Frank E. Yeomans, MD, PhD, "The TFP approach to the narcissistic patient"

Thank you, Sergio. And I'd like to thank the department of psychology here at the University of Milano Bikoka. It's a great opportunity for us. And uh, first of all, is the sound okay? Sounds okay.

Um, I am very grateful to Dr. Kerberg for having provided such a wonderful uh description of narcissistic personality disorder. I think we all have a richer sense of it now. So I'm going to try to help you understand what we do when we encounter the patient. I'll go through a little bit of the theory just as it applies to the technique. And in beginning, I want to mention other colleagues who are involved in this research, in particular Diana Diamond and Barry Stern, just to give you a little history in our group in New York, which has been meeting for 30 years. We have a weekly supervision group where we discuss our most difficult cases. And we started with our borderline cases. And over time, we began to notice about two years ago that all the cases that our therapists and we ourselves were bringing in for discussion were the narcissists. We realized that narcissistic patients are a bigger treatment challenge than borderline patients. And I'll try to explain some of why that is. So the four of us have been leading this study group and we hope to begin to publish a little bit more about our approach to this patient population. It seems as though you'll be able to get these slides later on, which is very good because I don't want to dwell on them. Uh, and these references might be of use to you, but as I say, uh, you'll be sent these by by email.

Um, in particular, in the Italian translation of our manual, it includes a chapter that describes some of what I'll be discussing with you today. I'm going to skip over a few of these slides since Dr. Kerberg has covered a lot of the basic material, but oh, sorry. No, I'm skipping over these. You're not supposed to be read, just you heard this from Dr. Kerberg, don't worry. And no test at the end. All right.

But uh, I would like to pick up with the concept of u self-esteem regulation and I'd like to begin to relate that to the issue of internal object relations because it's very important to understand the relationship to other and the relationship to self are very intimately linked because our relationship to self is based on internalized relationship. relationship images, paradigms of relationships that have been internalized and have become the building blocks of our mental structure. So, we each contain within us representations that exist as part of us that we don't always recognize as part of us and can confuse the internal image with the more objective reality around us. Of course, I'm talking about processes of projection.

When we talk about self-esteem regulation for an individual who's organized at a more at a higher level of psychological organization than borderline, self-esteem regulation has a lot to do with one's relationship with the ego ideal. The ego ideal is the image of what we strive to be. It's a condensation of values. The difficulty with a narcissist is there's no gap between the ego and the ego ideal. They feel they must be the ideal or they're nothing. Um, we're dealing with people who don't have an ability to observe that gap, who feel they have to live the ideal and as Dr. Kerberg very beautifully pointed out, they tend to separate and uh, divide and split off anything that is negative and devalued and see that as external, except of course that system breaks down.

So I just want to say a little bit more about the maintenance of self-esteem in terms of internal representations of self and other. The gap between the reality may might be in, excuse me, the gap uh, between the ego and the ego ideal could be in relation to an internal self-representation. So in a mostly unconscious way, the individual might be thinking, "I'd be happy with myself if I could be or do X, Y, or Z," whatever they idealize. And the other side of this coin is, "I loathe myself. I detest myself because I am not what I must be." On the other hand, the internal representation might be more a representation of an image of the other. So in this case, the narrative would be more, "I would be happy with myself if I lived up to his or her expectations of me." But we must remember these are imagined internal expectations, not corresponding to an external objective reality. So it's very important in narcissistic patients, as it is in all patients, to distinguish between what's in the self and what's objectively in the outside external world. That's a challenge for every individual and more so for narcissistic patients who tend to have a confusion of the internal representations and the external reality.

So an additional element of self-esteem regulation and narcissism, which Dr. Kernberg mentioned but I want to emphasize, is how we can experience and express our own aggression in a healthy way. Aggression, of course, has an impact on uh, interpersonal relations, on object relations. Dr. Dr. Kberg's most recent book has the wonderful title of the um, inseparable nature of love and hate. Intimacy is not what we see in Hollywood romantic movies. Intimacy is an int an intense mixture of a effects. And one of the challenges of both social and individual development is the integration of aggressive affect as Freud very well described in Civilization and Its Discontents, that civilization advanced more rapidly than the neurobiological structures of the individual can advance. So we're left with in intense affects and impulses that are very hard to integrate. And part of a healthy self is the integration of these aggressive affects. And I also want to make it clear what we mean by aggression. Because in the current world of mental health, there's a simplification of the concept of aggression which s tends to relate it only to trauma. And we distinguish ourselves from those people, which actually includes most of the other specialized treatments of borderline personality disorder. And that we see aggression not simply as traumatic interactions, but aggressive drives can be strong, ambitious drives, creative drives, competitive drives. So we don't dismiss aggression as merely an aspect of a trauma pathological system, but an aspect of any normal healthy individual. So self-acceptance includes the ability to experience and express one's own aggression in a healthy way rather than to think aggression must be eliminated as some naive approaches may tend to imply. So we focus on aggression since it's a basic part of all of us and interpersonal relations necessarily involve the management of aggressive affects.

