Transcript for:
Exploring Narcissism and Mentalization Therapy

all right welcome back to the podcast I am joined today with a a team of people we will be talking about narcissistic personality disorder we'll be talking about mentalization based therapy for patients with narcissistic personality disorder narcissistic traits um this is kind of like probably the world's best team for this that I'm bringing on uh if I can be grandio myself this is you know I was I was thinking about it and like 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 baitman he is the founder of uh co-founder of mentalization based therapy we have Bob droak the um uh who has been kind of huge in in bringing together together um a team to write this book mentalization based treatment for pathological narcissism and then we have Brandon unru who is in the trenches uh treating borderline personality disorder narcisstic personality order and I I kind of want each of you to introduce yourselves maybe um Bob drak you can start just a little bit like what is what does life look like at this point how much clinical duties how much research um and so yeah give us just kind of a brief intro okay all right thanks DAV thank you for having us it's really fun to be here we love your podcast so um yeah I'm a clinical social worker and um Clinical Director of the mentalization based treatment Clinic here at mlan um Brandon's the medical director and um work in a bunch of different programs here but a lot of a lot of what I do is sort of helping folks with narcissistic personalities disorder borderline personality disorder doing like individual and group treatment and very sort of squarely focused on MBT so um you know sort of most of what I'm doing is sort of helping folks with these challenges with doing sort of individual therapy um and then we have a narciss uh MBT group for folks with narcisstic personality disorder and then just do have a private practice where I do a lot of you helping folks with narcissism and um and do like consultations this diagnostic consultations of like how do we give the diagnosis um to folks with narcisstic personality disorder some of the audience will be wondering like why but like why is that your unique passion in life to work with patients with narcissism maybe we'll we we kind of come full circle to this um and then Brandon uh you want to introduce yourself I and thanks David it really is a a joy and a treasure to get to be part of this um great podcast thank you so much um you know like Bob I practice well I'm a psychiatrist and psychotherapist I've been based at mlan hospital outside of Boston since I finished my training there and and at the Mass General Hospital in Boston 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 um you know one of the so-called parents of the borderline personality disorder diagnosis and since then have just fallen into a variety of different um clinical and administrative roles um was involved with the founding of the MBT metalization based treatment clinic at mlan right from the get-go um and it's it's just been a joy to see that um 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 disorders 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 uh good psychiatric management so it's a bit of a mysterious e IC place in that way it sounds it sounds world class it really does I mean I um when I I've done an episode where we talk about like all the treatments that work for Borderland PR order and I feel like when I went through training um you know it was DBT right that was that was the thing uh and now it's it's become a lot broader um and so it's it's great to see that you are like really bringing together all these felds and I want to I want to hear learn a lot from you on those things and then Anthony baitman you're you're in England and uh you are someone who was on the podcast before with foni which was one of my favorite episodes so thanks for coming back okay yes I'm Anthony baitman and um I'm visiting professor at use University College London um and whilst I may be one of the co-founders of MBT I'm certainly a hanger on in this because the uh bulk of the work and studying and 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 the uh creativity is there not not mine I should say I'm actually a psychiatrist I currently uh just I better say I do not do any Private Practice I've never done any private practice so I do not accept referrals from outside our national health system here in the UK yeah just in case um but I primarily now advise the Anna fry uh uh for clinical work and training in mentalizing um and mostly other than that generate and write up uh 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 nice that's that's I'm excited to hear about that okay so I was thinking we' just kind of like launch into um what is what is narcissism um Bob maybe you can kind of direct us towards like grandiose vers vulnerable narcissism and speak specifically what you're finding in terms of the high percentage of patients with borderline PR disorder who also had narcissistic Tendencies and maybe the differential like what makes what stresses lead to someone um maybe decompensating who's more narcissistic versus more borderline precise or 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 s% which is pretty high um uh in terms of the sort of percentage of it folks with both BPD and narcism I don't know tons of research on that specifically um I can kind of speak a little bit about some of the symptoms atic overlaps but basically narcissism is um you know it's seen as they're being like two different subtypes and um grandiose and vulnerable um both tend to have uh uh we can really think about narcissism as like a disorder of self-esteem regulation you know and really the sort of the the excessive Reliance on what we call self-enhancement in order to regulate self-esteem and that can take a lot of different shapes for folks with sort of more the more grandio sub subtype there's this idea that I am great I am better than other people um 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 um sort of like the grandiose folks come to treatment because their family wants them in treatment other people want them in treatment where the vulnerable folks will be coming in because they're actually s 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 like achievement um uh success money attractiveness attractiveness of romantic Partners um 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 um so that's kind of the broad distinction both are joined um by what they call it's called different 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 beautiful no apprciate it Brandon that was the best ever Bob that was awesome I'm I'm gonna be making like some some just fun grandio statements during this whole can I can I add to that as well because Bob's uh um mentioned and you asked about borderline personality disorder and narcissism but in fact you find a much greater overlap I think generally with uh antisocial so uh the problem with narcissism to some degree in the grandio subtype is that it can get expressed through that entitlement and antagonism and that leads of course to social disruption and um once you feel grandly entitled to things you tend to start potentially committing crimes and so on but more importantly um and it's problematic for treatments is that you narcissistically have overcome your your developmental traumas so uh 