JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast, and I'm so glad you've joined us today. In this episode, Spencer speaks with Kayla Spicer about Borderline Personality Disorder, psychological diagnostic models, and reducing stigmas and developing self-compassion.

SPENCER: Kayla, welcome.

KAYLA: Hi, thank you.

SPENCER: So, is it true that you had borderline personality disorder?

KAYLA: Yes, I actually got diagnosed about four years ago. I went through the whole dialectical behavior process, doing therapy, and I can say that now I'm kind of on the other side of it. So while I was diagnosed with it, I don't necessarily identify with the diagnosis anymore.

SPENCER: I would say borderline personality disorder is very heavily stigmatized for those that know about it, to the point where I've even heard of therapists refusing to work with people because they told them that they had it. Was that your experience?

KAYLA: Yep, it was actually funny because I did my Master's in Counseling, and while I was doing my master's degree, I had a lot of professors in our psychopathology classes talking in highly stigmatizing ways about borderline personality disorder, talking about clients that they had, or really encouraging us to not take on those clients. Of course, my professors didn't know that I was struggling with this myself, but it's been my experience in terms of school and also just people are misinformed, or maybe therapists don't really know about the disorder as much as they should.

SPENCER: And why are therapists afraid to take on clients with borderline personality disorder? Obviously, there are some that will take them on, and there are some that even specialize in it. But why is that a relatively common phenomenon?

KAYLA: I think because when we think of a stereotypical person that is borderline, we think of someone that has a lot of emotional volatility. They can be really unpredictable. They can be really rigid in their thinking. From the therapist's perspective, if we're thinking of this traditional notion of BPD, I think that they are not inclined to work with them, just because the emotional toll can be really heavy. I can totally understand that. At the same time, it's just not accurate to say that all people with borderline present in the same way. I think that part of encouraging mental health professionals to be more open is to just speak more accurately about the disorder.

SPENCER: Now, throughout this conversation, we might sometimes call it borderline personality disorder, or sometimes call it BPD, just so the listeners are aware of that acronym. I had a friend who is a therapist who actually specialized in working with people with borderline personality disorder, and I remember one time she was coming to meet me for coffee, and she was really late. She said, "I'm so sorry. I'm so late because my patient was saying they were going to kill themselves, and I had to pull over to the side of the road." I suspect that the link between suicidality, or at least suicide attempts, and BPD might be one of the reasons why therapists are reluctant to take these patients on. Would you agree with that?

KAYLA: A hundred percent. Because I think what research shows is that about 70% of people diagnosed with BPD have attempted suicide at some point in their life, and of those 70%, there are about eight to ten percent who succeed. It can be really heavy emotionally as a therapist. It's kind of the reason why, when we're doing DBT skills groups as therapists, one component of it is that we are required to do a consultation with other therapists to have a support network, because it can be so challenging.

SPENCER: Those re shocking statistics, the frequency of suicide attempts with BPD. Could you tell us a bit about your story? How did you come to find out that you had BPD? What were the signs, and how did you get diagnosed?

KAYLA: For me, for as long as I can remember, I've always been very sensitive. I was really anxious as a kid, and I repressed my feelings a lot. I remember in high school feeling like I didn't fit in anywhere. People didn't understand me. Even though externally, you would never guess those things, internally, it felt very tumultuous. I felt very different from other people. I dealt with a lot of emotions that would cycle up and down. What's difficult is that when you are a teenager, you don't necessarily attribute those things as being problematic, because most teenagers deal with impulse control issues or not knowing who they are. It really wasn't until I started dating my husband that it became clear to me for the first time, when I was dating someone that was secure, that the behaviors I was exhibiting weren't necessarily normal. In my past relationships, I wasn't with people that were securely attached, and we would reinforce each other's patterns. It was through dating him, and then during a summer, I took a personality course at university, and I learned about BPD for the first time. I remember coming home and telling him, "I think that I have this thing. I learned about this in my class today, and I can relate to all the symptoms and signs." From that point on, I decided, "Okay, if I do have this, I want to get diagnosed, and I want to get help for this, because I'm not going to be able to maintain healthy relationships if I don't change." It was a combination of dating someone that was securely attached and finally being made aware of what BPD was. That was the aha moment of, "Oh, okay, I finally can put my finger on my experiences."

SPENCER: Is there one specific example that stands out that, looking back in retrospect, you think, "Ah, that scenario really suggests that I had BPD"?

KAYLA: This is kind of the example that I always go back to, and this is what I tell clients often. One of the things with BPD is that typically there is a high sensitivity to rejection or abandonment. I remember one instance where I was doing the dishes, and my partner had said something along the lines of, "Hey, Kayla, do you mind when you put the dishes away? Can you place them in this certain fashion instead of the way you're doing that?" At that moment, I felt completely rejected as a person. It went from zero to hundred in my feelings, feeling like, "Wow, I'm such a bad person. I'm not good enough. I can't even put the dishes away correctly. This person doesn't love me. They're wanting to leave me because of this." It turned into a whole argument. At the time, I wasn't able to realize what was going on, so I got very defensive. I was attacking the other person when, in reality, I was just feeling rejected, and I was scared that because of this, this person was going to leave me. When you look at this example, it's pretty evident that it doesn't match the facts. We have this sense of not being good enough fundamentally, so criticism can feel like a form of rejection or abandonment, and that's why sometimes moods get so dysregulated.

SPENCER: Yeah, I think that's a really good example. When I think about BPD, I feel the attachment is really at the heart of it. I'm curious if you agree with that, that intense attachment to a person, where their opinion of you feels like the most important thing in the world.

KAYLA: For sure, it is a disorder of attachment. It's also what I like to say, a disorder of perception in that individuals may experience, at times, very real triggers. Generally speaking, with BPD, what we do see is distortions in how situations, others, or even themselves are perceived, which can contribute to heightened mood swings or interpersonal difficulties, but all of that stems from a feeling of being inadequate, of being unlovable. When you understand it through that lens, it's much easier to have empathy for people who have BPD because it's an attachment wound.

SPENCER: The idea of being abandoned by the person that you're attached to. What was that experience like for you? If you start to think, "Oh, maybe this person doesn't like me or is going to leave me."

KAYLA: It was panic-inducing, to say the least. I think there's a tendency for me to fluctuate. I do think this is a pattern that I see with people that have BPD of this "I hate you, don't leave me" kind of fluctuation between avoidance and dependence. There were attempts to push the person away, maybe through self-sabotaging or feeling like I don't need them. When they would show signs of wanting to leave, with my husband and I, while we were dating, we had multiple conversations about how hard this was and whether or not this was something he wanted to pursue. In those moments, I felt like I needed to change and do anything I could so this person wouldn't leave me. We would fall into this pattern where he would get fed up, understandably so, and then I would promise that I was going to change. I would go really hard on therapy for a bit, and then I would kind of stop and feel like, "Well, maybe I don't need this person anymore." Then we got stuck in that cycle for a bit.

SPENCER: Could you explain the concept of a favorite person? This is to understand this terminology that people in the borderline community tend to use.

KAYLA: It's really this notion of having a person that we depend on almost fully. Earlier, when I talked about BPD being an attachment disorder, when we're little, we have primary attachment figures, typically parents or caretakers. It's almost like in adulthood, we're always trying to recreate that and get that sense of security from other people. It's the reason why there is that tendency to latch on to this favorite person, to this person that can do no harm. We idealize them. We feel like without them, we can't function. Because, again, if you don't have that secure attachment with yourself, you will be hyper-dependent to find that sense of being okay or being lovable through others.

SPENCER: People often associate the idea of a favorite person with a romantic partner, but could the favorite person be a friend or family member as well?

KAYLA: Yeah, of course, it could be anyone that you feel you have a deep sense of attachment to. Sometimes a favorite person can also be someone that they don't necessarily know that they are that person for you.

