Dimensjonal forståelse av personlighetsvanasker, del 1

Problemer med den tradisjonelle diagnostikken har ledet mot et paradigmeskifte i vår forståelse av personlighetsforstyrrelser. Vi spør: Hvordan ble den nye modellen utviklet, hvordan kan den anvendes og hvilken betydning har den for hvordan vi møter mennesker med personlighetsproblemer? I denne episoden intervjuer vi den amerikanske forskeren og psykologen Donna Bender, som var helt sentral i arbeidet med den alternative modellen i DSM-5.

Personlighetsmysteriet produseres av Nasjonalt kompetansesenter for rus-og avhengighet, alvorlige samtidige psykiske lidelser og personlighetsforstyrrelser

Transcript

Kjetil Bremer: 0:06

Personlighets misteri en jag podkast och vi utforskar personlighet som mer tröbbet sider. Personlighet är nog vi alla har, och du var mer eller mindre på lagms jag lämvård liv. Ingen har en totalt urför personhet. Så personhet bris sopps till brö för oss. Att man är för att lev ett obliv. Da kan man ha en personligt förstyrelse. Vi är really a plejord to have you here, Danabänder för en intervju i vår podcast. Det är allst podcast en English, så we bit excit och nervös.

SPEAKER_00: 0:50

How exciting för mig to. Thank you för. Jag really appreciat it. It is uh quite something to be here with you both today.

Kjetil Bremer: 0:58

Nice. I have a little introduction of you first, and then we just go into the questions.

SPEAKER_00: 1:05

Sounds good.

Kjetil Bremer: 1:06

Uh Donna Bender. She's a psychologist, psychoanalyst, clinician. Uh, worked for a long time on personality. She's published a lot in this field. And she is a member of DSM5 Personality and Personality Disorder Work Group. She's a lead author, Level of Personality Functioning Scale, which is a part of the alternative model, which we'll get into in this interview. So welcome.

SPEAKER_00: 1:36

Thank you.

Kjetil Bremer: 1:37

I think we'll start uh going back in time and where it all started. What was the spark that lit your curiosity and launched you into working with the field of personality disorders?

SPEAKER_00: 1:54

Well, um, I'm gonna go way back in time. Um in just uh thinking about this for a minute. When when I was a child, um I was very interested in in people and and what they were thinking. And I would go places with my family and I would look at people and just wonder, why are they doing that? Why did they say that? And my mother would say, stop staring at those people. So so I've been a student of personality, I think, for a long time, trying to figure people out. Um but my my formal involvement um with personality, um, I think from from a research perspective anyway, um, started my first week of my PhD program. Um, and I got my PhD from Columbia University in New York. And I knew that I wanted to very quickly get involved in research in my studies. And so I marched into the office of the chair of the department and I said, Hey, is there any good research going on in this department? And he said, Well, I'm glad you asked. So, in fact, he had been working um for several years already with a colleague at Yale University um looking at the way in which uh people mentally represent themselves and other people. And um, for them specifically, they were also applying it to how this works in um in psychotherapy. And so they had been doing some research on um how do people in therapy think about their therapists outside the session? And so um so I got involved with this wonderful collaboration um and uh worked on that well for for many years I ended up, I mean, that really was was the launching of of me into this field, and and we continued collaborating even um even after I finished my doctorate and I had started on another research project. Um and it was just um it was just so exciting, and we were creating new measures and um and it all made sense and it it actually is the is the core of of this level of personality functioning scale that I think we'll we'll talk a little bit more about today. It was really the inspiration um for for for things that followed in my career.

Kjetil Bremer: 4:28

Was it uh a development of an assessment scale or something that has a name that we can uh look into?

