Are People with Borderline Personality Disorders Defective at Reading Others, Or Superior?

One of the current theories about what creates borderline personality disorder is that somehow they are defective in their ability to mentalize, or have an accurate “theory of mind.” This means they do a poor job of figuring out what is going on in the heads of other people. In studies, this is mostly found on tests where they are supposed to read faces or interpret videos of people in various activities. 

I always thought this idea was very amusing in light of the fact that, in my extensive experience speaking with other therapists as well as in my own experiences, these very same people are so good at drawing three particular responses from therapists: a sense of anxious guilt, anxious helplessness, or fury. They are so good at it that they make most therapists hate them. They can ascertain the therapist’s weak points, and then go right for the jugular. How can they be bad mentalizers if they can do that?

When you live in an unstable, confusing environment in which double messages are flying back and forth and you can’t really predict what mood a parent is going to be in when they drop in on you, you become better at reading others than most people so you can quickly adjust to any new contingencies. And as I have repeatedly pointed out, error management theory would predict that you would err on the over-reacting rather than under-reacting, because the consequences of minimizing parental guilt and hostility are so frightful. This normal tendency is then mistakenly seen as something pathological.

Another big issue in research in personality disorders that bears upon this issue is that when patients are in studies responding to various stimuli in the study situation, they may be responding with a false self or persona (as described by psychoanalysts Jung and Winnecott)—in this case, the spoiler. This is, as my readers know, a role I believe they are playing to maintain smooth family functioning (family homeostasis). This makes them look impaired when in fact they are not. Performance is not the same as ability, as I described in a previous post. If you are not a good actor in situations in which fooling people is paramount, you wouldn’t be very good at doing so.

And to effectively play the role of spoiler, you have to make yourself to be way more impaired than you actually are. In particular, you have to pretend that you lack the ability to see both the good and bad in people simultaneously (so-called “splitting”), or evaluate both their strengths belied by their reputation among therapists for being master manipulators!! Deficient mentalization, huh?

One new study (Bora, “A meta-analysis of theory of mind and 'mentalization' in borderline personality disorder: a true neuro-social-cognitive or  meta-social-cognitive impairment?, Psychological Medicine. 51(15):2541-2551, 2021 11). of so-called mentalization “abnormalities” was based on a review of the existing literature. The author just assumes that what the studies see is “maladaptive” and therefore abnormal, but found no evidence of any primary neuro-social cognitive deficit! Hardly surprising in light of what I just wrote about. Instead, the author attributes the imaginary abnormality to their “meta-social cognitive style,” whatever that is. Again, it’s as if these patients exist in some social vacuum where certain assumptions would always be completely highly adaptive for anyone who didn’t have a deficient “theory of mind.”

A second study (McLaren, V. et. al. "Hypermentalizing and Borderline Personality Disorder: a Meta-Analytic Review, American Journal of Psychotherapy 75(1): 21-31) looked at "hypermentalizing" - the tendency to overattribute mental states to other - and found it was common in a wide range of disorders rather than in borderline personality disorder in particular. 

Personality Disorders: Researchers Continue to Make Misleading Assumptions

In this blog I have discussed several instances of researchers making unwarranted assumptions about both their study populations and in interpreting their results in a variety of ways. In this post, I’d like to focus on three recent articles about personality disorder research. The first is a possible refutation of a common presumption, while the second two assume facts not in evidence.

The difference between “cannot” and “do not:” Confusion based on lack of attention to subject motivation, and ignorance of the concept of “false self.”

Shane MS; Groat LL. “Capacity for upregulation of emotional processing in psychopathy: all you have to do is ask.” Social Cognitive & Affective Neuroscience. 13(11):1163-1176, 2018 11 08.

Could it be that a psychopath’s apparent lack of ability to be empathic stem from differences in motivation rather than ability? This article is certainly possible evidence that this is the case. Perhaps people who routinely engage in anti-social acts suppress empathic responses because that is their role in their family. That what has been observed results from subjects’ false selves? 

