76. Treating the Pathological Female: Why the Current Model Fails

Do I fucking feel it?

And these are the people we call empaths.

By the way, these are the people we think are so compassionate because we confuse emotional intensity with feeling for other people.

The reason I did the preventing borderline episode is that I have tried.

I don't really believe that once it's come so far.

that you can diagnose a borderline personality disorder.

I don't think that you can cure it.

But if you want to start talking about a treatment, you have to look at the whole picture and really understand the nature of the disorder.

And they misunderstand the nature of the disorder, which is why they've not developed a treatment that really works.

They only address the neuroticism.

They don't address the low agreeableness.

or the poor conscientiousness.

And it's the combination of these and the fast life strategy that has solidified into a personality that repeatedly use crises to move people around them.

That is what needs to be addressed.

And the treatment, the standard treatment, dialectical behavioral therapy, yes, it helps.

It helps curb those acute symptoms, but it does not lead to improved social functioning.

And it's because they only look at part of the picture.

They only look at the visible suffering.

This video perfectly describes their own attitudes towards this emotional intensity.

I swear to God, the worst part of a BPD crashout is not even the fact that I crashed out.

It's the fact that I can bounce back in minutes, and the people that I crashed out on can't bounce back for a day, a couple days.

I get it.

I get it.

I understand from their side.

But damn, it fucking sucks.

Like, I wish that everybody got over things as quick as I did, because holy fuck.

Yeah, to heck with them, I guess.

They don't care about the burden they put on others.

The mistake is this.

They think of themselves because they suffer so intensely and they're always told how much they suffer.

They're constantly validated.

They think that this intense suffering means they're suffering more than others.

They think that their intense emotions are an excuse for the burden they put on others.

That is the exploitation aspect.

That is the low agreeableness.

I feel so intensely, so I am entitled for you to soak all of that up for me.

And then I can just move on.

Oh, you don't move on that quickly? ah you know sucks for you this is female interpersonal predation and we don't recognize it because it's female and we'll get to that as well this is another example Oh, she needs a

fucking exorcism.

So they see their own behavior quite clearly in the aftermath.

Do they care? No.

Do they care enough to change? Not really.

It gets them what they want.

And the side effect, which is all the damage they cause to people in their lives...

You know, happens.

But I suffer more.

And these are the people we call empaths, by the way.

These are the people we think are so compassionate because we confuse emotional intensity with feeling for other people.

And there are in different, different domains of personality and they are low intensity.

and trait agreeableness.

And that is what therapy has to target, not just lowering the negative emotions.

And the big mistake that they then make is the way they measure improvement.

So they measure these acute symptoms.

How anxious are you feeling? you know, how happy with your life, how do you feel things are going? When was the last time you had suicidal ideations? Self-report in the therapy room, that's how they'll measure improvement, you know, alcohol consumption, such things.

And so I've seen family members and partners come into therapy, to family sessions, thinking like, now we're going to be heard and now someone's going to understand us and give us answers to how we how we're gonna go forward and then they're so confused because they have to sit there and celebrate improvement that they haven't seen they don't understand this sort of optimism around the so-called improvement and it's in this mismatch because we don't measure the social functioning properly we don't expect them to become contributing members of society.

And so this asymmetry does not exist when we talk about men.

And that's why I want to bring in a comparison here.

Consider the diagnosis that is in the same category as borderline personality disorder, namely antisocial personality disorder.

They both belong at the same place in the cluster B category of personality disorders.

Both, they have the same personality structure.

They share low agreeableness and poor conscientiousness, so they are impulsive.

They both have unstable relationships and poor emotional control, and they are both personality styles that act out, but in different ways.

So where the borderline dynamic will tend to use emotional escalation as a lever to move others, the antisocial personality, which are usually then male, they will tend to overt aggressive tactics, acting out aggressively.

And the reason why this comparison is so interesting is because our attitude towards them are so different and our treatment guidelines are so different.

So The borderline personality disorder, with them, we focus on the pain they experience.

The diagnostic criteria describe how she feels.

Does she feel chronically empty? Does she feel anxiety? Does she hurt herself? Does she suffer an unstable sense of self? And so on.

This is all code for heightened neuroticism.

With the antisocial man, however, we define him by the damage he causes.

Does he lie? Does he break the law? Does he act out aggressively? Does he exploit others? And so on.

And if you've been around a borderline woman, I have been around many.

And I know most of you guys have too.

You know she does all of these things.

But it is not black on white in the diagnostic criteria.

So you see the different attitude right there.

And what's so annoying is that with him, emotional intensity is... never confused with compassion or empathy for anybody.

And so the reason I established a comparison is not to excuse the antisocial male, like the male sociopath, but it's to say, why don't we establish the same type of treatment guidelines for the two? With antisocial men, we are remarkably clear-eyed about what's achievable, about their prognosis.

We approach the therapeutic expectations with caution.

Very few people believe that if you reduce their inner suffering, their behavior will change.

Instead, we try to shape their behavior through external constraints and incentives.

And then we leverage the resources offered to them to encourage employment, to insist on legal accountability, for example.

And then we treat the problems of the inner suffering.

For them, it's very common with substance abuse.

We treat that separately.

We say that is also important.

We don't think that when we treat the substance abuse, the aggressive behavior and the manipulation and the stealing and the criminal acts, that will be corrected automatically.

And what we never do is excuse his behavior unless he's an immigrant.

We've started doing that, shockingly, because he had a difficult childhood.

But modern psychiatry gets completely lost in trauma narratives when it comes to borderline patients.

It's not about being dramatic.

It's about a nervous system that learned early that love isn't safe.

I think part of the problem is that we sit there with the crying female, usually young, usually very attractive.

And we don't look past her tears.

We don't see the lives of the husbands, the children who are crying.

where the house is governed by her immediate emotions.

We don't see the parents who've spent a lot of money helping her out.

We don't see the sisters who have never been heard because it's always been about her.

We don't see the co-workers who've had to endure years of bullying.

What we choose to see is, okay, fewer emergency visits.

If we did, then we would equate treatment with improving social functioning.