Psychodynamic Therapy Beats DBT for Improved Reflective Functioning

In a study with patients diagnosed with Borderline Personality Disorder, psychodynamic therapy proved superior to DBT.


Patients diagnosed with Borderline Personality Disorder (BPD) may benefit from psychodynamic therapies that stress the ability to reflect on the psychological experiences of self and others. A new study published in the Journal of Counseling and Clinical Psychology reports greater improvement for patients diagnosed with DBT in psychodynamic psychotherapy compared to Dialectical Behavior Therapy (DBT).

The authors, led by John Keefe at the Albert Einstein College of Medicine, suggest differences in the outcomes of various psychotherapeutic treatments for people diagnosed with BPD depending on a patient’s reflective functioning–the ability to reflect upon their own mental states and those of others. For example, patients with lower reflective functioning at the beginning of treatment were more likely to improve in psychodynamic psychotherapies than those in DBT or the control group. On the other hand, patients with higher reflective functioning showed more improvement in DBT. According to the authors:

“Patients with normative RF [reflective functioning] may be able to take better advantage of the skills-focused approach of DBT. Without adequate [reflective functioning], it may be more difficult for an individual to effectively apply certain DBT skills—for example, in applying interpersonal effectiveness skills, normative [reflective functioning] may be helpful to accurately identify one’s own goals and the likely responses of others to best plan an effective communication to get one’s needs met. Patients with more normal [reflective functioning] may also not need as much the interpretive, mentalizing focus of the psychodynamic treatments, as factors other than [reflective functioning] may underlay their BPD… [Reflective functioning] may be a relevant prescriptive factor in matching BPD patients to treatments, such that TFP and SPT may be especially helpful for patients with low RF.”

DBT – a type of cognitive behavioral therapy (CBT) – has become the “gold standard” of treatment for people diagnosed with BPD and has been found to reduce self-harm and suicide attempts. Although DBT is often seen as a one-size-fits-all approach for treating BPD, there is evidence for the efficacy of other treatments. While some patients reap the benefits of DBT, others have spoken up against the treatment for multiple reasons, including the lack of sensitivity to trauma and understanding of difficult life circumstances.

Psychodynamic psychotherapy is among the treatments found to be as efficacious as cognitive behavioral therapies in treating psychiatric disorders in adults and adolescents, including mood disorders, anxiety disorders, and BPD. Among the evidence-based psychodynamic psychotherapies for BPD are Transference-Focused Psychotherapy (TFP), Mentalization-Based Therapy (MBT), and Supportive Psychodynamic Therapy (SPT).

Patients diagnosed with BPD often experience low reflective functioning (also known as mentalization), which the authors defined as “the capacity to understand the self and others in terms of intentional mental states, such as feelings, desires, wishes, attitudes, and goals.” The explicit aim of TFP and MBT is to improve this capacity. Research outcomes on these treatments have demonstrated that BPD patients who undergo TFP and MBT experience increased reflective functioning.

In TFP, the therapist fosters mentalization by encouraging patients to identify and understand “the motivations, thoughts, and feelings underpinning different self- and other mental states” or, in other words, help them understand their own psychological experiences and that of others. In SPT, therapists focus on creating a supportive environment for the patient in which they can freely express themselves while providing advice and emotional support. The aim is to help patients tolerate intense emotions and encourage the use of their own coping mechanisms or defenses.

The researchers of this study wanted to examine how the reflective functioning of patients at the beginning of treatment might influence the outcomes of different psychotherapeutic treatments (TFP, SPT, DBT, and eTAU) and compare their efficacy through two distinct randomized control trials (RCTs). Ninety people participated in the first RCT, while 104 participated in the second. Limited sociodemographic information was provided. In both trials, patients were seen for therapy for a year. The patients were randomly assigned to TFP, DBT, or SPT in the first trial. In the second trial, they were randomly assigned to either TFP or eTAU. The researchers measured reflective functioning and symptomatology at the treatment’s beginning and termination.

Keefe and his colleagues found that reflective functioning influenced the differences between psychodynamic psychotherapy (TFP and SPT) and other treatments (DBT and eTAU). Patients with poor reflective functioning at the beginning of therapy demonstrated more symptom reduction when partaking in psychodynamic psychotherapy compared to DBT and eTAU.

On the other hand, patients with ordinary reflective functioning saw more improvement in DBT and eTAU. It is important to note that the data might have been influenced by the higher dropout rates in DBT and eTAU and that eTAU included clinicians who engaged in cognitive-behavioral, psychodynamic, and other approaches to psychotherapy.

