Borderline personality disorder (BPD) is a common, yet often misunderstood psychiatric disorder. In this episode, Dr. Joseph W. Shannon describes the hallmarks of BPD, what is required for a formal diagnosis, and explains the best practices for treatment.
Along with being an expert on personality disorders, Dr. Shannon’s work includes training his fellow clinicians on how to diagnose and treat BPD and explains that if they would change their approach, they would get better results.
Joseph W. Shannon received his Ph.D. in Counseling Psychology in 1982 from The Ohio State University. He has over 30 years of successful clinical experience as a psychologist, consultant, and trainer. An expert in understanding and treating a broad range of mental disorders, Dr. Shannon has appeared on several television programs including the CBS “Morning Show” and “PBS: Viewpoint.”
Dr. Shannon has developed and presented training programs for medical, allied medical, mental health, and substance abuse professionals in the United States and Canada. He is recognized for innovative teaching methods including the use of film excerpts to illustrate distinct mental disorders. Dr. Shannon has consistently received exemplary ratings from health professionals and presents key insights and practical approaches with clarity, enthusiasm, and humor.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, Mental Illness is an Asshole and other Observations, available from Amazon; signed copies are also available directly from the author.
To learn more about Gabe, please visit his website, gabehoward.com.
Announcer: You’re listening tothe Psych Central Podcast, where guest experts in the field of psychology and mental health share thought-provoking information using plain, everyday language. Here’s your host, Gabe Howard.
Gabe Howard: Hey, everyone, you’re listening to this week’s episode of The Psych Central Podcast, sponsored by Better Help. Affordable, private online counseling, learn how to save 10 percent and get one week free at BetterHelp.com/PsychCentral. I’m your host, Gabe Howard, and calling into the show today we have Dr. Joseph W. Shannon. Dr. Shannon received his Ph.D. in counseling psychology in 1982 from The Ohio State University. He’s an expert in understanding and treating a broad range of mental disorders and has appeared on several television programs, including the CBS Morning Show and PBS Viewpoint. Dr. Shannon, welcome to the show.
Joseph W. Shannon, Ph.D.: Well, it’s a pleasure and a privilege to be on your show, Gabe.
Gabe Howard: Oh, it is a pleasure and a privilege to have you here as well. Now, I’ve been hosting this podcast for well over 200 episodes now, and I get two show suggestions fairly frequently and do something on borderline personality disorder is one of them. I’ve wanted to oblige my listeners for some time, but there just aren’t a lot of practitioners focusing on borderline personality disorders. Do you have any thoughts on why that could be?
Joseph W. Shannon, Ph.D.: Well, I think there are a couple of reasons for that. One is that people who have that disorder are notoriously difficult to treat, oftentimes having less to do with the patient and more to do with the fact that the practitioner just hasn’t been adequately trained. We don’t really receive adequate training in graduate programs in clinical and counseling psychology for treating personality disorders. And so a lot of practitioners, quite frankly, just aren’t well equipped for treating the disorder. And those of us who are well equipped, who have gotten the additional training beyond graduate school, there are so few of us that we typically have long waiting lists.
Gabe Howard: Why do you think that borderline personality disorder is so difficult to treat?
Joseph W. Shannon, Ph.D.: I think it’s difficult to treat because of the defenses that the untreated patient has are formidable. Meaning, defenses, there are ways that we defend against anxiety and pain, and people with borderline personality disorder have very primitive defenses. They act out. They can be very verbally abusive. They can be physically abusive. They threaten suicide. They cut themselves, they burn themselves. They oftentimes don’t respect personal or professional boundaries. They’re emotionally intense. They have major problems with managing their anger and their rage. I think that’s one of the reasons, if not the main reason why they’re difficult to treat.
Gabe Howard: Let’s back up for a moment, what is a quick explanation of borderline personality disorder?
Joseph W. Shannon, Ph.D.: I am so glad that you asked. The term was actually coined back in 1960 by a brilliant psychotherapist, by the name of Otto Kernberg. Dr. Kernberg was the clinical director of the Menninger Clinic in Topeka, Kansas, which is a world renowned, both intensive outpatient and inpatient psychiatric facility. And he used the term borderline personality to refer to an individual who was on the border of neurosis and psychosis. Much of the time, their thinking and their behavior is normal to neurotic, just like the rest of us. But every so often when the person with borderline disorder is under unusual stress, they slip over the border into psychosis, which means that their thinking and their behavior is so out of touch with reality, it’s delusional, psychotic, which makes them potentially very dangerous to themselves and potentially very dangerous to other people. Now, according to Dr. Kernberg, and this has been substantiated subsequently with very good empirical research. The number one trigger for people with this disorder that takes them from being normal to psychotic is real or perceived abandonment. For reasons that we don’t completely understand, people with untreated borderline disorder are exquisitely, some would say pathologically, sensitive to any type of limits that you put on intimacy with them. So if you set limits or if you set boundaries with them in any way, they perceive that as a type of betrayal and a type of abandonment. And that sets into motion a rage reaction. And they deal with their rage either by acting out towards the person who they think has wronged them or by acting in and doing something self-destructive, for example, attempting suicide. So that’s the essence, if you will, of the diagnosis.
