those 1076 00:57:10,744 --> 00:57:13,189 aspects of the self that I spoke about earlier, 1077 00:57:13,189 --> 00:57:16,410 the capacity for flexibility, the capacity for 1078 00:57:16,410 --> 00:57:19,118 an integrated sense of who we are, 1079 00:57:19,118 --> 00:57:21,788 the capacity for vitality, for creativity, 1080 00:57:21,788 --> 00:57:24,445 for reality testing, for all of the things 1081 00:57:24,445 --> 00:57:27,903 that help us to be functional and happy, 1082 00:57:27,903 --> 00:57:32,555 or at least content people in the world. 1083 00:57:32,555 --> 00:57:36,624 And it all comes down to an early experience of safety, 1084 00:57:36,624 --> 00:57:39,329 which then creates a fertile ground for the growth 1085 00:57:39,329 --> 00:57:43,352 of robust and flexible psychological processes. 1086 00:57:44,167 --> 00:57:46,568 A robust self protects the individual 1087 00:57:46,568 --> 00:57:49,229 from the stresses of everyday life. 1088 00:57:49,229 --> 00:57:52,263 A robust self is that which mediates 1089 00:57:52,263 --> 00:57:57,116 between our experience of the world and the world itself. 1090 00:57:58,394 --> 00:58:01,281 If this sense of safety 1091 00:58:01,281 --> 00:58:04,650 is ruptured or compromised, 1092 00:58:04,666 --> 00:58:09,029 or if it is inconsistent, or if it doesn't exist at all, 1093 00:58:10,966 --> 00:58:15,242 what it creates, what derives from that, 1094 00:58:15,242 --> 00:58:19,541 is the potential for the development of anxiety and anger, 1095 00:58:19,541 --> 00:58:22,292 which then become the way in which 1096 00:58:22,292 --> 00:58:25,514 the mechanism stabilizes itself. 1097 00:58:26,955 --> 00:58:30,583 So whilst, for a robust personality, 1098 00:58:30,583 --> 00:58:33,334 there is a flexibility to dealing with stresses 1099 00:58:33,334 --> 00:58:36,619 that come along every day and through life, 1100 00:58:37,603 --> 00:58:41,684 in the absence of an experience of early safety, 1101 00:58:41,684 --> 00:58:44,469 anger and frustration become the mediating factors. 1102 00:58:44,469 --> 00:58:46,274 Anger and frustration become the ways 1103 00:58:46,274 --> 00:58:49,269 in which the self is balanced. 1104 00:58:50,485 --> 00:58:54,159 Now, what is it that's going to create 1105 00:58:54,159 --> 00:58:57,385 the circumstances for this emerging self 1106 00:58:57,385 --> 00:59:00,700 to go along the wrong path? 1107 00:59:01,423 --> 00:59:04,490 The emerging self is most under threat 1108 00:59:04,490 --> 00:59:09,059 when in close emotional contact with another self. 1109 00:59:09,951 --> 00:59:13,830 So, in other words, when the mind of the infant 1110 00:59:13,830 --> 00:59:16,834 comes into contact with the mind of the other, 1111 00:59:16,834 --> 00:59:21,686 that is the most precarious experience of all. 1112 00:59:23,196 --> 00:59:25,930 If the mind of the other is receptive, 1113 00:59:26,576 --> 00:59:29,070 if the mind of the other is conducive, 1114 00:59:29,439 --> 00:59:32,313 then it is a safe connection. 1115 00:59:32,634 --> 00:59:35,031 But if the mind of the other is closed, 1116 00:59:35,031 --> 00:59:37,338 if the mind of the other is dysfunctional, 1117 00:59:37,338 --> 00:59:40,241 or disordered, or disorganized itself, 1118 00:59:40,964 --> 00:59:45,312 then that coming together creates 1119 00:59:45,312 --> 00:59:49,396 an explosion of disorganization that then 1120 00:59:49,396 --> 00:59:53,688 lays the foundation for the development of the self. 1121 00:59:54,165 --> 00:59:56,808 When mind meets mind, 1122 00:59:56,808 --> 01:00:01,681 it is the most dangerous situation of all. 1123 01:00:04,285 --> 01:00:06,189 When the mind of the caregiver 1124 01:00:06,189 --> 01:00:10,028 shows little understanding of the child's internal state, 1125 01:00:10,028 --> 01:00:14,551 then that child is setting off on a precarious course. 