Mclean Hospital

Podcast: Boys Have Borderline Personality Disorder Too

July 10, 2019

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Today, Trevor is joined by Alan E. Fruzzetti, PhD, director of McLean’s 3East Boys Intensive Program, to discuss gender as it relates to borderline personality disorder (BPD).

Alan talks about the differences in how BPD presents itself in men vs. women. He also notes that there is work to do in the clinical community to guide thinking about the occurrence of BPD in young men.

Episode Highlights

  • Trevor and Alan discuss the creation of McLean’s boys dialectical behavior therapy (DBT) program (05:37)
  • Alan shares that 20% of male inmates in Swedish prisons have BPD (18:58)
  • The two delve into Dr. John Gunderson’s impact on DBT and examine how males who seek treatment for BPD actually show less aggressive behaviors (40:18)

Relevant Content

Episode Transcript

Trevor: Welcome to Mindful Things. How’s everybody doing? On today’s episode, we have Dr. Alan Fruzzetti, Program Director for our 3East Boys Intensive Program and talk about that program, and specifically boys struggling with borderline personality disorder, something that I can relate to, and it was a really good discussion. Okay, let’s get to our interview with Dr. Alan Fruzzetti, I hope you enjoy.

Alan: Well, let’s see, I come in at 7:30, I usually try to answer mail, catch up what happened overnight in the program, remoralize the evening staff. Our program starts at 8:30, we have a community mindfulness with staff and residents. And then from there, it depends, some days I’m doing supervision, some days more administrative stuff in the morning, sometimes I’m teaching. Over the course of the day, I will also, on Mondays, for example, I run a parent group for two hours.

Trevor: Is it specifically parents of boys that are in the program at that time? So, boys are in the program, and then their parents come for a weekly meeting?

Alan: That’s right.

Trevor: Is it a general session? Or do you go to each parent and update them on what is happening specifically with their child?

Alan: Neither. We’re actually teaching them parent skills, and they’re practicing those things, and then they’re bringing their practice to either say, “Woohoo, it worked,” or “Help me, it didn’t,” and we teach new skills every week.

Trevor: This question is clearly me projecting, but do you find a lot of resistance from the parents?

Alan: No.

Trevor: No?

Alan: No. Actually, they’re eager, mostly, to learn, and willing to try. They know that it’s most likely to be helpful if they could do something different. What they’ve been doing hasn’t worked.

Trevor: Yeah, I guess that is a component of it. You get to a point where they’ve tried everything—

Alan: Yeah, exactly.

Trevor: So, anything new, you’re willing to—

Alan: They’re willing to give it a shot, yeah.

Trevor: And this isn’t a criticism, but I understand that feeling. When I came in here and did the program, and they diagnosed me and told me I had borderline, “What do I do?”, and they’re like, “DBT,” and I didn’t even think about it, I just dove right in.

Alan: Right.

Trevor: And so how long do those sessions go on for?

Alan: Well, we actually have a two-day jumpstart for the parents, two full days, which we do. And then they have weekly, for two hours a week, and they have family therapy, as well, as long as their son is in the program. And then we encourage them to continue to call in to the parent group, even after that, for a while.

Trevor: So, you’ll have a parent group going on, and then previous parents will call in?

Alan: Yep. They’re in the group as well, just on the phone instead of in the room.

Trevor: That’s not uncomfortable to the members that are there?

Alan: Not at all. This way, we have a range, they’ve got some ... some of the parents, when they start out, they think, “Oh my gosh, this is never going to get better, it’s been so awful,” and then they hear parents that, you know, two months ago, three months ago, four months ago, they were in exactly the same situation, and things are much better now, it gives them some hope, and parents can share some of the things that have worked, and provide some encouragement for each other, which I think is at least as helpful as hearing it from me.

Trevor: Yeah. Were the parent meetings, right away, included in the start of the program? Or was that something that your team and you discovered that you had to implement?

Alan: No, working with parents has been an important part of the program from the very beginning. It’s very clear when we’re working with kids, teenagers included, that the parents provide a very important social developmental context for everything they do.

Trevor: Yeah, that was not the case when I came up in the ‘80s. The only time the parents were involved is when they had to be accused of something, and then you had to go home to your parents, where you just had adults that you talked to in secret, and your parents are like, “You just accused us of ...” yeah, it’s fun times.

Alan: Yeah, I think that would be a much more conflictual way of going about things.

Trevor: Yeah, the ‘80s, they were a good time. And that was progress, compared to when it was in the ‘50s and stuff like that.

Alan: Sure, absolutely. Absolutely true.

Trevor: At least there was counselors for us at school.

Alan: Right.

Trevor: So, describe to me, in general terms, exactly what the program is and how it started.

Alan: McLean developed a program for teenage girls who were chronically suicidal/self-harming, most of whom also meeting criteria for borderline personality disorder, almost 12 years ago. At the time, that was a very innovative thing to do, built around dialectical behavior therapy, and it was quite successful. They started with a smaller number of beds, and grew, and just had a lot of success.