Gabe Howard: Generally speaking, somebody with borderline personality disorder appears as very dramatic or I’m going to go with scary, they appear very scary. Is that a fair statement? That even though the treatment is effective, that some people are just scared to treat people with borderline personality disorder?
Joseph W. Shannon, Ph.D.: Yes, that is a fair statement, and what you’re talking about is a type of what is called countertransference and countertransference would be any feelings that the therapist has in working with a challenging patient that make it difficult for the therapist to work effectively with the patient. Untreated people with this disorder can be very frightening, very off-putting. They can be very dangerous. Research indicates, for example, that a significant percentage of frivolous lawsuits alleging clinical malpractice are filed by people with borderline personality disorder. Ninety five percent of complaints that are filed with licensing and credentialing boards where the practitioner is ultimately seen as not having done anything wrong, ultimately, they’re vindicated, those frivolous complaints are filed by personality disorder patients, most notably people with borderline personality disorder. So a lot of practitioners simply don’t want to work with this population because they see them as extremely difficult and they see them as potentially litigious and they just don’t want to take on that liability.
Gabe Howard: What are some key features of borderline personality disorder, like what would you need to see in order to make a borderline personality disorder diagnosis?
Joseph W. Shannon, Ph.D.: Let’s start with the Diagnostic and Statistical Manual of Mental Disorders, which is essentially an encyclopedia of psychiatric disorders that is written by the American Psychiatric Association. And so it’s what mental health and substance abuse professionals use for purposes of diagnosis and treatment planning. According to the DSM-5, there are nine critical red flags that will tell you that you’re dealing with an individual who has borderline personality disorder. Now, interestingly enough, you don’t have to have all nine of these to be given the diagnosis. You have to have any five or more of these. So here they are. One would be you’re dealing with an individual who is incredibly impulsive and unpredictable. They typically don’t think about the long term consequences of their behavior. They seem to operate from a core belief that whatever I’m feeling in the moment, I need to act on that right now without really thinking about how that behavior is going to affect them or how it’s going to affect other people. So the first criterion would be impulsivity. Second criterion is that they have a pattern of unstable and intense interpersonal relationships that date back at least to adolescence. People with borderline personality disorder crave intimacy, but they ultimately repel it. They’re remarkably adept at seducing people into caring for them, but then they keep raising the bar. And if you don’t meet or exceed their expectations, they bite your head off. And so it makes it difficult for them to sustain intimacy. The third criterion is that they have a primitive, inappropriate type of rage and, Gabe, in my 45 years of being a psychotherapist, I’ll tell you, there is nothing more terrifying than the rage of a person with borderline personality disorder. There is an annihilating quality to their rage.
Gabe Howard: All right, Dr. Shannon, and number four?
Joseph W. Shannon, Ph.D.: The fourth criterion is they have an identity disturbance, so throughout their life they have major doubts or questions about who they are, their sexual orientation and their sexual identity, their gender identity, they just are profoundly confused about their identity. The fifth criterion is that they simply cannot tolerate being alone. They experience being alone as a type of emptiness, as a type of emotional death. And this is why they tend to glom on to other people. They’re not capable of self nurturing or self-soothing, so they rely inordinately on others for their emotional goodies. And when they’re by themselves, they’ll engage in all kinds of compulsive behaviors to fill that emotional void. They’ll eat compulsively, drink compulsively, have sex compulsively, spend compulsively. So they’re very prone to those types of problems.
Gabe Howard: All right, we’re moving right along. What’s the next one?
Joseph W. Shannon, Ph.D.: The sixth criterion is that they engage in physically self damaging acts, dating back at least to adolescence. Now, the most common example of that would be engaging in self-mutilation behaviors. They can cut themselves, burn themselves, pick at their skin, swallow razor blades, threaten to harm themselves, threaten suicide, attempt suicide. Those are all very common behaviors that we see with these individuals. Now, one question that I get asked frequently is why do they engage in this behavior? There are any number of reasons. If you ask a person with borderline disorder, like, why do you do this? You’ll find that they’re very honest with you. They don’t pull any punches. They’ll tell you that they’ll create physical pain because they would rather feel pain than feel nothing. They do it to punish themself. They do it to manipulate others into giving them special attention or sympathy. They do it as a power play in certain relationships, particularly romantic relationships. The seventh criterion is that they have chronic feelings of emptiness and boredom, most especially if they’re not in an intense romantic or sexual relationship.