SPENCER: So you kind of see the relationship as being much closer than they might. I imagine that must be especially painful in a way because they are really going to reject you, genuinely, not just you're going to perceive them as rejecting you.

KAYLA: I do think that part of it is, again, the self-sabotaging coming in. If you don't feel that you're good enough, then maybe you will be more likely to select people in your life that make you feel that way. It would make sense to select your favorite person as someone who is unavailable to you.

SPENCER: In your experience, do people with borderline personality disorder sometimes have multiple favorite people, or is it really like there's one person they hone in on and attach to?

KAYLA: I think it's pretty individual to the person. What I will say is I don't see it being a pattern of having, let's say, 10 favorite people, so maybe in the range of one to three, but no more than five. I think maybe some individuals, but it's not the typical pattern that I observe.

SPENCER: For someone with borderline, what does it feel like when they have no favorite person? Let's say they just had a breakup six months ago. There's nobody in their life that they're sort of attached to right now.

KAYLA: I think this is where we see a lot of those suicide and self-harm behaviors come into play with BPD, the risk-taking and stuff. It's a response to feeling so distressed emotionally. There might be a flare in self-harm or suicide attempts. There might be use of substances. Substance use disorder, for example, is highly comorbid with BPD, so there might be an increase of those things, basically an increase of maladaptive coping mechanisms to deal with the fact that they now feel completely alone.

SPENCER: Would you say it's fair to think of the favorite person as providing their sense of self-worth? So without a favorite person, they're just sort of like, "Well, what's the point? I'm unlovable. If nobody's attached to me, then why do I even exist?"

KAYLA: Yes, because a big part of having the disorder is having an unclear sense of self. If you don't know who you are, and the only worth that you attribute to yourself is negative, then you need other people to tell you your worth in the world. It's also interesting that there's a big overlap with perfectionism and borderline, where there's a lot of emphasis placed on their performance in the world and what they can give in order to feel good enough. So we might see perfectionism also as being a compensation behavior for BPD.

SPENCER: So I'm trying to get myself into this sort of mental state of someone who has borderline, and what I imagine is suppose that I thought that I was worthless unless I could get a person to value me, and then that was such an important thing, so incredibly important to me, that even the tiniest bit of evidence that that person no longer valued me would basically imply that I'm completely worthless. Does that seem like the right kind of way of thinking about this?

KAYLA: That's a great way of thinking about it. Marsha Linehan, who is the pioneer in dialectical behavior therapy, uses the analogy of those having BPD as having a third-degree burn covering 90% of their bodies, and so they don't have that emotional skin to deal with the difficulties of managing relationships, and their reactions are much bigger, because touch to them feels so painful, whereas the same touch or pressure to someone that doesn't have the third-degree burn wouldn't get that reaction. It's being very, very sensitive to the world, very sensitive to rejection from others. It's really always looking for a threat, and sometimes creating that threat for ourselves, because we, in some weird way, feel the most secure in feeling abandoned, because that's all we know.

SPENCER: As I understand it, that emotionality is not just linked to attachment. It's that borderline people tend to just be very emotional in general, very intense lows, but also potentially very intense highs; they might actually just be reactive in both directions to things happening in life. Would you say that's accurate?

KAYLA: That is definitely my experience for my own life, but also what I've observed in others; it's feeling the highs very intensely and feeling the lows really intensely as well.

SPENCER: I've seen a number of interviews with people at borderline, and one thing that struck me as fascinating is that some of them found it hard to give it up. As they were seeking treatment, they were kind of attached to their own highs and lows. "I want to feel the world deeply. I want to feel ecstatic. I want to feel the deepest throes of sadness when I lose something." There's something about that intensity that maybe is even appealing.

KAYLA: Yeah, and I think that we can have the intensity without it being ineffective, in the sense that I do feel as though my sensitivity and my capacity to experience things fully is a gift. It is what allows me to be a therapist and to connect so deeply with others. I would never want that to be taken from me. I wouldn't want that to be taken from others. It's just about learning how to master our gift so that we can utilize it for the best, for our own good and for the good of others.

SPENCER: Because that high sensitivity could be very valuable. You might be more perceptive at picking up on other people's emotions, which can be a really useful skill in many domains. Also, it's just a wonderful thing to feel your positive states really intensely, or to grieve really intensely when someone dies. These are not necessarily bad things in and of themselves.

KAYLA: No, definitely not. And again, as I said, it's just about our capacity to be effective with our feelings and our states and to be more in touch with reality, so to not create stories around scenarios that are happening, and to be more realistic with the scenarios or interpersonal situations at play. I think that once you have a good grasp on those things, then you can feel your feelings fully without it impacting others as much or yourself as much.

SPENCER: Something that links all personality disorders together, as far as I understand it, is that there's something happening to the person's identity that's unusual, where they lack a strong sense of identity that's independent of everything else. Most people go about the world and they know who they are, even if they were alone in the woods for six months with no human contact, they know who they are. But people with personality disorders tend to struggle with. How would you describe that kind of idea of lacking a strong, independent identity?

KAYLA: I think when it comes to personality disorders, if we're just thinking of the Diagnostic and Statistical Manual, they're defined as enduring patterns of thoughts, behaviors, and emotions that are rigid and inflexible, that are pervasive across various aspects of life, and that emerge in adolescence and early adulthood. So that is how they describe personality disorders, lacking a sense of self. I think that with personality disorders, there is a biological basis. What we do see is that often people who get diagnosed with personality disorders have endured trauma in their childhood. We know that when we are trying to figure out our mental models of the world as children, when we are not exposed to things that are coherent or that can make sense, it can become really destabilizing to make sense of things. I think that lacking a clear sense of self, in part, comes from the fact that the world around us doesn't make sense growing up. That's a childhood wound that gets carried into adulthood and transformed into other things.

SPENCER: If you're comfortable talking about it, do you feel that you have childhood experiences that impacted your sense of identity?

KAYLA: I think I was always someone that was genetically very sensitive and anxious. At a young age, my mom passed away from cancer, and dealing with the grief when you're a child and not really understanding what that means, and growing up without a parental figure was really difficult. Because of that, there were a lot of consequences that happened in our family that made home sometimes feel like a place that wasn't necessarily safe, not because there was any abuse, but because there was just no space for anyone's feelings because everyone was grieving, and it felt like no one was there to help just because they didn't have the tools to do so. It led to me internalizing everything and feeling like I had to be quiet and repress my feelings, not feeling validated emotionally, becoming really hyper-performant so that I could get attention in that way. I would really say that that is the trauma that I live with, that I think propelled everything into becoming so much worse for me as an adult.

SPENCER: Did you grow up feeling that you were unlovable?

KAYLA: Yep. I remember feeling that way. Given that my dad was a single parent and I had two other siblings, I was the kid who was able to take care of herself and was very independent, but because of those things, it felt like I got forgotten and that there was no space for me. I remember there were times that I would be upset or crying, and I was met with rejection or told that there was no time for me. In those moments, I felt very unlovable. I felt like there was something wrong with me, but I couldn't put my finger on it. To some extent, I do feel that with my mom passing away and not having anyone really explain what was happening, it felt like a form of abandonment, even though, of course, it wasn't her fault, and she didn't want that.

SPENCER: Do you feel that you kind of learned to try to get that sense of self-worth from the people around you, from your family members or friends or others?

KAYLA: I learned to get my sense of worth from being hyper-performant, so just doing really well in school, to get that tap on my shoulder, to have that praise, and finally have people tell me, "Wow, I'm proud of you, and look how smart you are." I think I got a lot of praise for the things that I was doing, but I never really felt praise for who I was as a person, so I felt like I always needed to achieve and get the next big thing so that I could continue feeling good enough.

SPENCER: So it wasn't that you're good, it's that if you do these things, then you'll be good, but then you just have to go do the next thing to kind of prove you're good again.

