Psychiatry & Psychotherapy Podcast - Narcissism with Jonathan Shedler, PhD

Episode Date: June 30, 2023

In this episode of the podcast, we are joined by Dr. Jonathan Shedler to discuss narcissistic personality disorder. Dr. Shedler is a psychologist, consultant, clinical educator, researcher, and author with over 100 scholarly publications. His article, "The Efficacy of Psychodynamic Psychotherapy," has garnered worldwide recognition for establishing evidence-based support of psychodynamic psychotherapy. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

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research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today again with Dr. Jonathan Shedler. Welcome back. Hi. It's good to be back. And we will be discussing narcissism today. And so I was thinking maybe we could start out because I know there's going to be some professionals who listen, mostly professionals,

but there may be some lay people that listen. And I know narcissism has kind of different definitions. There's the pop culture definition. You know, every ex-boyfriend is a narcissist. There's, you know, like, and then there's the psychoanalytic tradition, which there can be like healthy narcissism, unhealthy narcissism spectrum.

all the way to malignant narcissism, more of like that psychopathic narcissist. So, yeah, do you want to just start out with how you differentiate it? Yeah, I mean, I think you already put your finger on something really important. You know, this happens all the time with different psychoanalytic terms, diagnostic terms, that something, you know, it gets consumed by pop culture. And then, you know, all the clinical meanings disappear, all the nuance, all the psychological understanding disappears. And, you know, the word gets thrown around largely as a pejorative.

And I did a little research. Just, you know, I googled narcissist. And, I mean, it returned tens of millions of hits. And a lot of them were, you know, social media posts and blogs. And, you know, how to tell if your boyfriend is a narcissist. How to deal with a narcissistic boss? How to say no to the narcissist? And there are all these references to the narcissist, the narcissist, the narcissist.

And I mean, as a clinician, it drives me a little bit crazy because there's no such thing as the narcissist. And in most of these blog posts, it's like you might as well substitute the word the boogeyman. Everywhere it says the narcissist because it just becomes this, it's like this box. that you fill with every negative, pejorative thing. And I mean, it's funny because people on social media who are like, we shouldn't label people, we shouldn't use diagnoses, you know, these are social issues.

It's like somehow the narcissist is an exception to that, right? And then you can just keep all kinds of, you know, I mean, just all kinds of, you know, disparagement. So, you know, anyone who's mistreated you, who's been exploitive, you know, who's been insensitive, suddenly they're the narcissist. Yeah, and we don't want to negate someone who truly is, like if you have undergone abuse from someone who is narcissistic, when we'll get to like what we would consider narcissistic. We don't want to negate that experience. And that's the issue. Most of the things that are abusive and exploitive that people put in the

box and say that's the narcissist, most of it is actually not about narcissism at all. So narcissism, in popular usage, narcissism has become this kind of grab-bag category that actually mixes a number of different things. And then the people stop being three-dimensional human beings. They're just the narcissist. So maybe we should talk about... Well, before we move on, let me just make my mind. sort of what I've seen, and then I'm curious what you think about this, but a couple patients I've

had or, you know, friends, once someone, a boyfriend, husband is labeled as a narcissist, it's almost as if it's like a filter in which they see all future behavior thoughts statements. And all of the behavior thoughts statements, you know, like anything positive is love bombing, is they're trying to be lippelic. And everything negative is, you know, another example of their gaslighting. Yeah, and so we're not thinking psycho, I agree 100%. We're not thinking psychologically anymore. We're doing the opposite of thinking psychologically, which is putting someone in a box.

Right. And then we don't actually understand the meaning, you know, the meaning of what this particular individual is doing, right? you know, we just attribute every nasty thing in our box to them. And, right, I think you're onto something important because as a clinician, I think we always have to ask, are we using psychological terms or psychiatric terms or psychoanalytic terms? Are we using them in the service of facilitating our psychological understanding of someone, right? How do I make sense of this person's, how do I make sense of this person's behavior? behavior, what's going on with them psychologically, what's motivating it, right?

How do I understand them as a person? Are we using terminology to help us think about a particular person's psychology, or we're using terminology in the service of not having to think about it anymore? And, you know, that's really kind of doing violence to the work we do. That's good. So it's like a form of reductionism, and then you don't have to do your own work, right? Because if someone else is the problem, idealize your own experience, thoughts, emotions, fantasies, internal structure, and then vilify the other person. Yeah, I mean, if we're going to get technical about it, it's at best, it's externalization as a defense, right?

If you're in a relationship with someone, if you're in an ongoing relationship, it's very comfortable. There are two people's psychologists in the mix. There are two people's psychologists interacting. It's very hard to disentangle what's what. And as soon as somebody becomes in the relationship, the narcissist, or even worse, I mean, I see this on Twitter all the time, the narc. You're really dismissive. The externalization is, I don't need to understand anything about myself. I don't need to examine my own contributions or react to.

or, you know, what's going on in my psychology that drew me into this and keeps me in it and keeps it going, right? The externalization is a defense. All of the problems are outside. What I do is not reflected on and anything that I feel, you know, don't feel good about, well, that somebody else is doing. And that's the higher level defense. The lower level defense is splitting, where it's like I don't see the bad, the destructiveness in myself. And I split that off. It's a very primitive defense. I project it onto the other person. And now the other person becomes the repository of all of my own hate and anger and aggression and destructiveness. It's not me. It's them.

And sometimes people who are organized around splitting as a defense need. somebody, you know, bad in their orbit to be the repository of the things that they can't own in themselves. So things get very complicated in the real world. Yeah, this is where it gets complicated. So if you're listening to this far and you haven't, and this is bothering you, that's okay. Because we have to, I wanted to almost put this as a disclaimer before we jump into it, because this will kind of make people a little bit more hesitant to maybe point the finger at some relative or their spouse or, you know, relationship and, um, and realize that we're using this in a clinical sense. And so maybe let's, if you're ready, me or, me or our listeners.

