Transcription
The thing about narcissism is that you're seeing somebody sitting in front of you who's really struggling with their self-esteem and their sense of self-worth. Things like, "How do people see me?" Um, what's my status? Will I be loved if I am ordinary, average? um where people have these really high, often unrealistic standards that they work to achieve because it's the only way in which they really feel good about themselves. So if those parameters or that goal is compromised, their sense of self-worth, who they are, um crashes. It can bring them to suicidality, isolation, nonfunctional status. So the stakes are really high.
You couple that with somebody who has BPD, who's interpersonally sensitive, who's born sort of naturally emotionally vulnerable and can be more reactive. And that combination can be really painful for the person and really challenging to treat, especially if you don't see the narcissistic component.
I'm presenting everyone with Karen Jacob, who has been on the channel before predominantly as a therapist. I think one of the things that you see as people coming in to your treatment program pretty halled >> um with a borderline diagnosis, a narcissistic personality disorder diagnosis >> and now antisocial. One of the questions I had for you is what's it like at your program right now? Who's showing up there? You know, you said there are far less borderline personality disorder people showing up. And we could speculate on why. >> I'm guessing more information out there, more people that actually treat it. There are empirical treatments for it. But can you talk about how the tenor of your program has changed and also how you interpret that?
>> Yeah. So um I think that's multifaceted. Agree. >> First of all, you're absolutely right. Compared to the early 2000s, there are many more empirically supported treatments for BPD and more people are getting educated about the diagnosis, not just how to diagnose somebody, but then how to treat them. I really think many people are getting identified and and effectively treated in an outpatient setting. Seeing somebody with just BPD, I often say, is like a unicorn. Usually you see comorbid diagnoses, whether it's substance use, eating disorders, bipolar, something along those lines. Um, what we're seeing more and more are people who struggle with multiple personality disorders. So there's also a shift in the field where the practitioners who are working with personality disorders are seeing folks more on a continuum of what's called borderline personality organization. This was really born out of the TFP folks, Frank Yman's, Otto Karnburgg um who look at personality disorders along this continuum where antisocial is on the more severe end. Much, much harder to treat. Below that malignant narcissism, narcissism, BPD, and so forth. What we often see is people who are overlapping on that higher end, antisocial, malignant narcissism, narcissism, BPD. Um, and part of that again is, I think, that outpatient therapy is really effective for people who are struggling with BPD and other personality disorders that don't sort of meet that mark of narcissism and antisocial.
>> [gasps] >> I do think this is a generation that is also being raised um with social media, with more mecentric ways of looking at the world um with far more sensitivities to the social worlds, the social dynamics of the world, and that activates all sorts of things that just didn't exist before social media. So you see these anxieties earlier on socially and otherwise. Um, there's also a way in which people are um assuming that they should and can perform at these very high levels and without which um their value is meaningless or less worthwhile. So there's a way in which social media portrays the average person as often having these more glamorous lives and reaching these fabulous capacities and having these wonderful jobs. Um, and there's a big generation of folks who are growing up assuming that's life. And within all of those different presentations across social media, what's often not as present are the struggles, just the day-to-day struggles, um the challenges, the failures, um reckoning with your own limitations, um being okay with who you are rather than what you envision who you should be. So, it's a a confluence of um lots of different factors that we're seeing now in our program of folks who I think have tried a lot of different treatments and have been deemed treatment resistant and those having to interface with these environmental changes that um have been rapidly introduced to our society in the last two decades.
The other thing I would say is a lot of folks in my field would say NPD is the new BPD. That if you talk to folks 25, 30 years ago about BPD, it's sort of where the field is with NPD right now. Um, it's not necessarily so much that there are folks necessarily with more NPD. I think it's a good question that we need to still evaluate, but it is there and it's not being identified. So folks who struggle on that more higher end of personality organization, narcissism, malignant narcissism, antisocial may not be identified because clinicians still are being educated as to how you diagnose the problem. And then we're just developing treatments that we see help people. Right now we only really have mentalization-based treatment and transference-focused psychotherapy that are organized to treat folks with narcissism.
