1 00:00:00,231 --> 00:00:02,113 - How does mentalization develop? 2 00:00:04,328 --> 00:00:07,650 Very fundamentally, but not so simply, 3 00:00:07,650 --> 00:00:09,841 it develops through having been experienced 4 00:00:09,841 --> 00:00:11,479 in the mind of the other 5 00:00:11,479 --> 00:00:14,174 within a secure attachment context. 6 00:00:14,951 --> 00:00:18,535 In other words, through being held in mind, 7 00:00:19,556 --> 00:00:23,026 through being considered by the other, 8 00:00:23,717 --> 00:00:27,252 the capacity for mentalization develops. 9 00:00:27,782 --> 00:00:29,491 It is only once we have been held 10 00:00:29,491 --> 00:00:32,420 in the mind of the other that we can ever really 11 00:00:32,420 --> 00:00:36,800 begin to know ourselves as developing infants, 12 00:00:36,800 --> 00:00:38,586 as developing selves. 13 00:00:39,138 --> 00:00:43,974 If the context is not safe, if it is not secure, 14 00:00:44,619 --> 00:00:48,681 if it malevolent, what we often see 15 00:00:48,681 --> 00:00:51,437 in traumatized infants and children 16 00:00:51,437 --> 00:00:56,023 is a closing down of the mind to other minds in general. 17 00:00:56,670 --> 00:00:58,466 In other words, rather than having the mind 18 00:00:58,466 --> 00:01:01,957 being open to a caregiver who is malevolent, 19 00:01:02,449 --> 00:01:05,606 or negligent, that mind becomes closed 20 00:01:05,606 --> 00:01:08,348 once again as a protective mechanism, 21 00:01:09,059 --> 00:01:11,823 but it also becomes closed to other minds 22 00:01:12,351 --> 00:01:14,779 and so it doesn't ever develop. 23 00:01:15,136 --> 00:01:18,311 It remains in the solipsistic vacuum 24 00:01:19,316 --> 00:01:22,584 of non-development and of fragmentation. 25 00:01:23,012 --> 00:01:25,185 This is when we often see an experience 26 00:01:25,185 --> 00:01:28,034 of dissociation or detachment in severely 27 00:01:28,034 --> 00:01:30,896 traumatized children and adults, 28 00:01:31,874 --> 00:01:33,738 because for this person, the way in which 29 00:01:33,738 --> 00:01:37,266 they keep themselves safe through the terror 30 00:01:37,266 --> 00:01:40,444 of not being known in the mind of the other 31 00:01:40,883 --> 00:01:42,919 is through mental isolation. 32 00:01:43,580 --> 00:01:45,454 It's through the not knowing, 33 00:01:46,688 --> 00:01:49,209 it's through preemptive acts of aggressive 34 00:01:49,209 --> 00:01:53,568 in order to neutralize what they perceive to be a threat, 35 00:01:54,337 --> 00:01:59,337 it's through formulaic, schematic and often inaccurate 36 00:01:59,448 --> 00:02:02,397 representations of interpersonal interactions. 37 00:02:02,397 --> 00:02:05,692 In other words, there's not any kind of a subtle 38 00:02:05,692 --> 00:02:08,639 understanding of what happens inter-personally. 39 00:02:08,639 --> 00:02:12,204 There are formulae and schemas which are applied 40 00:02:12,204 --> 00:02:16,080 to interpersonal relating that are extremely rigid. 41 00:02:16,824 --> 00:02:19,125 There is a dominance of projective mechanisms 42 00:02:19,125 --> 00:02:24,125 that force unbearable mental states onto the other. 43 00:02:26,096 --> 00:02:30,512 In the terminology of Wilfred Bion there is minus K. 44 00:02:30,512 --> 00:02:32,307 There is no thinking. 45 00:02:32,699 --> 00:02:34,193 There is no thinking. 46 00:02:34,459 --> 00:02:37,271 There is a shutting down of minds. 47 00:02:39,921 --> 00:02:42,613 This is the presentation of traumatized mind. 48 00:02:42,613 --> 00:02:44,508 This is the presentation of a mind 49 00:02:44,508 --> 00:02:48,091 which was not known in the mind of the other 50 00:02:48,091 --> 00:02:52,903 in a secure and a safe and a proximal way. 51 00:02:54,733 --> 00:02:56,193 So where does this lead? 52 00:02:57,567 --> 00:03:00,980 I want to take you down this path now 53 00:03:01,460 --> 00:03:06,069 to help to distill and to begin to differentiate 54 00:03:06,069 --> 00:03:09,214 between some of the different manifestations 55 00:03:09,214 --> 00:03:12,135 of personality organization. 56 00:03:12,135 --> 00:03:14,443 So, to backtrack a little bit, 57 00:03:14,443 --> 00:03:17,461 we're speaking broadly about borderline organization, 58 00:03:17,461 --> 00:03:19,116 and within that borderline organization 59 00:03:19,116 --> 00:03:21,002 there are different manifestations. 60 00:03:21,872 --> 00:03:25,050 The biggest categories are the category 61 00:03:25,050 --> 00:03:28,790 of narcissistic personality disorder, 62 00:03:28,790 --> 00:03:31,553 of psychopathic or antisocial personality disorder, 63 00:03:31,553 --> 00:03:36,243 and then the borderline, as we know BPD to be. 64 00:03:36,243 --> 00:03:38,364 I want you to just go down this road a little bit 65 00:03:38,364 --> 00:03:40,292 to try to differentiate between 66 00:03:40,292 --> 00:03:43,407 the different kinds of manifestation. 67 00:03:45,542 --> 00:03:48,529 If we have the infant's mind that has been 68 00:03:48,529 --> 00:03:51,625 closed down to the mind of the other, 69 00:03:53,925 --> 00:03:56,680 then we have a propensity for violence 70 00:03:56,680 --> 00:04:00,430 and for aggression, which is used to stabilize the self. 71 00:04:00,757 --> 00:04:04,323 We see this propensity manifest in adulthood 72 00:04:04,323 --> 00:04:07,844 to violence, impulsive, inconsistent 73 00:04:07,844 --> 00:04:11,512 and incredibly emotionally volatile behavior. 74 00:04:12,126 --> 00:04:15,528 As soon as you see this presentation in an adult, 75 00:04:15,528 --> 00:04:19,437 as soon as you see this kind of dis-equilibrated, 76 00:04:19,437 --> 00:04:23,777 uncontained aggression and emotional instability, 77 00:04:24,206 --> 00:04:25,859 then you have to know that there is 78 00:04:25,859 --> 00:04:29,550 a reduced capacity for mentalization, 79 00:04:30,642 --> 00:04:33,443 and that everything that is happening for this person 80 00:04:33,443 --> 00:04:36,688 is an attempt, a primitive, infantile attempt, 81 00:04:36,688 --> 00:04:40,869 to protect the self in the absence of an internal 82 00:04:40,869 --> 00:04:45,012 apparatus that can erect feelings, 83 00:04:45,012 --> 00:04:47,641 that can erect life experience. 84 00:04:48,579 --> 00:04:51,407 If we look, for example, at self-mutilation, 85 00:04:52,132 --> 00:04:53,788 self-mutilation, which used to really be 86 00:04:53,788 --> 00:04:56,401 the cornerstone of borderline personality disorder, 87 00:04:57,506 --> 00:04:59,785 and I think it's less so now because we 88 00:04:59,785 --> 00:05:02,573 are starting to understand how self-destructive 89 00:05:02,573 --> 00:05:05,249 behavior manifests in so many different ways, 90 00:05:05,482 --> 00:05:08,624 but if we look at self-mutilation, for example, 91 00:05:08,624 --> 00:05:10,726 we can see this thing as an attempt, 92 00:05:10,726 --> 00:05:13,758 a desperate attempt, to self-regulate 93 00:05:13,758 --> 00:05:18,758 and to self-soothe in the face of overwhelming affect. 94 00:05:21,086 --> 00:05:24,080 The commonality which bridges all 95 00:05:24,080 --> 00:05:25,994 of the different personality classes, 96 00:05:25,994 --> 00:05:29,135 borderline, narcissistic, antisocial, 97 00:05:29,687 --> 00:05:34,687 is a fragile, brittle self-structure which manifests 98 00:05:34,905 --> 00:05:37,979 either as complete disorganization 99 00:05:37,979 --> 00:05:39,998 or as excessive rigidity. 100 00:05:39,998 --> 00:05:42,169 So you have these two polar opposites, 101 00:05:42,485 --> 00:05:45,247 an incredibly rigid way of being in the world 102 00:05:45,855 --> 00:05:49,940 or an incredibly disorganized way of being in the world. 103 00:05:51,119 --> 00:05:56,113 Let's look at the extreme of excessive rigidity. 104 00:05:57,814 --> 00:06:02,814 The narcissist and the psychopath shelters within 105 00:06:03,115 --> 00:06:07,577 the formulaic schematic representations of relationships 106 00:06:07,577 --> 00:06:09,390 in order to protect the self. 107 00:06:09,886 --> 00:06:12,608 In other words, the way that a narcissistic 108 00:06:12,608 --> 00:06:15,188 personality will engage with the world 109 00:06:15,188 --> 00:06:17,740 is to control the other, 110 00:06:17,740 --> 00:06:20,976 to control those with whom they are in relationship, 111 00:06:21,453 --> 00:06:24,755 so that there can be no flexibility, 112 00:06:25,499 --> 00:06:28,433 so that there's only rigidity of roles. 113 00:06:29,141 --> 00:06:31,450 Certainly, this is one of the ways, 114 00:06:31,450 --> 00:06:33,127 when sitting in the room with an individual, 115 00:06:33,127 --> 00:06:35,689 to formulate around whether a person 116 00:06:35,689 --> 00:06:38,149 is more borderline or more narcissistic. 117 00:06:38,614 --> 00:06:41,540 When I feel controlled by a person, 118 00:06:41,540 --> 00:06:44,711 when I feel like the way that I speak, 119 00:06:44,711 --> 00:06:48,419 the way that I look, the way that I greet them, 120 00:06:48,698 --> 00:06:51,643 the way that I comport myself in the situation, 121 00:06:52,924 --> 00:06:57,924 is being straitjacketed by their demands on me, 122 00:06:58,435 --> 00:07:00,276 then I start to have an inkling 123 00:07:00,627 --> 00:07:02,712 that I'm sitting more with a narcissistic 124 00:07:02,712 --> 00:07:05,279 structure in the room, 125 00:07:05,279 --> 00:07:09,594 where if I step outside of that rigidity, 126 00:07:09,594 --> 00:07:12,800 and of that projection of rigidity, 127 00:07:13,247 --> 00:07:16,664 then there's going to be some kind of a shattering, 128 00:07:17,378 --> 00:07:21,492 there's going to be some kind of a breakdown. 129 00:07:23,150 --> 00:07:26,552 So those who present with a more of a narcissistic 130 00:07:26,552 --> 00:07:30,792 structure are controlling and manipulative, 131 00:07:30,792 --> 00:07:32,361 and those who are in relationship with them, 132 00:07:32,361 --> 00:07:36,451 including the therapist, feel controlled and manipulated. 133 00:07:37,071 --> 00:07:41,832 The irony of this is that that kind of a person 134 00:07:41,832 --> 00:07:43,680 may present as highly stable. 135 00:07:43,680 --> 00:07:45,932 That kind of a person may present with a long-term 136 00:07:45,932 --> 00:07:50,046 relationship in which it looks like there's stability, 137 00:07:50,046 --> 00:07:54,973 but that stability is predicated on absolute rigidity 138 00:07:54,973 --> 00:07:57,073 and is highly dysfunctional. 139 00:07:58,745 --> 00:08:01,227 As we know, there are two kinds, thanks to Rosenfeld, 140 00:08:01,227 --> 00:08:03,028 there are two kinds of narcissists, 141 00:08:03,028 --> 00:08:05,215 the thin-skinned and the thick-skinned. 142 00:08:05,763 --> 00:08:09,089 Your thick-skinned narcissists are inaccessible 143 00:08:09,089 --> 00:08:11,306 and defensively aggressive and will show 144 00:08:11,306 --> 00:08:13,253 violence when threatened. 