Identity Diffusion

In this episode, Dr. David Puder and Mark Ruffalo dive into the history and theory of identity diffusion, from Kernberg's structural model and Gunderson's work on BPD to Akhtar's clinical descriptions. We explore how identity diffusion shows up in patients' lived experiences—feelings of emptiness, fractured self-image, lack of authenticity—and what these struggles mean for psychotherapy. You'll also hear practical insights into treatment, including empathetic confrontation, fostering continuity of self, and amplifying moments of authenticity. Whether you're a clinician, student, or simply curious about the complexities of identity, this conversation sheds light on one of the most important yet misunderstood dimensions of mental health. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-247-identity-diffusion-borderline-personality-organization

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:14David Puder?

  Welcome back to the podcast. I am joined today live in my office here in Winter Park, Florida with Mark Ruffalo. He is a world famous psychotherapist who has been on the podcast before. We talked about splitting borderline precise, or I would say you're becoming one of the most preeminent borderline precise or experts on Twitter, on X.

• 0:40Speaker 01

  Got a little bit of a following there, yeah.

• 0:42David Puder?

  Quite the following. Yeah, it's been, it's been fun to correspond with you. And today, we will be diving into something I've been curious about for years. And I really haven't taken the time until recently to dive into the history of it, identity diffusion. And I was reading, I was reading it this week, and I was thinking to myself, why is this so hard to understand? Like, why is it hard for me to get my mind around it? And if you have yourself kind of in that phase while you're listening to us, you may come back to this thought that I have that I'll share with you right now. You're learning about something

• 1:25David Puder?

  that is not defined. The very nature of identity diffusion is the lack of definition. It's like, we're learning about something that is the not something. It's like, it's like a stem cell awaiting to be having some identity, but there's no identity yet. So how would you like start it out?

• 1:50Speaker 01

  Yeah, no, I, I agree. I think that, you know, as we're talking today, I'm probably going to be working through my own ideas and thoughts on identity diffusion, which sort of lack of cohesion, which is ironic because, because of the nature of the syndrome or the problem itself. And so, yeah, it's something that I think is really, really hard to grasp, even for experienced clinicians.

• 2:26David Puder?

  Yeah, and so let's go through a little bit of the history of it. I noticed you're also, you have Gunderson's book, Open, and you, we also have an article by Salomon Akhtar. And so, yeah, where do you want to begin?

• 2:43Speaker 01

  I think it was Erickson who was the first to use the term "identity diffusion." And later work by Otto Kernberg linked the presence of this problem to severe character disorders or personality disorders, notably borderline narcissistic and schizoid personalities. You know, the, I think the only reference in the DSM to problems with identity is found in the Diagnostic Criteria for Borderline Personality Disorder.

• 3:21Speaker 01

  But Gunderson didn't really think that identity diffusion was a very useful diagnostic criterion because it's not really specific to borderline personality disorder. And so, he didn't find it all that useful in discriminating different types of pathologies and differentiating BPD from other problems. So, you know, a lot of what I'll talk about today with you is really in the context of borderline psychopathology, which has become, at this point in my career, my main area of interest and focus. But you also see this problem in other severe disorders. It's also notably lacking in other personality disorders, like obsessive compulsive personalities,

• 4:06Speaker 01

  histrionic personalities. And really, I think it's, in that sense, it's useful to differentiate the borderline personality patient from the histrionic personality patient, which can look, they can look sort of similar, but the borderline patient, the evidence is identity diffusion. So, so it was Erickson, Kernberg, Salomon Akhtar, in 1984 writes a paper, The Syndrome of Identity Diffusion, identifying, I believe, six clinical features of the syndrome. I think later he adds a seventh feature, maybe we'll get into that. That's a little bit of the history.

• 4:50David Puder?

  Yeah. I think that...

• 4:54David Puder?

  Pre-Kirnberg, there was really a thought of neurosis, psychosis, right? Like, two differentiating groups of people. Helene Dutsch, 1942, described an "as-if" personality, "which mimicked normal behavior but lacked genuine core self", foreshadowing this later notion of fragmented identity. Bruler, 1911, reported schizophrenic patients, saying that they often had lost their individual self, highlighting a profound disturbance in identity. This kind of crisis. And then you have this mid-century Erikson.

• 5:36David Puder?

  Identity, he talked about ego-identity, this multifaceted construct involving a conscious self of personal sameness. And, you know, there's a lot of, in his writing, like, what is a normal crisis of identity in adolescence? Like, every adolescent has a crisis of identity, starting to differentiate from their parents, starting to get in touch with their friend group, where what they believe, in contrast to what their parents believe, in contrast to what their friend group believes, trying on different types of identities. So some of that's very normal. Sure. And then, yeah, I agree.

• 6:18David Puder?

  There's Otto Kernberg, 1967, seminal paper called "Borderline Personality Organization", talked about psychotic, neurotic, and then this borderline level, which is between. Which, one of the seminal characteristics is diffuse identity, fragmented identity, unstable identity. And...

• 6:47David Puder?

  He observed that these patients could not provide a coherent description of themself or significant other, and they exhibited contradictory self-concepts, chaotic instability in goals and relationships. So this started there, right?

• 7:07Speaker 01

  Yeah, yeah. And a little bit of the history. For years, there was this group of patients who weren't overtly psychotic, but they would regress very transiently and briefly into psychotic states where they might hallucinate, become transiently paranoid. These were the same patients who would really worsen with classical psychoanalytic treatment, where they were on the couch four or five times a week. Classic paper by Knight described

• 7:45Speaker 01

  them as falling apart on the couch. So these were patients that were just hard to classify diagnostically. And so I believe it was Adolf Stern in the 1930s who first used the term borderline cases, two words, borderline cases, to describe patients who were somewhere in between psychosis and neurosis. And so it was Kernberg in the 60s writing about borderline personality organization, and then Gunderson in the 70s identifying a specific syndrome of borderline personality disorder, which eventually makes its way into DSM in 1980.

• 8:25Speaker 01

  And so Gunderson argued that the concept of BPO was far too broad to be very useful clinically, and only about 1 in 10.

• 8:38Speaker 01

  Patients who meet Kernberg's definition of borderline personality organization have borderline personality disorder. And the way that you treat someone psychotherapeutically with BPD is quite different from how you might treat someone with NPD. And so Gunderson argued that, well, the concept of BPO is far too broad. And while it does identify a group of patients who are organized in a certain way and rely on certain defenses, it's not very pragmatic, it's not very useful clinically.

• 9:16Speaker 01

  And that there is a distinct syndrome that is valid, coherent with a predictable onset course and treatment response that we ought to call borderline personality disorder. So that's a little bit of the history. So, you know, problems with identity are very common in BPD again, but they occur in other psychiatric disorders as well. But I think you described it pretty well. You know, we, in healthy or normal or neurotic people, there's, you know, a sense of cohesiveness to who we are.

• 9:58Speaker 01

  I think Akhtar in this paper sort of describes, you know, the healthy individual as, you know, as being able to maintain a sort of core sense of self amid change and with the passage of time, sort of regardless of what's going on in life, I still maintain a core sense of self. And then there are patients who come in, and I'm sure you've seen these types of patients, who will actually say explicitly, I don't know who I am. I'm not sure who I am, or something to that effect. And when I hear a patient say that, I start to get interested in these issues of identity.

• 10:40Speaker 01

  And that often opens the door to an understanding.

• 10:45David Puder?

  Or if they show up very different in different contexts. Or, I mean, we all do to some degree, right? We all have like a social veneer, different contexts, different degrees of revealingness. But when there's huge incongruencies in how they show up, when there's very different feelings towards different...

• 11:04David Puder?

  People, you know, as well, as well to themself. Like, do I hate myself? Do I love myself? You know, this kind of splitting is kind of like an identity Yeah. crisis as well. Um, one thing I wanted to say was, for those of you who are listening who are like, this isn't really a thing, like, identity diffusion isn't really a thing. Borderline level of functioning isn't really a thing. When I like have started to go down this road of like, actually, this is a really helpful construct. And there's actual ways of testing this, right? And once you have a good way of testing it, that's like, very consistent. You know, one person tested, the next person tested, very consistent. Cronkbock alpha is very high, right?

• 11:49David Puder?

  So for this one, based off of Kernberg's model, there's the Inventory of Personality Organization, IPO. And there's the Structured Interview of Personality Organization. And part of the facet of what it's looking at is identity diffusion. So this is kind of like a subdomain. And you could think of like borderline level of functioning as primitive defenses and identity diffusion. And you can have this in different types of personality disorders. And so when Gunderson moved it all to BPD, I think it did a little bit of a disservice

• 12:29David Puder?

  to kind of like, um, an understanding that you could be narcissistic with borderline level of functioning. Sure. You could be schizoid with borderline level of function. You could be paranoid personality sort of borderline level of functioning. And I think it's actually really helpful to think in these categories. And when I've looked at the STIPO, the Structured Interview of Personality Organization, and the different studies that they've done, they've done, um, different types of things to look at different severities and, and actually, this is like really helpful to understand what we're dealing with. Yeah. And, and to have empathy and compassion, I think. You can have intact reality testing.