As recently as 12 years ago, common myth was that 90% or more of people with borderline personality disorder were women, or girls. And more recent science is pretty clear that men and women, boys and girls, have BPD at about the same rates, pretty close to 50% on both. So, it became clear, as more and more parents of teenage males started calling, “Well, don’t you have a program for boys?”, that maybe it was time to organize a parallel program, in some ways, that would be largely overlapping, but might also include some different things because boys and girls do have some differences.

And so I got recruited to come and get the program up and running. We had some problems with the neighbors for a while, because they didn’t want to have boys with these kinds of problems in their neighborhood, but we opened it up.

Trevor: So, people who own property in the surrounding area, they didn’t want, not specifically boys, but anybody? Or was it boys?

Alan: Well, I think it was boys, more—

Trevor: If it was women with BPD, it might be a different story?

Alan: I think it might have been because much of the language in their complaint was about males, and most of it was, from a science perspective, not accurate.

Trevor: So, they had no data to back that up?

Alan: No, absolutely not. In fact, an interesting fact is that boys with borderline personality disorder, and men, actually have less aggression than boys and men who don’t have borderline personality disorder, so they’re actually a somewhat more peaceful group. And so we’re talking about a group of guys who are chronically suicidal and self-harming, and really struggling. They’re not harming other people.

Trevor: Yeah, I can be honest, I mean I think everybody’s had, so angry at somebody, the urge to be like, “I want to do something, but I can’t because I know better, and I’m a person who loves things,” but the irony is that me, myself, with BPD, I’m so far quicker to self-harm and suicidal ideation than I would ever consider harming something else.

Alan: Right. Well, that’s really typical.

Trevor: I mean it’s really fast how I can go there.

Alan: Sure, and that’s true for girls, too, I don’t want to leave that hanging.

Trevor: Absolutely.

Alan: But for boys, as well. This is just not an aggressive and violent group. But, anyway, the—

Trevor: How did they win that court case?

Alan: Well, you have to talk to our lawyer to understand the legalities of it, but McLean is appealing it, in the meanwhile, that’s going to take a long time, so we’re up and running, we’ve been up and running for two and a half years—

Trevor: In a different location?

Alan: Here on campus and have been really quite successful.

Trevor: What would have been the benefits of being off campus?

Alan: Well, we would have had room for twice as many kids.

Trevor: Oh, that’s a big deal.

Alan: That’s a big deal. Also, it was on a piece of property, there was room to run around; it’s not quite as easy here on campus, there’s no ball field or anything like that to go out and get some exercise, but we’ve compensated for that. We go to the Athletic Club every day, and we get outside and go for walks or play Frisbee. We find a way to compensate, and it’s actually been quite okay.

Trevor: We talked about this yesterday. I asked you, I think probably too pointedly, how good are the results for this program, thinking that it would be half and half, but you said that the program’s doing really well, and you’re seeing positive results, for the most part, not across the board, but for the most part.

Alan: Absolutely. It’s very important, well, in all services that are provided, but certainly in mental health services, to evaluate. It’s one thing to have an impression, “Oh, I think these kids are doing well.” It’s another thing to have data, because we all have our biases. And so, we’ve been collecting data from the get-go, and the vast majority of the boys who have come through our program are discharged to a less restrictive environment, and are doing quite well, either much less or not suicidal at all, have stopped self-harming.

If they’ve gone back to school, we’ve had a lot of kids who had not been able to attend school for six months or two years, and they’ve gone back to school successfully, or engaged in other productive activities, getting a job and so forth, gone back to live with their families, or being able to, for the older teens, start college, and live in a dormitory successfully and independently. We’ve had a relatively small number of real treatment failures, or drop-outs, very, very few, you can really count on one hand.

Trevor: That’s amazing.

Alan: Yeah, it’s been really good. Now, we have to find some money somewhere, because it’s hard to do without somebody paying, so we want to follow up people for a longer period of time. We don’t know what happens two years down the road, five years down the road, and of course that would be nice to know. But we know that at discharge, and at least for six months, which is getting a good start, our kids are doing well when they leave us.

Trevor: That’s great. I could tell you right now, my high school years were, as it is with a lot of kids, but definitely in my case, were very, very important formative years. I still hold on to those years. There’s a lot of regret involved in those years because I constantly think about how different it would be if I had DBT when I was 14 instead of 35, and how different my life would be if I not only had that, but also it was during a time where, and I’m not saying right now it’s great, the stigma’s real heavy, but it’s getting better. But back when I was coming up, if you were seeking mental health services, I mean ...

Alan: The options were few and far between—

Trevor: And the assumptions were ugly.

Alan: And the assumptions were ugly, the stigma was enormous, and if BPD was the problem when you were a boy, nobody ever even would consider good BPD treatment.

