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Personality Disorders in Therapy

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Psychoanalyst Dan Buie describes 5 deficits that cause great suffering for people with personality disorders and how to work with them in therapy.

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Published On: 01/17/2022

Duration: 18 minutes, 39 seconds

Related Article:Working With Severe Personality Disorders,” The Carlat Psychiatry Report, January 2022

Chris Aiken, MD, has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.


CHRIS AIKEN: What’s it like to have a personality disorder, and what’s the best way to work with them? Today, some answers from psychoanalyst Dan Buie

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor and coauthor of the new textbook Prescribing Psychotropics

People with personality disorders have a lot of trouble understanding other people’s thoughts and intentions, especially patients with borderline personality. Whether you call it empathy, mentalization, mirroring, or theory of mind, there’s a certain inner sense that is broken in these patients. And just as they have trouble understanding others, they have trouble understanding themselves, or acting in ways that reflect a consistent, stable sense of self. 

All of this makes it hard to empathize with these patients, and yet empathy is one of the keys to healing personality disorders. Psychoanalyst Dan Buie has spent his career studying these empathic breakdowns, beginning in 1974 with his classic paper Countertransference Hate in the Treatment of Suicidal Patients. We focused on that paper in last week’s podcast, and today we’re going to fast forward to a speech he gave at the American Psychoanalytic Association in 2012, which he published the next year as Core issues in the treatment of personality-disordered patients. But first, a preview of the CME question for this podcast:

According to Dr. Buie, patients with personality disorders have difficulty in psychoanalytic therapy because…

A. They have poor impulse control

B. They have deficits in their sense of self

C. They have difficulty staying in long-term therapy

D. They develop unworkable idealization or paranoia toward the analyst

And what is the core issue in treating personality disorders? Like with any medical disorder, it is to find the source of the illness and heal it. In this case, the source of the illness is a broken sense of self. That’s a bit more abstract than the traditional five senses of sight, sound, taste, smell, and touch, but not too far off from the 6th sense – proprioception – which lets us know where our arms and legs are at any given time, even with our eyes closed. 

We also have a sense of who we are – our identity and self-worth – our boundaries – where we begin and other end – and a sense of agency – what we’ve done and what others have done. As one patient said to me, “You know what it’s like to have a mother with borderline personality disorder – it’s like she does all these crazy things and then she blames you for doing them!”

But “sense of self” is still rather vague, and Dr. Buie tries to make it more specific, dividing it into 5 areas that people with personality disorders are deficient in:

(1) Self-realness. The awareness that they are real, and their relationships actually exist. 

(2) Self-security. These patients have trouble providing themselves an ongoing sense of security

(3) Self-worth. The experiential knowledge of one’s worth

(4) Self-love. The capacity to experience love for oneself

(5) Self-knowledge. The capacity to know one’s identity experientially.

“To boil this down,” in Buie’s words, “people need to experience that they are real, secure from aloneness, worthwhile, and deserving of their love, and that they possess an identity.”

[Dr. Buie]

Now let’s turn to Buie’s description of what it’s like to have a personality disorder. Listen closely, and you’ll hear how each of those 5 deficits contributes to the various ways that these patients suffer: “Patients with personality disorders are lost in terms of knowing who they are: they feel a dark aloneness; feel a grim sense of worthlessness; feel no warmth for themselves; and do not feel like a whole person with a genuine place with others.”

[Dr. Buie]

Last week we ended with the word of the day – neurotic personality organization. Although it sounds like a problem, it’s actually the healthier personality, the one that has their everyday worries and quirks but is generally functional. Contrast this with borderline personality organization, which is where the patient may seem rational and functional on the surface, but behind that façade they are out of touch with reality, unable to see things for what they are or understand themselves or those around them.

In Buie’s view, what makes the difference between everyday neurosis and a personality disorder is this: The neurotic individual has an intact sense of self, and all 5 of those functions are working, they know who they are, believe in their self worth, and love themselves. For the personality disordered patient, those 5 functions are broken, and the aim of therapy is to develop them, and it’s here that psychoanalysis fails without some modifications.

 In the 1960’s Otto Kernberg noticed that some patients got worse with psychoanalysis. They acted out, having multiple affairs, fell ill with somatization, followed the therapist home and stalked him, or became enraged with paranoid ideas about the therapist. He called these patients borderline, because they seemed normal or neurotic at first, but once on the couch they unraveled. Psychoanalysis is a very unstructured therapy, which is great for neurotics – by allowing them to free associate, they gain awareness into their unconscious conflicts and can resolve them. It’s not easy, but they can tolerate the distress because they have a secure sense of self. But for a borderline patient, free association can cause them to dissociate.

So over the years psychoanalysts developed ways to modify their techniques, including more supportive and structured elements in the therapy that addressed specific deficits in the borderline personality. In Buie’s view, what they need first is help with those self-deficits. Once they get that support, they may be able to work on the unconscious conflicts that are causing problems in their lives.

In the analytic view, people keep these conflicts in their unconscious because it’s just too painful to be aware of them. Neurotic and personality disordered patients differ in how they block all that out. For neurotic patients, conflicts are suppressed in the unconscious, and the analyst uses free association to bring them to the forefront. Patients with personality disorders use a much more rigid block – they deny and disavow their inner conflicts, often projecting unwanted qualities of their own self onto others. In Dr. Buie’s words, “What is denied or disavowed is not unconscious. It is barricaded from awareness by rigid suppression. It’s as if the patient has shoved the bureau, chairs, and bed up against the door so no one can get in and nothing can escape. Of primary importance in working with denial is providing safety for the patient. We try to help the patient feel it’s safe to open the door, at least a crack.”

 So how does a therapist create that safety? Empathy and support are what Dr. Buie recommends. “A crucial part of support is that the patient experiences that he or she matters to the analyst, that is, that the analyst cares about him or her as the person he or she is. Patients must also know that their meaning to the analyst is strictly about themselves, that they are in no danger of the analyst’s using them for his or her own purposes. That is, the patient is cared about with no strings attached. Another part of providing supportive safety is the analyst’s capacity to endure the patient’s feelings with equanimity, no matter how intense they are.”

[Dr. Buie] 

Dan H. Buie is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute

And now for the word of the day…. Oxycodone

Oxycodone is a synthetic opioid pain medicine that’s about 1 and a half times as potent as morphine. It’s been used since world war I, but for a long time physicians shied away from this opioid because of concerns about addiction. That changed in 1995 when Purdue pharma released Oxycontin, the first controlled-release version of oxycodone. Purdue marketed the drug well beyond its FDA indications, and claimed that oxycontin’s controlled delivery system prevented abuse. None of this was true, and the misinformation fueled the opioid epidemic, which has taken more than one million lives in the US alone since 1999. A new miniseries on Hulu, Dopesick, traces the history of that epidemic, and the tale it tells is so hard to believe at times that we had to fact check it. Tune in next week to see what we found.

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