• 13:15David Puder?

  And identity diffusion and primitive defenses. And this is what this has proven to be true.

• 13:22Speaker 01

  Yeah, yeah, yeah, I think, you know, there's so much confusion about the terminology. And I think you're absolutely right. I mean, borderline level of functioning, borderline personality organization. It absolutely captures something that really exists. So I believe, you know, Gunderson argued that borderline personality disorder is sort of the prototypical disorder at the borderline level of functioning and incorporates, in essence, much of what is seen at borderline level functioning.

• 14:05Speaker 01

  And so there's, you know, there's, it's really unfortunate that there's, you know, two different concepts with the same name, borderline. And I'm, I think that, I definitely think we ought to retain this concept of BPO, but some have argued that maybe we should rename it disorders of self or something of that nature to differentiate it from borderline personality disorder, which is what most people know nowadays and has, you know, has become, you know, the most widely accepted use of that term. So there's unfortunately a lot of confusion around it, though.

• 14:52David Puder?

  Yeah, and I think, of course, they, every single one of these people have contributed vastly to our understanding, you know, so it's like, but let's zoom in to Salomon Akhtar and let's go through the different domains of identity diffusion.

• 15:12David Puder?

  And I have written down some notes here, but maybe we could go one by one and just kind of like explore the different aspects of this. How's that sound?

• 15:24Speaker 01

  Sounds great.

• 15:25David Puder?

  So, and I, there's something really valuable in my mind. If you're reading, if you're listening to this and you're like, that you find some value in it, this is a paper you want to read. This one and as well, we're going to go through another, a second one. So, you know, as always, I'm going to write up some details on the podcast notes and this one, Salomon Akhtar from 1984, very worthwhile. Another one, Karstein Jorgensen from 2022, which I've actually corresponded with him.

• 16:04Speaker 01

  Very cool.

• 16:05David Puder?

  Yeah, he's, he's, uh, it's exciting. So that one is really amazing. We'll get to that one second. And that one will go through a group of borderline patients that he did a qualitative interview, extensive qualitative interview around identity. And he found commonalities. And so he, and I think that's a really powerful way to look at a concept and to look at like, what are things that are common between one group and another group? And it validates this as a construct as well, like further validates that this exists. And so there's really like multiple levels of validation that make me very confident

• 16:45David Puder?

  that this thing exists. One is the IPO Inventory of Personalities Organization, the STIPO, Structured Interview Personality Organization, and all the data that's come from that, the years of these tests being run, and then studies like this. But let's go to Salomon Akhtar, because I think this is a really nice look at this. Okay, his first one is contradictory character traits. What jumped out at you? And then maybe I'll read a part.

• 17:17Speaker 01

  Yeah, I think that there's a section in there where Akhtar talks about how patients with Identity diffusion have to rely very heavily on the immediate behavior of other people in order to read them. And he links this to sort of an inability to integrate cognitively and affectively the observed behavior of others into a dynamic composite conception that would reveal the constant aspect of the other's personality.

• 17:54Speaker 01

  So because the patient is lacking a coherent sense of self, they also lack an ability to construct a cohesive sort of narrative of what another person is about. And so they rely excessively on the last interaction with the other person. And so you see this very, very commonly in borderline personality disorder. So, you know, this is, you know, the contradictory character traits, you know, this is, this is paradox. And, and so, you know, tenderness towards others coexisting with extreme indifference towards them.

• 18:37Speaker 01

  Extreme love alternating with extreme hate. So this is, this is very closely and intricately tied to Kernberg's and Klein's notion of splitting. And so, you know, you also see individuals who lack a sense of vocational sort of purpose. So Akhtar in the paper talks about people who they simultaneously sort of want to become a physician and also a movie star. And so there's this ill organized ego identity. And so.

• 19:14David Puder?

  And one thing I might mention is like nowadays that would be a lot more normal. You know? And, and, and as you're listening to this, you may go like, oh, I'm a little bit like that. But then realize like it's you to be to have identity fusion, you have to have more of a global. It has to be more global.

• 19:38Speaker 01

  Yeah.

• 19:38David Puder?

  Okay. So, yeah, with this one, it's like marked tenderness towards others can coexist with extreme indifference, naivety with suspiciousness, greed and self-denial, arrogance and timidity. So you get these kind of like juxtapositioned character traits, right?

• 19:59Speaker 01

  Yeah, yeah, yeah, I think that's, I think that's it, yeah.

• 20:06David Puder?

  So, yeah, with this, you can see how it could be difficult if you're, if you're a therapist, as you're listening to them, do I empathize with which side? And I would say you could empathize with both. You could say, it sounds like on one hand, you feel warm towards your spouse, but on the other hand, you feel completely angry. You know, like when there's, when there's multiple emotions going on at the same time, or multiple experiences, self-experiences, you can empathize with the juxtaposition, with the contradictory traits.

• 20:49Speaker 01

  Yeah, yeah, yeah, and, and a bit of, you know, confrontation in the sense of pointing out the discrepancy to the patient, not necessarily interpreting, but, you know, pointing out to the patient that they engage in these very contradictory or self-contradictory ways, their views of themselves and others vacillate pretty readily and predictably, depending on the subjective experience of the other person. And so, pointing that out to the patient, as Akhtar, you know, notes in the discussion part of this paper, rather than interpretation is more helpful, I think, for, for these

• 21:34Speaker 01

  types of patients.

• 21:37David Puder?

  I would say pointing it out, but not to, but in a way that actually decreases shame. And so we point it out as a way of having compassion.

• 21:48Speaker 01

  Yeah.

• 21:49David Puder?

  Of course, it can be really, it can be really difficult to have a multiplicity of fluctuating experiences of another person or of ourself.

• 22:00Speaker 01

  Yeah, and I think when people hear the word confrontation, they, they think of it in, in sort of the everyday sense, not in the, you know, the strict definition psychoanalytically. And, you know, confrontation is completely compatible with empathy and, you know, and, and caring about the patient and, and warmth, you know, you can, you know, engage therapeutically in this way and still confront the patient. So it is.

• 22:28David Puder?

  Or it's another way of saying it, which it would be, is increasing their reflectiveness of themselves. You know, we aspire towards increasing reflective function. And we know that people with BPD have around, on average, a lower score on reflective function, around two point seven. It's an 11-point scale from negative one to nine. So they're around two point seven when they start, but they can increase it. And so it's by an increased knowledge of themselves and their self-experience that they actually increase it.

• 23:03David Puder?

  And realizing that you don't hate them despite their maybe multiplicity of mixture of their own things that they feel a lot of shame about. They may imagine you hate them, they may imagine you're critical of them. When they find that you actually care about them and you're curious and you're interested, but you're also like compassionate. I think that's when they can make a shift to seeing themselves in a more compassionate light as well. So, okay, so number one was contradictory character traits. And number

• 23:40David Puder?

  two is temporal discontinuity in the self. So what does it mean to have discontinuity in the self temporally?

• 23:51Speaker 01

  Yeah. The capacity to remain the same amid change and with the passage of time is how Akhtar describes it as the hallmark of a sound identity. That seems to make a lot of sense to me, that despite the ups and downs in life, what I'm going through, I remain more or less the same person.

• 24:13David Puder?

  Let me read this quote here from this. "The past, present, and future are not integrated into a smooth continuum of remembered, felt, and expected existence for these patients. They experience themselves as a very young and at the same time, old beyond rejuvenation." You know, like, I feel like I'm almost a toddler. And then I also feel like I've lived three lives, right? It's like that kind of level of like, temporal discontinuity.

• 24:49Speaker 01

  Yeah, yeah. And so, in the last paragraph there of that section, Akhtar describes, you know, sort of what it might look like. And he writes, "Keeping chronological photo albums, writing personal diaries, chronically searching for one's roots, and excessively reflecting about external events are often used as defenses against the disturbing subjective sense of temporal discontinuity in the self." So, trying to, you know, use these methods to develop some cohesive sense of who I am in the world.

• 25:27David Puder?

  It gives you kind of a new way of thinking about people who maybe excessively document and journal and like, this kind of like, desiring to ground themself into time and into memory, right? And that being said, I recommend journaling.

• 25:50David Puder?

  I recommend having reflectiveness. But you could see how for him, it's like there's a compensatory mechanism.

• 25:58Speaker 01

  Exactly.

• 25:59David Puder?

  That he sees in some people. Okay, number three is lack of authenticity. He writes, "Individuals with identity diffusion display feelings, beliefs, and actions that are caricature-like. In a given situation, they act as someone else they know would act, not in a manner that is genuinely their own. They lack originality and readily acquire gestures, phrases, ideologies, and lifestyles from others."

