Interview with Richard Moskovitz M.D.

Lost in the Mirror:  An Inside Look at Borderline Personality Disorder; Second Edition

Dr. Moskovitz, are you still treating patients with borderline personality disorder (BPD)? If so, are you doing this full-time? Do you plan to continue?

I currently practice outpatient psychiatry full-time, treating a wide range of problems, including particularly depression and anxiety disorders. I still treat some patients with BPD, but they make up only a part of my practice. The most important thing that I look for when deciding whether or not to accept a patient into my practice is evidence of a strong motivation to change and a willingness to take responsibility for being a partner in recovery. I have no plans to retire in the foreseeable future.

What initially attracted you to the field of psychiatry?

I was a Chemistry and Physics major in college. As part of my liberal arts education, however, I took a course in child development that was taught by an enthusiastic and inspiring professor. What I most recall about his classes was his remarkable capacity to mimic infants' facial expressions. I was hooked on psychology from that time on. Psychiatry, which is a medical specialty, combined my interest in the physical sciences with my interest in the mind. Moreover, I strongly believe that the mind cannot be studied in isolation from the body and that it is necessary to have a clear understanding of both in order to work most effectively with emotional problems.

What gave you the inspiration to write Lost in the Mirror?

I began my career deeply involved with inpatient psychiatry. Half of my eight years on the medical faculty at the University of Florida was spent as an Attending Psychiatrist on the inpatient unit. Following that experience, I was the director of an inpatient unit in a private psychiatric hospital for my first seven years in private practice. In both of those settings, many of the patients whom I treated suffered from BPD. They were among the most challenging of my patients.

Around the beginning of 1990, at a time when there seemed to be an unusually large number of patients with BPD on my unit, I discussed with several members of my treatment team the possibility of developing a group specifically for these patients. Since it was still uncommon in those days for clinicians to discuss the diagnosis of personality disorders with their patients, we decided that the first order of business in the group would be education. We told each patient why they had been included in the group and discussed with them how they met diagnostic criteria for BPD. We were astounded at how grateful and relieved people were to be given a framework for understanding their suffering. For most participants, the group was the highlight of their inpatient experience and their most powerful tool for recovery. Seeing the empowerment that knowledge about BPD conferred, I decided that it was time to write a book that other therapists could use to help them educate their patients.

How did you choose the name of the book? What does the book title mean?

I didn't choose the title. The publisher did! I understand that choosing book titles is a prerogative that publishers usually reserve. To their credit, they did little else to alter the substance of my manuscript and they came up with two outstanding cover designs. My original working title was Becoming Real: Growing out of Borderline Personality Disorder. Later, I submitted the manuscript under the title The I of the Storm. 

When the publisher told me that the title would be Lost in the Mirror, I didn't like it. I especially didn't like that it wasn't my creation. I suggested that they at least consider the more poetic Lost in the Looking Glass, but they didn't think that was contemporary enough for a young readership. That year, it turned out that several new books on psychological topics featured "Mirror" in the title. 

The title eventually grew on me. It does capture the central problem of BPD, which is the elusiveness of identity.

What were the main points you wanted to express in your book? 

I wanted people with BPD to understand that they were not alone in their suffering and to have a framework for understanding their distress that would enable them to participate in their treatment in a meaningful way. If recovery is to occur, it is crucial for patients and their therapists to have a common language for identifying problem areas and formulating goals of treatment. I also wanted to convey hope that recovery from BPD was possible as long as people are truly motivated to make changes in their lives and in their ways of relating to others.

I found it both interesting and helpful to read about Sara. Is she a real person?

No, Sara is not a real person. She is a fictional composite of characteristics of many people with whom I have worked. In creating Sara, I intended for each segment to illustrate a crucial principle from the chapter that preceded it while at the same time developing the story chronologically over time. I deliberately created a psychologically rather physically or sexually traumatic situation in order to provide a broader framework for understanding the nature of trauma. I also wanted to underscore that one of the most damaging effects of trauma is often the victim's irrational feelings of responsibility not only for their own suffering but also for the suffering of others.

Do you think we will see any major changes in treatment in the next 10 yrs?

Absolutely! Treatment is evolving all the time in both the psychotherapeutic and physical realms. Dialectical Behavior Therapy and EMDR are both products of the last decade and are both still in their infancy. Practitioners of each of these treatment modalities are creating innovations at a rapid pace. For example, in the last five years, the EMDR community has turned considerable attention toward a concept known as Resource Installation, which helps provide patients skills for managing self-destructive impulses that can interfere with trauma work before the latter begins. These strategies overlap conceptually with the Skills Training techniques of DBT. This has widened the scope of applicability of EMDR beyond Post-Traumatic Stress Disorder to include more patients with BPD.

