Crossing the Alphabet Divide: An Integrative Overview of BPD Treatments with Dr. Kenneth Levy

Welcome to the CARLAT Psychiatry podcast. This is an episode from the Psychotherapy podcast team. I'm your host, Abigail Russell, and I'm honored to be joined today by Dr. Kenneth Levy, PhD, to kick off our multi-part series delving into borderline personality disorder. Dr. Levy is a tenured professor in the clinical psychology doctoral program, the Pennsylvania State University, where he directs the laboratory for personality, psychotechnology, and psychotherapy research. He serves as an agent assistant professor of psychology and psychiatry at the Cornell Medical College, and is also a member of the Cornell's Personality Disorders Institute, where he serves as a faculty fellow and an executive committee member. Dr. Levy has been both a principal investigator and a co-principal investigator on many of the key projects of the PDI related to borderline personality disorder over the last ten years, and generally has played a really central role in a lot of the groundbreaking research that's been fundamental to how we conceptualize borderline pathology and what we know of treatment and treatment mechanisms today. So I'm very honored to have him here with us and to be able to kick off our series with the very first episode titled Crossing the Alphabet Divide, an Integrative Overview of VPD Treatments. We're excited to share that we've also created a companion article for this discussion that includes a CME post-test that you can complete in order to earn CME credits. That article is linked in the episode description in the podcast episode page on www.thecarlatreport.com. Dr. Levy, welcome and thank you so much for being here with us. Can you just start off by briefly sharing a little bit about anything that I might have missed in terms of your background and your expertise in the area? First of all, thank you for having me. It's a great pleasure to be here in an honor. I don't know how much more I could say about my background. I could tell a little bit about how I got interested in borderline personality disorder, started as a mental health worker working in an impatient unit, and being exposed to people who were struggling with the kinds of issues that are a typical of people who are grappling with what we call borderline personality disorder, and wanting to understand and be helpful and help people have the kind of lives that they aspire to. And I was fortunate enough to be exposed to really dedicated and talented psychiatrists and psychologists. And although I was planning to go to graduate school in clinical psychology, I already focused my interest in this area and then having read works of people like out of Kernberg and others, became interested in treatment, which has led not only to my clinical interest, but my research interest, which focus on, as you said, the treatment of borderline personality disorder, but specifically understanding the mechanisms of the treatment, how the treatment works, where the action is in the therapy, with a focus on understanding how identity consolidates and provides structures that allow for the regulation of emotions, particularly under times of distress, and 30 years later, here we are. One of the reasons I'm particularly excited to have you here with us today is I think a lot of what you focus on, particularly the mechanisms of change in psychotherapy for BPD is really at the core of much of what I hope to touch on in discussing the wide range of treatments that are available. So I'm looking forward to delving into that. I'd like to start off just by giving our listeners a little bit of context on BPD, so perhaps if you could give clinicians a working understanding and maybe take a few minutes to describe some of the core clinical features of borderline personality disorder as you see the most commonly presented patients. Probably the most prototypical presentation that clinicians will see is a patient that often comes into therapy, whether it be a patient therapy, or a impatient unit or emergency department, highly distressed in the midst of some interpersonal or work crisis, or even some pragmatic crises like housing crises, the patient may be tearful, crying, self-critical, even suicidal. The cheerfulness will often vacillate with frustration, even irritability and anger, and the self-criticism will often vacillate with the projection of or anger towards others about their situation. So you see both this presentation of extreme what we might call internalized effects like anger and self-criticism towards oneself, but also anger externalized outward. At times, those externalizations would seem quite reasonable. People may have had experiences where they were mistreated, but at other times the externalizations have a characteristic that seemed to suggest that the patient may be under-recognizing their role in the situation. True to the description in the DSM, these patients typically present with instability in their sense of self or self-concept or what we often call identity, instability in their reports and experiences of effects or emotions, which may also be observable in the consultation room, so you can see the patient vacillate between feeling one way and one moment and another way the next moment. And finally, we see instability in interpersonal relationships, which often strikes the clinician as chaotic with lots of ups and downs and idealizations and denigrations of the people who are being discussed and some maybe hypersensitivity to slights, both real and imagined, and concerns about people's presence and their abandonment. These dynamics