Transcription
[Applause] but first of all I would like to say hats off to Marann Goodman because she had very large shoes to fill. But Marann has proved to us that one can put together a conference as good as the ones that Mary Ann or and put together the past few years. I want to thank you for that. [Applause] Marann, I also want to do a little identity clarification here. For the next 15 minutes, I'm going to be Frank Yans, which won't surprise many of you. But for the following 15 minutes, I'm going to morph into Diana Diamond, which might surprise some of you. After which, I will return to being Frank Yans. I hope. Uh, time will tell.
But I also want to emphasize that like all of our work, this is a collaborative project. And the slides I'm going to be showing you include include contributions from Eve Cagor, Barry Stern, and Otto Kernberg. And a number of our group have been represented at this conference from the Wild Cornell Medical College and the BPD Resource Center. And we're happy to be here as a group who hope to share some of our experience with you.
In this talk, I'm going to focus on the role of psychological structure, which we consider the internal sense of self and also self in relation to other. I'm going to focus on the role of psychological structure as central to an understanding of and a treatment model for narcissistic personality disorder. So if you look at the DSM-5 criteria, you know of them: grandiose success, special, unique, admiration, entitlement, exploitative, a little bit different, a little more interpersonal, lacking in empathy, envious of others, arrogant, haughty. Those are all very familiar to people who might have run across a narcissist in their lives. But what's missing from the DSM criteria? That fragile sense of self that Elsa has talked about, that John's referred to, and the difficulties in self-esteem regulation. So we're trying to discuss with you today a model that gets a better handle on that vulnerability in contrast to the grandiosity.
So I'll refer very briefly to object relations theory as a way to look at the structure beneath the clinical presentation. And the central concept here is the lack of an integrated sense of self and a corresponding lack of an integrated concept of other. This leads to a sense of emptiness in the individual that has been mentioned many times in these two days of the conference. So this lack of an integrated sense of self complicates the experience of emotions, especially in interpersonal contexts. So we see this fundamental lack of an integrated sense of self as central to the whole range of personality disorders that we consider organized at the borderline level. So for us, the term borderline personality organization includes borderline personality disorder per se, narcissistic personality disorder, schizoid, histrionic, and others. So I'm just trying to introduce this broad concept, if you're not already familiar with it, of an organized personality lacking a coherent and integrated self.
So as I'm proceeding with this, you'll certainly understand the central concept is identity. Now, a normal identity is associated with a sense of self and others that is realistic, continuous, has depth and complexity, and helps achieve well-integrated affect states. In contrast, identity pathology is associated with a sense of self and others that is distorted, fragmented, and superficial, and has extreme, poorly integrated affect states. So identity integration versus pathology is central, as I said before, to the whole range of what we can consider serious personality disorders.
Now, I would argue that this structural perspective ties together the surface traits of narcissistic personality disorder. All NPD traits are related to a specific configuration of internal representations of self and others. And here's where the NPD patient begins to take on a distinctive flavor from the other personality disorders at the borderline level. What is the marking feature of NPD's structure is what we call the grandiose self. It's a concept of self that covers over, but does not really resolve, the internal chaos created by the lack of an integrated sense of self. The grandiose self associates all that is good and ideal with the self and connects all that is inferior and devalued on others. This relates to Dr. Kernberg's talk yesterday when he was talking about the radical separation in the mind between positive affect states and negative. In the case of the narcissist, all that is positive is associated with self, all that is negative is projected on the devalued other.
So, why consider this object relations model when we're talking about NPD? We feel it helps us understand and in particular empathize with the subjective experience of the individual with NPD. It's not always easy to feel good, to feel close, and to care about somebody who's sitting in front of you who is arrogant and devaluing. If you understand this structure and what it's covering, it's a lot easier to try to find that empathy. And this model, we feel, leads us directly to how to put together a treatment approach that we have found reasonably effective, but we've yet to study.
So just to look a little bit more and to understand in a little more detail this concept of the grandiose self, we want to emphasize that it's a facsimile of an integrated identity without being truly integrated identity. And as I said, it distinguishes NPD from the other serious PDS. But most especially, it's important to see it as a compensatory structure overlaying and trying to conceal and create a distance from that split self. So in contrast to a normal, solid identity, it's a defensive structure. So the problem is that it's superficial and distorted. It's rigid and brittle. This grandiose self requires constant external support. It's vulnerable to abrupt discontinuity in response to environmental stressors. And yet, because of the grandiose self, NPD and the NPD individual can have a more stable sense of self and a more stable functioning than personality disorders of comparable severity. This relative stability has treatment implications. In other words, it's harder to engage the person in treatment.