• 26:30Speaker 01

  Yeah, this is the essence of Helene Deusch's, I think it was 1948, paper on the as-if personality. Sometimes I refer to this as like the chameleon-like effect. The patient very quickly adopts the interests, hobbies, manner of dress, of the other person. It's in a sense, you know, trying to develop some sense of who I am by mirroring what people around me are doing. So sort of touching on the concept of the false self. I remember very early in my career, I started to see a patient who, in retrospect, probably

• 27:12Speaker 01

  had a borderline personality disorder, a male patient who, after a few sessions, would come into my office wearing bow ties. And for anyone who knows me, I sometimes, I sometimes wear bow ties in the, you know, style of Aaron Beck and John Gunderson and some other people. But anyway, this was a man who...

• 27:36David Puder?

  Oh, so you're mimicking. Are you adopting their identity?

• 27:40Speaker 01

  Yeah, I guess you could say that. But, but the patient started to, to come in and had never, revealed to me, had never worn a bow tie before in his life, but all of a sudden, he started to show up to our sessions, wearing bow ties. And at the time, I didn't really know what to make of it. I couldn't make heads of tins. Heads or tails of it. But but now, of course, in retrospect, I think that there was some identity problem here and and he was seeking some identification with me to anchor himself in the world. And so I think this is this is sort of what Dr. Tar is touching on here.

• 28:19David Puder?

  I think it's probably going to get worse. And I think it probably already is there. It's like when you act as someone else, right, genuinely not your own. Think about like all of the influencers now and people, youth, adopting mannerisms of the influencers. Ticks, sometimes mental illness characteristics, sometimes like adopting how they talk, mannerisms, dress. There's like different levels of this, right? So there's like probably a healthy level, which is like, you know, your patient wanting to be a little bit more like you. But then there's like,

• 29:03David Puder?

  you know, when the person doesn't have any groundedness underneath it. You know, like, we can all aspire to be a little bit like our mentors. That could be probably a good thing.

• 29:14Speaker 01

  Sure.

• 29:16David Puder?

  But then, but then to adopt, you know, like, I know exactly what Dr. Tar would say in most situations.

• 29:24Speaker 01

  Yeah.

• 29:25David Puder?

  But I'm not going to do it, right? Because like, I can, I can, I can hear what you would say in some situations, right? Probably not as accurate as you would say yourself.

• 29:38Speaker 01

  I think this is a really important point that's so confused. And, you know, all of this, I mean, all of these things we're discussing today exists on a continuum with normal, right? And so

• 29:51Speaker 01

  You know, and, and, and all defenses are, exist on, on a continuum with normal, or rather, they can be used by all persons. It's a matter of degree and, and whether they're used to the exclusion of healthier defenses, right? So, but that, you know, the dimensional nature of these traits doesn't negate the, you know, pathological nature of their excess, right? So, sometimes I like to say that, you know, hypertension exists on the same continuum as normal blood pressure, but, you know, people die of hypertension. Hypertension

• 30:31Speaker 01

  is a pathology, right? So, just because something exists on the same spectrum or continuum as normal, doesn't mean that an excess of that trait is not problematic, or a sign of a pathology, right?

• 30:43David Puder?

  Or, or maybe people don't die of high blood pressure.

• 30:46Speaker 01

  Yeah.

• 30:46David Puder?

  But people die of things that high blood pressure

• 30:49Speaker 01

  Sure, exactly.

• 30:50David Puder?

  leads to, like a stroke, right?

• 30:51Speaker 01

  Sure, yeah.

• 30:52David Puder?

  And so, you know, when I, with this, maybe they're not dying of identity diffusion, but maybe they're also suffering not knowing who they are, or not having someone attuned to their experience in a way that tries to get to, like, what's really going on for them? What do they really enjoy? What, what, what boundaries have they had where it's like, they, maybe they were in a relationship that pushed them and took away their personhood, and they adopted many of the things of this other person they were dating, up to a point. Usually, they've stopped it at some point and said, "No, no, no, I'm not going past

• 31:36David Puder?

  that line." For some patients, that's where I, that's where I get excited for them. I'm like, "Yes, that's you. That's your value. What do you value that's underneath that? Oh, I don't value..." Being used or abused, you know, maybe they were abused to some degree, but there was like some level at which they said no, you know, and that personhood would like reached out of the abyss and was like, absolutely not, I will not go past that line, right? And that's a great, so we're like, we're searching for the person.

• 32:11Speaker 01

  Of course, I think, you know, to humanize this, you know, for a moment, you know, the, the lack of authenticity. Well, you know, why, why is a person engaging in this, you know, as if type of way where they're mimicking the behavior of other people? Well, they, they want to be accepted. They, they want to be loved. They want to find a sense of, of who they are through this identity, this process of identification. And so, you know, sometimes, especially reading some of the older psychoanalytic literature, you know, the, the, the humanity can sometimes get a little lost, you know, but yeah.

• 32:51David Puder?

  And, and I would say like, going back to like conformity tests. So the, the Milgram experiment is a great example of how we are wired towards conformity. So you, you know, someone comes into a research room. The person says, okay, we're going to run a test. It's a memory test. You're going to shock this guy when he misses a, when he misses a question. And you have this person standing there saying, yes, please, please continue. Please shocking him. Yes, it's necessary for the research. 70% of the time, people go through all the way and shock to the person all the way up to like, what, you know, the max voltage, right? 70% of the time, they go all the way through.

• 33:33David Puder?

  Sometimes they feel very uncomfortable doing it, but they do it because they want to conform. So like, I would say the majority of human experience is conformity. And it's, it's the exception that you have someone who truly is willing to not conform. Right? And, and, and go out and to disagree and to, to take a stand. I would say we need to increase our ability to not conform. And they ran, they reran that test. I don't know if you saw my ex tweet on this.

• 34:04Speaker 01

  Uh-uh, no.

• 34:05David Puder?

  They reran it with a computer instead of a human saying to the person, please continue, please continue.

• 34:11Speaker 01

  Yeah.

• 34:12David Puder?

  We need to complete the study.

• 34:13Speaker 01

  Okay.

• 34:14David Puder?

  And so in this specific group, this, but the, you know, one group had the computer, one group had the researcher, and guess what the difference was?

• 34:22Speaker 01

  What was it?

• 34:23David Puder?

  Guess.

• 34:24Speaker 01

  Oh, uh, um, I would say people were less likely to conform to the computer.

• 34:32David Puder?

  They both conformed the same.

• 34:34Speaker 01

  The same, interesting.

• 34:34David Puder?

  In this, in this specific group, it was 90% complete conformity in both groups.

• 34:40Speaker 01

  Wow.

• 34:41David Puder?

  Which, which is, which I'm thinking, like, and if you think to yourself, well, I would never conform to a computer, we have algorithms feeding us information. Now, if on, if you're on any short form video platform and the algorithm is a computer feeding you information, do you conform? Do you just believe it? Or do you, after each video, reflect and say, well, I don't know if I agree with that completely. Okay. So, lack of authenticity is probably much more difficult. Winnicott talked about this with the false self.

• 35:14Speaker 01

  Yep.

• 35:15David Puder?

  Kind of this idea, and I, I love Karen Horni, who came afterwards, really brought this to life. It's this like idea of this idealized persona that we may create in our mind that we need to be. That's not our true self. So, looking for authenticity and looking for that, that true person. Anything you want to move on that before we move on to the next one?

• 35:39Speaker 01

  I think that's, I think that's all, yeah.

• 35:41David Puder?

  The next one is called feelings of emptiness. And so I think this is really where the pain, like, the other ones may be like, it's like, we're seeing this, but this is where like, a lot of the pain is. It's like a sense of inner emptiness under the absence of any social contact. So it's like, without social contact, I feel hollow. I feel like a shell. In, in loneliness, there's often a longing for a fantasized person or experience. But in this, in the, there's, there's a lack of capacity to fantasize for a person or experience. So that's a very different emptiness.

• 36:24Speaker 01

  Yes. Yeah. Yeah. And so-

• 36:28Speaker 01

  I think that the work of Gerald Adler and Dan Bowie in the 70s and the 80s, they talked about intolerance of aloneness as being very central to borderline personality disorder. And then Gunderson wrote a paper in 1996 on the intolerance of aloneness. And I think this is very, very similar to what Akhtar is describing here with feelings of emptiness. So the idea is that for these types of patients, when they are alone, there's such a feeling of emptiness, they are unable to evoke a sustaining internal

• 37:10Speaker 01

  object of representation in their minds to get them through these periods of aloneness. So they rely very heavily on other people, self-objects, if you will, to sustain them emotionally, to hold them and to soothe them. They can't do it themselves. So there's a constant searching, often in these types of patients, for a sustaining presence, you know, as a result of these feelings of emptiness. There's an intolerance of aloneness. And it differs from loneliness, which normal people can experience, but there's something very different about the quality of aloneness in patients with identity diffusion and borderline

• 37:55Speaker 01

  personality problems.

• 37:57David Puder?