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 um no not at all so they then Ed their narcissism in fact to deny any developmental problem that may impact on treatment for example so um that that then becomes a major problem of engaging that group of people in treatment nice um Brandon do you want to is how about is how does Envy play a role here well Envy can be particularly toxic uh in association with um narcissistic vulnerabilities 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 is lacking something and it's outwardly Direct 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 um sitting with some more vulnerable aspects of that experience of Envy it's it it becomes toxic rather than 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 we sometimes call this the narcissistic staircase of Doom where they they feel they have to pole vault themselves to the top of the staircase um rather than being able to tolerate the incremental steps along the way which is going to involve tolerating uh 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 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 um okay so let's let's go into the problems in mentalizing associated with with narcissism um so what kind of maybe let's start with a diminished emotional awareness or alathia kind of this inability to maybe identify emotions as well um more vulnerable emotions like sadness shame insecurity yeah do you wanna Bob do you want to jump in and yeah no this is I think a really this is sort of where MBT mentalization based treatment 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 and 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 Alexia 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 people are right or wrong around something you know and then you ask them a question well what was that like for you and they continue to just describe the situation you want to start wondering this this is what we often see with the Alexia kind of connected with narcissism and the idea is 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 to 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 I think it was it was so Superior how you put it it was just so good um I'm G be getting so much validation in this podcast Stoke is grandios soon be care I I need to not like have a plating tone here I gotta work on that um no I I really I really think it's good um I I think uh there's something about that like um it's like what do they have they have anger they have superiority they have this kind of detached demeanor um yeah and then what is it like in your work with 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 I I I don't want to be the only one talking but yeah Brandon what do you think I mean this we think about this all the time well I mean I think we wouldn't sort of be at this place of um having sort of invested enough in wanting to kind of develop a bit of a model and set of techniques if we didn't feel there was we were able to get leverage around this and some progress with with at least some of our patients and that's really what kind of galvanized um you know writing this up um but yes the it is a touch andgo process and that initial stage of Alliance formation that's so such a critical Universal element in Psychotherapy for any any cause uh targeting anything um it is a more Frau process the treatment Dropout rates as I think you've reviewed in your podcast previously are much higher in NPD even then than for BPD um because there isn't that kind of natural dependency seeking um you know that that that the Primacy of connectedness the wish to kind of stay in connection and manage connectedness with the 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 um it can really be kind of um uh 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 more easily but in NPD it is a much more fraught process I think so we're doing a lot early on to stay very contingent to our patients experience and 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 inwardly with reflectiveness into oneself and that takes we we believe this affect elaboration pathway that maybe Bob can speak more about it is inherently a challenge to the patients 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 in a kind of instructive pathway for clinicians to walk through that a bit more carefully and just to add to that um if it does it's might be important to emphasize that actually the the kind of empathic sort of joining that Brandon's mentioning in a sense has to be around the the idea the their 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 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 um first uh and you and if I can just put that in the MBT perspective we've rather um I suppose if I'm allowed to use the word sort of bastardized ey mode um which is uh the inner experience of eye and alexithymic or the inability to look inside to actually uh as it were integrate bodily experience into an emotion and and label it is actually what they have problems with and you asking about their mentalizing problems well this is one of the first components that IM mode isn't really working very well so we call it that for clinicians um when can you explain IM mode like what does it mean well Im mode in a is truly the experience of existence um um it work goes back to the 1890s and a sort of jamesan Consciousness and awareness of Consciousness but we s of developed it in a sense clinically simply to to get this self-reflective capacity the ability to actually integrate inner interceptive bodily experience into a representational level of meaning uh of oneself uh 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 um it eventually interacts obviously with others and when it's interacting with others we call that M mode and Bob's added you mode to it because we have to read other Minds uh and read them accurately to some degree which is what mentalizing about so that becomes me mode uh as it were you me mode anyway and we tend to personalize that we simply read other people but in reference to ourselves and we compare do they represent our mind accurately do they rep see us as representing their mind accurately and so on so then you're into the self and other interactive we call that M mode but that's also somewhat uh problematic for in narcissism but just to put this component in context 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 um and we would really not recommend that at first right so what anony 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 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 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 themsel 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 to 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 um you got to remember we're in a podcast so if you don't say anything that's you you all don't hear us nodding yeah yeah thank David I need I need some vocal validation thank you and's done a ton of these Brandon and I have no idea what we're doing yeah yes so yes you guys are doing great you guys it seem like you've had some public speaking training some like Advanced public speaking training despite despite that okay okay what about uh yeah and so what I would say is like let's go through the 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 this is a good one yeah I 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 your rap you know you should be uh we we can chip in okay Anthony that's very uh