are characterized by angry outburst threats, actual suicidality, as well as non-suicidal self-injury. Now, even with this presentation, the recognition of BPD can be actually difficult. Patients may report histories of trauma. They may include multiple types of traumas and traumas across several developmental periods, and there may be occurrence of quality from these experiences that are indicative of post-traumatic stress reactions or post-traumatic stress disorder. And therefore, it's sometimes easier to recognize the PTSD aspect of the patient's presentation than maybe the more personality-related issues. And when the trauma is not acute, but has been chronic, like I just described, it's often called complex post-traumatic stress disorder, CPTSD. And although this concept of complex post-traumatic stress disorder is still controversial and in debate, it's frequently used. And in my opinion, often misused in that it's often misdiagnosed as the central problem, but it's important to remember this idea of complex PTSD is usually not a good explanation for what we're seeing with borderline personality disorder. Our best study suggests, depending on samples, that 30 to 70% of borderline patients may have these kinds of traumas, but that 30 to 70% of patients don't have these kinds of traumas. Another complication is that patients may present with other comorbid conditions such as depression, panic disorder, and/or bipolar disorder. And in my experience, treaters often privilege such comorbid conditions, but it's important to recognize that the evidence suggests the opposite is actually true that when borderline personality disorder is present, it actually warrants strong consideration. There's data now from several longitudinal studies, large samples that suggest that disorders like anxiety disorders makes depression, bipolar disorder, when they're comorbid with borderline personality disorder, they don't actually affect the course and outcome of borderline personality disorder. But when those disorders actually have a comorbid BPD, the course and outcome of those disorders is actually affected by the presence of BPD. And they think it's reasonably strong evidence for the importance of the BPD diagnosis and actually privileging it as opposed to comorbidities that often in some ways distract clinicians from the core difficulties that the patient may be having. Just a circle back to your earlier point that you touched on in regards to CPTSD. This is something that I've heard quite a bit about in recent years, especially there's been a lot of debating discussion about the overlap between CPTSD and BPD, whether the two are actually one diagnosis or fall under the same umbrella. And I'm curious if you can speak a little bit to what the differential diagnosis would look like for CPTSD and BPD and what the really fundamental differences are that would enable clinicians to be able to tell one apart from the other. That's an excellent question and it can be very difficult for a clinician. There's a PTSD researcher Marilyn Kloitra and Kloitra ran a randomized controlled trial looking at an emotion focused treatment for PTSD resulting from childhood sexual abuse. She assessed over 300 individuals. She was actually able to empirically examine the very question that you asked how might you actually differentiate people with borderline personality disorder from somebody with complex PTSD. What's important is she was actually able to distinguish distinct groups, including a group of people with complex PTSD from people with borderline personality disorder. And then she looked at these groups in terms of their responses to various assessment measures that she had given him. She found that the people with complex PTSD certainly had a more serious presentation than the PTSD proper, but it was still a different presentation than the people with borderline personality disorder. One of the problems with complex PTSD, at least as it's conceptualized, is that many of the symptoms articulated are very similar to those that have been articulated in BPD, such as difficulties with one sense of self, emotion dysregulation, interpersonal difficulties, etc. and suicidality. And looking at people's responses, what she found was that the people with complex PTSD had problems with their sense of self, but it looked different than those with BPD. People with complex PTSD, their sense of selfs were tended to be on the overly negative self-critical side. And borderline patients actually presented with that too, but in addition to presenting with the self-criticism, they actually presented with what is prototypical of BPD, a more chaotic sense of self that vacillated in its perception of the self. So sometimes they were very self-critical of themselves. Sometimes they were very much critical of others and actually very much absolving themselves of any criticism. And this is consistent with the criteria in the DSM that talks about non-stable sense of self. And so there was a self-concept difficulty for people complex PTSD, but it was actually a stable negative self-concept that's opposed to a vacillating self-concept that you see in borderline personality disorder. Likewise, with regard to interpersonal difficulties, they found that the people who with complex PTSD tended to have fears of interpersonal relationships. So isolated themselves from others at a fear, they wanted to be close to others, but they isolated themselves because they were afraid that they might get hurt. And this was actually also a pretty stable isolation and fear of getting close to others. And again, in borderline personality sort of more consistent