KAYLA: Exactly. So it's a never-ending cycle, and it's exhausting.

SPENCER: One of the traits that's associated with borderline that we haven't discussed is this idea of splitting. Can you tell us what that is?

KAYLA: Splitting is a defense mechanism that we see in people with BPD. It refers to this tendency to see people, situations, or even yourself in an extreme, all-or-nothing way. You might view someone as being all good or all bad, but there's not really any room for complexity or any gray area. I do think that this, again, stems from the fact that most people who have BPD have experienced trauma. In childhood, as a kid, it's really difficult to make sense of people being so good and bad at the same time. For example, we see kids who watch movies and think of superheroes and villains, but we don't really have space for, "What about the villain who is also struggling?" Or, "What about the superhero who also did something bad in his past life?" To give a more specific example, if we think of a child who has an alcoholic parent, maybe when the kid wakes up for school, the parent is making them their favorite breakfast and is really nurturing and loving towards them. Then when they get back home from school, the parent is under the influence and is being really aggressive and loud and maybe physically abusive. As a child, it's almost impossible to make sense of how one person can be so loving one moment and so terrible the next. It's almost like a need to put people in boxes so that the world feels safer and more in control, and splitting then gets carried out into adulthood.

SPENCER: It often will cycle back and forth with the same person, right?

KAYLA: Yes. So it could be one moment you're the best, and then the next moment, the person interrupts you while you're speaking by accident, and then it flips the switch to you're terrible. "You don't care about me. Nothing I say is good enough for you. You can't even let me talk for two minutes without interrupting." So it can cycle really quickly; one person can be good and one person can be bad. The issue with this is that I think people with BPD tend to idealize people and think of them as being perfect, which no one is perfect, and at some point, people are going to let you down. But this is why it's so difficult to have healthy interpersonal relationships, because you can expect others to do you no harm, and then when they do at some point, because they're human, the reaction can be so disproportionate to what's happening that it can create a lot of tension in your relationships.

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SPENCER: I'd like to better understand that idea of flipping between seeing someone as idealized all the way to seeing them as terrible, kind of the opposite. What do you think is going on in the minds of people with BPD when this is happening, when that flip occurs?

KAYLA: I think because their sense of self is so fragile, it takes next to nothing for that to be brought to light. So again, going back to this example, if I'm talking to you about my day, and then your phone vibrates and you look down to put it on airplane mode so that you can pay attention to me, I interpret that as, "Wow, you don't love me. You don't care about me." It almost goes automatically back to this place if this person doesn't care about me. I'm unlovable. I feel like a crappy person inside. All those feelings come rushing back. It's like people mirror our internal experiences.

SPENCER: With splitting, there's often that anger reaction. You go from idealizing a person to five minutes later thinking that they're awful, but the anger suggests that you feel that they're trying to thwart you on purpose, or they're trying to harm you on purpose, or they deceived you on purpose, or something like that. So just trying to wrap my mind around why it produces anger in particular.

KAYLA: Yeah, I think when it comes to those with BPD, there is a difficulty understanding emotions, and so sometimes I feel as though the reaction that comes out isn't necessarily anger that they're experiencing inside, but the external reaction matches that of what we typically ascribe to an angry reaction. Marsha Linehan, who pioneered DBT, is the one who conceptualized BPD through a bio-social model, meaning that we have biological vulnerabilities, like being sensitive, but there are also social or environmental aspects that reinforce our reactions and behaviors when we're little. For kids, what typically happens is we have a reaction of normal sadness to things or being disappointed, and then no one really listens. So we are taught that our reactions need to be louder and louder until someone finally pays attention. If this is the way that we are conditioned to feel emotions growing up, so that they need to be extreme to be acknowledged, then we can make sense of why the splitting goes to anger so quickly, even though the person might just be feeling disappointed or might be feeling hurt, but the reaction is big and automatic because this is what they were taught growing up.

SPENCER: That's really interesting. Essentially, almost like I think of operant conditioning. It's like they try to do something, they don't get the reward. They try to do something, they don't get the reward. Eventually, over years and years, not even consciously, but even subconsciously, by having a bigger and bigger emotional reaction, they start to actually get the reward they're looking for, from the person paying attention to them or saying, "No, I'm sorry. I didn't mean to hurt you." I also wonder, suppose you had a really bad toe injury, and it was incredibly sensitive, and your partner knew that your toe had tremendous pain, and then they stepped on your foot. Even though they probably didn't intend to, and it was a complete accident, because it's so painful, you're in excruciating pain, and they sort of knew that you had that sensitivity. You might feel angry at them, even though maybe five minutes later you're like, "Okay, it's totally not their fault. They didn't mean to do it. It happens." Sometimes your immediate reaction might be anger because it hurts you so much, and you knew that I had this very sore toe. I wonder if there's also a bit of that. Sure, all the person did was look at their cell phone for five seconds while you're talking to them, but you know how much it hurts you, and you're in such tremendous pain when they do this. I could see why that would evoke a very visceral anger reaction.

KAYLA: Yeah, of course. When it comes to validation, it's all about finding the kernel of truth in the person's reaction. In that specific example, when you understand the context of that person's life, that they were chronically invalidated and made to feel as though they weren't important, maybe that's a trigger to them around cell phone use while they're talking because their parents did that a lot growing up. Then, yeah, you could totally understand the big reaction. I do think that there is sometimes that tendency with people with BPD to expect others to know what they're feeling. They're expecting perfection out of others. There's no room for error, which is why sometimes their reactions are so big, because again, maybe they were expected to be perfect growing up, and maybe there was no space for mistakes, so they kind of take that and dump it onto their partner, their friends, their coworkers, expecting the same things that were expected of them growing up.

SPENCER: That's interesting. So I think we kind of talked about three different reasons why they might have this big reaction. One is that they might have learned even subconsciously, because they get rewarded by the big reaction, by getting more of what they want, like the person saying they're sorry or giving them attention for the mistake. The second is it's just so painful to them, and they're so sensitized that that might produce this feeling of anger. The third is that this sort of self-internalized standard might be so high that they project that standard on others. That's interesting. That could be a few different things going on there.

SPENCER: Another thing that we didn't talk about very much is kind of risk-taking, because that's something that's often associated with people with borderline. They'll engage in risky behaviors, whether it's risky sexual behaviors or just reckless or impulsive behaviors. What do you think is going on there?

KAYLA: I think when you have a chronic sense of emptiness, it is normal to seek any sort of sensation through external things because if you feel numb on a daily basis, of course, you're going to look for that rush of feeling alive through, like you said, risky sexual encounters or spending money excessively, like gambling or reckless driving, because it's almost like, again, the experiences need to be extreme for you to feel something.

SPENCER: Because that almost sounds like a numbness. Whereas people with borderline often have an intensity of emotionality. So how do you put those two things together?

KAYLA: I think that the numbness can coexist with the intensity in emotions, and to some degree, you could even make the argument that this emotional reactivity is a way of compensating for the fact that you feel chronically numb. The numbness is always there in the background, and you don't have the tools to fill it up or to feel any sort of sensation of feeling alive without going to these extremes.

SPENCER: It might be hard to pinpoint, but it's not that emotions are not felt intensely, because some people feel numb, in the sense that they just don't feel anything. It's just dead inside. But that's not really what we're talking about. We're talking about sort of a numbness that's separate from all the emotions you're feeling moment to moment. This sort of lingering numbness. How would you describe that?

KAYLA: It's almost like an existential void, a lack of direction, a lack of purpose, maybe. So you don't really know who you are, what direction you should be going in, or what your values are. And so there's always this tendency to seek something externally, because inside, you don't ever feel satisfied.

SPENCER: That's really interesting. This reminds me of my conversations recently on the podcast with one person who's a sociopath and another person who's a narcissist. And there's definitely, it feels like there's some characteristics in common, even though, in many ways, the disorders are so different from each other, there's that sense of lack of fulfillment or emptiness. It feels like that cuts across them.