145 00:08:13,253 --> 00:08:14,740 That's really your antisocial 146 00:08:14,740 --> 00:08:18,182 and your psychopathic personality types. 147 00:08:18,182 --> 00:08:21,221 Whereas your thin-skinned narcissists are much more 148 00:08:21,221 --> 00:08:25,066 subtle in diagnosing and formulating. 149 00:08:25,450 --> 00:08:28,561 They present as vulnerable and fragile, 150 00:08:28,899 --> 00:08:33,078 and quite often the violence is towards the self 151 00:08:33,806 --> 00:08:36,381 rather than against the other. 152 00:08:37,566 --> 00:08:39,540 But both, the thin and the thick-skinned 153 00:08:39,540 --> 00:08:44,540 narcissist will react impulsively to the anticipated 154 00:08:45,423 --> 00:08:50,423 or to the actual experience of one important affect, 155 00:08:51,106 --> 00:08:52,781 the affect of shame. 156 00:08:53,891 --> 00:08:58,891 Shame is core to the vulnerability 157 00:09:00,110 --> 00:09:03,782 of the narcissistically constructed individual. 158 00:09:05,016 --> 00:09:08,317 Shame or humiliation is experienced 159 00:09:08,317 --> 00:09:10,882 as potentially annihilating. 160 00:09:11,484 --> 00:09:13,963 I don't mean symbolically annihilating, 161 00:09:14,178 --> 00:09:17,431 I feel like I'm being annihilated, I mean literally. 162 00:09:17,906 --> 00:09:21,031 The experience of shame when it floods the system 163 00:09:21,443 --> 00:09:25,164 feels like it's going to obliterate them. 164 00:09:25,164 --> 00:09:28,082 It's not an "as if" feeling. 165 00:09:29,395 --> 00:09:31,945 The psychological experience of mortification 166 00:09:31,945 --> 00:09:36,636 is equated with the physical experience of distraction, 167 00:09:37,173 --> 00:09:41,874 and so we call this ego distractive shame. 168 00:09:43,962 --> 00:09:47,910 Quite often, tragically, 169 00:09:49,466 --> 00:09:53,754 a thin-skinned narcissist will make, 170 00:09:53,754 --> 00:09:57,703 often, successful suicide attempts 171 00:09:58,778 --> 00:10:00,460 when faced with shame. 172 00:10:00,869 --> 00:10:04,825 For example, a highly successful entrepreneur 173 00:10:05,220 --> 00:10:07,487 who has had success all of his life 174 00:10:07,487 --> 00:10:10,129 and then is suddenly faced with failure, 175 00:10:10,604 --> 00:10:13,735 a breakdown of his rigid way of being in the world 176 00:10:13,735 --> 00:10:16,885 and his rigid way of seeing himself in the world, 177 00:10:17,129 --> 00:10:19,930 the shame of that failure is so intense, 178 00:10:21,176 --> 00:10:25,106 it's so annihilating, that the only way 179 00:10:25,106 --> 00:10:28,192 to respond to it is through an ultimate 180 00:10:28,192 --> 00:10:30,199 and fatal attack on the self. 181 00:10:31,639 --> 00:10:34,922 So quite often suicide attempts 182 00:10:35,444 --> 00:10:39,450 for the narcissistically constructed patient 183 00:10:39,450 --> 00:10:42,701 is in response to some kind of an experience 184 00:10:42,701 --> 00:10:44,783 of failure or shame. 185 00:10:44,964 --> 00:10:46,724 Once again, when you are taking a history 186 00:10:46,724 --> 00:10:49,444 or when you are starting to get to know a person 187 00:10:49,444 --> 00:10:51,349 and get to understand their history, 188 00:10:51,349 --> 00:10:55,752 you will start to identify experiences of shame, 189 00:10:56,353 --> 00:10:59,664 or experiences of humiliation that may have led 190 00:10:59,664 --> 00:11:03,029 to past breakdowns or past hospitalizations 191 00:11:03,029 --> 00:11:05,382 or past suicidality. 192 00:11:11,943 --> 00:11:15,722 This notion of the internal 193 00:11:16,645 --> 00:11:18,375 being the same as the external, 194 00:11:18,375 --> 00:11:22,678 in other words, shame isn't an abstract affect, 195 00:11:22,678 --> 00:11:24,550 it is a concrete reality. 196 00:11:25,034 --> 00:11:27,526 This is known as psychic equivalence, 197 00:11:28,091 --> 00:11:30,297 where there is no difference between what is happening 198 00:11:30,297 --> 00:11:33,547 inside and what is happening outside. 199 00:11:34,903 --> 00:11:37,026 It won't be I feel shame, 200 00:11:37,026 --> 00:11:39,521 it will be I am shame. 201 00:11:39,521 --> 00:11:42,546 The totality of myself is shame. 202 00:11:43,140 --> 00:11:45,347 Shame has taken over 203 00:11:45,708 --> 00:11:48,085 and it is annihilating me. 204 00:11:49,227 --> 00:11:52,105 It has the capacity to demolish. 205 00:11:54,838 --> 00:11:59,413 In summary, if we think about the core pathology 206 00:12:00,029 --> 00:12:04,856 of this broad spectrum of borderline organization 207 00:12:04,856 --> 00:12:08,818 and of the so-called Cluster B personality disorders, 208 00:12:09,501 --> 00:12:13,320 we see that there is an intrinsic instability of the self, 209 00:12:14,899 --> 00:12:17,141 which comes together with the defenses 210 00:12:17,141 --> 00:12:20,304 which are used to protect the self, 211 00:12:22,161 --> 00:12:25,444 and this results in the core pathology 212 00:12:25,444 --> 00:12:28,341 which we see presented in our rooms. 213 00:12:31,509 --> 00:12:33,981 What are the core differences between 214 00:12:33,981 --> 00:12:36,868 the borderline and the narcissistic presentation? 215 00:12:36,868 --> 00:12:39,149 Once again, I do think that accurate 216 00:12:39,149 --> 00:12:41,725 formulation is extremely important. 217 00:12:42,836 --> 00:12:45,406 For the borderline personality, 218 00:12:46,170 --> 00:12:48,914 the self-structure becomes unstable, 219 00:12:49,187 --> 00:12:53,426 most crucially when mind meets mind. 220 00:12:54,368 --> 00:12:57,026 In other words, as soon as this individual 221 00:12:57,026 --> 00:13:00,287 is in relationship, there is a possibility, 222 00:13:00,287 --> 00:13:04,319 in fact, there's the inevitability, of disorganization. 223 00:13:05,346 --> 00:13:09,552 This quite often results in a terrible, terrible tension 224 00:13:10,639 --> 00:13:13,619 between the longing that an individual has 225 00:13:13,619 --> 00:13:16,793 to be in a relationship, and the overwhelming 226 00:13:16,793 --> 00:13:20,324 disorganization which happens when they are in relationship, 227 00:13:20,963 --> 00:13:22,930 which basically means that there is no-- 228 00:13:22,930 --> 00:13:24,019 (clears throat) excuse me... 229 00:13:24,019 --> 00:13:27,853 which basically means that there is no safe space, ever. 230 00:13:28,067 --> 00:13:31,129 Being alone is overwhelming and terrifying, 231 00:13:31,430 --> 00:13:34,404 because another mind is needed. 232 00:13:35,036 --> 00:13:38,809 Being in relationship is terrifying and overwhelming, 233 00:13:38,809 --> 00:13:42,280 because the proximity of that mind is so frightening. 234 00:13:43,097 --> 00:13:44,415 It's frightening because there is no way 235 00:13:44,415 --> 00:13:48,144 of really understanding, mentalizing, making sense, 236 00:13:48,144 --> 00:13:50,320 of what is happening in the mind of the other, 237 00:13:50,585 --> 00:13:53,117 or of what is happening internally. 238 00:13:54,183 --> 00:13:56,494 For the borderline structure, 239 00:13:58,123 --> 00:14:02,223 the context of relationships is disorganized. 240 00:14:03,659 --> 00:14:06,445 For the narcissist or for the psychopath, 241 00:14:08,300 --> 00:14:10,358 relational representations, 242 00:14:10,358 --> 00:14:13,035 the way in which relationships are seen, 243 00:14:13,035 --> 00:14:14,891 or understood, are solidified, 244 00:14:14,891 --> 00:14:18,280 and the other becomes forced into a particular mold. 245 00:14:18,742 --> 00:14:22,336 This can look like relational stability, as I said. 246 00:14:22,698 --> 00:14:26,869 So you can have a narcissist who is in relationship 247 00:14:26,869 --> 00:14:29,530 with somebody who, for whatever their 248 00:14:29,530 --> 00:14:31,563 psychodynamic reasons might be, 249 00:14:31,563 --> 00:14:35,589 are able to take on the rigid projection, 250 00:14:36,057 --> 00:14:38,603 creating a stability of system, 251 00:14:39,097 --> 00:14:41,331 but within a very, very dysfunctional 252 00:14:41,331 --> 00:14:44,391 psychological milieu. 253 00:14:46,879 --> 00:14:48,858 The thing with the narcissist 254 00:14:48,858 --> 00:14:51,652 is that the self is incredibly brittle 255 00:14:52,462 --> 00:14:56,699 and can shatter very, very unexpectedly, 256 00:14:57,087 --> 00:14:58,924 very, very suddenly, 257 00:14:59,146 --> 00:15:04,146 and this can result in an outburst of intense violence, 258 00:15:04,322 --> 00:15:07,187 intense anger, intense rage, 259 00:15:07,187 --> 00:15:10,726 and so we talk about the narcissistic injury 260 00:15:11,092 --> 00:15:13,553 and we talk about narcissistic rage, 261 00:15:13,553 --> 00:15:16,713 which, once again, is this system's 262 00:15:16,713 --> 00:15:19,908 utterly desperate attempt 263 00:15:20,731 --> 00:15:24,667 to reestablish some sense of balance inside. 264 00:15:26,406 --> 00:15:29,007 During regressive behavior for the borderline 265 00:15:29,007 --> 00:15:31,228 patient within relationships, 266 00:15:31,228 --> 00:15:33,065 and for the narcissistic patient 267 00:15:33,065 --> 00:15:35,643 when there is a rupture of rigidity, 268 00:15:36,102 --> 00:15:38,729 there is always going to be a return 269 00:15:39,163 --> 00:15:41,664 to infantile modes of thinking, 270 00:15:42,440 --> 00:15:45,439 and this manifests in three possible ways. 271 00:15:46,198 --> 00:15:49,526 Firstly, through psychic equivalence, as I said earlier. 272 00:15:49,526 --> 00:15:52,448 This means that the internal and the external 273 00:15:53,089 --> 00:15:54,834 feel like they are the same. 274 00:15:56,458 --> 00:15:58,199 When sitting with a borderline patient 275 00:15:58,199 --> 00:16:03,199 who says to me, "I'm dying" and I might say to them, 276 00:16:03,724 --> 00:16:05,502 "You feel like you're dying" 277 00:16:05,502 --> 00:16:07,416 and she says to me, "No, I am" 278 00:16:07,979 --> 00:16:09,632 that is what she means. 279 00:16:10,003 --> 00:16:12,407 It means that this feeling inside of her 280 00:16:13,064 --> 00:16:17,266 is equated with the reality of dying. 281 00:16:18,217 --> 00:16:20,606 Affects are not "as if." 282 00:16:21,948 --> 00:16:25,798 Affects are the totality of experience. 283 00:16:26,242 --> 00:16:29,946 Affects are experienced as concrete objects 284 00:16:29,946 --> 00:16:31,401 inside the self. 285 00:16:31,713 --> 00:16:36,298 Affects are experienced as having the capacity 286 00:16:36,994 --> 00:16:40,335 to damage, to destroy, to annihilate. 287 00:16:41,283 --> 00:16:46,216 So when somebody says, "I'm in such a state of grief, 288 00:16:47,161 --> 00:16:49,871 "I fear that my grief is going to kill me." 289 00:16:51,568 --> 00:16:53,930 If they are sitting on the neurotic spectrum, 290 00:16:53,930 --> 00:16:56,098 then we can understand that they 291 00:16:56,098 --> 00:16:58,791 mean that in a symbolic way. 292 00:16:59,433 --> 00:17:01,752 But if they are sitting on the borderline spectrum, 293 00:17:01,752 --> 00:17:05,782 then we need to understand that their literal fear 294 00:17:06,412 --> 00:17:10,842 is of being killed off by their grief. 