Psychiatry & Psychotherapy Podcast - Pathological Narcissism: Effective Treatment with Mentalization-Based Therapy (MBT)

Episode Date: November 15, 2024

In this episode, Dr. David Puder, alongside experts Anthony Bateman, Dr. Brandon Unruh, and Robert Drozek, delves into the complexities of treating pathological narcissism with Mentalization-Based Therapy (MBT). They explore practical strategies to help individuals with Narcissistic Personality Disorder develop self-awareness, emotional regulation, and healthier relationships. Learn how MBT can transform the therapeutic journey for those who often feel misunderstood or resistant to change.  By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with a team of people. We'll be talking about narcissistic personality disorder. We'll be talking about mentalization-based therapy for patients with narcissistic personality disorder, narcissistic traits. This is kind of like probably the world's best team for this that I'm bringing on. If I can be grandiose myself, this is, you know, I was thinking about it. Okay, if you were really, really narcissistic, where would you want to get your, where would you want to go, you know, to be like to get your treatment? You would want to go to Harvard, right? And who would you want to go to? You'd want to go to the world best founder. So we have Anthony Bateman. He is the founder of, a co-founder of mentalization based therapy. We have Bob Drozac, who has been kind of huge in in bringing together a team to write this book. mentalization-based treatment for pathological narcissism. And then we have Brandon Unruh, who is in the trenches treating borderline personality disorder,

narcissistic personality disorder. And I kind of want each of you to introduce yourselves. Maybe Bob Drozak, you can start. Just a little bit like, what does life look like at this point? How much clinical duties? How much research? And so, yeah, give us just kind of a brief intro. Okay, all right. Thanks, David. Thank you for having us. It's really fun to be here. We love your podcast. So, yeah, I'm a clinical social worker and clinical director of the mentalization-based treatment clinic here at McLean. I'm Brandon's the medical director. And working a bunch of different programs here, but a lot of what I do is sort of helping folks with narcissistic personality disorder, borderline personality disorder, doing like individual and group treatment.

sort of squarely focused on MBT. So, you know, sort of most of what I'm doing is sort of helping folks to these challenges with doing sort of individual therapy. And then we have a NARISIS, MBT group for folks with narcissistic personality disorder and then just do have a private practice where I do a lot of helping folks with narcissism

and do like consultations, as diagnostic consultations of like, how do we give the diagnosis to folks with narcissistic personality disorder? Okay. And so some of the audience will be wondering, like, why is that your unique passion in life to work with patients with narcissism? Maybe we'll kind of come full circle to this. And then Brandon, you want to introduce yourself.

And thanks, David. It really is a joy and treasure to get to be part of this great podcast. Thank you so much. You know, like Bob, I practice, I'm a psychiatrist and psychotherapist. I've been based at McLean Hospital outside of Boston since I finished my training there and at the Mass General Hospital in Boston a number of years ago and got interested in personality disorders right in the middle of my training when I was being mentored by John Gunderson, you know, one of the so-called parents of the borderline personality disorder diagnosis.

And since then, I've just fallen into a variety of different clinical and administrative administrative roles, was involved with the founding of the MBT mentalization-based treatment clinic at McLean right from the get-go. And it's just been a joy to see that be a place that's still hanging on and continuing to be a place where clinicians can come across different disciplines and modalities and degree channels to get treatment and training, rather, in MBT, and where we're continuing to actually deliver insurance-based, specialized evidence-based care for personality disorder. which is a bit harder to come by, at least in this country. And then my other hat that I primarily wear is I'm the medical director of the Gunderson residence, an intensive residential program that is different from our MBT program and that it's a more integrative, evidence-based personality disorder treatment program

where we're integrating elements of dialectical behavioral therapy, elements of mentalization, elements of transference-focused psychotherapy, and some elements of John Gunderson's approach, of good psychiatric management. So it's a bit of a mysterious, eclectic place in that way. It sounds world-class. It really does. I mean, I've done an episode

where we talk about all the treatments that work for borderline for sali disorder. And I feel like when I went through training, it was DBT, right? That was the thing. And now it's become a lot broader. And so it's great to see that, you are like really bringing together all these fields.

And I want to learn a lot from you on those things. And then Anthony Bateman, you're in England. And you are someone who was on the podcast before with Fonigy, which was one of my favorite episodes. So thanks for coming back. Okay, yes. I'm Anthony Bateman. And I'm visiting professor at University College London.

And whilst I may be one of the co-factorial of MBT, I'm certainly a hanger on in this podcast because the bulk of the work and studying a pathological narcissism and mentalizing has been by Bob and Brandon. So I'm kind of joining from behind here. And I kind of steer occasionally, but the creativity is there. It's not, not mine, I should say. I'm actually a psychiatrist. I currently just, I better say, I do not do any private practice. I've never done any private practice. So I do not. set referrals from outside our national health system here in the UK. Yeah, just in case.

But I primarily now advise the Anna Freud for clinical work and training in mentalizing. And mostly other than that, generate and write up research projects which are coming to fruition, most recently about mentalizing an antisocial personality disorder, which we'll shortly be publishing a large trial about. Okay. Nice. That's, that's, that's, I'm excited to hear about that. Okay, so I was thinking we just kind of like launch into what is, what is narcissism? Bob, maybe you can kind of direct us towards like grandiose versus vulnerable narcissism and speak specifically what you're finding in terms of the high percentage of patients with borderline for society disorder who also had narcissistic tendencies and maybe the differential, like what

makes, what stresses lead to someone maybe decompensating who's more narcissistic versus more borderline for size disorder? I think that's really interesting. Okay. All right, great. Well, I think we'll probably all have stuff to say about this, but in terms of like the prevalence of sort of narcissistic personality disorder, at least in the United States, it's around 7%, which is pretty high. in terms of the sort of percentage of folks with both BPD and nursing, I don't know tons of research on that specifically. I can kind of speak a little bit about some of the symptomatic overlaps. But basically, narcissism is, you know,

it's seen as there being like two different subtypes, grandiose and vulnerable. Both tend to have, we can really think about narcissism as like a disorder of self-esteem regulation, you know, and really the sort of the excessive reliance on what we call self-enhance in order to regulate self-esteem. And that can take a lot of different shapes for folks with sort of more than more grandiose subtype. There's this idea that I am great, I am better than other people, sort of, you know, to be honest, in terms of the percentage of sort of those folks presenting for clinical care, it's much lower than folks with vulnerable narcissism. So the folks, you know,

it's a lot of times there's this sort of saying in narcissism treatment that like, sort of like the grandiose folks come to treatment because their family wants them in treatment. There are other people want them in treatment where the vulnerable folks will be coming in because they're actually, they're kind of suffering subjectively in a way. So in vulnerable narcissism is really this idea, not that I am so great, and this may be overly simplistic, but that I should be so great. I am only valuable if. So it's this construct of,

it's called contingent self-esteem, which correlates with vulnerable narcissism, and it's basing the sense of self on external factors, like achievement, success, money, attractiveness, attractiveness of romantic partners.

So a lot of folks with vulnerable NPD can really, you know, their self-esteem and their mood can rise and fall based on whether or not they're getting that external kind of positive feedback in a way. So that's kind of the broad distinction. Both are joined by what they call. It's called different things in the literature. But essentially, some people call it entitlement. That's been shown to correlate with sort of both subtypes. Some folks say antagonism. Some folks say self-centeredness. So the idea is that there is a unifying thread for those two subtypes.

and it tends to be sort of some elevation of self over other. I don't know. Anything. Yeah, beautiful. No, appreciate it. Brandon, that was the best ever, Bob. That was awesome. I'm going to be making some just fun, grandiose statements during this whole interview,

so just be ready. Can I add to that as well? Because Bob's mentioned, and you were asked about borderline personality disorder and narcissism, but in fact you find a much greater over. overlap, I think, generally with antisocial. So the problem with narcissism to some degree in the grandiose subtype is that it can get expressed through that entitlement and antagonism, and that leads, of course, to social disruption. And once you feel grandly entitled to things, you tend to start potentially committing crimes and so on. But more importantly, and it's problematic for treatments,

is that you narcissistically have overcome your developmental traumas. So you may have had considerable developmental trauma leading to antisocial dysfunction in adolescence, but actually you narcissistically have overcome it. So when you're questioned about your capacities to manage yourself, manage your emotions and all these things, they say, well, that's not a problem for me. I got over that years ago.

No, not at all. So they then use their narcissism, in fact, to deny any developmental problem that may impact on treatment, for example. So that then becomes a major problem of engaging that group of people in treatment. Nice. Brandon, do you want to, how about envy? How does envy play a role here? Well, envy can be particularly toxic in association with narcissistic vulnerability. I mean, because it's inherently, we would say, a challenge to one's self-esteem needs to kind of preserve a stable sense of oneself as measuring up to what one expects or senses other people expect.

But the experience of envy inherently contains within it a sense of myself as lacking something, as outwardly directed in the sense of looking at someone else who's got the thing that I think I want or had better have. So there's an inherent vulnerability in sitting with the experience of envy. I tend to actually think that envy may be the most challenging emotion, or one of them, to actually manage within ourselves for many of us. But it's certainly a problem in NPD. And the problem is really about sitting with the more vulnerable aspects of that experience of envy. It becomes toxic rather than a kind of healthy motivator that's adaptive for, well, if I see someone who has a reputation I kind of admire, well, maybe I could work on myself and go do the work

over time in a stepwise fashion and tolerate the uncertainty and be incremental in my approach to build myself up in that direction. But people with narcissistic vulnerabilities can't do that. And we sometimes call this the narcissistic staircase of doom where they feel they have to pole vault themselves to the top of the staircase, rather than being able to tolerate the incremental steps along the way, which is going to involve tolerates. that sense of not having something that other people have. And people with NPD tend to just opt out of that process altogether, rather than it's kind of staying on the path and allowing envy to function adaptively.