with the criteria, what she found was that people presented with vacillations in their interpersonal relationships, chaotic interpersonal relationships, getting close to other people withdrawing from other people, lashing out at other people, etc. And you didn't see that in the complex PTSD. And then importantly, although there was some suicidality in the complex PTSD sample, about 15 percent of the sample, in the sample that looked more like borderline personality disorder, you saw about 70 percent of individuals showing some suicidality, including on suicidal self-injury. And so when you ended up looking at the results, you could actually differentiate these two presentations. So for instance, if you're in clinical practice and somebody comes in and they've had complex trauma and they start reporting vacillations in their sense of self, chaotic interpersonal relationships with these extreme vacillations between derogations and idealizations and their reporting suicidality. Diagnostically, you might err to the side of borderline personality disorder rather than complex PTSD. And it's important not simply from a conceptual level, but it has treatment implications because if you're diagnosed with complex PTSD, you're likely to not get one of the specialized treatments for borderline personality disorder that have shown reasonable amounts of efficacy. And so you're not only misdiagnosed, but you're misdosed in terms of the treatment. So it does sound like despite some surface level similarities in terms of how these two disorders manifest sentimentically, once you really delve into the pathology and the origins of the symptoms and the behavior, there really are distinct, meaningful differences that could help one differentiate one from the other. So you touched briefly on so the specifically proven treatments to work for BPD and I'd like to discuss those. It's my understanding that at present there are five primary treatments that have a substantive evidence base in being effective for working with BPD patients. And I was hoping you could elaborate a bit on what those five treatments are and perhaps also on some of the key practical differences between them. I really how each of them are implemented in practice and what that model looks like for a therapist that's in the room and for the patient that's in the room. You're pointing out importantly that there are multiple treatments available. I tend to refer to the five main ones as the big five that would be dialectical behavior therapy, mentalization based therapy, transference focus psychotherapy, schema focus therapy, and good psychiatric management. The treatments I named are the ones I would call specialized treatments for borderline personality sort of although one could say that good psychiatric management is a more generalist approach. These are intensive treatments that involve individual therapies. There are other types of treatments, steps, and emotion regulation group therapy that are more group based, objective treatments that you could add on to existing treatments as a supplement. And then there is a dynamic deconstructive therapy which is a psychodynamic treatment that's been tested in a couple of small sample randomized control trials. But just is that there are a lot of treatments out there. Now these treatments, you can break them down into what are individual treatments or intensive treatments like DBT and transference focus psychotherapy and schema focus psychotherapy treatments that might be an adjunctive like steps or the emotion regulation group, specialized treatments like DBT, TFP, MBT, etc., and a generalized treatment like good psychiatric management. And you could also array these treatments as a function of whether they're cognitive behaviorally based or psychodynamically based. So there is a different ways of thinking about these treatments and different treatments out there that are available to clinicians. But it's important for clinicians to be aware of that because at this point what we know is that there are no differences in the effect sizes of the various treatments. Treatments all seem to be equally effective overall across a range of patients. What we also know is that although many patients get better in these treatments and these treatments have efficacy over treatment as usual out in the community, we also know that the treatments aren't universally effective for all patients. In fact, at this point we think about 50 to 60 percent of patients will show improvement within a year and that improvement is somewhat partial that is just showing improvement in terms of reductions and suicidality and your visits and increased functioning. But they're not at the levels of thresholds that one might aspire to in their lives. And so there's still work that needs to be done and some time for those patients that aren't getting better in any given treatment, it's quite possible that an alternative treatment would be actually useful in addressing their difficulty. That's a tricky thing to decide when you have to increase the dose of what it is that you're doing versus when it might make sense to actually change what it is that you're doing or what the patient is receiving. But nonetheless, while these treatments are effective, they were far from the place where we can celebrate and pat each other on the back and say, "Draw well done, everything's fixed." And instead, we have to be open and humble and think deeply about whether to intensify the thing that we're doing or whether that's simply putting a round peg into a square hole or a square peg into a round hole or whether we need to think about changing it up. The