  Let me read a quote here. "A particular deadening of inner emotional experience occurs. Few fantasy objects can be created, and a sense of self begins to crumble. Compulsive socializing, bulimic episodes, drinking, drug ingestion, impulsive sexual encounters, and even provocative behaviors ultimately fill one."

• 38:26David Puder?

  With rage are various measures that are used to ward off feelings of emptiness. Self mutilation, seeing blood flow out of oneself, may be a more regressive way to combat inner emptiness.

• 38:40Speaker 01

  Yeah, and sometimes I use the metaphor of a container without a bottom, a bottomless container. So, you know, Akhtar is talking about filling this container in these patients, but it just empties right out. There's this compulsive socializing, as he calls it, a need to maintain social contact and communication with others who are used to sustain them. Gerald Adler talked about a diffusion of self-objects for patients who will rely on multiple people, multiple others, to provide them with a sense of holding-soothing.

• 39:24Speaker 01

  And so, yeah, this is a major problem that I think really is quite prevalent in borderline personalities and differs, again, from loneliness.

• 39:35David Puder?

  Yeah. Loneliness can be mournful, but you may have fantasies and there may be many emotions. Whereas this, there's this compulsion to fill the void, compulsive socializing, bulimic episodes, drinking, drug ingestion, self mutilation, multiplicity of sexual partners. It's like, I'm trying to exit out of this feeling of emptiness.

• 40:02Speaker 01

  Yeah, and some patients will come right out and say something to the effect of, "I feel empty on the inside. I feel hollow." Not all patients are that insightful about it, but my experience is that some people will actually just say this directly, "And I just feel empty on the inside."

• 40:24David Puder?

  Okay. The next one is, according to Akhtar, gender dysphoria.

• 40:33David Puder?

  You want to break this one down?

• 40:34Speaker 01

  Well, to Akhtar, this is, you know, a problem in individuals with identity diffusion. He writes, "A cohesive gender identity is concordant with one's biological sex and shows harmony between core gender identity, gender role, and sexual partner orientation. This translates into an overall gender-appropriate demeanor, including attire, gestures, roles, social priorities, sexual behavior, and interpersonal relationships."

• 41:11Speaker 01

  And so, I'm not sure how well this has aged in the 41 years since this article was published in 1984. But, you know, Kernberg as well continues to talk about problems like this in severe character pathology. It does seem to be the case that individuals with gender dysphoria do have a higher prevalence of certain personality disorders. And so, there might be some merit to this idea, even though it's a bit controversial or very controversial to talk about nowadays.

• 41:53David Puder?

  And I would say, what we're looking for here is we're looking for the global picture, right? If this is a part of a multiplicity of these different domains of identity diffusion, then you may not overly focus on the gender portion, right? So I think in our culture, in our time, you know, there may be an inordinate focus on something, which is like, okay, maybe this is a bigger part of Cluster B or borderline level of functioning.

• 42:31David Puder?

  And so I can try to treat the cohesive picture of this person is struggling with identity.

• 42:41Speaker 01

  Yeah.

• 42:42David Puder?

  Crisis, this is an identity crisis.

• 42:44Speaker 01

  I think that's such an important point is that, you know, and, you know, that's why, you know, we have to look at the global picture and then not focus on any one indicator. And so, you know, is this, is this part of a larger picture of identity confusion? Or, you know, do you see these other signs or symptoms in the patient? Or does it seem to be something that exists separately from these other problems?

• 43:17David Puder?

  Yeah. And I would say if we get to more of the qualitative study, I think we can talk a little bit more about this. So maybe let's skip ahead to the next paper because I feel like this is such a hot topic to discuss and we're not trying to make a big statement here. We're trying to say like, look, there are some people with identity diffusion. It can be in every domain of their identity and gender, sexuality, sexual interest, sexual expression is all part of that. And so, yeah, let's keep going. Is there anything else from this article that you want to touch on before we move on?

• 44:00Speaker 01

  No, there was just one last criterion that Akhtar describes, which is inordinate ethnic and moral relativism, which I think, because we're going through the rest of them, I think just deserves to be mentioned. But, you know, he argues that individuals with identity diffusion display a peculiar power of ethnicity. This lack of an important historical, cultural basis of identity results in a peculiarity.

• 44:28Speaker 01

  Or a peculiar, a peculiarly polymorphous sense of ethnicity, which becomes evident in one's sense of history, cultural norms, group affiliations, object choices, lifestyle, and child rearing practices. It's a very interesting argument to me. Akhtar was Indian. I think he did his psychiatric residency in India and might have done a second here in the United States. And so I'm wondering how influenced he is by his own ethnic identity. But he argues that, you know, that individuals with identity diffusion lack any sense of ethnic or cultural, or often lack a sense of ethnic or cultural identification.

• 45:12Speaker 01

  And so it's an interesting point.

• 45:15David Puder?

  Yeah, and I think to myself, like, okay, the history of humankind was listening to myths, religious stuff, and they were rooted in myths or religion largely for, you know, forever, right? The oral traditions of mythology and the character traits that are passed on as like, these are valuable character traits, right? Think about the Iliad and bravery, think about the Odyssey and hospitality. As I read these myths, I think to myself, like, these, okay, so for thousands of years, people were hearing these stories and they were, it was grounding them in a sense of like, these are the things that we value as a culture, right?

• 45:59David Puder?

  So every culture has values and things that they value and that roots and grounds them. He makes an interesting statement here towards the end. He says, "The absence of inner morality increases the need for direction from others and sometimes involves a heightened vulnerability to isoteric religious cults." And I think it's an interesting statement.

• 46:21Speaker 01

  Very, very interesting. And I've long thought, you know, anecdotally, that people who get caught up in cults, they're searching for something. They're searching for a sense of belonging. They're searching for a group, a community. And so it makes sense that if someone's lacking an ethnic identity or a cultural identity, they may go looking for it in weird places and get themselves caught up in all sorts of bad situations with cult leaders and the like.

• 46:53David Puder?

  I think about some of the cults that I've studied. They've used things like LSD to kind of like create an increased identity diffusion. And then.

• 47:05Speaker 01

  Well, that's fascinating, actually.

• 47:07David Puder?

  Yeah. And so I think that the propensity of increased openness, right? We know that it's associated with psychedelics. I'm more hesitant to recommend something even like ketamine to someone who struggles dissociation, you know, for treatment-resistant depression or something like that. So I think this is something that we need to be thinking about as well in this, in this burgeoning field that could get heavily commercialized in the next decade.

• 47:35Speaker 01

  Yeah, good point.

• 47:37David Puder?

  So, okay. Shall we go to the next paper?

• 47:41Speaker 01

  Yeah, let's do it.

• 47:43David Puder?

  So this is a paper called, "How Does It Feel to Have Disturbed Identity? The Phenomenology of Identity Diffusion in Patients with Borderline Perisodias Order: A Qualitative Study," by Carlston Jorgensen, Reich, Boyd, Boye, 2022. So, a couple of interesting things in the intro. He talks about normal identity. And one thing he mentions is that Kernberg said that, "commitment in intimate, mature relations in which love and sex need not be split off from each other." That was kind of an interesting statement to me.

• 48:27David Puder?

  Like, this idea of normal identity has merged sex and love, and they're not split off from each other. But I've definitely met some patients where it's like sex is not, like sex can only be done outside of any attachment.

• 48:45Speaker 01

  Yeah. And if I think, if I understand Kernberg correctly here.

• 48:51Speaker 01

  It's not that healthy people are incapable of sex without love. They certainly are capable of it. But that they are capable of integrating sex and love. And that they can go together.

• 49:09David Puder?

  Yeah.

• 49:10Speaker 01

  So he argues that, you know, a healthier neurotic person is able to engage in casual sex, but is also able to integrate sex with love. And I think that's a vital point.

• 49:25David Puder?

  Yeah. He talks about how normal, so normal and consolidated identity involves a stable and coherent self-image, having a sense of inner core, continuity, and sameness of the self, other, time, and across different social contexts, we've talked about this, and capable to make stable communities. So I was thinking we could go through some of the core things that he found. So he was looking for, so basically in 16 patients with borderline personality disorder, I think it's very important to note that these patients actually had BPD, they were

• 50:09David Puder?

  known to have BPD, they were getting treatment for BPD. And so he was looking at these 16 adult women, average age of 27.6 years, so about 27 years old. And only two of them had comorbid narcissistic personality disorder. They did the inventory of personality organization that I had talked about earlier. They came up with an interview that was guided by Akhtar, Kernberg, Other Questions on Identity. We won't go through the questions that they gave, but you could look at that. And then he gave them, I think there was like, on average, about an hour and a half interview.

• 50:56David Puder?

  And read the transcripts multiple times, looked for things that were common between them. And yeah, anything else on the kind of the methods and the intro before we get into the commonalities?

• 51:08Speaker 01

  No, I think some of the questions are are interesting.

• 51:11David Puder?

  Okay.