This links up with Dr. Kerberg's discussion of narcissism and envy since, as he said, we all experience envy, but a narcissistic person experiences envy with an intensity of aggression that makes it very destructive. I'll simply mention in passing what Dr. Kerberg described in terms of levels of narcissism. First of all, there is a healthy level. In English, I'm not sure if in Italian, the term narcissism implies something bad. It has a negative connotation. But of course, healthy narcissism is our ability to successfully manage all of the competing parts of ourselves, our drives, our impulses, our affects, the constraints of external reality, the constraints of our super super ego system. So if we have a healthy narcissism, we're able to gratify our needs without getting into trouble with others or without feeling bad about ourselves. That's what we all strive for.

In terms of infantile narcissism, Dr. Kerberg described this very well, and that's something that's a developmental stage, but that may linger on in certain individuals, and it's characterized by an insatiable neediness. uh, a neediness that can never be satisfied. So the individual stance towards others is always wanting more and it's always a question of demanding from the other without any sense of mutual exchange. But this is different from pathological narcissism because, as the slide says, the other individual exists as a separate entity for these persons. So they're very needy, but they have a place for the other in their mental life. And this kind of infantile narcissism is frequent in many types of personality disorder. It's not exclusive to narcissistic personality disorder.

So when we turn to narcissistic personality disorder, we're talking about a specific psychopathological entity that has a specific structure. As Dr. Dr. Kerberg said, that structure is the pathological grandio self. And the first clinical point I'd like to make is we as clinicians have to find a way to empathize with that psychological structure. It's not easy to do since it's a structure which, I hope, is foreign to most of us. And as Dr. Kernberg said, there's a denial of dependency. And what's very important when you're sitting with these patients is to realize that they have a a refuge, a retreat into omnipotence. It's a grandiose illusion of omnipotence, which makes contact with the real world, very threatening. Simple contact with reality, including you, the therapist, is a challenge to their defensive system.

Now, I won't go over this slide in any detail because Dr. Kerberg mentioned and described the thick-skinned versus the thin-skinned. I would simply add that in terms of our structural understanding of narcissistic personality, we could consider the thick-skinned ones, the ones where the pathological grandiose self has more firmness, has a greater strength. It manages to stand up better to the challenges of reality. Whereas thin-skinned narcissists are extremely vulnerable. It's like a crystal sphere that breaks as soon as anything touches it. And we have to keep that in mind when we're dealing with our patients.

Now, the next slides will be helpful to you when you get them by email because they're a summary of Dr. Kerberg's description of borderline personality organization with an emphasis on the identity diffusion, that is the lack of integration of a sense of self, the lack of a coherent sense of self, rather the fragmentation of self. uh, that you can look at. And the next couple of slides were also very nicely uh described by Dr. Kerberg, but I will emphasize that um, I'm trying to read the translation here. Um, the narcissists reject dependency and eliminate relationships with others, which of course is difficult when you're entering into a therapeutic relationship because they're rejecting that relation as well as other relations.

So, one thing that I wanted to mention that Dr. Dr. Kberg didn't have time to say but wrote a beautiful article about when we're talking about the general clinical manifestations of narcissistic pathology is the destruction of time. Dr. Kerberg has described that one's subjective sense of the passage through time has to do with the internal elaboration of increasingly complex representations of self and other. However, if you have a narcissistic patient with the pathological grandiose self as their representation, it does not have any realistic richness or nuance. It does not develop over time. So there isn't a sense of the passage of time as we have normally in our lives. And these are the patients who have a terrible crisis as they enter into their middle years and realize they have a sense of nothingness.

Now the next slide is a bit complex, but you can read about it in our works. It has to do with the debate Dr. Kernberg was describing between dimensions and categories in the diagnostic system. And this is Dr. Kernberg's formulation of the different personality disorders. In this slide, it emphasizes the categorical quality, but this slide is not as nuanced as the concept behind it because in reality, these different diagnostic categories sort of merge into one another. But you can see that the narcissism as a personality disorder is part of the borderline structure. Once again, it comes back to the concept of identity diffusion, the lack of a coherent self.

So, uh, Dr. Kerberg has discussed the degrees of severity of narcissism. So, you're familiar with that. And I would just review very briefly the problem with superego development. In borderline personality, the superego is generally not coherent. This has to do conceptually with Dr. Kerberg's contribution where he linked object relations theory and ego psychology. Putting it as simply as I can, the self and other representations that correspond to the first building blocks of psychological structure, if they develop in a healthy way, merge into the three structures of Freud's tripartite system. So what in a borderline or narcissistic individual is a scattered set of representations of self and other, in a more mature individual become organized into a coherent sense of self and in the case of the super ego into a coherent value system that gives the person a sense of unity and guides the person.