The prospects for advances in biological therapies are just as exciting. There is considerable current research, for example, in all areas of medicine in defining genetic subtypes of illness that can match patients to the drugs that are most likely to help them. This strategy is likely to make drug treatment in psychiatry far less of a trial and error process than it is now. Genetic testing in the clinic could arrive as soon as five years from now. More sophisticated and permanent cures, such as techniques for repairing defective genes, could be available within the next ten to twenty years.

What was the reason that you released a second edition of your book?

The Second Edition was released primarily to cover some of the vast body of new information that has become available since the original publication of Lost in the Mirror. This includes the widespread application of Dialectical Behavior Therapy and EMDR as well as a clearer framework for understanding the elements common to all effective treatment approaches to BPD. Information about drug treatments is becoming rapidly outdated with the proliferation of new drugs and new types of drugs at this time in history. The information age has also made it difficult to stay current with specific resources. I therefore shifted the emphasis of the resource section toward navigating the Internet, where resources are being updated all the time.

Do you have any more information you would like us to know since your second edition has come out? 

I have become increasingly aware of a dynamic that forms an obstacle to the recovery of many people with BPD. Since BPD and the trauma that often lies behind it tends to be a family affair, the sufferers within a given family tend to be highly emotionally entwined with one another. Some people feel guilty, when they begin to recover, about leaving their other suffering family members behind. Without consciously being aware of it, they decide that if the whole family cannot move into health, then they do not have the right to abandon their own suffering. They therefore find ways to sabotage their treatment. They fail to recognize that continuing to suffer in no way benefits others. To the contrary, once one family member leads the way into health, it becomes more likely that their siblings and others will also find the way.

Some of the more interesting new areas of investigation have already been addressed in previous answers.

What drew you to work with patients who have the BPD diagnosis?

As I discussed above, I didn't look for BPD. It found me in the course of my work with psychiatric inpatients both in the University hospital setting and in private practice. As long as I worked in these settings, it became essential to learn how to treat patients with BPD effectively. I was fortunate to have the opportunity to work with colleagues in these settings who were also interested in learning how to improve their treatment approaches and were eager to exchange ideas.

Many mental health care professionals refuse to work with patients with the BPD as they are unsuccessful in their treatment and say that people with this disorder are "difficult and frustrating to work with." What do you tell them?

I would first have to agree that many people with BPD are indeed "difficult and frustrating to work with." Many of the most satisfying accomplishments in life, however, begin with daunting obstacles. There is little satisfaction in solving trivial problems. People with BPD, when they are sufficiently motivated to work with their therapists, are capable of making astounding changes in their lives. It has been a privilege as a therapist to participate in bringing about some of these changes and watching them unfold.

It would also be important to acknowledge that this work requires considerable training, skill, and discipline and that not all mental health care professionals are up to the task. It is important for people in all fields of endeavor to be realistic about their limitations and not to undertake work for which they have not been prepared. 

Even experienced therapists are wise to limit the amount of time that they allocate to treating patients who are likely to make the most demands on their time and emotional resources. It is important for therapists to attend sufficiently to their own needs to keep from burning out and to maintain their capacity to help those patients to whom they do commit their time. 

How long have you been treating patients with BPD?

I began my psychiatric residency training in 1974 and encountered my first patient with BPD within the first days of training.

I sensed a great deal of compassion from you when I read your book towards the patients who suffer from this very painful disorder. Can you tell me about that?

Compassion is an essential quality of any effective therapist. For me, compassion means the ability to perceive the fundamental good within people even when they are unable to see any goodness within themselves. It is recognizing that there is an "inner angel" within each person, however tiny it may seem at first, with which to join forces in the pursuit of health and which can eventually grow to fill the person completely.

How often do you use EMDR in your practice with these patients and what kind of results are you having?

While I use EMDR frequently in my practice, my use of this approach in treating patients with BPD has been more limited because of the risks of triggering self-destructive thoughts and behaviors when exposing patients to traumatic memories. Resource Installation is designed to alleviate these risks. While I am not yet trained in these techniques, I am scheduled to attend a seminar next month to learn more about them.

I understand that you are currently writing a novel. Can you tell us anything about it?

One of the main protagonists is a young woman whose recovery from BPD is chronicled in the novel. The work addresses the very nature of memory, how well it can be trusted, and its role in establishing identity.

Do you plan on writing any more books in the future and if so what kind?

My current dream is to publish my first work of fiction. If successful, I plan to continue writing fiction, which can be a very effective vehicle for educating and for addressing controversial issues.

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