295 00:17:11,979 --> 00:17:14,689 The second infantile mode of thinking 296 00:17:14,689 --> 00:17:16,548 is that of concrete reasoning, 297 00:17:16,945 --> 00:17:20,440 where suddenly there's an inability to think abstractly 298 00:17:20,440 --> 00:17:25,339 about life, about relationships, about experiences. 299 00:17:25,339 --> 00:17:29,824 Reasoning is reduced to primary process thinking. 300 00:17:29,824 --> 00:17:32,118 Reasoning is reduced to concrete, 301 00:17:33,425 --> 00:17:35,313 thinking to concreteness. 302 00:17:36,269 --> 00:17:40,842 Finally, there is a regression to dissociative states. 303 00:17:41,752 --> 00:17:44,406 Association can sometimes be achieved 304 00:17:44,406 --> 00:17:48,198 through self-mutilation or through self-destructive behavior 305 00:17:48,198 --> 00:17:51,909 but is also achieved through just shutting off the mind. 306 00:17:51,909 --> 00:17:55,743 So, in periods of regression for these patients 307 00:17:55,743 --> 00:17:58,799 we will see the tendency to just shut off 308 00:17:59,143 --> 00:18:04,143 and to disassociate from experiences, 309 00:18:04,211 --> 00:18:07,969 from feelings, from what is happening internally. 310 00:18:09,862 --> 00:18:13,495 It is usually in one of these periods of regression 311 00:18:14,348 --> 00:18:16,780 that we meet these individuals. 312 00:18:17,353 --> 00:18:20,670 Seldom, if ever, are you going to get somebody 313 00:18:20,670 --> 00:18:23,455 who manifests with a borderline organization 314 00:18:23,455 --> 00:18:25,320 come into your room and saying, 315 00:18:26,318 --> 00:18:28,449 "I'm just here to explore myself." 316 00:18:29,408 --> 00:18:31,246 That's not going to happen. 317 00:18:31,685 --> 00:18:36,336 We are going to meet these particular individuals 318 00:18:36,614 --> 00:18:40,876 in times of crisis, in periods of regression, 319 00:18:41,494 --> 00:18:43,468 following some kind of an experience 320 00:18:43,468 --> 00:18:46,350 which has precipitated a breakdown. 321 00:18:46,703 --> 00:18:48,843 So we are going to be meeting them 322 00:18:49,183 --> 00:18:52,938 in their most infantile states of mind, 323 00:18:53,313 --> 00:18:56,581 manifesting psychic equivalence, concrete reasoning, 324 00:18:57,116 --> 00:19:00,368 and dissociative potential. 325 00:19:02,589 --> 00:19:04,943 I certainly can recall meeting a number 326 00:19:04,943 --> 00:19:07,123 of my more long-term patients, 327 00:19:07,123 --> 00:19:10,948 with whom I have a much more reciprocal 328 00:19:10,948 --> 00:19:13,068 relationship now after many years of working 329 00:19:13,068 --> 00:19:14,822 with them and getting to know them, 330 00:19:15,525 --> 00:19:18,045 but with whom, in the first session, 331 00:19:18,045 --> 00:19:20,956 the first few sessions, I felt a terrible 332 00:19:21,268 --> 00:19:23,621 disassociated experience, 333 00:19:23,855 --> 00:19:26,234 where they simply were inaccessible to me. 334 00:19:26,820 --> 00:19:29,824 As I think about that now, I'm reminded 335 00:19:29,824 --> 00:19:32,841 of what brought them into my rooms in the first place, 336 00:19:32,841 --> 00:19:36,221 and how, from a place of absolute survival, 337 00:19:36,221 --> 00:19:37,524 the need for survival, 338 00:19:37,524 --> 00:19:41,746 there was a disassociation, a cutting off of the minds. 339 00:19:42,397 --> 00:19:44,198 It is the manifestation 340 00:19:46,403 --> 00:19:49,117 of infantile processing 341 00:19:49,893 --> 00:19:51,883 which we see in our rooms 342 00:19:51,883 --> 00:19:54,618 when we first encounter our patients. 343 00:19:56,612 --> 00:19:58,369 I want to turn now to the question 344 00:19:58,369 --> 00:20:02,665 of what is the underlying mechanism? 345 00:20:02,665 --> 00:20:05,580 What is the core psychological process 346 00:20:06,100 --> 00:20:08,420 activated through the attachment system 347 00:20:08,678 --> 00:20:12,523 which underpins all of what I've been describing? 348 00:20:12,523 --> 00:20:17,523 I've spoken about what happens when things go wrong, 349 00:20:18,057 --> 00:20:20,211 about the manifestation of that, 350 00:20:20,426 --> 00:20:23,398 about how that creates what we know today 351 00:20:23,398 --> 00:20:26,886 to be personality dysfunction or personality disorder 352 00:20:26,886 --> 00:20:28,448 or disorder of the self. 353 00:20:28,897 --> 00:20:30,589 But where does it come from? 354 00:20:30,589 --> 00:20:35,490 What is that core underlying difficulty? 355 00:20:36,481 --> 00:20:37,499 Now, I'm going to repeat 356 00:20:37,499 --> 00:20:39,003 because it's really important 357 00:20:39,003 --> 00:20:42,093 that the crucial context is the attachment relationship 358 00:20:42,093 --> 00:20:45,796 between the infant and the primary caregiver or caregivers. 359 00:20:47,018 --> 00:20:49,953 What optimally happens during attachment, 360 00:20:49,953 --> 00:20:53,650 and optimally this happens completely unconsciously 361 00:20:53,650 --> 00:20:57,454 and as part of the fabric of this developing relationship, 362 00:20:57,454 --> 00:21:01,188 what happens is what we refer to as affect mirroring, 363 00:21:01,188 --> 00:21:05,701 the mirroring, the reflection, of feelings, of affect. 364 00:21:07,603 --> 00:21:11,207 An infant or a child will have an internal experience, 365 00:21:11,207 --> 00:21:14,227 which will be expressed through facial expression, 366 00:21:14,227 --> 00:21:17,325 through gesture, or through an unconscious communication, 367 00:21:18,012 --> 00:21:22,164 and the attuned caregiver will mirror, 368 00:21:22,164 --> 00:21:27,101 in an accurate way, that feeling back to the child. 369 00:21:28,204 --> 00:21:30,442 Let me put that into more concrete terms. 370 00:21:30,877 --> 00:21:34,500 You have an infant or child who is having 371 00:21:34,500 --> 00:21:37,875 a physical experience internally. 372 00:21:37,875 --> 00:21:40,702 It's a physiological experience, 373 00:21:41,292 --> 00:21:45,217 which is a response to having had something 374 00:21:45,217 --> 00:21:46,655 taken away from them. 375 00:21:46,655 --> 00:21:48,225 They were holding a toy. 376 00:21:48,225 --> 00:21:50,139 That toy gets taken away from them, 377 00:21:50,139 --> 00:21:55,139 and they now have a surge of sensation internally, 378 00:21:56,084 --> 00:21:57,198 and the caregiver, 379 00:21:57,198 --> 00:21:58,634 let's call her the mom, 380 00:21:59,062 --> 00:22:01,088 the mom says to the baby, 381 00:22:01,419 --> 00:22:04,985 "You're so cross that Mommy took that toy away from you." 382 00:22:05,568 --> 00:22:10,542 In that moment, this internal physiological sensation 383 00:22:10,542 --> 00:22:15,305 becomes converted into an abstract construct. 384 00:22:16,241 --> 00:22:18,490 It becomes converted into the affect 385 00:22:18,490 --> 00:22:21,035 of frustration or of anger. 386 00:22:22,059 --> 00:22:25,069 It is through this affect mirroring, 387 00:22:25,069 --> 00:22:29,293 it's through this accurate attunement and reflection 388 00:22:30,118 --> 00:22:35,118 that self-states, the ways in which the child 389 00:22:35,934 --> 00:22:39,643 begins to know itself, become internalized. 390 00:22:40,783 --> 00:22:45,492 When that feeling arises again, and again, 391 00:22:46,156 --> 00:22:50,070 that child will have an internal representation 392 00:22:50,472 --> 00:22:53,844 that will help it to make sense of that feeling. 393 00:22:55,604 --> 00:22:58,389 The way in which the infant is seen 394 00:22:58,389 --> 00:23:00,403 and recognized and held in mind 395 00:23:00,403 --> 00:23:02,578 and then reflected back to themselves, 396 00:23:02,578 --> 00:23:05,524 will shape the self-representations. 397 00:23:06,514 --> 00:23:08,734 Let's say, for example, you have a child 398 00:23:08,734 --> 00:23:10,778 who has the same experience that I've just described. 399 00:23:10,778 --> 00:23:12,370 They have something taken away from them, 400 00:23:12,370 --> 00:23:14,870 and they're overwhelmed by the sensation 401 00:23:14,870 --> 00:23:17,948 which we know to be anger or frustration, 402 00:23:18,886 --> 00:23:21,345 and the mom laughs and says, 403 00:23:21,345 --> 00:23:23,233 "Oh, you're so funny." 404 00:23:24,169 --> 00:23:28,885 Can you see how inaccurate that reflection is? 405 00:23:28,885 --> 00:23:30,613 That that infant is left with a sense 406 00:23:30,613 --> 00:23:35,613 of not knowing what that sensation is really about 407 00:23:36,328 --> 00:23:39,640 and internalizing something that is just inaccurate? 408 00:23:39,640 --> 00:23:43,568 That's quite a simple concrete example, 409 00:23:43,568 --> 00:23:46,506 but I hope that it illustrates the point, 410 00:23:46,506 --> 00:23:49,535 which is that correct affect mirroring 411 00:23:49,535 --> 00:23:54,071 will allow for accurate internalization of self-states, 412 00:23:54,071 --> 00:23:58,810 which then allows for a growing self-knowledge, 413 00:23:58,810 --> 00:24:02,456 a growing knowledge, of what is happening inside of me. 414 00:24:03,904 --> 00:24:06,852 In order for affect mirroring to be effective 415 00:24:06,852 --> 00:24:10,976 and to be attuned, it has to meet two basic criteria. 416 00:24:11,303 --> 00:24:14,493 The first one is what we call contingency. 417 00:24:15,297 --> 00:24:18,289 What this means is that the reflection, 418 00:24:18,884 --> 00:24:21,566 the mirror, has to be an accurate reflection. 419 00:24:22,238 --> 00:24:24,416 If the infant is feeling sad, 420 00:24:25,625 --> 00:24:28,858 the affect mirror needs to be one of sadness. 421 00:24:29,921 --> 00:24:32,138 That's contingent, it's accurate. 422 00:24:32,404 --> 00:24:36,193 The second criterion is what we call markedness. 423 00:24:37,991 --> 00:24:40,943 Certainly, I've noticed this, if you just observe 424 00:24:40,943 --> 00:24:44,167 mothers and children in any kind of social context, 425 00:24:44,167 --> 00:24:47,238 you'll quite often see mothers responding, 426 00:24:47,238 --> 00:24:49,577 or caregivers responding to their children 427 00:24:49,577 --> 00:24:52,005 in a very, very animated way. 428 00:24:53,728 --> 00:24:57,661 The child at the cash register wants a chocolate 429 00:24:57,661 --> 00:24:59,986 and mom says, "No, you can't have a chocolate 430 00:24:59,986 --> 00:25:01,770 "because we're going home for lunch 431 00:25:01,770 --> 00:25:04,062 "and you're not allowed to have a chocolate before lunch." 432 00:25:04,062 --> 00:25:06,415 This little boy starts tantruming and screaming 433 00:25:06,415 --> 00:25:07,945 and crying and mom goes, 434 00:25:07,945 --> 00:25:11,638 "You're so cross, you're so cross, aren't you?" 435 00:25:12,255 --> 00:25:14,384 Can you see that kind of animation 436 00:25:14,594 --> 00:25:16,928 is what we refer to as markedness. 