If you're ready. Um, how, okay, so how do you clinically define narcissism? Okay. So one thing that we have to understand. And every personality style, and narcissism is a personality style among many, you know, narcissistic personality style, obsessive, compulsive, paranoid, you know, just walk through all the familiar personality styles, exists at different levels of organization, at healthier levels and at more disturbed levels. So, I mean, psychoanalytically, we differentiate between neurotic level functioning, borderline level functioning, borderline organization, not borderline personality disorder, and psychotic level functioning. And like every other personality style, narcissistic personality style exists at all of these levels of functioning. Most of the, you know, the really, you know, destructive, the toxic things that people

associate with narcissism are actually not about a narcissistic style. They're actually about a narcissistic style organized at a borderline level. Like people talk about, you know, gaslighting. That's not actually an inherently narcissistic thing to do. It's the thing that happens at a borderline level of organization for psychological reasons that we can understand. So with that as a preamble, every personality style has healthier and unhealthy variance. What does healthy narcissism look like? You need healthy narcissists in the world because they're the people who dream the big dreams, who have the grand visions, right?

They're innovators, their founders, they're charismatic leaders. They're the people, you know, they have. have some grand idea. And anybody else, you know, an internal voice in their head or external voices or no shortage of external voices says, you know, these are pipe dreams and your head are in the cloud, be realistic, and they give up on their dreams. And somebody with healthy narcissism believes in themselves enough to do it. And if they're, you know, if they have some interpersonal charisma, right, they're the visionaries, they gather people around, you know, who, you know, they, they gather people around

who want to be part of it. They can do great things in the world. You could, I've heard it argued that, you know, the world is run when it's run well. The world is run by higher functioning narcissists. So let me like translate this for maybe someone who's confused. The defensive style of someone who's narcissistically oriented is fantasy and kind of that grandiose fantasy of like something that could happen in the future, right?

And they may believe in themselves as, But they're connected enough to reality. And, you know, they're interpersonally related enough that they have the capacity to, you know, into doing something meaningful and effective. Yes. Okay. I'm not going to name names, but if you think of, you know, some of the major, you know, tech companies that kind of started with a charismatic visionary that are household names.

A lot of those people are fundamentally narcissistically organized. So are you saying that if you have fantasies of grandeur, like a vision for the future that you're trying to accomplish, that in and of itself would make you narcissistic or like what do you What are you saying there? No. I'm saying that the healthier version of narcissism is somebody who believes in themselves, who has the ability to persevere despite setbacks that would discourage other people and make them give up, where people say, who are you to do this?

What's so special about you? And somebody who's functioning at a healthy level of narcissism might say, well, I think I can do this and I'm going to try. Okay. To, that we can distinguish from an unhealthy version of narcissism where the grandiosity isn't connected to reality. You should treat me as special and grand, not because of what I actually have to offer, not because of what I'm contributing to the world, not because of what I have built or am building. You should treat me as special and important and grand on the basis of, my fantasy that I should be treated that way, you know, as if I've done something great,

as opposed to I'm actually trying to do something great, and I'm making some headway at it. So there's a huge disconnect between reality and... Yeah. There's a recent book by Glenn Gabbard is one of the... co-authors, and this phrase that they use in this book stands out in my mind, and he says, you know, it's a book about narcissism, but he says, you know, let's just, let's just set the stage from the beginning. You know, there's no such thing as the narcissist. It's not a monolithic category. It takes many, many different forms. He says, narcissism clinically is a many-headed,

which I think is a wonderful phrase. It sort of leads us to start thinking about, you know, what am I seeing in this instance in this particular person? And what does it mean? Rather than a box to put people in. So, okay, so in your chapter on narcissistic personality, you say the hallmark of narcissistic personality is the coexistence of feelings of grandiosity and feelings of inadequacy and emptiness. So I guess I'm curious like this sort of other side. We've talked a little bit about the grandiosity or confidence and like more of a healthy oriented person. Yeah, so let's get into into that. And even the DSM actually gets it wrong. I mean, it kind of misses the most important and the most important thing. You know, the DSM is not a particularly psychologically minded

document, especially when it comes to personality. So what we know clinically and from empirical research, including my empirical research, right? The defining hallmark, it's not just that the person feels, you know, is grandiose, self-important, entitled. That's one side of a conflict. The theme is actually that there's attention,

there's a contradiction, that the person simultaneously feels special, grand, important, envied, superior. And there's something in them that feels the opposite of all of those things, that feels damaged, weak, inferior, empty, vulnerable. So it's not that somebody with a pronounced narcissistic style is one or the other. It's the tension, it's the interplay between these two contradictory ways of experiencing themselves.

and what becomes of that, right? How that contradiction is resolved, how it plays out. And so the grandiosity is compensatory. These are defenses against underlying feelings of weakness and vulnerability and fragility and emptiness. And the person is trying to banish those feelings by inflating themselves. So what you see in somebody with a narcissistic style at any particular occasion really depends on, you know, the interplay of these two sort of, you know, contradictory facets of experience and how they're finding expression at a particular point in time. So now this brings us into into the area of, you know, closer to what people in pop culture mean when they say.

say, you know, the narcissist. Usually they're talking about, they're talking about the narcissist, whose narcissistic defenses are functioning, are functioning and are pretty airtight. And, you know, they're succeeding at keeping at bay, their feelings of vulnerability. Right.

