Episode 51: Rethinking Personality Disorders with Dr. Carla Sharp

Embark on a mesmerizing exploration of the human psyche with Dr. Carla Sharp, who guides us through the labyrinth of personality disorders with the precision of a master clinician and the insight of a top-tier researcher. As we traverse the landscape of developmental psychopathology, Dr. Sharp shares her pioneering work on early intervention and the dynamic nature of personality disorders, challenging the traditional categorical approach. Her expertise shines as we dissect the alternative model in the DSM and the elusive levels of personality organization, offering a fresh perspective on these complex conditions.

Our conversation with Dr. Sharp ventures into the HITOP model's major dimensions, revealing how they contribute to a nuanced understanding of disorders like Borderline Personality Disorder (BPD). Through her lens, we gain clarity on Kernberg's theory of personality's organizing function and the significant role of the Level of Personality Functioning Scale (LPF). Dr. Sharp's insights encourage a shift from stigma-laden labels to a more empathetic view of personality disorders, focusing on relational aspects and treatment possibilities that honor the individual's experience.

As the episode reaches its culmination, Dr. Sharp and I tackle the sensitive topic of how we name and classify personality disorders. We scrutinize the term "borderline," its historical baggage, and the impact of diagnostic labels on patient identity. The forthcoming changes, awaiting the American Psychiatric Association's approval, aim to align with the ICD-11's patient-centric framework. This pivotal shift heralds a more nuanced and dignified approach to diagnosis, promising a future where the language of mental health reflects the humanity of those it seeks to help. Join us for this compelling and transformative discussion, as we strive to understand and articulate the intricacies of personality disorders with the respect and sensitivity they demand.

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Transcript

Unknown: 0:02

Welcome to the mind dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland,

Dr. Kerry Horrell: 0:11

and Dr. Kerry her L. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in. Welcome back, everyone. Today we are very, very lucky to have Dr. Carlos sharp joining us on the podcast. Dr. Carlos sharp PhD is a John and Rebecca Morris Professor and Associate Dean for Faculty and research in class. She is also the director of the adolescent diagnosis assessment, prevention and treatment center, and the developmental psychopathology lab at University of Houston. She holds adjunct positions at the University of Texas, Baylor College of Medicine, University College London and the University of the Free State in South Africa. She is the current associate editor for the APA, which is the American Psychological Association. I am assuming we we've talked about both pretty frequently here, Journal of Personality disorders, theory, research and treatment, and a workgroup member for updating the American Psychiatric Association practice guidelines for BPD. Which

Unknown: 1:34

came out right. They the draft, the draft has been published, but it's finalized. Yes. Yeah, pretty sure. So

Dr. Kerry Horrell: 1:41

I do have a follow up question from your bio. What is class all caps? Last is

Unknown: 1:46

the College of Liberal Arts and Social Sciences. So that's psychology lives in the University of Houston. Yeah,

Dr. Kerry Horrell: 1:53

that makes so much that they sent in I was like, I don't actually, I don't know what that is. The passion. Welcome. Thank you so much for coming on.

Unknown: 2:00

Thank you so much. I'm so glad that you all are interested in this topic. And I'm just delighted to be with you. Sure.

Dr. Kerry Horrell: 2:07

We're not only interested in this topic, you've been a dream guest of mine since the you've been talking about this for a while. Yeah, since like the start of the podcast. I was like, we're gonna

Unknown: 2:16

get Dr. Sharpe on here. Someday we earned the right to Yeah,

Dr. Kerry Horrell: 2:19

I wanted this to feel a little legit. Yeah. Got you. So what's really good? All right,