Trevor: Why?

Alan: Well, there are a number of reasons why boys, historically, they’ve received hardly any treatment for BPD.

Trevor: Let’s explore this.

Alan: Yeah. So, one reason is this misconception that BPD is primarily a female problem, not a male problem.

Trevor: Where did that misconception come from?

Alan: Well, this is the self-fulling prophecy misconception. So, because the only people who seek services with me with BPD are women, only women must have BPD. But, of course, if we don’t invite men to seek services, we don’t offer a program for them, of course they’re not going to seek our services. And then, of course, the internet, which is full of both very useful and very damaging things.

Trevor: No. No, not my internet, there’s nothing dangerous on it.

Alan: Yeah, sorry to burst your bubble.

Trevor: Nothing toxic on there.

Alan: No. Of course, if you were a male struggling with these problems would never say, “Gee, maybe you’ve got BPD.” They would say, “Well, tough it up. Just knock it off.” Very invalidating, as though somehow … “Gee, I’m dyslexic, I have trouble reading.” “Well, try harder. Well, get to work, come on, you’re obviously not trying.”

Trevor: I was literally told these words: “We all go a little crazy sometime.” And I said, “What movie did you steal that from? That doesn’t even sound real.”

Alan: Yeah, what does that mean? I don’t know what that means.

Trevor: Yeah, and that was one that I got.

Alan: We all struggle sometimes, certainly with our emotions, that’s true, everybody does.

Trevor: Sure. But it was so dismissive, the way ... “You’re going through something everybody goes through.”

Alan: Right.

Trevor: Really, everybody goes through this? Because this is horrible.

Alan: Right. So, some of it’s that self-fulfilling prophecy bias. Some of it is because males seek mental health services, in general, at lower rates than females.

Trevor: And that’s still the case today?

Alan: And that’s still the case today. Although, recent evidence says that it’s narrowing, which I find to be very encouraging. Even with BPD—

Trevor: Is it narrowing across the board, age-wise? Or is there specific age groups where it’s ...?

Alan: It’s starting with younger people.

Trevor: Yes, okay.

Alan: Our younger people just seem to be less stigmatized and less stigmatizing. They have friends who are struggling, and they say, “Get help.” They don’t say, “Knock it off,” including boys, they’re more educated, they’re more flexible. I think some of these virtues our young people have are boding well for the future. So, that’s been a change. How that happened, I’m not sure, but it’s clearly happening.

We also have a bias among mental health professionals. We know, for example, that if you describe a person with male pronouns, and you describe the problems of BPD, and then you use the same description, word for word, but use female pronouns, and then you ask, “Well, what are the diagnoses you’re considering?”, you’re much more likely to get BPD with the description that includes female pronouns and much less likely to get BPD with the very same description that includes male pronouns.

So, practitioners have these built-in biases as well, which also means that, gee, your average primary care physician, your average therapist, psychiatrist, social worker, it’s not been on their radar to look for BPD in boys and men. I don’t mean this critically. They weren’t trained to do it. They were given inaccurate information about rates. If someone is 5% rate, you don’t look for it very much. But if something’s 50%, “Whoa, whoa, BPD is 50%, half of people with BPD are men? Well, huh, you’re struggling with your emotions? Well, let’s think about this, maybe this one fits.”

Trevor: What are the BPD rates among boys, right now, in America? Do you have any numbers for that? Boys from however age to 18.

Alan: That’s an impossible question to answer because—

Trevor: Yeah, I figured.

Alan: There are still many mental health professionals that think you can’t diagnosis BPD before 18, which isn’t true; our diagnostic manual is very clear that you can. But I would say that probably the vast majority of mental health professionals think you can’t give a BPD diagnosis to boys or girls before they’re 18 years old.

Trevor: I’m getting upset. Can you see how upset I’m getting? I’m getting very upset.

Alan: Sure, because it then keeps people from getting the treatment they need.

Trevor: Absolutely. Right, absolutely.

Alan: Yeah. So, we really have poor epidemiological data for both boys and girls before 18. Above 18, there’s some disagreement. It used to be thought that BPD was maybe 1, 1.5% of the population, but some pretty good epidemiological studies have shown that it’s probably higher than that. So, now, I would say current thinking would say it’s maybe 2, maybe even up to 3% of the population, so that’s a lot of people.

Now, of course, like any set of problems, they could be more severe or less severe. So, as we expand the pool and say, “Well, maybe it’s 3%,” that’s going to include more people with less severe problems; if we say, “Well, it’s 1.5%,” that’s going to be almost entirely people with pretty severe problems.

Trevor: Wow. So, how do you go about updating or informing the clinicians that this is a diagnosable condition? Do you have to hold conferences, do you have to write letters or emails, or do you have to just wait until they retire, and the new blood comes in?

