Episode 231: Borderline Personality Disorder: Splitting & Identity Diffusion with Mark Ruffalo

Audio Interview: Mark Ruffalo, David Puder

Transcript simplification and citing by: Jorge Salazar, MD, Al-Baab Khan

Editor: Joanie Burns, NP

By listening to this episode, you can earn 1.75 Psychiatry CME Credits.

Other Places to listen: iTunes, Spotify

Introduction to Burnham’s Article on Splitting in a Psychiatric Hospital 

00:00:16

Puder 

Welcome back to the podcast. Today, I’m joined by Mark Ruffalo. He is a person that I've become friends with, he's local to Florida. I would say he drove out to be in person for this.

I actually got to know him through the residents who were in the book club a couple times. They were big fans and said, ‘He’s the best teacher—you have to meet him!’ Later, we met on X (formally called Twitter), where I was like, ‘this guy knows a lot about BPD.’ I was also listening to some of your YouTube content and I knew we had to collaborate. Mark, I know you're a fan of the history of psychiatry, so in this episode, we’ll explore borderline personality disorder—even before it was formally called that. Would you say that’s fair to say?

Ruffalo

I think that's a pretty good description.

Puder 

Specifically, we’ll discuss a paper titled The Special Problem Patient, Victim or Agent of Splitting? by Donald L. Burnham, published in 1966. For those of you listening, you might wonder, “Why a paper from 1966?” Papers aren’t written like this anymore. Mark, this is one of your favorites, right?

Ruffalo 

Yes, it’s one of my favorite papers in the history of psychiatry. Burnham does such a good job describing the syndrome in a way that’s rare in today’s literature. I’m not entirely sure why, but I really love the older texts because of just how descriptive it is.

Puder

I think it's almost like the new stuff has gotten so far from the practical. You know, we look at correlations, like a 0.3 correlation between this group and that group, or we look at a lot of statistical things that are a little more esoteric or difficult to handle or understand. This is a paper about 12 women over a 10-year period at Chestnut Lodge, ages 16 to 35. Actually, there was a book written about Chestnut Lodge called, The Mental Hospital, which was published in 1954. So I was looking at that and thinking to myself, 'Okay, this is a place where people stayed for 18 months.' This is how it used to be done. You can imagine this place where you had these nurses and doctors, and you had 30, 40 people staying for a prolonged stay. The kind of data you could get out of that is so much richer than my experience of the psychiatric hospital, which was usually just three to four days for most patients with borderline personality disorder. And maybe someone stayed for six months if they were truly in a psychotic space, but that was a total exception.

Ruffalo 

For those who don't know, Chestnut Lodge was one of the psychoanalytic hospitals that opened in the early part of the 20th century to treat mainly schizophrenic patients. There were a few notable hospitals that opened during this time, with Chestnut Lodge perhaps being the most famous. Others included The Menninger Clinic, which is still around, obviously; Austen Riggs Center, which is in Western Massachusetts; and a few others. These were places that specialized in the psychoanalytic treatment of severe psychopathology. Virtually all of them, except for Austen Riggs, have closed. Menninger is still around, but now it's in Texas and has changed a bit. It's definitely a different era in psychiatry now, and many major names came through Chestnut Lodge, including Harold Searles, Otto Will, and several other big names in the history of psychiatry.

Puder 

And so I was thinking about, what do you get from studying people for 18 months, right? So when they talk about how they collected the data, they mention talking to all the staff members, and they have recorded sessions of these conferences. They’re narrowing in on 12 patients who evoked the most emotion and turmoil within the teams. I also love this from a team perspective. As someone who's run a partial and an IOP, I can visualize the people who split the team the best. As someone who's been in practice, I'm reading this and I'm sweating, my head is hot. I'm imagining scenarios, situations. If I had read this as a medical student, I might have been bored or slightly amused, just thinking, 'Okay, what?' But when you're reading this as someone who's in the trenches, in the deep interpersonal team dynamics, it hits differently. This week, I had a patient split me and my therapist, and you know, it happens, right?

Ruffalo 

I think it's hard sometimes to truly grasp the essence of splitting unless you've experienced it firsthand. You can read all the texts and papers in the world, but unless you've experienced the extremes of idealization and devaluation right before your eyes, it's hard to really comprehend what we mean when we talk about splitting. This paper, in essence, is about staff splitting, a term that’s used all the time now. One of the best contemporary scholars on this topic is Glen Gabbard, whose writing is really quite extensive on splitting in hospitals and among staff members. But I think Burnham here is discussing this phenomenon before it was fully elaborated, making it one of the early papers on this concept.

Puder 

Yeah. And I would say Glen Gabbard, one thing I didn’t know about him as I was reading his textbooks as a resident, is that he's become the go-to person for psychiatrists dealing with major boundary violations. He's essentially built his career off of this, consulting with psychiatrists, physicians, and therapists who find themselves in ethical quandaries. But here, we have a paper written about this before the term 'borderline personality disorder' was even really a word.

The Psychiatric Evolution of Borderline Personality Disorder 

 00:07:18

Ruffalo

So, you see, this is 1966. A bit of history on borderline personality disorder: It was John Gunderson, along with Margaret Singer in 1975, who coined the term 'borderline personality disorder.' But borderline states had been described in psychiatry as early as the 1930s, with Adolf Stern, who first described a condition existing somewhere between psychosis and psycho-neurosis. You see different terms being used—Bleuler, I think, talked about latent schizophrenia. Perhaps most notably, there was Hoch and Polatin’s concept of pseudoneurotic schizophrenia from 1949. A psychiatrist named Peterson discussed subclinical schizophrenia, and Kernberg in the 1960s described borderline personality organization, a broader concept that captures all personality disorders defined by the DSM. Then, Gunderson really described a distinct syndrome that we now call borderline personality disorder, which made its way into the DSM-III in 1980. There have been various descriptions of this condition or syndrome over the years, but it was Gunderson’s work that defined it as a distinct disorder. Another influential concept was Helene Deutsche’s 'as if' personality, which is sometimes grouped with all the historical antecedents to BPD.

Puder 

Yeah. And I think, you know, it’s not like it hasn’t been around or that it was invented. People used to call it hysteria, which probably meant something similar to BPD. What do you think?

Ruffalo 

Yeah, and there are some scholars, like Nancy McWilliams and Jonathan Shedler, who argue that a lot of what we call BPD is actually histrionic personality organized at the borderline level, to use Kernberg’s conceptualization. Others, like Gunderson, see it as its own syndrome. I think there’s good evidence to suggest that what we call BPD is actually a cohesive syndrome [Bohus et al. paper from 2021 supports BPD as a valid and cohesive clinical syndrome]. 

The symptoms tend to occur together, there's a course to the illness that begins in adolescence, and there's research on genetics. So, I do believe in BPD as a distinct psychiatric disorder. In fact, Otto Kernberg has come around to accepting this notion as well. He now incorporates BPD in his theory of personality organization.

Balancing Process and Skills in BPD Therapy 

00:10:20

Puder 

Yeah, this is something I’ve covered in past episodes, most recently on medications in BPD. In summary, many national societies are moving away from seeing medications as helpful for BPD itself. If there are comorbid issues, maybe you can treat those, but they’re moving away from the idea that people necessarily need to be on long-term medications.