437 00:25:17,209 --> 00:25:20,842 In reflecting in that marked way, 438 00:25:21,300 --> 00:25:24,850 mom is communicating that this feeling 439 00:25:24,850 --> 00:25:28,163 that she is expressing is not her own feeling, 440 00:25:28,163 --> 00:25:29,887 it's his feeling. 441 00:25:30,955 --> 00:25:34,998 He clearly understands mom is showing me 442 00:25:35,440 --> 00:25:36,719 what I am feeling. 443 00:25:36,719 --> 00:25:40,706 I am feeling cross, angry and frustrated. 444 00:25:41,801 --> 00:25:44,680 Markedness becomes a communication. 445 00:25:44,680 --> 00:25:46,437 This is your feeling, 446 00:25:46,810 --> 00:25:48,449 it's not my feeling. 447 00:25:48,839 --> 00:25:51,887 In that way, affects and feelings 448 00:25:51,887 --> 00:25:54,919 and emotional experiences can be taken back in 449 00:25:55,318 --> 00:25:57,750 in a processed way. 450 00:26:00,922 --> 00:26:04,174 If mirroring is not contingent, 451 00:26:04,770 --> 00:26:06,233 so, in other words, if the affects 452 00:26:06,233 --> 00:26:08,702 that are given back to the child are not accurate, 453 00:26:09,173 --> 00:26:12,033 let's just think for a minute what that, then, creates. 454 00:26:12,493 --> 00:26:14,474 It creates an inaccurate, 455 00:26:14,986 --> 00:26:17,485 a false internal self 456 00:26:17,881 --> 00:26:20,507 that actually doesn't correspond 457 00:26:20,958 --> 00:26:24,113 to what that person is actually feeling. 458 00:26:24,502 --> 00:26:28,250 The infant, then, internalizes a self-representation 459 00:26:28,998 --> 00:26:33,998 that doesn't actually reflect anything that is real, 460 00:26:35,308 --> 00:26:39,576 so you start to develop an ongoing falseness of self. 461 00:26:41,378 --> 00:26:44,432 If the mirroring is not marked, 462 00:26:44,432 --> 00:26:46,599 in the way that I just illustrated, 463 00:26:47,486 --> 00:26:50,011 then self-states, what's happening inside, 464 00:26:50,011 --> 00:26:54,640 is experienced as if they are happening externally, 465 00:26:55,557 --> 00:26:58,743 and so there's no internal symbolic representation 466 00:26:58,743 --> 00:27:00,198 of affect states. 467 00:27:00,802 --> 00:27:03,055 An infant doesn't begin to internalize 468 00:27:03,055 --> 00:27:05,186 what belongs to her. 469 00:27:06,060 --> 00:27:08,755 So these feelings remain outside, 470 00:27:08,755 --> 00:27:10,571 and they remain frightening, 471 00:27:10,571 --> 00:27:12,864 because they have not been taken back in 472 00:27:12,864 --> 00:27:15,556 and housed in the self. 473 00:27:20,004 --> 00:27:24,063 Wilfred Bion, who wrote a theory on thinking 474 00:27:24,451 --> 00:27:26,678 a long time before the attachment theory 475 00:27:26,678 --> 00:27:29,691 was written about, would refer to this 476 00:27:29,691 --> 00:27:31,556 as a breakdown of thinking. 477 00:27:32,070 --> 00:27:34,626 He would describe it as an inability 478 00:27:34,626 --> 00:27:38,368 to convert raw beta elements 479 00:27:39,082 --> 00:27:42,123 into processed alpha elements. 480 00:27:43,609 --> 00:27:45,602 What happens when beta elements 481 00:27:45,602 --> 00:27:48,003 are not converted into alpha elements 482 00:27:48,003 --> 00:27:50,466 is that because of their rawness 483 00:27:51,240 --> 00:27:54,086 and because of their overwhelming nature, 484 00:27:54,086 --> 00:27:56,024 they have to be expelled. 485 00:27:56,485 --> 00:27:59,039 This leads to the use of the mechanism 486 00:27:59,039 --> 00:28:01,024 of projective identification. 487 00:28:01,911 --> 00:28:06,534 If feelings are not converted into something manageable, 488 00:28:06,904 --> 00:28:11,904 they get thrust out, expelled projectively, 489 00:28:12,834 --> 00:28:15,461 and forced onto the other, 490 00:28:15,461 --> 00:28:19,346 so that feelings are never earned within the self. 491 00:28:24,275 --> 00:28:26,101 What happens in this case is 492 00:28:26,101 --> 00:28:27,968 that second order representations... 493 00:28:27,968 --> 00:28:30,213 A second order representation refers 494 00:28:30,213 --> 00:28:34,912 to the symbolic conversion of a self-state. 495 00:28:34,912 --> 00:28:36,473 The first order representation is 496 00:28:36,473 --> 00:28:40,209 how it's feeling inside at a concrete manifest level. 497 00:28:40,610 --> 00:28:42,506 When it gets given a word, 498 00:28:43,500 --> 00:28:45,769 when it gets converted into language, 499 00:28:45,769 --> 00:28:48,256 it becomes a second order representation, 500 00:28:48,256 --> 00:28:51,077 a symbol of the actual feeling. 501 00:28:51,487 --> 00:28:55,499 These second order representations are inadequate. 502 00:28:56,600 --> 00:29:00,302 This inadequacy, this inaccuracy, 503 00:29:01,057 --> 00:29:04,099 results in a sense of internal chaos 504 00:29:04,834 --> 00:29:07,078 which can only be stabilized 505 00:29:07,324 --> 00:29:11,175 through what we now know so famously 506 00:29:11,662 --> 00:29:16,155 as the acting out behavior of the borderline patient. 507 00:29:17,899 --> 00:29:21,663 We know that the way in which our patients 508 00:29:22,333 --> 00:29:27,333 survive and manage their lives is by acting out. 509 00:29:28,916 --> 00:29:32,373 Once again, I just want to make an aside here. 510 00:29:32,373 --> 00:29:34,430 That is a term that historically 511 00:29:34,430 --> 00:29:37,746 has become pejoratively used. 512 00:29:38,795 --> 00:29:40,699 You might say to somebody, "Oh, stop acting out" 513 00:29:40,699 --> 00:29:42,385 or "He was just acting out" 514 00:29:42,385 --> 00:29:43,268 or "They were acting out" 515 00:29:43,268 --> 00:29:45,433 or "There was a whole lot of acting out going on." 516 00:29:45,433 --> 00:29:48,704 But if we actually distill that and think about 517 00:29:48,704 --> 00:29:50,443 what it actually means, 518 00:29:52,043 --> 00:29:56,402 this person has no other option. 519 00:29:57,102 --> 00:30:00,570 The only way to get through the next moment 520 00:30:01,204 --> 00:30:04,007 is to do something, 521 00:30:05,066 --> 00:30:08,775 and that doing is the acting out 522 00:30:08,775 --> 00:30:13,542 of an aggressive impulse or a violent impulse 523 00:30:13,542 --> 00:30:15,389 in a way that will then help them 524 00:30:15,389 --> 00:30:20,169 to rid themselves of a particular kind of feeling. 525 00:30:21,407 --> 00:30:25,851 Then what happens is those internal feelings 526 00:30:25,851 --> 00:30:29,245 that are unmanageable can only be acted out 527 00:30:30,083 --> 00:30:32,688 and projected when there is a target 528 00:30:33,610 --> 00:30:35,946 for that projection, 529 00:30:36,354 --> 00:30:40,077 which means that this particular individual 530 00:30:40,530 --> 00:30:42,740 coming out of this particular inadequate 531 00:30:42,740 --> 00:30:44,380 development context, 532 00:30:44,380 --> 00:30:46,779 is going to constantly be on the lookout 533 00:30:47,137 --> 00:30:50,950 for another mind, an other, 534 00:30:50,950 --> 00:30:53,800 who can be the recipient, or the target, 535 00:30:53,800 --> 00:30:55,854 of the acting out. 536 00:30:58,460 --> 00:31:02,771 When alone, the borderline patient has to sit 537 00:31:03,285 --> 00:31:07,347 and contend with the internal persecutory 538 00:31:07,347 --> 00:31:12,055 and chaotic experience, which is psychically equivalent, 539 00:31:12,055 --> 00:31:15,598 in other words, which is real, as I said. 540 00:31:15,598 --> 00:31:17,540 They don't feel chaotic, 541 00:31:17,540 --> 00:31:20,522 they are chaotic. 542 00:31:21,211 --> 00:31:25,299 When in relationships, this chaos just gets projected out. 543 00:31:25,950 --> 00:31:28,696 So you can see this really, I mean, I think, 544 00:31:28,696 --> 00:31:31,757 quite tortuous double bind that these 545 00:31:31,757 --> 00:31:34,320 individuals find themselves in, 546 00:31:35,299 --> 00:31:37,721 where in being alone they are desperate, 547 00:31:37,721 --> 00:31:40,803 in being in relationship, they are desperate. 548 00:31:41,645 --> 00:31:43,979 There is very little peace, 549 00:31:44,620 --> 00:31:48,901 very few peaceful moments in either of those states. 550 00:31:52,869 --> 00:31:56,431 The three systems clusters of affect, identity 551 00:31:56,431 --> 00:32:01,431 and impulsivity all arise from an instability 552 00:32:01,446 --> 00:32:05,572 in the self-structure, which results from some 553 00:32:05,572 --> 00:32:08,254 kind of a constitutional propensity 554 00:32:08,254 --> 00:32:12,294 coming together with impaired early caregiving, 555 00:32:12,294 --> 00:32:15,411 and all of this results in an inability 556 00:32:15,411 --> 00:32:20,411 to narrate internal experiences accurately. 557 00:32:20,738 --> 00:32:24,169 In other words, all of this results in an inability 558 00:32:24,169 --> 00:32:27,942 or an inhibition of mentalization. 559 00:32:28,482 --> 00:32:31,473 Comprehension of one's own and of the internal 560 00:32:31,473 --> 00:32:35,730 world of others is significantly compromised. 561 00:32:36,336 --> 00:32:39,335 Relationships with others are a minefield. 562 00:32:39,335 --> 00:32:43,712 relationship to the self is a minefield, 563 00:32:44,373 --> 00:32:47,309 because there was not that initial context 564 00:32:47,895 --> 00:32:50,640 within an attachment relationship 565 00:32:50,640 --> 00:32:55,483 that provided the grounding for an accurate 566 00:32:55,483 --> 00:33:00,483 knowledge of self in a symbolic second 567 00:33:00,558 --> 00:33:04,070 order representation kind of way. 568 00:33:04,316 --> 00:33:07,083 Part of what makes this theory so compelling for me 569 00:33:07,887 --> 00:33:10,708 and part of what helps it to make so much sense for me, 570 00:33:11,164 --> 00:33:13,654 is that fact that it corresponds also 571 00:33:13,872 --> 00:33:17,009 with emerging neurobiological research. 572 00:33:17,493 --> 00:33:20,364 Let me give you a little bit of an insert around that. 573 00:33:20,364 --> 00:33:22,761 I'm not going to go into too much detail. 574 00:33:24,807 --> 00:33:26,888 What we do know is that in the first 575 00:33:26,888 --> 00:33:31,670 18 months of life, what develops first 576 00:33:31,670 --> 00:33:34,621 in the brain is the right brain. 577 00:33:36,900 --> 00:33:39,484 What develops within that right brain 578 00:33:39,981 --> 00:33:43,323 are the capacities for emotion regulation, 579 00:33:44,290 --> 00:33:47,335 the capacity for impulse control. 580 00:33:48,351 --> 00:33:53,083 The right brain becomes the template for making sense 581 00:33:53,083 --> 00:33:56,420 of interpersonal relationships and for relating. 582 00:33:56,420 --> 00:34:01,420 You can see that that right brain is implicit 583 00:34:02,034 --> 00:34:04,516 in all of the things that I've been speaking about. 