non-narcissistic of You by the way to uh 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 no I love that things on yeah Dr Dr tar my one of my one of my mentors we could talk for like 10 years years um together and oh cool he was far superior to me in his understanding of psychology and psychotherapy but he would always like he he had 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 I learn from them that's I hope that's my that's my youth I want to learn from them then I keep young yeah that's good well so 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 let's start with the let's start with the overconfidence in perspective taking that is really so crucial here and so that's the idea is that often times this is what MBT calls um psychic equivalence mode if I think it 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 I know I'm bad and not good enough so it's a bunch of different forms of certainty 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 um but like one is the sort of um 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 um my wife is too critical of me you know like something like that so that'll be like a negative judgment and so in MBT we would never take issue with that on first pass we 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 it 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 let's let's jump let's jump into this I'll be I'll be the narcissist here okay okay cool it it brings up rage for me Bob it brings up absolute rage okay all right yeah tell me more what's the rage well it feels so you know disrespecting yeah and it's like I'm I'm I'm working my butt off you know and then I do the dishes and then it's like yeah and then more crit and then I hear a critical word and it's like hey I'm 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 she would 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 new I have to offer here but I'm just curious is she always are we laughing at my comment here I'm I'm 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 you know I was I was I think I was laughing I thought 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 this is good you are really up here I don't know this is like getting too hot no no let's let's stay with it I want to see okay let's keep going well so I'm just curious though is she always is she has she always been this way uh no I mean I think when we were like initially you know the maybe the first six months it was kind of like you know I I felt like she was like very supportive and then something something flipped yeah I see okay okay um and then what just curiously yes so but when she was more supportive how did she treat you everything was gratitude and positive and okay 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 yeah maybe okay what what did she do that day oh she greeted me with a hug that was nice yeah what was that like well I don't know just you know it's like nice yeah that's sounds nice I mean I 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 okay you can pause there I would like Brandon to become the patient now what do you think was kid we David not to be too controlling but I really want to hear Brandon's thoughts on that because I so you want a bit of commentary on what happening there is it okay David if Brandon give some commentary about that because this yeah I I want to have increased Envy on Brandon being a better patient than me so I'm joking okay yeah let's hear you set the bar you set the bar David I think you set the archetype you're amazing yeah no I I think just a brief brief commentary I mean and kind of just pulling out some elements of the model so I think what you saw there was Bob was responding to you David with 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 anon's sort of um you know 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 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 um but um then 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 overly certain or rigid or maybe that's this is psychic equivalence to use the jargon but he doesn't press on that the the certainty or rigidity about it he doesn't go after that at first 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 um 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 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 he got interested in kind of what was it like when she greeted you with a hug or earlier in the relationship when she was 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 has this 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 um because you start off with such a narrow line which is a wife who is critical but actually you just simply expand it what from what we call the exploratory or not knowing stance really uh where you're not actually uh challenging the validity that's really important you're you're accepting it as seen from their perspective and and getting it expanded and interestingly people worry about it but 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 anything 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 appears so different across time in the one and she's like this but then she's like that what do you make of that do you see what I mean you're just continually opening up the field of sort of uh exporation here and I'm curious for you David like as because I had a when I asked that question 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 if I don't know if you remembered yeah I think um I think I was I was trying to um imagine my person that I was embodying not from a place of um my own experience and not from a place of uh like an identifiable patient so it's like I wanted to tell a story that was like unique and not necessarily like um something that was you know I I wanted to stay in character so I was like I thought you were beautifully in character here just to point out that that you came back at Bob in a in a in a wonderfully sort of dismissive way you said well You' 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 of piy 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 and so on so you're straight back into the 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 y yep yep yep no that's um and I think those moments and I 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 let's slow it down right there what what could be some other ways of approaching a patient when when they do kind of that direct attack right because and I'm curious Brandon maybe you could speak to like I know you've also trained some transfer Focus therapy because like I think they would jump on that as like a transference moment right um 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 Focus Psychotherapy which I use as well and value in my practice um I think there are some 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 uh was just the Still Standing sort of firm in the not knowing stance um he didn't actually use too much of 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 ex the the experience as 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 um to use Nancy McWilliams language and so 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 let 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 um 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 do 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 patients mentalizing is quite fragile 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 a as an opportunity to move into a kind