Now I'm skipping over this slide. There are stages of super ego development and the primitive state of super ego development, what we call super ego precursors, are based on the internalization of punitive representations of the other, which Dr. Kerberg referred to this morning as the don'ts. "You shouldn't do this. You shouldn't do that. You'll be punished if you do this. You'll be punished if you do that." That is the level of superego development which narcissists are stuck at if they have narcissistic personality disorder per se. If we have a healthier uh level of super ego development, we have the internalization of positive images and the neutralization of the punitive images. But that doesn't occur with our narcissistic patients. So we can expect people with a system that is only involving punitive images and not rewarding or soothing images.

Now, in terms of the theories of narcissism, I'm going to go very quickly, but simply to say that if you followed the literature over the past few decades, there's a debate in the field about whether narcissism is a disorder based on internal conflict or whether it's based on a deficit in psychological development. First of all, the whole debate about conflict versus deficit is a bit naive because I think everyone would agree there's some element of both. If you have deficit, excuse me, if you've got internal conflict, it impedes the healthy development of the psychological apparatus. So, you will have deficit as well. However, as you probably know, there's been a long-standing debate where the followers of Heinz Kohhat, in particular, see narcissism as an incomplete self, but they do not see the element of conflict, which we see as crucial. So, we're very much on the side of seeing narcissism as a state of conflict in which, as Dr. Kerberg said, all the negative hostile elements, the aggressive elements are segregated from the ideal elements. There's a defensive attempt to extrude these from the self. And even though the attempt is made, of course, they cannot be successfully extruded. So the individual goes through life with an ongoing tension in the conflict to separate self from negative affect and the inability to do so. So you'll have these in the slides you're given, but I want to move on to the clinical aspects.

So when we start thinking about our therapy with narcissistic patients, I first want to remind you about the way we conceive of internal structure and how it gets played out in your office, in your therapeutic sessions with the patients. Those of you familiar with object relations theory will understand this very simple schema which shows the mind of a person who does not have an integrated self. The internal world is constituted of object relations diads of a very different quality. This simple schema provides three sample diads, but there can be a a good uh, any number of those. This is just a very simple schema, but it's to show that separation, that splitting in the mind of the patient between representations of self that have a positive ideal quality and representations of self and other that have a persecutory and negative and aggressive quality. And the point from this slide is that depending on the immediate reality, which you have to remember is the reality in our psychotherapy sessions as well as in other settings, a minor event, a minor trigger can activate an internal representation that totally floods the situation. So the patient's experience of us and of themselves begins to take a great distance from the reality of the experience and is flooded, is overwhelmed by the internal representations.

Um, in borderline patients, the classic pathological diad is of the self experienced as the victim and the other experienced as the aggressor or the persecutor. Yesterday in Parma, I gave a simple example of a patient who was waiting for me. I was three minutes late for the session, and she exploded in anger and said that she now had proof that I hated her and didn't want her in my practice because I was three minutes late for the session. Example of how a simple event in reality triggers an internal representation that totally floods the experience of the individual. And at that point, there was no ability. I had no uh, chance of success in reasoning with this person. I couldn't say, "Let's be reasonable." If she were reasonable, she wouldn't be in therapy for the problem she had. So I had to say, "Let's look at how you see me." We go further into the internal representation so that the person can get to know it consciously better.

Now with narcissistic patients, the most common diad, as Dr. Kerberg said, is the grandiose self in relation to the devalued other. So rather than our patients with narcissism thinking that we're persecuting them, they spend a lot of time devaluing us. And I'll begin to give you a clinical example. I'll tell you about a 34-year-old woman who had been in psychotherapy and other forms of psychiatric treatment for half her life, since the age of 17. She was treated for almost all of those 17 years as a refractory depression, a woman suffering from a biological depression. And she had, in the course of her 17 years of treatment, a number of hospitalizations. She had suicidal ideation and she had electroshock therapy twice. She had something which, imagine you have here now, which is relatively new in our country, transcranial magnetic stimulation. She and her parents just looked everywhere in the world, and literally everywhere in the world, because at that time she had to go to another country to get transcranial magnetic stimulation for her untreatable depression.

So, she came in for the initial consultation and I must say, she dressed, she looked as though she were from Milano, because I must say, in Milano, you dress a little bit better than we do in the States, and she was dressed perfectly and she was coiffed perfectly and she came down. She sat down, telling me that she was suicidal and that um, there was no reason to live. And the big problem right now was that her parents, who were paying for her life since she had no job and earned no money, wouldn't pay for an apartment in the neighborhood she wanted to live in in New York, live in a place that was a bit more bourgeois. And this was the current reason for her depression and suicidal thinking and her accusation toward her parents of treating her very badly and having no concern for her.