Ruffalo 

It was just a few weeks ago that the American Psychiatric Association published some new guidelines on treating BPD. They basically said psychotherapy is the treatment of choice, and while medications may be useful at times and for targeting specific symptoms, they are not advised long-term. What’s also noteworthy about the guidelines is that the APA acknowledged that psychodynamic treatments are effective, and that there isn’t one single effective psychotherapy for BPD. For years, decades now, dialectical behavior therapy has been talked about as the gold standard, and it can certainly be an effective treatment. But now, there's greater recognition that therapies like transference-focused psychotherapy [see also Episodes 130, 140, 170, and 171] , which is based on Kernberg's work; good psychiatric management, which was Gunderson’s approach and is still being taught and written about; and also mentalization-based therapy [see also Episodes 29, 115, 206, and 224],  which I know you’re interested in, are also valuable.

Puder 

Well, I've been covering all these topics. So, when this report came out, I was like, have I somehow influenced the APA? But probably not. We’ve been talking about this for a while. I had an episode with Feinstein where we went through five different well-studied therapies. There are studies comparing dialectical behavior therapy with transference-focused therapy, and they both show great results. In some ways, I’d argue transference-focused therapy is better, because there seems to be an improvement in reflective function. I’ve covered that topic [see also Episodes 41, 206, 213, and 224], and that has really helped my understanding of BPD and severe psychopathology in a way that’s much deeper than just saying ‘the therapeutic alliance is so important for psychotherapy.’ 

Puder

I used to be a huge proponent of therapeutic alliance, but I think I’ve shifted more towards the view that what we’re really trying to do is improve reflective function. Not just in our clients, but in ourselves as therapists as well. That’s a much more complex and nuanced process, and it uses things like transference and countertransference.

Okay, but I want to get into this paper because it's so good. I want to read parts of it to you guys. It starts out discussing internal splits—how the patient's experience and presentation of herself are divided. It says 'herself' because all of the clients in this cohort were female. The typical patient in this series was very poorly integrated and, in certain respects, poorly differentiated. It’s going to go through what that means palpably. I just want to point out that when we think of BPD, there are different levels of functioning, and these patients are probably more on the severe level of dysfunction. I was also thinking, do these patients become dysregulated in such an intensive setting?

Ruffalo

Sure.

Puder 

And I wonder about that.

Ruffalo 

Yeah. I wonder about that as well. There are certainly mixed opinions on treating BPD in the hospital setting, with some people arguing that these patients should not be admitted to general psychiatric units. I think there’s some valid reasoning behind that. The exception might be if you have a unit specializing in personality disorders, like Kernberg’s unit in New York, where it might be more appropriate to treat these patients in an inpatient setting. But, yeah, you have to wonder whether the length of stay and intensity of treatment are factors. Years ago, there was this idea of transference psychosis in borderline patients. Kernberg talks about this, and he recounts a case from early in his career where a patient saw him walking down the sidewalk in New York City and hallucinated Dr. Kernberg spitting on the ground out of contempt for the patient. The patient had a transient hallucinatory experience related to the therapy. It was noted that the intensity and frequency of classical psychoanalytic treatment—seeing the patient on the couch three, four, or five times a week—was not suitable for borderline patients, as it could trigger a transference psychosis. So, one has to wonder, when patients like this are hospitalized for long periods, whether regression occurs as a result of the hospitalization itself. In fact, hospitalization might worsen these patients, even though we might not recognize or see it in that way today. These are important considerations.

Puder 

Yeah, I think when you consider most DBT tracks I've seen, they’ll have a process group once a day. So, you might be processing five days a week, but you’re not the only one sharing with one person in a dyadic way. The program I used to run was focused on psychosomatic patients, and every group was process. For some patients, it was just too much. In our program, each group had an element of process. I think that’s one reason DBT tracks focus a lot on skills-based groups. You know, they have transfer focused therapies twice a week.

Now, if you look at the papers on mentalization-based therapy, where it’s been very successful, they start with five groups a week, then go to three, and then two, for about a year and a half. By the end, patients might have had around 500 treatments. It's a lot of time and a lot of hours—500 hours of treatment. But when you think about the full spectrum of someone's life and attachments, 500 hours is just a blip in their overall life trajectory. Even 50 hours can make such an impact sometimes. In fact, 75% of people improve in just 50 hours of psychotherapy. That’s impressive. [see also Episode 144]

Ruffalo

So, I don't know for certain, but I imagine that here in the 1960s at Chestnut Lodge, a lot of these patients were seeing their psychiatrist for psychotherapy probably every single day. For 50 minutes or an hour, I would imagine that was the context. And then also group psychotherapies and attention from the nursing staff.

Symptomatology & Self-Perception 

00:18:01

Puder 

Yeah. So when I read the book that was written about this, it mentioned— and I was specifically looking at the boundary violations—some of the staff members, especially nurses and aides, became too close to certain patients. They would spend disproportionate time attending to favored patients, sharing personal details of their own lives, and relying on the patients for emotional support. And that's the type of patient we're talking about today. Yes, they would elicit this incredible bond in the staff, and through that bond, the normal frame of how you might relate to a patient would dissipate.

Ruffalo 

There's a great quote from Burnham (1966) in the article that captures this—the very essence of what you're describing. He writes, “No one could remain indifferent to or only mildly interested in the appeal. Its irresistible, gripping, insistent demand quality evoked the most intense feelings, whether of love or of hate” (p. 109).

Puder 

I would say that the appeal is like this request from the patient for a special type of relationship with a particular person. They hoped to obtain the ideal self, they hoped to obtain this perfect maternal role. Right?

I want to talk about when they looked at the commonalities of patients. I want to go category by category and just kind of break this down. So, the first category was body image disturbances. This is on page 107, and it says:

She also reported such experiences as her arms swelling, her head shrinking, her body being dismembered, tenuously glued together, or suspended in midair, somehow apart from herself. Other patients spoke of feeling dead, encased in cement, and uncertain whether they still were breathing (Burnham, 1966, p.107).

Ruffalo

These are obviously symptoms that point to this historic notion that borderline personality was a schizophrenia-like syndrome. I mean, we're really talking about psychotic symptoms here. One has to wonder whether some of these patients included in the group of 12 did in fact have a psychotic illness. I've done a little bit of writing on these types of symptoms in BPD. I think they're underestimated. I think the DSM does a really poor job of appreciating the frequency and severity of these symptoms in borderline patients. I mean, in the diagnostic criteria, all we see is a reference to transient paranoia, which certainly does happen in BPD. But I think if you look a little bit closer and really do a good job evaluating the patient, you'll see brief experiences of hallucinatory phenomena, similarities in terms of how patients use logic and how they come to conclusions—similarities between BPD patients and schizophrenia patients. And other commonalities including disturbances in how one perceives one's body.

Depersonalization & Dissociation 

00:21:52

Puder 

When I read a lot of these, first of all, it's very visceral language. And this is why I'm saying like, no one writes like this anymore when they write about BPD. I just haven't read anything like this. To me, it's a very dissociative phenomenon that I'm reading. It's a way that I've understood a lot of the complexity of these symptoms: when you feel tenuously glued together, suspended in midair, somehow, it seems like a very dissociated state.

Let me go on to depersonalization, because that is the very definition of dissociation. It says: they felt like a stranger to themself, whose body is this, is it all mechanical and doesn't have human feeling? They refer to themselves in the second or third person. One patient referred to her eye as 'the thing one sees with,' and she strongly implied that her use of the word 'I' would be criminal misappropriation of a scarce item, which others deserved far more than she. These patients shared a pervasive doubt concerning what of themselves and others was real and what was false. They were enormously preoccupied with how to distinguish the genuine from the pretended, most obviously, in their testing of others, but fundamentally in trying to resolve their uncertainty of self-definition.

Ruffalo 

Sure. This is touching on what we would say in modern object relations theory is self and object differentiation. You know, where do I end and where does the other person begin? And all sorts of disturbances here in the patient's object relations.