1126 01:00:15,766 --> 01:00:18,442 If the early attachment environment is not good enough, 1127 01:00:18,442 --> 01:00:20,695 and we're not saying perfect, remember 1128 01:00:20,695 --> 01:00:23,425 that Winnicott said we need a "good enough" 1129 01:00:23,425 --> 01:00:26,261 early environment, not a perfect one. 1130 01:00:26,538 --> 01:00:28,775 If the early attachment environment 1131 01:00:28,775 --> 01:00:32,404 is good enough, the child will develop 1132 01:00:32,404 --> 01:00:36,183 a sense of agency, an agentive self, 1133 01:00:36,183 --> 01:00:40,509 where thoughts and feelings can guide action, 1134 01:00:40,509 --> 01:00:44,294 and this is facilitated and stabilized by a caregiver 1135 01:00:44,294 --> 01:00:48,676 who provides a particular intersubjective context, 1136 01:00:48,676 --> 01:00:50,500 and the self becomes increasingly 1137 01:00:50,500 --> 01:00:53,090 strengthened through interaction. 1138 01:00:53,090 --> 01:00:56,456 But in cases of neglect, or of insensitivity, 1139 01:00:57,532 --> 01:01:00,261 or of all of the other ways in which 1140 01:01:00,261 --> 01:01:03,346 poor attachment manifests, 1141 01:01:03,346 --> 01:01:07,015 then the self becomes unstable, 1142 01:01:07,461 --> 01:01:10,579 resulting in anger and aggression, 1143 01:01:10,579 --> 01:01:12,984 and this anger and aggression then becomes incorporated 1144 01:01:12,984 --> 01:01:15,582 as part of the self-structure. 1145 01:01:15,582 --> 01:01:18,657 So, that means that anger isn't 1146 01:01:18,657 --> 01:01:22,769 an experience and an affect that can be used 1147 01:01:22,769 --> 01:01:25,981 when it is needed, so for many of us, hopefully, 1148 01:01:25,981 --> 01:01:29,097 anger and aggression can be used in the service 1149 01:01:29,097 --> 01:01:33,311 of motivating or of managing a situation, 1150 01:01:33,311 --> 01:01:35,367 and then discarded. 1151 01:01:35,367 --> 01:01:40,037 No. Anger and aggression become part of the self. 1152 01:01:40,037 --> 01:01:43,538 They are intrinsic to the self. 1153 01:01:43,538 --> 01:01:48,538 And this means that any attempt at self-assertion, 1154 01:01:50,024 --> 01:01:54,793 any expression of a need, of a wish, of a demand, 1155 01:01:54,793 --> 01:01:56,732 is always going to be accompanied 1156 01:01:56,732 --> 01:01:58,815 by some kind of an aggression, 1157 01:01:58,815 --> 01:02:02,693 in order for the self to remain intact and stable. 1158 01:02:03,383 --> 01:02:05,528 And so self-assertion can never 1159 01:02:05,528 --> 01:02:08,991 be separated from anger or aggression, 1160 01:02:08,991 --> 01:02:11,913 there's always going to be an aggressive underbelly, 1161 01:02:11,913 --> 01:02:14,208 an aggressive component. 1162 01:02:14,792 --> 01:02:16,419 And of course, as I said earlier, 1163 01:02:16,419 --> 01:02:20,988 this is also going to differ depending on constitutionality. 1164 01:02:21,742 --> 01:02:25,295 Kernberg, as I said, he was very much, 1165 01:02:25,295 --> 01:02:26,944 I mean he was a very interesting theorist actually, 1166 01:02:26,944 --> 01:02:28,670 I really like Kernberg because he was 1167 01:02:28,670 --> 01:02:30,775 one of the people who tried to marry 1168 01:02:30,775 --> 01:02:33,459 drive theory with object-relations theory. 