Unknown: 2:25

so why don't we start out how we usually on tell us about your career, and like how you got interested in studying, you know, and understanding personality disorders? Well, my my route to personality disorders was really through mentalizing and social cognition. So I did my PhD at Cambridge University in England. And I was interested in theory of mind at the time. So this was 1997 to 2000. And a lot of people were studying theory of mind in the context of autism, I was very fascinated by this construct, that you know, is about how do we how are we able to connect with other people, how are we able to, to have relationships, how do we understand people? How do we clear up misunderstandings between people, so, very fascinating, this idea of theory of mind as the mechanism by which we can make sense of ourselves and other people or mentalizing. So initially studied that in the context of conduct disorder in my PhD. And then when, when we moved to, to Houston, it was actually my husband and got a position at Rice University was a year ahead of me. We moved and I got to know Peter Fonda Gi, read Montague Ephraim. My first position was with Menninger Clinic, actually, at that time, 2004, I was introduced to personality pathology as the typical or perhaps archetypal condition in which Theory of Mind mentalizing goes awry. So I was obviously primed to study it or be curious about it. But that's that was where my journey for for personality disorder began. And because I'm a developmentalist, I, my PhD was in developmental psychiatry, was in Goodyear, and wasn't a PD person or an autism person or a theory of mind person, for that matter, but he was my advisor. So he was but he was a developmental psychiatrist. So he introduced me to developmental psychopathology. And because I'm a developmentalist, I naturally became interested in the early precursors, or the development of personality disorder. And interestingly, at that time, 2004 Very few people were doing this kind of work. Ephraim Bleiburg was one of them. He was sort of one of the pioneers with Paulina, kernberg, and some others, but there wasn't really an empirical body of knowledge and it was the meaning of the data that we collected between 2009 and 2016. That really contributed to putting early intervention prevention for personality disorder on the map. So you know, my my credit and thanks to the Menninger Clinic, one

Dr. Kerry Horrell: 4:55

in this this is reminding me we had you know, Dr. John Oldham. You know, longtime manager, faculty chief of staff on the podcast, we were just saying, I think about a year ago, and he talked to us about his work in, you know, being part of developing the alternative model of personality disorders in the DSM and sort of understanding and thinking about personality disorders in perhaps a different way than just categorical, but from a more dimensional view, and how important that is. And I imagine that is as a developmental psychologist that that's it like, we have to think about things not as categories, but as dimensions and as sort of an that that's how you can guide our treatment. And I think that's a lot of where we're gonna go today. But I thought maybe since it's been about a year, if you could refresh us and refresh any listeners who, who's joined cents and haven't heard that episode, what is the alternative model? How does that differ from like, the chapter in the DSM on personality disorders? And yeah, if we could get a little refresher on that, that's

Unknown: 5:53

my my bread and butter, I'm happy to do that. So. So you know, we are all familiar, and I was also schooled in in the 10 Personality Disorder, the 10 categories. And so you know, you'd have your cluster a, your Cluster B and your cluster C personality disorders and BPD would be in that sort of Cluster B group with antisocial personality disorder, narcissism histrionic, and then you'll have your more eccentric folks that are schizotypal, and schizoid, and paranoid and Cluster A and then you'd have your more avoidant anxious people OCPD, and the Penland in, in cluster C. So we all grew up with the sort of thing categorically defined personality disorders. And there's a couple of problems with that. Number one is that there are so many ways of meeting criteria for any of those personality disorders. So if you you can meet up people have counted, you can meet borderline personality disorder 256 ways. So that means that there's a lot of heterogeneity. You can have Sally who meets criteria for BPD. And you can have Sarah, who meets criteria for BPD. And they actually don't look similar. All Yes. And that calls into question the validity of the disorder because of if I can have the flu, you know, with a runny nose and a sore throat, but I can also have the flu with with a sore toe, or an ache in my head. You know, that says