Right. So you're saying that unless there's a treatment to treat the problem, it's hard to diagnose because the people learning treatments to treat the problem are thus being skilled in the capacity to diagnose. >> Is that both of those things? >> Okay. >> First, can you diagnose it? >> Forget about the treatment. Do you see it when it's there in front of you? And really well-trained clinicians may not have exposure to what that looks like. Is it just that they're then sort of misdiagnosing them? Why? Because they're looking at just sort of like a collection of symptoms and saying, "Okay, you're ADHD cuz you can't, you know, finish work and you're, you know, substance abusing and this and that and the other thing." But they're not able to put the picture together to figure out how the parts add up. Is that so it it may be a misdiagnosis. Sometimes they say it's a missed missed diagnosis. So somebody knows they're struggling and many people will seek help. The diagnosis is a really I think critical part of then what treatment do I provide for this person? What can I offer somebody that I know has some evidence so that I can really offer them a pathway forward? I can't do that if I can't see the problem. So I first have to know, oh this is a narcissistic problem and that will organize my way of thinking about therapy. So well-educated clinicians who are really good at what they do may not know how to diagnose NPD.
How do you know if you have someone who's NPD sitting in front of you? [snorts] Like what would you tell a clinician if they're seeing people? What are some of the hallmarks? So, how do you diagnose somebody with NPD? Yeah. So, first of all, everyone has a little bit of narcissism. Let me start by saying that, just like everyone has a little bit of BPD. The thing about narcissism is that you're seeing somebody sitting in front of you who's really struggling with their self-esteem and their sense of self-worth. When I say that very generally, you might think of lots of problems that people can um struggle with in response to issues of self-esteem and self-worth. The challenge becomes with somebody who struggles with more pathological narcissism is when their self-esteem, their self-worth, their identity becomes really contingent on external factors. Things like how do people see me? Um, what's my status? Will I be loved if I am ordinary, average? Um, where people have these really high, often unrealistic standards that they work to achieve because it's the only way in which they really feel good about themselves. So that means if those parameters or that goal is compromised, their sense of self-worth, who they are, um crashes. And when you see somebody in these more extreme states, it can bring them to suicidality, isolation, nonfunctional status. So their real capacity to feel okay about themselves and and engage in the world is compromised when they don't reach these high standards and or are seen in a particular way. Um, so the stakes are really high.
You couple that with somebody who has BPD, who's interpersonally [music] sensitive, who's born sort of naturally emotionally vulnerable and can be more reactive. And that combination can be really painful for the person and really challenging to treat, especially if you don't see the narcissistic component.
When you just said that I and you said the BPD thing, it sounded like you were saying there is a little bit more of maybe a genetic loading to that or just the way you're born as someone, you know, more emotionally riled, royd by things and based on what you were saying about the prevalence of social media, do you think NPD is less born into and more situationally generated? Is that >> that's a really good question and um I think the the jury's out as to how biologically loaded NPD is. We do know there are environmental factors, overvaluing your child for example um that can influence somebody's development of sort of their expectations of themselves and their place in the world.
Can you just I'm sorry to interrupt. >> What do I mean by that? >> That I've gotten tagged for doing and I get um but can you just define what that would look like for those of us out there who now don't want to overvalue our child but love them so much? >> Rebby, you are so wonderful and talented. I see you're so great with a camera. You should be a director of movies. a blockbuster. Would it be blockbusters? Not just it ranges, but this sort of concept of overvaluing not just your child, your capacities to have these pretty high expectations that often are unrealistic and have that in many ways define or value the person you're sitting in front. And again, I'm speaking in a little more concrete black and white extreme ways, but that's the message that kids may get. Um, and so we do know that when you see a child who has NPD, it's likely that parents struggle with something similar, even if it's some kind of trait, whether that's biological, environmental, combination, probably accommodation. As I mentioned, the field of NPD is still in the process of gaining steam and more and more research over time.