• 51:12Speaker 01

  Uh, yeah, let's just read through some of them. You know, can you tell me a little bit about how you feel when you're together with other people? How does it feel to be you? How do you feel when you're alone, touching on, you know, emptiness and intolerance of aloneness? How do you see your own future? What do you imagine life will be like in five or 10 years from now? Uh, could you tell me what sex means to you and what it means in your life? So, you know, from the first article that we talked about, the Akhtar article, uh, you know, there's an attempt to capture, I think, the different domains. Sexuality, emptiness, contradictory character traits, splitting, uh, and the like.

• 51:55Speaker 01

  So I thought it was a, a, a good questionnaire for the study.

• 52:00David Puder?

  That's great. Yeah. And so then they looked at table two, they described the different themes and categories that emerged and how often they were present or not present. And most of them were present in each of the people. And if they weren't present, it was often just insufficient data. But very rarely were they not present, which I think goes to show that if you have patients with BPD and you dig into identity diffusion, across the board, they're going to have a lot of these domains.

• 52:37David Puder?

  And so things like, don't know who I am, using facades, self is broken, self does not fit in, inner emptiness, doesn't know what I want, don't know what I want. Contact to stabilize identity. Relational paradox. Sex as self-regulation. It's pretty much in all of them.

• 53:00Speaker 01

  Yeah, yeah. And again, you know, ACTAR, you know, 40 years ago, syndrome of identity diffusion. All of these domains really fit in pretty neatly to what he described in 1984. And so, yeah, it's when I was looking at the data, it's actually quite striking to see that these things were present in a very, very high percentage of the study participants. You know, meaning, in essence, like you said, that if you have a patient with borderline personality disorder, there's a very high likelihood that they evidence these problems, these problems with identity.

• 53:43David Puder?

  One thing I will mention is that this population, they scored high in identity disturbance in the IPO that I talked about. They scored on average 78.4 standard deviation of 10.2, demonstrating a very high level of identity disturbance. So this was a sample that had a high level of identity disturbance in them. Now, I don't think they picked them because of that. I think they picked people who had borderline personality disorder, who would be a part of this thing. But they did have a high level of identity diffusion per other tests. And I think that's important. Like, if you wanted to run an IPO on people,

• 54:27David Puder?

  I don't think that would be that hard. And they didn't score high in identity diffusion, then they probably wouldn't have identity diffusion. Right? So, okay, that was one of my thoughts. I'll just, I think, I think it might be good to kind of go one by one through these and give a couple of the quotes, just so we can give some, like, meat to what this means. And once again, if you're struggling with us at this point, trying to get your head around it, remember, this is the something that you, it's like, hard to get your head around, because it's the thing that is diffuse. It's like, number one, I don't know who I am. So this is fluctuating and disintegrated self-image. So they said things like, there is no me.

• 55:12David Puder?

  This is exactly my problem.

• 55:16David Puder?

  And it's terribly confusing not being able to navigate who I am, what I really, truly think and feel and what my view is on things.

• 55:28David Puder?

  Here's another quote, "What I am saying is something I really mean. If what I feel is something I really feel, the thoughts I have in my head about who I am, are they even true, really?" Here's another one, "I don't feel that I can wholeheartedly say one single thing about who I am."

• 55:51Speaker 01

  Yeah, very, very common statements for those of us who've treated and worked with borderline patients. And, you know, I think, you know, this sense that there, there is no core me. Some people have linked, you know, self-injury and cutting to attempts, unconscious attempts by the patient to recognize or realize that they are in fact still alive. And that I'm in possession of a body, which is an interesting conceptualization. But

• 56:28David Puder?

  Well, it's interesting, but it's also like, it's suffering to not know that you are alive. It's awful. It's horrible. It's a horrible feeling. And it's a horrible feeling to not feel like there is any you. And we rightfully suffer with them in the not knowing often in sessions. It's like, it is so painful to not know where you are, where you start, where you begin.

• 56:54Speaker 01

  Yeah, right. And that's a good point. I mean, the countertransference reaction to a patient who struggles with identity in this way is a feeling in me, I don't really know who the patient is either.

• 57:11Speaker 01

  And I'm having a hard time making sense of what's going on with the patient.

• 57:16David Puder?

  Or another one I've heard from a lot of, especially people who haven't had a lot of training on countertransference, like nurse practitioners. I know a lot of them are getting it after they get through their program. But in their program, they're not getting a lot of that. They'll say to me things like, I don't, I come out of this session and I think to myself, am I like, what, what am I? Who, who am I to treat this person? Am I good enough to treat this person? Do I even know? So it's like, you have to imagine when someone's, when you're sitting with someone who really

• 57:54David Puder?

  doesn't know who they are and who it's like, um, a common countertransference could be that you don't have a sense of your own professional consolidation. And it could, and I see it coming out with people with like this insecurity about their own abilities, their own personality.

• 58:17Speaker 01

  Yeah, very, very good point, projection, projective identification, uh, and, uh, professional sense of insecurity or a sense of incapacity. I'm not good enough to help this person. I don't know, I don't really know what I'm doing. And, and perhaps in treating other patients, the clinician feels pretty skillful and, and, and pretty competent. Um, and, and so I think that's the point you're getting at. Yeah.

• 58:46David Puder?

  Yeah. So maybe it's like, um, for you as a professional, if you're listening to this, that's a feeling you have when you treat some patients. It's like you have to step back and you have to say like, okay, what, what am I feeling from this person? And then how do I use that to give them empathy? Um, or to increase their reflectiveness, you know, of, I think it's painful specifically. It's this emptiness that's painful.

• 59:12Speaker 01

  Yeah. And using the countertransference also to understand what plays out in the patient's outside relationships. If the patient's making me feel this way, well, then the patient's probably making others in their life feel this way. And that might contribute to the interpersonal dysfunction that we see in the lives of, of these types of individuals.

• 59:33David Puder?

  Okay, so we're going through the "I don't know who I am." "I have never known who I am." "How it feels to know who I am is confusing to me." That kind of like line was common with these patients. Because of that, sometimes there were statements like, "I am completely dependent on the person I am currently dating." This kind of like utilizing the other for self-definition.

• 1:00:02Speaker 01

  As an anchor, yeah. I'm gonna anchor myself to that person. And my entire sense of self depends on whether this person is present, cares about me, loves me, is in communication with me, et cetera. And without this person, I fall apart.

• 1:00:26David Puder?

  You know, and I hear, I've heard people who are narcissistic, who talk about dating. And they actually look for this type of person that they can mold into their own image. And sometimes they'll talk about like, why they date young people. And it's like, "Oh, bro."

• 1:00:45Speaker 01

  Yeah.

• 1:00:46David Puder?

  Like, it makes me angry. But then also, one thing that they'll say is they never show any weakness. And I used to be confused about that. I brought it up with Sue Johnson. And it finally occurred to me, why? Do you know what I'm gonna say?

• 1:00:59Speaker 01

  No.

• 1:01:01David Puder?

  Because when a narcissist shows weakness to a borderline that they're dating, or someone with really bad identity infusion, they may go into devaluation quickly. And so, they have to stay in the idealization.

• 1:01:15Speaker 01

  Yeah.

• 1:01:16David Puder?

  Because that's where they feel good.

• 1:01:17Speaker 01

  Yeah, yeah, yeah. This unconscious dance between these two personality-disordered individuals is very fascinating, right? Because they're each playing a role for the other unconsciously, right? The narcissistic individual is providing the borderline patient with

• 1:01:39David Puder?

  A solidity.

• 1:01:40Speaker 01

  A strong, solid, at least outward appearance of someone who's very strong and solid and knows who he or she is and that sort of thing, right? And a sense of identity, right? And the borderline patient gives the narcissistic individual, at least in the early stages of relationship, Idealization and what does the narcissist need and want so greatly is to be idealized. And so there's a very complicated, complex sort of dance there that goes on, I think, sometimes interpersonally, which is not to say that that normal or healthy individuals can't find themselves in relationship with personality disordered people. Certainly,

• 1:02:24Speaker 01

  that's probably the rule or the majority of these types of situations. But when you have a situation with two people who are severely characterologically ill, you have quite a situation on your hands.

• 1:02:40David Puder?

  You know, it's really, really painful to watch a dysfunctional relational dance where you they're in this. And, you know, by the way, if you're in any relationship, there's going to be a dance, right? The Sue Johnson withdrawer pursuer dance, right? That's always there. Someone doesn't feel quite enough.

• 1:03:07Speaker 01

  See, I'm not I'm not entirely sure that that's always there in healthy relationships. I would argue that in healthy, in two healthy persons, when one person leans in, the other person leans into.

• 1:03:20David Puder?

  Oh.

• 1:03:21Speaker 01

  And there's a coming together. There isn't this follower chaser, you know, withdraw sort of dynamic.

• 1:03:31David Puder?

  I think that's the ideal. And I think a relationship can stay there for a while. But I think inevitably, most relationships fall into a dance of sorts where there's some level of disconnection. I think it's rare to find a super highly connected relationship.

• 1:03:48Speaker 01

  That's probably true. Yeah.

• 1:03:49David Puder?