That's really, that's good. I really appreciate that. That's good. Okay, so let's go into the problems in mentalizing associated with narcissism. So what kind of, maybe let's start with, diminished emotional awareness or alexathemia, kind of this inability to maybe identify emotions as well, more vulnerable emotions like sadness, shame, insecurity. Yeah, do you want to, Bob, do you want to jump in? Yeah, no, this is, I think, a really, this is sort of where MBT mentalization

based treatment, though folks listening to this podcast, because David has done such an amazing job covering, mentalizing and reflective functioning in this podcast, which is, Really, I think, exciting for us. But just to kind of make sure people are kind of on, you know, top of what this idea means of mentalizing, it's really the ability to reflect on mental states in ourselves as well as other people. So what a lot of times people, when they think about narcissism, they'll think like, okay, they have folks with NPD have difficulties putting themselves in other people's shoes.

They have equal difficulties with putting themselves in their own shoes. and that's something that can often be missed. So like if, you know, in terms of what's been shown through research is narcissism is correlated with alexothymia, difficulty putting words on emotions, difficulty finding emotions in the self. So these are the patients, you want to start thinking like when you're sitting with them in session and they're describing lots of scenarios, you know, very externally focused, talking about whether or not other people are right or wrong around something, you know, and then you asked them a question, well, what was that like for you? And they continue to just describe the

situation. You want to start wondering, this is what we often see with the electathymia kind of connected with narcissism. And the idea is that it's just hard. There's not quite a language for emotions in themselves. And so, and that's been shown, you know, I think you cited some of the research, David, that, you know, specifically sadness, insecurity, shame, and dependency on others has been shown through research that folks with narcissism really, they don't spontaneously put words on those emotions. So there's a bias in what they mentalize in themselves. And so a lot of the treatment is actually,

the early stages of treatment is helping them find a broader array of emotions in themselves. Anything you, Brandon Anthony, you would add around that, the difficulties, no? I think it was so superior how you put it. It was just so good. I'm going to be getting so much validation in this podcast. Sorry.

Stoke is grandiosity soon to be kept. I need to not like have a placating tone here. I got to work on that. No, I really think it's good. I think there's something about that like, it's like what do they have? They have anger. They have superiority.

They have this kind of detached demeanor. Is it like in your work with them? them. Like, you really do see, like, okay, people probably, this is what I'm imagining, the audience is thinking, wait, you see people move past that? Like, is that what you guys actually see happening? Well, I mean, I think we wouldn't sort of be at this place of having sort of invested enough in wanting to kind of develop a bit of a model instead of techniques if we didn't feel there was, we were able to get leverage around this and some progress with at least some of our patients. And that's really what kind of galvanized, you know, writing this up. But yes, it is a

touch and go process. And that initial stage of alliance formation, that's so, such a critical universal element in psychotherapy for any, any cause, targeting anything, it is a more fraught process. The treatment dropout rates, as I think you've reviewed in your podcast previously, are much higher in NPD, even than for BPD, because there isn't that kind of natural dependency seeking, you know, that the primacy of connectedness, and wish to kind of stay in connection and manage connectedness with the therapist, that isn't there in the same way. It's not there as an adaptive motivator. Even though that's disordered in BPD, it can really be kind of co-opted in a productive way by the

therapist. If you lean in with interest and you're basically empathic and validating, that goes a long way. And a lot can be forgiven by somebody with BPD more easily. But in NPD, it is a much more process, I think. So we're doing a lot early on to stay very contingent to our patient's experience. And then the kind of subsequent moves are often, as Bob's describing, around trying to enhance an affective vocabulary. But it's really the mentalizing capacity to look at the mentalizing capacity to look inwardly with reflectiveness into oneself and that takes we believe this affect elaboration pathway that maybe Bob can speak more about it is inherently a challenge to the patient's certainty about what they see or don't see inside

themselves and so it is a kind of narcissistic challenge in and of itself to be pushed to look for more within oneself you know what more might might be there beyond your immediate angry reaction or that sense of being diminished, you know, what other feelings might be around. And that's why we developed more of a kind of instructive pathway for clinicians to walk through that a bit more carefully. And just to add for that, if it does, it might be important to emphasize that actually the kind of empathic sort of joining the Brandon's mentioning, in a sense, has to be around the idea that they're experience that they look inside themselves.

and they're very uncertain what they find. And that in itself is dangerously painful because you can't then formulate really your inner experience all that easily and at least not in a flexible, rather generalized way or even in a specific way. So you tend to then start operating along very narrow, rigid sort of ways and so on. So you have to be empathic to that, not to the anger as such or anything like that in a way first.

And if I can just put that in the MBT perspective, we've rather, I suppose if I'm allowed to use the word, sort of bastardized eye mode, which is the inner experience of eye. And elixothymic or the inability to look inside to actually, as it were, integrate bodily experience into an emotion and label it is actually what they have problems with. And you're asking about their mentalizing problems. Well, this is one of the first components. Their eye mode isn't really working very well. So we called it that for clinicians. Can you explain eye mode? Like, what does it mean?

Well, I'm mode in a truly the experience of existence. Work goes back to the 1890s and a sort of Jamesian consciousness and awareness of consciousness. But we sort of developed it in a sense clinically, simply to get this self-reflective capacity, the ability to actually integrate in a interceptive bodily experience into a representational level of meaning of one's self.

And that is a self that's then continuous across time and doesn't require self, it doesn't require referencing with the world. On your own, you can carry this self wherever you go. It eventually interacts, obviously, with others. and when it's interacting with others, we call that me mode, and Bob's added you mode to it

because we have to read other minds and read them accurately to some degree, which is what mentalising's about. So that becomes me mode, as it were, you me mode anyway. And we tend to personalise that. We simply read other people, but in reference to ourselves,

and we compare, do they represent our mind accurately, do they see us as representing their mind accurately, and so on. So then you're into the self and other interactive, and we call that me mode. But that's also somewhat problematic in narcissism, just to put this component in context.

And David, along the lines of what Anthony's saying, do you want us to talk about, like, the treatment techniques for this now, or are we sort of holding that for later? Yeah, I'm just going through questions one by one, and then, you know... Well, so I guess, David, to the point of what Anthony's saying, it's a real important part of like how we go about helping folks with this because a lot of times when folks are treating folks with NPD, they'll want to say, well, what do you think what that was

like for your wife when you said that to her? And we would really not recommend that at first, right? So what Anthony is talking about is that we really need to be prioritizing like an infrastructure of selfhood prior to moving to other. So the idea would be, is like, how did that make you feel when your wife said that to you. So I was so pissed off. You know, so you explore the pissed off feeling. But then, to Brandon's point, we got to expand it. You know, I'm curious, what about when she said to you that you weren't,

you're not really a good husband? Did that bring up anything other than just pissed off? So we're just trying to horizontally expand the person's experience of themselves. There's anger. There's hurt. There's shame, right? That is all working from within their own perspective. first. So that is a core kind of element of what we're kind of thinking about here before kind of

going to the helping them mentalize other people. Got it. Okay. So yeah, it's the deepening of their experiential self. And then it sounds like also like also trying to help them find who they are outside of other people and other people's like external validation. Is that, I'm getting some nods. You all don't hear us nodding? Yeah, yeah, thank you, David. I need some vocal validation. Thank you. He's done a ton of these.

Brandon and I have no idea what we're doing. Yeah, so, yeah. You guys are doing great. Yeah, and so what I would say is, like, let's go through the areas of where they struggle with mentalizing. And then I love, let's already incorporate kind of like how you approach it. I love that. So how about the overconfidence in perspective taking and impaired empathy? It's fun.

This is a good one. Yeah, I don't want to be the first one to respond. So, Anthony, why don't you take that? No, no, no, you go, Bob. This is your wrap, you know, you should be, we can chip it. Anthony, that's very non-narcistic of you, by the way, to allow your young protege to have the floor so much. But that's what you have to do as you get older.

It's a narcissistic hurt, but it's something that you have to come to terms with. I love that. I take things on. Yeah. Dr. Tar, one of my mentors, we co-taught for like 10 years together, and he was far superior to me in his understanding of psychology and psychotherapy, but he would always, like, he had that spirit about him of like, you teach first, and then I'll jump in and kind of slightly correct you, which I appreciate it.

I learn from them. That's, I hope. That's my youth. I want to learn from them. Then I keep young. Yeah. That's good. Also, you said kind of two things, David.

You said sort of the certainty and perspective taking and then the problems in empathy. We kind of put those in different camps. You do kind of deal with a little differently clinically. Okay. Let's start with the overconfidence in perspective taking. That is really. It's so crucial here. So that's the idea is that oftentimes this is what MBT calls

Psychic Equivalence Mode. If I think that makes it so, it's really, really relevant for narcissism. And it's not always, sometimes it's like I know that I am a certain way. Sometimes it's, I know that what that person did was wrong and this person's horrible in some way. Sometimes it's like, I know I'm bad and not good enough. So it's a bunch of different forms of certainty. And so this really comes out of Anthony's formulations about treating personality disorders more generally. So we didn't really do anything new on this one.