The results of this study might serve in the decision-making process when choosing a treatment for patients with BPD, as some patients might better benefit from psychodynamic psychotherapy. In contrast, others might benefit from DBT or eTAU.



Keefe, J. R., Levy, K. N., Sowislo, J. F., Diamond, D., Doering, S., Hörz-Sagstetter, S., Buchheim, A., Fischer-Kern, M. & Clarkin, J. F. (2022). Reflective Functioning and Its Potential to Moderate the Efficacy of Manualized Psychodynamic Therapies Versus      Other Treatments for Borderline Personality Disorder. Journal of Consulting and Clinical Psychology, advanced online publication.

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José Giovanni Luiggi-Hernández, PhD
José is an instructor and qualitative researcher who received his doctorate from Duquesne University. He also has a background in public health, receiving his master’s from the University of Puerto Rico, Medical Sciences campus. His research and clinical interests involve understanding the lived experiences of colonized people using phenomenological, psychoanalytic, and decolonial frameworks. He has also studied LGBTQ issues, psychotherapy for physical health concerns (e.g., chronic pain and diabetes), among other projects.


  1. I don’t see that this study indicates anything. First of all BPD is a dubious diagnosis. How can this DSM created condition be studied when it is such a questionable disorder?

    Then there’s the admission that one of the therapies studied (eTau) included therapists who used “other approaches” to psychotherapy. Can we really trust that the remaining treatments didn’t also use other approaches? Maybe the good therapists just used what seemed to work. And I’m not even addressing the issue of the accuracy of the supposed improvements.

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    • BPD isn’t just dubious, it’s entirely subjective. So the only thing they CAN measure is “people who have been diagnosed with BPD.” Which is an extremely heterogeneous group, so the assumption that all will respond to the same or similar “treatment” is absurd.

      I think you are correct, good therapists use what seems to work and discard approaches that are ineffective. It’s very intuitive, and the diagnosis is essentially completely irrelevant to good therapy. It’s also increasingly rare, as the DSM approach has dominated trainings and courses nationwide. So you’re right, measuring “effective therapy” for “DBT” is a fool’s errand.

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      • Steve says, “It’s very intuitive, and the diagnosis is essentially completely irrelevant to good therapy.”
        I couldn’t agree more.

        The word “intuitive” doesn’t describe most therapists I’ve had the distinct displeasure of working with. Instead, the most intuitive people I’ve known and know have nothing to do with the “mental health” system. I think that says a lot about the mental health system and the type of people that work in it.

        It’s like a breath of fresh air speaking with someone who’s truly intuitive. I feel instinctively heard, understood and totally validated, as they help give voice to the frustrations I can’t find words for. It’s the complete opposite of the clumsy but always praised “psychotherapy process” — but it’s incredibly “therapeutic”. Try putting THAT in some “research” paper and call it the “The Fool’s Errand Intuitive Study”.

        And another thing: My “getting better” didn’t happen until I got enough sense to stay away from the mental health system. And when did that happen? When I finally learned to trust my own intuition, which is something the mental health system never tells people to do –

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          • I think the biggest problem with psychotherapy is the “therapy” itself. It gets in the way by clogging therapists’ brains with judgement-laden “diagnoses” and biased “therapies”, making the so-called “therapy” a synthetic, scripted interchange shaped by a therapist’s agenda, leaving little room for a spontaneous, genuinely heartfelt and therefore meaningfully honest human experience between equals. It’s totally artificial, bland, flat and useless. No truth in it at all.

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        • I really think that’s the core of it. We are taught not to trust ourselves and our internal intuitions, starting VERY young! We are taught to “trust the adults, they know what’s going on” and to dismiss our own valid observations over and over again. Then, as adults, if we find we’re having difficulties, once again, we are taught to ignore our own instincts and just do as we’re told. Well, that’s how we got INTO this mess in the first place! I have no objection to true collaboration and agreed restrictions based on the needs of a group or community, but simply dismissing a large proportion of the populace’s observations as invalid or unimportant is certainly not going to lead to a better world, or even better “mental health” for the individuals involved. It’s kind of like saying I slammed my finger in a door, and the “treatment” is to now hit it with a hammer! Doing more of what made us “crazy” in the first place is not a solution!

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          • Steve says, “We are taught to ignore our own instincts and just do as we’re told.”

            No therapist ever told me to trust my own instincts, which I now realize was all I needed to hear.