good news is there are other treatments. The bad news is that we haven't been able to disseminate these treatment sans DBT in very large-scale ways. DBT is quite available to people, maybe not as available as it needs to be, but these other treatments are even less available. And of course, they might be helpful, particularly in cases where DBT is not working, where you see patients going into DBT coming out of it and relapsing and needing more treatment than sometimes you see this revolving door in terms of the way that the treatment is being used, then in those cases, it certainly might make sense to try a different treatment. Therapists have different sensibilities to themselves in terms of the treatments that they're attracted to in terms of what they can execute and use, but patients also have different sensibilities to them in terms of what might resonate with them and might work for them. And so we have to be sensitive to that. What would you say are some of the key distinctions between these treatments, whether in their underlying conceptualization or in the techniques and methods that they utilize, I really set one apart from the other and justify having facts that are approaching. First off, I would say that it's important to recognize that these treatments are actually much more similar than people might think. They share certain commonalities, at least conceptually, if not necessarily how they look in the room and deploy this commonalities across these treatments that might be responsible for their effectiveness. So first of all the treatments are well articulated conceptually and have a conceptual model to them that typically resonate with the clinician that's actually practicing it, but also can resonate with patients. I think that having a coherent model that resonates is actually an important aspect of a psychotherapy and Jerome Frank, a psychiatrist who in the 60s wrote about common factors in psychotherapy, talked about that in particular as one of the common factors in therapy in general, but in thinking the treatments that we were just talking about, DBT, TFP, MBT, etc. Again, you have this coherent model that they all adhere to, at least model specific to the treatment. Second of all, all these treatments actually devote a lot of attention to training and supervising therapists and getting therapists to a certain level of adherence and competence to the models. And so you have people who are quite conscientious and committed to a specific way of working and a lot of attention is paid to making sure that they are working in ways that are consistent with that. So all the psychotherapy studies, for instance, that have been done to show the effectiveness of the treatments, have involved therapists in supervision. And most of these therapies, as they are practiced out in the community, involve therapists who are in either supervision or some sort of intervision, meaning that they're in some pure supervision with one another. And Linahan talked about the importance of the consultation group in psychotherapy and the importance of having people that you're talking about, your clinical work with to help you contextualize the work that you're doing. So now we have two sets of commonalities. One is a coherent model. Now, second is a lot of attention to adherence and competence in that model. Additionally, these treatments all put a lot of attention to assessment of the patient and the provision of feedback to the patient about the impressions from the assessment in an effort to be transparent with the patient and collaborative, but also to have a shared view of what the difficulties are and what the interventions around those difficulties might be. And so there's a lot of effort in these treatments to being very explicit about what the difficulties are and what the frame of the treatment will be, what the therapist roles and responsibilities are in the therapy, what the patients roles and responsibilities are in the therapy, even small things like we start sessions on time and we end sessions on time and how we handle cancellations and schedule changes and things like that one might take for granted. Those things become very explicit, but more importantly, what becomes explicit is how the therapist sees the therapy working and what the tasks of the therapy will be, what the goals of the therapy will be are very explicit. So everything's very explicit in the frame. In addition, these treatments put a lot of attention to dealing with the interpersonal relationship between the therapist and the patient, paying attention to ruptures in the relationship and not trying away from those, but instead actually turning into them and trying to understand what's happening and how those ruptures can be repaired. And in doing that, all these treatments are very focused on the interpersonal context. So there are a lot of similarities between these treatments, regardless of how they're actually carried out in session. Now the treatments can look very different from one another in session, dialectical behavior therapy, in particular, but somebody other cognitive behavioral treatments hear more skill-focused. There may be diary cards that are used. There may be exercises that are done. One thing that we noticed in our randomized controlled trial that compare a transference focus psychotherapy dialectical behavior therapy and a supportive psychotherapy to one another is that an easel will often come out in DBT where an easel rarely will be brought out by the therapist in transference focus psychotherapy. So if you were watching the tape and not able to hear the sound or see anything else, you