But like one is the sort of the most common form of certainty that you'll see with a lot of folks with narcissism is like a negative judgment of the other person. You know, so some version of like my wife is too critical of me, you know, like something like that. So that would be like a negative judgment. And so in MBT, we would never take issue with that on first pass. We would want to be saying like, okay, well, so tell me more. In what ways is she so critical? You kind of like help them kind of make their case to you. And then you explore the impact on the patient.

And so, okay, wow. So when she's treating you in that way, how does that impact you? What does that bring up for you? So, again, not in any way sort of challenging. But the problem is, is that if we only do that, we're not really helping patients to see things from a more flexible perspective. So we've got to do more. And what Anthony has sort of envisioned. So let me, let's jump into this.

I'll be the narcissist here. Okay. Okay. Cool. Well, it brings up rage for me, Bob. It brings up absolute rage. Okay. All right.

Tell me more. What's the rage? Well, it feels so disrespecting. Yeah. And it's like I'm working my butt off, you know? And then I do the dishes. And then it's like, yeah, and then I hear a critical word. And it's like, hey, I'm doing a lot here.

Absolutely. So it's like you're literally working so hard so much of the time. And so it's enraging that she sort of would even speak to you in that. way. Yeah, that's exactly what I said, Bob. Good. You're repeating back to me exactly what I'm telling you. Is this what I'm getting from Harvard? Like, is this what I'm getting? Well, it's fair. It's fair. I don't know how much sort of knew I have to offer here, but I'm just curious. Is she always sort of... Are we laughing at my comment here? I'm trying to pour out my heart here, Bob, and I feel like you're like making light of this. I'm sorry. I apologize. I think it was laughing.

I thought you were kind of joking a little bit with the Harvard thing. I appreciate that. No, I was. I was. I was messing with you, Bob. Well, so let me just ask you, just to be clear. Wait, can we pause? How's my character here?

I'm like heating up here. I don't know. This is like getting too hot. No, no, let's stay with it. I want to say. Okay, okay. Let's keep going. Well, so I'm just curious, though, is she always, has she always been this way?

No, I mean, I think. when we were like initially, you know, maybe the first six months, it was kind of like, you know, I felt like she was like very supportive. And then something flipped, yeah. I see. Okay, okay, okay. And then just curiously, yeah, so when she was more supportive, how did she treat you? Oh, like everything was gratitude and positive and, you know, warm and, Uh, and yeah. Okay. And I'm just curious now, like, this past week,

has there been, have there been any days where she's been any, like, better than others? Uh, yeah, maybe. Okay. What did she do that day? Um, she greeted me with a hug. That was nice. Yeah, what was that like? Well, I don't know.

It was just, you know, it's like, it's like, Nice. Yeah. It sounds nice. I mean, I really appreciate what you're putting words on here because there's a really way in which you work tremendously hard and it doesn't seem fair that she would just come and criticize you. And yet there are these other moments where it sounds like you see a different version of her

and where she's kinder, she's warmer, she hugs you, and there is something nice about that. Yeah. Okay. We can pause there. All right, okay. So, and it doesn't... Can I like, can I have... Because I would like Brandon to become the patient now?

What do you think? Well, so, can we, David, not to be too controlling? But I really want to hear Brandon's thoughts on that. Because I didn't... Do you want a bit of commentary on what I thought was happening there? Is it okay, David and Brandon give some commentary about that? Because this is, yeah. I want to have increased envy on Brandon being a better patient than me.

So, no, I'm joking. Okay, yeah, let's hear Brandon's comment. You set the bar. David, I think. You set the archetype. You're amazing. Yeah. No, I think just a brief commentary, I mean, kind of just pulling out some elements of the model. So I think what you saw there was

Bob was responding to you, David, without any sense of challenging or really questioning your initial experience. I mean, that's the first thing. You know, in MBT in general, and this is really Anthony's sort of, you know, I mean, insight from the beginning, first place is to just get

impressionistically alongside the patient as best as we can. And that can sound like psychotherapy 101, but it really is starting point for MBT, and it's important to be very contingent to the subjectivity of a narcissistic person, just as a get-go. So you saw Bob just trying to join you in that. He wasn't questioning. He wasn't criticizing. But then he starts to just take up that experience without questioning it itself. And he may be thinking in his mind, well, this sounds a bit over. overly certain or rigid, or maybe that's a psychic equivalence to use the jargon, but he doesn't press on that, the certainty or rigidity about it. He doesn't go after that at

first. He just starts asking elaboration questions. And he's interested in, you know, how did you get to this sense that she's critical all the time? And he starts to use his own reflective power, his own mentalizing, to just ask clarifying and elaborating questions. And what I think happened there was that those questions, without him really challenging, you know, your experience, started to expose some areas of potential nuance, some potential gray area. And these would be things that we'd seize on and come back to work with later in our pathway for managing this certainty problem. Because these would be potential footholds where we may be able to turn on some mentalizing. Get some curiosity going. get out of that all-knowing stance and actually introduce some uncertainty.

So I think you saw Bob doing that saying, she always been like this? And then you got interested in kind of, well, what was it like when she greeted you with a hug or earlier in the relationship when she seemed a little less critical? So what we hope we've achieved so far is we've got a patient, actually,

that's moved out of that position of complete certainty. They're a little more interested and uncertain about, this has changed over time, you know, maybe even now in the past week, does this change over time? Do I have different experiences that fluctuate or don't I? And it's introducing that uncertainty. That's really priming the mentalizing pump. That's the first few steps. Yeah. So in the model, it's very much expanding the field of sort of discovery because you start off with such a narrow line, which is a wife who is critical. But actually, you just simply expand it, from what we call the exploratory or not knowing stance, really, where you're not actually challenging the validity.

That's really important. You're accepting it as seen from their perspective and getting it expanded. And interestingly, people worry about it. You're in a way, as Bob and Brandon have said, landing actually alongside the patient and looking at the whole thing through their eyes, not trying to get them to see any. different at first. And that's where we actually end with an empathic validation. So in a way, we're scaffolding the narcissism first here. We're not trying to demolish it. You're just scaffolding it so that actually here we are, this is where we are, now we're together. And you could get empathically validating already to some degree about this person who actually can't quite work out, how his wife now can see appear so different across time. In the one hand, she's like this.

but then she's like that. What do you make of that? Do you sort of mean? You're just continually opening up the field of sort of exploration here. And I'm curious for you, David, like, because I had to go, when I asked that question,

and has she always been that way, you stopped and you looked, and you had a couple pauses that sort of end up having. I was curious, what were you feeling like in those moments? I don't know if you remember. Yeah.

I think I think I was, I was trying to imagine my person that I was embodying, not from a place of my own experience, and not from a place of, like, an identifiable patient. Okay. So it's like I wanted to tell a story that was, like, unique and not necessarily, like, something that was, you know, I wanted to stay.

in character. So I was like trying to imagine this character. I think you're beautifully in character here, just to point out, that you came back at Bob in a wonderfully sort of dismissive way. You said, well, you've just repeated what I've said. And that's exactly the sort of area that you need to get in because it was so sort of pithy and direct and say, well, what's new here? Have I got anything to learn from you? It doesn't seem that I have, really. So on. You're straight back into the sort of. sort of narcissistic management of whatever your experience was, which was disappointment, or really I thought I'd come to Harvard, but what I'm getting is some kind of echo chain,

but hell, you know, what is this? And so. Yeah, yep, yep, yep. No, that's, and I think those moments, and this is why I wanted to illustrate this for my audience, those moments are some of the most painful, difficult moments to manage. And so, yeah, okay, let's slow it down right there. What, what could be some other ways of approaching a patient when they do kind of that direct attack, right? Because I'm curious, Brandon, maybe you could speak to, like, I know you've also trained some transference focus therapy. Because, like, I think they would jump on that as like a transference moment, right?

But I'm curious as well, like, how mentalization would differ in your approach to that specifically. Well, this is a good question. And with, you know, full appreciation for transference-focused psychotherapy, which I use as well in value in my practice. I think there are some real differences here in both theory and technique, and just to keep this on the briefer side, what I think you saw Bob doing was just standing sort of firm in the not knowing stance. He didn't actually use too much of, you know, his own mentalizing, I thought, in that moment, to come up with some idea about what might be going on in the patient's mind. He didn't do anything interpretive.

You wouldn't do that in TFP either right out of the gates. But in general, MBT really views the experience is really quite co-constructed. I mean, a real think, Anthony, correct me if you wouldn't agree with this, but really a two-person model in that sense to use Nancy McWilliams language. And so Bob sort of stays with the sense of, I don't know if I can be helpful to you. It's kind of like, well, let's see. I really don't know. He doesn't get defensive and he doesn't get interpretive. He just kind of rolls with it. And he also doesn't stop and take it up immediately and kind of do a deep dive on exploring the relationship in the here and now. And I think he's done that. Bob, tell me if this is not how you were thinking in that role play.

But I think he's doing that because Bob senses there's so much certainty here already operating. And I think he's kind of made a clinical assessment. this patient's mentalizing is quite fragile and it may even be rather offline at the moment. There's so much certainty that's operating. So in general, we may not use that as an opportunity to move into a kind of depth exploration of what's going on in the representational object relations diet, as you might do in TFB. Bob just stays really contingent to the patient's experience and continues to explore that. I think in the hopes of trying to get some mentalizing going first and foremost, knowing that if he goes to analyzing the relationship in the moment, that's generally a higher order mentalizing challenge for all of us, really.