Now, in the first session, it was clear that although she expressed depression and she expressed suicidality, this was not a biological depression. This was a narcissistic problem. The reason I'm bringing you this example right now is because she was such a good example of this particular diad, which very quickly became manifest in the transference. Um, first of all, after the structural interview, which I did with her, I came to the diagnosis of narcissistic personality disorder and I discussed that with her. Some people are surprised we discuss diagnosis with our patients. Some therapists don't think diagnosis has relevance, but we think diagnosis is very important in how to conceptualize the illness and how to plan your treatment with a patient. And even though, as I said, in English, the term narcissism usually is used as an insult, I said, "You know, you have something we call narcissistic personality disorder." And I just gave a sort of explanation of how a personality disorder is a problem within the self. I felt it was necessary that we establish some agreement about this because this woman had been seeking somatic treatments for 17 years and in a way that might or might not fit into your system here. I then had a meeting with the patient and her parents. Now, at that meeting, the parents, who, as I said, for 17 years have been paying for all these treatments for depression, I suggested this different diagnosis of personality disorder and they seemed quite relieved because there was a new way to understand her pathology that um, provided some promise.

Now I'm going to tell you a little anecdote which I hope you'll take in the right way. It has to do with our understanding of the internal world is made up of different parts and we have to respect them all. We have to respect the negative as well as the positive. So the anecdote is that the day after the meeting with the parents, the patient called me up ostensibly to change an appointment because we have a policy. We don't do therapy over the phone, but if you have to have a practical matter taken care of, you can do that. So, she wanted to change the appointment. And in, after we'd rescheduled the appointment, she said, "And by the way, thanks a lot," with a lot of sarcasm, "for the session with my parents. Now, my parents think I'm just a nasty bitch."

Now, this was a challenge for me because even though "nasty" is not a psychological term, it does correspond to a certain self-representation and it corresponds to a part of her that was very aggressive, but she usually didn't acknowledge. So, I thought, "Well, you know, she's not wrong. I mean, but it's not the whole picture. It's not the whole picture. And her problem is having a split internal world that either you're perfect or you're a nasty." Now, I could tell she was appealing to me to reassure her and say, "Oh, please. You're not a nasty. Don't be silly." But then I wouldn't be neutral in my approach. I would be just, I would be taking sides with her defense against her internal aggression. So I thought for a minute and even though this was over the phone, this is a kind of intervention we could use as an interpretation. She said, "Now my parents think I'm just a nasty bitch." So I thought for, I said, "How can I help her integrate that?" I said, "Look, you and I both know you're not just a nasty bitch." Showing an understanding that even though that was part of her, there were other parts of her we had to appreciate and integrate.

But the reason I'm talking about this patient in relation to this slide is as soon as we began the therapy, the whole first weeks of therapy were total devaluation of me. She would sit in her chair and look at me and say, "What have you got to offer?" And I'd say, "Well, you know, I'm trying to provide psychotherapy for you." She, "Well, psychotherapy is stupid. I've been to psychotherapy for 17 years. I know more about psychotherapy than you. You don't have anything I don't already know." So, I was subject to this dialogue for weeks. Now, we'll go back to the concepts. Then I'll get back to this case as we get further into our techniques. But one of the problems with our patients is when they arrive at this internal structure of the pathological grandio self, they have to maintain it desperately because it defends against all of these affects: inferiority, aggression, hatred, envy, rejection, humiliation, and incompetence. So what the grandio self is is an unrealistic attempt to create a coherent self that rejects and splits off major parts of the self. So it's a false impression of a coherent self. In that way, narcissistic patients often on first approach, on first presentation, seem healthier than borderline patients because borderline patients do not have that false illusion of a coherent self. Borderline patients are terribly inconsistent. One day they're feeling one thing, next day they're feeling the opposite. So, they look more disorganized. The problem with narcissistic patients is you have to find a way to work with the grandiose self so that they can open themselves up to getting to know what that grandio self is defending against. Putting it simply, once we begin to work with that defensive structure of the grandiose self, the narcissistic patient begins to look more borderline because you see the disarray and the fragmentation and the lack of integration beneath it. So, as therapy progresses, often they seem worse because the confusion is more apparent.

So uh, I'll skip over this slide. What we have, if you know the system of object relations, is the understanding that if an individual has a part of their internal psychological structure, any particular relationship diad, such as this diad of the grandiosity of self in relation to the devalued inferior other, we can expect that there will be reversals, that there will be oscillations of this diad. With borderline patients, there are very frequent oscillations. With narcissistic patients, the oscillations are less frequent because the grandio self protects against that identification with the devalued object. So, we're actually trying to get the narcissistic patient to get unstuck, to get a little bit more movement in their system because they're less likely to have this oscillation than a borderline patient.