So the grandiosity and the self-importance, you know, helps to keep out of awareness, something that's very, very vulnerable, right? Something that's in pain. Feelings of emptiness and inadequacy. So if you talk about one side of narcissism, we know that the other side is here. And now this brings us to two different manifestations of narcissism. You know, one is the grandiose narcissist, the defenses are, intact, all you see is the self-importance. And various things follow from that. You know, one is,

one is the person really doesn't have mutual relationships with, you know, genuine attachment and connection, you know, mutual meaning that two people, you know, two people matter in the relationship, that the person has empathy for the other person. They care about the other person. The grandiose version of that, relationships become damaged. Intimacy and connection becomes impossible because other people become an audience, right?

They're not there as whole human beings in their own right. They're there. They're there to be an audience to the person's magnificence and importance and specialness. So you're there to bolster those defenses, and if you serve that purpose for them, then you have a role in their life. If you don't serve that purpose for them, then you can be discarded. And you cease to exist, yeah. Yeah.

So that's one side of it. What happens when the narcissistic defenses are working and they're intact? And we see a lack of empathy, a lack of relatedness. Other people are used to serve a function, which is to prop them up. The other side of it, when the narcissistic defenses are failing, you don't see anything that resembles what's described in the DSM. You certainly don't see anything that's described in, you know, social media and, you know, blogs on the topic. What you see is somebody who looks beaten down by life, you know, who's deflated, who's broken down. When they come to therapy, you know,

they usually come in, they look depressed and they get diagnosed with depression. And, you know, Some, you know, not insignificant number of people who are in treatment for quote unquote depression are actually deflated narcissists. Their narcissistic defenses have failed. And they're coming just face to face with their feelings of being, you know, beaten down, taking advantage of, put upon a failure, of weakness, of vulnerability. You know, our hearts go out to them. And, you know, the way we make the differential diagnosis, you know, is this depression? And is this, you know, another kind of depression or is this a deflated narcissist? It's when you get below the surface of their pain, do you find out is that their mental life is, you know, largely organized around fantasies of how special and important they are or should be and how the world is, you know, the world is doing them wrong by not recognizing their talent.

their ability, their importance, right? Right, right. And I would say, like, vacuous. It's like interpersonally broken relationship after broken relationship. They don't have long, meaningful friendships often. And they're the central, right? I mean, we all tell ourselves narratives about ourselves in the world. The narratives are always, you know, they're always the hero of the narrative. Thoreau is the central character. And I'll give you kind of, it was amusing. A kind of, on the one hand, sort of trivial and silly example of what deflated narcissism looks like,

but on the other hand, actually not silly at all because it really captures something central. So a person has a house guest, and the house guest notices, they, you know, if they wash the dishes, and they leave the sink in the, they leave the sponge in the sink. And the person who, you know,

we now understand is functioning from a place of deflated narcissism, says, oh, you know, that's a no-no, you know, germs, you should take the sponge out of the sink and, you know, ring it out and let it dry out. You know, bacteria grow, which I think is true. But, and, you know, of course, it's hard to change a habit.

It's not like somebody tells you that. And then automatically from that point on, you never put the sponge in the sink. Well, so the next day, sure enough, the damp sponge is in the sink. And the reaction is, how could you think so little of me? You have no respect for me.

You know, you look down on me. I told you, you know, I told you this is important and you're disregarding me. It becomes all about them. It's not about the sponge and the sink and the dishes anymore. It's about, you know, now they have a grievance. You're wronging me.

You're putting me down. Right. So when I say, you know, they present as likely depressed, you know, beaten down, aggrieved. When you scratch the surface of it, they're still the hero of all the stories. It's all self-referential. Yeah. The victim at times, you know, and the hero most of the times, right? You're the hero or you're the unsung and un-sung and unrecognized and mistreated hero.

Recognize that you're supposed to be the hero. Yeah. And so I think the sponge example is kind of like they have this deflated sense of self that's in there. And then a little thing like a sponge can align with their narrative of themselves, the way they see themselves. It's a personal slice. it's not a sponge anymore. Yeah. Yeah.

So it kind of like fits into their global, you know, idea of themselves. Yeah. And I want to emphasize because, you know, especially in popular culture, it's like it's just, it seems like it's become the norm that, you know, we're just going to vilify these people. And a lot of people who have narcissistic styles, narcissistic organizations, you know, suffer quite a bit. Their lives are not fulfilling. They don't have meaningful connections with others, which of course is ultimately what makes life meaningful and worthwhile.

So they're kind of bereft of meaningful connections with other people that, you don't face it. I mean, life is hard. Life can be cruel. We all get our share of hardships. It's our connections with other people. are meaningful connections that make life meaningful and make life worth living in the face of all of the hardships. Well, if you take meaningful connections out of the person's life, they're a miserable,

you know, they're a miserable suffering person. Yeah. And I think, you know, to treat them as, you know, to treat them from the get-go is, you know, villain, you know, you're the villain and you're victimizing other people. I think it's just really not understanding the psychology of what's happening. Yeah, I think the self-referentialness of like someone who's kind of narcissistically wired comes out as well when you're working with someone as how much they think of you or care about you, the person that's, you know, are you like a trash can that they heap their horribleness into?