SPEAKER_00: 4:35

Well, the the uh the main instrument that had been developed prior to my getting involved is called the therapist representation inventory. Um the specific assessment um instrument that we were working on in our in our little collaboration um had to do with um different different aspects of these mental representations. And so um, for instance, one of the uh dimensions, so so we would ask people to uh take five minutes describe your mother, take five minutes, describe your father. And then um so so one of the dimensions we were working on was called deillusionment. This is one of the ones I always found so interesting because um folks, folks who have struggles um with, you know, within themselves, around themselves and other people, sometimes see things in black and white terms. And and in therapy, we we try to help people to find the gray, to find the beauty of the gray. Um and this de-illusionment um dimension, it's not disillusionment. So disillusionment is is more of a black and white thing. So de-illusionment was meant to capture sort of active work in this description of, well, there there are some aspects of my mother that I find more difficult. Um, but I I have found that if I think about it and and uh as I've learned more, I've really um come to terms and I see that my mother does have these vulnerabilities, but she also has wonderful things to offer. So so that's sort of the would be the highest level of functioning in on this dimension, is that you you get some understanding that the person has done the work um to uh to find the beauty of the gray, to find more balance, to be able to see the whole spectrum uh of complexity of this special individual.

Kjetil Bremer: 6:58

So um that was your uh doctoral uh work uh researching in this area.

SPEAKER_00: 7:06

Yes, my dissertation has a very long name that I probably I cannot remember. But it was personality, psychopathology, um, attachment. We also did some attachment measures, um, and it was uh a bit of a longitudinal study looking at patients in uh psychodynamic therapy, and we followed them over a year. So we would give them the measures at the beginning about six sessions into therapy, then after six months, and then um at a year, um, and to see how these mental representations and um personality dimensions might be changing um over the course of this year in treatment.

Kjetil Bremer: 7:56

Did it change?

SPEAKER_00: 7:58

Uh yes, in fact, we we found we found that there are there were changes um over time. And um I think the and there were there were some correlations, um, and this is this is what one might expect. There were some some correlations between some of the significant others, between, say, the mother uh representation and the therapist representation, because um if if uh your your level of representations internally, one would expect that it colors how you see other significant figures. However, they were not identical. They were not identical. That the the therapist was uh was someone new to be discovered, you know, and didn't it didn't have um the baggage yet, so to speak, early on in therapy. And I I think we do find too that um sometimes it takes some time in therapy for you know what we might refer to as the transference as as to to unfold. And that's when things start getting more complicated with the therapist uh representation. But but we did definitely, we definitely saw some um we saw some change in these patients. And um one of the the key findings using the therapist representation inventory is um, and this has been replicated a number of times, is that people um who uh think about their therapists in between sessions and are able to um use their mental representations of the therapy in constructive ways to continue the work are are you see more uh quicker positive outcomes, you know, um more positive outcomes. But the patients, and this makes a lot of sense, patients who who struggle more, who are more vulnerable, um, and and might tend to focus on um more perceived uh negative aspects or disappointing aspects, um have um more challenges, you know, and and that makes a lot of sense, right? It makes a lot of sense that the work will be more complicated in therapy and will probably take a little bit longer time uh for the patient to to find maximum benefit in therapy. Um but the mo the the important point is that um to to focus in the work on how the individual does characteristically think about themselves and other people. Um and and that's that's again, that's that's kind of at the heart of um my clinical and research work um my my whole career is is really getting to know people in this kind of way.

Kjetil Bremer: 11:00

Uh ask more and are more curious about their representations of you and themselves in a way? As an explicit focus?

SPEAKER_00: 11:10

Well, I think I think one needs to um one needs to weave it in with each patient. Um we we create together our own language, our own vocabulary according to what that patient needs. Um and I think that um it is certainly the one of the significant lenses that I am using as I am interacting with the patient, but but I would find all sorts of ways to learn about the patient and how how they think um about the representations. And you know, sometimes very vulnerable patients, um one as a therapist early on, you you just must choose how you occupy the room with the patient very carefully, right? And and so sometimes it could be a long time before you're even saying very much with the patient, besides maybe perhaps just reflecting back what they're telling you, you know. And so so this is all to say that it's what uh it's part of what I'm listening for, but each each journey is individual with with a particular individual person.

Kjetil Bremer: 12:24

Um you played a significant role in creation of the alternative model for personality disorders. Can you walk us through your involvement in this groundbreaking uh endeavor and uh highlight uh the specific contribution uh of most importance for you?