584 00:34:05,293 --> 00:34:08,450 It's implicit in all of the functioning 585 00:34:08,450 --> 00:34:13,450 that is so severely compromised for the borderline patient. 586 00:34:15,378 --> 00:34:18,036 What we know, then, from neurobiological research 587 00:34:18,036 --> 00:34:20,559 is that the integrity of that right brain 588 00:34:20,559 --> 00:34:24,489 and the way in which it develops is directly linked 589 00:34:24,855 --> 00:34:27,206 to the early attachment context. 590 00:34:28,173 --> 00:34:32,680 So in situations of trauma or abuse or neglect 591 00:34:32,680 --> 00:34:36,693 or insensitivity or impaired or disrupted attachment, 592 00:34:36,693 --> 00:34:40,728 for whatever reason, that right brain 593 00:34:41,455 --> 00:34:44,859 is not going to develop optimally. 594 00:34:45,342 --> 00:34:48,431 Those capacities for emotion regulation, 595 00:34:48,431 --> 00:34:52,383 for impulse control, for making sense of interpersonal 596 00:34:52,383 --> 00:34:57,383 contexts, becomes contaminated in some way, 597 00:34:57,923 --> 00:35:00,658 becomes compromised in some way. 598 00:35:01,679 --> 00:35:04,950 So at 18 months with this developed right brain 599 00:35:06,475 --> 00:35:09,994 there comes the development, the consequent development 600 00:35:09,994 --> 00:35:13,308 of the left brain, and with that, the consequent 601 00:35:13,308 --> 00:35:16,224 development of verbal acuity. 602 00:35:17,047 --> 00:35:20,069 If the right brain is malformed, 603 00:35:20,601 --> 00:35:24,543 or if it hasn't developed to its optimal capacity, 604 00:35:25,301 --> 00:35:29,089 then the left brain's verbal capacity 605 00:35:29,089 --> 00:35:34,089 to narrate experience is also compromised. 606 00:35:36,848 --> 00:35:40,637 So we often see, with our borderline patients, 607 00:35:41,269 --> 00:35:46,269 an incredible inability to find words for affects. 608 00:35:47,634 --> 00:35:50,976 That's linked to mentalization, as I've described. 609 00:35:52,236 --> 00:35:57,236 It's linked also to a verbal paucity, 610 00:35:57,578 --> 00:36:00,841 a paucity of vocabulary around feeling words 611 00:36:00,945 --> 00:36:02,427 and feeling states. 612 00:36:02,906 --> 00:36:07,150 I've so often had an experience of asking a patient 613 00:36:07,150 --> 00:36:09,248 what they're feeling, only to be faced 614 00:36:09,248 --> 00:36:11,146 with complete blankness. 615 00:36:12,769 --> 00:36:15,458 They can be having an affect storm in the room, 616 00:36:15,458 --> 00:36:18,530 tantrums and shouting, and I can say, 617 00:36:18,530 --> 00:36:20,093 "What are you feeling?" 618 00:36:21,101 --> 00:36:23,120 They might say, "Freaked out!" 619 00:36:23,588 --> 00:36:26,149 I say, "Freaked out is not a feeling word. 620 00:36:26,331 --> 00:36:28,237 "Can you give me a feeling word?" 621 00:36:29,057 --> 00:36:33,398 There's a complete stuckness and an inability 622 00:36:33,398 --> 00:36:38,398 to find a word that accurately corresponds. 623 00:36:38,640 --> 00:36:42,212 Can you see here, then, the complex intermarriage 624 00:36:42,212 --> 00:36:44,271 between the attachment theory, 625 00:36:45,076 --> 00:36:49,096 where this person has not been given an accurate 626 00:36:49,096 --> 00:36:51,523 affect representation from the caregiver, 627 00:36:52,181 --> 00:36:55,074 and simultaneously they have not developed 628 00:36:55,074 --> 00:36:59,045 the verbal acuity in their brain development 629 00:36:59,705 --> 00:37:03,651 to narrate an affect experience? 630 00:37:03,808 --> 00:37:07,398 So you have, I think, a very, very snug 631 00:37:08,171 --> 00:37:11,929 parallel relationship between attachment theory 632 00:37:11,929 --> 00:37:15,427 and neurobiology, which just makes the theory 633 00:37:15,427 --> 00:37:17,695 that much more compelling for me. 634 00:37:19,697 --> 00:37:21,771 It also helps me to think a little bit 635 00:37:21,771 --> 00:37:24,983 about what my job is in the room 636 00:37:25,105 --> 00:37:27,311 and a little bit about what might be happening 637 00:37:27,311 --> 00:37:31,272 neurobiologically between myself and the patient. 638 00:37:33,380 --> 00:37:35,145 Sometimes I like to... 639 00:37:35,145 --> 00:37:36,659 Well, it's not something I like to do 640 00:37:36,659 --> 00:37:39,128 but I find it necessary or important 641 00:37:39,128 --> 00:37:43,174 to remind myself that when I'm sitting 642 00:37:43,174 --> 00:37:44,841 with the most compromised 643 00:37:45,386 --> 00:37:49,193 of my disorders of the self patients, 644 00:37:50,380 --> 00:37:53,009 I am sitting with literal brain dysfunction. 645 00:37:55,208 --> 00:37:58,512 That helps me, sometimes, to manage the frustration 646 00:37:58,512 --> 00:38:01,781 that I feel, the impatience that I feel, 647 00:38:02,269 --> 00:38:05,982 when whatever I'm doing is just not working. 648 00:38:08,223 --> 00:38:12,001 What is fundamental for me to always recall 649 00:38:12,557 --> 00:38:15,084 when sitting in those situations, 650 00:38:15,084 --> 00:38:17,868 is that whatever that person is feeling right now 651 00:38:18,279 --> 00:38:20,530 is absolutely overwhelming for them, 652 00:38:20,990 --> 00:38:23,008 and what I am feeling doesn't even 653 00:38:23,008 --> 00:38:25,643 come close to their experience. 654 00:38:28,105 --> 00:38:32,564 I'd like to move, then, onto the second part of the lecture. 655 00:38:32,564 --> 00:38:37,087 I'd like to move on to thinking a bit about the practice 656 00:38:37,578 --> 00:38:41,223 of what we do with this knowledge about attachment 657 00:38:41,223 --> 00:38:44,353 and with this knowledge about neurobiology 658 00:38:44,464 --> 00:38:47,348 and about the importance of the relationship. 659 00:38:50,682 --> 00:38:54,314 When working with BPD, there are a few things 660 00:38:54,314 --> 00:38:56,861 that we have to take into account, 661 00:38:56,861 --> 00:38:58,432 that we have to take as a given, 662 00:38:59,717 --> 00:39:01,491 that we have to know is there. 663 00:39:01,491 --> 00:39:04,057 We have to know that there is always 664 00:39:04,057 --> 00:39:07,457 going to be extreme anxiety. 665 00:39:10,751 --> 00:39:11,800 We have to know that there is always 666 00:39:11,800 --> 00:39:14,977 going to be intense reactivity. 667 00:39:16,717 --> 00:39:18,680 There is going to be the capacity 668 00:39:19,300 --> 00:39:24,300 for very regressive disorganization. 669 00:39:27,052 --> 00:39:28,559 We have to know that there is the lack 670 00:39:28,559 --> 00:39:31,447 of self and object constancy. 671 00:39:33,702 --> 00:39:35,383 We have to know that there are fears 672 00:39:35,383 --> 00:39:38,967 that coexist with the longing for attachment. 673 00:39:40,150 --> 00:39:44,517 All of these are going to manifest themselves 674 00:39:45,097 --> 00:39:48,270 and permeate in the room, 675 00:39:49,253 --> 00:39:52,932 that anxiety, that reactivity, 676 00:39:52,932 --> 00:39:56,650 that incredible fragility and vulnerability 677 00:39:56,650 --> 00:40:00,059 to what's happening moment by moment in the room, 678 00:40:00,059 --> 00:40:03,137 the very, very rapid regression 679 00:40:03,137 --> 00:40:05,144 to a disorganized way of being, 680 00:40:06,737 --> 00:40:09,481 the fears of abandonment that come 681 00:40:09,481 --> 00:40:11,989 from lack of object constancy. 682 00:40:15,176 --> 00:40:17,395 I'm just pausing because I'm actually thinking 683 00:40:17,395 --> 00:40:20,088 about a conversation I had before I took 684 00:40:20,088 --> 00:40:23,118 the break to teach this summer, 685 00:40:23,118 --> 00:40:26,576 and was saying goodbye to one of my very, very 686 00:40:26,576 --> 00:40:29,399 longstanding patients who is significantly 687 00:40:29,399 --> 00:40:31,632 borderline in her presentation, 688 00:40:32,013 --> 00:40:34,437 and as she walked out the door her looking back at me 689 00:40:34,437 --> 00:40:37,957 and saying to me, "What happens if you don't come back?" 690 00:40:38,517 --> 00:40:41,209 and being reminded in that moment of, 691 00:40:41,512 --> 00:40:44,221 in spite of all of the evidence that I always come back, 692 00:40:44,594 --> 00:40:47,177 and in spite of all of the evidence of a long history 693 00:40:47,177 --> 00:40:50,000 of a relationship between the two of us, 694 00:40:50,299 --> 00:40:54,716 she still can't know the constancy 695 00:40:54,716 --> 00:40:56,920 of our relationship. 696 00:40:57,465 --> 00:41:01,070 So lack of object constancy is going to bring up 697 00:41:01,070 --> 00:41:03,710 all sorts of abandonment fears, 698 00:41:04,389 --> 00:41:09,370 all sorts of fears of being left, of being rejected, 699 00:41:09,932 --> 00:41:12,766 during times of absence, during breaks. 700 00:41:13,094 --> 00:41:15,873 In fact, at the end of every session, 701 00:41:15,873 --> 00:41:19,656 there is the possibility of an abandonment fear 702 00:41:20,145 --> 00:41:23,386 because the connection is coming to an end. 703 00:41:23,666 --> 00:41:26,077 For many people, holding onto the connection 704 00:41:26,077 --> 00:41:29,940 between sessions becomes incredibly difficult. 705 00:41:30,626 --> 00:41:34,001 It's almost as if, when you walk into the room 706 00:41:34,135 --> 00:41:36,490 and you sit down with your patient, 707 00:41:36,924 --> 00:41:38,742 these factors have to be something 708 00:41:38,742 --> 00:41:42,050 that is in your mind all of the time, 709 00:41:42,625 --> 00:41:44,818 knowing that it's there. 710 00:41:47,166 --> 00:41:50,712 In order to mediate that, part of what we have to do 711 00:41:50,712 --> 00:41:55,526 is to offer a therapeutic context that includes 712 00:41:55,526 --> 00:42:00,405 clear limits and structure, consistency, 713 00:42:00,947 --> 00:42:04,563 and even at times possible contracting around behavior. 714 00:42:04,563 --> 00:42:07,529 Of course, we know that Kernberg was one of the people 715 00:42:07,529 --> 00:42:10,665 who really advocated 716 00:42:10,665 --> 00:42:13,939 for acting out contracts, 717 00:42:13,939 --> 00:42:15,601 contracts around acting out behavior, 718 00:42:15,601 --> 00:42:20,154 around suicidal gestures, whereby he would, 719 00:42:20,154 --> 00:42:23,077 and he does still, as far as I know, 720 00:42:23,077 --> 00:42:27,935 put in place contracts which state that if the patient 721 00:42:27,935 --> 00:42:30,468 acts out in a particular way or does a particular thing, 722 00:42:30,468 --> 00:42:33,270 there will be treatment repercussions. 723 00:42:33,628 --> 00:42:36,563 Many people found this punitive or disastrous 724 00:42:36,563 --> 00:42:38,475 in terms of building up trust, 725 00:42:38,475 --> 00:42:40,686 but, in fact, what he is doing, 726 00:42:40,686 --> 00:42:44,161 and what we are creating by contracting in that way, 727 00:42:44,269 --> 00:42:47,217 is a set of limits which can create 728 00:42:47,217 --> 00:42:49,445 an experience of safety. 