So I think he's trying to stay with, okay, we've got a patient who's overly certain. Let's just try to get some uncertainty and curiosity into the mix around this area before we go to what's likely to be a more fraught challenge to mentalizing. Does that make sense? And the other bit may be important a little bit there is that, and I don't know that this is a differentiation, it may not be, but just for the importance of it, is that Bob was the creator of that problem. So in a sense, he was the source rather than the patient being the source. And very often when you're talking about transference, at least, the patient is seen as the source. And in this case, actually MBT would see this as a joint sort of creation, but it started in a sense with Bob, who created an anxiety in the patient, unwittingly unknowingly, as it were, of which destabilizes the patient. So they actually have a vulnerable self at that point.

So in order to create a more stable self, you actually create a stable self by dismissing the other mind. So you recreate your own mind. So I think we'd probably see a lot of that reaction as secondary say, rather than actually being, I don't know, indicative of primary aggression or something, whatever, you know, that other people may see things in a slightly different way. And then that alters, of course, your technical intervention as well, as well as seeing the other mind as actually being ineffective mentalizing, therefore not open to exploration so easily you actually see the source.

of the problem as being triggered, in this case, by the clinician. That probably is the most important technical distinction, I would say here, which is that in our kind of model for mentalize, we do a lot of relationship work in MBT. Lots, I think, that's one thing I think that there's a sense that, oh, TFP does the, in the relationship work, MBT sort of just does the sort of the reflective work. I don't know how you both see it, but I definitely do tons of relational work, but the difference is if we presume that it's co-constructed, then that expands our interventions. Because I think what I said there, because I was a little bit, uh-oh, I mean, part of it's like, oh, is this going to make me look bad?

Because I'm role-playing on a podcast, right? So that was one part of my experience, right? But what I said is like, oh, I'm sorry. I thought you were joking, right? Which is sounds like a very quick move. But if it's too person, I can apologize for my contribution. And that's so important in the treatment of narcissism because that regulates the patient. Right. I think you were laughing because you were stepping out of the... I was. That's true.

You were stepping out of the roleplay and you just thought like, okay, this is getting really comical, like the amount of like how this flipped so quickly. And then instead of like pausing the role play to like laugh with you, I decided to like dig into it even more. That's true. You got me, David. You got me. Oh, man.

Brandon, were you going to say something? Just underscoring, I think there is a difference in the models here. You know, we're really quick to kind of, as we say, take it on the chin sometimes. We're quick to sort of own whatever we think may have been a potentially real contribution to the problem for the patient in the moment. So we're, you know, it's not that we're not interested in how some of this, what just happened between us may be an expression of the patient's psychopathology, but we're explicitly, I think, verbally showing that we're quite open to how we impinge

on the patient's mind. In real ways. Brandon, but don't you want to narcissistically defend against that you are the cause of their suffering? Isn't that like a deep profound desire of ours as clinicians? that I am not the problem. It's your parents, right? It's your parents. It's the transference. You're not really angry at me. You're angry at your parents right now. I didn't cause any of this anger, right? Well, I think Bob will have something to say, because this is some of his other work

on the ethics in psychotherapy and prioritizing sort of awareness of where is the clinician's self-esteem at. But I think you're getting at that, David. This is an important piece of counter-transference or counter-relationship, as we'd say in MBT, and working with Narcestine. statistics individuals, we do have to actually kind of be able to manage that sense of, gosh, am I going to be useful to this person? Gosh, I'm feeling quite inadequate and powerless to help and deskilled and unskilled. And where did all my training go and feeling quite helpless to be helpful here? So those are common counter-relational experiences that are, I think, more unique, are more prominent in treating NPD than even BPD. So yes, we do. We do.

have to be able to manage that. But in MBT, we don't, you know, we're going to be a bit more forthcoming about some of some of that in the moment. But Bob, you may have more to say about this. Yeah, I love the question, David. And it's really, I think it's such an important point. And if we think about it, what are the parenting styles that have been shown to kind of be correlated with the development of narcissism? Parental psychological control. It's been shown that folk that parents with NPD are more likely to have kids with NPD. So that's the, this is a really important thing.

That's why I love MBT as a model for treating narcissism, because the not knowing stance and taking it on the chin, as Brandon says, is kind of anti-narcissistic. Like, we need to be willing to own our part first. And this is consistent with like contemporary psychoanalytic thinking. Right. That's right. Interceptivity theory.

And, but the cool thing is, is we do that, folks down regulate. But then the thing is you can't stop there. Because if you stop there, then it's like, well, I'm glad you've, I'm glad you've sort of figured out that you've done something wrong, right? We can't stop there. Then we've got to say, I hear you. And, you know, I think we can both have a part.

So can we also take a minute to look at what your part might be? So it's two minds in the room. And I think my experience is if I'm willing to own my part, that makes patients much more more interested and willing to actually look at their own part. Anthony, what do you think about that? It's so central to the model. Yeah, yes. Thumbs up from Anthony.

That's okay. Yeah, that's fine. Man, I feel like, I feel like there's so much here to get through, and I'm, like, so wanting to get through all of it. So I feel like we're just scratching the surface, you know? It's like, it's good. Okay, so let's get, there's so much more around like the mismentalizing. One of the things is like externalization of blame.

How do you help people in the midst of that? And I think it's kind of similar to what we've been talking about. Do you see it as the same as what we've been talking about? Do you see it as different? Like the overconfidence and perspective taking externalization of blame, are those two separate things? Just for like in terms of ground to cover, it kind of, the techniques kind of go into the same area because they're both certainty, right?

Certainty that it's your fault, certainty of whatever it happens to be. So broadly speaking, we are going to get alongside the person, find nuance, and then share our own perspective. So I do think technically there's, it covers relatively similar to terrain. Okay. But I don't know if you want to hear more about it. The aphorism for it in a way is what we've said, which is see it from their perspective and scaffold the whole thing.

So you get the content, as Bob always talks about, scaffold the whole thing so that their experience a sense that you do see it as they see it and as they experience it. So you're then joint in some form. Once you think that's established, you can start chipping and then chip away. But you don't demolish. You don't explode the whole thing.

and show them that really they're dismissive and they're misinterpreting, and it's their narcissism are there to blame. This would be disastrous. But you then just technically chip away within the frame of your now stable and rather empathically sort of organized relationship. So you just question slightly. You say, do you know it occurred to me something else here and pop it in and see how it's taken?

Do they bite? Do they say, well, why? you see it like that? I told you it wasn't like that. He said, well, I think it came to my mind just when you were saying this and so on. So they have to consider your mind and your perspective. You're just 100% done theirs. Now, hang on a minute. With two of us, what about my perspective? We can only do that once you've actually, as it were, engaged with them and they experience you as seeing it from their perspective. So with borderline precise order, I see it as like there's an interpersonal stress which leads to destabilization.

And so when I look back through someone's history, you see these like breakup and then the cutting and the suicidality that comes after. Do you see similar events in narcissism? And I think you mentioned it's like these like self-esteem challenges, right, which could be a loss of a job or a boss saying a certain thing or, you know. But how do you specifically work with these insults? Yeah, that's definitely, that requires a sort of different set of techniques. I'm glad you're asking about it, David. So this gets to a construct that we cover in the book, which we kind of, so Anthony has developed this idea of teleology, which is sort of interpreting mental states

in terms of what's visible. We've kind of expanded that to sort of think about the sense of self and narcissism. So it's teleological self-esteem. So myself sort of rests on external things. And for that, like absolutely, what are the kind of precipinence to treatment for narcissism? It's sort of problems at work, problems in relationships, other people not treating them in the way that they feel like they deserve. Okay, okay. So explain that to a third grader.

So it's the idea is it's sort of, it's often stays very externally focused, but there is some situation. situation in life that, I don't say makes them feel bad about themselves, that they just find upsetting. And that leads to sort of psychiatric decompensation. That's not a third grader language. But I can put it in second grade language, probably. But in a way, I am, you know, what I do, or I myself, I am what I do, or what happens to me. So if I lose a job, I am nothing. I fail in some way to do something I expect of myself, then my self-esteem plummets because I didn't do it. I didn't manage it. Definitely. Okay. Okay. That entails two parts, though. What Anthony is saying, the first is, I should be blank. And the second is, if I'm not, then I'm bad. Right. I almost,

like, feel like some Karen Hornay here, like neurosis in human growth, like the shoulds that define the person, and they have like, I should be this and I should be that and they should be this. And then it's like when they come into life and life shows them that they're not that way, then they kind of decompensate, right? So they have this like false self that should create this like false persona, just the true persona, which is kind of hidden there, right? I don't know if you guys are fans of her work, but that's what I'm hearing in kind of a way. I think of it as also a sense of there's some kind of expectation or should or this is

how I have to see myself or be seen. And this is, of course, not entirely conscious, generally speaking, but it's some way in which I'm not aware, but may actually be behaviorally quite insistent on being seen a certain way by others or seeing myself a certain way through my own mind's eye. It goes to that eye mode. What kind of person am I? But there's an insistence on, you know, this is my worth. This is, you know, I'm competent because I'm intelligent because, I'm attractive because of the number of followers I have on Instagram. I'm capable vocationally because of the number of graduate schools I got into. And when there's some concrete disturbance in that channel of self-stabilization,

then it throws the whole sense of self off. It just capsizes, as Anthony is saying. So that can be a threat coming at the self-esteem. in virtually any channel. It can look like an interpersonal, you know, disturbance. But it's a narcissistic disturbance because it actually, it's not so much about being connected to that person and having that disrupted as it is about kind of being connected to or living out or, you know,

expressing actually this image of myself. And that's what kind of get these stabilized. Would you agree with all that, Bob and Anthony? Oh, absolutely. And the thing is that's interesting about these patients is often, they are not saying it in these like really, you know, clean ways that Anthony or Brandon are describing. They're just saying, I'm just depressed or I'm just so anxious and I just feel so horrible, right? You have to kind of explore and get at those external triggers.