            Deep down I sensed that “therapy” wasn’t for me. It just felt wrong. And I now know I wasn’t “depressed”, and I didn’t have an “anxiety disorder” — I was grief stricken and anxious from feeling the grief.

            So what made me “go to therapy”? Buying into society’s notion that uncomfortable feelings are “abnormal”. And what makes me think I didn’t need therapy? The fact that “therapy” made me feel worse, and the fact that stopping it made me feel better.

            And I always had the nagging feeling that therapists often don’t tell clients to trust their own instincts because they know deep down they may lose clients. Which is why deep down I never had any real respect for any of them I had contact with.

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          • Interestingly, during my brief stint as an official “therapist,” my goal was always to have the person NOT need me as quickly as possible. I didn’t WANT them to keep being my “clients!” Of course, I got paid by an agency regardless of who I saw, and there were always more “clients,” so the financial conflict of interest really wasn’t there in that role. So we’d get down to business, almost from the first words out of their mouths. But when it comes to GOOD therapy, the least necessary to get the client functioning on his/her own should be the goal! Yet I know it often is not.

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    • Robert,

      Agreed. I’d guess the funding is from whichever people are trying to recoup lost revenue from bad press. so the attack therapy therapists may be the puppetmasters here.

      Though ‘fix the borderlines by force’ is a pretty constant mythos in the MH system. This coding of hysteria has so many horrible connections. I’d love to know the who’s and why’s too. Still hoping for transparency but until then, its safe to assume the usual corruption and just hope you never get this (not) new treatment

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  2. This article works off a false, but insidiously common MH system bias, that the practioner is morally superior to their clients. In pursuit of my own epistemic justice, I need to “push back” on this entire premise and whatever conclusions have been drawn. We have enough bad therapy for BPD. Irreverent therapy, which is just bullying, is still a common “approach”.

    Honestly, I’d prefer insight into how psychiatrists and therapists can improve their own reflexive functioning. No more groupthink passed off as research. Acknowledge reality.

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    • Thank you anotherone, for saying, “This article works off a false, but insidiously common MH system bias, that the practitioner is morally superior to their clients.”

      Yes! It’s the “insidiously common MH system bias, that the practitioner is morally superior to their clients” I found impossible to ignore, despite my best efforts to participate in the god awful garbage called “psychotherapy”. Without question, the therapist’s self serving belief in their totally imaginary “power imbalance” is what made “therapy” not work for me. And at the risk of sounding conceited, l have to say that most of what any of them had to say were things I already knew, which irritated them, because it meant they couldn’t get an ego boost out of saying I lacked “insight”.

      And FYI: I was never “diagnosed” with BPD, or any other ridiculous personality “disorder”, thank goodness. But apparently, MDD (major depressive disorder”) was enough for psychiatrists and other therapists to sit on their high horse and spout off their own unreflective “therapeutic” bullshit.

      anotherone concludes with, “I’d prefer insight into how psychiatrists and therapists can improve their own reflective functioning. No more groupthink passed off as research. Acknowledge reality.”

      Yes. That would be nice, but it’s unlikely to happen with people attracted to groupthink, which is all the MH system amounts to. And yes, “just acknowledge reality”. And what’s the reality? That psychiatrists and therapists are NOT morally superior to their clients. And I should know, as I’m the daughter of a psychiatrist and have personally known people who became therapists. These people are as screwed up and behave as badly as anyone they “treat”, and their belief in their moral superiority (and in the MH system) is what makes them the most screwed up and dangerous people out there.

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      • Birdsong,

        Your endorsement is an honor. Thank you for speaking truth to power.

        100% agree to all of your words. Regarding my assertion that the author acknowledge reality, This is EXACTLY what I meant:

        “These people are as screwed up and behave as badly as anyone they “treat”, and their belief in their moral superiority (and in the MH system) is what makes them the most screwed up and dangerous people out there.”

        The article itself doesn’t say much, but like you, i know the implications. Nobody should have to survive pointless punishment for profit. Vindicating that so many here see this for what it is.

        MIA, please incorporate our feedback against this article.

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      • One of the reasons most psychotherapy is so ineffectual is because most therapists don’t know the difference between “reflexive thinking” and “reflective thinking” — and most can’t understand the difference even when it’s explained to them — because for them, education means regurgitation, confusing recitation with true understanding — which is what makes most therapists pseudo intellectuals motivated more by gaining social status and personal validation, not by an “empathy” so many lay claim to. Their training teaches them a paint-by-numbers approach, which they need, because most aren’t capable of sensing emotional nuance—and a lot of times those who do sense emotional nuance get the heck out of the training program, because they realize that no one needs a degree to help someone understand their feelings, motivations and thought processes.