SPEAKER_00: 12:43

Sure. So it was um it was quite an adventure, this alternative model. Um so just to to sort of back up for a second, um when um the work group was put together, uh the leadership of uh the DSM um said to us, look, we know there are a lot of problems with these categorical diagnoses that we've been using in DSM for. Um and we also know that the the whole field, not just psychiatry, but medicine in general, is moving toward a more dimensional approach. So we are charging you with coming up with a dimensional model for personality disorders. We think you are going to lead the way in the context of DSM. And so this was the assignment that was given us, and this was great because many of us on the work group had been working this way for years and were chosen to be on the work group because this was our our perspective. So um the tricky part, the really tricky part, was um trying to take the field forward in this kind of way when for so many years the categorical diagnosis, and even on today, of course, as as you know, the categorical diagnoses were the ones kept in section two of DSM V. Um, again, that's a very complicated story as how we ended up there. But um, so what we were trying to do is come up with a model um to address some of the shortcomings of the categorical diagnoses, um, to address some of the things that were missing. But I believe what we saw as time went on um keep enough of a bridge to the existing approach, um, so so that the the the road to the new was hopefully not so rocky. Um so in doing this, um we knew that one thing that was missing was a severity measure. And so you could give somebody a diagnosis, but that didn't necessarily tell you how how the extent to which they were struggling. Um and so um so that's one of the things that we figured out that we we needed a way of expressing severity. And so so that was the the simple aspect that led to the level personality functioning scale. And so um there were several of us on the work group who had been working with this self-other approach. Um, and another thing that we which is which is at the heart of the the level personality functioning scale, I'll I'll call it the levels um, but we also needed a unifying concept for personality disorders overall, because that was lacking too. You know, we we had these categories, but it was just a mixture of sort of signs and symptoms, and um, you know, for birdline personality disorder under under the DSM4 criteria, did you know there's 256 different ways one could manifest as borderline? Well, so that's you know, so so so they're just you know all the different things that we've talked about over the years. So, but but we needed a conceptual um basis for for to weave together all of the personality disorders because um we we really felt like there's something at the heart of this. Um there's something at the heart of this that um lead to these different flavors of difficulties that we see for people. And so again, so that came down to the the self-other orientation. Um so um because of um the things I had been working on uh for many years already, uh this is how I ended up um sort of I and and Les Mori uh took the lead on the level of personality functioning scale development.

SPEAKER_01: 17:22

Wow, thank you. Uh I was wondering, would you say that the alternative model provides a more accurate description of personality disorder compared to the categorical model? And uh in talking about this, could you perhaps describe uh criterion A self and interpersonal function as it relates also then to both severity as you talked about now, but also the trait model. How does this all fit together?