Yeah. This is really good. Or there's been a suicide attempt. I mean, it's, usually people with NPD don't talk about their suicidality. There just will be a serious higher lethality, higher risk. you know, suicidal behavior. And that's the downstream behavioral consequence of the capsizing of that sense of self that's more abstracted, that's healthier, mentalizing. That's gone. It's all become concretely fused with, you know, the professional failure or the marital failure

or having a double life exposed or whatever it was that happened concretely. But the injury is to how I see myself. And David, I would say here, this is really where, this I think is crucial for treatment because, and we would propose, in order to help somebody with narcissism, we need to get at what are those conditions that they base their self-esteem on? And we've got to put that front and center in the treatment and help them begin to kind of reflect on that rather than just running with it. Okay. So this is really good. So it's like I hope other people who are listening to this have epiphanies as well. I'm like thinking of some patience.

I'm like, oh, gosh, that makes so much sense. But I don't know if I tell them that they're narcissistic. And it sounds like that's like part of the label of your program. It's like, how do you get true narcissists to go to a program with narcissist in the label? You know? Like maybe I would have like spouses of people sending their husband there. Yeah. on that? Just brief side note.

Well, so we do it a very, it's a big part of the treatment we provide a McLean. I think, Anthony, I'll be curious here what you thinking if it's any different in the UK, but one of the groups that I run is MBT for Narcissistic Personality Disorder. And when I

started that group, the feedback that I got from a lot of people around the hospital was like, you can't call it that. You can't call it, you know, MBT for narcissism. Call it, MBT for people with interpersonal problems. But there is a stigma that's associated with narcissism that is really, I think, can like hinder these folks.

So in terms of giving the diagnosis, I would say, and we have a whole chapter in this on the book of how to give the diagnosis in an experience near way. But I would propose it's really, really important because so often with these patients, you're going to reach a point very soon in the treatment where they're going to be insistent that the problem is outside of them. And often we need the diagnosis in play and agreed upon to have enough therapeutic leverage to actually look at it in treatment. So that's why we give the diagnosis.

Well, in fairness, MBT itself, a mentalizing, doesn't require a diagnosis in a sense because it's a transdiagnostic concept anyway. And what it requires us to do in the early phase, as Bob's explaining, is to actually get the assessment done so they begin to recognize what the mentalizing areas of difficulty are. And then we might be able to say, and I think Bob always mentions this, we tend not to necessarily say narcissistic personality disorder, but we do say that there's a pathological narcissism operating here.

And it's pathological because it's leading to trouble for them and their self-esteem management and also in their lives, in their relationships, and it really is what we mean. So we can then actually normalize narcissism. It's a perfectly legitimate experience for all of us. We have to have a level of narcissism. The problem here is it either become vulnerable or over souffle. You know, there's too many eggs in the souffle and so on.

So we've just got to moderate and help moderate. So it's not something that we need to put across is you're pathological here in a way like, you know, so on. But we do say it's a PN. Pathological Narcissism, I say, but not a category of personality disorder necessarily. Very quick coda on that. You know, this is really a standard piece of MBT is that we're not just looking for the patient then to be parroting back to us, okay, I have pathological narcissism or I have this disorder, but that we deliver a formulation that's very experienced near to the patient. And that's part of standard MBT. We've just kind of, you know, airlifted that into

MBT for narcissism, but it has a few tweaks because we're going to be sure that we are saying something in our formulation after the first four weeks of assessment about what are the conditions for self-esteem and self-worth that this individual holds. We have to get to that as clinician. So we do specifically assess that, and we want to give it back to the patient in language that's experienced near, empathic, and as Anthony says, it's on the continuum of what we've all got to manage in ourselves. And that normalizing component is really at the heart of MBT, for me anyway. It's got to be talked about explicitly, and we do need the patient to see it in some way within themselves. And agree that it's got to be worked on in this treatment to move forward.

So shall we, shall we do a roleplay on that, Brandon? And I'll be, tell me, tell me, tell me what the scenario is. Tell me who I am. Tell you who you are. What are my, what is the insult of my life? You need you to stabilize who you're going to be. No, Brandon, I need you to tell me what is my failure that I've had that has led me to see you because I, I don't know what it is. It's like when you and I were talking about, you know, how you became suicidal after you were waiting for that, you know, 14th letter from that 14th graduate school that you applied to. And I think you told

me in our assessment sessions that as each of those, as you were coming to the end of your undergraduate, you know, final year, and you had this certainty that you were going to get at least to one of these programs. And, you know, it seems to me that actually something really important happened there with each rejection letter that you got as it rolled in.

You told me that you felt more and more nervous. and you didn't want to think about it, but part of you kept waiting for that next letter to roll in. But when that 14th out of 14 letters came in, and you took that overdose, you know, I think you and I've been trying to understand together how those things might be connected.

And one of the things I think I've understood in trying to get to know you this last month is that something intolerable happened for you there, within your sense of yourself, when you got that 14th rejection. and you couldn't see a way forward. You couldn't feel there was anything left in yourself worth hanging onto.

So you just had to end it. That might be an example. The thing that jumps out to my mind, Brandon, if I can call you by your first name, as my patients do. The thing that comes to my mind is my best friend got in everywhere and to all the graduate programs

that I didn't get into. And so here's the guy. What was happening for you? you saw your best friend getting all these acceptances that you weren't getting. Oh, I was so, I was just irate. I was like, we studied together, we took all the same classes, we were in research lab together, pretty much the same identical person in terms of like grades and extracurriculars. And here he gets in everywhere, and I don't get in anywhere.

And I'm just like, what the heck? I mean, I'm really getting a picture of that to the irateness that you said, you know, I can see that quite clearly, actually. What else was going on around that? I was just reminded of what you said earlier about how you were banking on. You had your whole sense of your future kind of mapped out based on getting in. And what happened when you saw that that door was closed for you? What else was going on, if anything?

I think I just started waking up in the middle of the night with my fist clenched. and I would just think about like, like how could they not see, you know, how awesome I would be? So when it was challenging your sense of whether people could see how awesome you are, how are you feeling about yourself? I was feeling rage at them. I don't know if I was feeling at myself at all. You did go under the,

I think do something pretty serious to yourself. What else? Were there any other emotions around that? There's the anger at them. But I wondered if there was anything about yourself. I think this is why I went to my stepdad's house because that was where

it was like a fuck you dad, stepdad, uncle, person I barely know. You know, like, I mean, I know what he expected of me, but I think like I took the pills right there in his bathroom as a big, fuck you. And what were you hoping that that would change within yourself? I just was hoping it would let him take the, you know, let him actually feel some guilt for the harm he called me, caused me over the years. Did you have a sense of how that would feel differently for you if you were able to cause him to feel guilt?

I'm noticing I said instead of caused me I said called me you know and I think it was him calling me all sorts of names when I wouldn't amount to shit um I'm sorry I forgot your question well anyway we could keep going no this is good and I think it's I think this so far I mean if I can tag up was it getting too real there was it getting too uncomfortable no I think in Bob and Anthony would each do that a little differently, I think. But, you know, it's around exploring suicidality. You know, we're particularly interested in NPD or pathological narcissism and getting a hold of, you know, what's going on within the sense of self, feelings about self. And so we've got a piece of the anger there. That's really clear. But I was trying, you know, not so successfully, but to kind of push the

curiosity about how's this person evaluating and feeling about their sense of worth, competence, their sense of having a future. Yeah. And measuring up to expectations, but Bob will probably do it differently. And I want to hear Bob's debrief here. Bob looks excited. Bob looks like it was enjoyed it.

Brandon, no, I wouldn't have done it differently because I think Brandon was doing the right moves there. You were asking you got at the impression about reality in the situation that was triggering and said, how did that make you feel about yourself? But you're very externally focused, David. So I think I, and this may not work what I'm about to do, but I think one last gasp I would try at this.

And I would just sort of say, I'm just curious. You know, David, as we're talking about this, I keep asking about your emotions around self and self-esteem. And all I'm hearing is like the men, they anger at other people, which is fine. But I'm just curious, do you have any negative feelings about yourself around getting rejected and all these ways? Yeah, and I think this is where I was, what I,

what I think I've it's kind of entered it in my mind while we're here okay and I don't I don't want to go easy mode on you Bob and and difficulty mode number 10 on

Brandon here but we'll consider you guys the same person Brandon's interventions were great so you're yeah I'm riding on them right now yeah so yeah okay let me get back into it what I was saying was that I was like when you asked me that question earlier, I think I thought about my stepdad

and his role in this because I think I think I was, I internalized some of his anger and need for me to do things perfect. Okay. And I think that's part of why my anger was turned towards him. So you're kind of explaining it, David, which I totally appreciate, but I just generally want to know, how did it make you feel to get rejected by those 14 grad schools? Like, other than anger, what else was in there for you? You know, embarrassment. Okay. I was incredibly embarrassed.