        And most therapists are prisoners of their own reflexive thinking, (courtesy their training), so for them, “therapy” means having clients reflect the therapist’s reflexive thinking.

        It’s amazing how much difference one consonant can make.

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  3. Marie and Steve, totally agree. this quote exemplifies your points:

    “Without adequate [reflective functioning], it may be more difficult for an individual to effectively apply certain DBT skills—for example, in applying interpersonal effectiveness skills, normative [reflective functioning] may be helpful to accurately identify one’s own goals and the likely responses of others to best plan an effective communication to get one’s needs met.”

    So context still doesn’t matter in psych research. The author noted limited data on socioeconomic environments of participants of the study…

    If someone is surrounded by people or institutions (i.e. the medical system) who dislike them and want to harm them, it’s more helpful that the client realistically asses their actual situation instead of complying with an idea that the client is to blame for their life. If their environment sucks, it’s not because the person is difficult or has low empathy. Lots of situations are sucky right now and piling on the state-sponsored blame and shame isn’t helping

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    • What happens when the “client” starts applying these skills to the staff that are teaching them how to do so successfully?

      I had a young friend who was in 5th or 6th grade. The school had a training on Carl Rogers’ “reflective listening” skills. During the assembly, they even did role plays. Afterwards, Jeremy sat on the edge of the stage, and a teacher came up with a raised voice and told him he’d better get off the stage. Jeremy said, “I feel uncomfortable when you yell at me. I’d like it if you could talk in a quieter voice.”

      He was immediately sent to the Principal’s Office for “talking back” to the teacher.

      I think the lesson is clear enough.

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      • Steve, you’re right. “The beatings will continue until moral improves” is what happens. they keep trying to rebrand totalitarianism. I don’t buy it.

        To my fellow madpersons here:

        “You have to act as if it were possible to radically transform the world. And you have to do it all the time.” Angela Davis.”

        We can end the perscribed harm. We can get restoration and we can radically transform the world

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  4. Mad in America is perpetuating the stigma against BPD – diagnosed people with the “angry scared split woman” illustration accompanying this article. Everyone just piles on and then it’s Oh So Surprising when “another borderline gets angry”.

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    • To substantiate (to myself) that I was not “reading too much into things” or “being too sensitive,” I looked up the source of the image, which was described by the illustrator as follows:

      “Destructive feelings and self-condemnation. The girl who is afraid of guilt and inner criticism.”

      Please stop playing into “borderline” stereotypes. It’s harmful for everyone concerned.

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  5. “We, the experts, are just going to skip over the part where we explain how we graded all of the patients on their reflective functioning and decided who was normative and who wasn’t. We’re not going to get into that, how we climbed inside their brains and gained access to all of their thoughts and feelings, and then ranked our findings using our totally objective, extremely scientific measuring system. Just take our word for it. We’re experts.”

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    • Right!

      Its like- Nothing to see here! The profit incentive is totally no biggie. This authority that *definitely* learned from its big woopsies like lobotomies and aktion 4s is now fully trustworthy. Will fix the bpds! If it wasn’t so disturbingly obvious, I’d laugh.

      “One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.”

      – Carl Sagan

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  6. I’m not a big fan of this article to be honest. It’s a mistake to assume people given this horrific label struggle with metallization. Many people do not at all. Lots of people are actually not loved at home and not treated well. Lots of people actually have harmful mental health providers and are perceiving their provider accurately. Instead of arguing that this population should try this other treatment, let’s take a look under the hood at the conceptualization of this so-called diagnosis in the first place, consider trauma, and question the epistemic injustice in the field. It is a huge mistake to think these individuals labeled with this crap diagnosis lack metallization. It’s not that people who struggle with metallization will struggle with DBT. It’s that people who realize that this assumption about them is wrong and who do not enjoy harmful treatment will find DBT for what it is, which is harmful and and often, abusive. Please stop using this pejorative label. I’m sad to read that this label is even still being used and that this mentallization treatment is just another gas-lighting approach to working with people.