Well, and so that would be the more inflated side of the inflated, deflated conflict. And that would be moving into the more disturbed areas of narcissism, because you can have somebody who's narcissistically organized who is capable of connection and caring about people. And, you know, arguably the difference between, I'm not sure whether or not I agree with this, but a strong case can be made, that the difference between a healthier and a more disturbed version of the style, you know, it isn't so much that the presence of primitive or costly defenses, but the absence of, you know, healthier capacities. right so you know you can be kind of narcissistically organized you know self-important you know you tend to you know you tend to be the main characters in your character in your story but if you're functioning at a healthier you know higher neurotic level and and for you know listeners who

don't know i mean thinking psychoanalytic terms neurotic is as good as it gets and neurotic is neurotic is the healthy level of functioning right you know say maybe be narcissistically organized, but they have the capacity to invest in relationships with other people. They can care about other people. They can have empathy for other people. That's the higher functioning version of narcissism. And the other person can say, you know, it felt really shitty when you did this or that. And, you know, there's a reasonable chance that they can hear you and take that into account.

because they do care about you. As we get into the sicker ranges of a narcissistic style, they actually don't care about you except to the extent that you provide narcissistic supplies, which is to say, you know, a constant, you know, a constant feed of approval, admiration, you know, validation in the service of propping up this person's inflated, but very precarious image of themselves. Yeah, and what I was going to say is, I think the sicker narcissistic type for me is the type that has some psychopathy.

And by psychopathy, I mean like specifically low affective empathy. Well, let's get into the sicker kind because we've been on the healthier end of this. I also want to elaborate on something you said about what it feels, as you get into a relationship with somebody in the more disturbed narcissistic range as a clinician. One of the experiences that's very common, we, you know, our first indication of what we're dealing with is often in the countertransference. And I think you were trying to describe a particular kind of countertransference that's really common,

which is we feel like we're not really, you know, we're not really there. in a relationship, you know, being seen as a person in our own right, you know, we're there to serve a function. And there's a version of that experience. I called it, I named it, the beam me up Scotty experience. Okay. And, you know, people who watch the old Star Trek, you know, they're Scotty on the, you know, the Starship Enterprise, and he had this, you know, teleporter.

And what you could do is there'd be somebody down on the planet, you know, living their life. And you just, you know, send this beam. and they would just disappear. They would just be beamed off the planet and put back in the ship, and you could beam somebody else down to the planet. And what I call the beam me up, Scotty experience, is you're the clinician or in a relationship with the person. And you have this sense that if, you know,

Scotty on the enterprise beamed you up out of your chair and, you know, put somebody else down in your place, you're not sure the patient would even notice. Okay, yeah, yeah. So it's like this idea, okay, so as the therapist you're imagining, like, is there anything about me that is not replaceable very quickly? Is there anything about me that, you know, that is there anything about me that allows me to feel that I matter as another person? Right.

Yeah. And not just as someone who's serving, you know, serving a function, a purpose for them in the moment. And, you know, when you get into the sicker range of narcissism, then relationships become very transactional. Right. Because they're not based on empathy or mutuality. They're based on what do I need from you? Where do I have to give you to get what I need? Yeah.

It's like I've been to some business parties. where it's like you kind of have this feeling like everyone in there is just trying to be polite, but at the same time trying to like see how they're going to utilize other people to accomplish what they want. And you kind of get that feeling. Yeah, the feeling is that you're being used for something. And, you know, in therapy, it's that we have the Be Me Up Scotty experience. We have the experience, all this is countertransference of existing as a sounding board. The patient wants you to listen to them. You're going to serve the function of being an audience, but they're not particularly interested in you participating or what you might have to say about it. Yeah.

Yeah. And I feel, so I think I'm curious if you've seen, this may be like jumping too far ahead, but patients that come in more of the depressed narcissist type, the deplete narcissist, and then they start doing better, right? Maybe life goes well. and you've done a little work together, and now they're, you know, doing better. And they make jabs at you almost on the way out of therapy where they're like, you know, thank God you got that genetic testing done, you know, like, because I'm like, no, but you did like a year of therapy.

Like, I don't think it was the genetic testing that helped you, like, you know, change your dreams. Well, there's two characteristic three, actually. two major characteristic kinds of transference in therapy. Transference and a corresponding counter transference. And one is that the patient is overtly devaluing, which tends to leave therapists feeling bored, disengaged, angry, you know, wanting to put, they either want to, you know, they either want to, you know, kind of withdraw and just, you know,

emotionally disconnect, you know, or they want to retaliate and put the patient in their place, you know, because the patient is putting them down. So that's one, and of course, none of that, acting on that countertransference is particularly helpful to the patient. The other countertransference, right, so one countertransference is you're on the receiving end of a lot of devaluation and what you said, a lot of, you know, like subtle and not so subtle digs, jobs. The other countertransference, is right so you're devalued. The other is you're idealized. You're seen as, you know, very important, special, larger than life. But it's not exactly just, you know, reality-based admiration. I mean, the patient wants to see you in this idealized, in this idealized way so they can feel

better about themselves as their association with you. My, you know, my therapist is the best. the smartest, you know, the highest credentialed. They went to this program. They make this amount of money. They treat stars and celebrities. It's not really about you. It's like, you know, if I'm your patient, I get to feel a little more important by virtue of my association

with something so special. But the thing about both of those transferences, the devaluation and the idealization, is that neither of them have a lot to do with who you actually are. By definition, devaluation is, I'm not seeing you as a whole three-dimensional person as you are. I'm seeing you through a certain set of lenses that serve my purposes. It isn't really about you. You know, same with the idealization.