Dr. Kerry Horrell: 7:14

very different treatment. Yeah,

Unknown: 7:15

there's different treatments. So this this was a challenge for personality disorder. The other challenge is that and you know this very well, when you meet a person with BPD, and you diagnosed them, they probably have or will meet criteria with structured interview for two or three more personality disorders reach we Yes, absolutely. So so this high comorbidity clinicians get frustrated because they can't box, a person with personality disorder into one category. And so they end up getting a PDD NOS diagnosis, they say I can feel something's going on here. There's personality disorder here, but I can't it's just it's not quite, it's not quite paranoid, it's not quite, you know, just doesn't fit any of the categories. So they go for PDD NOS, or they don't diagnose personality disorder at all. This happens often in sort of primary care and which is, which is a problem because these folks fall through the cracks, they don't get the treatment, they have to get really severe before and they end up in a in a place like the Menninger Clinic before they get properly diagnosed and treated. So both the heterogeneity within disorder and the comorbidity across PDS, in addition to axis one, so old axis one, you know, person with PD will always have depression anxiety most often substance use. So there's just it just seems like our categories weren't doing great in covering this disorder. And of course, we know if there's a problem in diagnosis, there's probably going to be a problem in treatment, because we probably not going to hit it hit it as effectively as we can with a treatment. So these are all of the questions that were mulling through the minds of the DSM workgroup pre 2013. And the way that they tried to resolve this issue was to say, Okay, what do all of the PDS have in common? What do they all share? What is the common core of all of personality disorder and I think for anybody working with personality disorder, we would agree that it is maladaptive self and interpersonal functioning, whether it manifests as a sort of antagonistic, angry kind of blood flavor like you would get in narcissism or perhaps BPD. Or whether it manifests as someone who's just completely withdrawn an anxious like an avoidant person, or someone who ends up using, you know, eccentricity as a kind of defense like a schizotypal person, no matter how it manifests itself, or the flavor of it is what is shared. The Common Core of all personality disorder is this maladaptive self and interpersonal functioning. And that is what people ended up doing queening level of personality functioning. Now since then, there's been a lot of confusion about what is meant with level of personality functioning because, and actually John Holdren, I've detected John and I talk about it's slightly different. So here if you can hear the difference. Interesting, interesting. Yes. So with level of personality functioning, people have started using the word as just impairment, general functioning general impairment level of severity. And that it's actually more than that. So what if when people talk about level of severity, they tend to talk about, you know, you've got your traits, which is criterion B, you've got the flavor how their personality disorder manifests itself. And then for those folks level of personality functioning is just the consequences of those traits. So you've got high levels of traits, maladaptive traits, and because you're very emotional and disinhibited, and all of the risks, you're going to be impaired in your functioning. But for most, most people now, 10 years later, after the publication of LPF, what we mean with LPF is more than just your level of personality impairment, what it means is maladaptive self and interpersonal functioning, something that happens in your mind. So the source of the disorder, not the consequence of high levels of traits, but the source of the disorder where the disorder originates from. And so if we think in attachment terms, you know, you you never learn to have an integrated sense of self, you never get the kind of feedback that helps you bind your personality or who you are as a person. And so what happens is that you have real trouble holding on to yourself in the serve and return with other people, it gets confusing for other people, you end up projecting what's in your mind on other people or taking on what you think might be in other people's minds into your own mind. And there's this porous boundary between you and other people. And so that really fits with the original intention that kernberg, for instance, had a level of personality organization, which is about self other functioning and about object relations. So really, I want us all to just be clear, and I think John and I agree on this, but I've heard him sometimes talk about level of personality functioning as impairment, or the consequence of high levels of traits, while actually it's flipped around, the source of the disorder lies in in criterion A in the maladaptive self and interpersonal functioning. And that causes high levels of maladaptive trait, of course, the two are always in in reciprocal relation with each other because we are born with dispositions. But the fact that I'm impulsive or emotional in itself doesn't give me a personality disorder. For me to have personality disorder, I can be highly so emotionally sensitive and impulsive, but I can make sense of that. I can attenuate it, I can I can make those traits work for me in my context, then I don't have personality disorder. So really the core the the distinguishing features lying criterion i What do I do with my traits? How do I manage my traits? And how did my parents helped me manage my traits? as I as I developed and grew up? So just want to make that that's clear, you know? Yeah, I think you're getting at it. But can you say a bit about like, why it's important to have this distinction? I mean, why? Why do we need the levels of severity? Why do we? Well, we need that. And this is a really important question, because then I don't know how much you've kept up with hightop. But when we hiked up is the hierarchical structure for for persons for psychopathology. In general, when we look at all symptoms, if we take symptoms of depression, anxiety, substance use, psychosis, psychosis, and all of those symptoms, and we factor analyze them, we basically get three major dimensions, three big dimensions internalizing, externalizing, and psychoticism. So that means that all of our general symptoms in the DSM, or we can account them account for them by these dimensions, underlying dimensions. Now, if you ask a clinician, is there a difference between someone who is high in internalizing, and someone who's high in externalizing, and someone who is high in psychoticism? And someone's personality disorder? I think if you can answer that question for me, I think a clinician would say, Yes, I do think that someone with BPD is different from someone who's just high in severity. So we still are looking for something that is a distinguishing feature that can distinguish the patient with BPD compared to the patient who has just really high levels of severity, generally. But I think that's an open discussion, open question. And for us, so people of my persuasion, we think that there is something special about that interest psychic function of what you do in your mind in terms of yourself and your other relationships. And that's, that ends up what personality disorder is and what personality functioning is. Does that make sense?