And just to finish with the more theoretical appreciation, as with borderline patients or as with any patient organized at a borderline psychological level, the fundamental split in the internal world is between that segment of the psyche that is characterized by ideal libidinal images and that segment of the psyche that is characterized by negative aggressive punitive uh, envious and other um, emotions of a negative of a negative character. So you can see that in their attempt to maintain the grandio self in their appreciation of themselves, the narcissist is stuck in a very negative diad in relation to the other. Because in order to maintain the grandiosity, the other is devalued and there can be nothing in terms of a successful libidinal contact. All of that is defended against. All of that is out of the picture. But we must assume that there are some libidinal strivings in these patients because if they are, if there are not any libidinal strivings, as defended against as they may be, then the patient is in the category of the pure antisocial personality and as Dr. Kerberg said, the pure antisocial personality is a case we do not know how to treat. Not only we do not know how to treat, but our field does not know how to treat at this stage of its development.

Now, of course, we're trying to help our patients get to an internal world where the self, represented by the oval in the middle, is appreciated in terms of its positive and negative characteristics, its libidinal and its aggressive affects. And others in the life of the person are appreciated for the complexity and fullness, as Dr. Kernberg's title said, the indivisible nature of love and hate. These things are integrated. We're trying to bring our patients to this more integrated state.

So what are our complications when we try to apply transference focused psychotherapy to the narcissistic patient? We're met with that rigid defensive structure of the pathological grandio self. It's more impermeable to most of our interventions. It's more tenacious and as I said earlier, instead of switching, instead of oscillating, it tends to be ossified. It tends to be stuck in place.

So now I'm going to switch to some of the clinical challenges when we address these patients. The first is accurate diagnosis. These patients often do not present as narcissistic personality disorder. In fact, I think it's rare if a patient comes to our office and says, "I'd like help for my narcissistic personality disorder." As with the case I mentioned, her presenting symptom was depression. But we often have patients with narcissistic personality disorder who present as obsessive-compulsive because the demand for perfection can lead to obsessive-compulsive traits. And often, well, not as often, but sometimes we have patients who have an underlying narcissistic structure, but whose clinical presentation is hypochondriacal. It's a very interesting variant where the split-off aggression is directed toward the body. So the aggression that is not integrated is experienced as attacks on the body. And sometimes you get people with repeated physical symptoms who've been to all the specialists. Nothing can help them. And if you get them into therapy, you can see that it's attacks on their self which lead to their physical symptoms. I've seen this most often in my practice with people with untreatable headaches, and sometimes it's able to help them through psychotherapy.

Now, after we have the diagnostic challenge, if you know our system of treating patients, the next stage, once the diagnosis is in place, is setting up the treatment contract. Setting up a frame of treatment that defines what we do and that describes to the person their responsibilities to the treatment and the therapist's responsibilities of the treatment. So um, when we think about the contract, we have to think about certain aspects of narcissistic patients because their grandiosity cannot be maintained when they have contact with reality because reality doesn't support their grandiosity. They live in isolation. Sometimes the hardcore narcissists manage to live more in the real world, but the the thin-skinned tend to live more in isolation. Part of our treatment contract is to begin to have some involvement with the world. That is a great threat to the grandio self. So instead of accepting engagement in any activity, the patient often has a cavalier attitude towards treatment and towards our treatment recommendations. "Why should I accept that? That's a submission."

So I'll give you an example here, and it is an example also of why we must maintain a very, very, very tactful neutrality toward these kind of patients. This lady was 50 years old. Like the earlier patient I mentioned, she was living in a rather isolated way. And once again, her parents were paying for her apartment and for all of her expenses, and she couldn't function in the world. She was quite isolated. She said she had some friends, but it was a group of people half her age where she'd go out to nightclubs. And you could sort of get the feeling she was considered the oddball, that they were kind of relating to her as an eccentric person. Didn't sound like there was any depth to the relations. Now she was suffering from a horrible sense of inferiority against which she was defending by a very grandiose attitude. She came into my office looking like a movie star and sweeping her hair back and sitting back in the chair and treating me like I was supposed to do a manicure or something like that. And I said, "Well, you know, again, I said, uh, why are you here?" And she said, "Well, I'm not sure. Um, my other therapist thought you might be able to help me." So, she was often, narcissists can't even admit they have a problem. So, I talked with her about her life and I said, "Well, it might be helpful, you know, if you had a job. um, because you haven't been working and you know that's usually part of life and helps one feel good about themselves." She said, "Well, that's that's good you bring that up because I'm having interviews, I'm up for a job right now." I said, "Oh, that's that's wonderful. Uh, what what's going on?" She said, "Well, I'm interviewing with a major company and tomorrow I have an interview with one of the vice presidents and on Thursday have a second round of interviews." So, I thought, "This is terrific. You know, this is exactly what we want for therapy involvement with the world."