It's not about who you really are, getting to, you know, know, know, know, experience you as you are in the session. It's about I need to see you in a certain way through certain lenses. because that serves a function. And then often patients will go back and forth. They'll alternate between idealization and devaluation. Yeah, I've had this patient I've treated for years. And he went from jabs, like devaluation jabs that would sting to now true concern about me as a person and about my family

or about like, you know, and it's almost like, it surprises me. You're helping them. And it's, it's been a long time coming. Like, I don't know, like, I'm definitely like, I like, I like to see the end of the story, you know, so I stay with people for a long time if they're willing. Yeah, and this is really important, right? So, I mean, what, you're, I mean, this is significant change. Whatever you're doing with the, you're doing, you're doing good, doing good work.

what people who aren't trained in psychodynamic therapy often don't understand is the importance, the centrality of the therapy relationship. The goal of therapy isn't so that the patient should have a better relationship with the therapist. That's not why the person has come in. But the thing is, the person, I mean, the fundamental problem is, here's somebody who in their life doesn't know how to have a relationship that works for two people, that two people can feel okay about. doesn't know how to have a relationship where they even register that the other person is, you know, also a whole person with their own inner life, their own, you know, their own life experiences, their own difficulties, their own feelings. I mean, the idea is we work it on it in the therapy relationship. It starts in the therapy relationship because that new way of experiencing self and others. can then carry over into other life relationships. If we can make some headway with the narcissistic defenses

that get in the way of seeing you as a person, as a whole person, then the likelihood that they can start to see their husband, their wife, their friend, their co-worker, the likelihood they can see them as real people. changes dramatically. Do you kind of see what Cohut was talking about, like, the mirroring, you know, being attuned, giving them the empathy that they need, kind of like meeting that in a way that's maybe more truthful than childhood.

Where do you align with that? God, that was such a tempest at the time. So in the psychoanalytic tradition, there was a kind of war that went on for a decade or more. And the two major theorists around narcissism were Heinz Kohut and Otto Kernberg. And Otto Kernberg's still alive. They had radically different views. And this is a gross simplification. But basically, you know, Cohut believed that the treatment for narcissism,

narcissism was empathy, understanding, mirroring, which is that the patient has a need to be admired. And we provide that admiring. So they basically co-hut saw it as a developmental deficit, that the person didn't get something that they needed from their primary caregivers in childhood. The therapist can provide that for them, empathy, attunement, understanding. and by virtue of getting that, that the person would naturally sort of resume a developmental trajectory and grow beyond that. Kernberg was dealing with narcissistic patients who were actually much more disturbed, who were much sicker, and he was dealing with borderline functioning level narcissists.

I think Kohut was dealing with much healthier neurotic-level narcissists, narcissistically organized people who I think they were dealing with different I think they were different animals they called them both narcissism but they were different people that would actually be my

my intuition was to think that Kernberg was seeing a little bit more of the low affective empathy group that needed a little bit more truth and that respond to truth someone who's a little bit more a killer, you can, if you just kind of bluntly tell them what they're doing and how it's messing up their life and you're strong, sometimes they respond with like, oh, okay. Well, I think Cohut was working with students and analytic candidates.

So these were sort of high-functioning people who are dealing with a sense of emptiness or meaninglessness or a feeling of, you know, it was kind of incoherence, like, who am I really? Mm. Just very different from what Kernberg was dealing with, which is where I was wanting to get to this. Okay. Yeah. When we get into narcissism of the kind that would get a DSM diagnosis of narcissistic personality disorder, we're already at the borderline level of personality organization

organized around splitting. And then something very different is happening. And this is, we're going into pop culture, all the horrible things that narcissists supposedly do. This is the kind of narcissist. But we have to understand. We're also seeing a borderline personality organization, which is to say organized around splitting. So how does the splitting work? First of all, the person isn't actually experiencing this conflict between feelings of vulnerability and inferiority

and feelings of grandiosity. They develop really airtight defenses, and Kernberg calls it, the pathological grandiose self. And the airtight defenses are that all of the negative feelings, the feelings of inadequacy and inferiority, get dissociated.

They get split off, right? Not me. I'm not aware of these feelings of myself. They get split off. They get projected onto somebody else who becomes the repository of all of the inferiority. And having done that, through projection, I can now proceed to treat them as inferior.

So they exist as objects, you know, objects to, you know, that exist from my satisfaction and my pleasure. I'm going to devalue them, right? So you take all of the idealization and, right, the sort of idealized representation of your sense. self, you know, that's you. You take all of the things that, the parts that are devalued, they get projected onto someone else, and now you can treat them as inferior and treat them with contempt. And now we start getting into the range, what people on, you know, on social media blogs are

calling the narcissist, right? Let's be clear, this is one particular, you know, version of the many-headed hydra of narcissists. And then the defenses are really, you know, airtight. You are treated as lesser than. And, you know, if you try to interact with them, you feel that. Yeah. A couple of things I note as you talk that. Devaluation, microexpression of disgust. And then the last line, you had some anger. It's like, you have lived. See, I think most people when they like, it's so hard to think about psychology until you've seen, like, probably, I don't know, you've probably seen like 50,000 hours of patients at this point, maybe 40,000, right? And so it's like, and so you have these patterns in your brain of this

type of stuff and you have the years of experience and then, and then you're reacting emotionally to it. So if you have a chance, go check out our YouTube on this as well. And, uh, but it's like, you know, there's like, you can't not have countertransference to someone devaluing, you know, And you have to use the countertransference, which means not doing what comes naturally. This is our training. This is why we have personal psychotherapy and personal psychoanalysis and, you know, and supervision, you know, consultation with senior colleagues. I mean, because the pull is, I mean, the patient, you know, treats us in this devaluing dismissive high-handed way. and the pull is either to slap them back, you know, fuck you, I'm more important, you know, or to disengage and withdraw. You know, we can board and lose interest in them. And, you know,

working skillfully with a patient who functions this way, you know, as first of what we want to say, what's going on between us? What's going on interpersonally that's evoking these feelings in me? you know and and instead of either you know trying to put the patient down or disengaging with them can I address and speak to what's going on between us right and and can I do it in the context of they didn't come to therapy for for sport they came to therapy because something is broken so we always want to be able to

I'm digressing a little bit but when it patient comes in for therapy. In the very first session, we really want to know three things up front. What's wrong? You know, why have they come? I'm just going to repeat that. The patient didn't come for sport. They came because something in their life hurts. Something is broken. Something is causing suffering. We need to get that on the table. That can take a lot of work with somebody who's narcissistically organized who may well come in with the attitude, you know, I'm fine. You know, I'm fine. You know, let's talk about what's wrong with you. We have to get to the pain.