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    • Rebecca, words cannot express how grateful I am for your platform. You have so much behind-the- scenes support for your prior article. And well said, Kate. Am in agreement with you both.

      also, this is on point:

      “It is a huge mistake to think these individuals labeled with this crap diagnosis lack mentallization. It’s not that people who struggle with mentallization will struggle with DBT. It’s that people who realize that this assumption about them is wrong and who do not enjoy harmful treatment will find DBT for what it is, which is harmful and and often, abusive. Please stop using this pejorative label.”

      This article is the status-quo stigma. Like Kate explained, BPD stigma dog-piles are brutal for psych survivors, so I’m holding the line. Will keep commenting support for my fellows.

      MIA, can you screen these types of articles? This is problematic

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    • Rebecca says, “Lots of people actually have harmful mental health providers and are perceiving their providers accurately.”

      Yes – unfortunately, many people actually DO have harmful mental health providers. And things can get worse if patients tell this to their providers/therapists. Not very “therapeutic”.

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  7. I agree with Rebecca 100 percent.

    Maybe the treatment providers should focus on their own mentalization competence. For starters, what must it be like for a patient who has gone to a psychiatrist or therapist or the like seeking help for their suffering only to be told that they are this horrible stigmatized kind of thing. They get this diagnosis and then of course look it up on the internet, see it spoken about on social media and in the press and, God forbid the true crime blogs, and now they either, if they want to continue to get “help” from the helping people, they need to take on this horrible stigmatized diagnosis (because they’ve already understood that what’s even worse than a borderline is a borderline who refuses to accept her diagnosis). That’s just a starting point, where the people you’ve sought help from are now calling you a name that sounds horrible, that by definition is horrible and these are the people who you are supposed to trust…trust that they think you’re a worthwhile human being worthy of help, worthy of understanding, etc. Try to keep those two ideas in your head for any amount of time. And like I said that’s only the beginning. It will get way more confusing and disturbing. There will be gaslighting upon gaslighting, and in my cases, real physical and emotional harm inflicted by the helping system. It will most likely be entirely denied, minimized or ignored.

    I honestly don’t think any of my treatment providers gave a second thought to what it was like to live with this diagnosis, to know what was written about me in my medical records and still attempt to trust in them and the system they represented. Any time I went to them with concern or upset about encountering blatant examples of stigma, discrimination or hate speech against “borderlines” (at times the source was their own colleagues), they would go strangely silent. The most they could tell me was to ignore it. I don’t think they gave a lot of reflective functioning to what it was like to be a patient. They should start there.

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    • KateL says, “I don’t think they (psychiatrists and therapists) gave a lot of reflective functioning to what it was like to be a patient. They should start there.”

      I don’t think most psychiatrists and therapists are capable of realizing what it’s really like to be a patient. I think if insight and sensitivity were their strong suit, they wouldn’t have become therapists or psychiatrists. Most are in a league of their own in their capacity for unreflective thought, self delusion, and their attraction to holding power over others.

      Morally judgmental professions require morally judgmental people, and working as a psychiatrist or therapist more than fills the bill.

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      • And the real motivation for most of those who work as psychiatrists or therapists isn’t a desire to help – it’s an ego-related but unconscious desire to hold power.

        And souped-up terms like “psychodynamic therapy” or “reflective functioning” are just fancy words for thoughtful discussion or individual introspection, which, btw, is something people can do on their own.

        And as for DBT — thankfully I’ve never been subjected to that, but it sounds very controlling, like obedience training for humans.

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        • And thoughtful discussion doesn’t require a therapist, believe it or not, or even a friend, for that matter, which is better, because the most honest discussions we have are the ones we have with ourselves alone.

          Here’s the “therapy” bullshit decoded:

          CBT: question, challenge and reframe negative thoughts

          Psychodynamic therapy: question denial of problems, consider and search repressed feelings as possible root cause of problems

          DBT: getting sucked into some idiot control freak’s idiot idea of “mindfulness” and “being in the present”. Just be ready to wag your tail like a dog and go fetch to please the therapist who’s got you on a leash –

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          • And why are most psychiatrists and therapists such secretly neurotic kooks?
            Hard to tell for sure, but you can bet it has something to do with their affinity for ridiculously elaborate and essentially useless theories like “object relations” — that collection of wordy bullshit better understood by simply using common sense, insight, and a little imagination, which just happen to be the three qualities most deficient in most therapists, which is why most therapists need to rely on using so much intellectual masterbation, which inevitably leads to peddling bullshit like CBT, DBT, and, of course, psychodynamics.