729 00:42:51,116 --> 00:42:53,495 This is often difficult to do 730 00:42:53,701 --> 00:42:57,431 because this kind of individual as a patient 731 00:42:57,699 --> 00:42:59,893 is also going to be the kind of individual 732 00:42:59,893 --> 00:43:02,584 who is going to ask for intercession contact, 733 00:43:02,584 --> 00:43:05,669 who's going to email or phone or message you 734 00:43:05,669 --> 00:43:07,640 or ask for extended sessions 735 00:43:07,640 --> 00:43:09,531 or not be able to end sessions 736 00:43:09,881 --> 00:43:11,981 or act out in all sorts of ways 737 00:43:11,981 --> 00:43:15,552 around the limits of a therapeutic relationship. 738 00:43:16,998 --> 00:43:21,074 If you're empathically attuned to the vulnerability, 739 00:43:21,074 --> 00:43:23,966 or if you are role responsively drawn into 740 00:43:23,966 --> 00:43:27,147 an enactment of a particular kind, 741 00:43:27,147 --> 00:43:31,239 it may be very, very tempting to succumb 742 00:43:31,673 --> 00:43:33,625 to the needs of this person 743 00:43:33,625 --> 00:43:36,442 and to give them what it appears that they need, 744 00:43:36,442 --> 00:43:38,993 which is your constant attention 745 00:43:38,993 --> 00:43:42,247 and your ever availability, 746 00:43:42,342 --> 00:43:46,244 but, in fact, what that does is it increases anxiety 747 00:43:46,874 --> 00:43:50,363 and it increases the potential for regression 748 00:43:50,834 --> 00:43:53,427 and for fears around abandonment. 749 00:43:54,038 --> 00:43:58,586 So, always stick to what we know about the frame 750 00:43:58,586 --> 00:44:01,268 and about the boundaries through clear limits 751 00:44:01,268 --> 00:44:04,195 and structures and consistency. 752 00:44:04,718 --> 00:44:08,394 That includes clear 753 00:44:09,009 --> 00:44:12,070 and advanced warning of breaks, 754 00:44:12,070 --> 00:44:15,747 of vacations, of holidays that are being taken, 755 00:44:15,747 --> 00:44:20,048 so that that can be anticipated and worked with. 756 00:44:22,038 --> 00:44:27,038 As a therapist, we need to be a real person. 757 00:44:28,583 --> 00:44:30,697 Working in the classically analytic way, 758 00:44:30,697 --> 00:44:33,117 on the couch or with long silences, 759 00:44:33,117 --> 00:44:35,302 with absolute neutrality, which of course we know 760 00:44:35,302 --> 00:44:39,636 is not possible, but more neutral than usual, 761 00:44:40,736 --> 00:44:44,394 that will only be experienced as persecutory 762 00:44:44,894 --> 00:44:48,687 and it will only evoke intense anxiety, 763 00:44:48,950 --> 00:44:50,453 and that is not something 764 00:44:50,453 --> 00:44:53,210 that we want to give to our patients. 765 00:44:53,488 --> 00:44:56,455 So we need to be real in the room. 766 00:44:57,568 --> 00:45:00,532 We need to be authentic in the room. 767 00:45:02,479 --> 00:45:07,082 We need to have, for our patients, a genuine devotion. 768 00:45:07,591 --> 00:45:11,357 That doesn't mean that we like them all the time, 769 00:45:11,905 --> 00:45:13,601 that we love them all the time. 770 00:45:13,601 --> 00:45:15,432 In fact, it's almost inevitable that there are 771 00:45:15,432 --> 00:45:16,958 going to be times when we dislike them 772 00:45:16,958 --> 00:45:18,385 or even hate them, 773 00:45:18,901 --> 00:45:22,002 but we need to feel a genuine devotion 774 00:45:22,400 --> 00:45:25,045 to their treatment and to their care, 775 00:45:25,045 --> 00:45:27,322 and not because that's part of our job 776 00:45:27,322 --> 00:45:31,243 as a clinician is to be devoted to people. 777 00:45:31,807 --> 00:45:34,432 It's because this particular patient 778 00:45:34,432 --> 00:45:38,273 is going to very quickly know 779 00:45:38,838 --> 00:45:43,552 whether you are authentic in your clinical attempts 780 00:45:44,109 --> 00:45:48,055 or whether you are holding back in some way. 781 00:45:49,379 --> 00:45:51,168 So there needs to be some kind of authentic 782 00:45:51,168 --> 00:45:53,072 and genuine devotion. 783 00:45:54,664 --> 00:45:58,063 Borderline patients are incredibly and exquisitely 784 00:45:58,063 --> 00:46:01,743 sensitive to shifts in affect of tone. 785 00:46:02,542 --> 00:46:05,045 If you are slightly off, perhaps you're having a bad day, 786 00:46:05,045 --> 00:46:07,226 perhaps you're going through some of your own life trauma, 787 00:46:07,917 --> 00:46:10,786 and it comes through in any way in your tone, 788 00:46:10,786 --> 00:46:12,724 in your manner, in your body language, 789 00:46:12,724 --> 00:46:16,324 in your gestures, the borderline patient will pick that up. 790 00:46:16,324 --> 00:46:18,868 That's not to say that we can never bring 791 00:46:18,868 --> 00:46:19,957 that into the room. 792 00:46:19,957 --> 00:46:21,011 Of course, we're human. 793 00:46:21,011 --> 00:46:23,329 How can we not bring that into the room? 794 00:46:23,682 --> 00:46:25,532 But it is about understanding 795 00:46:25,764 --> 00:46:27,591 that when the patient responds to us 796 00:46:27,591 --> 00:46:29,335 we need to somehow authentically be able 797 00:46:29,335 --> 00:46:33,854 to respond in return, and to understand 798 00:46:34,006 --> 00:46:37,209 the impact that that can have 799 00:46:37,654 --> 00:46:40,218 on their experience of the relationship. 800 00:46:41,471 --> 00:46:43,910 We need to remember that they are easily terrified 801 00:46:43,910 --> 00:46:48,068 that they will be criticized or abandoned or humiliated, 802 00:46:48,642 --> 00:46:53,118 that there's always the threat of that happening. 803 00:46:55,345 --> 00:46:57,208 A note about the transference. 804 00:46:58,616 --> 00:47:00,800 In my opinion and in my experience, 805 00:47:00,800 --> 00:47:04,234 it is absolutely not helpful to work with transference 806 00:47:04,234 --> 00:47:06,456 in the classical analytic way, 807 00:47:06,813 --> 00:47:08,841 in other words, to make historical links 808 00:47:08,841 --> 00:47:11,525 with early object relationships. 809 00:47:12,091 --> 00:47:16,084 Rather, to work with transference in the here and now, 810 00:47:16,084 --> 00:47:18,021 in other words, to work with the relationship 811 00:47:18,021 --> 00:47:21,526 in the room as it unfolds and as it develops 812 00:47:21,914 --> 00:47:24,538 in a much more present way. 813 00:47:25,174 --> 00:47:27,842 This is because for the borderline patient 814 00:47:27,842 --> 00:47:31,005 transference is very seldom experienced 815 00:47:31,005 --> 00:47:32,683 in an "as if" way. 816 00:47:33,904 --> 00:47:37,188 For example, for a more neurotic patient, 817 00:47:37,188 --> 00:47:38,717 she might say to you in the session, 818 00:47:38,717 --> 00:47:40,274 "You're just like my mother! 819 00:47:40,274 --> 00:47:42,338 "How can you be doing this to me?" 820 00:47:42,338 --> 00:47:43,872 At the end of the session she gets up 821 00:47:43,872 --> 00:47:45,373 and she turns to you and says, 822 00:47:45,373 --> 00:47:46,957 "Thank you very much, I'll see you next week." 823 00:47:46,957 --> 00:47:48,483 She's left the transference in the room, 824 00:47:48,483 --> 00:47:50,621 because on some level there's an understanding 825 00:47:50,621 --> 00:47:52,286 that you are not her mother, 826 00:47:52,755 --> 00:47:55,209 but that this is something about this interaction 827 00:47:55,209 --> 00:47:57,614 in this room and she's leaving it here. 828 00:47:57,614 --> 00:47:59,142 Whereas for the borderline patient, 829 00:47:59,142 --> 00:48:03,691 you are her mother, so if you say, 830 00:48:04,790 --> 00:48:06,437 "You're responding to me like I'm you're mother" 831 00:48:06,437 --> 00:48:07,840 she's going to say, "Yes, isn't it terrible 832 00:48:07,840 --> 00:48:10,211 "that I've found a therapist who is my mother?" 833 00:48:10,967 --> 00:48:13,508 There isn't that "as if," stepping back, 834 00:48:13,508 --> 00:48:17,290 self-observing quality that is necessary 835 00:48:17,290 --> 00:48:20,749 to be able to work more classically in the transference. 836 00:48:22,493 --> 00:48:25,101 The therapeutic approach needs to be structured 837 00:48:25,101 --> 00:48:29,778 and active and affectively expressive. 838 00:48:31,221 --> 00:48:33,818 Expressing affect is cornerstone. 839 00:48:35,612 --> 00:48:38,676 What are some of the treatment strategies 840 00:48:38,676 --> 00:48:39,936 that we're going to use coming from 841 00:48:39,936 --> 00:48:42,642 this more attachment-based approach? 842 00:48:43,348 --> 00:48:45,889 The overall and rather, I think at times, 843 00:48:45,889 --> 00:48:50,679 grandiose goal is to stabilize the self-structure 844 00:48:51,774 --> 00:48:55,720 through the development of stable internal representations, 845 00:48:55,720 --> 00:48:58,731 so really to give an experience, ultimately, 846 00:48:58,731 --> 00:49:02,090 of internalizing representations of the self 847 00:49:02,090 --> 00:49:05,035 that are accurate and stable, 848 00:49:05,779 --> 00:49:10,361 and in this way, being able to stabilize the self. 849 00:49:11,941 --> 00:49:14,926 We aim to work towards the formation 850 00:49:14,926 --> 00:49:16,814 of a coherent sense of self, 851 00:49:16,814 --> 00:49:19,117 who am I in the world, 852 00:49:19,117 --> 00:49:22,004 and the capacity to form secure relationships. 853 00:49:22,908 --> 00:49:26,114 But if we look at the hierarchy of therapeutic 854 00:49:26,114 --> 00:49:30,308 and treatment goals, this overarching goal 855 00:49:30,308 --> 00:49:33,357 may well feel like it's completely out of reach 856 00:49:34,092 --> 00:49:37,427 and so we need to break it down 857 00:49:37,980 --> 00:49:39,493 and look at particular strategies 858 00:49:39,493 --> 00:49:41,222 that we can use moment by moment, 859 00:49:41,222 --> 00:49:44,868 session to session, sometimes for years upon years 860 00:49:44,868 --> 00:49:47,591 when working with severely 861 00:49:47,989 --> 00:49:51,712 personality compromised patients. 862 00:49:53,329 --> 00:49:57,735 At the outset, there needs to be a clarity of purpose 863 00:49:57,735 --> 00:50:00,682 and of therapeutic expectations. 864 00:50:02,014 --> 00:50:04,705 Very, very often somebody who sits with BPD 865 00:50:04,705 --> 00:50:08,724 will judge the motivation of others based on outcomes. 866 00:50:09,761 --> 00:50:13,337 So if at the outset we can agree on a set 867 00:50:13,337 --> 00:50:15,885 of expectations around the therapy, 868 00:50:15,885 --> 00:50:18,138 then that is very containing, 869 00:50:18,887 --> 00:50:22,082 it's very safety inducing. 870 00:50:24,050 --> 00:50:27,541 The way in which you decide to work with this person 871 00:50:28,741 --> 00:50:31,407 needs to be based on an understanding 872 00:50:32,063 --> 00:50:34,155 of how this particular patient 873 00:50:34,155 --> 00:50:36,039 is stabilizing their self-structure. 874 00:50:36,039 --> 00:50:37,939 In other words, are they stabilizing 875 00:50:37,939 --> 00:50:40,499 their self-structure through somatizing? 