1169 01:02:33,459 --> 01:02:37,135 So he basically believed that we are all born 1170 01:02:37,135 --> 01:02:39,638 with the intrinsic drives, the libidinal 1171 01:02:39,638 --> 01:02:42,187 and the aggressive drives, and that 1172 01:02:42,187 --> 01:02:45,812 we take those into the world with us. 1173 01:02:45,812 --> 01:02:48,056 But then he flipped it over to object-relations theory 1174 01:02:48,056 --> 01:02:50,620 and said that the way in which those particular 1175 01:02:50,620 --> 01:02:53,953 libidinal and aggressive instincts manifest and are shaped 1176 01:02:53,953 --> 01:02:58,953 then becomes predicated on the early environment, 1177 01:02:59,067 --> 01:03:02,740 the early developmental context into which we are born. 1178 01:03:03,294 --> 01:03:06,721 And so, depending on the constitutional propensity 1179 01:03:06,721 --> 01:03:10,526 for anger or aggression, the volume 1180 01:03:10,526 --> 01:03:15,051 of that anger or aggression will differ with each person. 1181 01:03:16,266 --> 01:03:19,930 So we have a situation now of an infant, 1182 01:03:20,576 --> 01:03:24,260 of a child, who has been born into an environment 1183 01:03:24,260 --> 01:03:28,746 that isn't going to offer her a reliable sense of self. 1184 01:03:29,208 --> 01:03:30,971 She's been born into an environment 1185 01:03:30,971 --> 01:03:34,292 where there isn't the safety and proximity 1186 01:03:34,292 --> 01:03:38,451 of a stable caregiver who's able to hold her in mind, 1187 01:03:38,451 --> 01:03:41,660 in an accurate and safe way. 1188 01:03:41,660 --> 01:03:44,597 And this then creates a self-structure 1189 01:03:44,597 --> 01:03:49,126 that is predicated on anger, that is basically unstable, 1190 01:03:49,126 --> 01:03:52,105 and that can't hold a center. 1191 01:03:52,859 --> 01:03:54,938 The fundamental question, 1192 01:03:55,612 --> 01:03:58,500 a very important question for us as clinicians, 1193 01:03:58,500 --> 01:04:00,126 is around whether or not these 1194 01:04:00,126 --> 01:04:03,952 distortions of the self are irreversible. 1195 01:04:03,952 --> 01:04:07,633 And certainly when I was first training, some time back, 1196 01:04:08,739 --> 01:04:11,030 one of the overriding beliefs in this area 1197 01:04:11,030 --> 01:04:14,580 was that these kinds of distortions couldn't be reversed, 1198 01:04:14,580 --> 01:04:19,061 that if you were born into a context which then created 1199 01:04:19,061 --> 01:04:22,770 a disorder of the self, or a disordered personality, 1200 01:04:22,770 --> 01:04:25,921 the potential to shift that, or to change it, or to 1201 01:04:25,921 --> 01:04:30,108 grow through that was incredibly hard, if not impossible. 1202 01:04:31,001 --> 01:04:33,811 But increasingly now, with research around attachment 1203 01:04:33,811 --> 01:04:35,604 and with neurobiological research, 1204 01:04:35,604 --> 01:04:38,970 which I'm also going to speak about a little bit later on, 1205 01:04:38,970 --> 01:04:41,699 there is the increasing evidence that, in fact, 1206 01:04:41,699 --> 01:04:44,655 these distortions can be reversed, 1207 01:04:44,655 --> 01:04:49,108 if treatment is offered in a particular kind of way. 1208 01:04:49,108 --> 01:04:53,155 So the question is, "Are these distortions irreversible?" 1209 01:04:53,155 --> 01:04:56,701 And increasingly we are knowing and understanding 1210 01:04:56,701 --> 01:04:57,835 that the answer to that question 1211 01:04:57,835 --> 01:05:00,365 is no, they are not irreversible, 1212 01:05:00,365 --> 01:05:02,766 that within a particular treatment context, 1213 01:05:02,766 --> 01:05:05,629 or within particular life conditions, 1214 01:05:06,618 --> 01:05:10,819 these early distortions of self can be 1215 01:05:12,247 --> 01:05:17,247 mediated and hopefully even reversed. 