  Like one that's very life giving.

• 1:03:51Speaker 01

  Yeah.

• 1:03:52David Puder?

  Once in a while, you'll see it and you'll be like, wow.

• 1:03:56Speaker 01

  Yeah. My, my sense is that, yeah, I mean, relationships can be at times difficult, but I don't think they have to be inherently difficult.

• 1:04:06David Puder?

  Sure.

• 1:04:06Speaker 01

  I think sometimes people who say, well, relationships take work and relationships are hard. I think sometimes that's a defense against their own pathological modes of relating. You know, healthy people tend to have pretty stable, you know, relationships. They tend to feel good about their relationships most of the time and there, there's a good flow and they feel connected. And so I, I'm really, you know, sort of against this notion that

• 1:04:36David Puder?

  Okay.

• 1:04:36Speaker 01

  has become very popular, that relationships are somehow inherently difficult. I, I think, I think for some people, yes, relationships are inherently difficult and those people often have at least some pathological personality traits, if not full-blown personality disorders. But I think well-adjusted people get along with their partners most of the time and there's a good, a good flow to things and there's a sense of comfort and, and certainly there's disagreements. But so, yeah, this has come into the pop culture and the pop psych world quite a bit and I'm not entirely sure that I agree with these notions, but yeah, that's, it's a good topic.

• 1:05:15David Puder?

  Well, maybe, maybe my, um, my repertoire of patients that I've seen over the years tells me otherwise. That being said, when one partner is very well-connected to the other, treatment usually goes a little bit different. You know, the, the issue's more discreet, time limited. I have this one couple and it's like the most supportive, loving couple. One of them's bipolar.

• 1:05:47Speaker 01

  Ah.

• 1:05:48David Puder?

  And they're getting through it, you know?

• 1:05:51Speaker 01

  Yeah.

• 1:05:51David Puder?

  But it's so much harder when there's, there, you know, like with personality disorder comes chaotic interpersonal relationships. So they don't have these longitudinal.

• 1:06:06David Puder?

  You know, monolithic relationships that have gone on for decades. Like, if you're wondering if you have identity diffusion and you have great friends that you've had for decades, meaningful relationships, you're probably lower risk.

• 1:06:20Speaker 01

  Yeah. And my experience with borderline personality disorder patients is that they can maintain long-term relationships. And I see this sometimes in my practice, but often the partner or the spouse is not what Gunderson would call the major object. They're not the fixation. The patient often has someone else, a friend, a family member, that their interpersonal world is centered around. And so they can sustain, perhaps in a marriage, long-term, where the partner is actually not the

• 1:06:57David Puder?

  Yeah, I've seen that.

• 1:06:58Speaker 01

  the favorite person, or the major or the primary object. And so

• 1:07:03David Puder?

  And sometimes they pick that partner

• 1:07:05Speaker 01

  For that reason.

• 1:07:06David Puder?

  As a higher level of stability.

• 1:07:08Speaker 01

  That's right. That's exactly right.

• 1:07:10David Puder?

  Yeah.

• 1:07:11Speaker 01

  They pick the partner for that reason, unconsciously usually, sometimes consciously.

• 1:07:14David Puder?

  Okay. That's interesting. Some digressions here. Good digressions. Okay. Number two, fake it till you make it, using masks and facades to stabilize the self. So, some of the women said that they try hard to look and act normal, in some cases in an attempt to be socially accepted, in other cases mainly to hide feelings of inner vulnerability, sadness, and what they see as bad or unacceptable parts of themself. Interestingly, he's gone on to write a book, Jorgensen, on shame and the use of shame in psychotherapy. And so you can kind of see some of the potential reasons for that.

• 1:07:59David Puder?

  Am I good enough in the imagined eyes of the other? One participant described always trying to be the sweet girl, always pretending to be very happy, very, very sweet to others, even in situations where she's angry and feels like being and doing something completely different. I keep up this facade. Here's another quote, "I have many different facades. Behind them, there's chaos, not knowing who I am, or how you're supposed to act on the outside. I have no problem appearing calm, in control, completely integrated, but inside, I am going 150 miles per hour, trying to figure out,

• 1:08:42David Puder?

  am I doing the right thing? Am I giving the right answer?

• 1:08:48David Puder?

  What appears in these statements is a self that is haunted by anxiety and constant fear of being exposed to be as defective, phony, and inadequate, and ultimately of being rejected, should the mask slip, which it often does.

• 1:09:05David Puder?

  Whew. Reflections?

• 1:09:08Speaker 01

  Yeah, lots of good stuff here on the fake it till you make it stuff. You know?

• 1:09:15David Puder?

  You know, it's kind of like painful to imagine this person feeling so inadequate that they need to be someone that they're not to fit in.

• 1:09:30Speaker 01

  Yeah, it makes them feel like an imposter, I would imagine, sometimes.

• 1:09:33David Puder?

  And we're talking about with the people that probably love them the most. Or maybe they pick partners that will be very conditionally loving, which is sad, too. Maybe they had parents that were very conditionally loving. That's also very sad and difficult. And, you know, as a provider, they will imagine that I will be conditionally caring towards them as well. And so they will project all sorts of ways of being and like things that they have to do in order to appease me. And, you know, it's kind of a superpower in a lot of their domains of life. They can be incredibly successful, reading people

• 1:10:17David Puder?

  and melding who they are to fit various people's necessities. Yeah, and they find themselves in very narcissistic oriented relationships where they can be a certain way, show up a certain way, and get accolades and get appreciation. And that can be stabilizing for a time, but inevitably potentially leave them very empty.

• 1:10:45David Puder?

  So I'll often say to a patient who has this, I'll say, if you feel like you can tell what I want to hear, and that consciously goes through your mind, can you share that with me? Rather than trying to appease that part of me, because I know, like, we all have bias. Like, every therapist has probably things that they want to hear, more or less, right?

• 1:11:09Speaker 01

  Sure.

• 1:11:10David Puder?

  I've seen this in patients who have a flight to health, very quickly on in treatment, because they imagine that that's what I want for them. But when I look at them, they look like they're really suffering. Like, it doesn't look like they're better.

• 1:11:21Speaker 01

  It's the good patient.

• 1:11:24David Puder?

  What's that?

• 1:11:25Speaker 01

  They're the good patient. They come in, and you've cured them in, you know, two or three meetings.

• 1:11:31David Puder?

  Right.

• 1:11:32Speaker 01

  They fly right into health.

• 1:11:33David Puder?

  Right.

• 1:11:34Speaker 01

  So I want to be the good patient for you, doctor.

• 1:11:37David Puder?

  I've had patients who do good behaviors, imagining that I want them to do those good behaviors. And we, as professionals, need to not be naive that this is a good reason to not talk about certain topics and preferences. Like, I don't talk about my political preferences online, ever, because I probably have some patients who will read that and want to adopt, or maybe they'll have some vitriol. One way or the other, it's probably not a good thing.

• 1:12:08Speaker 01

  Sure.

• 1:12:09David Puder?

  But, you know, and they can look at my books out there. I've had patients look at my books.

• 1:12:17Speaker 01

  Yeah.

• 1:12:18David Puder?

  And start to include different aspects of my books into what they're saying. And I'm like, are you doing this because you're trying to connect? And, you know, like, some people are very skillful at connecting. And that's awesome.

• 1:12:34Speaker 01

  Sure. Yeah. And so we always have to ask ourselves, why? You know, what's going on that's driving this and motivating this? But you make a really important point, and that all of this stuff that we're talking about here... That exists intra-psychically, within the patient's own mind, or in their outside relationships, plays out in therapy too. And I mean, it's such a basic point for people psychodynamically oriented. But to others, you know, this is often not talked about. It's not mentioned. So, you know, this is going to play out in the transference and the counter-transference, what happens between you and the patient.

• 1:13:18Speaker 01

  And it becomes very, very useful information to inform diagnosis, to understand what plays out typically in the patient's outside life. And so, all of it occurs with us too.

• 1:13:34David Puder?

  Yeah. One thing, I think that it's important for us to talk about how it plays out in our relationship with the patient. Because if you aren't psychodynamically informed, and I would say, it's not like you can just read books and understand this, like, it's like supervision and seeing patients and then experiencing it yourself and reading books and more supervision. It's like slowly you get goggles and eyeglasses that see this as it plays out, right? One of the people, Yeoman, recently said, "If you want the transference to be evoked, try to reinstate the frame."

• 1:14:10Speaker 01

  Yeah, you just have to stay neutral.

• 1:14:12David Puder?

  You just, I mean, if you, well, I don't know. Even if you, like, I'm probably, you know, different people have different degrees of warmth, right? Or I'm probably, I try to be more on the warm side. I would hope, I would imagine myself to be that way, right?

• 1:14:30Speaker 01

  You seem that way, David.

• 1:14:31David Puder?

  If I truly am warm, I try not to say something that isn't true.

• 1:14:36Speaker 01

  Yeah.

• 1:14:37David Puder?