I didn't want to tell anyone, and I thought it would be better to kill myself than to tell anyone that I didn't get in. So I actually burned all of the letters before I killed myself, so that no one would find if I successfully killed myself, no one would know. Wow. Well, yeah, absolutely. Like, it literally would be better to not exist than it would be to have to feel that sense of embarrassment. Yeah. I wonder, I mean, what do you think if we would use this treatment to kind of work on this? Because that's what stood out to me as kind of, it was a, it was a punch in the gut. Yeah. Yeah, I felt, I felt a literal punch in the gut. Like, it was, it was like someone that hit me. Yeah. Yeah. I don't know what you think about this, but it does strike me there is a way in which you can really base your sense of self-worth on these external things. I don't know if you would agree with that.

Yeah, because that's what matters in life. Like if I can't get through school, grad school, then I can't become, you know, an aerospace engineer in the way that I want to. Okay. And so what else do I do? There's no plan B for me. there's only plan A. So I need to succeed. I need to kind of have professional success in order to even have a life actually. I mean, doesn't that make sense to you? Isn't that what's happened? I mean, you obviously have success and are here and have got through grad school.

I guess just throw this out there. I'm not trying to disagree with you, but I'm worried about it. Because I'm worried that it's like you're putting all your eggs in that basket. and what happens when the basket topples? So you want to kill yourself. So I'm interested in using this treatment, I don't know what you think, to help you with that.

So you're less vulnerable. What would you think about like trying to use this treatment to kind of help you with that? As much as I don't like the word vulnerable, I think, yeah, maybe. Maybe give it a shot. So what's it like, David, then?

And if you are coming into treatment, sort of seeing someone like me who you just said you see is really quite successful, comparing as you're saying to yourself, who used to understand it, even in the middle of the night, it begins to sound like you're thinking yourself as unsuccessful, not worthy of anything. Yeah. You know, I just don't think there's any way that you could know how this feels because you have obtained the pinnacle of success. Yeah.

So what's it like? Can I put it back to you again? What's it like you actually sitting discussing this with me? Because we're going to have to sit here quite regularly to try and work on this. I feel like you have no clue what this is really like. I think you're trained and you know kind of what to say. But deep down inside, you have no idea what it feels like to really fail like this. Yeah, you're quite right in a sense. So that's why I'm trying to find out how it does. feel for you just at the moment, especially being in a world where you see me is successful and yourself is unsuccessful. I don't know what that's like. It feels horrible, gut-wrenching. It feels like therapy is the most painful thing, and I question if I should even do this. Yeah, absolutely. Yeah. I just read this book called something like awful things. therapy and it said therapy isn't helpful and I'm I'm wondering if this is going to be helpful.

Yeah. But that's quite an elephant for us, isn't it? I mean, I think we might have to sort of put that on the table and sort of know that actually every time we're meeting that actually there's a dangerously painful sort of place around potentially, particularly created a bit by you seeing me as so successful as well and yourself as unsuccessful. Can we put that down as something we need to really watch out for? Great. Yeah. I mean, another thing that I'm failing at, I guess.

Sorry, I'm just like, it's kind of comical because I'm like, I know. No, no, and I know, I know that you. As Paul's saying, tries to get it to sort of the relational area, particularly right at the beginning, I think Bob was taking up as well. And Brandon, a little bit, but initially what we call pretend mode, you had these sorts of explanations for things, which were rather, in my view, rather sort of over-explanatory tri-well, it's because my stepfather was like this, and therefore I've learned to do that, and that's why I'm like I am. You think, oh, well, that's fine, then. Off we go home. We've explained it all. But actually, this is what we call pretend mode, where you actually over-explain things. It's not really rooted in reality.

It's not grounded, in a sense. It doesn't link really through to coherent memory, coherence, of one's history and so on. It's just sort of thrown out into the world and so on. And we then have a problem because Pretendmo is very common in narcissistic function. Interesting.

Okay, so this is, wow. And all three of you guys, awesome, just awesome. Like, I don't want you to feel like I'm, like, I was being very difficult. David, you're awesome. You need to, like, go into acting. I mean, can I tell you, Bob?

Like, I mean, and I've, I've told this before, but like, I tried out for Berkeley acting class and I could not get in. What? Yeah, I did not get into their, we should write a letter. I did not get into their intro to acting class. And so whatever my patients tell me that, I feel like you're acting, I'm like, no, I'm not a good actor. I like, my- That's that genuineness of MBT. just you know you saw that i think in anthony's sort of final response there the patient says you can't

know what this is like he just says quite right you have to tell me i am trying to find out what it's like i need your help with that can we do some of that together can we try and that's so central in mbt in general just giving the patient the experience someone's trying to find out about my mind even if they can't possibly get it exactly right there's a lot of that in BPD work, but I think it comes out in a different way with NPD, tolerating these inevitable misalignments. We're never going to get it exactly right. And that itself is more of a trigger, I think, in NPD than BPD.

So we have to be very ready to just roll with that and actually lean into it, as Anthony did. You got me pegged. I can't understand it. I don't understand it. Can you try to explain it to me? I see that Anthony has to go shortly. David, you would ask the question about problems in empathy, and Anthony has done so much work with this around the antisocial stuff, and it's so set-treating narcissism. I don't know if we could hear about that. I'm super curious, yeah. And I'm specifically curious because I've always thought that some people with narcissism also have like dark triad psychopathy. And psychopathy, I think, is a deficit of affective empathy. And so I'm curious, Anthony, your thoughts on this. Like, It seems to me that once you go beyond a certain level of psychopathy,

there's not a lot of help that therapy can bring you. And I also think, Anthony, just to kind of deepen this, just to give you kind of download my thoughts as we go into this, when you did the, when Phonigy did the reflective manual, the people who were in the prison had the lowest scores on the reflective function, lower than the psychiatric hospital. And so I found that specifically interesting when you think about a lot of them are there for violence.

A lot of them are not putting to words their aggression, but they're acting it out on the world. So, okay. Yeah, I mean, your question is unanswerable, but I'm going to slightly reverse it, but I think you're quite right. And it's in the literature about the absence of the affective empathy sort of component

as you move towards the psychopathy sort of way of the mind, the psychopathic way of the mind functioning in a sense. It has no concern of other minds at all to a large degree. And that's a big problem. But I think the thing that people might like to think about is that this sort of reverse occurs, that in a sense you have a counter-relational problem to this so that they're not curious about your mind in a sense.

And actually, they also, you can be with someone with strong psychopathic traits and realize that this is going to sound odd, that their mind is not transmitting. So it's really difficult to read what's in their mind. In fact, and I think whether they are deliberately covering up what's in their mind, say, or actually they simply don't naturally transmit their mind. mental states to others. In other words, they're walled off, their kind of secret in a sense, is incredibly discomforting for the other person. So you're kind of with someone who actually doesn't seem to want to read you, but you equally can't read them. And you try and you ask

them and you get a blank in a sense. You may get verbalisation, but it's cold, it doesn't seem to root in some way. So you have quite a problematic counter-responsiveness in these situations. So then it's very hard for you to be empathically validating to them because you can't read it. Yeah. So I think, and in general, the antisocial, who also may have some levels of affective empathy problems, they don't care about the other in a sense, or they don't then feel guilty about how the other experiences something, for example, they don't get the feedback system. They do tend to actually transmit. So they're not very good liars of mental state, if you see what I mean.

They tend to say, no, I don't feel like that. And yet it's kind of obviously that's what they're expressing. And so you've got something to hook into when you're kind of working with them. And that's rather different. Okay, so we're talking, I think, like when I think antisocial personality disorder, it's like, I'm thinking DSM-5, like we're, you know, people who end up in prison, they're doing illegal activities. They could have some psychopathy. They could, they could have lower levels of psychopathy and just be kind of more of the baked in a bad environment, surrounded by people who are like, you know, doing criminal acts and they themselves get kind of pulled into it. Are you treating, which category of people do you normally come across? Are you doing a psychopathy checklist? The one was in our trial, we were treating those with, well, the issue is aggression in a way, isn't it?

Or the violence that ensues. And that was what we were really asked. So it was the group with antisocial who were recidivist violent criminals. So they were responding to provocation or general stressors, if you like, in life simply through violence. So they were repeated violent offenders. Was it more impulsive violence or was it like a predatory violence for most? It was more impulsive violence, but we measured their psychopathic sort of levels. And that was a range, actually, from low levels to.

much higher, up to 29 Europeans, which is 32, 34 U.S. measure on the PCL. Okay, okay. So then, wow. Okay, so you're dealing with some true psychopathic individuals at that point. Well, yeah, to be honest, we were trying on to. You know, but we were measuring the PCL because we had a cut off of 29. And then so what did you find in the research? well, I'm not at liberty to say what we've found in a sense

because it's not yet published, but for the antisocial violence, we can say that we're positive outcomes for improving their mentalising. So in a sense, we were working on the basis that a problem with aggression is that aggression is a necessary survival phenomenon and so on. And mentalising is inhibitory in that sense.

So we block being violent in the main. We may experience a sense, oh, I want to get rid of someone or hit the, or whatever, when we're five and we bash them a bit. You know, but gradually mentalizing takes over. We socialize and we actually inhibit. And the problem is that mentalizing, therefore, is a partial mediator towards aggression and violence.