This study of course does not address that latter issue, but thinking about it certainly suggests something which could explain the results. (Of course, it would help in that endeavor if we could read minds, because the thing about a false self is that it is based on someone lying to themselves in order to fulfill a social function, so they are highly unlikely to tell experimenters the truth during a short interview).

In any event, in this study, high-psychopathy participants showed typical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

The locations of these increased neural responses included several brain regions involved in the generation of basic emotional responses and which have often been shown to be reduced in psychopathic populations. Thus, despite baseline differences from non-psychopaths,  high-psychopathy participants appeared capable of deliberately manifesting emotional responses to the negatively toned pictures within several brain regions believed to underlie emotional processing. 

Of note was that the magnitude of these deliberately evoked emotional responses was comparable to levels exhibited by low-psychopathy participants’ during passive processing.

A high index of suspicion versus an “inability” to correctly read the mental states of others

Quek et. al., “Mentalization in Adolescents with Borderline Personality Disorder.: a Comparison with Health Controls.” Journal of Personality Disorders, 33 (2):145-165, April 2018.

Mentalization refers to an individual’s capacity to understand and interpret the meaning of one’s own and others’ behavior by considering underlying thoughts, feelings, intentions, and desire. As in other studies, this was “measured” in adolescent subjects with borderline personality disorder (BPD) and normal controls while interpreting the mental states of others shown in pictures, videos, and narrative vignettes of people in various social situations.

The authors of this paper mention almost in passing that the ability to mentalize  is thought to develop within the context of, and is dependent on, the quality of infant- parent interactions. In the experiment, the differences between the performance of the BPD subjects compared to the control group on the various tests became much greater when the material they interpreted suggested attachment-related stress or arousal. 

Additionally, the major differences between BPD subjects and controls seemed to primarily involve what the authors describe as hypermentalization (that is, making much more complex inferences than expected about social cues, signs, and mental states) by the BPD subjects, rather than through a loss of detail.

Despite all this, the authors don’t seem to consider the obvious possibility that attachment figures’ influence on their children’s ideas about the social behaviors of others continues unabated long after they are no longer infants.

So let’s do a mental experiment. How might you evaluate the motives of other people if you were to grow up in an family environment characterized by your being constantly invalidated and given highly confusing double messages about how you are supposed to think and behave, and even being verbally abused— if not physically or sexually abused—if you seem to have guessed wrong about that? Do you think you might have a higher index of suspicion about other people’s intentions than someone who did not grow up in that environment? Do you think you might have more difficulty making sense of other people's behavior? Ya think??

So, do kids with BPD grow up in that environment? Well, in addition to Linehan’s theory of an invalidating environment being part of the etiology of BPD, and my own paper from 2005 (Comprehensive Psychiatry, 46[5] pp. 340-352) which showed that adults with BPD reported about three times the number of double messages from their parents than non-BPD controls, consider the following paper.

Changing parent’s behavior towards BPD children can make those with BPD better—but their behavior apparently had nothing to do with their kids having developed the disorder in the first place

Grenyer et. al., “A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons with Borderline Personality Disorder.” Journal of Personality Disorders 33 (2):214-228, April 2018.

As mentioned in a post on my blog on Psychology Today, researchers into BPD have of late developed an interest in the “burdens” on parents and other caretakers (almost always other relatives) of having a child or adult child with the disorder. Such “carers” are the subject of this particular study, and were recruited through flyers distributed to mental health services, local media, patient advocacy groups, and patient family and support networks. The recruits were put into groups and given a lot of “psychoeducation” about their charges.

The first thing that jumped out at me in this paper was the fact that, even though the carers were evaluated for being critical and over-involved with their BPD children, there was nothing mentioned about seeing if the parents had been guilty of physically or sexually abusing their charges when the fledgling BPD patients were children. This, despite the fact that every empirical study done on this subject in BPD patients finds a high level of significant abuse history. Of course, parents who respond to flyers and volunteer to be research subjects in this sort of study are highly unlikely to have been seriously abusive. So right away, the experiments are selecting for a somewhat atypical sample of parents of children with BPD.