So we want to know three things. What's wrong? How are they hoping that therapy can help? And why now? Because something has happened. That's tip the scale, right? In the direction of coming into treatment now, as opposed to years ago or a year from now.

If we have that as a starting point, then we can keep our eye on the ball. The patient has come in because something is wrong. We've reached a meeting of the mind. about what goes wrong. I mean, commonly it's, the patient is, you know, their relationships feel empty. They can't get close to people.

There's an emptiness in the background, you know, just under the surface, and it's not really that hard to access. So, you know, maybe that's the reason. We hold that in mind as we think about what our reaction is to them. And then we can connect it to what matters to them. We can say something like, you know, I'm thinking about why you came in. And, you know, what brought you to therapy? And, you know, I'm thinking about how you told me that your relationships all seem to

fizzle out and don't go anywhere and that you're ultimately left feeling alone. Right. Yeah, yeah, I said that. You know, it seems very far. It seems very far away at this moment. Isn't it? It's like, well, you know, I'm not feeling that way right now. But, you know, there might be something happening between us

that might help us understand something about why your relationships fizzle out or never get traction, don't seem to go anywhere. No. Because I'm noticing. you know, I'm noticing there doesn't seem to be a way for me to participate in our relationship, in this session, in a way that feels all right to me. What do you mean? We want to use the countertransference.

So, you know, I think, you know, you've let me know multiple times that I'm not quite up to snuff. Oh, I didn't mean it that way. Well, you said this that left me feeling that way. You said that that left me feeling that way. Do you see how that might land on my side of the relationship? Oh, I didn't mean it that way. No, perhaps not. But it's something that's been in the air here between us.

and we both know it's not just us. We know that something goes wrong. And when you try to have relationships with other people, maybe this is a little window into that something. It's a way of working with a certain kind of narcissistic defenses. I appreciate it because you put it in terms of his goal, you know, his or her goals. Well, if we don't do that, there's nothing in it for them. It has to be tied to.

why did they come to treatment? What is their pain point? Yeah. What is their like, yeah, reason that they're here? And then it's like, well, what if what's going on between us is a little, you know, a little window. Hey, little window. And we could talk about it and be curious about it.

Into how things go generally. Yeah. You know, and then you might be able to get to a point where to say, you know, it seems like something happens, you know, between us. us, and of course not just between us, where somebody has to come away feeling lousy, either you or the other person, but somebody has to feel bad about it. Do you see how that's playing out here? So we want to keep inviting their curiosity and stimulating their curiosity,

always keeping our eye on the ball of they've come because something is hurting. You had asked, I want to make sure we talk about this before we ran out of time. You asked about the malignant narcissism. They were really disturbing. Let's talk about malignant. Most of what people are writing about on social media, the narcissist, exploitation, gaslighting, Darvo, blaming other people for everything. It's actually not about narcissism.

It's about malignant narcissism. And malignant narcissism is really the place where narcissism starts to shade into outright psychopathy. So clinically and empirically, we know when we start talking about malignant narcissism, there's really an overlap between these groups, right? I mean, a psychopath is somebody who is out for number one. And basically, their only real pleasure in life is in getting something over on you. right, power for its own sake. Not to do something good, not in the service of any other goal, just for its own sake, power, dominance, cruelty, sadism,

that becomes a chief source of pleasure when we're talking about a psychopath. And people are using the word narcissist when they mean psychopath. And it's not about narcissism, it's about psychopathy. So you can think of a spectrum, you know, there's a kind of narcissistic. that we've been talking about so far, at some point, there's no ability to invest in a caring way in anybody else. And our relation to other people, to our object, to use psychoanalytic language, is just suffused with aggression and sadism. Other people exist to be so that I can lord over them and take advantage of them and toy it with them for my own sport. And that's the intersection of the most severe kind of narcissism with psychopathic personality.

That's a very small subset of the narcissistic spectrum. And there's actually debate about whether people in that range can even be treated at all. There's some general consensus, there's some debate here too, but a true, you know, somebody who's truly psychopathically organized, may well be beyond the reach of psychotically. And the more that somebody, you know, somebody with malignant narcissism, the more psychopathic they are, you know, the less likely that they can be reached in psychotherapy. Yeah. I think, I think you're right about that. I think it's like, first of all, they usually don't come to psychotherapy before, you know,

like, I want to improve my relationships. because people are like cockroaches to them. People are like inanimate objects. And that's really the psychopathic version. And I'd like for listeners, especially listeners who are not in the field. I mean, this is such an important distinction. Because it's just like all over Twitter, you know, the narcissist, the narc. Most of the time they're talking about either psychopathic personality or border

personality. And borderline personality is about splitting and all of the badness is in someone else. It's in you, not them. So you get blamed for everything. Then we get into what gets called and these are not clinical or psychological or psychoanalytic terms, you know, but what's popularly called gaslighting. Then we get into gas lighting. If it's not done consciously for manipulation, if it's unconsciously for manipulation, then it's psychopathy. If it's not done consciously, but done automatically, unthinkingly, unconsciously, gaslighting is a function of splitting and projection. I did something bad with consequences that hurt people.

But like, oh no, I'm only good. Any badness that I might experience or perceive at all is dissociated, which is a split, projected onto someone else. and I'm going to blame you for it. And I'm going to blame you so effectively that you start doubting yourself. It's like, oh, my God, I thought I did the right. Maybe I did something awful. Like, am I this horrible, monstrous person that this person is making me out to be?