Dr. Kerry Horrell: 14:43

So it's making so much sense. I'm obsessed, I have so many follow ups, at least 10. But the thing I want to take us back to and I'm honestly kind of selfishly doing this because, as I, you know, teach a lot about this, and I feel like I'm just excited to have this as a resource to share with other people. And so I wanted to say the least to second kind of go back to kind of kernberg In theory, because my sense is he kind of like started this idea of like, let's think about not just the flavor, not just again, even the severity, but let's think about where their personality is organized. And again, we said this before we started recording, but we use that language a lot here at the clinic. And I think a lot in dynamic analytic circles of like, you know, we talked about shorthand, borderline personality organization BPO. Like, I might say, this patient has a pretty like, dependent style, but they're pretty low BPO. And we might again, like, a lot of times, I think people understandably don't know what that means, and also where that came from. And so I wonder if you could talk us through just a little bit of the history of the kind of neurotic borderline psychotic spectrum, and maybe what we mean when we're talking about personality organization, rather than personality style, you

Unknown: 15:52

know, so I think I think all of the TSP people and Otto kernberg, I know for sure, he was very excited when, when the LPF came out. So we're all the MBT people because it did legitimize the thinking that's been going on for a long time from different perspectives, MBT was different than than for for autos group. But I think what what it legitimized for them was this idea that we are that that personality has an organizing function, the personality is something that that our minds do. It's not just who we are. And so I'll just as a footnote, say, This is why another reason I'm so excited about the LPF, because I think it gives us a malleable treatment target, it's very difficult to change who people are. And it's quite stigmatizing to talk about how people who people are and that is this order in who they are as a person. With LPF, we have a malleable treatment, we move away from traits, and we have a malleable treatment target, we say your personality is organized in a way that causes trouble for you, that causes you not to feel safe in a relationship that causes you not to get on with people that causes you to feel not comfortable and settled in yourself. And that really is the core I think about current works. position on personalities, organization is their personality as an organizing function. It helps us make sense of self and other in the context of our most important attachment relationships, but also all of our other attachment relationships. So how can they who has that personality organized, when I when my personality is doing a good job of organizing myself in in terms of myself other object relations, then I you know, I'm I at the zero level in terms of LPF, I have an integrated sense of self, I have self directedness, I can manage all of these complex things constantly. And I use mentalizing. By the way to do that, that's where mentalizing Yes, but when I am someone who struggles a little bit with this, then I'm at the neurotic level of organization, things are still pretty intact, I've got good reality testing, my defenses are kind of healthy, I can most of the time, manage, manage, you know, I can stay in touch with, with my own thinking, to a large extent, but I'm nervous, and I'm neurotic, and it's not comfortable. For me, that's the neurotic level of organization. We then moved to the borderline organization. And remember, he called it borderline not in the same sense of BPD borderline personality disorder for me. For him, it never was a category, it was on the border between neuroticism and psychoticism. So here, our defenses are starting to play real havoc with us, we have some starting glimpses of reality testing, although it's not not too bad. We will talk in mentalization based theory, we will talk about psychic equivalence, what's in my mind is true. But there's not a real break with reality. After borderline organization, we then move to a more severe level, which is psychotic organization, where there is a real break with reality and the reality texting is really affected. And so that's really Otto's level of personality functioning. But it maps perfectly onto our level of LPF. Because in LPF, we had zero, which is most of us all, but quite frankly, a lot of us this is the other beauty of LPF it gives all of us humans, the capacity to move up and down that continuum ourselves. I have bad personality days where I move from zero to one, I don't know who really functions at zero all of the time. Anyway, I think most of us are really lucky if we're a zero or a one most of the time. And then sometimes we have two days. But we want to keep it at a 01 Most of the time to we become eligible for a clinical diagnosis of disorder, three range, and then and then four. So it's a five level that's a five level scale, then we can move up and down. But that is how it maps onto kernberg. But they were super excited when they have found this legitimization 50 years later basically, of thinking, Yeah, well