And it's an inhibitory mechanism. So if it's not working well, you know, impulsivity comes through and so on. So we improve that. Wonderful. Reduce their violence. So I just want to make sure to speak to this because Anthony is sort of talking about antisocial. And when we're like in terms of the folks that we're more likely to see at McLean, and I don't know if this applies if you would agree with this, Brandon, but whenever I give the sort of narcissism diagnosis,

the most common response that I get is, but I can't be narcissistic. I don't really, it's not that I lack empathy. So, and I really think it's important to not, like, to basically, to think about this more dimensionally. And so the way that sort of we explain it to patients is like, absolutely, I'm not in any way saying that you don't have empathy. The challenges, though, is that sometimes it seems to me that when your sense of self-worth is threatened, it can be harder for you to empathize with others.

you're more likely to go to a place of anger than empathy. I don't know what you think of that. And then patients usually will be able to see themselves in it. So we sort of see it as more context-dependent empathic deficits rather than categorical empathic deficits. Do you think we all have that to some degree? Totally. Because I feel like when I'm really tired or like, you know, after nine hours I've seen clients and I'm hungry, it's like sometimes I'm just like, can I just eat before we?

have this discussion because I need my brain to like come back on you know um absolutely and I would say that's really in service of like we would say that to patients directly like this is not a this is not just a you thing or a narcissism thing this is a human thing when our self-esteem is under threat it can be harder for us to put ourselves in other shoes and so hopefully like normalizing that can make it feel less like a dig or something brandon what do you think about this that's exactly we normalize it is just yeah when any of us at the core of how we see ourselves are destabilized or dealing with some really rotten disappointed sense of ourselves you know it makes total intuitive sense really that we're not in going to be in the optimal circumstance for paying close curious

caring attention to what's going on in other people's experiences you just kind of normalize it like that and without wanting to explain away what's kind of unique about narcissistic problems, but it is on that spectrum of that continuum of normal human experience. We had a very poignant example, actually, of this, just at the Gunderson residents earlier this week, in our MBT group, one of our patients had been given formally the diagnosis of NPD, and this is her mentalizing question that she opened the group with. It wasn't so much a question as a statement. I can't be NPD because, as Bob said, because I can be quite empathic sometimes. Isn't that how all of you experienced me, kind of looking around to others in the group?

And what was actually really poignant is that other group members, as we focused on her for the course of an hour or so, we're able to actually empathically and gently give examples where they could see both at moments she could be quite empathic and interested in attuned. But at other moments, and it was in these moments where there was these threats to self-esteem, And in those moments, others' experience of her was that she was not interested or curious about them. And that could be happening when she was quite aggressive and really doing damage in these relationships. And other people would feel totally kind of bewildered by, you know, angry with her. But she's kind of left in a vacuum of really dealing with her own feelings about herself and just missing other people's experience. So it was quite poignant.

And I think that by the end of the group, it just shook up that sense. Let me, I just want to say, Dr. Bainman, thank you so much for coming on. I really appreciate you. And it's, it's a, I think there was a comment earlier like, oh, we're so glad you guys are talking. My podcast is talking about mentalization. And honestly, like, it's an honor just even talk to you face to face. That's the way I feel. As someone who, like, has read your book since I was a resident, you know, and appreciate you. So that'll fuel my narcissism for the time being. Thank you very much. Thank you very much for having me.

Thanks for coming, Anthony, making the time. David, I think that what Brandon's saying also, just from a technical standpoint, because I know so many of your listeners are psychotherapists who want to know how to treat narcissism, I think that what happened in Brandon's group really illustrates a key part of treating empathic deficits in narcissism, which is that at the start of treatment,

we write up, I don't know how much, you know, you sort of folks are aware, but we write up at what's called an MBT formulation, which is a written document, itemizing patients' problems and mentalizing. And this is where we put. Is that for yourself, or is that for sharing with the patient? We write it up, we give it to patients,

we get feedback about it, and we as a focus for treatment. It kind of hides the whole treatment. Is this what you do in a one-on-one private practice, or is this what you do in like a group therapy setting? Yeah, all the research on MBT's outcomes include having a formulation, for individual MBT includes a formulation. So even in our private practice, we're writing formulations for people.

Okay. So you write the formulation, you give it to the person. How does that go? Well, so we can talk about that, but I just want to make sure the empathy point isn't missed is that we've got to put the problems of empathy in the formulation. And sometimes it seems to me when you disagree with people, it can be harder for you to put yourself in their shoes.

Or you can see what they're feeling, but you don't always fully care. That's your point about affective empathy. Put that in the formulation. And then there's a reaction. How does it go? There's often pushback, disagreement. We're curious about it. We kind of play with it together.

But we end up sort of using the treatment to actually help with those issues. Okay. Yeah, that's really, that's good. Any more about how it goes? Well, just to emphasize, we set that up as, again, within the kind of two-person intersubjective model. So we usually will preface this. First of all, we tell the patient that we're going to have, you know, a series of four or so assessment sessions. I'm just going to be asking you questions, trying to get to know you as a person, what problems you're coming in with, what your goals are for treatment, like you would with any new case. But then we tell them early on, you know, there's some structure to this. After a month or so of meeting, I'm going to actually, you know, go through this exercise of writing down as best I can see it.

My understanding that what I think I've heard from you about your difficulties, your symptoms, you know, how they kind of make sense and connect to challenges in mentalizing and some predictions about how it might go if we begin formal treatment together. And so you had an example of that earlier where Anthony's saying, we've got to keep an eye out for that elephant in the room between us. That, you know, there's a sense that I can't possibly understand you because I'm too successful and you're too much of a failure. So those kind of things we would put in in writing, along with the kind of catalog, as we've understood it, that's experienced near of the patient's difficulties in their functional realities, you know, how they are in relationships. if people regard them as unempathic, if their spouse, their partner, their friends, their boss, we're going to have gotten that information and we're going to put that into the formulation. This is a goal for treatment. We're going to work on your capacity to tune in with curiosity and interest to the experiences of others,

especially when your sense of self is threatened or you're feeling rotten about your accomplishments. And so all that's made explicit. It's on paper. And patients usually get interested in the, this. Well, oh, that's coming. Okay, maybe I'll stick around for that and see what this person's got to say about me. And even if they see it with a very critical kind of scrutinizing lens, we just welcome that. You know, we say to people, get your red pen ready. You know, I would like you to come in and tell me what you would correct, what you would change, what you think I got

wrong. So we really just invite that, you know, help me understand better. That doesn't mean we'll necessarily change everything. But what we think this does is it accelerates the process of, it gets some of those implicit relational processes that maybe we don't usually talk about so early in treatment with these patients for fear of upsetting them too quickly. It gets those up to the surface and it gets us talking about them we find more quickly earlier in the treatment. Helps with treatment drop out. That's good. Yeah, no, it sounds like it really makes sense, especially with this population. But you're also doing this with like borderline precise order,

all your patients, right, at that center? Yeah, it's one of the distinguishing features is what makes it different from just traditional psychodynamic psychotherapy because we're putting stuff in writing, revising, and then that becomes the target of treatment. Yeah. Interesting.

Okay. Yeah. And then also like there's difficulty in tolerating ambiguity, black and white thinking. that's another mismentalizing thing that you commonly see, right? Is that correct? Brandon, you don't look like. Oh, no, I'm agreeing.

I'm letting Bob take this one. But absolutely. Black, I mean, there's particular forms of black and white thinking and that manifest characteristically an NPD, supposed to be PD. A lot of this falls under the kind of category of the certainty that we talked about earlier. You know, different versions of the certainty. the only thing that I would add to it that we didn't get to in the role play that's really, really important is that we're trying to help the patients see their perspective, as Anthony described it, broadening it. But at the end of that, we're also going to share our distinct perspective.

And so that's a really crucial piece. A lot of times clinicians can feel afraid of being forthright with these patients because of the devaluation that you've so expertly kind of roleplayed today, David. And so we can hold back our truth. You're calling me an expert on devaluation, are you? An expert at role-playing devaluation. Yeah, yeah. But basically, but the point is we can hold back how we see things out of fear of getting a negative reaction. So we have to be willing to actually say at the end of it, once we've explored their perspective,

their perspective, what supports it, help them to hopefully see things from more nuance. Like that patient we talked about earlier who was devaluing his wife and he's, oh, she's okay on Tuesdays, not on Wednesdays. And then at the end of that, I am going to have to say something like, well, I got to admit, I know your wife can sometimes be critical of you. It's also stood out to me sometimes that you can actually be quite critical of her. Ooh. What did you just feel?

But I'm only critical of her because she's critical of me, Bob. I hear you. No, I'm joking. Yeah. So that's the idea. So we got to bring in our perspective, and it often does hurt a little bit, but that's how we help people. That's how we help patients begin to consider these other perspectives. And the idea is, if they can do that with us, they're going to be able to do that more easily with people outside their room.

And think about that, what that requires the patient to do, actually, and why we put this at the end of the interventional pathways. once we've already kind of got mentalizing restabilized somewhat, only then would we do something like what Bob just did? Because that's, again, inherently more challenging for all of us to grapple with this kind of input or feedback, you know, how we're seeing from the outside that's really different for how I see myself. That's hard for all of us. It's maybe harder if you've got NPD. So that comes at the tail end of all these more contingent interventions to flesh out horizontally the nuance, the gray area, the uncertainty within the patient's current perspective. And then we think there's a bit more mentalizing online. Maybe there's room now to at least, it's not to try to get them to agree

with us. We're never trying to just persuade, like a cognitive therapy, like a kind of persuade of an alternate perspective. We're trying to get mentalizing going, which is all about just perspective taking and reflecting on the myriad coexisting perspectives that exist at any one time. And can this patient do something, reckon with the fact that Bob has this additional thing that he's throwing in, whether or not I see it in myself. So what do I do with that? Can I consider it? Can I take it up reflectively or not? That's what we're aiming for. Well, I'm having some transference developing with you guys where I feel like I would really enjoy a dual relationship of going out to a good meal or something.