could distinguish them at that moment. So the treatments can look different. I've heard from therapists that TFP may feel too unstructured to therapists that like the kind of structured at DBT provides. And likewise, I've heard from therapists that DBT can sometimes feel too scripted and rigid. The therapists that are more interested in the evolving interpersonal context than therapy there. But there's other things that can look different in DBT. There is the validation can look different. There's cheerleading as a technique that's provided the self-disclosure and TFP self-disclosure's minimal. And you would necessarily have as over validation in the same way that you would have in DBT. So it can look very different. It can feel very different to patient. In TFP, the therapist is trying to help with patient develop internal psychological structures that will provide stability for the patient. And DBT will appear like there's a lot of tension play to external structures to help the patient stabilize. And so it can feel very different to patients in that way. And it can feel very different to therapists that are actually connecting the treatments. More commonalities than people will imagine, but certainly differences. And it would be interesting to talk to patients that have been in both DBT and TFP to hear about their experiences of it. They am thinking about one patient who would, I think, describe it as different in their mind. And that DBT was more focused on the external structures than TFP more on the internal structures. But I also have talked about a patient who was in TFP and DBT and didn't see the difference between the two. I thought that they worked the same, although they didn't necessarily articulate exactly how. I think your point about the commonalities between the treatments is a really interesting and really under-recognized one. And that I do think that a lot of people believe that distinct treatments exist to address distinct aspects of the pathology and function in very fundamentally different ways both conceptually and technically. It's a really important point and it brings us quite naturally to the next step in our discussion, which is your concept of the alphabet divide, which I think encompasses a lot of what you're referring to here. So can you share a little bit about what the concept of crossing the alphabet divide means to somebody that hasn't heard about it before? Well, I'll say is that the idea of the alphabet divide came to me just by the sheer number of three initial treatments or four letter treatments that are out there, DBT, TFP, Schema Therapy, et cetera, et cetera. And I guess two metaphors came to mind. One was like an alphabet soup of letters and the other was this idea that those of us in one camp versus another camp seemed to be in these separate victims where we know a lot about the treatment that we were trained in and practiced in but know very little about the others. And the idea of that divide wasn't necessarily helpful for the field at a conceptual level but also wasn't helpful to patients pragmatically. And I've talked with clinicians out in the community who have no idea of these other treatments. They only know of the treatment that they were trained in and that was very disconcerning to me. This divide to me seemed problematic, particularly in light of the fact that empirical data was showing that there were no differences in the effectiveness of the various treatments. And why this divide if all these treatments are actually equally effective and can be useful for patients. And that's where the concept came up. And I presented and then wrote a number of papers where I articulated this idea of the alphabet divide really as a criticism of where the field is at and a call for more coherence among those of us that practice and those of us that study personality disorders related to this idea that early on as I started recognizing the importance of different treatments and early on. So historically, people practice psychodynamically. There were books by Gunderson and Wallander and Kernberg and others talking about the conceptualization of BPD and how one might go about treating it and talking about cases. And there really wasn't much empirical work. And things exploded in 1991 with the publication of Lin-Anne's Seminal Paper on Dialectical Behavior Therapy where she actually could show that you could treat a cohort of patients in long-term psychotherapy. And it was just that one RCT. And then several small RCTs that she conducted right after that. And the field was looking as if the only thing that's really worth practicing is DBT because it's the only treatment that's been tested and shown advocacy. While being in small samples, much of the healthcare policy in the United States with regard to borderline personality disorder was based on one study with 19 patients. But over time, fate-minute finding came out with their randomized control trial of MBT and then schema-focused therapies. And TFP came out with their studies. And all of a sudden, there were more out there than dialectical behavior therapy. And at that point, there was equivalency in direct comparisons and in the effect sizes and meta-analyses. And of course, that finally continued to be found. So my idea was that we need to get away from this alphabet divide. And at the time, when this first story coming out, I was like, okay, a lot of communities have DBT. But they need something else besides DBT because DBT doesn't necessarily help every patient. And there are these other treatments that are effective. Over time, I've actually come to the idea that not only does every