Dr. Kerry Horrell: 19:57

I was thinking of, you know, a common question thinking About all my patients who we think about personality with, there's a few things I say to my patients to try to disarm them right away. I always say this is my least favorite name of any category of disorders, I don't think it's quite right. There's not a disorder with who you are, there's a disorder with how you experience yourself in relationships. And I wish we have another name for it. But I love the idea they had and thinking about it more and like, then how you flow along this chart, or this sort of spectrum. The other thing I was thinking about was it mean, we all know this BPD is such a stereotype. And if you Google it, or anything, you know, you're gonna get the stereotypical thing. And so you have a patient come in, we're trying to talk with them about their personality, and some of the struggles they've had. And we name it, borderline personality disorder. And a lot of times they're like, make this make sense. Like without the DSM, they're like, looking for the things. They're looking through the traits, and they're like, this is not fitting me, no, I'm not gonna make it make sense. And I think that's why often we, you know, at least on my team, we do tend to use the alternative model a lot. And we'll, we'll give them this horrifically long thing, other specified personality disorder, alternative model impairments, anything, but it is just the most aggressively long, but it actually captures their experience so much better. And then the other financing, as you were sharing was, how often I get the question, what is it? What is borderline mean? And I'm like, Well, okay, it's kind of complicated, because the term actually comes from being on the borderline of neurotic and psychotic. And that's a scary thing to say to them. So I usually just find a way to not answer their question, but I do wish we find a new name for it. And the other thing, and

Unknown: 21:32

they've toured with other names, right. I mean, you know, as we're speaking, I'm chairing the committee, that's been we've been invited to put in a new a new proposal, a streamlined APD. Because the MPD is quite complex, as it currently stands in Section three is these complicated three steps. So the job the steering committee gave us was to make this even simpler. And the if, if it's successful, they will be voting on it at APA right now, this made, if it is successful, we will just talk about personality disorder. That's it. And that's how the ICD 11 talks about just as a generic term, just personality disorder. So if you go to ICD 11, which is now the accepted ICD 11, in 2022, since 22, these personality disorders, same five levels, then you have optional, you can optionally give the flavor. So you can say is it is it more of a antagonistic narcissistic flavor? Is it more of a neurotic, which is borderline negative affectivity? Kind of flavor? Is it more of a, you know, withdrawal flavor does the social flavor so ICD has moved on? They've kept the borderline specified, just kept the blood, right? We have we've been going back and forth with a with a committee, should we be keeping the borderline specifier? You know, for all the reasons you just mentioned, carry that it is stigmatizing. You know, the other side of the argument that I'm a border, I've been a borderline research all my life, you know, and I'm happy to move on. But there is just as large literature base for it. And we've got the treatment, we kind of but but I should also say I think people are starting this, I'm aware of at least three or four NIH grants now that are using LPF defined personality disorder. So what I expect we will see is that all of the treatment literature that we've worked so hard to develop over the over the last 1020 years will be readily appliable to LP if defined PD it's kind of the same thing. BPD has always been special in that way that it maps onto the general factor of personality pathology much better than any of the other flavors. Because if you go down the nine criteria, it is about self and interpersonal functioning more so than some of the other criteria of peds, which are much more descriptive, behaviorally descriptive. There's something about the PT criteria that is about your your emptiness, how you see yourself identity, all of those things that are at the core of criterion I O Levels personality function. I'm