I know it's too bad you live in Florida, David. I mean, not too bad. For us, when to come, David? Oh, man, would you guys fly down? In the wintertime here. There's some really good food down here. We should make that happen, and we could do our next one in person. Well, I really appreciate it. I didn't expect just to be frank. I was a little worried about joining just because I don't sort of, you know, don't sort of tend to do these sorts of podcasts,

but it was genuinely fun actually talking about this stuff with you. Yeah. Well, I mean, you guys are like, you guys are in the trenches, right? So it's like it's my job to try to pull out the wisdom of being in the trenches with this population. I feel like, you know, you guys have a lot of experience, a lot of wisdom on treating this population. I appreciate having this conversation where other people, you know, across the world can hear it.

And hopefully it can spark their curiosity where they want to continue to learn more. And so kind of as we wrap this up, like, are there any big categories, any pearls that you have that we haven't really hit on that you want to just reemphasize? Mm-hmm. Good question. Oh, yeah, yeah.

I do, actually, I do have one thought. Actually, yeah, yeah. And it relates to the stuff you were asking about the ruptures and self-esteem. Okay. So that for me is in the teleological self-esteem stuff. We also need to actually put very, very clearly in the formulation something like you tend to base your sense of self-esteem on blank. Oh, okay.

Okay, really, really important. And ineptly, as you're moving through the treatment, there are going to be moments of emotional disruption that are linked to that. And then those are like crucial moments for the treatment, because then I've got to be able to say, okay, so we get there. It's like it almost sounds like that your boss seeing you that way really made you feel quite bad about yourself. Yep.

This reminds me of what we kind of talked about before, how you can kind of base your self-esteem on achievement and other person's views, can we look about that a little bit? This idea that you're bad because she sees you in a negative light. Could we look at that? And so you actually then have to transition

to actually try to stimulate reflection about this idea that their value rests on outside things. And without that, I would say these narcissistic processes just continue because the person just keeps feeling horrible about themselves when the world doesn't kind of meet them where they're hoping it will meet them. Yeah.

Yeah. That's really helpful. This is really good. It makes me think of so many things. With so many things, I'll have to say offline. I can't say on the podcast type of things. Okay. But, yeah.

Okay, Bob, one more question before we get off with this for you. Like, what led to you getting so excited? about this feel like what what drew you in well interestingly so I worked when I was first trained in MBT I worked at the VA I was at the Veterans Administration and I was doing a lot of individual MBT with patients I started up like three MBT groups we knew these folks had characterological disorders I think at the time I probably put them more in the BPD camp because there was a suicidality that Brandon had kind of mentioned but Then when we started learning more, there's a huge amount of research done in the past 10 years

on treating narcissism. I came back to McLean, met Brandon, sort of we were working together, and we started realizing, oh gosh, these patients likely meet criteria for NPD. So, but what was kind of interesting about it is that I realized that a lot of those patients I was treating at the VA who was very disconnected from their emotions, they leave the military, they're feeling horrible about themselves. there's a big emphasis on strength, power. A lot of them had MPD. And so sort of a lot, you know, in that respect,

I'd kind of been working on this without even knowing it. And Brandon and I started kind of developing these principles for these patients in the MBT clinic. And it just sort of all kind of sprung from there. And we started finding that using the, kind of adapting the principles somewhat. Like there's some differences between MBT for narcissism. and standard MBT, these patients we found were really getting better. And the first patient that we diagnosed with MPD formally in the clinic, I won't get into,

you know, great details out of them. We know we got to stop shortly, but this is a patient who is in four times weekly psychoanalysis, very suicidal, inpatient, multiple inpatient admissions, and came to us for once weekly MBT. Brandon did this person's evaluation, and we ultimately diagnosed him with narcissism and gave him the treatment that we do in the clinic. And this is going to sound really out there. But within a year, Brandon did the group therapy,

I did the individual therapy. Then a year of him being in treatment with us, he was no longer suicidal. He was no longer inpatient. He had no impatient admissions. He was excelling at work. He was finally reporting feeling good about himself. And now he's sort of probably no longer meets criteria for NPD

and is in his first romantic relationship of his adult wife. So like when we started thinking, whoa, this is really working, we started wanting to write the treatment manual. You know, a side note on that, when I think about, and I think that's just,

first of all, it's awesome that you guys collaborated and worked with it and get to work with Bateman. I mean, how amazing. And I think giving him clear feedback and direction, like, hey, here's the things you need to work on. I can imagine. that that was very actually helpful and not as amorphous as maybe other therapy could be.

Okay, the second thought I had was I see a lot of these patients who are successful, who continue to be successful, but it's the fantasy of losing the success that actually is the distress. Yeah. Brandon, what do you think about that? I love that question, yeah. Oh, yeah, that's a really evocative question. I mean, I mean, honestly, where I go just in my heart listening to that question is, gosh, yeah, I mean, do we all have that a bit? I mean, it makes me go to where I was going to close my piece just to say that I think one reason this work is so gratifying is because, and I think Bob McGrute feels the same way, just like with borderline patients, you know, with narcissistic patients, we can really see parts of ourselves that are on this continue.

These are human problems that are quite ordinary. you know, the fears of losing, whatever it is, we've been able to accumulate for ourselves in this life. You know, I know I do, clutch it too tightly sometimes. So that's not to minimize, you know, what's unique about having a personality disorder. But just like with borderline patients, you know, I can see in myself those idealizing desires for a perfect relationship to be perfectly connected and understood. Well, in narcissism, I can also, you know, really relate to that sense of, gosh, if everything I value, you that fueled my sense of self was suddenly taken away or threatened, how would I do with that? That is a scary thought.

It doesn't answer your question necessarily, but I try to, I think both Bob and I are, try to be grounded as humbly as we can in a sense of, you know, so to speak, there, but for the grace of God, go I, you know, we're with our patients on this kind of human adventure. It sounds a bit cheesy, but I think it does anchor us in the clinical moment when we don't know what else to do, you know, it grounds our empathy for these patients. And it's quite gratifying to see that these are universally human problems we're sometimes able to help people with in some powerful ways. Very, very good. And that, that statement, but by the grace of God, there go I, Paul, right?

And in the midst of trials and in the midst of six, success, right? And in the, and I think it's almost like, I was actually thinking more of like the stoic solution to the fantasy, but that seems like the Christian solution to the ego, right? It's the grace of God. It's not my own ability in all things. The stoic solution is actually to imagine losing it all and to be peaceful. Well, but this is key, David, and this is how we end up treating the teleological self-esteem

because it's like, I am only good if I have professional achievement. So then you've got to ask the question along those lines. I'm just curious, if you got everything that you wanted, like, you know, can you ever imagine yourself still feeling bad?

Of course, I would feel bad. Of course, I would be stressed about this. I would be stressed about that. So, oh, interesting. Okay. What about have there ever been, you know, can you even try to imagine the possibility that even without this thing, you could actually have value as a person?

Just try to consider that. And that is, that parallels the Stoic solution, right? The sense that we have a sense of worth and a sense of connectedness, independent of the externals, As patients begin to wrestle with that possibility, we see improvements in self-esteem and improvements in functioning. Yeah, so think about it. Less contingent self-esteem and sense of identity. And I don't know whether that's Stoic or Christian or what it is, but I think that's a really essential element in ultimate recovery, you know, living with narcissistic vulnerabilities and really diminishing them over time. This is, we think this is core for this model. Yeah, and I think about the other thing that kind of makes me think about it is Victor Frankl, right? And so one of his quotes,

we who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man, but one thing, the last of human freedoms to choose one's attitude in any given set of circumstances, is to choose one's own way. Wow. And that's a freedom, an internal degree of mentalizing freedom that someone with NPD

does not usually feel they have. But it's all taken from me. If I get those 14 rejections from graduate school, I don't have that freedom to define myself or feel worthy in any other way. And that really does speak, I think, to that final ultimate freedom. and we're trying to actually kind of grow as some nascent quality in our patients alongside them. Yeah. Yeah.

So I think, yeah, it's like, can you imagine, if you are successful, losing, but then being like Victor Frankel and seeing it as a path, it's part of the hero's journey. And, you know, taking the role of the, the giver, like how he chose to help up. I think typhus patients at one point, which saved his life, actually. Well, on those lines, David, the patient that we mentioned that, like, was, you know, had such a tremendous recovery from narcissism in the MBT clinic,

one of his sayings that he implemented in his relationships, which is interesting, and it's non, for him it was not religious, but it was this question. He said, how can I be of service to this person? That was his mentalizing prompt. Beautiful. How can I put myself in the other person's shoes and try to actually contribute to their experience? And he's found that the more that he's done that, he actually experiences an internal freedom, which I think is also related to your quote. Beautiful.

Well, I think that's a good place to wrap it up right there. Thank you guys for coming on. I appreciate you. And I do extend the offer when you come out to Orlando. knows how I phrase that to come to come grab some world-class sushi or

steaks or whatever you're into or both and we'll leave it there for today. This is really fun. It's really amazingly fun and what an opportunity. Thank you. Awesome.