So she came to the next session and said it's looking good for the job. I got through the first interview. And then the next session after that, we're about five sessions into our work together. We hadn't really got involved in therapy and uh, she came in and said, "I got the job." So I said, "Notice I was drawn into her internal reality. I was responding the way I was programmed to do by her internal representations." She said, "I got the job." I said, "Oh, well, notice I'm not totally neutral here." I said, "That's great. What's the job?" And she said, "Well, I report to my company every morning and then I go into the room where uh, my particular group within the company is stationed and then I go to my desk and I pick up the phone and I call people and I try to get them to buy our product." And all of a sudden, the grandiosity was, I mean, in my mind I thought, "Wait a minute. She sounded like she was going to become a major manager in this country in this company." And in a way that was not neutral, I said with a sort of honest look of surprise, "Oh, you're a telemarketer." That was the kiss of death for this. But serious, you can see how that simple reference to a reality totally shattered her self-image. She got very angry at me. And I was wrong to do that. I was wrong to not be neutral. We have to be neutral to establish the therapeutic alliance. So she said, well, she said, "I, she said, I don't think I'm going to come back to this therapy." So I realized I'd making a bit, I'd made a big mistake and I said, "Well, you seem to be quite angry and you know that might be a reason to stay in therapy because when emotions become activated, that's when we have them to work on." I was trying to engage her to stay in therapy. So I said, "Why don't you think about it and come to the next session?" She called me up that evening to say she was never coming back. Now, generally we don't call people between sessions, but in a desperate situation, we do. So I called her up and said, "You know, I really think it would be good to come in. I can see a lot of emotions were stirred up." Her response to me was, "Why should I come to a therapist who doesn't even know the English language?" And I just realized it was hopeless because I had challenged her grandiosity prematurely. I was totally rejected by her. So this is to tell you how tactful we must be at the beginning of treatment.

So just saying that the treatment has certain requirements is a challenge to the patient's grandiosity. Take the lady who wanted to kill herself because her parents wouldn't give her the nice apartment in the bourgeois neighborhood. Usually with our patients, we say treatment must proceed in certain conditions. So we have to meet twice a week. This lady said, "Wait a minute. Wait a minute. Wait a minute. I'm not sure I want to come here twice a week because I don't see what you have to offer." So one of the modifications we make for narcissistic patients is to be a little more flexible at the beginning. It allows a little more room for movement that you can establish an alliance without prematurely challenging their grandiosity. So unlike the technique I would use with a pure borderline patient, I said to the lady, "Oh well, you don't want to set up regular sessions. How about setting up another appointment for this week?" She said, "Oh, all right." So, then we had the second appointment. I said, "Well, maybe we should set up regular sessions." She said, "Why should I do that? I don't know if you're any good." So, I said, "Well, why don't we set up an appointment for next week?" So, after a month where we had set up the appointments one by one, I said, "You know, at the end of each session, we spend five minutes scheduling the next appointment. Maybe we should set up regular time." So then she agreed, but at the beginning, it was a challenge to her control and her grandiosity to just submit to a schedule. So you can see how the simple requirements of the treatment can be considered a power struggle and a problem with submission.

Now, as you can see from this slide, um, another problem is secondary gain. Those benefits that a patient gets from their illness, the fringe benefits which Dr. Kerberg mentioned. This lady was getting her life paid for by her parents. She wasn't paying her own way in life. We have a lot of borderline patients and a lot of narcissistic patients who could be more autonomous, who could be functioning, and people give in to their demands to be taken care of. This is not only unhealthy for them because it leaves them in a sick position, it's unhealthy for society because we're paying for the caretaking of a lot of people who could be contributing. So, we are clear that in the vast majority of narcissistic and borderline patients, there's no reason to put them on medical disability. Some of our patients will not take a job because they cannot be president of the corporation, but they could be a secretary. And that's what somebody with less of a grandiosity would do. And I'm not trying to imply they might only be a secretary, but they might be a secretary and then move up through the chain of events. In fact, this patient who uh, wouldn't do anything, she eventually got into law school, and that was good because it was actually enough of a superior profession to satisfy her grandiosity. But still, it was a great challenge for her because she had to confront the fact that she didn't know everything.

Now in the next slide, I'm going to say something that might seem just mildly contradictory to what I said earlier. The more serious the case, the more strict and fully developed is the frame. I just gave you an example of how the treatment frame could be more flexible. The stricter frame is when the patients are at the lower level of the narcissistic spectrum of pathology and have antisocial traits. We get patients, they're usually young adults, they write bad checks, they misuse credit cards, they would be in jail if their parents hadn't bailed them out. So they think they can be excused from rules and regulations. They're above those things. They're dishonest. They don't tell the truth. So in a case like this with antisocial traits, you need more of a frame because you need the agreement at the beginning of treatment that a third party will be available to confirm the information you're getting from the patient. So with this young man I got, who would waste his parents' money gambling, who would miswrite bad checks, uh, who told them he was in at a university, so they gave him thousands of dollars to pay for his university education. He actually didn't even enroll in the university and he was using the money to gamble. With that patient, I had to have a system where at least for the first phase of therapy, there was a report every two weeks from the parents to see if the patient had done uh, what he was telling me he was doing. So that's the case of more rigidity. I've given you at the bottom of this slide an example of more flexibility with those more thin-skinned narcissists.