Dr. Kerry Horrell: 23:59

grinning over here, if you could see me on camera, folks, I am grinning. The reason why I'm grinning is because I talked about this a lot. And I say, I say this is kind of my own sense of where the literature is and where other people are. But you should try to own it when I'm teaching about it. Or I'm talking about patients because I know it's not completely reflected in the DSM. But I talk about how BPD in many ways is our general it's our general way of thinking about personality. And so when I especially have a patient who they're like, this doesn't fit what I know BPD am I gonna get let me back up and say this is sort of my understanding, that's kind of our most general flavor, one where the trouble is, I'm going to help you see yourself you use relationships, and you can cope with the pain of the feelings that you have. And I've thought for a while and I'm gonna I'm just feeling really legitimized by what you're saying. I just wish we had one that was more general because I just think like, like it is in the in the NPD. Like, that's, there's just the one person you know, I don't think it's called general personality sorter but just like let's just call it that. Let's call it the most sort of like this is what a personality disorder Yeah, yes. There's flavors in different ways. But like, we just need this one. Yeah. Because, yeah, it feels so different than like being on here. Here's all these different flavors of BPV. Just one flavor. It's like, well, no icbp is more in the middle as sort of like everybody with a significant personality sorter kind of SBPD. They just have it in different, like, ways in which that shows up,

Unknown: 25:18

it's helpful to hear that things may be changing, because up until now, DSM really has, if anything, it's kind of gone the other way, Korea, you know, they didn't obviously didn't adopt the alternative model except as in the appendix of DSM the first time around, because I guess, because it seemed awful complicated. And as far as level of functioning, I mean, like, if you remember, like, we used to actually, diagnosis provide diagnoses, and then they dropped that. So it seems to be kind of going in the other direction. Right now, I think it's a really good, good, good, it's a move in the right direction, in the sense that we can go to the sort of more general general idea of what personality is, what personality functioning is, how is it different from others, other psychopathology, you know, and, you know, coming back to your point earlier, do we really need a personality construct to say what's going on with someone? I think we do. I don't think we can, we can capture just with depression, anxiety, substance use psychotic disorder, what's going on with a person with personality disorders. So we need something to describe that process of a cell function and interpersonal function, I think just a general personality functioning, diagnosis gives us that opportunity. The other big advantage, I think of this sort of dimensional view. And with dimension, I don't mean just that we put something on a continuum, people often think it's just that, but it's more than that, it means that we are looking for an underlying shared dimension that explains the covariation that the the comorbidity of a lot of different problems, just with one unidimensional severity criterion, which is then LPF. But I think it opens up the door for developmental approaches, because now we can start seeing we can use this dimension to talk about how is the self developing, how is your capacity for empathy and intimacy developing especially in adolescence, when you're supposed to be be making these developmental transitions, you're supposed to be moving to a more integrated and reflective self, you're supposed to be moving towards a place where you can have healthy relationships with people of the same or opposite sex, you're supposed to be at the moving away from your parents one attachment relationship. So how is this transition occurring in these domains of solving interpersonal functioning for young people, so that we can intervene early, so again, we don't have to give a kiddo PD diagnosis, you know, but we can say, your personality functioning needs support right now. And here's a moment that can help you to support your personality functioning, so that you can grow up and you can be the captain of your own ship, you can have self directedness you can have, you can know who you are, it's not like sand through the fingers. You can have relationships that you find rewarding that you get something out of. So all of those things, I think opens up the LPF opens a developmental pathway for this that we can chart we can manage and we can intervene with