1216 01:05:17,613 --> 01:05:22,041 The capacity to create a narrative of thoughts, 1217 01:05:23,979 --> 01:05:26,642 the capacity to mentalize 1218 01:05:28,103 --> 01:05:30,775 around thinking and around thoughts, 1219 01:05:30,775 --> 01:05:35,339 can overcome the early flaws within the self-system, 1220 01:05:36,338 --> 01:05:39,019 can overcome the early experience 1221 01:05:39,019 --> 01:05:41,772 of disorganized attachment and create 1222 01:05:41,772 --> 01:05:44,738 an internal situation of balance. 1223 01:05:44,738 --> 01:05:46,904 And so I want to move on to now, 1224 01:05:46,904 --> 01:05:50,448 an understanding of what I mean by mentalization. 1225 01:05:51,522 --> 01:05:55,147 And to say that I'm not sure how 1226 01:05:55,639 --> 01:05:59,154 commonly discussed, or thought about, 1227 01:05:59,154 --> 01:06:02,542 or described mentalization is in this country, 1228 01:06:02,542 --> 01:06:07,058 because it really is a term that derives from British, 1229 01:06:07,058 --> 01:06:10,438 a British school, from the British attachment school, 1230 01:06:10,438 --> 01:06:14,099 from Anthony Bateman and from Peter Fonagy and Mary Target, 1231 01:06:14,099 --> 01:06:18,095 who work out of London, and they have created 1232 01:06:18,095 --> 01:06:20,864 and developed a very, very coherent attachment 1233 01:06:20,864 --> 01:06:24,667 model based on mentalization and mentalization practices. 1234 01:06:24,667 --> 01:06:26,902 Now, mentalization is not a new term, 1235 01:06:26,902 --> 01:06:28,705 it's certainly not a new construct, 1236 01:06:28,705 --> 01:06:31,151 but it is a term and a construct that they have 1237 01:06:31,151 --> 01:06:35,546 popularized more recently and which we can draw on 1238 01:06:35,546 --> 01:06:38,763 and which I certainly draw on a lot in my work. 1239 01:06:38,763 --> 01:06:42,056 But mentalization really refers back 1240 01:06:42,056 --> 01:06:46,265 to the capacity to think, it refers back 1241 01:06:46,265 --> 01:06:50,553 to the capacity to understand and interpret human behavior, 1242 01:06:51,445 --> 01:06:54,063 in terms of underlying mental states. 1243 01:06:54,063 --> 01:06:57,722 So in other words, if I have the capacity to mentalize, 1244 01:06:57,722 --> 01:07:00,900 it means that I am able to describe 1245 01:07:00,900 --> 01:07:03,902 what is happening in my internal world, 1246 01:07:03,902 --> 01:07:07,433 in terms of underlying mental states, 1247 01:07:07,433 --> 01:07:10,475 in terms of my desires or my beliefs, 1248 01:07:10,475 --> 01:07:14,620 I can talk about what is happening inside of me, 1249 01:07:14,620 --> 01:07:18,939 in quite a dimensional and nuanced way. 1250 01:07:19,723 --> 01:07:23,210 Similarly, I am able to mentalize around 1251 01:07:23,210 --> 01:07:26,339 what might be happening in your internal world. 1252 01:07:26,339 --> 01:07:30,134 So, through unconscious cues, through social cues, 1253 01:07:30,134 --> 01:07:33,549 through intuition, through the knowing that comes 1254 01:07:33,549 --> 01:07:36,759 from interpersonal interaction, I might be able 1255 01:07:36,759 --> 01:07:39,648 to understand, and to pick up, and to then 1256 01:07:39,648 --> 01:07:42,411 describe what is happening in your internal world. 1257 01:07:42,411 --> 01:07:44,719 And we do this all the time. 1258 01:07:44,719 --> 01:07:47,548 We do this all the time. 1259 01:07:47,548 --> 01:07:49,331 We do it unconsciously. 1260 01:07:49,331 --> 01:07:51,783 We do it implicitly. 1261 01:07:51,783 --> 01:07:54,719 You're in the shop, you go to the cash register, 1262 01:07:54,719 --> 01:07:58,414 you're paying for your goods, and your intention 1263 01:07:58,414 --> 01:08:01,610 had been to say to the person at the cash register, 1264 01:08:01,610 --> 01:08:05,000 "Hey, how are you doing? Isn't it a beautiful day outside? 