community need more than one type of treatment available to patients, but that every therapist needs to be aware of the multiple treatments. They don't necessarily need to practice the multiple treatments, although that would be nice if they did. But they need to be aware of these other treatments. So the alphabet divide is really a concept that's meant as a critique to where the field is at and to try to move away from that to a more cohesive and comprehensive view of how we might provide for patients in need. So given this evidence that we have that really no one treatment is superior to the other, and they're all pretty equally effective, what do you think is keeping the field so rigidly stuck and attached to this concept of the alphabet divide? We don't have the studies. We have several RCTs. Debent may be 25 to 30 of DBT alone in the United States. We have several others of MBT and TFP and Schema focus therapy. And we know that the effect sizes are similar and direct comparisons. There aren't differences, but we know very little about what would predict who might do better in one treatment or another. For years, we knew that there was some prognostic indicators like being high on anti-social traits or being high on narcissism, predicted doing more poorly in treatment across the treatments for the most part, although there's now evidence that suggests that MBT might be particularly good for people with anti-social traits and TFP might be particularly good for patients that with a high in narcissism. Although we had these prognostic indicators, we didn't have a lot of prescriptive indicators. What would predict who would do better in what particular treatment? At this point, I would say if you have a patient with low reflective function or low mentalizing capacity, the evidence is strongest for TFP. If you have a patient that's high in anti-social traits, the evidence is strongest for MBT. If you have patient with high narcissism traits, the evidence is strongest for TFP. DBT and MBT I think have the strongest evidence about reducing suicidality and parasyuosidality, but this is rather idiosyncratic. All these findings, and I'm not sure if we were able to test these things across the multiple treatments, if we would actually still find those kinds of differences. We're really not at a great place to be able to say empirically, here's how I would identify who would go to TFP versus who would go to Schema-focused therapy versus who would go to DBT or MBT or GPM. I think where we're at this point is just knowing that there are other treatments available and being attentive to whether somebody seems to be improving or not to what their sensibilities are and what treatments they might do well, and sharing with the patients these modalities and what they look like and trying to think very thoughtfully with them about which treatments might actually be best for the difficulties that they're dealing with. I wish I could say more about what people might do in terms of finding the kind of treatment that best predict what their improvement then, but we just don't really have those studies yet. Of course, those of us in the BPD world know that the research in borderline personality disorder is grossly underfunded, and most of the funding that has been done with borderline personality disorder has been done with regard to one treatment modality. We're in the infancy of that. Given this lack of evidence and information and unfortunately the lack of studies that we have in helping us determine which treatments are more clinically indicated or which type of patient profiles, how do you recommend a therapist that is just starting off working with a client with either suspected or diagnosed BPD determine which treatment is really the best one for them to start off with. Of course, with the knowledge and the understanding that modality can change along the road, but given the information that we have now, are there any strategies that one could use in the very early stages to even suggest the starting point of treatment for a client? Or do you really just go with what you're best trained in and hope that will be efficacious for the patient as well? I think very pragmatically, therapists need to start where they have some expertise. So if you're in a community where you can get trained in DBT, you get trained in DBT, if you're in a community where you might have TFP, maybe you have a choice between DBT and TFP and you might choose one or the other, but ultimately you have training in a particular modality and that's obviously where people should start, but at the same time they need to be very reflective and humble. What bothers me sometimes is I see people in one camp or another where they think their treatment is the only treatment and to do anything else is derelict and I don't know that's the right attitude at all. I think the better attitude is to obviously believe in what you're doing, you wouldn't be doing it if you didn't, but to be humble about it and to be aware of other things and to share with patients, what the options are and why you're suggesting what it is that you're suggesting and then being very vigilant for whether that's working for you. As a therapist starting off in the field, you can look at the different treatments that are available and value yourself of those trainings. There are workshops that are online all the time by people who have developed the treatments or trained other people to train other people, certified trainers, for instance, and you don't have to be in New York City and around Ado Kirmberg to get trained in TFP. You don't have to be in Seattle to get trained in