876 00:50:41,269 --> 00:50:43,014 Are they stabilizing their self-structure 877 00:50:43,014 --> 00:50:44,760 through violent acting out against 878 00:50:44,760 --> 00:50:46,558 somebody in their life? 879 00:50:46,558 --> 00:50:49,242 Are they doing it through self-mutilation 880 00:50:49,242 --> 00:50:50,712 or suicidal gesture? 881 00:50:50,712 --> 00:50:52,973 Are they doing it through substance abuse? 882 00:50:53,690 --> 00:50:57,893 What are the particular manifestations 883 00:50:58,637 --> 00:51:02,371 of the stabilization techniques for this particular person? 884 00:51:03,743 --> 00:51:07,595 In understanding that, you then need to fashion 885 00:51:07,595 --> 00:51:10,005 your interpretations and your interventions, 886 00:51:11,054 --> 00:51:14,332 which are then relevant to that. 887 00:51:16,597 --> 00:51:21,597 Mental closeness is an absolute prerequisite. 888 00:51:23,056 --> 00:51:26,129 In other words, you need to be present 889 00:51:26,619 --> 00:51:29,372 in the room as much as you can be. 890 00:51:30,174 --> 00:51:34,655 You need to offer mirroring that is contingent 891 00:51:35,419 --> 00:51:37,963 and marked, that is accurate 892 00:51:39,889 --> 00:51:43,579 and which shows that you're communicating 893 00:51:43,579 --> 00:51:46,554 the internal experience of the patient. 894 00:51:50,689 --> 00:51:53,150 The task, really, is to find a way 895 00:51:53,150 --> 00:51:57,566 to mirror and to shadow the patient's mind 896 00:51:57,566 --> 00:52:00,907 in such a way that it creates 897 00:52:00,907 --> 00:52:03,909 an experience of proximal safety. 898 00:52:07,402 --> 00:52:09,926 It's important to make interpretations 899 00:52:09,926 --> 00:52:13,009 and interventions based in the here and the now. 900 00:52:15,406 --> 00:52:18,814 Sometimes they need to be concrete 901 00:52:18,814 --> 00:52:22,031 in order to move towards a more symbolic way 902 00:52:22,800 --> 00:52:26,754 of making interpretations or interventions. 903 00:52:29,621 --> 00:52:33,187 Working with a BPD, we absolutely have to be able 904 00:52:33,187 --> 00:52:36,716 to accept becoming, at times, aspects 905 00:52:36,716 --> 00:52:39,160 of the alien self if necessary. 906 00:52:39,160 --> 00:52:41,291 In other words, we have to be able to accept 907 00:52:41,291 --> 00:52:43,908 that we will experience, at times, 908 00:52:44,254 --> 00:52:46,399 what it feels like to be the patient, 909 00:52:46,845 --> 00:52:48,163 that their internal experience 910 00:52:48,163 --> 00:52:50,767 will be projected onto us and into us, 911 00:52:50,767 --> 00:52:54,406 and that we will be asked to hold and to bear, 912 00:52:54,683 --> 00:52:56,912 the experience for and with them. 913 00:52:57,416 --> 00:53:00,529 That is part of the job that we do. 914 00:53:03,322 --> 00:53:06,519 I want to talk in more detail about 915 00:53:07,339 --> 00:53:09,762 the identification of affects. 916 00:53:10,509 --> 00:53:13,516 Even though affect dysregulation is a symptom 917 00:53:13,740 --> 00:53:16,187 of a deeper underlying deficit, 918 00:53:16,187 --> 00:53:18,531 the deficit around mentalization, 919 00:53:19,113 --> 00:53:22,319 because affect storms disrupt treatment, 920 00:53:22,840 --> 00:53:24,825 we do need to work with our patients 921 00:53:24,825 --> 00:53:27,922 towards achieving affect control. 922 00:53:29,883 --> 00:53:31,762 Firstly, we need to make sure that we present 923 00:53:31,762 --> 00:53:34,467 a context that is safe and non-punitive. 924 00:53:35,996 --> 00:53:38,541 Then we need to help the patient 925 00:53:38,961 --> 00:53:43,279 develop a vocabulary around affects, 926 00:53:44,164 --> 00:53:46,465 to develop a vocabulary which then allows them 927 00:53:46,465 --> 00:53:49,627 to start saying things like, "I feel" 928 00:53:51,181 --> 00:53:55,369 and then to link that feeling with the cause. 929 00:53:55,846 --> 00:53:58,367 I feel because... 930 00:53:59,050 --> 00:54:03,081 So how can we start to link feeling, 931 00:54:03,081 --> 00:54:05,657 or affect, with experience? 932 00:54:06,609 --> 00:54:11,190 How can we start to identify the precipitance 933 00:54:11,663 --> 00:54:15,672 of affect storms or affect outbursts? 934 00:54:18,150 --> 00:54:21,277 We need to clarify and name feelings. 935 00:54:21,477 --> 00:54:25,334 We need to give words when words are absent. 936 00:54:26,489 --> 00:54:29,998 We need to help our patients to be able to understand 937 00:54:29,998 --> 00:54:33,321 the sequence of events that leads them 938 00:54:33,726 --> 00:54:36,622 to feeling emotionally out of control. 939 00:54:37,540 --> 00:54:39,532 Then we need to be able to help them understand 940 00:54:39,532 --> 00:54:43,388 how the sequence of events may well be 941 00:54:43,388 --> 00:54:47,169 a replication of other relationships, 942 00:54:47,619 --> 00:54:49,932 so if this is how you are being with me 943 00:54:50,317 --> 00:54:53,300 when you get angry with me or upset with me, 944 00:54:53,796 --> 00:54:57,770 or when I do something that feels dangerous to you, 945 00:54:58,244 --> 00:55:00,613 is this also, then, the way that you feel 946 00:55:00,613 --> 00:55:03,825 when your partner does something similar, 947 00:55:03,956 --> 00:55:07,714 or when your child does something similar? 948 00:55:08,697 --> 00:55:11,755 To broaden the impact of the intervention 949 00:55:11,755 --> 00:55:13,927 beyond the therapeutic context. 950 00:55:18,465 --> 00:55:20,715 The way that I think about therapy 951 00:55:21,149 --> 00:55:22,952 in the borderline realm 952 00:55:24,554 --> 00:55:26,615 is that I like to think about it as a constant 953 00:55:26,615 --> 00:55:28,765 and ongoing act of translation. 954 00:55:29,954 --> 00:55:33,382 We are called upon to be interpreters 955 00:55:33,464 --> 00:55:35,979 of the internal world of the other, 956 00:55:36,315 --> 00:55:38,728 and to translate into meaningful language 957 00:55:39,271 --> 00:55:42,590 an experience for them which previously has been 958 00:55:42,590 --> 00:55:46,751 beyond translation and beyond understanding. 959 00:55:47,560 --> 00:55:52,560 Identifying affects is a core, core, core task of this work. 960 00:55:54,340 --> 00:55:56,627 Enhancing mentalization. 961 00:55:57,551 --> 00:56:02,407 As a therapist, we must maintain a mentalizing stance. 962 00:56:02,677 --> 00:56:06,294 In other words, we need to be constantly questioning 963 00:56:06,294 --> 00:56:11,294 and asking ourselves what internal states in you 964 00:56:11,983 --> 00:56:15,154 and in me can explain what is happening now, 965 00:56:15,720 --> 00:56:19,741 so that we can start to link external events 966 00:56:19,741 --> 00:56:21,555 with internal experiences. 967 00:56:21,907 --> 00:56:24,442 At any given moment in a session, 968 00:56:24,442 --> 00:56:27,612 we need to be aware of our ongoing narrative 969 00:56:27,848 --> 00:56:30,975 of our internal process, as well as of what might 970 00:56:30,975 --> 00:56:33,676 be going on internally for the patient, 971 00:56:33,676 --> 00:56:35,812 and then to surface that, 972 00:56:35,812 --> 00:56:40,642 so that effectively we begin to model mentalization, 973 00:56:40,642 --> 00:56:44,465 we begin to show what it's like to mentalize 974 00:56:44,465 --> 00:56:48,206 even though we mostly do it in our ordinary lives 975 00:56:48,206 --> 00:56:50,694 in a more implicit kind of way. 976 00:56:52,036 --> 00:56:54,343 Modeling mentalization in this way 977 00:56:54,856 --> 00:56:56,714 and talking about what's happening 978 00:56:56,714 --> 00:56:59,146 in you and in me and between us, 979 00:57:00,189 --> 00:57:03,913 then allows for the development of a particular language 980 00:57:04,554 --> 00:57:09,129 between patient and therapist whereby we can begin 981 00:57:09,129 --> 00:57:12,662 to start to communicate with one another 982 00:57:12,983 --> 00:57:15,307 in a very, very particular way, 983 00:57:16,160 --> 00:57:20,529 and we can start to learn the kind of words 984 00:57:20,529 --> 00:57:24,603 that make sense in this particular context. 985 00:57:25,922 --> 00:57:30,062 Modeling mentalization is about being articulate 986 00:57:30,766 --> 00:57:35,089 about the internal narrative of self and other. 987 00:57:41,967 --> 00:57:43,931 I've spoke a little bit already 988 00:57:43,931 --> 00:57:45,896 about the countertransference, 989 00:57:46,764 --> 00:57:48,482 but I want to mention it again 990 00:57:48,482 --> 00:57:51,378 because countertransference can be incredibly 991 00:57:51,378 --> 00:57:54,658 useful and important as a tool for understanding 992 00:57:54,658 --> 00:57:57,227 what is happening for our patients. 993 00:57:57,779 --> 00:57:59,617 I want to translate countertransference 994 00:57:59,617 --> 00:58:01,456 in this particular context 995 00:58:01,456 --> 00:58:03,700 into projective identification. 996 00:58:03,700 --> 00:58:06,337 Obviously, not everything that we feel 997 00:58:06,337 --> 00:58:08,298 is going to be projective identification. 998 00:58:08,298 --> 00:58:09,751 Part of what we feel is going to be 999 00:58:09,751 --> 00:58:11,627 our own role responsiveness. 1000 00:58:11,627 --> 00:58:14,250 Part of it is going to be our own woundedness, 1001 00:58:14,250 --> 00:58:16,075 our own trauma, our own history, 1002 00:58:16,075 --> 00:58:17,936 our own currency and everything else 1003 00:58:17,936 --> 00:58:19,190 that's going on with us, 1004 00:58:19,190 --> 00:58:21,696 and we know that about countertransference. 1005 00:58:21,696 --> 00:58:24,814 But a great deal of what we're feeling in the room 1006 00:58:24,814 --> 00:58:27,171 is going to be projective identification, 1007 00:58:27,171 --> 00:58:28,846 and it's going to be projection. 1008 00:58:30,077 --> 00:58:34,938 Always have a vigilant eye around that in trying 1009 00:58:34,938 --> 00:58:38,358 to make sense of how this is communicating 1010 00:58:38,358 --> 00:58:40,450 a significant aspect of experience 1011 00:58:40,450 --> 00:58:42,845 from the patient to ourselves. 1012 00:58:45,086 --> 00:58:48,313 It's incredibly important when working 1013 00:58:48,313 --> 00:58:53,313 with a borderline patient to bear in mind the deficits. 1014 00:58:56,207 --> 00:58:59,485 I have worked with many people who have been hospitalized, 1015 00:58:59,485 --> 00:59:01,870 who have been hospitalized repetitively, 1016 00:59:01,870 --> 00:59:06,829 who have long histories of suicidality 1017 00:59:06,829 --> 00:59:11,290 and self harm, who bear all the literal scars 1018 00:59:11,449 --> 00:59:13,858 of a borderline personality disorder. 1019 00:59:14,277 --> 00:59:16,558 But then I have worked with people who, 1020 00:59:16,558 --> 00:59:21,558 upon meeting them, are articulate and insightful 1021 00:59:22,190 --> 00:59:26,019 and intelligent and functional in the world. 