SPEAKER_00: 17:56

Sure. Um I think that um I don't know uh so accurate. That's an that's an interesting word. I would say from my perspective, um I think it gets more to the heart of um of where people live, all people. Um to to think about yourself and to think about um others. It's universal, right? As humans, this is this is what we do. And so I think uh to get more experience near in that kind of way um is more clinically useful. Um and I think that um because often, and not not to say that sort of behaviors and certain symptoms should not be focused on, that's not what I'm saying. Um but I think say, say for instance, if if someone is um uh is doing so uh some not so positive behaviors, maybe um, I don't know, drinking too much or something like that. So there are lots of different reasons somebody could be drinking too much. And so so one needs to sort of sort sort of get underneath what's driving that. And and I I think that uh beliefs about oneself, about about the interpersonal world, about how the world is going to meet you, how other people view you, um is is really again, it's it's often the foundation of why the person is doing some things that may not be particularly beneficial for them. Um and so so I think this model gives a a much more direct way in uh to that. Um and I think that uh the way the pieces fit together, so so severity is the level of personality functioning scale. Um and as you mentioned, there is then the the trait domains and facets. Um and so so um so that's a way of so so so the the levels get you to um some of these um capacities. How how well are you doing mentalizing, uh what are your your internal representations like? Um sort of the four subfacets of that are um identity, self-direction, empathy, and intimacy. And again, it's these are all fundamental um human uh human characteristics, human capacities. And so um so we we start there with a model and learn about the person in that way. And then the the traits are there to to get um if if you like, and this is the thing about the alternative model, it's it's a it's a telescoping model. Um so so the let me just go through the parts of it. So the levels, you have the traits, and then uh we have the six personality disorders. Um however, you do not have to use all of those parts of the model. You could do a levels rating and stop there. Um you could decide you're just going to use the trait aspect of the model and choose a few um key traits that you think um best describe the patient. Um or you can you can look to give a personality diagnosis. Now, in giving the personality diagnosis, however, uh so so that those personality diagnoses, and this is the criterion A, criterion B, um are now defined using um uh a typical portrait, identity, um, self-direction, empathy, and intimacy. Say let's choose um avoidant personality disorder. So so we have kind of a typical portrait that one might expect in in those four areas of the levels. That's criterion A. And then we have several traits that we find would be most associated with someone who might have avoidant personality disorder. So um, so again, this is this is giving sort of a unified approach then to all the personality disorders. So they they all are defined using the criterion A, um the uh the four aspects of functioning, and criterion B, again, the traits that we find would be most commonly associated with someone with this personality disorder. And so so you have a consistent way across the disorders of thinking about what you're trying to learn about the patient. So um you, if you're going to make a personality disorder diagnosis or or you're looking to, um one must first do the level of personality functioning scale assessment because um we do the threshold that we found um empirically is that a two or or greater, and it's it's uh zero is quote, healthy down to four. So a two, a three, or a four um is an indication that there might be a personality disorder there. And so um the the field really needed um needed us to somehow set a threshold in that regard. Um again, from from my perspective, I am, I suppose, less interested in assigning a diagnosis and more interested in really learning about this personality functioning, because for me, that's that's the heart of where I work as a clinician. Again, the the the label could tell me something, but I still need to learn. I still need to learn all the textures and all the complexity um of the person beyond that.

Kjetil Bremer: 24:42

Uh as you've come to use the criterion A and criterion B, is there a big overlap? Uh I mean in the severity uh level three pathology? And uh would you expect to have more traits, uh pathological traits on criterion B? Is there a is my question clear? In a way, is there?

SPEAKER_00: 25:09

I I I think I I think I I see what you might be asking. Um so well, let's address the overlap part to begin with. Um there have been some studies who that have looked at this, and there are definitely correlations between aspects of the levels and aspects of the traits. And um I don't think that's any surprise because again, we're we're looking at at just very, very basic human characteristics, and uh they're bound to be correlated. Um and so uh some of the the representational things that you're picking up with the levels are going to manifest in certain kinds of traits. Um there's no doubt about it. Now, as far as um if if you are scoring lower on the levels, um and would you expect to see more pathological traits? I don't know about more necessarily, but it might um it it it might focus you on certain kinds of traits, right? On on particular traits associated. Again, it it depends upon what um what kind of level three you have, you know, right? And so that's that's where the traits can help um uh map out the territory a little more specifically in that way, if that if that's your interest in in learning about the person in that kind of way. Um so I think that within the personality disorders, we do have um the several traits that we have chosen for each diagnosis that we think are most likely to characterize um that that diagnosis. So um does that does that uh help speak to your question?

Kjetil Bremer: 27:12

Yeah, sure. And I was also having in mind uh uh what you said about you can do uh the criterion A, the the levels and and stop there. Yes. So uh because uh doing both is uh takes more time, is more uh uh detailed, is more uh uh so uh in these days where clinicians are looking for effective ways of sort of uh mapping the personality problems, yeah. Uh just doing the levels might be uh a good start in a way. Is that where you're well, yes.