Now, getting to the treatment situation, the narcissist has certain typical transference patterns that we have to be aware of. Sometimes they come into therapy and they don't want to engage us as a helper to help them change. They want us to be an audience to admire them. We have to be aware of that. We tell people, "Your job as a psychotherapy patient is to speak freely," but we have to be attentive as the sessions go on. Are they just looking to us for admiration? Do they have no interest in what we say? So that might be a transference that has to be identified. Or, as the case with the young lady, do they treat us as a devalued object that they dump all of the badness in life into us? How do we deal with that? I'll tell you in a moment. Sometimes they relate to us as an exploitative, envious object. They project their own exploitation and envy onto us. In those cases, we have to transform an antisocial transference into a paranoid transference.

In the case of the young man who would steal and write bad checks, it was very difficult to begin therapy with him because his behavior didn't change quickly. He would miss a lot of sessions, and I would bring up with him as the priority issue, "You've been missing a lot of sessions." And he looked at me and said, "Why do you care if I miss sessions? My father pays you even if I miss sessions." And that was our entrance into a discussion of his psychopathic transference. I could say, "Oh, you see me as an individual who has no interest whatsoever in you. I'm only interested in your father's money." He said, "Of course." I said, "Well, that's interesting. Well, then how do you explain that I'm making such a big issue of the times you're missing the session? If your representation of me was accurate, I'd be happy when you missed the sessions because I could sit and read the newspaper." And then he began to get anxious because there was a reality that was different from his projection.

Um, and as the bottom of this slide says, these transferences are very intense because if these transferences aren't in place, the alternative to the grandio self is annihilation. They're either everything or they're nothing. So we have to deal with narcissistic resistances. We have to find a way to tactfully get to know the grandio self without prematurely challenging it. Um, and we have to be able to address the dynamics that come up. So as I said, and to summarize, the transferences are: we're devalued, we have no importance, we're someone who has to be defeated to show that they're stronger, or we're someone who will exploit them. We have to be aware, as always, of our countertransference. We can be bored. We can have no interest in them. This is extremely typical. We've done studies, as have other people, about the attachment style of narcissistic patients. Narcissistic patients tend to have a dismissive, detached attachment style. It's very easy in your countertransference to mirror that because there's actually a humiliation in being treated as a devalued, dismissed object. Uh, another countertransference is we might be anxious or afraid of the patient. Some of these patients are extremely exploitative. Some of these patients set therapists up to then challenge them in the United States, sue them for malpractice. So, if you're not comfortable with empathizing with the mind of somebody who's narcissistic, even to the point of antisocial traits, you might fall into the trap of trying to help in a way that you're later accused of doing malpractice. Sometimes the therapist is seduced. On the simple level, you're seduced into admiring the patient and becoming the audience of the grandio self. Very occasionally, you're seduced physically, and some of our therapists, no, not our group, but some therapists get into big trouble by having sexual contact with these patients, and then the aggression is that the therapist is attacked for their boundary violation. And another bad countertransference is when you're devalued enough, you might begin to attack the patient and in your interventions become critical and hostile. We've seen that happen sometimes in supervision.

Um, now I'm going to skip over the slide on countertransference and talk about obstacles. Again, when we interpret, it's a great challenge with narcissists. Interpretation, by definition, is trying to bring the patient to a greater level of awareness. These patients have a phobia about increasing their awareness because it's a challenge to their grandiose defense. So I'll discuss in a minute how we deal with that. Um, often interpretations are perceived by patients as an attack on their self. So we have to be very cautious in how we proceed interpretively. And you find patients who often have what we call an allergy to interpretation. Anything that comes from you is devalued and depreciated because it's not a part of themselves. It also is a way of warding off their dependency. They have a fear and anxiety about dependency. If you could help them, they would be depending on you, and they have to avoid that at all costs. So, as I said earlier, they're stuck in a position of grandiosity. They tend to devalue us. They can't take an observing distance. They can't take the step back to look at how they are and why they are that way.

So one technique that we've begun to use more regularly with these patients are what we, well, what is called analyst or therapist-centered interpretations. This is something that has been described in detail by John Steiner, is something we use increasingly in our group. And how do we understand a therapist-centered interpretation? If we look at the mind of the narcissist borderline patient as being comprised of representations of self and other, some of which are defended against, we can choose to discuss the representation that is not in their awareness as a part of themselves. But that doesn't usually work with narcissists. A narcissist cannot include in their appreciation of themselves anything negative. So since by projective processes, the patient is putting what they evacuate from themselves into us, we explore it as a part of us. We help the patient get to know the negative representation as it's projected without immediately connecting it to themselves, and then only gradually do we bring it back to their own internal psychological structure.