How can you though um I I guess even how would you self assess as a parent of a child or as a person if you have NPD traits? How do you separate drive and ambition from narcissistic pathology? Like when does it tip over into that and then your kid would absorb that curse? >> Yeah. So, as I mentioned, my hope is everyone has a little bit of narcissism. And I'll also say something about what it looks like because I think it's misunderstood in the world. Um, when anything tips over, it really is talking about severity and impairment of functioning. So, is my sense of self-worth and my capacity to regulate my self-esteem contingent upon capacity to achieve in these high >> in a high way unsustainable? um when I don't achieve these things, can I manage? >> Can I regulate myself? Can I stay engaged in the world and what I'm doing? So, you're looking at the level of functional impairment and severity of emotional reaction. Um, that can be a fallout of what I might say a narcissistic injury or a narcissistic blow like I didn't get that promotion, which by the way most people experience. And for somebody who's truly narcissistic, that's a real blow to their self-esteem. And it's hard to rebound >> and become resilient to those failures, real or perceived.
The thing about narcissism, most people think that somebody who's narcissistic feels like they're all that. Um, they're full of themselves. That's a misperception. Somebody who's narcissistic truly struggles with feeling good enough within themselves. Very pained by who they are and often using these achievements in the world, the way they look, um their job, um some level of whatever measure they feel is um worthwhile. They measure their own self-worth based on achieving those things because inside they feel so terrible about themselves. So it's a really painful thing for somebody to experience. And what's unfortunate is if we really see a narcissistic presentation because it's so widely misunderstood when you tell somebody I think you struggle with either traits of narcissism or NPD that there is this response of but I'm not full of myself but that's not me. And that's a real misrepresentation of what the problem really is. It's actually no, I don't think you're full of yourself. I actually think you really struggle with feeling good enough. So all of these things that you do protect you from contending with how you really feel so you can hang your hat on the achievements that you have or the way that you present yourself in the world so people see you in a certain way.
If you're a therapist, which you are, um, how does it feel different to sit in a room with someone who is narcissistically or narcissistic personality disorder inclined versus someone who is BPD because I think the feeling is different, >> right? >> Very. >> So, as a therapist, very different. >> As a therapist, it's important to know that. >> Absolutely. >> It's your one of your antenna to help diagnose. So somebody who's BPD oriented is actually cares deeply about relationships. They really want to feel connected to somebody. And I say that because that from John Gunderson's standpoint is part of the diagnosis is a real orientation towards the interpersonal piece. A desire really to be sort of valued or liked to feel connected. So the dynamic matters a lot and what you do >> in that therapeutic relationship is very felt by the person you're working with. When you're working with somebody who's narcissistic, you may not actually feel like a relevant presence for a year in therapy. And therapists may not even realize that while they're initially working with somebody who's narcissistic, but to sort of get a word in edgewise or to share an observation or challenge somebody in the room, that comment or observation may be just sort of brushed off, talked over, dismissed, challenged, not really considered. So asking clinicians to pay attention to that becomes really central. Even feeling devalued in the therapeutic relationship. Maybe you offer something or you know this evidence has shown um some intervention may be helpful or a challenge may be helpful and the person you're working with may either blow it off or actively um dismiss or maybe they think they know better. I often say to people who have all sorts of questions about like the program I run. Um, I can sort of now tongue and cheek say things like maybe maybe you can run the program better than me. And it's not a way of making fun or being snarky. It's sort of trying to join somebody if they really realize that these are the vulnerabilities that they are challenged with. Oh, maybe that thing is coming up again. You don't like something. >> That's okay. But then feeling as though you may know better >> is something a therapist may experience pretty regularly in the therapeutic relationship.