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          • What’s the best therapy for therapists?
            CBT? DBT? Psychodynamic?
            Well, it’s probably not CBT…
            Really? How so?
            Because most therapists are too narcissistic.
            You know, grandiose –
            That’s true…but what about DBT?
            Nope. Most are too controlling and talkative to sit through that –
            Okay, well I guess that leaves psychodynamic psychotherapy, right?
            Psychodynamic has a shot, but I wouldn’t count on it. Most of the time even that doesn’t crack their lids.
            Because they’re too locked in denial –
            But they lead you to believe they have a lot of introspective ability!
            But that’s their biggest delusion, which is why many of them became therapists.

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  8. After all, why do something as simple as respectfully listen to someone when you can charge hefty fees for using half-assed theories and gobbledygook language? Or think you’re practicing medicine when all you’re doing is a form of whitewashed drug dealing backed up by meaningless “bioscience”? Yup, “mental health” is a great career for narcissistic know-it-alls.

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  9. I agree, Birdsong. Most therapists I’ve dealt with are not people I’d give high marks to in the area of, “putting oneself in the other person’s shoes” (which, as far as I can tell, is what is meant by mentalization and reflective functioning. The focus on these “skill deficits” seems like just a fancier way of perpetuating the old stereotype, “borderlines lack empathy.”)

    If therapists were able to put themselves in the patient’s shoes, they would quickly learn how humiliating and hope-destroying it feels to be labeled and studied and “managed” by people who are paid to help.

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    • Thanks KateL.
      I looked up “mentalization” and “reflective functioning” and found these:

      Mentalization: “the ability to understand your own and others behavior on the basis of mental states, and “the ability to understand the mental state of oneself or others — that underlies overt behavior…sometimes described as “understanding misunderstandings”…mentalization…is weakened by intense emotion”.
      Reflective Functioning: “an ability to step back from a behavior, think about its impact and meaning, imagine what might be going on in the mind of another person and see it as distinct from one’s own mind”.

      Interesting definitions, but I wouldn’t throw away emotion so handily, as emotions can be our best guide….when kept under control….and as I recall, this didn’t happen a lot “in therapy”, thanks to the therapist, who usually tossed aside my honest thoughts and feelings….which makes me think about “understanding misunderstandings”—but give me a break— that’s a bridge too far for most therapists, as most show up to “therapy” convinced they already understand everything….and, as I recall, you’d better run for cover if you happen to show them they understand next to nothing….and as for “reflective functioning”….humm.…functioning”, ehh?…okay—why can’t therapists just saying reflective thinking?….but I guess that sounds too pedestrian for most therapists’ egos….yup, therapists feed off their junk food jargon FOR SURE….just hearing their own jargon tickles their fragile egos….at these moments I recall feeling an uncomfortable mixture of surprise, frustration and pity for the therapist….which quickly turned to disgust at myself when I recalled I agreed to pay for this nonsense called “therapy”….but wait—could I possibly be “reflectively functioning”!?…..and…as I recall….this is when I reflectively walked out their door, for the very last time…

      But KateL says it best, as she knows better than anyone the real meaning of empathy and reflective thought, which she has in herself, in spades:

      “If therapists were able to put themselves in the patient’s shoes, they would quickly learn how humiliating and hope-destroying it feels to be labeled and studied and “managed” by people who are trained to help.”

      KateL is right. Therapist should shut up and learn to take their own advice.

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      • KateL said, “If therapists themselves were able to put themselves in the patient’s shoes, they would quickly learn how humiliating and hope-destroying it feels to be labeled, studied and “managed” by people who are PAID (not “trained”, my bad) to help.”
        I do apologize, KateL.

        I think the fact they people are paid for this abuse and call it “work” is grotesque.

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    • KateL,
      The thing I can’t understand is why some people who are upset are said to “lack empathy”. I think people get upset because they haven’t been heard properly. And I think the therapists who can’t do this “lack empathy”, which is absurd, because you’d think a therapist would be reflective enough to not think like that. It’s disturbing and cruel.

      I think the whole damn mental health system needs to learn some “mentalization” and “reflective functioning”.

      And I don’t think you lack empathy or reflective thought, AT ALL, KateL

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      • Yes, Birdsong, the power imbalance is huge and routinely gets ignored in studies such as this one.

        The failure to account for the power imbalance plus the long list of implicit assumptions that the “findings” of the study depend on makes the results meaningless.