Like, God, like, maybe I am. I didn't realize that. So you start second guessing yourself. That's the gaslighting part. The gaslighting is like, you know, just like describes a social phenomenon. I'm trying to describe the psychology of what we're. we see in very severe borderline level narcissistic conditions that gives rise to the experience that we might then call gaslighting.

That's good, yeah. I got to see it as like you have a very confident assertion from someone because of their defenses are guarding themselves so tightly that they are all good so they can't be bad. So you have to be bad. And so they project that confidence. and if you are a empathic human being, like most therapists, with good mirror neurons, you feel. You start to feel it.

You feel that confidence, and you question yourself. And that's the projective, right? So there's a difference between projection, which is, I can't see something awful in myself. I see it in you. You're that person. That's just projection. What you're describing is projective identification. and projected identification takes it a step further,

which is I don't just project the badness onto you. I treat you in such a way, and it can be super subtle. I treat you in such a way that I can actually elicit those feelings in you. So it's not just that I'm seeing you, seeing you and treating you as if you were some horrible monster, I'm going to interact with you in a way that actually gets you to feel. I'm an awful monster. And it takes a lot of work on the part of a therapist. This is, again, where our consultation and our personal psychoanalysis comes in.

And it's like it takes work to work ourselves out of the position of thinking the other person's thoughts and feeling their feelings. And back to a position where we can start to think our own thoughts again. I can reiterate that. I think if you are a psychiatrist, therapist, and you're seeing someone, and they are evoking their own world in you powerfully. I mean, that's like psychoanalytic work, right? If you're seeing someone three times a week, they will evoke a lot of stuff in you. And that's a borderline level of personality organization. That's someone who does that to you?

Yeah. Because at a neurotic, right, at a neurotic level, you can say, you know, something that I just said, or, you know, something we just did, you know, is stirring up the kind of feelings you had when your mother did, you know, X, Y, Z to you. It's stirring up those same feelings that come from there. We're basically interpreting transference, and the patient sees it as transferential. They're like, yeah, okay, I mean, I know you're my therapist and you've actually been really helpful to me. And I do know you have my best interested heart. And yeah, like, you're really tapped into some, you know, some feelings that, you know, that come from elsewhere. Right. Right. So there's a kind of

an observing ego. There's the ability to, you know, to consider the possibility that the intensity or the feelings is coming from somewhere else. It's not just about you. versus at the borderline level, no, you are exactly like my mother, my bad mother. And, you know, God, what a disaster that I ended up with a psychiatrist, you know, who's just as just the same kind of rotten person my mother was or my father was, right? Right, the self of, you know, the observing ego disappears, and it's now a fact. You really are that. to use the language of Fonagy's mentalization-based therapy,

there's a collapse in mentalization, and my thoughts and feelings are now, in my mind, synonymous with actual reality. He calls it what, psychic equivalence. Yes, he does. Like, my world is now your world, right? Yeah, I feel hurt. You said something, and it was hurtful.

Therefore, it's a fact that, your intention was to hurt me. Yeah. And in fact, your intention was to hurt me because you're getting off on hurting me, because you enjoy hurting me, right? And any shades of, you know, gray and nuance just are gone, right? Psychic equivalence. I think it, I feel it, it is therefore true. And this would take us very far afield. But there's an awful lot of that going on and, you know, our culture at this particular juncture. Splitting? You don't, you really?

You think the, the U.S. is doing any splitting? I feel, no, I mean, I feel a certain way, I feel mistreated in some way. Therefore, it's factually true that you are a bad person and you are victimizing me. There's no differentiation between, you know,

a feeling on the one hand, and what may be happening in reality on the other. Got it. Yeah. You intended to be sadistic towards me. Therefore, you are a sadistic, narcissistic, horrible human being. It's like, whoa, I just left the sponge in your sink. That was a nice breaking it full circle. Exactly. I apologize. It wasn't you a sadistic human being. In the case of that particular example, in the case of that particular example, it's like,

you don't give a shit about me, you don't care about me, you completely contemptuous toward me. No, no, no, you are leaving, you are leaving that in the sink after I told you to torture me with germs. It's sadism. Okay, I'm changing your story. It's okay. I'm like, I'm like, but the version you're telling is a version that happens. And if we're getting into the borderline level of functioning and mentalization collapses,

then the projection becomes a fact. It can no longer be considered as at least in part, plausibly a projection, something I'm bringing. And this is where like it's so hard. One of the tortures is when you're treating a patient who continually goes back to that, like let's say they are in a very abusive. situation. You know, like the average, how many average domestic violence leavings do they, does someone have to do before they leave? Maybe it's like nine or 11, you know, sometimes it's like less, sometimes more.

But when they go back to that and they get like almost like reprogram that they are all bad and then they come back to you and then you're like faced with this like, you know, like, okay, wow, this person just went from. some form of psychological health to like once again complete devaluation of themselves. Yeah. Torture. Torture, but I'm there for it. I can tell you've been there. I'm like, I'm in it for the long haul. Let's go.

Hopefully. You say, you know, but I mean, that's getting into a borderline range of functioning already what you're describing. You know, I mean, one of the things we know, and if there's, you know, and if there's, If there's any big, you know, grand takeaway message, people are complex. We have contradictory feelings about everything. You know, people aren't, you know, heroes or villains. People are human beings. We exist in shades of gray. Everybody, you know, has the capacity to be destructive. Everybody has the capacity to do good, to be caring, to be loving. You know, we're a mix. You know, we're a mix, we're a bundle of contradictory motives and impulses.