The second thing that jumped out at me was that the psychoeducation provided for the subjects was supposedly based on Bowen family therapy theory, when the researchers mentioned and seem to know absolutely nothing about one of the major tenets of that theory. You know, those that involve intergenerational transfer of dysfunctional family patterns. The researchers mention nothing about the parents being somewhat responsible for the development of the disorder in their kids in the first place!

That they seem to make this assumption is even more awe-inspiring when you look at what was being taught to the parents and which apparently led to improvement in the BPD child’s behavior as well as in the parent-child relationship. They were taught to:

1.      Be non-judgmental, validating, attentive and appropriate.

2.      Reduce their reactivity and try to remain calm and “mindful.”

3.      Attend to their own needs through staying connected with friends and family, attending to their own physical and mental health, and taking breaks.

4.      Model appropriate assertiveness and setting appropriate boundaries and ground rules for the relationship.

5.      Get outside help when crises arise and having a crisis plan.

So, if they had to be taught these things, and if doing those things leads to improvements in their children, maybe the fact that they were doing the opposite of those things all the time previous to the experiment was what was creating their child’s problems in the first place. Exactly what you would expect considering the family dynamics of BPD.

Intrapsychic Conflict and Dysfunctional Family Patterns

There have not been a lot of studies done looking at how personality problems affect individuals over three generations within a family, and how they may be passed down from one generation to the next. Today’s emphasis is studying mostly biogenetic factors.

However, the few studies that have been done generally show the same types of things. Although there is never a one to one correlation (because people’s development is affected by the chaotic interactions of thousands of different variables – genetic, biological, interpersonal, and sociological), certain issues are highly likely to be passed down.

Earlier studies have shown what is known as intergenerational transfer of certain types of dysfunction for, as examples:

• Boundary disturbances such as maternal overprotection and relationships characterized by lack of affection, enmeshment, and/or parent/child role-reversals (Jacobvitz et. al., Development and Psychopathology, 3, 513-527, 1991).
• Emotional dysregulation with poor disciplining skills with children (Kim et. al., Journal of Family Psychology, 23(4), 585-595, 2009).
• Substance abuse with parental substance abuse combined with abuse and/or neglect and low levels of family competence (Sheridan, Child Abuse and Neglect, 19 (5), 519-530, 1995).

In understanding this process, I try to incorporate concepts from different "schools" of psychotherapy. The most important task in integrating different psychotherapy models is to pose the question of how concepts from different therapies might relate to one another, and how slight modifications to specific aspects of these concepts may make relationships between them more clear.

In this post, I will focus on the relationship between several such concepts. We have the concept of intragenerational transfer of dysfunctional behavior from Bowen family systems therapy. Then we have a primary concept from psychodynamic therapy, intrapsychic conflict. People have conflicts between their innate desires and the values they have internalized as they grew up within their family and culture. 

To see how these two concepts can both be valid and also when combined explain certain human behavior, we can take a closer look at the intergenerational transfer question.

The attachment theorist Bowlby first suggested that these transfers occur, not through specific observable behaviors like “abusiveness” or psychiatric diagnoses per se, but through the generation of mental models of interpersonal behavior in the affected children. These working mental models are now called schemas by both psychodynamic and cognitive-behavioral therapists. They are also subsumed under the rubrics theory of mind or mentalization by another set of psychodynamic therapists. We need to look at the subjective experiences of the involved children throughout their development.

Zeanah and Zeanah (Psychiatry, 52, 177-196, 1989) discuss the concept of organizing themes. They mention that studies show that abusing mothers tend to attribute more malevolent motives to their own children compared to other people’s children. More generally, they react with more annoyance and less sympathy to videotapes of crying infants than do non-abusive mothers. To think that these patterns would not be noticed or sensed by children through their daily interactions with their parents, and would not affect the development of their schemas, would be extremely naïve.

In turn, abusive mothers reported more threats of abandonment and role reversals with their own mothers than did control mothers.

These findings are probably the tip of the iceberg in terms of subtle characteristics of repetitive parent-child interactions, and as the Zeanahs say, “Patterns of relating are considered to have more far-reaching consequences than specific traumatic events” (p.182).