Alan: I love your list. I think it’s all of the above. And I think because there are going to be some recalcitrant people who, no matter what the data say, they’ve known this their whole professional life, they’re not going to change. But most people, I think, when you put it in front of them at conferences, and you publish good data, “Oh, look, look at this, we just showed that we can treat teenage boys, gee, with BPD, successfully,” “Oh, boy, boys have BPD? Oh, that’s interesting,” I think people will start to take notice. An interesting study got published recently, a guy in Sweden looked at consecutive incarcerations—

Trevor: Yeah, I wanted to talk about this.

Alan: Into Swedish prisons and showed that 20% out of a large number of consecutive incarcerations actually were men who met criteria for BPD, so they were being sent into the prison system instead of into the mental health system.

Trevor: 20% of men—

Alan: In prison.

Trevor: In the prison system in the United States—

Alan: Well, this was in Sweden.

Trevor: I’m sorry, in Sweden.

Alan: But we have no reason to think it’s particularly different here.

Trevor: 20% male inmates, BPD.

Alan: Likely are BPD, that’s right. Almost none of whom, there are a couple of very progressive places in the country, but only a couple, two or three, in all of the others, they will receive no services.

Trevor: So, how do you combat that?

Alan: Well, I think with education.

Trevor: But how? Do you have to go to these prisons and ...?

Alan: No, this is a political issue—

Trevor: Really?

Alan: I think, first and foremost. If you think about it, if you ask the average person on the street, “What’s the purpose of a prison?”, what do you think the answer is?

Trevor: Well, I have two answers to this, is, one, to protect the public and to have a place where criminals pay for their crimes, whatever they’ve been found guilty of. That said, since the prison system is mostly privatized, 20% of the population, if they were suddenly released to treatment, that’s a big chunk of change from whoever owns that prison.

Alan: Right.

Trevor: Am I on the nose there?

Alan: You’re identifying some of the disincentives to identify these things, absolutely.

Trevor: Money, there’s money to be made off of people with BPD in the prison. Well, that’s just great.

Alan: Well, and it’s also the case that people don’t think about prisons about being rehabilitative very much anymore. There was a time when at least many people would say, “Well, prisons are to protect the public.” I don’t think anybody would disagree with that, and then, of course, when people commit crimes, there’s a certain consequence, you have to pay for your crime.

Trevor: Absolutely.

Alan: And I think most people would agree with that. But beyond that, okay, so given that, in that context, when someone’s going to be released, and the vast majority of prisoners are eventually released, do you want them to have been punished, or do you want them to have been rehabilitated?

Trevor: We want them to be rehabilitated. I imagine whoever owns the prison wants them to relapse so they end up back into the prison system, that’s my guess.

Alan: That’s a very cynical answer that probably has some truth to it. But I’ll give you some facts.

Trevor: Sure.

Alan: So, for example—

Trevor: And, yes, that was a total guess on my part. What I just said, folks, was not rooted in any statistics whatsoever. Alan was correct, it was very much rooted in my cynicism; for that, I apologize. Please.

Alan: Well, and it may well be true, in some cases. But I think there’s a political argument here. For example, there was a meditation program, so now we’re not talking about treatment for BPD, we’re talking about just meditation for prisoners, and these were hardcore prisoners who had done really ugly, nasty things, who weren’t going to get released anytime soon.

And this meditation program was completely voluntary, and the people who participated showed enormous growth and change. The incidents in the prison, the fights in the prison went way down. These men tried very hard to make amends to their victims, wrote letters and so forth. And, actually, a subset of them, anyway, really liked this meditation program.

Well, when word of this got back to the state legislature, which had funded this pilot program, this was not Massachusetts, the state legislature said, “These guys don’t deserve to have a good life, so we’re not going to allow this program to continue. They should be suffering. They shouldn’t be having a better life in prison.” So, there’s a kind of vengefulness around this. And I think that’s some of the difference, also, that’s gendered, to some extent.

I often use the example that a high school student who is really struggling, and let’s say the paper was due yesterday, and I didn’t get it in. But I stayed up late last night and finished it, and I bring it in today. And I bring it to the teacher and I say, “Okay, I know it’s a day late, but I did finish it,” and the teacher says, “I’m sorry, I was very clear, I won’t accept late work.” Which, of course, is completely reasonable, right? Totally reasonable.

Trevor: Absolutely, you need to learn deadlines. You have to.

Alan: And, understandably frustrating, right?

Trevor: Sure.

Alan: And so imagine that a 16-year-old girl hears this, and, I won’t do it because I don’t want to make a big sound, but kind of pounds a little bit on the table, says, “I can’t believe you won’t take it,” and pounds on the table, “I can’t believe that, I stayed up until 3 in the morning to finish this, and oh my gosh,” and the teacher, maybe somebody walking by in the hallway, what they’re likely to do is stop and say, “Okay, what’s the matter? What’s going on? What’s the matter?”