Gabe Howard: Now, you said that there were nine total, so clearly there’s going to be another one.
Joseph W. Shannon, Ph.D.: They have a tendency to have difficulty with emotional regulation in general, controlling or modulating their emotions. They’re very moody people, but they seem to have particular difficulty managing anxiety and anger. Those are the two feelings that they seem to have the greatest difficulty with.
Gabe Howard: All right, and the last one, Dr. Shannon?
Joseph W. Shannon, Ph.D.: The ninth and final criterion, according to the DSM-5, is that when they’re under intense stress, they can become extremely paranoid, meaning they become unduly suspicious of the motives and the intentions of others. And another thing that can happen to them when they’re under stress is they can dissociate, meaning that they leave their body. They are not able to stay fully grounded in their body. So those are the nine primary red flags that clinicians use when they’re trying to determine if a person has this disorder. And, Gabe, what’s really important is that these symptoms have to date back at least to adolescence, if not before.
Gabe Howard: Are people with borderline personality disorder aware? I guess one of the reasons that I ask is I imagine that somebody doesn’t sit down in front of you and say, you know, I attach myself to people in an unhealthy way because I have abandonment issues and I don’t want to feel alone. Does that make it difficult to tease out, considering this is diagnosed by self-reporting?
Joseph W. Shannon, Ph.D.: That’s a great question, and in all of the years that I’ve treated people with this disorder, I can count on less than one hand the number of people who have come into my office and have self-reported having a personality disorder in general or a borderline personality disorder in particular. The vast majority of the people that see me, Gabe, they don’t come in even knowing what a personality disorder is, much less what borderline personality disorder is. They present with the same kinds of problems that just about any patient could present with. They have anxiety, they have depression. They typically present with relationship problems. It’s very common for them to present with a substance abuse problem or other addictive disorder.
Gabe Howard: I know that borderline personality disorder is very difficult to diagnose for any number of reasons, I know it’s a very stigmatized disorder and I know that a lot of practitioners don’t want to practice it and/or they’re not trained to diagnose it or to treat it.
Joseph W. Shannon, Ph.D.: Mm-hmm.
Gabe Howard: All of this has to make life extraordinarily difficult for somebody suffering from borderline personality disorder. Yet you describe the treatments as very effective. That’s one of those very hopeful statements and very negative statements all rolled in one. What are your thoughts on all of that?
Joseph W. Shannon, Ph.D.: Let me just back up about your earlier statement that it’s difficult to diagnose. It’s only difficult to diagnose if the patient is seeing somebody who doesn’t know what they’re doing. It’s a specialization, there’s no question about that. But even that being said, Gabe, that the markers are so clear that if you know the questions to ask to tease out the diagnosis, which is part of our training, you can diagnose it. So diagnosing it isn’t that much of a problem, although I will say that it can overlap with other psychiatric disorders. It can, for example, overlap with bipolar II disorder. It can overlap with post-traumatic stress disorder, particularly if it’s related to sexual abuse. It can overlap with what is called intermittent explosive disorder. So differential diagnosis can be tricky at times, but apart from those notable exceptions, it’s not that difficult to diagnose. And then once it’s diagnosed, it’s just a matter of, OK, now that we know we’re dealing with this, there are certain empirically validated treatment approaches. And if the clinician who diagnoses it isn’t trained in those approaches, then the ethical thing to do is to refer the patient on to a provider who has training so that the patient is in the type of treatment that they’re really going to benefit from.
Gabe Howard: But I think of all of the discrimination that’s out there and all of the stigmas out there, and I also think very, very specifically of some of the things that you said earlier about the hallmarks of borderline personality disorder. And one of them is the rigidity. They’re very rigid. And if you try to make them change, they respond not well. I forget what exact words you used.