  Because I feel like that's also a facade of sorts, right?

• 1:14:41David Puder?

  Okay, one thing I was thinking about was my use of micro expression. So I read micro expression on people's faces. Like if you flash a little bit of frustration when I say something that you slightly don't agree with.

• 1:14:52Speaker 01

  I think you did this the last time I was here, actually.

• 1:14:55David Puder?

  I think you may have just flashed an expression. No. And I think what that does, though, is it helps me get to their true self. So it helps kind of like reroute me from my experience into like what's going on inside of them. And I think it's true. I think it's like a piece of true knowledge, you know?

• 1:15:16Speaker 01

  Yeah.

• 1:15:16David Puder?

  Like a dream. Dreams are like true knowledge. Because there's only one dreamer. It's not you and the person interacting. Like, they are in their own mind in the dream. You know? Okay. Let's keep going. So painful feelings of self as broken, defective, unvulnerable. Here's some quotes. "I feel like there's a hole in the middle of my soul that nothing can repair. I am always the odd one out. The others think I am wrong." It goes on to the body, their feeling of their body. And I've seen this with patients. And it doesn't matter how attractive or unattractive.

• 1:15:59David Puder?

  It's completely unrelated to how tall or short. They may say something like, "I hate my body. I always have. I can't remember a time when I didn't hate my body. I am fat, I'm too short. Well, everything. I'm not happy with any part of my body and never have been." One woman said, "The greatest wish is to be born as a man. And this body and this mind-soul would fit together. I am deeply dissatisfied with my body. Different parts of my body are disconnected, like Lego bricks that don't fit together." And I would say like, just like with body dysmorphia. Sometimes you have patients with body dysmorphia that have, they have like lots of these thoughts.

• 1:16:40David Puder?

  And it could be like linked to this bigger issue of identity diffusion, right?

• 1:16:45Speaker 01

  Mm-hmm.

• 1:16:46David Puder?

  If they have surgeries...

• 1:16:49David Puder?

  One plastic surgery, two plastic surgery, three plastic surgery. A lot of these patients still have body dysmorphia. So if you have a patient like this, they're still gonna have identity diffusion, unless you treat the identity diffusion.

• 1:17:05Speaker 01

  Yeah, lots of, lots of interesting ethical questions there with plastic surgery and the like, which are interesting to, to think about. But, but yeah, I mean, I think, I think this is linked to self-destructive behaviors in these patients, self punishing behaviors, masochistic behaviors. I feel so bad about myself that I deserve to feel pain. And so I think we can link some of the sadomasochistic behaviors that we see in these patients to, to these painful feelings about themselves.

• 1:17:47David Puder?

  It's like, I hate myself, I hate my body. And then the, what feels natural for me is to have other people hate my body or hate me. And so it's like, I'm, I'm gonna search out maybe relationships where the person will have some large amount of hate towards me. And that's, that can be masochism. That can be a masochistic sort of relationship, right? Here's another quote. "I am like a broken bucket with a small hole on the bottom where the water keeps running out because somewhere, because something is missing and I have no idea what might plug the hole."

• 1:18:32David Puder?

  And so you can see that, the desperation, the agony, the pain.

• 1:18:36Speaker 01

  Yeah.

• 1:18:36David Puder?

  In that hate, right? And, and so you might ask, how does this play out like in your relationship? Well, if they have hatred towards themselves, they could project onto you that you will hate them, get you to identify that, and then maybe you do end up hating them. And then as a provider, you may have a hard time hating a patient. That, that may be something that you can work through in supervision. You can get to the other side of it. You can work through a mixture of emotions that you have towards another human being, right? We all have a mixture of emotions.

• 1:19:14David Puder?

  Thoughts on that?

• 1:19:14Speaker 01

  Yeah, yeah, no, no, I mean, hate in the countertransference, Swinacott. You know, I think, yeah, there's, there's, you know, there's just the sense of defectiveness, sense of brokenness that leads these individuals into bad situations unknowingly often and unconsciously. And just this, you know, this really core sense that I am just bad. There's just a badness about me. It must be a horrific way to go about life. It must be very, very painful.

• 1:19:56Speaker 01

  And so, but you're touching on projective identification too, which is, you know, which is the eliciting in the treatment situation of feelings within the therapist or the analyst that, you know, sort of the patient's own feelings are dumped into the therapist and then the therapist begins to experience them. And if they act on them, then it's projective identification. And this is, occurs unconsciously. Very, very, very difficult thing to experience, something that, you know, really requires expert consultation and supervision often. And it becomes very murky, becomes very clear, you know, are these my own thoughts?

• 1:20:41Speaker 01

  Or are these the patient's? Am I, you know, there is a coercive quality to projective identification. Gabbard talks about this. It can feel like, like I am, I am feeling and experiencing something that I've never felt and experienced before. This is uncharacteristic of me. Why am I feeling these things? Why am I acting this way? Normally, I am.

• 1:21:10Speaker 01

  Patient and I'm warm and I try to approach each patient with empathy. But all of a sudden, I feel myself, you know, thinking about, you know, about kicking the patient out of my office, or I'm looking at my watch, I can't wait for the session to be over, or I feel like I want to, I want to erupt, I want to yell at the patient. How could you say that? Or how could you be thinking that way? Or something like that? And of course, a skilled therapist doesn't do those things, but we feel them sometimes. And, um, and so, uh, you know, that's sort of the essence of, of what you're talking about there.

• 1:21:52David Puder?

  Yeah, and I would add, um, I, one, I've referred a provider to you, which I think you were able to, to help them, even in one session, you can help someone like, when they've gotten pulled into this really deep, you can help them kind of understand what might be going on and why this is, and, and just even knowing that this is a thing, I think is very helpful.

• 1:22:18Speaker 01

  Yeah, it's, it's not taught, you know, uh, you know, my, my friend.

• 1:22:22David Puder?

  It's this, like, when you get pulled into it, though.

• 1:22:25Speaker 01

  Yeah.

• 1:22:25David Puder?

  And if you're listening to this and you're like, oh, that's never happened to me. It's like, okay, but when it does, remember back to this talk, come back here, listen to this again.

• 1:22:34Speaker 01

  I've heard it described before as, as feeling like you're in shark-infested waters. And I think it's a pretty damn good metaphor for this type of experience, if you've never had it before as a clinician. But yeah, I mean, I just want to quickly add, you know, this stuff unfortunately isn't taught at the graduate level very often, if, if at all.

• 1:22:57David Puder?

  Because, and here's the thing, is like, a lot of the teachers that are teaching in a lot of programs, they're not treating severe.

• 1:23:07Speaker 01

  If they're treating anyone at all, and often they're just researchers.

• 1:23:10David Puder?

  Often they're just researchers, yeah. I picked the residency that I went to because the people, every person that I would work with, was working forty to eighty hours a week and had been for decades. For me, that was like, it was a kind of a workhorse program. I chose to go there for that reason, because it was like, I was gonna get this mentorship of people that have actually done this. I've rotated at another program, where it's like, I would have a guy teaching for the week who had been doing research for the last fifty weeks of the year. You know, so if you haven't gotten this, you're getting it here. I'm glad that we can give it to you here in a small dose. Okay, I wanna, I wanna wrap it up in like, five minutes, okay?

• 1:23:54David Puder?

  So this is my goal. So hang with me here, guys. Number four, feeling that the self does not fit in. The self is not experienced as an integrated part of social communities. Okay, I'm not gonna go into that, we've talked about that quite a bit, but this feeling that I'm not belonging, I'm a lone wolf, I'm, if I'm around other people, I feel rejected. Okay, and some of that is maybe happening, some of that maybe is part of the projection, right, of, and maybe that's part of like, the difficulty of feeling a sense of self, so you can't feel a part of a group.

• 1:24:37Speaker 01

  Mm-hmm. This ties into what Akhtar was talking about, the cultural, the cultural stuff, the ethnic relativism, right? I don't really feel like I'm a part of a group. I don't really feel any sense of connection to my ancestors, or to, to a larger, you know, a group, you know, to which I belong.

• 1:24:58David Puder?

  You know, I was, I've been reading a book on Hitler, and I think Hitler had some of this identity diffusion. I mean, this guy was practically homeless for a big portion of his life. Artist. And the war, World War I, he was kind of described as this odd guy, like wouldn't join in the laughter, reading books on the side. But when he was able to talk about politics and he disagreed, he would go into these rages in front of people. And there were some people that really listened to him and gravitated towards him. And I think over time, the war gave him an identity.

• 1:25:37Speaker 01

  Yeah.

• 1:25:37David Puder?

  And the antisemitism gave him a subgroup. And the political stuff and the, his knowledge, because I think he was fairly bright, gave him things to talk about that led to people following him. But he was a very odd interpersonal person.