of depth exploration of what's going on in the representational you know object relations diet as you might do in tfp Bob just stays really into 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 frat challenge to mentalizing does that make sense the other bit may be important a little bit there is 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 um 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 BT would see this as as a as a joint uh 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 um 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 that other people may see things in a slightly different way and then that alters of course your technical uh uh 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 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 intervention cuz I think what I said there cuz I was a little bit uh oh I part of it was like oh is this going to make me look bad cuz I'm role playing on a 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 it sounds like a very quick move but if it's two 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 I think you were laughing because you were stepping out of the the was that's true you were stepping out of the role play 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 gonna say something Ju Just underscoring I think there is a difference in the models here um you know we're really um quick to kind of as we say take it on the chin sometimes you we're quick to sort of own whatever we think may have been our 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 this some of this what just happened between us may be an expression of the patient Psychopathology but we're um we're explicitly I think um verbally showing that we're quite open to um how we impinge on the patient's mind Brandon but don't you want to narcissistically defend against that you are the cause of their suffering like isn't that like a deep profound desire of ours as clinicians like to that I am not the problem it's your parents right it's your parents it's the transference um 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 self-esteem at but I think you're getting at that David this is a an important piece of counter transference or counter relationship as we'd say an MBT and working with narcissistic individuals um we we do have to actually kind of be able to manage um that sense of um gosh am I going to be useful to this person gosh I'm feeling quite inadequate and Powerless help and deskilled and unskilled and where did all my training go and feeling quite helpless to be helpful here um so those are common counter relational experiences that are are I think more unique are more prominent in in treating NPD than even BPD so yes 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 um but Bob you may have more to say about this yeah I love the question David and you're it's really I think it's such an important point and if we think about it what is the what are the parenting styles that have been shown to kind of be correlated with the development of narcissism parental psychological control um it's been shown that folk that parents with NPD are more likely to have kids with NPD so that's the that's 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 and Inter subjective intivity Theory and but the cool thing is is we do that folks down regulate and 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 got to say I I hear you and you know I think we we can both have a part so can we also take a minute to look at what your part might be so it's 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 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 yeah that's okay yeah that's fine so I uh I feel like we're just scratching the surface you know it's like yeah it's good okay so let's let's get there's there's so much more around like the Mis mentalizing one of the one of the things is like externalization of blame how do you 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 um do you see it as the same as what we've been talking about do you see it as different like the overconfidence in perspective taking externalization of blame are those two separate things I just for like in terms of ground to cover it kind of go the techniques kind of go into the same area because they're both certainty right certainty that it's your 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 our own perspectiv so I do think technically there's Rel it covers relatively similar terrain okay but want to hear more more about it the aphorism for it in a way is 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 they experience a sense that you do see it as they see it and as they experience it so you then joined in some form once you think that's established you can start chipping then chip away but you don't demolish you don't explode the whole thing um and show them that really they're dismissive and they're misinterpreting and it's their narcissism and they're to blame this is this would be disastrous but you then just technically Chip Away within the frame of your now stable and rather empathically sort of uh 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 do you see it like that I told you it wasn't like that I said well I think it came to my mind just when you were saying this and so so they have to consider your mind and your perspective You' 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 and and they experience you seeing it from their perspective so with borderline prise order 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 um but how do you specifically work with these um insults yeah that's that's definitely that that requires sort of different set of techniques I'm glad you're asking about it David so um this gets to a construct that we cover in the book which we kind of so Anthony has developed this idea of tileology 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 teic self-esteem so my self sort of rests on external things and um for that like absolutely what are the kind of precipitance 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 slow that 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 um some situ situation in life that I don't say makes them feel bad about themselves just find upsetting and that leads to sort of psychiatric decompensation okay that's not a third grader language I can put it in second grade language but 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'm nothing if 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 that until two parts though what anony is saying the first is I should be blank and the second is if I'm not then I'm bad right I I almost like feel like some Karen horai here uh like Neurosis in human growth like the shs that Define the person and they have like I should be this and I should be that and I 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 shoulds create this like false persona it's the true Persona which is kind of hidden there right it's I don't know if you guys are fans of her work but that's that's what I'm hearing in kind of a way I think of it as um 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 you not entirely conscious generally speaking but it's some 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's it goes to that IM mode how 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 I'm capable of vocationally because of the number of graduate schools I got into and when there's some concrete