But if it’s a male who pounds the table and says, “I can’t believe you’re not doing this, I can’t believe you’re not accepting my paper,” the person walking by may say, “Hey, back off.” See the difference? One recognizes there’s distress, the behavior might be tricky, right, I don’t want anybody slugging anybody, but our gender bias gets us to see, okay, girl, a 16-year-old girl might need some help, emotionally, but the 16-year-old boy just needs to knock it off, isn’t supposed to have those strong emotions.

Trevor: Well, I want to take it one step further. I don’t even know if it’s so much strong emotions. It’s the way that I think society views vulnerability. Vulnerability, and I’m not making a crass generalization, but I have found that vulnerability in men has been mostly frowned upon, in my experience. I’m vulnerable and emotional all the time, that’s why I have BPD and NPD and extreme depression—

Alan: Right, it’s emotion vulnerability.

Trevor: My emotions are always up. And I’ve seen that that has elicited more fear and confusion from people than it ever has compassion, where if I’ve seen that same behavior from a female, I’m not saying that the result was always positive in their favor, but more often than ... for me, it was, and it never at all made me angry with women, it just made me angry at, “Well, this person’s vulnerability is more accepted than mine.”

Alan: That’s right. And you’re pointing out, I think, a pretty well-documented gender difference. And, of course, the solution isn’t to be less compassionate towards women, it’s to be more compassionate towards men.

Trevor: And to be more compassionate to men, do people feel threatened by that? Just the idea of being more compassionate towards men, do people think that that is going to make men weak or weaker if we show them compassion? I think it is.

Alan: Well, I think you know that we’re in the middle of a cultural, I don’t know if it’s going to be a transition, but it’s certainly an upheaval about masculinity and what it means, the different kinds of masculinity. We have terms like “hyper-masculinity” and “toxic masculinity” that some people think are useful because they’re describing certain behaviors that probably are problematic for other people, but other people who push back on that, saying, “Oh, we’re just trying to neuter men, make everybody androgynous.” I don’t think that’s true, but there’s kind of a culture war going on around this. And this cultural upheaval, who knows where we’re going to land?

If you think about it, I don’t know if you’d agree, but maybe pose this to you. So, if you think about how ... I don’t know how old you are.

Trevor: I’m 43.

Alan: All right, so if you go back to your youth, and you think about 30 years ago, there was still ... you probably have to go back 40 years, but nevertheless, if you think about—

Trevor: ‘79.

Alan: What the range of ... to be a female, a teenage girl, what was the range of acceptable ways to dress and act, compared to today?

Trevor: I was really young then, but dresses, skirts, and if you wore pants, bell-bottoms.

Alan: Right. So, I would argue, and I think that there’s some sociological research to support this, that the women’s movement, and other factors, have been very successful in expanding the definition of what’s acceptable for women.

Trevor: What’s an acceptable wardrobe and attire.

Alan: Not just wardrobe, but ways of being in the world. Women are now in jobs that they didn’t use to have and perform quite satisfactorily. That was probably ... It’s obvious to us today, but in the 1950s and 1960s, it wasn’t obvious to the majority of people. So, the ways that one can be, as a female, that are acceptable are much broader. There’s many more opportunities. I would say that for boys, we have to go back, it’s more like what it was for girls, 40 or 50 years ago. The range of acceptability is still pretty narrow.

I think about one of my, I have four kids, and one time, I don’t know, we were at some fast food place, and my son had gotten whatever the kids’ meal was or something, and he wanted whatever the toy was, I think this was a Beauty and the Beast, they had the Beast and they had Belle, and he wanted Belle. And the person behind the counter said, “Well, you can’t have Belle, that’s the girl toy.” It’s like, “Well, geesh, he wants ... I don’t know why that’s a girl toy, but if that’s what he wants, I mean what’s the big deal here?”

Trevor: One thing I’ve heard the majority of my adult life, ever since I was old enough to have a drink is, “Oh, that’s a girl’s drink.” Yeah, they’ve actually gendered alcohol. And I’m like, “Well, okay, whatever, I like that drink, it tastes good to me. Whatever, it’s a girl’s drink, okay, whatever.” What world do we live in?

Alan: Right. So, all these things contribute, I think. We obviously have stigma for people with any version of mental health problems; across the board, there is stigma.

Trevor: Absolutely.

Alan: And then certain pockets of stigma are greater for certain kinds of problems. The people where it’s harder to understand, people get more scared by, and one of those pockets is, and sometimes it’s women or girls who are more stigmatized for certain things, but in this particular case, with BPD, it’s boys.

Trevor: Really? If the changes in women, you say 40 years ago, my guess is that a lot of that influence came from, I don’t know what wave it was, but the first or second wave of feminism that came through the 60s and 70s. Is there any kind of movement men could have that would not come across as ...?

Alan: Misogynist?

Trevor: Yeah.