• 1:25:54Speaker 01

  Yeah, yeah. I'm, I'm, I don't know if I've told you this, but I'm, I'm in a, a one-year training program with Otto Kernberg right now on personality disorders. And, you know, Kernberg's written a little bit, and he's spoken a little bit in this program on, on Hitler. You know, for those who don't know, Kernberg had to, had to flee Europe as a young person because of the rise of Nazism. And Kernberg is Jewish, and he went to Chile and did his psychoanalytic training in Chile and then came to the United States. But anyway, Kernberg has argued that Hitler suffered from the syndrome of malignant narcissism.

• 1:26:37David Puder?

  And. So borderline level of functioning. So he had reality testing intact. He had identity diffusion. He had primitive defenses. But in that, a very pathological narcissism.

• 1:26:51Speaker 01

  Yes, that, that is, you know, so malignant narcissism is Kernberg's term for a, in essence, a combination of narcissism and with antisocial behavior.

• 1:27:05David Puder?

  Psychopathy, yeah.

• 1:27:06Speaker 01

  And, yes. But he didn't, he did not. Um, think, or he does not think that Hitler was a psychopath. Or that Hitler had antisocial personality disorder because to Kernberg Hitler had the capacity for some non-exploitative human relationships. He was capable of a love relationship with Eva Braun. And so he is so Kernberg argues he has this had the syndrome of malignant narcissism. It's an interesting, just an interesting historical point.

• 1:27:37David Puder?

  So I ran him on the PCLR, the hair psychopathy checklist, and he scored thirty out of forty, which puts him right at that edge of psychopathy.

• 1:27:46Speaker 01

  Yeah, interesting.

• 1:27:48David Puder?

  Um, he, he didn't, he scored lower in like, usually people with psychopathy will have a multiplicity of sexual relationships, but he did not. So I would actually say that I think he had some psychopathy.

• 1:28:03Speaker 01

  Yeah, I think that's captured by malignant narcissism.

• 1:28:05David Puder?

  I'm, I'm reading the, the book where it talks about his friendships and he didn't really have any long, a lot of these friendships, the, the people were very passive that, that he was able to relate to.

• 1:28:18Speaker 01

  Interesting.

• 1:28:19David Puder?

  And, um, I, I think that a lot of his relationships were not based on a normal connectedness.

• 1:28:28Speaker 01

  Yeah.

• 1:28:29David Puder?

  But more, I think later, later it was based on more like ideology.

• 1:28:33Speaker 01

  Yeah, yeah, I, I don't, I don't know enough about his relationship with Eva Braun. He had, he had some German shepherd dogs and apparently was devastated.

• 1:28:44David Puder?

  He was more devastated by his dog.

• 1:28:46Speaker 01

  About the dog, about, you know, he, he killed the dog the night before he killed himself, my understanding is.

• 1:28:52David Puder?

  He didn't, he didn't have psychopathy to the level of like harming animals of like, but, but there was some, but he was very dehumanizing. I mean, so.

• 1:29:02Speaker 01

  Oh, absolutely.

• 1:29:02David Puder?

  Like, yeah. This, I hope, I hope I didn't, um, you know, okay, so I, one more thought on him and then let's move on. His father was actually very stern and would like, um, would try to steer him in the right direction through pretty strict discipline, maybe some like spankings or stuff, maybe even worse, right? He would leave his dad and his mom would coddle him. Hmm. And so I almost think with that, you know, like he had no. Well, it's, it's a perfect setup for splitting, right? It's, it's a split, it's a setup for splitting, right? And, and so you could hear

• 1:29:45David Puder?

  that and you could say like, oh, Dr. Peter, do you have empathy for someone like hitting their son? Or are you saying that the mom should not empathize with the son? And I would say, no, no, you're, you're misconfusing me here. Yeah. Okay. You're not understanding the situation. If a father disciplines a son for something that the son should have been disciplined for, in the proper amount, and then the mother negates that through coddling, not empathy, because empathy would properly be saying like, hey, you had aggression, your father was trying to steer you in the right direction, right? Empathy would be congruent to the situation. This is not empathy. This is coddling.

• 1:30:25David Puder?

  So coddling is like, um, it's like overly nurturing to something that doesn't need to be nurtured. Yeah, yeah. Okay. So hopefully I can parse that out. That leads to splitting, right? Yeah. So, okay, enough on Hitler. We'll get further in the book and I'll have some more thoughts. So, okay, I wanted to touch maybe on the last one, because I think his, his take on sexuality was, was interesting. And all but one person had issues with sex.

• 1:30:59David Puder?

  Using sex to distract the self and regulate painful self-states, painful confusion around sexual needs. So, almost all women, almost all women have used sex as a way of gaining acceptance and recognition from others and avoiding abandonment. Quote, "Most of my life, I've used sex as a way to be accepted and recognized as good enough, primarily in one-night stands where having sex made the other person feel happy. Personally, I could easily do without it." Here's another quote, "Sex is a way for me to be affirmed as being good enough."

• 1:31:43David Puder?

  Others have used sex as a distraction, quote, "A means of handling emotional problems," end quote. One woman contemplated what she is looking for in sex. "I don't know what I'm looking for. Maybe I'm looking for some artificial form of care, love, tenderness. I don't know. I think attention is what I'm looking for."

• 1:32:07Speaker 01

  Yeah, and so I think what you're seeing here is that the sex is, it's about much more than sex, right? And I guess an argument could be made that sex is always about more than sex. But in these individuals, it's magnified, right?

• 1:32:24David Puder?

  It's an extension of a desperate attack, a desperate desire for connection.

• 1:32:30Speaker 01

  Correct.

• 1:32:30David Puder?

  A desperate emptiness that we've already talked about.

• 1:32:33Speaker 01

  Yeah.

• 1:32:34David Puder?

  It's a coping strategy. It's a way of helping someone else feel better about themselves. So it's like, instead of like their own identity, what they would desire, it's like, this is me merging with the other person's desires and giving away my own sense of self.

• 1:32:54Speaker 01

  And it's different from... I think in normative functioning, it's nice to feel desired. We all like that. We all enjoy that. But in this subset of patients, it's not just nice to feel desired. It's needed and sought compulsively, often with a number of objects, a number of people, over and over again. And the person really never feels satisfied, filled up, and good enough.

• 1:33:30David Puder?

  And so I think sex is like a manifestation. It's like a playing out. It's like an acting out of some of the distress. It's a powerful way to connect with other people. And it's utilized for that, but in a way that doesn't lead to the desired outcome, sometimes.

• 1:33:53Speaker 01

  Yeah.

• 1:33:54David Puder?

  And I think it's something where, as a clinician, you know, how do I have empathy for the person? For the yearnings underneath, for the yearnings for connection that feel thwarted, for the yearnings to find a sense of self, to rediscover sexuality. What is sex for them in a meaningful way? Right? As they start to get in touch with more of their personhood, more of what they would desire, not more of just what they would submit to the desires of others for other satisfaction. Like, what would they yearn for? And they described a lot of the people with kind of like an asexuality, almost.

• 1:34:40David Puder?

  Like, because they're so distanced from desire.

• 1:34:44Speaker 01

  Yeah, yeah. And sex is meaningful connection. And so...

• 1:34:50Speaker 01

  And I guess the last point I want to make on this is that there's an inherent self-destructiveness here as well. The risky, impulsive behavior, you know, sometimes it's very, very apparent to the clinician, but the patient themselves doesn't necessarily see this type of behavior as self-destructive. And Gunderson talks about this a little bit. I think it's an important point, is that what might be glaringly obvious to us when we look about, look at this patient's life and what they're doing, may not be apparent at all to the patient themselves.

• 1:35:26David Puder?

  Yeah, and I think like, the doctor's side of me is always a little bit cautious with the higher, more higher-risk behaviors that can lead to lifelong consequences, right? It's, I want to, I want to not increase the shame that someone might feel, but I also want to help a person not have consequences that could lead to lifelong suffering, if at all possible. So, okay, well, let's wrap it up on this one. This is, hopefully, this has been meaningful. Hopefully, this has been helpful for you guys, listening to this. Hopefully, you can jump on X.

• 1:36:10David Puder?

  I might post the whole video, the whole audio, actually, on X. We didn't record any video today. So that people could put comments, or there should be someplace that you can throw up a comment, or something that you vehemently disagreed with us, or you felt like we were really off track, you can just let us know, you know, because that's what, that's what we do on Twitter. Or you can put up a kind, thoughtful comment on something that was helpful.

• 1:36:32Speaker 01

  Yeah, those aren't that common.

• 1:36:33David Puder?

  I like, yeah. But it's really meaningful to have you down. Really appreciate you coming.

• 1:36:42Speaker 01

  Absolutely, it's been real. This has been good.

• 1:36:44David Puder?

  This is a good conversation. I feel like if we, there were things that we did not get to, right? And so if you could get these two papers, check them out yourself, spend some time reading them. If you had any strong disagreements with us, maybe that's a first step. Read the articles, front to back, and you can come up with disagreements you have for them, juxtapose with different disagreements you have with us, you can have some nuance between the differences, right?

• 1:37:13David Puder?

  Okay, alright. Thanks David. We'll leave it there for today.