Dr. Kerry Horrell: 28:10

Oh, no singing to you. Yeah, I think my qualm and I actually don't have a solution to this. And sometimes I struggle to talk about qualms I have no solution for but I just wish we had a different word than personality. I wish we had just like, I wish that's not what we call this. Like, I can appreciate why it's that's why we call it because you're, of course, we need to talk about this, when we work with patients who clearly are in the realm of the struggle has to do it at its core personality functioning, like you know, you know, it, when you see it, when you're in it, this was a different word. Because as I, I'll tell patients, you know, I'm like, I do a lot of psych testing, I said, we're going to do testing around your personality functioning. And I'm like, just so you know, that doesn't mean we're gonna do like the Myers Briggs or like, we're gonna be talking about your, your hobbies, which I can still appreciate why that might be where your thoughts going, we're talking about these other pieces, but just a different word. I don't want to this is my own, like, I don't want to call this people's personalities, because there's so much more than that, you know, and I feel like that's what we think your personality is who you are. It's like, this isn't just who you are. This is how you're coping and managing and I don't know, that's my I

Unknown: 29:10

know, I know our time is up but I think that's why it's important that we move the definition from personality to not what who you are but what what your personality does, that that function that Glenn Beck talked about, you know, the organizing function of personnel, I think the trait and remember trade the trade perspective is only 70 years old. The traits people think personalities only traits, but it's more than that. So so we can change the narrative. We can say personality doesn't mean who you are. personality doesn't mean your traits personality means how you organize yourself, your it's really how you organize yourself. So I think we can change the narrative carry doing it. Yes.

Dr. Kerry Horrell: 29:54

We do have a little bit more time. One thought I think we wanted to ask you about or think about was, and this is kind of a big I shouldn't so take it wherever your mind goes. But how does this turn into interventions? Like how does utilizing this perspective, especially, you know, thinking about clinicians who might be listening, who maybe do have less experience with personality disorders, but they can sense that like that might be going on? Like, how does thinking about this, from the viewpoint of kind of a dimensional viewpoint, translate into how we think about interventions.

Unknown: 30:24

While I do think it shifts our focus, to be very intentional about self and interpersonal functioning. So, you know, if we think about as I think DFP, and MBT two of the main ingredient people

Dr. Kerry Horrell: 30:38

say, transference, focus therapy, mentalization based therapy, just so case, people, thank

Unknown: 30:43

you, thank you. They were designed for LPF, they were designed, they come out of the attachment theory, they come out of object relations. So they are designed for self other processing. That's what they're designed for. When we think about DBT. I always say to my students who get training and everything, and I wait, you know, I train them in MBT but I also probably also they get fantastic training in DBT, as well. I always say to them, if you go and read martial and it has 1993 book, it's all about self and interpersonal functioning, the dialectic is about self and interpersonal functioning, we got a little sidetracked with DBT, to be to trade focus to be too focused on negative affectivity. One manifestation of personality pathology, which is that sort of emotion dysregulation neuroticism component of it, but if you go back to the original text for her, it was always about finding a balance between self and other functioning. And she's actually talked about that many, many times, you know, when she gets together with, with the folks on the other. So I think we can do, we can just continue to do what we do. But we shift our focus to just be very intentional about our valuable treatment target. If we just going to try and reduce emotion, or increase emotion regulation, reducing emotional dysregulation, we're not really going to move people, we have to get to the place where they think differently about themselves and others where they shift in terms of the organizational capacity for self and other, then we start seeing the really move, we can do it via DBT, but we can do it via MBT and TFP as well, we can do it even through CBT. I'm a big proponent of generalist approaches, that's a conversation for another day, John Anderson's approach, I think, I really do believe there's a lot in there to enable and make PD treatment accessible for all we don't have to be highly PD trained to do this. I think everybody can help. Because we can keep in mind, what am I what am I supporting, I'm supporting this person's capacity to think and reflect on the self in the context of other relationships. And that's it, you know, if we, if we keep our focus intentionally on that, I think we move the needle for patients,