Alan: This is the great question that we have to figure out an answer to: how to be trying to be very helpful to young boys without being against young girls, without being misogynist. I think the gains that women have made, that we’ve made for girls, are fantastic, and Heaven forbid we should roll those back. That doesn’t mean that we can’t create similar gains for boys around things like being able to express their emotions accurately. How to do that is a tough question to answer.

Trevor: Well, I mean, I think having programs like yours is ... But the whole point is not to—

Alan: But these poor guys have to get to a pretty severe point before they’re going to come to a program like ours.

Trevor: Right, exactly. Yeah, that’s a really tough question. One thing we talked about yesterday is how emotional dysregulation can be biological, which I think is somewhat the case with me. I think I’m a perfect storm of biological, how I was raised, situations I just fell into, the era that I grew up in. But there can be people that are born with vulnerability, but, as you said yesterday, if they’re matched with the right parents, if they have compassionate parents, it could go positive for them. But for a lot of the times, that’s not the case.

Alan: Right. This is tricky, this issue of emotional vulnerability. I think we have to finish the phrase: they’re vulnerable to what? What are they vulnerable to? Let me give you a completely unrelated example. So, somebody might be born in the Caribbean with a disorder, something like urticaria, where if they’re in cold water, they will get hives, their throat will swell up, and it could be very serious, kind of an allergy to the cold.

But they live in the Caribbean their whole life, nobody ever knows they have this preexisting vulnerability to something. They’re lucky, right. But if they grow up in Manitoba, Fairbanks, or Boston in the winter, pretty soon you realize, in certain situations, what is clearly, in that case, a biological vulnerability gets expressed, and then you have to do something about it.

Now, I think we tend to think about mental disorders in the same way. But the evidence doesn’t really support that so much, those models have not held up well under scrutiny. Our models of vulnerabilities are more like vulnerable to certain kinds of social responses. For example, let’s imagine that I’m a very sensitive kid, emotionally, and you’re my parent, and you’re just not that sensitive, perfectly normal, but just not that sensitive.

So, when I start saying, “This thing happened, I saw this thing on my way home, these people were arguing, I could hear them on their porch, and it was really upsetting to me.” And you’re not a sensitive to person, you say something like, “Well, why don’t you just mind your own business? Why are you listening to other people’s arguments?”

But if you were a sensitive person, you’d recognize I didn’t have any choice. I’m like the magnet for other people’s emotions. I receive them, and so I’m sensitive to getting upset, but maybe you help. But if you’re a very sensitive person yourself, you not only recognize that I’m this magnet, but you actually help me manage it so that I’m less and less of a magnet over time so I don’t get so overwhelmed by other people’s things that actually don’t have anything to do with me.

So, it’s more like I’m vulnerable to getting invalidated, and that invalidation, that not being understood, not only is the validation itself painful, right, when somebody says, “Well, you shouldn’t feel that way,” nobody likes that, but it also means that you don’t get the help you need. And so what happens is kids who may not be born ... there’s no evidence that you’re born with a vulnerability to BPD, per se, but there certainly are genetic substrates around things like impulsivity, and affectivity, that have a piece of genetics in them.

But there are lots of impulsive people who don’t have any mental health problems, lots of people who have a lot of emotion, but don’t have any mental health problem, like artists and therapists, for example, who may not have any mental health problems at all. So, those things aren’t bad things, they’re not problems in and of themselves. They are problems if the person has learned to be ashamed of them and hasn’t learned how to manage them.

Trevor: I relate to that, totally. That’s—

Alan: So, it’s this much more idiosyncratic, tiny, step-by-step process over time. It’s a little bit like if you have a baby who’s sick. It doesn’t take that long before the parent is stressed, but if you have a parent who’s stressed, it doesn’t take very long for a baby to also be distressed. So, they’re influencing each other. Now, by itself, those things could be very time-limited, but if you’ve got a mismatch of the child and the parent, temperamentally, say, for example, there’s never any relief. They just keep fueling each other in a more negative way. They may be very nice, other things. It’s not like they can’t be lovely, other pieces. It’s just that from an emotional development standpoint, there’s not as much help as that child might need.

Trevor: Do you think parents that are involved with their child that they’re trying to help them or raise them? Do you see that, specifically with boys, they’re raising them to face maybe the logistical realities of the world, you know, obey the law, get a good job, these things, but there is a lack of emotional development for the emotional realities of the real world?

Alan: Right. Well, we see this in a multi-layered way. By the way, this does not mean this is the way in every family, for Heaven’s sake, but we see that parents are more attentive to their girls’ emotional development than they are their boys’ emotional development, on average. But then what happens is it gets exacerbated because now you’ve got, say, school-aged children, or middle school-aged children.

So, maybe the boys didn’t get as much help about managing their emotions from their particular parents, but now their peers, the other boys didn’t either, there’s not much peer help with this. Whereas, a girl who had parents who maybe weren’t so helpful emotionally, now she’s 11, 12, 13, her peers are actually emotionally skillful, and she can get some of that help from her peers. So, it’s the second layer. And then, of course, if you get a little older, then you have the outliers, girls and boys, and now it starts to look a little different.