DBT and so I think that people can avail themselves of these other treatment modalities and train in these other treatment modalities and I do think of the whose people to be aware of the different modalities and that sufficient depth that they could actually convey that information to patients and that they should not simply say to a patient, I'm recommending DBT or TFP because that's what I do, but that they actually have a rationale for why they think this treatment would be appropriate for the kinds of difficulties that the patient is having and to be very cognizant and even have this discussion about what getting better would look like and what not getting better might look like and whether we would need a consultation about potentially changing the treatment. I think your point about really remaining aware and open-minded to how the patient is progressing over the course of a treatment is a very important one because as you mentioned different patients respond very differently to different treatments and different approaches and was effective for one patient with certain set of difficulties may not be effective for another patient when another set of difficulties and I believe that it is the ethical responsibility of a therapist to be able to really think very critically about how patient is progressing and to explore other alternatives that it's clear that the approach that they're utilizing is not in the service of the patient and so to that point over the course of an active treatment what would you say are really some of the clearest indicators that a therapist should be looking out for that sort of serve as a warning sign that perhaps it's necessary to look elsewhere or to adapt their strategy or their approach to a given client. Maybe you could touch on some examples of shifts in symptom patterns or in presentation that for you would suggest that you take a different stance or a different intervention as a treatment provider. The question I'm not sure I have a good answer to it because the reality is when you're treating patients with borderline personality disorder is that the treatment is going to take time and so there can be long periods of time where you may not necessarily see much improvement or variable improvement you see some improvement and then the patient reverts back to earlier ways of functioning and I don't necessarily know that those are indicators that the treatment isn't working and that you should shake things up at that point so you know that's a difficult question in that regard. I think if you can periodically assess whether people are moving more to their goals it's not uncommon to have a patient come into therapy really frustrated feeling as if they think they're not getting better fast enough or getting better at all and that's understandable. Anyone with any kinds of problems would want to get better as fast as possible but the metaphor I often use is you can't cook a stew any faster just simply by turning up the flame a stew takes time for flavors to be released than things to call ass and it often happens over a low flame and sometimes the treatment of people with personality disorders is similar that way that it's going to take a long time but you should be moving in the proper direction and you should see indicators that suggest that the patient is showing some improvement. Occasionally patient will come in and they'll say I'm really frustrated I don't think I'm getting better and when the patient says that often I experience it kind of transferentially as a punch to the gut you want them to get better and immune you're like well then you have to think and reflect for a moment and see if that's true and often in my mind I can say okay here are some ways that the patient is better and usually what I say to the patient in those moments I say they hear what you're saying and I understand that you're frustrated with the pace of the treatment then that's understandable why wouldn't you want to get better as fast and as completely as you can but I'm not sure that I see it exactly the same way that you do and that you're not getting better at all I think there are indications that you're improving albeit slower than you would like and not necessarily as large of improvements as you would like and then I share it with them for instance I say when you first came into treatment often you came and tell me about times you blew up at somebody at work or somebody at home often you found yourself angry with me and you came in and there was some frenetic quality to your presentation and in the last few months you haven't come in with the same kinds of concerns you've actually come in much more balanced in your perception of things with other people both at work at home and when you're upset with me in session you've been able to share it in a way that has allowed us to unpack it and talk about it and sometimes you seem not only able to do that but feeling quite relieved after we have those conversations where my sense was when you first came in and we'd have those conversations you often left as frustrated if not more and I'd say does that sound consistent with your experience of the therapy or do I seem off the mark and often though the knowledge that yeah that they recognize that and sometimes that satisfies them and sometimes it makes them feel but I wish things were even more better than that that's not enough or it's taken so long to get here empathize with that frustration who won but if you don't see those things you know then maybe this indication one thing I've seen that often to me has suggested somebody should be in another therapy just watching them