Puder

I think of this as dissociation, like when all the other defenses break down. Things like sublimation, rationalization, humor, denial… When those break down, it kind of ends in this more dissociated state. Do you see it differently than I do?

Ruffalo 

I see it very similarly. I would say either a dissociative state or psychotic defenses at that point. So, you know, paranoid projections, hallucinations, and the like.

Puder 

I've had a patient that I worked through successfully who had a dissociated transference of me. So it's not that she didn't exist, although she felt like she was often in a cloud or disconnected from her body. She went from seeing me as this kind, warm, generative figure she could bring to mind when she was distressed, to seeing me as a frightening, scary presence, as if I didn’t exist at all. Even when I was there with her in the session. It took about a year and a half—this was the most prolonged dissociative transference I’ve ever encountered with a client. It was a year and a half before we worked through it. To be vague, it required consistently showing up and being as present as I could. But even during the sessions, I started to feel dissociated. I had to ground myself, bring myself back into my body. I would sometimes feel extremely sleepy at times and needed to stand up or even pinch myself to stay grounded.

Ruffalo 

What you're describing, of course, is the patient inducing a phenomenon that's very similar to their own experience. And this is the essence of countertransference. With these types of patients, we often experience intense countertransference reactions, and these reactions give us insights into the patient. I’m sure you’ve discussed this with other guests before, but it’s important. It reveals something significant about the patient, especially in cases of borderline pathology.

Puder 

Yeah. It took me a while to realize this with this particular patient. I found it helpful to interpret it this way: much of her childhood was shaped by her experience with her parents. She viewed them as these ghostlike figures. And in a way, she was reprocessing that experience through me. When we worked through it, she could tolerate being around her parents more.

The Interplay of Self-Worth, Soothing, and Hypersensitivity 

00:26:33

Puder

Okay, let's move to the next category:

Inside-outside uncertainty

She often perceived shifts in her feelings as drastic changes in the appearance and intentions of others. In the midst of all this inner-outer uncertainty she had little sense of autonomous control, but felt at the mercy of her environment.

One patient said, "Whose thoughts are those? They must be some- thing from a movie or a book. People have me connected up and are putting slides in my head to make me see and say what they want (Burnham, 1966, p.107).

Puder

It’s like a bunch of opposite paradoxes to some degree. Inner-outer uncertainty… She felt at the mercy of her environment and others, like where do other people end and I begin? Mentalization theory discusses this concept, calling it 'psychic equivalence mode,' where patients feel like their thoughts are reality. So when they perceive that other people are thinking something, they are actually thinking it.

It’s not just 'Dr. Puder might be angry with me,' or 'Maybe, Dr. Puder is angry with me, but I could be wrong.' No, it’s 'Dr. Puder is angry with me.' It's an absolute certainty.

Ruffalo 

This also touches on Gunderson’s notion of interpersonal hypersensitivity. Patients are incredibly sensitive to what’s going on around them, often misperceiving their environment. As Harold Searles said, the borderline patient has no symptom-free moments. He pointed out that every little thing, from how you greet the patient in the waiting room to how you answer the phone when they call to change their appointment, could be vulnerable to misinterpretation.

Puder 

Exactly. There’s this exquisite hypersensitivity. And it’s driven by interpersonal fear. It’s like, 'Are you and I going to be okay? Do you really care about me? Am I really your special patient? Am I someone you really care about? Am I important to you?' It’s intense fear around these questions.

I don't know if you heard my discussion with the mentalization-based guys on narcissism, but it was like an epiphany for me. I realized that the same level of fear in narcissists is tied to the question: Is this person wounding my perception of how others see me? It’s not about the relationship itself; it's about this image I have of myself, as this wonderful teacher, being wounded by this slight from this person.

Ruffalo

Yes, exactly. So, I think the deficit in narcissistic patients is in the area of self-worth. In borderline patients, it’s both in self-worth and in the ability to hold and soothe themselves. This was part of Gerald Adler's work in the 80s. He talked about a borderline-narcissistic continuum. So, we often see in borderline patients the same deficits as in narcissistic patients, but with an additional aspect of the illness when it comes to the inability to soothe and hold themselves during periods of aloneness. We could go into that idea of a continuum more if you'd like.

Puder 

Yeah, help me understand that continuum. So, people with borderline personalities are really struggling to soothe themselves when they’re alone, right? And, as you know, many therapies have… when I heard Marsha Linehan talk about DBT [see also Episode 140], she would mention how borderline patients would call her. Patients with borderline traits—I'm trying to be careful about saying the 'borderline' because it labels them at the core of the disorder. I think it's the person who struggles with borderline traits. So, they would call her. I don’t have this feature in my practice, right? I think there's a different way of framing it, and the frame is very important to maintain. Therapy takes place within the session.

Ruffalo 

Yeah. So, Kernberg and the transference-focused people argue that the therapy contract is essential when working with borderline patients. One of the first things that should be done is outlining the role of the patient, the role of the therapist, and maintaining the frame. Keeping the contract is vital in treating these patients. Now, Gerald Adler, whose work on BPD I really like, argued that the goal of treatment is for the patient to internalize a holding, soothing object in the form of the therapist. So, Adler recommended that when the therapist went on vacation, they should send a postcard to their patients so that the patients have something to remember them by. This might sound odd to other psychodynamic theorists, and I doubt Kernberg would agree with this approach, but Adler believed that the goal of treating borderline patients, at least the borderline segment of the pathology, was for them to internalize a soothing, holding object that could sustain them during periods of aloneness. So, they wouldn't need to reach out to others in frantic efforts to sustain themselves. This ties into his idea of evocative memory, which I find to be a very useful concept. I'd like to talk about that for a moment. Adler thought that the fundamental deficit in borderline patients was in their use of evocative memory. In healthy, normal functioning, we are able to summon a mental representation of a healthy internal object that provides us with comfort and soothes us. So, we don’t have to rely on other people to do this for us. We can do it ourselves and feel fine being alone. Adler believed that borderline patients can’t do this. They rely on self-objects, meaning they rely on other people to perform this vital psychological function for them. When these self-objects aren’t available, the patient falls apart. Adler links this idea to developmental psychopathology and developmental theory. He talks about object constancy and the formation of evocative memory in early life, somewhere between 12 months and 2 years of age. Any disturbances during that time may give rise to some of the symptoms of BPD. I think this concept of evocative memory and object constancy is really powerful for understanding why a patient becomes so frantic when their primary object is unavailable

Nature vs Nurture in BPD 

00:34:46

Puder 

Interesting. Two thoughts come to mind. One is from my episode on the prisons of Mesopotamia (see also Episode 172), where we discussed solitary confinement. It's actually toxic to everyone’s brain—being alone for months in solitary confinement shrinks the brain. There have been a lot of brain studies on this. It’s incredibly harmful to the brain. Afterward, everyone has worse mental health, with higher rates of psychosis and other issues. So, I think I might challenge this idea that we should be okay alone. I’m not so sure that’s always the case.

Ruffalo 

I think there's nuance there.

Puder 

Yeah, there’s nuance. Maybe it’s not the level of desperation or the real painful agony of separateness.

Ruffalo 

I’ve had BPD patients tell me that it feels like they’re dying—like metaphorical death—when the object isn’t available.

Puder 

Yeah, it’s absolute agony. It triggers a stress response in my body, just thinking about the suffering from the agony. When I read this paper, it mentions that several of the patients had been adopted, or had been cared for by a series of parent surrogates. Almost all of them had deep doubts about who their real parents were. They often developed compensatory fantasies, imagining they were descended from famous or royal figures. These were tough childhoods. Some might argue, 'I know someone with BPD who came from a really warm family, what about them?' But I’d say, 'How much do we really know about what that family was like for that child?' Was there a personality mismatch in that family? Were there messages from the parents like, 'You can’t show up emotionally, because my emotions need to be fully present and there’s no room for yours?' Or was there hostility or anger that silenced a sensitive person? I see expressions on your face that suggest you resonate with something or maybe have some memories of these things.