disturbance in that that that channel of sort of uh self-stabilization then it throws the whole sense of self off it just capsizes as Anthony is saying so that can be um a threat coming at the self-esteem in in virtually any channel it can look like an interpersonal you you know disturbance but it's a it's a narcissistic disturbance because it actually it's 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 me 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 way that Anthony or Brandon are describing they're just saying I'm just depressed or I'm just 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 or there's been a suicide attempt I mean it's you usually people with NPD don't talk about their suicidality there just will be a serious higher lethality higher risk you know suicidal 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 is crucial for treatment because in we would propose in order to help some 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 I I I hope other people who are listening to this have epiphanies as well I'm like thinking of some patients 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 I would have like spouses of people sending their husband there um yeah any thoughts on that just brief side note well so we do it a very it's a big part of the treatment we provide at mlan I think Anthony I'll be curious to hear what you thinking if it's any different in the UK but um you know one of the groups that I run is MBT for for narciss personality disorder and when I started that group the feedback that I got from every you know a lot of people around the hospital 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 and so 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 okay and often we need the diagnosis in play and agreed upon to have enough therapeutic leverage to actually look at it in treatment um so that's why we give the diagnosis um well in fact MBT itself a mentalizing doesn't require a diagnosis in a sense because it's a trans diagnostic 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 necessarily say narcissistic personality disorder but we do say that there a pathologic narcissism operating here uh and and 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 in 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 Sula you know there's too many eggs in the Sul and and so on so we we just got to moderate and help moderate so it's not something that we need to put across as your pathological here in a way like you know so on but we do say it's it's PN pathological narcissism I say but not a category 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 paring back to us okay I have pathological narcissism or I have this disorder but that we 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 clinicians so we do spefic 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 at the heart of MBT for me anyway it's got to be talked about explicitly and we do need the patient to um see it in some way within thems and and agree that it's got to be worked on in this treatment to move forward so shall we shall we do a role play on that Brandon and I'll be tell me tell me what the scenario is tell me who I am oh tell you who you are what are my what what is the insult that's your ey mode we need you to 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 I don't know what you know it's like 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 um 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 coming to the end of your undergraduate you know final year and you were you had this C certainty that you were going to get in 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 you didn't want to think about it but you just kept part of you kept waiting for that that 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 have been trying to 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 14 rejection and you couldn't see a way forward you couldn't feel there was anything left in yourself worth hanging on to so you just had to end it the that might be example the thing the thing that jumps out to my mind Brandon if I can call you by your first name as my patients do I um the thing that comes to my mind is is 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 when you saw your best friend getting all these acceptances that you weren't getting oh I was so I I was just i r 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 iraist that you said you know I can see that quite clearly actually um was it what else was going on around that I 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 was what happened when you when you saw that that that door was closed for you what else was going on if anything um 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 like so when 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 I don't know if I was feeling at myself at all I well you did you did go on to then I think do something pretty serious to yourself what 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 you Dad stepdad Uncle person I barely know you know like I mean I I know what he expected of me but I I think like I I took the pills right there in his in his bathroom as a big you and what were you hoping that that would change within yourself I just was hoping it would it would let him take the you know let it 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 different for you if you were able to cause him to feel guilt I I I'm 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 um I'm sorry I forgot your question well anyway we could keep going no this is good but I think it's I think this so far I mean um if I can tag getting too real there was it getting too UNC no I think and Bob and Anthony would each do that a little differently I think but um 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 I was trying you know not so successfully but to kind of push the uh curiosity about H how's this person evaluating and feeling about their sense of worth competence their sense of having a future yeah sense of Measuring Up to expectations but probably do it differently and I want I want to hear Bob's debrief here Bob looks excited Bob looks I love that and Brandon no I wouldn't have done it differently because I think he Brandon was doing the Right Moves there you were asking you got at the impression that about reality in the situation that 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 the me the anger at other people which is fine but I'm just curious do you have any negative feelings about yourself around getting rejected and in in all these ways I don't I don't want to go easy mode on you Bob and and and difficulty mode number 10 on Brandon here but um we'll consider you guys the same person Brandon's interventions were great so you you yeah I'm riding on them right now yeah so yeah okay let's let me get back into it um what I was saying was that I 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 um I I think I was I I internalized some of his anger and and and need for me to do things perfect okay um and I think that's part of why my anger was turned towards him so you're 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 um you know embarrassment okay I was incredibly embarrassed um 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 it 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 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 uh grad school then I can't become