Trevor: In a deidentified way, besides the first example of the home you tried to build for the boys and the neighbors pushing against it, what pushback have you gotten, specifically with your approach to treatment and this program?

Alan: We really haven’t had a lot of pushback. We’re doing a treatment that has the best data for treating these kinds of problems, and therapists who are certified to do it, who do a good job with it. So, actually, I think, in general, there’s been a lot of support, not only from within the hospital community, but from parents and people, other professionals. I think they’re very supportive of a program like this.

Trevor: And you used to work with Dr. John Gunderson?

Alan: Dr. Gunderson, of course, was a very key/central person, not only here at McLean, in terms of development of programs for BPD here at McLean, but really understanding BPD and making BPD something to be understood instead of vilified in the professional community, and he had a role, certainly, in the idea of developing a boy’s program.

Trevor: I’ve never met Dr. Gunderson, and he passed last year, which is very sad, but he is still, even in death, a rockstar to me, like I—

Alan: Yeah, and appropriately so.

Trevor: Yeah, I don’t want to use the “idolize,” but I really ... if he had a baseball card series, I’d collect them all, like that’s how I feel about him. And I’ve seen video of him talk, and he was amazing.

Alan: Absolutely. Real inspiration. Fortunately, he had a big positive influence on so many people, professionals, patients, families.

Trevor: I want to start wrapping up, but there’s something that you said yesterday that I want to talk about real quick to assure people who may be listening that think that they may have a child with BPD, or a relative, or a loved one, or maybe themselves, the data that supports that BPD is, in fact, treatable.

Alan: Absolutely. The data from both dialectical behavior therapy and another treatment, called mentalization-based therapy, are very good. I know the data for DBT better, so I’ll say, for example, in good DBT, and, of course, like any treatment, there’s better and worse treatment, and people who are well-trained in doing the treatment in a faithful way—

Trevor: From personal experience, I want to underline that, he said “in a faithful way.” DBT works when you are absolutely committed to it. And I can tell you, from the moment where I wasn’t committed to it, the moments where I was like, “I need a break from this,” that’s when my life, 100%, always fell apart, always, always, always.

Alan: Yeah, you’re a good advertisement for working in treatment.

Trevor: Yeah, always.

Alan: Because treatment is something that the professional and the client do together. It’s not like getting your tooth filled, somebody’s doing it to you or for you.

Trevor: Once I get back on Mass Health and get insurance, not only am I going to get a therapist that understands DBT, but I want to go back into the DBT program, if I can, just to continue, just to get back into the regular practice of it. But I have my workbook right next to my bed.

Alan: That’s smart.

Trevor: And on really bad days, I bring my workbook with me everywhere I go, and I have certain pages photographed, and in my phone, just in case I don’t have my book, I can go to them real quick.

Alan: Right, but you’re describing what commitment looks like, right?

Trevor: Yeah. I mean I don’t know if it saved me, a combination of things saved me, but it was definitely a key factor.

Alan: But now you’re steering your own life, right?

Trevor: Trying.

Alan: So, the data, I think to grossly summarize the data for dialectical behavior therapy, is that about a third of people who come into DBT either drop out or don’t get much help, at least on the first run. But among the other two-thirds, the vast majority of them do very well, and end up without a diagnosis of BPD, and live a really satisfying, normal life after treatment.

And even the others, the other group, are much more stable. They may struggle, but they are much more stable, and still have a decent life, a life worth living. And I would say the mentalization data are fairly similar, and they’ve done an excellent long-term follow-up showing that those results hang on there for years. So, there doesn’t seem to be a lot of relapse in either treatment, people continue to do well.

And this is very important because on the internet, you will hear people still say that BPD is not treatable. I remember working in a clinic, this was many years ago, when I first started, and I was a young professor starting an outpatient program, and one of my senior colleagues, every time he heard that somebody I was supervising was taking on a patient with BPD, he said, “You have two sessions, terminate the treatment. These people don’t work in treatment. They don’t succeed.” So, I found another place to work because, of course, if you don’t treat them, they don’t get better, of course.

Trevor: Yeah, that’s 2+2=4, right?

Alan: Yeah. So, what Mary Zanarini, who’s done some of the very best longitudinal work keeping track of what happens to people with BPD over time, sometimes says that BPD is actually a good prognosis, diagnosis, I think that’s her term for it. That means a couple of things, but the way I’m interpreting it at the moment, it also means that good treatment’s available and can make a huge difference. By the way, for adolescents, the outcomes are perhaps even better, maybe even higher rates of the success, long-term.

Trevor: It’s amazing. It’s really amazing. You were going to add something?

Alan: Of course, the problem is getting access to good treatment wherever you happen to be. It’s not always available, and that’s, of course, deeply frustrating for patients and for parents and for partners, to have something that’s available but that isn’t available in your city, or your insurance doesn’t cover it, or whatever it might be.