Ruffalo 

Yes, it’s very complex. You're right, there are some patients who seem to come from fairly normal childhoods and still develop BPD. Joel Paris, who’s in Canada, talks about this and finds it quite problematic to say that all BPD cases result from trauma (Paris, 2020). I think that resonates with me. When we look at genetic research, about 40-50% of what we call BPD appears to be inherited.

Puder 

That's similar to ADHD, which is more like 60%. For height, it’s about 90%. So, yes, I agree some of it is genetic. But I also want to highlight the role of adverse childhood experiences [see also Episodes 88, 92, 203, 204, 215, 217, and 224]. I recently did a deep dive into this, and as you move from one to two, three, four, five, or six different types of adverse experiences, the odds ratio for developing BPD jumps to about 25 when you hit five.

Ruffalo 

Does not surprise me at all.

Puder 

Exactly. While many conditions show an odds ratio of 2 (things like heart disease, diabetes, physical issues), BPD and complex PTSD have a much higher increase. It’s striking.

Ruffalo

I think psychodynamic theorists have known this for decades. I get a little frustrated when people talk about trauma as if it’s a new idea in the field. If you read historical texts, you’ll see attachment, neglect, and abuse have been discussed for a long time in psychoanalysis. It’s not a new discovery. In terms of psychogenetic factors, I think neglect is likely a more significant or relevant factor than overt abuse in BPD, though overt abuse is certainly present. Linehan and Kernberg seem to agree that neglect is a more important factor. However, there were studies in the '90s showing that 60-70% of patients with BPD had experienced sexual abuse. [This 1995 paper by Kenneth Silk et al. found that among 37 psychiatric inpatients with BPD, 76% had experienced sexual abuse.] So trauma is obviously relevant. But I worry when we go on a search for trauma in every patient’s background.

Puder 

Yes, and that’s a pet peeve of mine. It’s concerning when therapists ask very leading questions, because their own journey can imprint onto their patients in the same way, which is problematic.

Ruffalo 

That’s very problematic nowadays.

Puder 

Yes, I’ve seen this with a religious figure in one of the towns I lived in. He seemed to think that certain types of people had certain trauma, and he became EMDR [eye movement desensitization and reprocessing] certified even though he wasn’t a therapist. That was a bad combination. I also knew a therapist who had been through sexual abuse herself, because several of her patients told me similar stories. We must be aware of our own issues and how they might affect our work.

We also need to consider disorganized attachment, which can be observed at four months of age and linked to higher rates of dissociation by age one and a half. So, there’s a link between early attachment wounds and later difficulties (see also Episodes 69, 87, 88, 194, 206, and 225). We’re not just talking about the still-face experiment, but how repeated experiences of emotional unavailability and chaos create disruptions in development. For some of my patients, their mothers were addicted to meth, alcohol, and other drugs, making them chaotic and emotionally absent. For others, their mothers had schizophrenia and were psychotic, paranoid, and erratic, often not on medication. Some of my patients were in and out of foster homes, leading to very erratic, chaotic environments. So, it’s important to recognize there are many different scenarios here. We can’t assume one path or search for the same experiences in every case.

Ruffalo 

Right, exactly. Kernberg highlights this, and it’s important to note that there’s no single path to borderline personality disorder. We see trauma, abuse, neglect, as well as genetic factors, especially innate aggression and attachment pathology. BPD is complex and doesn’t have one cause. That’s why a biopsychosocial approach is crucial in understanding it, and in psychiatry overall

Identity Diffusion: Gender, Sexuality, Age & Role Dynamics 

00:43:45

Puder 

One section that I found interesting discussed gender and sexuality in BPD patients. It’s important to note that these issues are fluid and change from moment to moment. Sexual identity and role also were uncertain and conflictual. These patients were tormented by questions such as, "Am I woman or man, girl or boy? 'Which do I want to be? Am I like my father or my mother?" These conflicts were outwardly manifest in oscillations between masculine and feminine choices of dress, grooming, and activity interests. One patient, apparently in a determined effort to deny all femininity, sheared off her hair, smoked cigars, and wore trousers. A few weeks later, however, at a hospital party she was most decidedly feminine in a low-cut gown and evening gloves, and obviously enjoyed flirtatious exchanges with many of the men present. She, like most of the special-problem patients studied, often displayed feminine- masculine oscillations within spans of a few days or even hours.

Ruffalo 

Yes, absolutely. This speaks to identity diffusion in these patients.

Puder

Exactly. I wrote down 'distinct gender identity crises in BPD.' It’s not that these individuals have always had a very concrete, fixed identity. The question is, how do we, as therapists, approach this in a nuanced way? We must avoid seeing it as monolithic and instead view it as part of a broader identity diffusion. I don’t think we talk enough about this aspect, but it’s crucial in understanding the complexities of BPD.

Ruffalo 

We certainly don't talk enough about sexuality in this context. It’s a controversial territory and it’s sometimes difficult to navigate when it comes to issues of sexuality in borderline personality disorder. But going back to the '80s, Akhtar described the syndrome of identity diffusion, and one of its core symptoms is a diffusion in sexual identity. As you pointed out, it’s not just about identity confusion—it’s about the rapid and frequent changes in one’s sense of self, particularly in sexuality. These shifts can happen within days, or even hours, as noted in this paper. There’s something significant about that rapidity.

Puder

Yes, and in the next section, it mentions that age can fluctuate too.

Several claimed ages older or younger than their actual ages, and their appearances tended to fit these claims. Not infrequently, they had been encouraged to premature competence, or rather, pseudo competence, in various sectors of behavior. For example, one patient described with mixed pride and resentment how, before the age of five, she had made her way alone around the New York City subway system. —Notice it's with pride and resentment—.  Others had been included in adult social activities at inappropriately young ages. Several had been recruited by their mothers as special confidantes and companions, to be leaned upon and entrusted with intimate details of the mothers' problems, including those of their marital relationships. The usual boundaries between generations had been blurred, and at times the usual independent-dependent axis of the mother-child relationship had almost been reversed. The daughter-father relationships had been similarly distorted, with frequent not-so-subtle invitations to "be a better wife to me than your mother is” (Burnham, 1966, p.108).

or as a patient has told me, 'My dad dumps all his issues on me.' There was no space for the children to express their own concerns because their parents had turned them into emotional support systems.

Ruffalo

Yes, that’s a total blurring of family dynamics. We see that all the time.

Puder 

Exactly, it’s the parentification and it’s the role reversal. I think about my own kids, and while I share things with them, it’s never in a dysregulated way. But many of my patients talk about growing up with dysregulated parents—where the mother or father would rant for hours about personal issues. It’s an incredibly unhealthy dynamic.

Ruffalo

Yeah. And many of these children grow up to work in the helping professions, ironically.

Puder 

Oh, absolutely. And those of us who’ve been in similar situations understand it. It often comes with this mixture of pride and resentment. It’s like, 'I had this valuable place in the family unit.' There’s a certain power in it, a special role, but at the same time, it’s suffocating for a lot of my patients. They feel this weight, like their emotional system wasn’t ready for it, but they had to deal with it. Then, they become the person that others turn to because they’re seen as a good listener. This social connection might be what they wanted or needed, but it also brings the burden of taking on other people’s emotional weight. And sometimes, they’ll come to therapy saying, 'This is the first time I’ve had a place where I can share.' But even then, they’re often afraid of burdening the therapist. I'm still afraid that it's too much. I shouldn't be sharing with you my weight or my stuff. So, it's like somehow that was imprinted and then transferentially shows up in the relationship.