KAYLA: Yeah, and I do want to say that when we're looking at the personality disorders in the DSM, narcissism falls within the same cluster as borderline and antisocial personality, which is similar, there are traits that overlap with sociopathy. It's normal to have traits or similarities, and even when we think of the way that personality disorders are categorized in the DSM, I feel like there are a lot of issues with using diagnostic labels.

SPENCER: Yeah, I definitely want to talk about this sort of idea of labeling, but before we get there, just in terms of what the disorders have in common. I was thinking about this recently, and the things that I was able to pinpoint are one, unstable relationships. People with narcissistic personality disorder, antisocial personality disorder, and borderline personality disorder all have unstable relationships, lack a strong independent identity, which we talked about, proneness to sudden anger, potentially proneness to promiscuity, and a history of trauma or neglect. I think those are some common elements. It's interesting because I think sometimes people with borderline are mistaken to have either narcissistic personality disorder because people view them as very attention-seeking, or even antisocial personality disorder because people view them as being very manipulative, as if they're trying to control you. I can see why people would make that mistake, but I think it's an interesting mistake because the disorders really are so fundamentally different. I'm curious to hear your comments on that, of people confusing it for those other disorders.

KAYLA: Yeah, and what's actually funny is that what we often see is that men who have borderline get misdiagnosed with having narcissistic personality disorder. There's a bias for clinicians to see borderline as a female disorder. Going back to this whole thing of attention-seeking, I think the main way I can explain this is that for people with BPD, it is such a knee-jerk reaction to an interpersonal situation that there's not necessarily a thought-out plan behind this "attention-seeking behavior." If we think again of this analogy of having that third-degree burn, if you touch this person and they punch you in the face because they're in so much pain, I don't think they were thinking premeditatively that they were going to hit you because you did something "bad" to them. It's this automatic reaction to something happening. It's hard because when you're in the thick of it, we aren't other people, so we can't really know what's going on in their minds. We don't know if there is any sort of intent behind the actions. From my own experiences and from working with people that have BPD traits, I can really see that it's not something that's done intentionally. It's just this knee-jerk reaction to being so scared of being abandoned.

SPENCER: It might come across as attention-seeking at times, but it's in reaction to a feeling of threat, whereas someone with narcissistic personality disorder might be more proactive, like they're trying to seek attention because they really enjoy attention.

KAYLA: Exactly.

SPENCER: And then on the confusion with antisocial personality disorder, I think it comes from people perceiving borderline individuals as being highly manipulative, as if the person with borderline is trying to control you or trying to capture you in some way. What's your reaction to that?

KAYLA: I think it's very similar to what I just said, in the sense that I don't think that it's premeditated. When we think of people with BPD, they're very empathetic, sometimes to a fault. Sometimes too empathetic.

SPENCER: It's almost the opposite of antisocial personality.

KAYLA: It's kind of the opposite.

SPENCER: So, what could come across as manipulation? Like, "Oh, why is this person freaking out over this tiny thing? Why are they yelling at me when I barely did anything?" It's like, "Well, that could be driven by an attempt to manipulate." But for someone with BPD, it's much more likely to be driven by trying to regulate their own pain or stabilize their sense of attachment or something like that. Would you say it's accurate?

KAYLA: Hmm, yeah, they're trying to get their needs met, and sometimes it's the only way that they know how is to have these big reactions. So it's not done with this intent of, "I'm going to go out today and do this thing because I want to punish this person for hurting me." No, it's these reactions that happen instantly and that can be perceived a certain way. However, the internal experience is not the same as someone that has antisocial personality disorder or that has narcissistic personality disorder. Of course, there can be overlaps and traits and those kinds of things, and it's not a clear-cut box that someone has BPD, and that's it. We can have traits that overlap, and generally speaking, it is different in terms of the internal intention behind actions and reactions.

SPENCER: Right. That makes sense. You also touched on how men and women can kind of be misdiagnosed in different ways. The traditional view of borderline is that it's more common among women, maybe three to one. But some research has challenged this, saying that might actually be an issue of misdiagnosis, that men are less likely to be diagnosed properly. What do you think is the case in terms of gender balance?

KAYLA: So in clinical settings, what we see is about 75% female, 25% male, but we think that in society, it's much closer to 50-50. The reason being is that, as I had mentioned, there is a bias in clinicians to see BPD as a female disorder because we think of women as being highly emotional. I do think that because of our gendered expectations in society, men with BPD might show symptoms differently. They might be really angry all the time, but not necessarily dip into this self-hatred in front of others. Or they might compensate with substance use disorder or other things that we then mistake for some other condition when in reality, it's BPD.

SPENCER: Would you agree that, on average in society, women tend to have stronger emotional reactions than men, and men tend to be more dulled emotionally?

KAYLA: I think that there's more acceptance for women to express feelings than men. So I wouldn't say that men experience fewer emotions or are less emotional, but what I do agree with is that we are conditioned to act in a certain way because we have different expectations. It's more acceptable for women to be more demonstrative when it comes to emotions, rather than men.

SPENCER: So you see it as more different in kind of external behavior rather than sort of internal experience.

KAYLA: Yes and when we do look at personality scores, so the Big Five, for example, women on average do tend to score higher in neuroticism, so that does say something about the way that they experience emotions.

SPENCER: In my own research, I found that, especially on the trait of anxiety, women score higher, and that drives part of the neuroticism components, since anxiety is part of neurosis. What about the prevalence of BPD? What's the best kind of evidence of what percentage of people, let's say, in the US or similar countries, have BPD?

KAYLA: Anywhere from one to 6%, probably closer to the 6% mark.

SPENCER: It is high.

KAYLA: Yeah, it is high. I think it's one of the personality disorders that has the highest prevalence, and it's also one of the personality disorders that is the most stigmatized, which is kind of ironic.

SPENCER: This makes me think about something that I've also thought about with these other episodes about personality disorders that we've done, which is that if you talk to people about personality disorders, they'll generally say, "Oh, I don't know anyone that has that," except maybe narcissism. Everyone thinks they know lots of narcissists, but for some reason, they think they know lots of people with borderline personality disorder, although most of those people probably don't have narcissistic personalities. Or, interestingly enough, they might be narcissistic to some degree, but with borderline, whether it's 2% or 6%, most people will know someone with borderline personality, sort of whether they realize it or not.

KAYLA: Yeah and this is why it's really important to be informed for yourself, of course, to be able to deal with the struggle of interacting with emotional volatility, but also to be better equipped to support those who do have BPD.

SPENCER: I definitely want to get to that towards the end and talk about what you can do to support someone who has BPD. I think it's a very important topic. Something that you mentioned a little earlier, or the DSM categories. Do you see these as helpful? Do you see this as problematic? Some people say, "We should just get rid of categories altogether. We should talk about spectrums." Even if someone doesn't have BPD, they might have BPD-like qualities. What's your thought on that?

KAYLA: I definitely think that when it comes to personality disorders, we should move more towards a dimensional model. The DSM right now is set up through a categorical lens, so you either have a disorder or you don't. The working group for personality disorders for the DSM-5 actually argued that this is an over simplistic way to understand complex traits, and it doesn't really account for individual differences when we're using these categorical models. Their comments got denied, and so the way that it's set up in the DSM-5 is still using a categorical model. But at the back of the DSM, there's actually an alternative model for personality disorders that functions as traits existing on a spectrum, which to me seems a lot more in tuned with the reality of the experiences of people that have disorders, because it's very rare that, "Okay, today I have five out of the nine symptoms, and then in two months I have four. But now I'm all good, and there's nothing I need to work on anymore." No, there are still things that I struggle with. I think that when we understand people as being a bit more complex than either or, it can help to better inform treatment and reduce stigma. Also, because people that do have BPD, it's highly stigmatizing to have as a label. Of course, I do see the utility in it. Personally speaking, when I got diagnosed, I was like, "Oh my gosh, finally, there's a way, there's a name for my experiences, and I can finally understand myself." So I do see the benefit in doing that. It can be extremely validating for some, and for others, it can be highly stigmatizing. Moving towards a more holistic approach, a more dimensional model of diagnosing disorders, I think, is the way we will most likely move towards in the future.