>> Yeah, I spent about a week with people who were NPD diagnosed [snorts] and I adore them. Um, but uh it was actually very intrapersonally complicated in a way that was really different from my time with BPD people. >> Yeah. um in any particular way. >> Um with one of them um I had to be very careful about showing too much care or empathy. It was like this strange combination of them feeling like they had duped me into caring about them because they weren't really deserving of care and at the same time thinking that I was too stupid to realize that they were duping me and thereby they were like diminishing me. >> So it was this like very complex dynamic. And so what was hard about it for me was like I really cared about them and having to manage the show of care because I knew that it sort of triggered them was just a really different experience from working with BPD people. I mean it makes me sad to think about actually you know not being able to just accept real care from someone >> you know that was like that's yeah that's very sad. >> Yeah. you know, it limited the scope and the expansiveness of the relationship. That was what was striking to me is the boundedness of my expression um with them. I'm probably exaggerating it for to make the point.
>> I think one of the things you're describing importantly though, if you're somebody who struggles with self-esteem >> Yeah. and you don't feel good about yourself and you don't feel worthwhile >> or lovable. For somebody to express love and care may mean either are they lovable, which they don't see, or you're crazy >> because I don't see what you see in me. And that is a very um painful reality that that somebody who struggles in this way contends with.
>> How do you when you're treating someone I mean how do you handle your own compartment when you're dealing with people >> Yeah. >> who are in that space? What I do now is different than I would have done say a decade ago because knowing what I know about that inability to tolerate being loved when you can't even love yourself like you're describing I would have reigned in my natural reactions for fear that presenting something in a particular way that does not align with their self-concept would contribute to an evaluation of oh this person really doesn't know me because if she did then dot dot dot >> right >> now I just say it >> when I genuinely noticed like a desire to really appreciate somebody >> even if they've said or done something that they feel is completely egregious that I I have this urge to sort of respond to them in a way where I see them as a very loving kind person despite all of these things. But saying that may make them think I'm bananas >> because I know that they don't see themselves in that way. And just saying that um puts a spotlight on the conflict for them that's now being played out between the two of us.
>> It sounds like that's like a smart therapeutic strategy, you know, that discovered [clears throat] by accident in a way, but >> Well, not so much. I would say that is sort of aligned with, for example, a TFP approach and maybe even NBT. You know, NBT is about what's going on in your mind that may be different than what's going on in my mind. So, I'm trying to access what I assume is going on for you while at the same time presenting what's going on with me. And from a TFP perspective, it's that same sort of organization of highlighting >> um that person's sense of self and how they see themselves in this world interpersonally and otherwise. And I'm honing in on that. My description of it then is offered in a way to highlight that very problem. So for me, maybe it's because I know a lot more about TFP or MBT or I've seen a lot in my many years. Um, but it's kind of my way of thinking at this point.
>> As a clinician, you've absorbed all these trainings, all these strategies, but as a former patient of yours, I never felt strategy. And I felt just you. And I wonder if you could talk about that. >> Um, so yes, there are strategies and those strategies are important whether you're doing exposure work, exposure plus response prevention, whether you're doing MBT, but then there's just you as a therapist, as a person. So when you and I met, I wasn't putting on a hat of I need to, you know, be a DBT therapist for Rebby. I was thinking who are you and what do I know that might be helpful and the way that emerges in a therapeutic relationship is organic to who you are >> and who I am. The technique is not driving our dynamic. It's offered as a map and then how we navigate that map has to do with us and who we are. So, if you're a therapist listening to this and you feel like you are um you know like a cook in a kitchen and you have a recipe and you you are a drill sergeant and doing X and Y and Z that's not infusing who you are as a person. So I don't go into our meeting thinking this is my organization. >> I'm just the deliverer. I'm thinking yes, these are important components that really will be helpful in our process together and how we work together. Our dynamic is not about a skill. I think some of the most effective therapy I've had, there's been a core sense that the therapist uh had a real like care or love for me >> and that that was such a prominent sense more so than anything else and that mattered. >> And I'm curious, is that necessary? Clinicians will say different things. I'd say yeah, it really does. I think it really does need to be there, especially in this work.