1022 00:59:26,919 --> 00:59:30,243 It's very, very easy for those people, 1023 00:59:30,243 --> 00:59:34,681 with those people, to forget the underlying deficit. 1024 00:59:35,977 --> 00:59:37,774 For many of those particular people, 1025 00:59:37,774 --> 00:59:42,772 the underlying deficit becomes activated 1026 00:59:43,360 --> 00:59:45,495 in the context of relationships 1027 00:59:45,495 --> 00:59:48,945 where suddenly they become concrete 1028 00:59:49,776 --> 00:59:53,426 and impoverished in the intellect and in the insight 1029 00:59:53,426 --> 00:59:55,382 in relation to themselves and others 1030 00:59:55,382 --> 00:59:59,304 because being in a relationship has undone them. 1031 01:00:00,297 --> 01:00:04,101 It is the recipe for the disorganization 1032 01:00:04,101 --> 01:00:06,798 of the early attachment context. 1033 01:00:07,380 --> 01:00:09,738 Once you know that somebody falls within 1034 01:00:09,738 --> 01:00:12,835 the borderline organization spectrum, 1035 01:00:13,284 --> 01:00:15,133 don't take your eye off the ball. 1036 01:00:15,605 --> 01:00:19,875 Bear in mind the deficits and remember 1037 01:00:20,678 --> 01:00:25,441 that intellectualism and verbal acuity 1038 01:00:27,135 --> 01:00:30,748 does not equate to the capacity to mentalize 1039 01:00:31,351 --> 01:00:33,468 and to be aware of that. 1040 01:00:34,350 --> 01:00:37,263 Similar to bearing in mind the deficits 1041 01:00:37,960 --> 01:00:39,644 is the importance of the keeping in mind 1042 01:00:39,644 --> 01:00:43,006 the possibility at all times of the worst 1043 01:00:43,006 --> 01:00:47,551 outcome of self-harm or self-destructive behavior. 1044 01:00:49,247 --> 01:00:51,141 I learned this the hard way 1045 01:00:51,141 --> 01:00:53,420 when I lost a patient to suicide. 1046 01:00:54,388 --> 01:00:58,368 It was an invaluable lesson for me 1047 01:00:58,888 --> 01:01:01,782 and remains an invaluable reminder 1048 01:01:02,542 --> 01:01:06,174 of how somebody can move from a place 1049 01:01:06,174 --> 01:01:09,356 of seeming to be fairly balanced 1050 01:01:09,356 --> 01:01:14,326 and fairly stable to taking their own life 1051 01:01:15,542 --> 01:01:19,095 from a place of impulsivity and disorganization, 1052 01:01:19,095 --> 01:01:22,798 in response to an external precipitant. 1053 01:01:22,798 --> 01:01:25,246 We are working with a population 1054 01:01:25,246 --> 01:01:29,232 of individuals who face despair in a way 1055 01:01:29,246 --> 01:01:31,310 that is incomprehensible to many people, 1056 01:01:31,946 --> 01:01:34,757 and who sometimes will step over the edge 1057 01:01:34,757 --> 01:01:36,907 and will do so successfully. 1058 01:01:38,101 --> 01:01:41,668 Always bear in mind the possibility 1059 01:01:41,668 --> 01:01:43,914 of acting out in that kind of way. 1060 01:01:44,541 --> 01:01:47,554 On that note, I suppose in your own mind 1061 01:01:47,554 --> 01:01:49,978 to establish a therapeutic hierarchy. 1062 01:01:49,978 --> 01:01:52,986 As I said earlier, we're finally aiming 1063 01:01:52,986 --> 01:01:55,696 to create a coherent sense of self based 1064 01:01:55,696 --> 01:01:58,513 on accurate self representations, et cetera, et cetera. 1065 01:01:58,943 --> 01:02:02,459 But for each person the priority in the treatment 1066 01:02:02,459 --> 01:02:03,974 is going to be different. 1067 01:02:04,233 --> 01:02:07,988 For some people, it is about keeping them alive. 1068 01:02:09,006 --> 01:02:11,392 For other people, it is about helping them 1069 01:02:11,392 --> 01:02:13,273 to survive their relationships. 1070 01:02:13,826 --> 01:02:15,181 For other people, it's about helping them 1071 01:02:15,181 --> 01:02:18,056 to adequately parent their children. 1072 01:02:18,673 --> 01:02:21,234 But always bear in mind what your primary 1073 01:02:21,234 --> 01:02:26,234 priority is for this particular intervention. 1074 01:02:28,968 --> 01:02:33,968 Always hold in mind the role that we play 1075 01:02:35,026 --> 01:02:39,031 for these people fundamentally in their development. 1076 01:02:40,025 --> 01:02:42,870 Part of the role that we play is the role 1077 01:02:42,870 --> 01:02:44,770 of maternal container. 1078 01:02:45,675 --> 01:02:48,206 Elizabeth Meins described the notion 1079 01:02:48,206 --> 01:02:51,157 of maternal mind-mindedness, 1080 01:02:52,543 --> 01:02:55,979 which is the way she described the way in which 1081 01:02:56,009 --> 01:02:59,680 mothers respond to their infants 1082 01:02:59,680 --> 01:03:02,171 when using mental state language. 1083 01:03:03,259 --> 01:03:05,808 Through being a maternal container, 1084 01:03:06,285 --> 01:03:10,180 and through maternal mind-mindedness, 1085 01:03:10,180 --> 01:03:12,764 we are essentially an interpreter 1086 01:03:12,764 --> 01:03:16,091 of the mental states of our patients. 1087 01:03:17,528 --> 01:03:19,733 Remember that the value of therapy 1088 01:03:19,733 --> 01:03:23,863 for the borderline patient is in the experience 1089 01:03:23,863 --> 01:03:28,294 of another mind which has their mind in mind 1090 01:03:29,538 --> 01:03:34,523 in a compassionate, thoughtful, mentalizing way. 1091 01:03:36,494 --> 01:03:38,511 For many of these patients, 1092 01:03:39,195 --> 01:03:42,037 that is a new experience. 1093 01:03:42,037 --> 01:03:44,904 It's something that they've not experienced before. 1094 01:03:45,684 --> 01:03:47,623 They have never had somebody hold them 1095 01:03:47,623 --> 01:03:50,176 in mind quite in that way. 1096 01:03:50,176 --> 01:03:53,764 They haven't had somebody try to fathom 1097 01:03:53,764 --> 01:03:56,897 what is happening for them internally. 1098 01:03:57,892 --> 01:04:01,228 For them, this relationship with you 1099 01:04:02,402 --> 01:04:05,381 as their clinician and as their therapist, 1100 01:04:05,381 --> 01:04:10,381 becomes their first experience of being held in mind. 1101 01:04:13,942 --> 01:04:16,942 As clinicians when working with the borderline 1102 01:04:16,942 --> 01:04:19,289 personality disordered patients, 1103 01:04:19,563 --> 01:04:24,563 we don't only offer warmth and containment 1104 01:04:24,969 --> 01:04:29,702 and compassion, we also offer a thinking space. 1105 01:04:30,648 --> 01:04:32,999 In fact, I quite often start off my therapies 1106 01:04:32,999 --> 01:04:35,428 by saying to new patients, 1107 01:04:35,535 --> 01:04:38,976 "I'm offering you a space to think about yourself." 1108 01:04:39,575 --> 01:04:43,471 To many people that might seem almost simple. 1109 01:04:43,471 --> 01:04:45,704 Think about myself. 1110 01:04:45,704 --> 01:04:49,231 But for many people, thinking is a task 1111 01:04:49,231 --> 01:04:52,833 which they have not yet accomplished, 1112 01:04:52,833 --> 01:04:55,861 and it's a task which can be accomplished 1113 01:04:55,861 --> 01:04:58,689 through the therapeutic relationship. 1114 01:04:59,438 --> 01:05:04,438 Once again, for me the most comforting 1115 01:05:04,936 --> 01:05:07,820 and certainly exciting aspect of current 1116 01:05:07,820 --> 01:05:12,820 neurobiological theory is around the suggestion 1117 01:05:13,282 --> 01:05:16,061 or the evidence that brain functioning 1118 01:05:16,061 --> 01:05:20,445 can be literally shifted through an attachment 1119 01:05:20,445 --> 01:05:22,709 relationship or an attachment context, 1120 01:05:22,709 --> 01:05:24,933 which means we may well have somebody 1121 01:05:24,933 --> 01:05:27,034 who starts the therapeutic journey with us 1122 01:05:27,034 --> 01:05:29,734 with a relative degree of brain dysfunction 1123 01:05:30,178 --> 01:05:33,447 because of an impaired early attachment context. 1124 01:05:33,790 --> 01:05:36,945 But through our maternal mind-mindedness, 1125 01:05:37,164 --> 01:05:39,178 and through the thinking space which we offer 1126 01:05:39,178 --> 01:05:42,490 and which we create, there is the potential 1127 01:05:43,118 --> 01:05:48,118 to correct, to heal, the neurobiological deficit 1128 01:05:49,006 --> 01:05:51,589 which was there initially. 1129 01:05:54,266 --> 01:05:57,629 Now I want to make one final point before I end. 1130 01:06:00,269 --> 01:06:04,097 It is so easy to lose ourselves in this kind 1131 01:06:04,097 --> 01:06:07,105 of a therapeutic context precisely because we are dealing 1132 01:06:07,105 --> 01:06:10,794 with primitive states and primitive feelings, 1133 01:06:10,794 --> 01:06:13,779 all of which we, ourselves, have experienced 1134 01:06:13,779 --> 01:06:17,329 and do experience at different times in our lives. 1135 01:06:18,309 --> 01:06:21,339 There is always the invitation, the pull, 1136 01:06:21,580 --> 01:06:26,351 to regress, to collude, to act out, to join, 1137 01:06:27,010 --> 01:06:30,876 to lose, in a disorganized way, our own bearings, 1138 01:06:31,561 --> 01:06:35,389 which is why when working with the borderline patient, 1139 01:06:36,314 --> 01:06:40,045 just as they need a mind to hold them in mind, 1140 01:06:40,278 --> 01:06:42,447 so we, as the clinician, need a mind 1141 01:06:42,447 --> 01:06:46,253 to hold us in mind, which is why supervision 1142 01:06:46,253 --> 01:06:50,805 or consultation is absolutely essential 1143 01:06:51,531 --> 01:06:55,919 if you choose to work with this particular population. 1144 01:06:55,919 --> 01:06:59,615 We need a space in which we can have our own 1145 01:06:59,615 --> 01:07:03,021 internal processes and our own management 1146 01:07:03,021 --> 01:07:08,021 of the situation, held thoughtfully by another person. 1147 01:07:10,543 --> 01:07:13,301 I want to end by saying that there's one phrase 1148 01:07:13,301 --> 01:07:16,407 which I carry with me into the room 1149 01:07:16,407 --> 01:07:20,841 whenever I work with personality. 1150 01:07:22,044 --> 01:07:25,526 It's a phase which carries a lot of meaning 1151 01:07:25,526 --> 01:07:28,182 around the importance of thinking, 1152 01:07:29,008 --> 01:07:30,948 around the importance of reflection, 1153 01:07:31,526 --> 01:07:33,544 around the importance of slowing down 1154 01:07:33,547 --> 01:07:36,301 in order to make sense of something. 1155 01:07:37,425 --> 01:07:42,286 That phrase is the job that we have, 1156 01:07:42,667 --> 01:07:45,033 the task that we have with every one of our patients 1157 01:07:45,359 --> 01:07:48,843 is to help them to create a moment of pause 1158 01:07:49,251 --> 01:07:51,744 between the impulse and the act. 1159 01:07:52,244 --> 01:07:53,547 I'll repeat that. 1160 01:07:54,144 --> 01:07:57,003 Creating a moment of pause 1161 01:07:58,931 --> 01:08:01,781 between the impulse and the act. 1162 01:08:02,522 --> 01:08:07,522 If we can accomplish that in small or big ways, 1163 01:08:08,353 --> 01:08:11,027 then we have accomplished something 1164 01:08:11,027 --> 01:08:14,248 extremely significant and curative. 1165 01:08:16,016 --> 01:08:17,317 Thank you.