you know um an aerospace engineer in the way that I want to okay and so what what do 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 does doesn't that make sense to you well that what's I mean you obviously have success and are here and through grad school and I 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 that it's like you're putting all your eggs in that basket and what happens when the basket topples so you you want to kill yourself so I'm interested in like using this treatment I don't know what you think to help you with that so you're less vulnerable and what do you 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 what what's it like David then if you are coming into treatment sort of seeing someone like me who you just said you see as really quite successful comparing as you're saying to yourself who you as I understand it even in the middle of the night it begins to sound like you're thinking yourself as unsuccessful not worthy of you know I I 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 are you're you're 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 I 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 as successful and yourself as 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 I just read this book called something like awful 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 is 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 saying tries to get it to sort of the relational area particularly right at the beginning I think B 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 overex tra 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 overe explain things it's not really rooted in reality it's not grounded in a sense it doesn't link really through to uh coherent memory coherent Narrative of one's history and so on is just sort of thrown out into the world uh and so on and we then have a problem because pretendo is very common in narcissistic function wow and both all three of you guys awesome just awesome like I I don't want you to feel like I'm like I I I was I was being very difficult and David you're awesome you need to like go into acting I amazing 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 we should write a letter I did not get into their intro to acting class and so whenever my patients tell me that I feel like you're acting I'm like no I'm not a good [Laughter] actor I like my that that's that genuiness of NBT and I 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 BP 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 you you got me pegged I can't understand it I don't understand it can you try to explain it to me I would love before Anthony has to leave um David you would ask the question about problems and empathy and Anthony has done so much work with this around the antisocial stuff and it's so in 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 um and psychopathy I think is a deficit of affective empathy um you know and so I'm curious Anthony your thoughts on this like it seems to me that uh once you go beyond a certain level of psychopathy there's there's not a lot of help that therapy can bring you um and I also think Anthony just to kind of deepen this just to give you kind of download my my thoughts as we go into this um when you did the when uh foni did the reflective um manual the people who were in The prison had the lowest scores on the reflective function U 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 yeah I mean your question is unanswerable but I'm going to slightly reverse it but I think you're quite right and and it's in the literature about the absence of the effective empathy sort of component As you move towards the psychopathy sort of way of uh 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 um and that's a big problem uh but I think the thing that people might like to think about is is that the sort of reverse occurs that that in a sense you have a counter relational problem to this so that not curious about your mind uh in a sense and actually they also um 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 um whether they are deliberately covering up what's in their mind say or actually they simply don't naturally transmit their mental states to others in other words they're walled off they're 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 verbalization but it's cold it's be it doesn't seem to root in some way so you have quite 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 so um so I I think uh and in general the antisocial with with uh 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 they're not very good liars of mental state if you see what I mean they tend to be a they tend to say no I don't feel like that and yet it's kind of obvious they that they they're that's what they're expressing and so you've got something to hook into uh when you're kind of working with them and that's rather different when I think antisocial personality order it's like I'm thinking DSM five like we're charact 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 the baked in a bad environment um surrounded by by people who are like you know doing criminal acts and they themselves get kind of pulled into it um are are you treating um which which category of people do you normally come across are you doing the psychopathy we were treating those with uh uh well the issue is aggression in a way isn't it or the the the uh violence um that ensues uh and that was what we were really asked so so it was the group with antisocial who were recidivist violent uh criminals uh so so they were uh responding to um uh provocation or general stressors if you like in life simply through violence so they were repeated violent offenders that group impulsive violence or was it like a predatory violence for most it was more impulsive violence but we measured their Psychopathic sort of levels um and that was a range actually from low levels to much higher up to 29 Europeans which is 32 34 um us measure on the PCL okay okay so then wow okay so you're dealing with some true Psychopathic individuals at that point well yeah yeah to to to be honest we were trying not to I mean you know but we were measuring the PC because we had a cut off of 29 and then so what did what what did you find in the research well I'm not at Liberty to say what we 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 mentalizing so um uh in a sense we were working on the basis that the problem with aggression is that aggression is a necessary s survival phenomenon uh and so on um and mentalizing is inhibitory in that sense so we block being violent in the main we may experience a sense I want to you know get rid of someone or hit the you know whatever when we're five and we bash them a bit you know but gradually mentalizing takes over over we socialize and we actually inhibit and the problem is that um mentalizing therefore is is a partial mediator towards uh 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 reduce their violence so I just want to make sure to speak to this because Anthony is sort of talking about antisocial and when when we're like in terms of the folks that we're more likely to see at mlan um and I don't know if this applies if you would agree with this Brandon but whenever we I give this sort of narcissism diagnosis the most common response that I get is but I can't be narcissistic because 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 not in any way