SPEAKER_00: 27:50

I mean, cer certainly you can tell that is the this is this is my leaning, this is where I live. Um we sweet we talked we talked a lot about this as we were developing the model, and I and I think that um uh part of what is um I think helpful about this model is that it is useful to clinicians who have been trained in a variety of traditions. So the levels might speak most clearly to me, but somebody else uh who comes from uh maybe a different profession, a different tradition, might find the traits more illuminating. And so they might say, well, um I I think I'm gonna I'm gonna go straight to the traits and I'm going to find the traits that um that most definitely characterize this person that I'm trying to help. Um and and that would be that would be fine if if that if that is the thing that best informs um their ways of helping a patient, then then by all means that would be the way to go. Um I do I do think though that um even if you go the trait route, you're you're going to get information from the patient that fits with the levels, right? If the lens that you listen through is personality disorder, since those are defined in terms of traits and level, so you're you'll you'll get the material. It it depends upon where you as the clinician um might want to focus your work. It also depends upon sometimes um where you are in the phase of the treatment, right? Because you might start out early on with some really prominent trait behaviors. And and that's maybe that you as a clinician, you say, well, we really have to start there right now because this is what is is forward facing, and we're going to do that. But you know, maybe as things unfold and

SPEAKER_01: 30:00

learn more about the patient and and you find out that they have uh perhaps certain um longstanding beliefs about themselves that that are driving these traits that are underpinning these traits then then then that comes in may come into the room yeah I have a question here uh regarding this um this might be a bit leading but when it comes to the level of severity though that thus this uh could this have a potential of having a destigmatizing effect in regards to being open for change and perhaps also um inspire people to to diagnose or check this out early in more preventative measures well this is this is uh this is something very personal for me and and this was this was one of the main motivating factors for me to get involved in the DSM Vroup because it was increasingly looking to me and again this is my perspective that something was happening in the field and that that um people were getting very very caught up in these categorical diagnoses um to the extent that um we it seemed like we were labeling people and we were treating the people as other as different um and I don't I don't believe that that's how we should be working um in the mental health field.

SPEAKER_00: 31:56

I I believe that um we all have these capacities we all have our vulnerabilities it is universal and I think that um I wanted to create something that captured that and that that's in part why the level starts at healthy functioning um that this is this so that we can see okay these these are the ways that people live we all do and so um I was hoping to to get us to think more along those lines because often you know I I was finding that um that patients particularly the patients who who were more vulnerable who who have more um uh more struggles with their identity um would would be given a diagnosis and then that would be that would become the identity um and and you know patients in my practice um and often I'm you know this the one comes up obviously most often the borderline diagnosis it's it's uh the one we most talk about in this field I think um some of my patients who had been diagnosed in other places perhaps in the hospital with borderline personality disorder um it it can be helpful in certain kinds of ways but but with time um it looked like it was a a burden and and some and just a label that had to be um overcome in some way that that that the the sometimes the family would say oh well you're just borderline and and so it was impeding change in a way and and I and I know that this is the there are different perspectives on this in the field and I do understand that um but speaking from my my own perspective um again I was just I was trying to work um to establish something that um that hopefully would destigmatize that hopefully would give the clinicians um a way to to meet people where they are and instead of sort of you know focus on well this this this diagnosis over here no you who you are sitting together with me we're going to learn about you and and what's important for you um what makes it hard sometimes for you uh what use do clinicians report on this new uh model uh how yeah yeah our uh our Norwegian colleagues um who have been doing research now since uh well 2014 is when I first came to train uh the the NOREMP clinicians here at University of Oslo and um at least with the the skid interview that we created they've they've they've sat with hundreds of patients now with this and and the report back is that that the patients really like it they really liked being asked these questions about themselves and people in their lives and how did they get along um and um you know back in Norway now because um our colleagues are developing an adolescent version of this uh this skid 5AMPD interview and so far um the interviews that they have done with with the young people the young people have reported the same thing that they they really like being asked these questions um that the this really this is really helpful to them um and so questions like how would you describe yourself and how do you think other people see you and who are the most important people in your life and what do you think about them and how do you get on um basic very basic stuff but you learn very quickly about somebody in this kind of way um how does the new model contribute to uh treatment preparation and case formulations um I think um I think there there have been some some things published on this already and I think that um from a research perspective um there there is definitely evidence that clinicians uh find the alternative model to to be more informative in certain kinds of ways um in in clinical utility treatment formulation um really early on like right after DSM5 was published in uh 2013 um les mori took the lead um and did a survey I believe uh several hundred clinicians and had them take a look at the alternative model versus the categories um the DSM IV categories and um really the the finding was the only thing that the categories had going for them is the fact that people were familiar with them. Most of the aspects of the alternative model the clinicians say oh yes I see this this could be very useful so so I think um I think we have evidence um that it it is a useful model I think that um I w I wish I knew though I can't tell you sort of um if people are starting throughout the world to uh adopt the usage of the alternative model. I don't know how many people are being even taught it I have to say um and and I wonder if people understand so it used to be if something were put in sort of the second half of the DSM it was for further research right that's what it was don't use this yet we're still researching it. This is not the case with the alternative model.