        This study is done on people diagnosed with BPD. The authors have not proven that BPD is a real illness nor have they shown how the patients in the study were diagnosed and based on what criteria. Who diagnosed them? Because we all know that a patient can be seen by five psychiatrists and come away with five different diagnoses or no diagnosis. A patient can be labeled as having depression by one psychiatrist, as having bipolar by another, and borderline by a third. I personally had seen at least four doctors over a 20-year period during which I always was diagnosed with some form of depression. Then at age 40, after ECT, I was told for the first time that I had borderline personality disorder and that was given as the explanation for “why the ECT didn’t work”. The psychiatrist who had recommended and performed the ECT (based on my having what he determined to be treatment resistant depression as I had not responded to SSRIs, Klonopin, Adderall and more, all prescribed over a 6-year period by his colleague who kept no records) never explained to me why he was unable to diagnose me with borderline prior to the ECT, which would have spared me the ECT-induced brain damage).

        I would really like to know, who were these patients in the study who had been given a borderline diagnosis. What was their history of interactions with the mental health system? How many times had then they been denied help, abused, mocked? Prescribed an antidepressant and then when they reported side effects were told that it was their inherent mental illness causing their problems, not the drug? Did these patients who got the diagnosis have any history of trying to speak up for themselves, advocate for themselves, challenge the authority of the psychiatrist, the therapist, the system? Point out the invalidity of the DSM? Mention a book they read, such as Anatomy of an Epidemic?

        How many had suffered abuse as children? Was the thing that the study authors deemed “impaired reflective functioning” actually a form of hypervigilance resulting from early trauma?

        There are so many assumptions that follow on top of these. None even get acknowledged. Who determined that any of these patients had impaired reflective functioning (impaired was the word used in the abstract to the study)? Did the treatment providers who were involved in the studies undergo the same tests to see what their level of reflective functioning was? Did the authors of the study?

        And of course, like you said, the power imbalance that plays a role in all of this type of treatment gets ignored.

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        • KateL says, “The failure to account for the power imbalance, plus a a long list of implicit assumptions that the “findings” of the study depend on makes the results meaningless.”

          I wholeheartedly agree with everything you say here. And “implicit assumptions” are the magic words.

          I particularly appreciate these two insightful and compassionate questions: “How many had suffered abuse as children?”, followed by, “Was the thing that the study authors deemed “impaired reflective functioning” actually a form of hypervigilance resulting from early trauma?”

          So — what’s the first and worst “implicit assumption” of all? That “BPD”, or any other “personality disorder” is a “disorder” or “illness”.
          SO. NOT. TRUE.
          And that goes for the rest of “mental illness”.

          Your keen observations and the questions you raise highlight what’s wrong with the “mental health” system—both broadly and at its core, as you have the critical thinking and empathy most “mental health professionals” so grossly lack.

          And it’s questions like yours that make me implicitly assume the gross stupidity of the entire “mental health” system.

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        • KateL,
          I don’t think you have “BPD” or any other “psychiatric diagnosis”. I don’t think anyone does. People have struggles, but struggles don’t mean illness. You just went through hell that the “mental health system” denied, dismissed and continued with its own brand of hell.

          The “mental health system” is what’s “sick”, NOT YOU –
          And as for its beloved “power imbalance” — that’s bullshit on top of bullshit —

          So what does that make the “mental health system”?
          A messy mass of implicit assumptions –

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        • KateL,
          I highly recommend the podcast “The Scientific Emptiness of Psychiatry” with Dr. David Cohen. The ending might blow you away. Also worth the time is reading the blog “The Problem of High Functioning Anxiety”. Each offers its own bird’s eye view of the mental health system, and are critical thinking at its best.

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  10. functioning (another ill defined concept. You can’t crawl into another person’s mind and observe their thoughts, let alone grade them), and that the subjects of this study actually suffered from this real disorder called borderline? Where is the proof?
    As an aside, were the subjects all female?

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  11. “To be eligible for membership you must (provide) documentation of an Axis I mental health diagnosis.”