Trevor: I can’t tell you how lucky I was. I mean I literally lived five minutes down the road, I was 35, and I was having the breakdown. I remember staring at a huge tree trunk with my foot on the gas, just looking, and I took my seatbelt off—

Alan: So awful.

Trevor: And was just staring at it. And the fact that I had no inclination to take it out of park, but I was staring, I was looking at it, I was entertaining this possibility.

Alan: Yeah, it’s awful.

Trevor: And little did I know that the best mental health hospital in America was five minutes down the road. I didn’t know this.

Alan: Right. But somehow you found your way.

Trevor: I did. Because ever since I’ve been in this program, I’ve learned about people that don’t have access, people in the same place that I am, and they don’t have ... and I attribute luck and people who cared about me—

Alan: Because these resources vary enormously from city to city, from state to state, region to region. And certainly, I would argue, it’s not fair that if you happen to be living in this city that you can’t get access to the care that you need.

Trevor: Absolutely. Like, I’m talking with a friend, and she’s convincing me, she’s like, “I think I want to move to somewhere quieter, and I think we should go together,” and I would like that, a lot, I want to be in a quieter place, but, no, because I need my resources, I need them.

Alan: Right. Well, and to illustrate your point, in our program, we get teens from actually all over the world, not only from the Greater Boston area, actually some, but in the Northeast part of the United States, but also from the South, and the Midwest, and the West, and from many other countries, so it’s not just in the United States that this is a problem.

Trevor: Right. Is there anything else you want to add before we wrap up? Anything we missed?

Alan: I don’t think so. I think we’ve covered quite a bit. I guess the only thing I would add is if it’s not clear that this is a time in our history to be more hopeful, we’ve really learned a lot and can help people more than we used to be able to, and with that, hopefully, stigma also goes down, because when your friends and neighbors and cousins hear that you’re struggling, hopefully they can say, “That’s so hard, I’m really sorry. Have you found a treatment program?”, instead of “Knock it off, just toughen up a little bit.”

Trevor: I mean, if people don’t believe there’s a stigma, I’ve said this before on the episode, I’ve been in treatment for almost eight years, I am the host of a podcast for the most reputable mental health hospital in the country, and my parents still don’t know about my condition.

Alan: Wow. Yeah, that does say quite a lot.

Trevor: Yep. So, don’t say it doesn’t exist, because it really does.

Alan: I work with parents, and we have a funny saying: when you take your teen to the hospital, and the teen has, let’s just say, a broken leg, or Heaven forbid, has leukemia, or some other medical malady, and the kid’s in the hospital, and then you bring the kid home and there’s this casserole brigade, right, people, cousins, and aunts and uncles, and neighbors bring food, and they leave little notes of support. And they take their kid to the psychiatric emergency ward, and the kid ends up in a psychiatric facility for a couple of days or longer, and then bring the kid home, there aren’t any damn casseroles.

Trevor: Yeah, where’s my casserole? Come on, I love a good casserole.

Alan: That’s the expression. So, the parents, they get this, “We get no damn casseroles.”

Trevor: Yeah. Even my friends that were compassionate and understanding, telling them, it was still ... you couldn’t hear a pen drop, cliché, but ... I’m sorry, you could hear a pen drop, silence.

Alan: Right.

Trevor: Yeah, it’s fascinating. Thank you very much, Alan, I really appreciate you coming, and this has been really great. I was really invested in this subject, obviously, and you helped me understand a lot of things, and hopefully you helped a lot of listeners as well.

Alan: Wonderful. Thanks for inviting me. It’s a pleasure to do this and try to get some of this information out.

Trevor: Thank you so much.

All right, what did you think of that? We really enjoyed Dr. Fruzzetti. It was nice to talk about borderline personality disorder and DBT with him. Those are things I kind of know a little bit about. I apologize, Dr. Fruzzetti, that I’m not a little more energized or chipper. I wish I could have knocked it out of the park with the intro and the outro, but I also believe to not sugarcoat these intros and outros.

The average person might not find this very professional. I hear you. Those that suffer from depression or are mentally ill, well, you’re my brothers and sisters, and you get it, and I don’t know if there’s anything positive that can come from it, I guess. You can at least understand that, I don’t know, I don’t know. Is it okay for me to say, “I don’t know”? Is that acceptable? Because I don’t know acceptable. I don’t know.

We will be back in two weeks, that’s a promise, because I’ve already recorded the episode, and it’s a good one. I think so. So, I will see you in two weeks. And I’ll be fine. And, hopefully, anybody out there that’s feeling what I’m feeling, hopefully you’ll be fine, too. See you in two weeks.

Thank you for listening to Mindful Things, the official podcast of McLean Hospital. Please subscribe to us and rate us on iTunes or wherever you listen to podcasts. If you have any suggestions for special topics or future guests, email us at And don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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