SPENCER: I could see the appeal of both systems. On the one hand, obviously, a spectrum is more nuanced. It helps capture people that maybe are just near the boundary of the categories or have some of the traits, but not all the traits. On the other hand, just the way human minds work, it's useful for people to have a kind of archetype. Human minds are good at dealing with archetypes, like, "Okay, I've got the archetype of someone who has this sort of set of traits." So maybe it's easier for people to think about, although I do think it loses a lot of nuance. It's not as accurate, but maybe it's easier for people to work with.

KAYLA: Yeah, we like when things make sense, and we like to put things in little nicely packaged boxes; it's easier to understand. We don't do well with nuance as humans, and we like definitive answers to things. I think that's the reason why we have been leaning towards a more categorical model when it comes to mental health diagnoses.

SPENCER: We found something funny in a study of ours, where we tested people on the Big Five personality traits, and we also tested them on their Myers-Briggs style personality traits. The Myers-Briggs puts them into categories, and we find that if we use the Big Five to predict people's life outcomes, it's quite a lot more accurate than if we use the Myers-Briggs. So it's better at predicting things about people using the Big Five, but people actually feel worse getting the Big Five results, and they perceive the Myers-Briggs results as more accurate. It's fascinating because, even though they predict less well, people feel better about them. I suspect this might be part of the reason; people want a category. They don't want to just have a bunch of numbers representing their percentile.

KAYLA: Yeah, maybe that's it. I know some people don't like the word neuroticism too, so there may be a part of it.

SPENCER: People feel worse about themselves with the Big Five. The Big Five doesn't pull punches; it tells you you're neurotic, closed, and disagreeable, and so on. When I think about people I know who've dated someone with borderline personality disorder, they have experiences that, from the point of view of a partner, are almost borderline traumatic. Let's say they forget to text their partner back for five hours, and then the partner comes home, and the partner has cut themselves and is bleeding, completely distraught. Or, let's say they stay out late one night hanging out with friends, and the next day their partner is in a rage, asking, "How could you do this? How could you?" The partner is confused, thinking, "What? I was just hanging out with my friends. You knew where I was." This is very difficult. I think this is also part of where the stigma comes from. People have these experiences with individuals with borderline personality disorder, and they are shell-shocked by these experiences. We've talked about how, from the point of view of the borderline person, when you get into their mind, it makes a lot more sense. They might feel, even though the behavior of the partner was maybe not so bad or not at all bad, completely rejected, or feel like this means they're totally unlovable, or that this person did something that caused them tremendous pain and should have known better. But you can see how, from the partner's perspective, it's still very difficult to deal with. I'm just wondering, what would you say to someone who is dating or has dated someone with borderline personality disorder that you think might be helpful to consider?

KAYLA: I completely understand from both perspectives, and these are conversations that my husband and I have often where we think back on the journey and how much we've grown as a couple. I tell him all the time, "I don't know how you put up with the behaviors and stuff that I was doing." I don't think I would have stayed. It's not because I think I'm a terrible person or that I was doing these things intentionally, but it's very draining to deal with for some people. I can completely understand that. What I would offer as advice to partners or friends in those situations where maybe the person with BPD has traits that are a bit more intense or reactive than someone else with BPD is you need to take care of yourself before anything else. This is the analogy of putting on your own mask in the airplane before helping others. When we're dealing with situations that can be so intense, it's really easy to feel burnt out, to feel completely drained, to lose a sense of who you are as a person, and even sometimes leave those relationships not feeling so trusting of others or not feeling securely attached anymore, because it can be traumatic to bear witness to someone self-harming and feel as though you're responsible for those things. So first and foremost, take care of yourself, and it's really important to be firm with boundaries. Boundary setting is extremely difficult because with BPD, sometimes it's a thing that will set them off. When you tell them, "Listen, I know you're uncomfortable with me going out with my friends, and this is also something that's really important to me. I need this to re-energize myself and feel like I'm taking care of myself." The person might have a big reaction, and it's important to go anyway. We can validate people's feelings, or we can validate, "I understand that you're feeling insecure because maybe you've been cheated on in the past, and I understand why you're having this reaction," but we're not ever going to validate ineffective behaviors. So not validating self-harm, not validating calling people names or those kinds of things. It's really important to just be firm with your boundaries, be firm with your needs, to only validate the valid, and encourage the person to seek therapy and seek therapy for yourself also, because at times it could be really draining, but you're also not their therapist, and they need to do their own work. You don't have to be the person that is the savior for them.

SPENCER: I think that the boundary point is really important. But as you say, it can be really hard to assert a boundary. If someone's threatening suicide or they're in a rage, it can be really difficult, and clearly, the path of least resistance is just to give in. It's like, "Okay, fine. I'm not going to go out." I've also heard about therapists asserting boundaries. For example, I believe one therapist who works with borderline personality disorder told me that they would set rules with their patients, saying, "Look, it's fine to do X, Y, and Z, but if you do P, Q, R, then I am going to not speak to you for seven days." Essentially, it's setting up a system of punishments, where there are certain behaviors that are not acceptable ways to get my attention. I'm curious, what's your thought on that?

KAYLA: I think that boundary setting is a huge part of learning secure attachment, and it is something that those with BPD need the most. They need people to be consistent and firm with them, to say, "I'm not accepting this. I still love you. I don't think you're a bad person, and I'm also not giving in to this behavior." In therapy, when working with those types of clients, it's extremely important to be very firm with them. For example, when we're thinking of DBT skills groups, clients typically are allowed to have phone consultations or phone coaching when they're feeling as though they're about to engage in self-harm. But the rule is that if you've already engaged in self-harm behavior and you call your therapist after, they will hang up on you, and you're not allowed to call for 24 hours, because there need to be boundaries. We're not going to reinforce and validate the fact that you just did something terrible. We can help you before it happens, but you also need to be able to put in your skills and healthy, effective coping mechanisms once a thing has already occurred, and they need to learn how to do that without relying fully on others.

SPENCER: This reminds me of another story of someone I know who's dating someone with BPD, and the person they were dating would get very distraught when the person would spend time with one of their close friends. They basically said to them, "I don't want you to spend time with your close friend unless I'm there too." The person kind of accepted this as, "Okay, it's not ideal, it's not great, but I can deal with that." My thinking at the time, and I would love to hear your check on my thinking, was that this is not something that you should be okay with as a way of setting boundaries. If it's, "Oh, you can only see this person if your partner is there," to me, that seems like a slippery slope in a pretty bad direction in a relationship.

KAYLA: Of course. And there's always context. Who knows, with the front and stuff, there might have been some things going on, I'm not sure, but yeah, let's just go along with the idea that there's nothing wrong with that friend, there's nothing wrong with that friendship. Yes, what I would tell people is, "No, let's be firm with a boundary. They will learn to trust." We can compromise. We can say, "Okay, maybe for the first couple of hangouts, I can check in with you more regularly. Or maybe you go out and do stuff with your friends at the same time, so you're not sitting at home by yourself just thinking about that." But there needs to be a conversation. We need to have some sort of middle ground compromise without infringing on our own boundaries necessarily.

SPENCER: What about when a friend or partner who has borderline personality disorder is in the throes of intense emotion, like they're extremely distraught because they feel rejected? What can you do at that moment?