saying that you don't have empathy the challenge is though is that sometimes it seems to me that when your sense of selfworth 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 and um and like because I feel like when I'm really tired or like you know after nine hours of seeing 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 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 a youth thing or a narcissism thing this is a human thing when our self-esteem is under threat it could be harder for us to put oursel 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 how we normalize it is just yeah when 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 narciss narcissistic problems but it is on that spectrum of um that Continuum of normal human experience we had a very poignant example actually of this just at at um the Gunderson residence earlier this week in our MBT group one of our patients um had been um 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 I can't be NPD because as Bob said because I I can be quite empathic sometimes isn't that how all of you experience 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 were able to actually empathically and gently give examples where they could see both moments she could be quite empathic and interested in the tuned but at other moments and it was in these moments where there was these threats to self-esteem 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 you know bewildered by you know angry with her and 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 I think that by the end of the group it just shook up that sense let me I just want to say Dr Dr Bayman thank you so much for coming on I really appreciate you and um it's it's uh I think there was a comment earlier like oh we're so glad you guys are talk my podcast is talking about mentalization and and honestly like it's it's an honor just to even talk to you face to face um that's the way I feel as someone who like has read your book since I was a a resident you know appreciate you so oh you're muted Anthony that that'll fuel my narcissism for the time being very thank you very much for having me thanks for coming Anthony making the timey um David I think that what Brandon's saying also just from a technical standpoint because I know so many your listeners are psychotherapists who want to know how to treat narcissism I think that what happened in 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 what's called an MBT formulation which is a which is a written document itemizing patients problems and mentalizing and this is where we put is that 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 use as a focus for treatment it kind of guides the whole treatment is this what you do in a like a 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 just for well we could talk about that but I just want to make sure the empathy point isn't Miss is so but we got to put the problems of empathy in the formulation and'll be sometimes it seems to me when you disagree with people it can be harder for you to put the put yourself in their shoes and or you can see what they're feeling but don't always fully care that's your point about affective empathy put that in the formulation and then where's a there's a reaction How does it go there's often push back disagreement we're curious about it we kind of play with it together but um but we end up sort of using the treatment to actually help with those issues well just to emphasize we set that up as again within the kind of twers inter subjective model so we usually will preface this well first of all we tell the patient 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 that elephant in the room between 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 patients difficulties in their functional realities you know how they are in relationships if people regard them as unempathic if their 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 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 IAL kind of scrutinizing lens we just welcome that you know I 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 and so we really just invite that you know help me understand better that doesn't mean we'll necessarily change everything but we will 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 about soly 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 Dropout that's good yeah no it it it it sounds like it really makes sense especially um with this population and but you're also doing this with like borderline precise order all your patients right at that Center yeah it's one of the it's one of the distinguishing features what makes it different from just traditional dnamic Psychotherapy because we're putting stuff in writing revising and then that becomes the the target of treatment yeah yeah um and then also like there's uh difficulty in tolerating ambiguity black and white thinking that's another Mis mentalizing thing that you commonly see right is that correct Brandon you don't look like oh no I'm agree I'm letting Bob take this one but no absolutely black I mean there's particular forms of black and white thinking and uh that that manifest characteristically an NPD supposed to BPD a lot of This falls under the kind of category of um of the certainty that we talked about earlier you know different versions of the certainty um 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 um 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 m 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 um and so we could hold back our true opinion you're calling me an expert on devaluation are you an expert at role playing devaluation yeah yeah but but but basically um 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 what their perspective what supports it help them s hopefully see things from more Nuance like that patient we talked about earlier who was devaluing his wife and he's ah she's okay on Tuesdays not on Wednesdays and then at the end of that I am going to have to say something like I got to admit I know your wife can sometimes be critical of you I it's also stood out to me sometimes that you can actually be quite critical of her o what what did you just feel but I'm only critical of her because she's critical of me Bob I I hear you yeah yeah so 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 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 seen 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 with in the patient's current perspective and then we think there's a bit more mentalizing online maybe there's room now to at least not it's not to try to get them to agree with us we're never trying to just persuade like like a nitive therapy like kind of persuade of and 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 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 it's too bad but tell us when to come David man would you guys fly down going into winter time here in there's some really good food down here I'll that we should we should make that happen and we could do our next one person well I really appreciate it I didn't expect just to be frank I mean I I I was a little worried about joining just because I've sort of you know don't sort of to tend to do these sorts of podcasts but it's was genuinely fun um actually talking about this stuff with you wonderful yeah well I mean you guys are like you guys are in the trenches right so it's like I'm it's my job to make to try