Dr. Kerry Horrell: 32:53

I was thinking about how when I go, we do we have we call these diagnostic conferences, it's where we meet with our patient and their families or loved ones are other treatment providers. And we share not just our diagnoses, but our conceptualization, and it was we're going through the whole thing, we're talking about the, you know, attachment traumas and painful experiences and how this has impacted how they trust and I'll stuff a lot of times the family patient, others, they might be like, this is a lot, that's usually a reaction, that's just a lot. And I'm like, yeah, and the beautiful thing is that the treatment is actually quite simple. Like, it's hard, I'm not gonna say it's not really tough skills to learn, but the treatment is learning how to get to know these parts of yourself, like the treatment of all of these things that it can feel like, here's five diagnoses and a list of core issues. But the thing that you're doing and all the things that's on what you're already doing, it's making sense of it, talking about it processing through like mentalization, basically, of like, this is what this is, and it's actually not that it's not that profound, as far as like, it's not, that's all good. It's very hard, but it's not like, Oh, you need that at least these five different treatments and all this, it's like, no, you do this thing. And I think that's actually been a great comfort to a lot of patients to hear like, okay, salutely

Unknown: 34:04

Absolutely. I mean, I'm all for cross diagnostic core components, you know, and I think that's, that's what it is, it is really boiling it down to the essential features, we don't need six different treatment manuals to help you, we can, can focus on this sort of core malleable treatment target and get better. I think the goal here is to go into more depth about the model. And I think we have, I

Dr. Kerry Horrell: 34:29

feel like we could talk for so much longer because I just, I can I will say I just I said this when I've identified as I'm such an admirer of your work and the ways in which you can make this really accessible to people you have great way of taking in this complicated thing. And I'm, I mean thinking back to when I was a fellow and when I was in my doctoral program, when we would talk about some of this especially because I didn't have a lot of experience yet working with people with severe personality pathology. It all just felt like mumbo jumbo and I was like I don't I I'm not totally getting this. And so in some ways, I do think you need to, like meet these patients and work with them to really get it. But I think your way of explaining it and putting words to it makes it very accessible in a way that I can I hope people hear this and say this is really reasonable. This isn't some like high, you know, fringe analytic way of thinking about it. This is a very reasonable I try to think about people, especially about trauma, who are struggling with how to think about themselves in relationships and how we can actually then tangibly plan with them and help them. Well,

Unknown: 35:27

thank you so much, Carrie. And to both of you, thank you for the opportunity to talk with you. It was a real pleasure. And again, just a big shout out to the Menninger Clinic woods, who's you know, has been instrumental for more than a more than 100 years in helping helping, helping the agenda move forward for for for personality functioning and personality disorders. So, you know, thank you. Thank you for the opportunity to share shame to my thoughts.

Dr. Kerry Horrell: 35:54

Well, you know, I've been absolutely delighted I'm sure everyone else has to be listening to Dr. Carla sharp. And we've been here on the mind I've podcast I'm one of your ilosone Dr. Terry Earl,

Unknown: 36:04

Bob Boland,

Dr. Kerry Horrell: 36:06

thanks for the mind dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen. For

Unknown: 36:18

more episodes like this, visit www dot Menninger clinic.org.

Dr. Kerry Horrell: 36:23

To submit a topic for discussion, send us an email at podcast@menninger.edu