    This quote is from the admissions paperwork for a clubhouse for people with mental illness diagnoses in the very liberal city where I live. I was attempting to become a member of the clubhouse because one of their services is helping people who have mental illness diagnoses and who have been on disability find employment. I was very much in need of employment but was unable to find it on my own, mainly because of a decade-long gap in my work history due to not being able to perform at my job after ECT. I had applied to a couple of places including a salvation army thrift store but did not get so much as a phone call in response to the application. I needed work for multiple reasons. One of which was I needed to be less isolated and feel that I was contributing in some way. I also was trying to get onto MassHealth and had been denied due to being on Medicare. Medicare is rarely accepted by health providers that I have sought services from, and when it is accepted, Medicare does not cover many important things including dental care. When I needed surgery on my ankle due to breaking three broken bones and dislocation, Medicare would not cover the cost of me staying in a facility until such time as I was able to put weight on my foot. I was sent home to a third floor apartment where I was trapped for the next several months and alone. So I was very interested in getting on MassHealth and had been told that the only chance I had to get on MassHealth was to get a part-time job. I went for an interview at the clubhouse. The woman I spoke to was very nice and I gave her some of my history, including how devastated I felt after the ECT and then being told by the psychiatrist that the ECT hadn’t worked because I had something called borderline personality (I had never heard of it before and he didn’t even tell me what it was, but just gave that as the reason for the ECT not working). I told her that getting that diagnosis had been devastating for me because of the stigma and the hopelessness surrounding it.
    When I left the interview, this woman handed me the paperwork containing the above quote. I didn’t see it until I had already gotten home. I was extremely upset and called to ask whether people with a borderline diagnosis are not welcome at the clubhouse, since I was aware that the BPD diagnosis is on Axis 2.
    First, I got a lecture from the woman who answered the phone, explaining to me that Axis 1 and Axis 2 categories were done away with years ago. When I reiterated that the mention of the two categories was on the paperwork I had just gotten from the clubhouse, the woman only said, “we just want to make sure that anyone trying to join the clubhouse is actually suffering from a mental health condition.”
    I approached multiple other people at multiple other agencies asking for help with this situation. I still wanted to join the clubhouse and find work and get on MassHealth, but I realized that the process of meeting the admissions requirements was not something I could do alone. Every person I asked for help refused in one way or another (I got responses that were anywhere from, “call the social security department” to “why don’t you try being a greeter at Walmart?” to “I’m not co-signing any of this” to, “that sounds clinical”. No, I don’t know what any of that means either.)
    Eventually I gave up on joining the clubhouse.

    Did I demonstrate poor reflective functioning? Poor coping skills? Did I see discrimination where it didn’t exist?
    If that’s the case, and this is all due to my mental disorder, shouldn’t there be help–accomodation–for my disability? Because that doesn’t exist either. I get accused of being manipulative. Yes, I’m trying to manipulate my way into health insurance so that I don’t get trapped by myself in a third floor apartment again.
    I’ve been dealing with all of this for 4+ decades, and still it’s the powers-that-be that decide who is privileged and who is marginalized and which narratives should be prioritized while at the same time no amount of direct reportage from people who have experienced harm seems to move the needle in the right direction. Are we really experiencing a paradigm shift or incremental change? I’ve been in survival mode for years but continually get accused of complaining and playing the victim and refusing to help myself.
    I was asked once by a DBT therapist, “Do you want to keep going in circles?”. The answer is, no one does. No one wants that. The system does this to people. Calls them worthless, treats them like they are worthless until they break, then turns it’s back. “Oh, she had enough help.”. I’m supposed to just live like this, not have any needs I can’t meet myself, indefinitely.
    I would expect to find an article like this one on any mainstream outlet that sees no reason to challenge the status quo that leads to so much harm and lived destroyed.

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  12. KateL,
    You’ve tried very hard in an impossible system where people fall through a cracks while running around in circles. And it sounds like the therapist who asked you, “Do you want to keep going in circles?” is part of the circle.

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      • You’re welcome KateL.

        I don’t think many therapists are aware of the obstacles people can face in the healthcare system. What I was trying to say is that the therapist who said that sounds like someone who didn’t appreciate what you went through.

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  13. I had one DBT therapist who seemed to have some clinical skills and intuition. The others I’ve interacted with did not, and in fact seemed to almost deliberately resist emotional and spiritual connection and sensitivity in favor of attempting to force-fit the rather shallow, trite principles to any patient regardless of actual needs and response. Of course any request for explanation or deeper discussion is met with the “you’re unwilling to change” accusation. I have found some suggestions in DBT useful, but generally only as a starter at best. And any mention of the poor quality research on DBT seems to trigger marked defensiveness in its practitioners.

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  14. I think there is a typo in the first paragraph of this article, Psychodynamic Therapy Beats DBT for Improved Reflective Functioning.

    It is written that “A new study published in the Journal of Counseling and Clinical Psychology reports greater improvement for patients diagnosed with DBT in psychodynamic psychotherapy compared to Dialectical Behavior Therapy (DBT).

    I believe it should state “patients diagnosed with BPD” NOT diagnosed with DBT.

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