KAYLA: I think the only thing you can do is be a pillar of stability for them. So trying your best to not get swept up in the storm, to not get swept up in the arguments. My husband is the most wonderful man on the planet, and he is amazing at doing this, and he has really been incremental to my development. He stays really calm when I feel really dysregulated. He doesn't engage with me saying things that don't match reality, but what he will do is say, "Listen, I love you. I'm not getting the sense that this conversation is super productive. Maybe we just put a pin in this, and this also matters a lot to me." So he'll come back in half an hour, and he leaves. It's really hard to deal with sometimes because I want to solve the problem or I want to express myself, and with him leaving and setting that boundary, often it gives me the space to cool down on my own, to just realize that my reaction was probably not proportionate to reality, and I can kind of do my own reflection. By the time he comes back, we can talk about things from a more factual perspective, so there's nothing wrong with walking away from situations, and I actually encourage that if the person is not responsive or if they are really coming at it from an emotional place. It's okay to just put a pin in it. Remind them that you love them, that this matters. You're going to come back, and you each will take a second to cool down, and then you'll come back and talk about things.

SPENCER: It seems to me that there are a few different elements to that recommendation that all seem valuable. One is sort of reminding this person that you do care about them, so helping to remove some of the insecurity there, like, "Look, I love you," but then second is setting that boundary, like we talked about, "Okay, this is not productive right now. Let's come back to this." But it seems like there is another element too, which is sort of modeling or setting a standard of not getting sucked into the emotionality of it, which would kind of maybe even intensify the other person's emotion.

KAYLA: Yeah, it's exactly that. It's not just about saying, "Okay, you're being irrational and I'm leaving now." No, we want to still be conscious that this person is having a strong emotional reaction and that they are suffering in this moment. So we want to acknowledge the fact that, "Hey, I know that this is probably really hard for you, and I love you, and I'm here for you, and I also care about you so much, and I care about this. This is really important. So why don't I just step away and come back in 30 minutes so that we can really talk about these things?" So it's remaining calm. It's offering compassion to the other person. It's not abandoning them, but it's also showing them that people can leave and still love you and come back and be true to their word, because that's probably something that they've never had, and what a gift that is to offer it to them.

SPENCER: Showing that someone kind of distracted from the conversation temporarily doesn't mean you're going to be abandoned, and kind of retraining you to realize the relationship is strong. You're not going to get suddenly left by that person.

KAYLA: And it also gives you permission to do that also, to say, "Hey, I'm gonna walk away from this conversation, and I know that I love you and you'll be here when I come back." It gives people permission to also assert their own needs, because I guarantee you that a lot of people with BPD struggle with that and that they were not allowed to walk away from conversations when they were little or they weren't made to feel safe. So it's a two-way thing that is helpful to everyone.

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SPENCER: You mentioned earlier the phrase "only validate the valid." It reminds me of something that I came up with I call "light gassing," which is kind of the opposite of gaslighting. You'll often see people do it when a friend is feeling really bad, let's say they've just gotten broken up with. They'll say things like, "Oh, that person didn't deserve you anyway," or, "He was such an asshole." It's basically where people will validate false perceptions in order to make you feel better. Whereas gaslighting is getting people to doubt their correct perceptions, which is sort of the opposite. And it sounds like basically what you're saying is, "Don't light gas the person with borderline personality," because they might have misperceptions, and you don't want to kind of reinforce them.

KAYLA: Yeah, we want them to have an accurate perception of what is happening. We don't want to reinforce behaviors that are ineffective to them and to other people. We want to reassure them that we love them still, but we're not giving in to this whole dance that they're used to doing because we care about them and we don't think that this is the best thing for them.

SPENCER: It seems that to do all of that well, you would need to be very steadfast or very in control of your own emotions; otherwise, I feel it's really, really difficult to behave in a way that's productive in those scenarios.

KAYLA: Yep, and this is the importance of why I mentioned doing your own therapy, so that you can learn your own emotion regulation skills and have healthy outlets for your feelings, so that when these situations come up, you have tools and people that you can rely on to help you, because it takes a whole village to support loved ones of people that are struggling with any sort of mental health conditions.

SPENCER: I've heard that DBT therapists, who specialize in treating borderline patients, often do their own therapy as a way of being able to handle these situations.

KAYLA: It's part of a requirement. When you are DBT therapists and you are teaching skills groups, you have to also attend consultation groups with other DBT therapists so that you have a support network, because it can be very challenging.

SPENCER: Now, as I understand it, DBT, which stands for Dialectical Behavioral Therapy, is considered an evidence-based treatment for Borderline Personality Disorder, and we mentioned Marsha Linehan a few times. She's the creator of it, and my understanding is that she kind of completely shocked the world of therapy, because after developing this treatment and it being used for a long time, she came out and said, "By the way, I probably had more than one personality myself," which was, I think, mind-blowing to a lot of people.

KAYLA: I don't think it's uncommon for people that go into certain fields because they're trying to find answers to their own experiences. When we think of, for example, Steven Hayes, who is one of the pioneers of Acceptance and Commitment Therapy, he struggled with anxiety and his own issues and panic attacks, and Acceptance and Commitment Therapy was kind of his way of helping himself, and it turns out that it also helps millions of people. So that's fantastic, and kind of the same thing for DBT.

SPENCER: So what does the protocol look like if someone goes into DBT therapy, what are they going to be expected to do?

KAYLA: So DBT is really the gold standard treatment for Borderline Personality Disorder. What is typically recommended is that clients partake in weekly, two-hour group sessions, where they are taught very specific skills relating to distress tolerance, emotion regulation, and interpersonal effectiveness. Simultaneously, they should also be doing one hour of individual psychotherapy with a trained DBT therapist during the week. The skills groups typically last about six months. They recommend going through them twice, so you should be in full DBT treatment for a full year, meaning that you go through all the modules twice, paired with weekly individual psychotherapy. It has really promising results in terms of the research around DBT, and just personally speaking, having gone through the program, it was life-changing. I would not be on the other side of things without it. I am a strong advocate for DBT. It has a very special place in my heart.

SPENCER: I know that there are many techniques that are used during the therapy, but what are some of the core things that you learn in DBT?

KAYLA: The main things, I would say, are distress tolerance, which is a really important module. During distress tolerance, we learn how to cope with really difficult emotions without necessarily making them better, but we learn tools to not make them worse. One of my favorite tools, or skills, for example — DBT is all about acronyms so if anyone out there has done DBT, you'll know — the TIP skill, which stands for temperature, intense exercise, paired muscle relaxation, and there's a breathing exercise too that you can do. Using cold exposure helps regulate our nervous system when we're feeling dysregulated, or using intense exercise to also regulate ourselves. Going for a run, doing push-ups, or jumping jacks, you could do progressive muscle relaxation, where you intentionally tense up parts of your body and relax them. We also have breathing, where we exhale longer than we inhale. They are all tools that are very physiological to try to regulate ourselves. It's a bottom-up approach because we know that when we are very dysregulated, our brain shuts off, and there's no amount of reasoning that we can do to get ourselves back to baseline. DBT is very aware of this. It understands how emotions work and gives tools that allow people to calm down through physiological interventions.

SPENCER: What are some of the other skills you learn?

KAYLA: Yeah, so the TIP skill is one of them. There's also some of my classic favorites in the interpersonal effectiveness module. There's the DEARMAN, which is a kind of formula that you can use to make requests. So just quickly, you would describe the situation, express yourself, assert a request, and then reinforce why it's beneficial for both of you. The "M" part of it is staying mindful during the conversation. The "A" part of it is that we want to appear confident going into these conversations. And "N" is for negotiating. So when I'm trying to have a conversation with someone and making a request, rather than saying, "Hey, you left your shoes out and you suck and you're terrible," When we use DEARMAN, we can say, "Okay, describe the facts. When I came home, I saw that your shoes were on the floor." That's it. Express, "That makes me feel unappreciated," or whatever a certain need. "Can I just ask that you place your shoes on the shoe rack instead of leaving them on the floor? And why is that beneficial for us? Well, it's going to ensure that neither of us are tripping on the shoes when we're coming home and stubbing our toes on the table." So that's another really good skill that is really instrumental, especially when you're learning how to set boundaries and make requests. It could be daunting, but what I love about DBT is that it is very clear and actionable. There's a process to everything; there's a logic to things. When you're learning the skills, it can feel a bit robotic at first because it's not necessarily natural, but after a while it just becomes part of who you are.

