Transforming Trauma: Episode 149

Did you know that the diagnostic criteria for borderline personality disorder (BPD) has remained the same since it was officially added to the third edition of the Diagnostic and Statistical Manual for Mental Disorders in 1980? 

Forty years later, BPD remains deeply misunderstood by the public and isolating for those who live with the condition. One psychotherapist thinks it’s time for a change. He wants to help mental health professionals, especially those who are newer to the field, gain greater appreciation for the nuances inherent to the disorder and compassion for clients with BPD.

On this episode of Transforming Trauma, host Emily Ruth chats with Mark L. Ruffalo, MSW., D.Psa., about his extensive work in the field of borderline personality disorder. The pair discuss the history of BPD, its symptoms and characteristics, and overlap with C-PTSD. They also explore the agonizing realities of living with BPD and the moral judgments that many clients must endure. Mark also gives advice on how to apply effective psychotherapy when treating clients with BPD.

Mark has broad clinical experience in the psychoanalytic treatment of a range of psychiatric conditions, with particular interest in the psychotherapy of schizophrenia and borderline personality disorder.  “The term borderline––existing on the border between psychoneurosis and psychosis––has been used in psychiatry and psychology for 80 years or so,” Mark says. However, the concept of borderline personality disorder wasn’t operationalized until the 70s when John Gunderson argued that the core of BPD manifests itself in interpersonal relationships. “Very unstable, chaotic relationships,” observes Mark, adding, “often marked by a push-pull pattern where I’m going to push the other person away, then pull him or her back in towards me, and then I’m gonna push them away again.”

While the maladaptive behavior and communication strategies may have arisen as coping mechanisms in response to childhood trauma (BPD and C-PTSD are often co-occurring conditions), Mark cautions practitioners not to generalize. “A large percentage of BPD patients have endured horrendous childhood abuse. But, then you see cases where there really does not seem to be any evidence of childhood mistreatment, maltreatment, abuse, or neglect,” he says. “There’s good research to show that about 50% of BPD seems to be inherited, that there’s a genetic component to this condition.”

Treating clients with BPD poses unique challenges, especially for newer clinicians. Mark describes how he uses a clinical approach called transference-focused psychotherapy (TFP). “In TFP, the focus of the treatment is on the relationship between the patient and the doctor or the patient and the therapist,” Mark explains. “That becomes the arena in which all of these conflicts and problems and dilemmas play out.”  Similar to the intersubjective approach of NARM, the relational component becomes very important, particularly since many therapists struggle with strong countertransference reactions with clients with BPD.

One such countertransference reaction is when the therapist feels compelled to collude with a client’s distorted worldview. “Therapists can get into a lot of trouble if they repeatedly simply validate the patient’s externalizing defenses,” confides Mark. His advice for therapists is for them to recognize their narcissistic desire to be seen as helpful, then enlist ongoing support from a supervisor or peer group. “BPD is a very nuanced, complicated condition. And the relationship between you and the patient is even more complicated because you’ve got two psychologies at play. You’ve got the patient’s mind and your mind,” Mark emphasizes. “Any attempt to oversimplify this really complex condition is bound to fail.”

Transforming Trauma thanks Mark for challenging our community to reject the oversimplification of borderline personality disorder and practice greater discernment when entering into therapeutic relationships with clients living with BPD.  

 

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Mark L. Ruffalo, M.S.W., D.Psa., is a psychotherapist in private practice in Tampa, Florida, and serves as Assistant Professor of Psychiatry at the University of Central Florida College of Medicine and Adjunct Instructor of Psychiatry at Tufts University School of Medicine. He has broad clinical experience in the psychoanalytic treatment of a range of psychiatric conditions with particular interest in the psychotherapy of schizophrenia and borderline personality disorder. During his training at the University of Pittsburgh, Mark worked with severely ill patients in long-term psychotherapy, an area in which he has developed significant expertise. 

He has published previously in the American Journal of Psychotherapy, Psychoanalytic Social Work, Psychiatric Times, and the Journal of Nervous and Mental Disease. He currently serves as Co-Director of the Psychotherapy Track at the UCF/HCA Orlando Psychiatry Residency Program and is the Founding Editor of The Carlat Psychotherapy Report. Mark’s current research interests include the object relations theory of borderline personality disorder; communication dilemmas, paradoxes, and double binds in personality pathology; and deficits in logical reasoning in psychotic and borderline states.

MENTIONED IN THIS EPISODE

Carlat Psychotherapy Report

John Gunderson, MD

I Hate You––Don’t Leave Me

Gerald Adler, MD

The Concept Of Paleologic Thinking According To Arieti

Joel Paris, MD

Marsha Linehan, PhD

Otto Kernberg, MD

Glen Gabbard, MD

Frank Yeoman, MD, PhD

The Menninger Clinic

Paul Watzlawick

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