Caution in the Patient & Therapist Relationship with BPD 

00:50:35

Ruffalo 

Yes, I think when we observe this dynamic in a therapist who was raised in such an environment, it often manifests as what is traditionally referred to as a rescue fantasy. This is the therapist's sublimated need to "rescue" a broken parent, a drive they channel into their work with patients. While this can serve as a powerful and effective motivator in therapy, it also carries significant risks. A therapist with such a strong desire to save or rescue their patient may inadvertently blur boundaries, potentially leading to ethical violations or emotional entanglements.

Puder

Absolutely. And it’s crucial to approach this dynamic with compassion and curiosity rather than judgment. For example, when working with therapists as a supervisor, I don’t adopt a punitive stance if boundaries have been crossed. Instead, I explore the underlying factors: What happened here? What led to accepting client calls at all hours of the day and night? Pulling back from these patterns can feel excruciating—not just for the therapist but also for the patient, who may perceive it as deprivation.

Ruffalo

That’s precisely why establishing a clear therapeutic frame or contract is so vital. When a therapist begins to step back and enforce boundaries, it can feel to the patient as though they’re being denied care or compassion.

Puder

When this happens, the patient can quickly shift from idealizing the therapist to devaluing them entirely. The rage that was previously directed inward—through self-harm, negative self-appraisals, or other behaviors—might now be directed at the therapist. For someone whose identity is tied to helping, this can be an exquisitely painful experience.

Ruffalo

Absolutely. It can be deeply painful and have profound effects on the therapist. Harold Searles wrote a paper in 1959 titled, “The Effort to Drive the Other Person Crazy,” which is language we wouldn’t use today. But when the patient is subjected to alternating between idealizing and devaluing patterns, it can have a profound effect on the psyche of the therapist, creating confusion: What is it that you want from me? The patient, in essence, projects disavowed aspects of themselves onto the therapist, in the attempts to induce in the therapist feelings similar to what the patient experiences.

Puder

Yeah. This is projective identification. The patient projects these feelings onto the therapist, and the therapist, depending on their own developmental history, may unconsciously identify with them. Interestingly, I used to work at a clinic that Dr. Randy Sansone did research out of, and he found higher rates of Borderline Personality Disorder in resident clinics compared to regular outpatient clinics (Sansone & Sansone, 2015).

Ruffalo

Interesting.

Puder

Yeah, and I can think of a couple of reasons why this might be the case. Having sent patients to resident clinics, I often referred patients who were really difficult to place with other therapists. Many therapists would see these patients once and decide they weren’t a good fit. However, residents were generally more open to taking on anyone. So sometimes that was the reason. But I think there’s something more to it. But yeah, I think there's something about that. Just beware, if you're a young professional listening to this.

Presentations of BPD in Literature 

00:53:30

Puder

Uncertainty of Self Valuation: 

The typical special-problem patient fluctuated unevenly between global good and bad self-appraisals. Once again, we’re talking about identity diffusion—the sense of self shifting so quickly. at one time regarding herself as a kind, generous near-angel, and at another as a loathsome, evil monster. She also oscillated between the opposite poles of many pairs of component attributes. Among the most salient of these were the sick-well and the dependent-independent polarities. (Burnham, 1966, p.108).

Ruffalo

Right, we’re seeing contradiction and paradox here—self-splitting. When splitting is discussed, it’s often framed as the patient viewing others as either entirely good or entirely bad. But patients also engage in self-splitting. At different points, they might see themselves as intelligent, attractive, and worthy, and at other times as foolish, unattractive, and unlovable. Self-splitting is just as significant.

Puder 

Yeah. They also talked about:  “Her grooming ranged from highly fastidious to totally neglectful; her eating habits from gluttony to ascetic starvation; and her communicativeness from lively conversation to muteness. Sometimes she was kind and considerate, at other times sarcastic and demanding” (Burnham, 1966, p.109).

Do you see why this paper is such a favorite?

Ruffalo

You just don't see this type of writing anymore.

Puder
It’s beautiful writing—really beautiful. It’s so delightful to read such beautiful writing, but at the same time I had a stress reaction reading it. At the same time, I’m empathizing with many patients I’ve seen over the years who struggle with these dynamics.

Ruffalo
It feels very “experience-near,” whereas much of today’s scientific writing feels “experience-far.”

Puder 

It's intellectualization, creating a sense of distance—like operating on a cadaver. In the paper, they mention that terms like "mixed" and "borderline" were frequently used when attempting to place the patient in a diagnostic category. Even here, "borderline" was applied as a kind of in-between classification when they weren’t sure where she fit.

Ruffalo

As Nancy McWilliams puts it, “Too crazy to be neurotic, but not crazy enough to be psychotic.” Of course, I don’t mean “crazy” in a pejorative sense—that’s McWilliams describing the ambiguity often associated with borderline cases.

Variability of Self & Exploring BPD Relationship Dynamics 

 00:58:37

Puder 

Okay. Here's another one:

Also filled with uncertainty were answers to vexing questions of her capacity for self-control and responsibility. At times she appeared to be a purposeful, even willful, active agent; at other times a helpless, passive victim. The variability of her behavior also spawned doubts about her sincerity and genuineness, similar to her own unsure- ness of where her masks left off and where her real self began. How to distinguish the genuine from the pretended plagued the patient and staff alike. (Burnham, 1966, p.109).

I think, as someone experienced with these cases, it’s important to avoid moralizing. I’m not trying to figure out what’s “real” or not; What are your thoughts on this?

Ruffalo

So often, borderline patients express, “I don’t know who I am. I have no idea who I am.” Burnham (1966) writes that “it’s difficult to determine where their masks end and their true self begins” (p.109 ). The variability between seeing themselves as capable and competent versus utterly helpless and victimized is striking. And yes, the concept of “victim” is significant here. When we consider the victim-victimizer dynamic, persecutory objects often play a role in their lives. At different times, therapists or psychiatrists may find themselves cast into these roles. I agree—it’s important to avoid moralizing the behavior. We can describe it and understand its phenomenology without passing judgment. But I think we run into trouble when we shy away from describing the behavior entirely. I think that some people get offended just by sort of talking about the behavior the patient engages in as if it's a bad thing to do.

Puder (01:04:31):

Right. So where does this identity diffusion come from? The struggle to form a coherent sense of self often leads to vacillating between extremes. Let’s dive into the appeal made by these patients:

It comprised requests for healing, rescue, and protection from suffering. The theme of intense need was communicated variously: "I need you... You are my lifeline… You make me alive, complete, and real…You are absolutely essential to me." Obviously, such poignant statements readily evoked wishes to help in persons who had elected healing roles. More than this, they prompted in many listeners a profound sense of being chosen as the needed person, a response which Main termed "the arousal of omnipotence” (Burnham, 1966, p. 109 ).

Ruffalo

This is one of my favorite passages in the paper because Burnham is talking about the vulnerability of therapists, doctors, and nurses to this kind of appeal. And the feelings it evokes in the other person to be needed and wanted. When a patient expresses that their survival depends on you—conveying something like, "Without you, I will fall apart. You are essential to me"—it resonates deeply, especially with those who have chosen a helping profession as their life's work. This appeal evokes a profound reaction, a sense of purpose and importance. And this is often a source of conflicts we see interpersonally. Burnham highlights how the chosen caregiver often becomes deeply invested in their role as the "needed person." There's something profoundly significant about being selected as the one who is uniquely required, and this sense of indispensability can both empower and complicate the therapeutic relationship.