SPENCER: So with the DEARMAN technique, it sounds like it's about expressing yourself in a healthier way that leads to better outcomes, rather than sort of going with your emotion at that moment.

KAYLA: It's all about learning how to be more effective in the world with communication and our emotions. Even in the emotion regulation module, there's a skill called "Check the Facts," where you go through a whole PDF, and it has questions like, "What are the facts?" And by facts, I mean, if I followed you around with a camera, what are the things that I would see? And then you write what your assumptions are, and then, based on the assumptions, it's like, "What is the fear and what's the worst-case scenario, and how would you deal with that?" So you go through a whole exercise to help you be more in touch with reality, to help de-escalate your feelings. And it really works.

SPENCER: What about self-compassion techniques, where you learn to talk to yourself the way you would talk to a friend that you loved, rather than berating yourself or telling yourself that you suck?

KAYLA: So the classic DBT, when it was first conceived, did not include self-compassion. Now the newer versions of it are including more self-compassion practices, and that's something that I would encourage people or DBT practitioners to include more of, especially in their individual psychotherapy sessions, because, again, borderline personality is an attachment disorder, and self-compassion is all about learning how to reparent ourselves. It's about learning how to develop a secure attachment with ourselves, and we do need that for people who are so self-critical and filled with shame, learning how to be mindful of our experiences without getting stuck in it, to remind ourselves that suffering is part of the human experience and we're not alone in these things. We're not defective because we're experiencing this, and then offering ourselves words of kindness that are not lying to ourselves, so saying things like "You're doing your best," not "Everything's going to be okay," because that's not how it feels in the moment, but just offering that kindness that we would to others.

SPENCER: I would argue that DBT skills can be really useful, not just for people with borderline personality disorder, but anyone who has similar kinds of challenges, like they have intense emotionality, or they tend to idealize people, or they tend to have trouble asking for what they want, and instead, they kind of will have an intense expression of emotion. Would you agree with that?

KAYLA: I think everyone could benefit from learning DBT, to be quite honest, whether or not you even have traits of BPD. I think these are just life skills that people should have. And it's funny, because even with the stuff that I learned through going through the program, we're now practicing this as a therapist, and when my friends are struggling, I'll send them PDFs of things that they can do, and I talk about skills, and they benefit immensely from these things, even though we don't have the same experiences necessarily.

SPENCER: One book on DBT that I really like is the Dialectical Behavioral Therapy Skills Workbook. I don't know if you know that one in particular.

KAYLA: Yeah, I've used it and you need it when you're going through the DBT program.

SPENCER: I'll put a link in the show notes. I tend to not find a number of those skills as useful as some other people, just because I tend to not have intense emotionality and I tend to be quite assertive, but I can see the incredible value of them. I definitely would recommend people who have any kind of struggles in this direction to check out a book like that.

KAYLA: Or even if you just have a hard conversation that you don't know how to formulate using skills like the DEARMAN. There are even things on sleep hygiene in DBT, so things that we could benefit from knowing outside of maybe emotions.

SPENCER: DEARMAN reminds me of nonviolent communication. I feel like there are quite a few similarities there.

KAYLA: Yeah, it's all about staying very present focused. It's about sticking to the facts. It's about understanding that relationships with people are complicated and that we need to be flexible in the way that we communicate, even though we have needs and others have needs. It's about mutual respect with others.

SPENCER: Before we wrap up, I have kind of a grab bag of random questions I've always wondered about borderline that we haven't touched on. So maybe I'll do a little bit of a rapid-fire ground question, if that works for you?

KAYLA: Yeah.

SPENCER: Anecdotally, I've observed that there seems to be some kind of pairing off of narcissists and people with borderline personality disorder, and I've heard other people notice this as well. Do you think there's anything to that where they tend to be attracted to each other?

KAYLA: I do because I think that they both have unmet needs that they can provide to each other. So for the person who is borderline, well, first of all, if you meet someone that love bombs you at the beginning, instantly you feel like, "Wow, this person really loves me, and this is all I've kind of been looking for." And for the narcissistic partner, they also feel like they need this attention or narcissistic supply, and this person who's willing to bend over backwards and not leave them, and that's what the borderline person does for them.

SPENCER: So if the borderline person idealizes the narcissistic person, that's amazing. That builds up their ego in this very satisfying way. But I've also seen narcissists that they tend to build up the people around them as a kind of form of narcissism. If they're dating someone, then that person they're dating is the best, the most amazing, and sort of like that may validate the lack of self-esteem or fragile self-esteem of the person with borderline personality disorder. So it's almost like it could be familiar in a way. That's, "Oh, this is what I'm used to. I grew up or something." But yeah, it's so interesting to me because it seems like early on in the relationship, you could see why they both would be meeting each other's needs, but ultimately, that's got to be one of the most toxic pairings in the long term you can imagine.

KAYLA: Oh, it's terrible. It's terrible for both of them. Unfortunately, we do see that happen quite often.

SPENCER: Another thing I've wondered about, I've heard people with BPD talk about this, that they feel they can struggle to know what they think about things. They don't know what their favorite movies are. They don't know what their taste is, etc. They are kind of looking to get it from other people. Has that been your experience? And have you noticed that with other people who've been diagnosed?

KAYLA: Yep, it's definitely been my experience. It's the reason why I did three different degrees at university, changed jobs a bunch of times, and didn't really know what my style was for clothing or music for the longest time. It's my experience. I think it's also something I've observed a lot in others, and the best way I can explain this is when you grow up in an environment that invalidates you and doesn't give you any space to be your own person, you kind of become this chameleon who gets really good at blending in, but when you take them out of those contexts, they don't really know who they are because no one has ever given them the space to explore what it is that they actually want or like in the world. A part of recovering from BPD is really untangling what values belong to you and what values belong to others. That can take some time, but it's definitely doable.

SPENCER: Sometimes people use this phrase, quiet BPD. What is that? And what would you contrast that with?

KAYLA: Quiet BPD is not a formal subtype, so it's not in the DSM, but it's a term that people use to refer to individuals that experience BPD in a more internalized fashion, so they act in rather than act out. They may experience intense emotions like fear, mood swings, and rage, but typically they're directed more internally. The key traits that we see with quiet BPD are people pleasing, unhealthy boundaries, avoiding emotions, low assertiveness, self-sabotage, shame, self-hatred, a strong desire to avoid conflicts, and low self-esteem. I think this presentation of BPD is just a matter of how you were raised or what experiences you endured growing up that will make the traits display in a certain way.

SPENCER: Why is it that so many people with BPD engage in self-harm?

KAYLA: Self-harm is a way to cope with really difficult feelings. When you're feeling really dysregulated, it might be an emotional release to self-harm. We know that self-harm does release endorphins, and we do get physiological relief from that. Another reason, going back to this chronic feeling of emptiness, is that when we don't feel anything, it might be a way for people to feel alive, or something.

SPENCER: Is there an element of self-punishment in it as well, where they feel like they're worthless and they deserve to be punished?

KAYLA: Yep, I think that is one of the driving factors of BPD. It is feeling fundamentally unlovable and inadequate, and feeling as though the things that happen to you, you deserve to be abused, or you deserve to be in these relationships where people abandon you and treat you poorly, because fundamentally, that is how you feel about yourself.