graduate from therapy go back out into the world and then relapse so to speak and needing to come in for treatment and you've seen sometimes this revolving door of somebody going into treatment leaving treatment then coming back into treatment going into treatment particularly in day hospitals or in patient units and to me that often feels okay this a revolving door and we're doing the same old and maybe something different is needed the other time I think that something is sometimes different is needed is not when the patient's not getting better what has they get better they sometimes might graduate into a different therapy so I've certainly seen this where patients come in and the structure of DBT is helpful to keeping them contained but as they go through DBT and have made improvements in being more stable they are able to avail themselves of a treatment like TFPity and so I've know several patients who have been in DBT and later TFP and I think that the treatments were appropriate to the stage of where they were at they might not been able to do TFP in the beginning and DBT might not necessarily been as useful at some point because now they have a capacity to reflect on their experience in a way that allows them to make use of a treatment like TFP I think that's a great point that sometimes it is necessary or valuable to switch gears not only when something isn't working but also when something is working I'd like to circle back to a point that you've touched on quite a bit of the underlying commonalities and the similarities between the big five and I'd be curious if you could speak to what the core active ingredients are that are really shared amongst all of the treatments that actually drive the improvement in BPD patients really regardless of the specific treatment model. One thing I've heard from my patients when our treatments have finished and I've asked them what they thought was helpful in their treatment the one thing I hear the most is that patients talk about my remaining calm during their what might be called affect storms and sessions when they've gotten upset whether it be at someone else or whether it be with me and I've been able to keep calm and be responsive to them and one of the ways I think about it is that it's really important as a treater that during those kinds of expressions of affect that one is as a therapist is able to maintain their thinking which allows them to work with the patient to understand what is happening in the moment and I think that regardless of treatment therapists when they do that help drive the capacity for the patient to tolerate their experience as you're tolerating it and to develop a more integrated sense of themselves and sense of others which I think is actually the act of ingredient regardless of treatment even though it's not necessarily articulated in some treatments. So when you get a therapist who can maintain their thinking through the affect storm that might be occurring and help the patient develop a more integrated sense of themselves in that context I think it leads to the kind of positive change we see in patients helping them to develop those psychological structures that will allow them in the absence of other things be able to regulate themselves maybe an idiosyncratic answer maybe somebody from another orientation would talk about the development of motion regulation skills I think I am talking about that too but I'm talking about it coming from a different arena but I have been pretty curious about when I talk to patients they uniformly say that same thing that it was my ability to remain calm and be interested in them while they were very upset with me some of them even described that it was infuriating to them at the time when they were upset with me that I wasn't reacting to that but in the end they actually felt that it was important and helpful and so I think the therapist could obviously listen be present not be thrown off balance by what's happening with the patient if you are thrown off balance to recover quickly so that you can respond in a tactful respectful collaborative way that it shows that you value the patient's experience and then want to understand it that's actually one thing that I think all the treatments do is that they actually help the therapist approach the patient from what might be called a non-judgmental stance where the therapist is able to hear the patient's experience without necessarily judging them and then that allows that to be reflected upon and understood in a way that wouldn't necessarily happen otherwise and allows the patient become more compassionate to themselves because the therapist in some ways in doing that is actually modeling being compassionate once then so I maybe that's more of a TFP response than other general response but that's certainly how I would understand it. I think that's all the time that we have today but thank you so much for joining us Dr. Levy it's been very fruitful I think we've given listeners a lot to think about and digest just wanted to check in and see if you have any closing remarks or closing thoughts that you'd like to leave our listeners with before we sign off. Thank you for inviting me to speak with you I think this series that you articulated is very important and I'm honored to be able to participate and to lead it off I think that consistent with what I was saying about the importance of being thoroughly familiar with the various treatments this series that you're starting is a good step in that direction and hopefully we'll lead to remediation or resolving of this alphabet divide that exists in our fields so thank you very much.