Puder

“The arousal of omnipotence” (Burnham, 1966, p.109). What do you think about that phrase?

Ruffalo

I don't know exactly what Main is referring to there, but  I think it refers to the sense that the therapist or caregiver believes they are the only one capable of truly understanding and helping the patient. This belief can create a "hero complex," where the helper sees themselves as the savior.

Puder

Oh yeah, it’s a hero. A type of fantasy, right? When you go back. Exactly. You mentioned victim, abuser, and hero. And this is why, when I talk about the hero's journey, I like to pose the therapist not as the hero, but as the guide, right? Yes. If anything, in the story, you're the guide which is kind of like in the hero's journey—it’s the common mythological structure. The hero ventures into a foreign land, needing to overcome obstacles. Encounters a guide to equip them in some way to overcome the obstacles they go, then separately overcome the obstacles and come up against maybe malevolence or evil, overcome it, and then go back home and bring some of the gifts that they learned along the way.

Ruffalo

That's a good metaphor. In therapy, this often plays out when the therapist assumes the role of a boundless helper or savior—believing that they can rescue the patient. The therapist might think, "It will be because of me that I save this patient." This can lead to several problems in treatment. For instance, if you're involved in psychopharmacology, you may end up prescribing medication that isn't appropriate or fail to hospitalize a patient who truly needs it because you believe you can handle everything. The mindset might be, "I'm the only one who truly understands this patient." Over time, this can lead to more significant boundary issues as well.

Puder

In the article, they talk about the origins of the appeal:

The patient's urge for a very special relationship, tantamount to rebirth into a good-mother-self union, was rooted in her conviction that herself was directly and currently shaped by proximate per- sons. In a manner typical of her faulty self-other differentiation, she experienced her good self as resulting from current contact with good persons, her bad self from contact with bad persons, and her uncertainties and variations of self-definition from the inconsistencies within and among others (Burnham, 1966, p.110).

Ruffalo 

I think this is 10 or 15 years later when we see Gunderson discussing the same concept—the sensitivity of the patient to relationships with others. He defines the syndrome as an interpersonal problem at its core, explaining how the patient’s emotions are intricately tied to the dynamics of their relationships, to use Gunderson's term, with the “major object.” If they feel good today, it's because things are going well with the major object. If they feel depressed, it’s likely because there is some problem in that relationship. And their sense of goodness, or how good they are in the world, is shaped by ‘proximate persons,’ to use Burnham’s term. Their sense of self-worth, their sense of goodness, and even their will to continue living in some cases are linked to whether they feel appreciated, cared for, and loved by the ‘major object,’ (further highlighting how interconnected their self-concept is with their relationships).

Splitting: Good Objects vs. Bad Objects & How it Manifests

Puder

The paper describes how some nursing staff noticed they were perceived as the “good objects,” and they tried to encourage others to become good objects as well. Meanwhile, the patient identified other individuals as “bad objects” and tried to distance themselves from them. Additionally, the patient attempted to “purify” themselves by projecting their bad self-elements onto those defined as bad objects. Essentially, all the negativity from the patient, all of the badness, was transferred to these bad objects. This unique form of splitting creates factions within the unit. Some staff members thought, “We just need to love this person more and give them what they want,” while others believed, “This person is manipulative, lying, and taking advantage of the system. We need to be stricter.”

Ruffalo 

Yes, and this dynamic often escalates. Members of the first group may accuse those in the second group of being too punitive, authoritarian, or lacking compassion. It can become quite contentious. Gabbard discusses this phenomenon extensively in his writings on staff splitting. These intense divisions can sometimes align along professional lines—for example, differences between nurses, social workers, and psychiatrists—or they may simply depend on individual personalities. Another related paper that touches on this theme is from the 1980s. It’s titled “Treating The Patient Who ‘Can’t’ Versus Treating The Patient Who ‘Won’t’”, and it explores splitting in the context of whether a patient is unwilling or unable to do something. Some staff members may assert that the patient isn’t trying hard enough, while others argue that the patient’s illness genuinely prevents them from accomplishing certain tasks. These kinds of divisions often take similar forms.

Puder 

I love how you incorporate insights from other papers into this discussion—that’s so good. The paper further discusses: 

The urge for an all-good self participating in all- good relationships runs counter to normal integration of both good and bad within the self and within particular relationships. These points of contrast are important in understanding the nature of the appeal (Burnham, 1966, p.111).

Ruffalo

Yes, it ties back to fundamental object relations theory. Integration—the ability to see both good and bad qualities in oneself and others—is a key part of healthy development. For example, being able to say, “This person has both good and bad qualities, but overall, they’re a decent person.” When someone hasn’t achieved that developmental milestone, we see splitting. Here, they perceive people as entirely good or entirely bad. For example, a person is seen as composed only of good qualities or only of bad ones, with no nuance. Achieving integration is a vital developmental achievement in object relations theory.

Puder 

So the appeal starts often with the call from the referring agency. When I read this part, I thought, “Wow.” So you can imagine it says: 

Often the initial referral was made through special channels and contained a mixed plea and warning that the patient required and deserved special treatment. The referring person would emphasize how vital it was that the patient be met by sensitive understanding lest the basis for treatment be undermined at the outset. His advance briefing would include warnings of others' failures at this task and invitations to rectify their insensitivities and mishandling of the patient. Requests for the assignment of the especially skillful and experienced therapist of a specified age and sex were common (Burnham, 1966, p.111)

Ruffalo 

Yes, we still see this all the time today. I’m not sure if you follow this on social media, but I’m a member of some local groups where people post looking for referrals for certain types of patients. Often, you’ll see something like the case you just described. They’ll say, “I have a very vulnerable patient with special needs who requires particularly sensitive care.” Then, they’ll specify that the patient needs a therapist who is either a male or female of a specific age range, someone inclusive, and so on. This is exactly the kind of phenomenon Burnham was talking about over 50 years ago.

Puder 

From the outset the typical problem patient engaged in a quest for persons who might fit the 

good-mother, magic- helper mold (Burnham, 1966, p.112).

So, this patient is searching for this person. They're searching and I would say there's some that are just better at cultivating, and like getting this type of relationship, you know?

Poignant depiction of the theme of love- deprivation in her life was outstanding. This was conveyed by myriad subtle hints as well as by full descriptions. She avowed that her parents had been so troubled, insensitive, or otherwise preoccupied that they had neglected her needs (Burnham, 1966, p. 112).

Potentially that really did happen. So potentially... I'm like, where do I stand right now? I'm not really the magical helper, in the way I frame it.

Ruffalo 

Yeah, I think that the theme of love deprivation is really interesting to me. I think clinically this often plays out when a patient comes in and starts talking about how other therapists have failed them, that no one has ever really understood them, no one has really "got" them. They've been deprived of good treatment by their past providers. Now, you and I both know there’s a lot of good therapy out there, and there’s a lot of bad therapy as well. So, you certainly can’t diagnose a patient based on this alone. But this theme of feeling deprived by all past providers or love partners is very common in borderline psychopathology.

Puder 

Yeah, it’s a mixture. It’s complicated, like you said. This is where, if it's a one-off, ‘I know this provider well, I’ve had many patients with this provider,’ and this person says this, it's like, "Wow." But if it’s the 10th story about that provider, as a psychiatrist, I’ll sometimes hear the 10th story about a specific provider, it’s like, ‘Oh, take note of that too.’ But inevitably, most providers, I can kind of figure out who they work well with and who they don’t. It’s also how they cultivate certain stories about the provider, it’s like they’re splitting from the very beginning.