So I'll give you an example of this. If you take the patient who was uh, treated for 17 years as depressive, who came in thinking uh, she would kill herself because her parents wouldn't move her to the nice neighborhood. As I told you earlier, all of the sessions at the beginning of therapy were challenges to me. "What have you got to offer? I've heard all this before. Somebody told me you'd be different from the other therapists I've had. You're no different at all. You're just as stupid as they are." Then she would go into even more devaluing things, saying, "I can't believe that you therapists have the nerve to call yourself doctors. You're not doctors. You're charlatans. This is outrageous. This is a public scandal." I mean, this was going on for sessions and sessions and sessions and um, she said, "You know, it should

be an issue in our society. Therapists should be exposed in the press for their falseness, for their phoniness, for the pretenses they have, for the claims they make that have no basis.

Um, and what I began to do, oh, was to interpret her aggression. This is what we would do in a standard way with a patient. We would identify the object relationship that's being enacted with us, which I think is pretty clear here. You've got somebody angry and aggressive and hostile who's attacking the person who's the object of the hostility. So I said, in a way that I thought was accurate, I said, "You know, I'm not here to debate what you're saying. I think you have every right to think what you think. But I would like to point out that there's a particular relationship that repeatedly gets enacted here where you're quite angrily and relentlessly attacking me, and I'm the object of all your criticism and judgment." I said, "That's fine. I'm not saying you don't have a right to do that and shouldn't do that. But I think there might be a difficulty because what we're seeing between you and me, I would imagine, takes place within yourself. And that may be why you're depressed. I have to be subject to this only two sessions a week. Somewhere in your mind, the same attacks that you're carrying out on me are directed toward yourself. And of course, that would make anyone hopeless and suicidal." I thought that was a reasonably nice interpretation.

What did she say? She said, "I can't believe you just said that. That's the stupidest thing I've ever heard. I read that in a book. I knew that was what we were going to say. That's the kind of thing you therapists do. You just read from your books. This has nothing to do with who I am." So at first, I felt a little disarmed. My best effort to interpret went nowhere.

Now, then I switch to a therapist-centered interpretation. What's that? The next time she tells me how useless I am, how I have the incredible nerve to charge a lot of money and do nothing, and so on and so forth, instead of interpreting her aggression, I decided to describe the devalued object in myself and I simply said, "It must be difficult to have a therapist who's so limited." And that surprised her because I wasn't reacting to her. I wasn't meeting her on her terms. I said, "It must be difficult to have a therapist who has so little to offer." And she couldn't argue with me because she's the one saying, "I have nothing to offer." But what was I doing here? I was letting her know that an object can be imperfect but can continue to exist without being annihilated. I was naming a weakness but showing a continued ability to exist with a weakness. And it was kind of interesting for her. She wasn't used to this. She was used to people counter-attacking her. So I was showing her that one doesn't have to be perfect to continue to exist, and I was getting her to be familiar with a part of her internal world, the devalued self, as she was putting it in me.

So in that sense, this is what we feel the process, um, boils down to. The patient gradually begins to experience a conflict between the refuge he has taken into the grandiose self and an increasing awareness of reality. Why would this happen? Why aren't they content to stay in the grandiose self? Well, the therapist has become a representative of reality. The therapist becomes a bridge to a real alternative to the patient's exquisite isolation. In the process of coming on a regular basis to the sessions, even though it's totally out of the verbal realm, there begins, except in the case of antisocial patients usually, to be an affective link that the patient experiences on a somewhat subliminal level. But this is the establishment of a therapeutic alliance, which can only be established out of visibility because if it's visible at the beginning, it's humiliating. But as we offer ourselves as the consistent object who will neither submit to the patient's attacks nor react to the patient's attacks, the patient begins to sense there might be an alternative to the isolation and the grandiosity. So this begins to make them more available to comments and questions and interventions that begin to put a different perspective on the grandiosity within which they've been stuck. As they begin to establish some sense of a rapport in an alliance with us, it becomes the support they can fall back on when you begin to unravel and deconstruct the grandiosity which was their only support until now.

So to conclude my remarks, we see, as Sergio Datsi said in his comments, the fundamental role of reflective functioning in this therapeutic process. Reflective functioning, of course, is defined as the ability to accurately understand internal states of oneself and internal states of the other. Patients with a narcissistic grandiosity, by definition, have very little reflective capacity because their reflection is limited to one state. They are totally blind to and they defend against having awareness of other states within themselves. So, as Dr. Dati said, in our treatment, through the process of clarification, confrontation, and eventually interpretation, we help the patient begin to have an observing distance that increases reflective functioning, which helps the patient see that the grandiose self, which was the totality of their subjective being, is one mental state among others. And if they're to exist in the world, they have to get to know the rest of themselves and begin to integrate it. They begin to realize that the grandiose self may have been reassuring on a moment-to-moment basis, as it protected them from attacks and devaluation from themselves. But the grandiose self was maintained at a terrible cost, at the price of any real contact with the outside world, which is what we begin to offer as the first consistent representative of that in our therapy sessions. Thank you. Great.