SPEAKER_01: 38:11

The alternative model is in section three and this is emerging models and and so it actually is ready for use um and it says it yeah right there in the DSM so again but I don't I don't know exactly it's hard to know how many people um have have begun using I know there's quite a lot of research happening um uh on the model yeah I would uh hope that more people using it well we would hope biased her I guess I like it um so I have one question uh and it relates to I guess my own personal experience and someone who I would say cared deeply about the alternative model and recognize a lot from it as I struggled with self and interpersonal functioning. But as that relates to trait I was curious about if you have any comments to this I like to see kind of when you're living with personality disorder like your personality traits become more a negative hyperbole of your regular traits as for now today I am I score quite high on impulsiveness and I am a very spontaneous person or or both openness and openness and impulsivity is kind of two traits I score quite high on. But when I was living with personality disorder that was kind of what made me go like oh that's a pill I'm gonna take that or end up in as is said in the medical journal like absurd and uh quite dangerous situations. But today it's more I'm the entrepreneurial curious uh spontaneous person. So like where does dysfunctional traits begin and where do they end?

SPEAKER_00: 40:11

And is there oh yeah I love I love that I love that story of transformation. Oh thank you um well so so I think that's a good question. I think the the traits in the alternative model um were you know were a significant project um that we worked on over several years and I think that um our initial intention um was in fact to try to portray traits that that ranged from uh sort of I'm not really that fond using the word normal, but you know the the not the pathological range. So so to to have trait profile that captured human traits that are very common and that um and but big because of the way the model unfolded we we ended up using um just sort of the pathological uh more pathological end of the traits. But I think what you're pointing out is in in fact to think about um and and this is this is a uh a much more useful way to work clinically I think in instead of um focusing on well what's the extreme um manifestation that's getting you into trouble to try to think about okay so you are spontaneous you are creative and that's wonderful and so what do we need to understand about what's going on for you that is turning up the dial that is is taking this this trait um off in a direction that is is is not good for your well-being um and I think that um so so that that is a a much more um uh complicated nuanced um helpful way of thinking about traits I think is that is that these are human inclinations that uh sometimes become exaggerated because of the struggles and the vulnerabilities that an individual has but but what we're trying to do is we're trying to learn about the strengths the strengths that this person has um because that's that's that's where this work wants to concentrate because if if we can help people see um the beautiful parts of themselves that are uh the foundation of this work the the things that they they were born with and somehow experience um experiences may have led them down other paths um it's it's it's it's finding finding the way back to to that to the to the wonderful self um that that we're trying to trying to do with this work so so I really do appreciate your your observations and your sharing about the traits it it's uh um yeah a way I haven't thought about in in a little while and I'm glad to be brought back there so so thank you for the question well and thank you for the answer it was great I also just regarding this stability and change there has been a debate uh about how stable is our personality in a way and uh you said uh earlier that your uh doctoral work um uh about change in mental representations you you saw some change that's right do the alternative model also uh uh tap uh sensitive is it sensitive to change and uh is there any new information about the stability of our personality right um let's see I'm trying to think about if I know of any research that's been done yet with the alternative model about change over time and nothing nothing right now is coming to mind but it is it is certainly built for that um that is part of why we used uh we created this severity measure and the traits as well have um have a scale uh associated with them as to how present this trait is that one can use if you so choose to and so so you could measure um over time and the level personality functioning scale in fact is so some people ask well what when you use that are you talking about within the last two weeks within the last two years because it used to be there was a time parameter the DSM4 diagnoses there's a time parameter the functioning scale is not a time parameter associated with it and for very good reasons because it's it's asking the question how is this person functioning now? And so that's important to know and um people may say well yeah but if there's if there's not um the presence of this sort of thing over time then is it a disorder? And again it it's it's a question of your lens and if it's important for you to just to to assign a disorder then you might want to use a broader perspective on this over time. If you're looking at how is this person doing now with the functioning and where do we need to be talking now thinking together now then then that is is the beauty of using the the levels sort of within the the the present um so that's a a complicated complicated answer that I'm not sure speaks to your question uh sufficiently but um that's that's kind of what where where I think about it right now.