Ruffalo 

Very often in the initial stages with this type of patient, you’ll be cast in the role of, you know, the White Knight. You know, they’ll say, "You’re the best doctor I think I’ve ever seen. You have all these great reviews on the internet, and I’m so thankful you’ve accepted me as a patient." And, you know, the idealization often begins pretty early. But as Jonathan Shedler (2022) says, “If you're cast as the White Knight in Act One, you're almost certain to be cast as a villain in Act Two” [sic]. And, of course, he’s talking about splitting and the inevitable devaluation that follows in the treatment of these patients.

Motivations of Suffering & Manipulation with BPD 

01:17:33

Puder 

I think it's worth going through like this one little part that talks about:

 Her sufferings took on the form of intense loathing and accusations of herself using such epithets as “dirty, disgraceful thing…monster…. horrible murderer... disgusting piece of garbage.” She experienced some of these accusations as arising from within, others from outside. 

Episodic self-mutilation was also frequent. Her violent hatred and rejection of parts of herself had multiple meanings, several of which will be discussed later (Burnham, 1966, p. 112).

I want to focus on the meaning of self-hatred as a form of suffering. And I would say, there is a lot of suffering in these patients. So, as we talk about this, I don’t want us to miss the heart of it, which is that we study this to help, and not over-idealize ourselves as they idealize us, or over-devalue ourselves as they devalue us. But to have some thick skin to ride through it and see ourselves with the constancy that they don’t necessarily see.

Ruffalo 

I think the point about suffering in these patients is so important. When I was in graduate school and doing my internship and psychotherapy training, we certainly talked about the suffering of schizophrenic patients, those with bipolar illness, and the severely depressed patient. I believe the suffering we see in borderline personality disorder is amongst the most severe, if not the most severe, in all psychiatric illnesses. As I’ve worked with borderline patients, I think the suffering is different in some ways from how a patient with psychotic illness suffers, but it’s still profound. I think some people interpret discussing the nature and symptoms of the psychopathology as somehow missing or neglecting how much the patient suffers or what their experience is like. But I don’t see it that way. I think discussing the nature of the psychopathology is a way to understand the depth and severity of the suffering. If you don’t talk about the nature of the psychopathology, you miss it. So, there’s room for both: we can understand the pathology and also appreciate the intensity and severity of the suffering these patients endure.

Puder

I would add that, as someone who has led a team, particularly in the partial IOP that I ran, I would sometimes see the splitting. Being able to point that out to the team, put words to it, and get both sides to talk about it was some of the most important work I did. My psychodynamic understanding of transference, countertransference, and projective identification helped me in that process. When I imagine talking to you, it’s about keeping the team together as well. I imagine that as people move forward in their profession, they become team leaders, whether it’s in a small community or overseeing people who work for them. Having this ability and this paper as a tool, is important. I wonder if you could speak to this point: 

The present series of patients also presented evidence of childhood experiences that taught them the power of displays of suffering and threats of self-harm to influence others. Frequently, one or both parents had used such methods of appeal or coercion in other instances. Strong self-destructive urges, while not manifesting in the parent's overt behavior, had featured prominently in their fantasies and dreams (Burnham, 1966, p.112).

Ruffalo 

Yeah, I think it just makes sense that in the context of neglect, a child might learn to resort to all sorts of means to garner love, attention, and sympathy. So, I think this is often the seeds or the root of some of what we describe as manipulation. And I think this is an important way of understanding it.

Puder

And when we think of manipulation, we often think of someone manipulating us to get money, sex, or control. But this isn't necessarily what we're talking about here. We're talking about manipulation with the goal of having you as a love object, this stabilizing force internally, the soothing mother for them. This perspective helps us have more compassion for the tactics they use. A lot of this isn't conscious— they don’t realize they’re doing it. I'm also reminded of stories of sociopathy, where someone was born into a family with a father who was a conman, and they ended up doing similar things. Perhaps their parent used illness as a way of regaining connection. Maybe the mother threatened suicide when she needed something. Some of these behaviors may have been caught, not learned consciously.

It's not about shaming that, but about understanding it.

Ruffalo 

Yeah, I think of somatic or hypochondriacal symptoms often developing this way. If a child's emotional needs weren’t attuned to, if they weren’t listened to emotionally, but instead a parent would bring them to a doctor at the first sign of a cough or fever, unconsciously, the child may start to exhibit physical symptoms to garner emotional attention and love. It’s a powerful idea.

Puder

Yeah. And I think the skillfulness determined how well they probably were able to achieve that. They talk about how ‘She further exemplified the care she desired by ministering to substitute objects, including live pets or cuddly toy animals. For instance, she would embrace and rock one of these, saying, ‘She is frightened and wants to be held’ (Burnham, 1966, p.113). I had one attending who said, you know someone likely has borderline personality disorder if they come into the office with a stuffed animal.

Ruffalo 

Yeah, I heard the same thing at Pitt. It was very commonly said, and I think there’s truth to these notions that have been around for decades.

Puder 

They talked about how they described their room- one patient even tacked on the wall, pelts of pets that had died. You can think about these as transitory objects, love objects from the past.

Ruffalo

Again, to sustain the patient, right. In the failure of evocative memory, to go back to Adler, the patient needs some tangible representation of a good object. I've heard of patients who will hold on to something that reminds them of their partner when their partner is gone, to remind them that their partner still exists in the world. It could be a small gift or something they hold in their pocket—some type of souvenir that the patient can use to conjure up the mental representation of the partner in the absence of the other person. So, in this case, the pets on the wall could be something akin to that.

Puder

A staff member once commented, "Going into her room is like going inside her." The urge to create an all-good world of perfect constancy was clearly evident.  The quality which she most desired in the supplies was genuineness. Again and again, she sought proof that they were real, not pretended, but her doubts never seemed quite fully allayed. Repeatedly she said explicitly and implicitly, "You don't really care. If you did, you would do something to prove it more tangibly (Burnham, 1966, p.110).

Ruffalo 

Yeah. This touches on what the psychiatrist Grotstein talked about when he was describing the "black hole." He used this metaphor to describe the futility of satisfying a patient who’s plagued by this type of problem. It's sort of like pouring into a glass with no bottom—there's nothing that can be said or done that truly allays the patient's abandonment anxiety. The patient always requires more and more proof from the object that you're not going to leave them. And sometimes, this is asked explicitly in therapy. I have patients who ask me, you know, sometimes weekly, "You're not going to retire, are you? You're not going to move, or you're not going to fire me, are you?" And that may allay their concerns for a short period of time, but as Grotstein would say, it’s like a black hole phenomenon.

…01:28:52

Puder 

I recently did an episode on OCD (Episode 228), and they talk about not reassuring the patient, but sitting in the doubt. I wonder if that's how we should approach that type of anxiety.

Ruffalo 

That's interesting. Yeah.

Puder 

It's almost like it's really distressing. I think this is what Dr. Tar would say, what he taught me. It's so distressing to think that I might leave, and I just want to sit with you in that distress. Then I'll keep reading from this article: 

“If you really cared, you would give me more than talk." She spoke of many earlier experiences in which the actions of others had belied their words. Her word-wariness and seemingly insatiable desire for something more, of course, presented difficult problems in psychotherapy  (Burnham, 1966, p.113).

Ruffalo 

Yes. Words are not enough. You need to show me. I think that's a pervasive communication in these patients.

Puder 

They go on to sharing secrets. So you can start to see where this is, where there's some slight boundary violations. There may be some places for sharing stories from your own life, but for her, the appeal was sharing secrets and receiving secrets. As Maine termed them:

 …The precious little jewels of information, while telling each that this information was something she had been unable to tell anyone else, and extracting from each a promise that the secret would be revealed to no one else. Thus secrets were offered, and frequently accepted, as a valuable token of trust and esteem, creating a two-person secret society (Burnham, 1966, p.113).