to pull out your your the wisdom of being in the trenches with this population I I feel like you know you guys have a lot of 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 um and hopefully uh it can spark their curiosity where they want to continue to learn more and so kind of as we wrap this up like are what are are there any big categories any pearls that you have that we haven't really hit on that you want to just reemphasize I do have a I have one thought actually yeah yeah and it relates to the stuff you were asking about the ruptures in self-esteem okay so that for me is really in theological 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 inevitably as you're moving through the treatment there are going to be moments of emotional disruption that are linked to that and then those 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 that sounds like that your your boss seeing you that way really made you quite 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 the pro 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 where they're hoping it will meet them yeah that's it's that's really helpful that's 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 okay but yeah okay Bob one more question before before we get off with with um with this for you like what led to you getting so excited about this feel like what what Dre you well interestingly so I worked um 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 mvt groups we knew these folks had characterological disorders I think at the time I probably put them more in the BPD Camp um because there was a suicidality that Brandon had kind of mentioned but then when we started learning more there there's a huge amount of research done in the past 10 years on treating narcissism I came back to mlan met Brandon sort of we were working together and we started realizing oh gosh these patients likely meet criteria for NP 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 um a lot of them had MPD and so sort of a lot you know in that 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 patient in the MBT clinic and it just sort of all kind of sprung from there um and we started finding that using the kind of adapting the principles somewhat like there there some differences between MBT for narcissism and standard MBT these patients we found we're really getting better um and the first patient that we diagnosed with MPD formally in the clinic um I won't get into you know great details we know we got to stop shortly but this is a patient who is in four times weekly psycho analysis um very suicidal impatient multiple impatient Admissions and came to us for once weekly MBT Brandon did this person's evaluation and um 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 of Brandon did the group therapy I did the individual therapy within a year of him being in treatment with us he was no longer suicidal he was no longer impatient 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 life so like when we started seeing 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 I I think that's just first of all it's awesome that you guys collaborated and worked with it and get to work with baitman I mean how amazing and um and I think giving him clear feedback and Direction like hey here's the things you need to work on I can I can imagine that that was very actually helpful um and not as amorphous as maybe other therapy could be right um okay the the second thought I had was I see a lot of these patients who are successful who continue to be successful but the fantasy of losing the succcess that actually is the distress yeah Brandon what do you think about that I love that question yeah oh yeah no it'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 uh I mean it just 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 agre feels the same way just like with borderline patients you know with with narcissistic patients we can really see parts of ourselves that are on this these are 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 we clutch it I 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 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 valued that fueled my sense of self was suddenly taken away or threatened how would I do with that you that is a scary thought so that doesn't answer your question necessarily but I try to I think both Bob and I are try to be grounded as as humbly as we can in a sense of you know so to speak they're before the grace of God go eye you know we're we're 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 Universal human problems we're sometimes able to help people with in some powerful ways very very good and and that um that statement there but by the grace of God they're go Paul right and in the midst of [Music] um in the midst of Trials and in the midst of success right um yes and in the and and I think it's almost like uh I I I was actually thinking of more of like the stoic solution to the the fantasy but that seems like the Christian solution to the um ego right it's the grace of God it's not my own ability in all things there you sto the stoic solution is actually uh to um to imagine losing it all and to be peaceful well but this is 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 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 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 can you even to try to imagine the possibility that even without this thing you could actually have value as a person yeah just try to consider that and that is that that parallels the stoic solution right the sense that we have a sense of worth and a sense of connection ESS independent of the externals as patients begin to wrestle with that possibility we see improvements in self-esteem and improvements and functioning less contingent self-esteem and sense of identity and I don't know whether that's stoic or Christian or what what it is but um 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 I think about um the other thing that kind of makes me think about is Victor Frankle right and so one of his quotes um 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 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 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 is that really does speak I think to that that final ultimate Freedom we're trying to actually kind of grow as some nent quality in our patients um alongside them yeah yeah so I think yeah it's it's uh it's like can you imagine if you are successful um losing but then being like Victor Frankle and yes and seeing it as a path it's part of the hero's journey um and uh you know taking the role of the you know the giver like how he chose to help about I think Ty his 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 in from narcissism in the MBT Clinic um one of his sayings that he implemented in his relationships which is interesting and it's it's non for him it was not religious but it was this question he say how can I be of service to this person H that was what 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 a good place to to wrap it up right there thank you guys for coming on I appreciate you and I I do extend the offer when you come out to Orlando um knows how I phrase that to uh to come to come grab some world class Sushi or steaks or whatever you're into or both and we'll thank you very much D this is this is really fun it's really amazingly fun and what an opportunity thank you