>> If somebody's struggling with personality vulnerabilities, there's likely interpersonal strife, especially BPD, right? That's the nature of the problem, which may feel unappealing to the other person in the the relationship. But when you really understand the problem and you can see the struggles that that person is experiencing, being able to really have a genuine appreciation and [snorts] love is a really I would say essential part of the process because it's so hard for both of you that not having that makes bearing those challenging times really difficult. You know, John used to say to me all the time, "Well, do you like that person? >> Do you like them?" And I I think he used to say that importantly because if you don't, then it makes it really hard to contend with the things they're struggling with since it inevitably comes out in the interpersonal relationship. So I personally and therapists are going to have their own experience of this. Um, I genuinely think finding something that you really can appreciate about that person. And what I found over time is as they learn more about themselves, there is a growing sense of appreciation and affection that I at least experience. And I I'm not alone having talked to many other clinicians in my field. um they often experience the same thing and the person themsself can experience themselves as more appreciated and lovable and that's progress that's huge for somebody who struggles in this way.
The biggest question I would put to you and I think people would want to hear about also is what in your observation gets people better? >> That's a big [laughter] big question. >> Small question. If I had to pick one thing, willingness, it would be willingness. And what that then generalizes to is willingness to stay in this with me. Willingness to try things that make you really uncomfortable. Willingness to come each session as planned even when you don't want to. Willingness to look at yourself even when it's painful. Willingness to try different interventions even though every cell of your body is saying, "I don't want to do an ice dive. I want to go get high." Those kinds of things. Willingness to hear contributions on your part that may be really painful. willingness to see yourself for all of who you are, even the parts of yourself that you want to deny.
And is that something that can develop? And have you had to ask people to leave if the development of that seems intractable? Is there a point at which you give up on someone? I hate to say it like that because the willingness is not there. So um I may be an internal optimist in this way but I do believe that um every person that has crossed my pathway has crossed my pathway because there's some some desire to change even if it's this much. Um, sometimes people come under court order or because of parental boundaries they've created that have um required them to seek therapy. And sometimes people come on their own accord, which is all of those things are very often different trajectories. The times where I worry about somebody in treatment with me is if the willingness is instrumental. What does that mean? What it means is I'll do this because of some outcome that's required of me to get something else that I might want. So there's no real willingness. It's sort of willingness in this artificial sense. So court order is a great example. It doesn't mean everyone that's courtordered that seeks therapy is doomed. Not at all. People can change. There are stages of change. There's different ways to help people get motivated. Um, but when somebody is doing something like engaging in therapy because they don't want to go to jail, which happens, there's an artificial more behavioral engagement of I'll do these things to avoid an outcome I don't want. But there's no real willingness to understand themselves. to see their contributions and therefore their capacity to really change beyond behaviorally is compromised.
Would there be a good tool you could just give people here now to selfassess and then a suggestion for where or how to begin to get help for it. So, if you're somebody who sees yourself as struggling with self-esteem issues and you think that this describes you, um, yeah, there are self-report measures, something called the NPI, for example, that you could use. What I would seek out though is a clinician hopefully who's seasoned in personality disorders because it's really a very specific problem and somebody who is an expert in personality disorders has seen hopefully a range of people struggling with some of these vulnerabilities um to confirm what it is you're seeing in yourself and to provide some direction for treatment. So accessing folks who have this particular expertise, just like if you had a problem with your knee and you want to see an orthopedic surgeon, you're probably not going to go to the orthopedic surgeon that specializes in hand surgery. You want to go to somebody who really has a sense of how to assess that problem and then how to provide a treatment approach that we know has traction. And we know because they may have to tell the clinician or direct the clinician that is the reality. So the treatments that we know that are being tried or tested for this struggle are our mentalization-based treatment MBT which was developed by Peter Fongy and Anthony Baitman for borderline since been disseminated to treat other problems. um and transference-focused psychotherapy. Frank Yman's and his crew does a really nice job of conceptualizing the problem and have developed a really solid treatment approach >> um that we know has some legs that we see really good outcomes from. And I would say like mentalization-based therapy feels TFP is so specialized and so it is so expensive um is the truth and so probably more affordable is going to be mentalization-based therapy until the TFP people can scale TFP which may not be scalable in a way that it is more proliferate and more affordable. It is an interesting great therapy but it is not yet >> scaled.