When Bowen therapists started doing the genograms of their patients, which describe family interactional patterns over at least three generations, they noticed something that has not really be described much in empirical studies. While some children of dysfunctional parents had problems that were similar to their parents -  such as substance abuse - other children seemed to have developed behavior patterns that were exactly the opposite – they became teetotalers!

I have seen this sort of thing many times in taking genogram-related family histories from my own patients. One son of a workaholic will also be a workaholic, while his brother becomes a complete slacker who can’t seem to hang on to a job, or who does not even bother to look for one and goes on disability of some sort. Or who is enabled by the workaholic father.

In fact, in some families one generation has a lot of alcoholics, the next generation a lot of teetotalers, and the third generation goes back to having a lot of alcoholics. Or impressive successes in one generation are followed by remarkable failures in the next. McGoldrick and Gerson, in their book Genograms in Family Assessment, traced the genograms of some famous people like Eugene O’Neill and Elizabeth Blackwell and readily found such patterns.

If these sorts of issues were entirely genetic, it would be difficult to explain how progeny of the same parents could be so completely opposite from one another, as well as completely opposite from their own parents. So what might be going on psychologically within people that might lead to interpersonal behavior with their own children that generates such bizarre patterns?

This is where intrapsychic conflict may come in. Say a father was a young adult during the Great Depression of the 1930’s. He had grown up feeling that work defined him, and that he was obligated to keep his nose to the grindstone in order to support his family. He was lucky enough to have a job, but his boss made his life miserable. He could not quit because he would not be able to get another job, and therefore he began to subconsciously resent the very values with which he has defined himself.

This could lead him to develop an intrapsychic conflict over hard work which starts to tear him apart. He may relate to each of his sons in a manner that – very subtly - suggests to one son that he too should be just like him, while the other son is subtly rewarded for acting out the father’s hidden resentment towards hard work and self-sacrifice.

Likewise, a patient might come from overly-strict religious parents who had rejected any and all hedonistic pursuits, but who had preached to their child about the evils of alcohol in a highly ambivalent manner. Such ambivalence usually arises in them because of their having received mixed messages from their own parents. Their son may feel pushed to rebel, and therefore lead a licentious, alcohol-drenched lifestyle. Such a person often destroys himself in the process, because if his parents observe him being successful in spite of drinking, this would exacertate the conflict in his parents and destabilize them. This would frighten him. So he becomes a self-destructive alcoholic.

His behavior would be sort of compromise. He would be following the repressed urges of his parents and allowing some expression of them, while at the very same time showing his parents that repressing the urge was indeed the way to go.

In the next generation, his children may “rebel” just like he did, but the only way they can do so is by going to the opposite extreme themselves. They become teetotalers. Their children, in turn, “rebel” by becoming alcoholics.

I’m tremendously over-simplifying this process so the basic outline is clear to the reader, but I see these types of patterns – with many fascinating twists and turns - every day in my practice.

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder, Part I

The purveyors of Cognitive-behavioral psychotherapy (CBT), one of the large number of “schools” of thought in the fields of psychology and psychiatry, like to tout their randomized controlled outcome studies (RCT’s) as proof that theirs is the most “evidenced based” type of psychotherapy. When it comes to the psychotherapy of borderline personality disorder (BPD), which provides a microcosm for almost every type imaginable of behavioral/relationship issues that are confronted by psychotherapists, two of the most studied paradigms are actually related more to what many psychologists consider to be the opposite type of psychotherapy: humanistic/psychodynamic psychotherapy.  Those models are called transference-focused psychotherapy, TFP, and mentalization-based treatment, MBT.  

A third “empirically validated treatment” called schema-focused therapy (SFT), while based initially on some CBT concepts, takes quite a detour from those and employs techniques adapted from a number of alternate psychotherapy schools.

Actually, the one type of RCT-studied therapy for BPD that is most associated with CBT, dialectical behavior therapy (DBT), also borrows considerably from other schools of thought.  Not only that, but it really has been shown to be effective only for a couple of BPD symptoms, most notably self-injurious behavior (SIB) such as self-cutting.