1265 01:08:05,000 --> 01:08:06,516 "I hope you have a good day." 1266 01:08:06,516 --> 01:08:10,364 But as you approach her, you see that her eyes are downcast, 1267 01:08:10,364 --> 01:08:13,073 her body language is turned away from you, 1268 01:08:13,073 --> 01:08:16,140 and there is everything about her demeanor which says, 1269 01:08:16,140 --> 01:08:18,366 "Don't speak to me." 1270 01:08:18,366 --> 01:08:20,645 And you pick up on that implicitly. 1271 01:08:20,645 --> 01:08:22,866 It's not a conscious process, you don't think to yourself, 1272 01:08:22,866 --> 01:08:24,587 "Oh I'm not actually going to greet this person 1273 01:08:24,587 --> 01:08:27,836 "because I can see that they don't want to be intruded on." 1274 01:08:27,836 --> 01:08:30,884 It's an unconscious process of understanding 1275 01:08:30,884 --> 01:08:33,948 what might be happening, internally, for her, 1276 01:08:33,948 --> 01:08:37,439 And then it's an unconscious pulling back on your part, 1277 01:08:37,439 --> 01:08:39,857 which is a respectful response 1278 01:08:39,857 --> 01:08:42,783 to what you have implicitly read. 1279 01:08:42,783 --> 01:08:44,906 That's mentalization, and it's 1280 01:08:44,906 --> 01:08:46,890 something that we take for granted, 1281 01:08:46,890 --> 01:08:48,962 many of us, in our relationships. 1282 01:08:48,962 --> 01:08:53,962 But it is something that is so crucial, absolutely pivotal 1283 01:08:54,059 --> 01:08:57,165 to the healthy functioning of interrelating. 1284 01:08:58,040 --> 01:09:02,843 It is a capacity, which for the borderline person, 1285 01:09:02,843 --> 01:09:04,783 for the borderline patient, 1286 01:09:05,197 --> 01:09:10,197 is either impaired or it is lacking. 1287 01:09:11,416 --> 01:09:14,966 And once again, having worked with a number of people, 1288 01:09:14,966 --> 01:09:18,624 I have seen situations where mentalization 1289 01:09:18,624 --> 01:09:21,296 is more or less intact, and certainly situations 1290 01:09:21,296 --> 01:09:25,337 where mentalization is almost entirely absent. 1291 01:09:26,538 --> 01:09:30,104 So much so, where I might say to a person, 1292 01:09:30,104 --> 01:09:31,923 "You know, if you're going to cancel that arrangement 1293 01:09:31,923 --> 01:09:36,778 "with your friend, how might they feel about that?" 1294 01:09:36,778 --> 01:09:40,171 And she looks away from me, and pauses for a moment, 1295 01:09:40,171 --> 01:09:42,642 and then turns back and says to me, 1296 01:09:42,642 --> 01:09:44,658 "How can I know how she's going to feel about it? 1297 01:09:44,658 --> 01:09:46,264 "I'm not her." 1298 01:09:46,803 --> 01:09:49,363 And can you see in that simple statement, 1299 01:09:49,363 --> 01:09:51,767 a fundamental breakdown in the capacity 1300 01:09:51,767 --> 01:09:56,767 to have any sense of, to intuit, to know, to narrate 1301 01:09:57,406 --> 01:10:01,350 the impact of her actions on another person. 1302 01:10:01,350 --> 01:10:04,781 It's a fundamental breakdown of mentalization. 1303 01:10:04,781 --> 01:10:07,353 And so the capacity to understand and interpret 1304 01:10:07,353 --> 01:10:11,125 human behavior, in terms of underlying mental states, 1305 01:10:11,125 --> 01:10:15,362 is the most profound interpersonal 1306 01:10:15,362 --> 01:10:20,171 mechanism which we have, and it is that mechanism 1307 01:10:20,171 --> 01:10:25,111 which is lacking for the borderline experience, 1308 01:10:25,111 --> 01:10:28,822 and it is that mechanism that we want to try to work on 1309 01:10:28,822 --> 01:10:33,822 when we are working clinically with this type of person.