What you're describing is something that actually it deserves a little bit of attention, which is that these specialized treatments are hard to access. And the reason they're hard to access are multifaceted. One is because as a therapist to get trained in any one of these treatments, it's really expensive for the therapist >> and it requires not only the initial training but ongoing supervision. And you really want that for the therapist that you go to see that they've been well trained so that they're capable and competent of handling whatever you're bringing into the treatment. So it's expensive, it's time consuming. And so those two factors already weeded out a lot of therapists that don't have the financial means nor the luxury of time to be trained and then have ongoing supervision around these different approaches for clients or people struggling with these problems similar issues to find these therapists means that it's then expensive to be seen. And for a TFP approach, you're investing multi- sessions per week. It's not a once a week therapy. It's at least twice a week therapy. No intersession contact. There are all sorts of things that go along with the TFP organization. MBT is a bit easier to train and there's less ongoing supervision because of that. Um, getting ongoing supervision of course is going to um help strengthen whatever that therapist learns during a training process and generalize that knowledge to all sorts of patients that you might see. But the treatment itself for somebody seeking MBT is really once weekly therapy and even a group when you do group therapy by definition it's less expensive than individual therapy. And the final thing is insurance companies are not always that generous in their coverage as much as I would like them to be. So it's not so straightforward. >> Yeah. >> And it's not as accessible. >> Yeah.
Let's say you can't afford it and you can't find it. What are your thoughts on ways that people can take care of themselves if they can't find the support? It's a really good question and it's a problem with the field. Um, if you're self-diagnosing, even if your funds are limited, I would seek out at least a consultation for accurate diagnosis because you don't want to assume you have one thing only to learn that you have another. But if it is something that's confirmed or say you were in treatment and you no longer can um continue because of financial limitations, [sighs] um group therapy is something to consider. Sometimes group therapy requires that you also have an individual therapist and how you how frequently you go and those different pieces of therapy may modulate the cost of treatment. But somebody who struggles with NPD, and I say this a little tongue and cheek, but it's relevant. It can be like the world according to that person or the rules don't really apply to me. >> I would encourage folks who see some parts of themselves in what I'm describing to really think, huh, do I really think those rules apply to me? And if I don't, that is a really important consideration. Because one recommendation would be to get a job and to get a job with a boss >> where you're not calling your own shots, where you have to acclimate to what's being asked of you, where you might have to do some things that you're not thrilled about, which most of us have to do in in jobs. Even if we're owning a company, we may have to do things we don't want to do. But being asked or required to do something that's part of your job can be very activating for somebody and make those vulnerabilities more obvious to that person, which just gives them an opportunity to see those vulnerabilities more clearly and they can contend with those vulnerabilities very differently than if they lie dormant. >> And they can lie a little bit dormant when that person orchestrates their world. And if they can orchestrate their world according to them, there's less friction and less confrontation with those parts of themselves that they would see if they were working and in a job with a boss or having to acclimate to an environment that they didn't dictate. >> That makes a lot of sense. >> Yeah. >> Painfully a lot of [laughter] sense.
Um, let people recover. I think >> people recover. People recover. Very effective treatments for not just BPD. NPD is growing and these diagnoses are not death sentences. There are really good clinicians and treatments out there that can be very effective. You need to know what you're dealing with and you need to have somebody who can be skilled enough to respond to those needs. >> Thank you. This has been such a pleasure. >> It's always wonderful to see you. Joy. That's a joy. >> Thank you for having me.