This idea of secrets was later somewhat dismantled when the staff would come together in sessions and realize that multiple staff members had received the same secrets. So, it was a way of connectedness that was common.

Ruffalo 

Yes. "I'm going to tell you something I've never told anybody else"—in reality, I've told multiple others this exact thing, but yes.

Puder

Another side to the patient's bestowal of secrets was her encouraging her confidants to reciprocate by confiding in her. She implied that this would go far toward proving their trust and esteem of her. She further encouraged confidences by a remarkable, though uneven, capacity for empathic reading of the inmost thoughts of others  (Burnham, 1966, p.114).

These patients are often very sophisticated in reading the room, picking up on small grudges between individuals. Exploiting those grudges, gathering secrets about staff members, and potentially using those as weapons.

Ruffalo 

Yes, this is what’s often referred to as triangulation. Much of it is motivated by unconscious forces, but it manifests as attempts to divide and conquer, reflecting the underlying pathology.

How BPD Bargains & Projects Unconsciously 

01:32:27

Puder

The next topic is the "bargain." 

A special feature of “the appeal” was “the bargain”, which as offered by the patient and accepted by the staff, was largely unspoken and perhaps largely unconscious. It involved the patient offering the implicit promise that not only that her needs were temporary and satiable, but also that if they were met, she would become well. “If you will temporarily be a good mother to me, I will then become strong and self- sufficient, even to live up to my potentialities.” (Burnham, 1966, p.114).

This dynamic becomes challenging for the provider because it demands breaking the normal frame of care. The patient conveys that colluding with her in a special type of relationship is what will be healing.

And, and this is where I think as providers, we need to be very sure that our normal way of doing things is sufficient. 

Ruffalo 

Exactly. What’s communicated is essentially, "I need you to bend or break the rules for me." The implication is that if you really cared about me, you’d do so. If you truly wanted to help me, you'd deviate from your established practices. Practically, this might look like texting or calling outside of sessions, meeting in non-clinical settings like parks or restaurants, or doing something outside the standard therapeutic framework. The unspoken bargain becomes, "This deviation from the norm is essential for my healing."

Puder 

And I’m thinking: is it behavioral therapy to meet a patient in a park if they're anxious about going to parks? Maybe for someone with OCD, but not necessarily for this type of patient.

Ruffalo
Sure. This is why diagnosis is so important. Not every patient is treated the same way. There’s so much anti-psychiatry rhetoric out there, but this is one of the most important aspects of diagnosis in terms of psychotherapy. Treating a personality-disordered patient is very different from treating someone with other types of pathologies. I was just reading Kernberg yesterday, and he discusses how, in less severe pathologies, there’s often a blurring between psychodynamic and supportive psychotherapy. But when we're dealing with severe personality pathology, it requires a different approach.

Puder 

I think one thing we may not fully address is how through this special relationship with the patient, there’s a dynamic where they can turn you against another staff member. What happens is, because of the intense self-hatred that the patient carries—the cutting, the self-harm—it needs an outlet. That inner conflict and badness have to be directed somewhere. It’s like they want you to align with them, to collude with their own anger and vitriol, and project that onto another person. So, the other staff member becomes “all bad,” in their eyes. They split, and that internal conflict manifests outwardly—through self-harm, through their interactions, and even in their dreams. 

Ruffalo 

Yeah, I think Gabbard has commented on how a patient's projection of their own internal conflicts can serve to alleviate those conflicts when they see them externalized—manifesting as conflict between staff members. The projection of inner turmoil onto others becomes as a mechanism for resolving unconscious forces within the self.

Puder 

The paper touches on this further, particularly the concept of splitting. It discusses how team meetings became a critical tool in managing the splitting dynamic. This aligns with approaches like mentalization-based therapy and DBT. Marsha Linehan, the creator of DBT, once said at a conference that if you're not meeting as a team regularly to discuss these patients, you're not actually practicing DBT.

As leaders—because I consider all my listeners to be leaders—you're instrumental in facilitating teamwork and addressing splitting dynamics.

Provider Education on BPD & Closing Remarks 

01:37:46

Puder 

One of the things that stood out to me is that you may enlist colleagues to meet the patient’s needs. Your own internal regulation can reach a point where you are no longer able to meet those needs. It escalates to where you start seeking more and more support to help you regulate. I remember a colleague coming to me who was completely dysregulated after working with one of these patients. He didn’t even know she had borderline personality disorder. He had completed an entire counseling degree and had never been taught how to treat it.

Ruffalo 

Such a failure of education. It's very unfortunate. Very unfortunate.

Puder 

Even just saying, “This person has borderline personality disorder,” was a revelation for him. He looked at me with this expression, like, “What is that? And how do I treat it?”

Ruffalo 

It's very unfortunate. Very unfortunate.

Puder 

He got some books on different ways of treating it, and he’s doing good work now. It’s been several years, and the patient is thriving, at least the last time I spoke to him. So one of the things they comment towards the end of this paper was that sometimes the group meetings were not enough. And so have some compassion for yourself as a future provider, as someone who will be a part of teams.

“In outlining the benefits from these group meetings, it would be inaccurate to leave the impression that they were a sure..fire cure-all of the splitting problem. This they were not; sometimes they foundered or totally collapsed” (Burnham, 1966, p.122).

This was awesome. I feel like if we had another hour, we could do justice to the rest of the article. But you’ll have to check it out yourself. On my website, psychiatrypodcast.com, we’ll link the full article, so you can go there and read the whole thing.

Ruffalo 

Definitely. I encourage your listeners to read it. It’s, you know, 49 years old now—1966, right? At first, you might think, "Oh, it’s outdated," but no, there’s real gold in this article.

Puder 

Yeah. And what I appreciate about you is that you don’t neglect these older, valuable articles. I’d love to have you on again, maybe to go through more of them one at a time and really do them justice. There’s so much wisdom in these historical works. Honestly, I could see this as a great CME opportunity—you know, continuing medical education credits—because it’s so in-depth. And even though this article is 50 years old, it has timeless insights. I was thinking about how history is essential. You can’t have a philosophy or theory without grounding it in historical facts. This author and the research team did a good job summarizing the dynamics of 12 patients who effectively split the unit over a 10-year period. They captured it in a qualitative way—not with a lot of statistics, but through early qualitative research, which is the foundation of so many great papers.

Ruffalo 

Absolutely. The foundation of psychiatry, psychopathology, and psychotherapy was qualitative work and case studies. If you don’t know the history, you might think you’ve invented something new, when in reality, it’s been explored for decades—sometimes even a century or more.

Puder 

Exactly. That’s the “grandiose naivety,” right? It’s probably why you and I won’t create our own schools of therapy. We recognize that we’re not better than the greats who came before us. There’s just so much value in learning from them.

Okay, we’ll leave it there for today. Thank you so much for coming on—I really appreciate it. Now we’re off to enjoy some steak.

Ruffalo

Yeah. Thanks so much for having me. Been looking forward to this and appreciate the opportunity.

Puder 

And I heard you’re thinking about writing a book that compiles many of these excellent papers.

Ruffalo 

We're in the early stages of that right now, but yeah, I think it's gonna be an ‘essential papers’ sort of book on BPD where I write an introductory chapter and sort of try to weave all the theory together.

Puder 

Let me just plug you here—you didn’t ask me to do this, but Mark L. Ruffalo. You can find him on Twitter, or X. He’s worth following to learn from the articles and insights he shares. Okay. We'll leave it there. 

Ruffalo 

Thanks David.

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