John F. Clarkin is a highly respect psychotherapy researcher who has perhaps the most experience of anyone in the field.  He recently published an article in the Journal of Personality Disorders (Vol, 26 (1), Feb. 2012, pp. 43-62) entitled, “An Integrated Approach to Psychotherapy Techniques for Patients with Personality Disorder.  In it, he makes what I consider several extremely important and crucial points in the debate about the various treatment ideologies.

John Clarkin, Ph.D.

First, he points out, the empirically "validated" models often focus only on symptoms and not on the more important and enduring aspects of personality. In fact, in longitudinal studies of affected individuals, the personality disorder criteria and symptoms change over time, often all by themselves, while their interpersonal dysfunction does not change very much at all.  This implies that that, while symptom reduction is important, it is the interpersonal issues that should be the major long term focus in therapy. The heart of the matter in personality disorders is the patient’s conception of self and others.  The ultimate goal of treatment should be interpersonal functioning that allow for pleasure, interdependence, and intimacy in relationships.

Second, the literature on outcome studies is based on average scores on symptom-based outcome measures. This covers up the obvious fact that in any treatment, some patients change and some do not.  This is further complicated by the issues of “comorbidity.”  Patients with BPD, for instance, often meet criteria for one or more additional personality disorders, not to mention additional psychiatric disorders. And even within the definition of a single personality disorder, many different combinations of traits are possible to arrive at the diagnosis. Much more so than in any other field of medicine, patients with personality disorders are highly unique. Therefore, no one treatment can or will work for everyone.

Third, as Clarkin states, “A close examination of the treatment manuals…suggests that each manual contains some strategies that are unique and essential to the treatment, and some that are common (sometimes with different jargon) with other approaches."

A fourth important point he makes is that all of these therapies consist of multiple interventions, and the studies do not show which ones are important and which ones are not, or even more importantly, which ones may even be counterproductive: “…most probably contain low doses of effective practices, ancillary but important aspects that make delivery of the treatment more palatable, superstitious behaviors (those we think that matter but do not), and factors that impede or fail to optimize therapeutic change.”

A fifth point he makes that I would like to mention is that it is the delivery of the techniques that is often more important than the techniques themselves.  Techniques can be done skillfully, “…or in an abrasive, authoritarian, or uninterested aloof way.  There is plenty of research data that suggests that the skill of the therapist can be, in many instances, far more important to good results that an individual techniques."  Clarkin adds, “The therapist is not a technique-dispensing machine. Many of the techniques are applied common sense, and could be read out of a book."

Last, let us not forget that the receptivity of the patient is another major factor in whether or not therapy is successful.  If patient factors are not taken into account, the effectiveness of any technique “approaches zero.”  Furthermore, despite the rejection of the concept of transference by CBT therapists, “Some patients with severe needs for attachment with no relationships outsider of treatment may become intensely attached to and preoccupied with the therapist in ways that are detrimental to growth.”

In short, it makes a lot more sense to integrate the various techniques across treatment strategies from the treatment manuals in a way that tailors them to the particular patient in front of the therapist.  Throughout treatment, individual decisions must be made, which takes a skillfull therapist indeed. 

Of the four treatment paradigms that have been subjected to RCT’s, in my opinion schema focused therapy does the best job. Of course, the concepts of "mental schemas" and “mentalization” share much in common. (I will not be defining them in this post).  

My own model, unified therapy, has not been subjected to an outcome study. I applied for an “exploratory” grant to get some initial (pilot) data and was of course turned down by the National Institute of Mental Health. That may or may not have something to do with the fact that the only family-systems-oriented reviewer on my NIMH review committee was replaced at the last minute by DBT founder Marsha Linehan. Someone on the panel accused me of not being “mindful” enough.  I wonder who that might have been?

  

But maybe I’m just being paranoid. As Nassir Ghaemi says, the NIMH's "...limited funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known." The study most likely to be accepted by the NIMH is one that has either already been done, or whose outcome is not really in doubt.

To be fair, doing meaningful psychotherapy outcome studies is diabolically difficult. In my book, How Dysfunctional Families Spur Mental Disorders, I went into great detail about a lot of the reasons for this. I’ll summarize what I said in part II of this post.