Joseph W. Shannon, Ph.D.: Yeah, what you’re talking about, there is an example of technique that you use with them. Again, this is not based on Joe Shannon and his practice. It’s based on really terrific empirical science. When I am reasonably certain that a person has this disorder, I tell them. I lay it out for them in language that they’ll understand. I can’t empower them to manage this disorder if I don’t give them a label. And yes, you’re right, there is a stigma associated with the label. And so a very important part of what I do when I work with people is to destigmatize the diagnosis. I tell them that it’s a serious diagnosis, but there’s nothing to be ashamed of. It’s no different than being diagnosed with cancer or with kidney disease, it’s a diagnosis. What I also tell them is that there is an empirically based treatment for this disorder. It’s called dialectical behavioral therapy. I explain to them what that treatment’s going to involve and I tell them that I’m going to be with them every step of the way with that treatment.
Gabe Howard: We’ll be right back after we hear from our sponsors.
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Gabe Howard: And we’re back discussing borderline personality disorder with Dr. Joseph W. Shannon. You mentioned dialectical behavioral therapy, DBT, of course, what is it, how does it work? Where did it come from?
Joseph W. Shannon, Ph.D.: Dialectics is a process of achieving balance, that’s what the term dialectics means, and in dialectical behavioral therapy, it translates into the therapist balancing their style between different polarities. So, for example, one of the things you said earlier, which was just absolutely on target, was is that if you come on too heavy with confrontation with the person who has borderline disorder, they don’t react well to that. They react defensively to that, which is understandable. On the other hand, if you come on too strong with the supportive therapy, oh, you poor thing, I can’t imagine how awful this has been for you. What you can end up doing is enabling the very pathology that you should be treating. You’re essentially providing purchased friendship instead of change-oriented psychotherapy for the patient. So with dialectical behavioral therapy, one of the ways in which the therapist balances his or her style is there’s a balance between accepting the patient and supporting the patient while at the same time helping the patient identify specific attitudes and behaviors that must be changed if they’re going to function at a higher level.
Joseph W. Shannon, Ph.D.: The person who developed this approach, I say without any hesitation, is a genius. Marsha Linehan is a Ph.D. psychologist and she’s a professor of psychiatry and psychology at the University of Washington in Seattle. She developed dialectical behavioral therapy in the late 1980s, and it is now the most extensively researched and validated approach for treating people who have borderline disorder. Dr. Linehan has trained hundreds, if not thousands of providers to treat people with borderline disorder using this approach. It’s a 52 week treatment protocol and the patient is in treatment three hours a week. They have an hour of individual one on one therapy, and then they’re also in a skill building group two hours a week where they learn specific cognitive and behavioral skills. In addition to the formal therapy, they can participate in ancillary treatments as well, which would include pharmacotherapy, day treatment, self-help groups, that sort of thing. But the core therapy is the three hours a week over the course of 52 weeks.
Gabe Howard: Now you’re on a mission to educate clinicians, to help people with borderline personality disorder and in fact, you teach a class called Effective Treatment with the “Impossible” Client. Can you talk about that for a moment? Because as you said at the top of the show, people aren’t trained. They don’t want to. They’re scared of it. They’re worried about lawsuits. They’ve got all of these reasons to avoid helping these people. And you’ve got a lot of reasons that they should rethink that stance.
Joseph W. Shannon, Ph.D.: That’s exactly it. In fact, that’s why I call it effective treatment with the “impossible” patient. I’ll note for your listeners that I have the word impossible in quotation marks. And my reason for that is the very first thing that I say to people who attend that workshop is the idea that people with this disorder are impossible to treat is a myth perpetuated by people who had bad treatment experiences because they were poorly trained. When in doubt, blame the patient. The research indicates that the vast majority of patients who have treatment failure, not just people with borderline disorder, but patients in general, they have that treatment failure not because of anything that they did or didn’t do. It was because they were with somebody who was poorly trained. Therapists have a way of rationalizing their treatment failures by blaming the patient. And I think it’s outrageous. The bottom line is that people with borderline disorder are treatable. That’s what I’ve been trying to do the last 40 plus years of my life with the training that I do, with the patients that I work with. It’s very treatable. A lot of the patients that I see, Gabe, who come to see me for a second opinion, have languished in therapy for years, oftentimes with the same therapist. And they haven’t made significant therapeutic gains because they were working with someone who was well-meaning but poorly trained, and they didn’t get the type of treatment that they needed. The person never even told them what their diagnosis was, talking about insulting, talking about undermining the patient. It’s just awful. And if you look at the research that Dr. Linehan has done and others, the research supports what I’m saying. People with borderline personality disorder are incredibly strong, resilient people. They want you to level with them. They don’t want you to beat about the bush. They want you to lay out for them, here’s what you need to do. This is the part that’s going to be difficult. In fact, it’s going to feel like you’re going through hell at times. But I’m going to be with you every step of the way. And when you emerge from this treatment a year, maybe 18 months tops later, you’re going to be amazed at how wonderful you’re going to feel. So that’s basically it, Gabe. They do not run screaming from my office when I give them the diagnosis and talk about the treatment. I’ve had them sit in my office and cry because they’re so relieved to hear that they actually have something that has a label and that there’s a treatment for it. When I use that model with these patients, I’m telling you, they get well. They get well. And I’m not alone in that, Gabe. There are many therapists who have been trained as I’ve been trained using approaches like DBT, and they’re having success with these patients. They really are.