SPEAKER_01: 46:14

Well we are uh getting uh getting close to the end so I would like to kind of look into the future do you think that the new model could help more people like those who do not receive specialized treatment today for today is mostly those with borderline here in Norway people with avoid we are starting to there's emerging avoidant personality disorder treatment and I know that some like a few places they're starting to treat antisocial but you think do you think that more people who do not necessarily get into treatment today will uh will get that in the future with the new model well that that is that is absolutely the hope um that clinicians will learn about the model and become comfortable with it and um and because we are uh we've developed a model whose components are so universal the hope is as well that um clinicians who don't just work in the area of personality will learn about this because um because if you find the symptom disorders the anxiety depression again you you need to get beneath that and and beneath that is often um these uh ways in which people think about themselves and other people that drive the anxiety that drive the depression and so so if we could get more people um to to think in terms of uh these these internal uh dynamics of how one thinks about oneself and other people we can speak a more common language right because I I think often it's like well okay we're gonna send them over there for specialized personality disorder treatment which is great if they recognize that but everyone could be helpful in the mental health field if they were thinking along these lines and listening for for who the person is in these kind of ways and and I think that it has an incredible amount of potential and they're not ideas that are complicated right thinking about identity and and how you see yourself it's it's everywhere it's in it's in poetry it's in song lyrics it's in it's just everywhere it's who we are and so so if we if we bring it back to basics um I I just think everybody will will benefit a lot more all around clinicians too because clinicians can can think about how how they enter into a conversation with somebody and and and their assumptions about themselves as a clinician as a person and how how how these things may be coming up because of how you're reacting right to someone else and and again it's it's knowledge is power.

SPEAKER_00: 49:28

Knowledge is power uh knowledge is transformational knowledge this kind of knowledge is connection and and I think in this day and age you know I think many countries have been talking about this epidemic of loneliness. And I think when when you have a language like this where you can connect on something so basic about yourself that I think is transformational because when somebody feels heard and understood and and seen for who they are they're not going to feel so alone.

SPEAKER_01: 50:09

And I think that that that again it's just it's so universal and that's from my perspective what that's where the work is that's that's that's where we are that was touching I think that many patients I hope some patients hear this I think that that would be highly appreciated.

Kjetil Bremer: 50:32

Yeah really nice uh and I also uh like the uh the bridging of the diagnostic work and the therapeutic alliance that you describe here bringing us closer to the same meaningful phenomena the inner world of the patients and their struggles so it has been really nice to have you here and uh really enjoyed listening to you and um I want to thank you for your huge contribution to this field.

SPEAKER_00: 51:06

Uh before we uh sum up are there anything else you want to say or uh have in mind regarding this or uh well um I'm just grateful that you you asked me to to share here with you today um and um this is my first podcast so so yeah old dogs can learn new tricks maybe but but uh grateful grateful to to so many wonderful colleagues um who who are on this journey who who are dedicated to to discovery and helping helping people in in these kinds of ways I just think it's it's more more and more important um you know and we we are our the connections across the world are are uh so complicated now um but but the fact that we are connected across the world because of our technology and social media is is indisputable and so that leads to some very wonderful opportunities and some not such great things and so we we want we want to use use our our our efforts here I think to to enrich and amplify the great things and the and the lovely things and the beautiful things. So thank you so much again for for having me thank you very much