SPENCER: There's this phrase emotional reasoning, where when you're feeling an intense emotion, usually a negative emotion, you view that emotion as being reality. You say, "I'm feeling angry, therefore this person wronged me, or I'm feeling sad, therefore I've lost this thing, or I'm feeling fearful, therefore this thing's dangerous." Rather than seeing your emotion as having to do more with yourself than what's happening objectively, and my understanding is that everyone engages in emotional reasoning from time to time, especially with strong emotions, but that it might be especially common among people with BPD.

KAYLA: Yeah, for sure. I think again, it goes back to it being a disorder of perception. The way that others are perceived, or events are perceived, often don't match reality. It doesn't match the intensity. There is a difficulty with understanding our own feelings, and if you don't understand your own experiences, then how are you supposed to make sense of the world and external experiences? And that's why I think we revert back sometimes to a more simplistic way of, "Well, I'm angry. So this is the way." It's this either-or, black-or-white way of thinking about the world.

SPENCER: As I understand it, sometimes the behavior of people with BPD can almost come across as delusional or paranoid or dissociative, especially when under stress. Can you give us some understanding of what's going on there?

KAYLA: Yeah. With dissociation, again, this is another form of a coping mechanism to extreme amounts of stress when we don't have the tools to cope with being so dysregulated. We can dissociate. We can dissociate in the sense that we don't necessarily know who we are, or we can also dissociate from the environment, so we have this out-of-body experience, and our way of thinking can start to get a bit loopy and not really make the most sense. It's almost like you're in a fog and you're losing touch with reality. It's not full-blown psychosis, but stress can definitely induce some paranoid thoughts or dissociation.

SPENCER: Do you think it's just caused by such an intensity of emotions or something else?

KAYLA: I think it's caused by intensity of emotions, and at times, I also think that dissociation can be caused by normal amounts of stress. It's just that we are so conditioned to leave our bodies or zone out when we experience any amount of emotional intensity that it kind of just becomes this go-to thing. It's part of the reason people with ADHD tend to zone out so much whenever there are things that are stressful. Maybe it's two out of ten stressful, but they dissociate, zone out. It's the same thing with BPD. It could be just related to a coping mechanism that we've developed, or it could be related to really intense stress.

SPENCER: Sometimes people with BPD are thought of as being very sensitive to criticism, and you could see why this would be, because criticism might lead the person to jump to a conclusion like, "Oh, this person doesn't care about me, or they're going to reject me," especially if it's a person they're strongly attached to. How would you suggest giving criticism to someone with BPD? Because obviously in a relationship, we sometimes have to say, "Hey, I'd really like you to do this thing differently, or I'm unhappy with this thing you're doing."

KAYLA: I think something that works really well for me is when the person asks me, firstly, if I am receptive or in a good headspace to have a conversation that might be a bit more difficult, so asking the person. Secondly, just reminding them again, "I appreciate everything that you do, and it's okay that this happens, or it's okay that you don't know how to put the dishes away in a certain way. It's not a big deal and..." So using a lot of "and" rather than "but" language. So asking, "Can I just ask that maybe the next time this is done this way, and don't worry, it's not a big deal in the grand scheme of things, I just think it's something that would make everyone's lives better." So lots of reassurance, lots of being open, loving, and being really calm, asking the person if they're willing or receptive to criticism or feedback. Something else too, just quickly, that does work well, I find so often with clients, when I provide feedback to them, it's often easier for them to understand when I give an example of a story that has nothing to do with them, but that is exactly what they're experiencing, so that they have an easier time understanding, "Oh, in this fictional scenario, yeah, of course, this makes sense." Then I get them to relate that to their own situation, so that it doesn't feel as personal and feels more normal when they know that this is something that happens to others as well, and they don't feel as defective in this.

SPENCER: If someone listening to this starts to wonder, I wonder if I might have borderline personality disorder. What would you recommend they do next?

KAYLA: I would say, if you believe that you have borderline because maybe you feel dysregulated often, have mood swings, or you're very sensitive, go to therapy. You don't necessarily need to get diagnosed. That's a very personal thing, whether people want to or not. But I would definitely say, if you struggle with BPD traits, find yourself a good therapist, someone that you feel really comfortable with, that you feel provides you with unconditional positive regard to help you navigate the turmoil that you might be experiencing, and that person can help provide you with further steps in terms of if they think that you should be doing DBT, or if maybe a diagnosis would be helpful for you, but definitely seeking therapy would be the next thing to do.

SPENCER: If someone has intense emotionality, but they don't have the attachment stuff, like they don't have this specific person that they'll feel really strongly attached to, and where they're incredibly sensitive to rejection, do you think that means they probably don't have BPD, or might they still have it?

KAYLA: I don't think it's black or white. I think it just depends. But if the person is just sensitive, but they are still able to feel secure in relationships, then no, they probably don't have BPD if we're just looking at the diagnostic traits from the DSM.

SPENCER: It seems to me that a danger that people with BPD end up in is that if they get attached or their favorite person is someone who's harmful for them, that could just be devastating, because their whole world relies on this person validating them and making them feel lovable, but this person's actually a bad fit for them, either just incompatible, or maybe just really mean, et cetera. What kind of advice would you give to someone who might be in that situation?

KAYLA: I think that with anyone that is struggling in abusive relationships, there's no amount of us forcing them to leave that will work. I think the best thing you can do is to encourage them to find support and people outside of this relationship to make them feel like they belong to something bigger than this relationship. So whether it's volunteering or work or their group of friends, just making sure that they are involved with people that are supportive of them, that they feel like, if they choose to leave this relationship at some point, that they will not be completely on their own.

SPENCER: That reminds me so much of cults, where cults will often isolate a person and then the whole world for that person now is the cult. All their friends are in the cult. Everyone is constantly validating the cult beliefs, and then even having that one strong tie outside the cult can be so useful for leaving, because it's like their whole world doesn't end. They at least have this one lifeline that's not connected to the cult.

KAYLA: That's exactly what I was thinking of cults as well.

SPENCER: Final question for you, what do you want people to come away with from this episode? Most of the people here listening don't have borderline, but what do you want them to remember from the episode?

KAYLA: What I would want people to take away from this podcast is to remind themselves or learn through this conversation that BPD is something that is very painful to live with. It's something that can be really exhausting, it can be alienating. And it's not the choice of people who have BPD that they have this condition. It's a result of their sensitivity, but also their experiences in the world. I would like people to be more compassionate towards those that have BPD, to be more open-minded, less judgmental, and to really reduce the stigma around this disorder.

SPENCER: Kayla, thanks so much for coming on.

KAYLA: Thank you so much for having me.

[outro]

JOSH: A listener asks, "I understand there are studies indicating that people become happier as they grow older. Could you tell us about these? What lessons could younger people take from this insight? Is more happiness later in life connected to wisdom?"

SPENCER: Most of the studies I've looked at tend to find a U-shaped curve where people have the highest happiness when they're young and then when they're old. In middle life, they tend to be a little bit less happy on average. I don't think it's super well understood why that is. I think you could debate what you should expect there because on the one hand, as people get older, maybe they get wiser. Maybe they better figure out what they want in life. Maybe they care about proving themselves less. Maybe those things are all good for happiness. But on the other hand, you might argue, well, when you get older, isn't it easy to become lonely? Isn't it harder to find meaning if you don't have work to do anymore? Let's say you're retired. Does the relaxation of retirement for those that get to retire counterbalance the lack of meaning in your work and the lack of socialization that you might get from work? And so on. And then, of course, as you get older, you tend to have more health complications, which tend to hurt happiness. So it's a very complicated thing. And I think it is interesting and maybe a bit surprising that it's U-shaped in most studies. I think basically what happens is that to some extent, people become less neurotic as they age. And that probably is a factor. They probably do become better at figuring out what they really want and don't pursue so many things that don't get them what they want as much. Then eventually, as they get much older, health effects probably do lower their happiness. But probably we have to look at much older populations to see that make up for the other advantages in older life.