And, you know, if we're trying to be self-aware, you know, trying to become better human beings as we go about things, we're not shutting out our capacity to do harm or, you know, our pleasure that we might take in cruelty. We're not pretending or dissociating and saying that's not me. What we're saying is, I feel those impulses. I have fantasies. I have thoughts.

You know, fantasies are free. Fantasies are not the same as acting on it. Fantasizing, you know, about paying someone back is a world of difference from actually setting out to pay them back, you know, right for my own. own, you know, my own pleasure and revenge. When somebody gets in the kind of relationship you're describing, you know, and somebody is the abuser, and all of a sudden, there's no aggressive or destructive or cruel impulses in them, right?

Then, you know, there's a lot of distortion going on. Now, it may be true. perhaps they're actually objectively in an abusive relationship. But it also serves a function psychologically. I don't have to reckon with any of the badness in me. The badness is in that person. And then you ask the question, well, you try to pry them out of this abusive relationship

for their own safety and well-being, and often they go back. And then you have to ask psychologically, why? What is it? What is it doing for them? And then there's a lot, a lot, a lot different answers. But one answer is some people require, you know, they need to be in the presence of something evil.

Because then we know that the evil is located there in someone else. Okay. You know, I think as well, this makes me think about like our own countertransference to working with clients. It's like, yeah, you may have anger. discussed, your own. And I would say if you are a human being who does not have any access to your own anger, you're probably needing to do some deeper work, right? You're probably not going to be a very good psychotherapist.

So I think it's really important to, as well, emphasize, like, yeah, if you're working with clients who are on the borderline spectrum of functioning, this is, or borderline personality, or both of them probably evoke the same, different, strong countertransference, right? Like, it's all part of the process, right? And you will, in the process of doing therapy, I think more emotion is evoked in you than maybe you were aware existed, right?

And that's why every one of the, you know, we now have several evidence-based treatments for borderline personality. Evidence-based, meaning they've been studied in controlled trials, and we know they offer help. Every one of them emphasizes the necessity of consultation, supervision, support for the therapist. Because there's a recognition. You know, we're going into really turbulent waters.

There's some big waves coming, and you don't want to go it alone, and you want somebody else to be able to, when you think about mentalization or refrable, about your transference, of your countertransference, you want somebody else to be able to help you think about it and say, you know, perhaps you're feeling this way, you know, because. And you need somebody else to kind of help you separate yourself from the projected identification, you know, the thoughts and feelings that are, you know, that are being evoked in you and help you find your way back to a place where you can think your own thoughts

and say, how can I understand this? What's going on? Yeah. Yeah, that's really good. It's like, until you are able to do this deep work, you may not even realize the need for a good supervisor. But then you just inevitably get, do very superficial work or like, you know, you're teaching the mindfulness or something very like, you know, coping skills. Which is, you know, which might help stabilize somebody in the midst of, you know, who is affectively dysregulated. But it's not addressing.

the underlying psychological structure that's making them so vulnerable to repeatedly getting disregulated. Right. They did, there was one study on transference focus therapy, which is kind of what we're talking about today, versus dialectical behavioral therapy.

Both of them did very well, treating borderline for a sali disorder. Both of them highly, you know, good evidence-based treatments, but the Transverse Focus Therapy group improved their reflective function. a little bit. They improve their ability to attach. Yeah, you're thinking of a study.

The lead author was Ken Levy, and it was a comparison of transference-focused therapy with DBT. And when they looked at just, you know, external measures, like things, it's been a while, but as best I can remember, things like, you know, hospital admissions, emergency, you know, emergency room visits, you know, suicide attempts, you know, suicide attempts. in the immediate short run, both therapies were helpful. They reduced these harmful behaviors. But what they found in the transference focus group, which is to say this echo-analytically oriented therapy, is that people, two things happened. One is people's attachment styles changed.

So people were moving from insecurely attached styles, avoidant or anxiously attached to more securely attached. styles. In other words, they were developing something that could change their lives on an enduring, ongoing basis. We're taking people who really couldn't consistently connect with other people. Ultimately, what's really stabilizing is, you know, we're not going it alone. We feel connected to others. We're taking people who didn't have that in their lives and giving them that capacity. And then hand in hand with that were changes in reflective function. Reflective function is the name of the research scale that measures the concept of mentalization, which is to say

they were not continuing to equate their feelings and their perceptions with external reality. They were developing the ability to think about it, to place it into context, to call them, to call their own perceptions into question, and therefore to act differently in the world. So there are things that are sort of life-changing. And I don't recall that this got a lot of airtime in the literature, but my understanding was that the benefits of DBT began to decay over time, right? They kind of, you know, the maximum benefits were at the point when therapy ended.

and then the gain started to slip away, whereas in the transference focused or the psychoanalytic therapy, the gain seemed to endure. Yeah, I'm not, I'd be curious to look at that second piece if you have that research. We'll put that in the article. And yeah, we've got to bring it together here. So, okay, any final thoughts?

Any summations? I guess I'm just making a case to remember that human beings don't exist in, you know, black and white categories of heroes and villains and victims and oppressors. And we're talking about human beings, you know, not storybook characters. And, you know, being a human is complex and nuanced. Okay. Any word for the person who keeps commenting on all my YouTube's. Where's Jonathan Shethler? Bring Jonathan Shethler back.

You have some people idealizing you out there. Well, I was just going to say they sound like a very thoughtful and discerning individual. Yeah. Oh, man. Okay. Well, there you go. I hope this looks like to the expectations. Every YouTube I post in the future

We'll probably have multiple of those then Okay, thank you Well, it's been fun discussing these issues with you All right, we will leave it there for today And yeah, if you want to have Jonathan Sheller back You'll have to tweet at him, you know, incessantly They should direct all the commonly

At me, right? Okay, all right, we'll leave it there for today. Thank you. Thank you, David.