Gabe Howard: Let’s talk directly to people with borderline personality disorder for a moment. What message do you want them to understand and to take away?
Joseph W. Shannon, Ph.D.: The first message that I want when I give to them would be this, you are not your disorder. Borderline personality disorder does not define the totality of who you are. Part of the reason why I like working with people with this disorder is they have so many positive qualities that they take for granted. I’ll tell you something, Gabe, I have never met a stupid person with borderline personality disorder. They usually have very high IQs. They are survivors. I always tell my people with borderline disorder, if there’s ever a nuclear holocaust, I hope I’m standing next to you because I’ll have a greater chance of surviving. They are extremely loyal. If you work with them and treat them with respect and kindness, they come every week. They put themselves out there. They really work hard in treatment. So I want to say all of that. The other thing I want to say is this. If you’re having difficulty finding a clinician who is trained in dialectical behavioral therapy, who can treat your borderline disorder, here’s what you need to do. Go to this website, BehavioralTech.com. That is Marsha Linehan’s Web Page at the University of Washington. And you can click an icon on that Web page. And it’s a directory of every DBT trained mental health professional in North America.
Gabe Howard: You have another class that’s called Understanding Intense, Impulsive, and Volatile Relationships. Can you tell us more about that? Because that is one of the hallmarks of borderline personality disorder, is it not?
Joseph W. Shannon, Ph.D.: Yes, it is, but I would be remiss if I didn’t say that there are many types of people who have intense and volatile relationships because they have some sort of untreated psychiatric disorder. Borderline disorder is just one of those. But here’s the deal. The larger area that we’re really delving into today is personality disorders. And when we say that a person is personality disordered, let me tell you what that means in everyday English. It just means that they have a collection of traits that are inherited and habits that are learned that are inflexible and damaging. This creates pain and difficulty for the personality disordered person. And make no mistake, it’s going to create difficulty and perhaps pain for people who interact with them, Gabe. Those personality types have the potential to have really screwed up interpersonal relationships, most especially romantic relationships. They will engage in behaviors, be they conscious or unconscious, that will wreck relationships that they try to establish. With borderline disorder, because they are so confused about their identity, because they’re emotionally turbulent, because they have such difficulty with boundaries, because they have such intense dependency needs. That’s what tends to make them so difficult to manage in a personal relationship. I’ll just put it to you bluntly. They suck you dry, complain when you’re empty, and then they move on to another host. And that’s just difficult to be on the receiving end of.
Gabe Howard: Let’s move this away from borderline personality disorder. In fact, let’s move this away from mental health. If you are the primary caregiver or you live with somebody who has a chronic physical illness, that’s going to start weighing heavily on you. But because we have more understanding and knowledge of a chronic physical illness, we tend to internalize that and turn it into compassion and understanding. Whereas because of the misunderstanding of mental illnesses and in particular borderline personality disorder, that manifests as anger. And why won’t this person just do the following? Arguably, why won’t they change and be better?
Joseph W. Shannon, Ph.D.: That’s brilliantly put. That’s exactly it. So the most common feeling that people have when they’re living with an untreated borderline individual is they feel like they’re in a catch 22.
Gabe Howard: Dr. Shannon, thank you so much for being here. I really appreciate it. You are awesome.
Joseph W. Shannon, Ph.D.: Thank you so much for having me. Again, it’s been a pleasure and a privilege, Gabe. I love your show and what a service you provide for people. It’s just terrific.
Gabe Howard: I’m never going to get tired of hearing that. I appreciate your kind words.
Joseph W. Shannon, Ph.D.: Oh, my pleasure.
Gabe Howard: Thank you, Dr. Shannon, so much for being here. My name is Gabe Howard and I’m the author of Mental Illness Is an Asshole and Other Observations. It’s 380 pages of awesome that you can get over on Amazon.com. Or if you head over to my Website, gabehoward.com, you can buy it there for less money. I’ll sign it and I’ll throw in Psych Central Podcast swag. Wherever you download this podcast, please subscribe. Also rank and review it. Use your words. Tell other people why they should become The Psych Central Podcast listeners. We’ll see everyone next week.
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