So to emphasize its role as a defensive structure, it provides this superficially organized sense of self. It serves defensive functions in relation to underlying anxieties. And we have to understand what the anxieties of the NPD person are. First and foremost, it's the anxiety around the danger of dependency. The grandiose self defends against having any genuine needs and having to rely on others for complex reasons. As John said, the attachment style tends to be dismissive, and relying on others is something around which narcissistic people tend to have a phobia. Dependency is an extremely risky proposition for these folks. Other anxieties that the grandiose self protects against are fears of humiliation, inferiority, exploitation, anxieties about being the victim of a sadistic attack. This gets to issues of the role of aggressive affect in NPD, which is a little beyond the scope of this talk. But in NPD, there are aggressive affects which tend to be directed toward the other, but on a dime, they can shift and be directed toward the self, leading to so much of a sense of humiliation, inferiority, and desperation. And also the anxieties of shame and humiliation. And this, in my mind, relates to Mary Zini's talk yesterday because, as Mary said, one of the hardest stages of therapy is that coming to terms with what has been lost because of the pathology. In the later stages of treatment, you have to do a kind of taking stock of what has what is missing, what you have missed in your life because of things that were part of you that may have been modified and you have to really get over and integrate. It's a process of mourning, if you will, for lost opportunities. But if you don't do that process of mourning, the pathology just continues indefinitely.
So to summarize, let's talk about the grandiose self, reality, and interpersonal functioning. Now, the grandiose self involves the need to maintain the illusion that the self contains all that is good. And this leads to a defensive withdrawal from genuine relationships and to varying degrees, a defensive withdrawal from reality. Why is that? Simple contact with other people does not support your grandiose view of yourself. Simple clinical example: a young man came into therapy four years out of college, hadn't done anything in those four years. He was referred. John said, "Why do these people come to treatment?" His father referred to him. Father was desperate. Son was doing nothing, spending his days watching video games. And the father sort of arranged the consultation. The son, the patient, was quite calm and unconcerned. And when I said to him, you know, and I think Elsa gave beautiful examples of how you have to be very tactful with these people, I said, "Well, you know, most people eventually get around to getting involved in some kind of work or career at some point in their life." Which is my kind way of saying, "Why don't you get a job?" But, and I said, "Have you thought about what you might do when you start thinking about work and career?" And without skipping a beat, with no irony, the young man said, "Yes, I've thought a lot about that, and I've just decided that when it comes time for me to work, I'm going to be the head of a major movie studio." And when I said this example in Los Angeles, they said, "People literally kill other people to become heads of major movie studios." This man thought he could walk right into it. Now, this is why we find that our NPD patients sometimes border on seeming psychotic. This is why this person couldn't get close to anybody. You're not going to go out to coffee with this guy. He'll tell you his career plan, and you say, "Oh, just tell me how you're going to do that," because it just seems so removed from reality. And when you're that far removed from reality, it's hard to find buddies who are going to get very close to you without questioning. And when you're questioned, you don't like that.
So contact with the real world threatens the person's psychological equilibrium. And my colleague Eve Caligor put it very succinctly: for the narcissist, reality is an aggression. Just think about it. And to go beyond what Elsa was saying, we feel that it's not just self-esteem, but the entire sense of self that is at stake if you challenge the grandiose self. So these people are at risk of feeling annihilated. It's a true existential crisis that can come up in the treatment setting. And relationships with others are used to support the grandiose self. So they're not in-depth, they're not mutual. Therefore, the experience of others is shadowy, vague, and superficial.
So in summary, the grandiose self provides protection against anxieties, but at the cost of sacrificing genuine connections with others and to some degree with reality. I already gave you the example of the young man who was going to be the head of a major movie studio. I'll continue on, hoping to be able to provide more clinical examples.
Now, just before we get on to the treatment considerations, we have to consider what has been described in the literature for a very long time. And the descriptions in the literature go into many more distinctions, but for the purposes of this talk, we can talk about the overt or grandiose type of narcissism and the covert or vulnerable type of narcissism. The first is what is most commonly understood as narcissism: arrogant and haughty behaviors, self-enhancing interpersonal behaviors, self-promotion, boastfulness, and competitiveness. That's more in line with the DSM. But the covert or vulnerable seems modest and self-effacing on the surface, but they are preoccupied with self-enhancing grandiose fantasies. So you scratch the surface, and underneath the mild-mannered and sometimes even very depressive surface, there are all kinds of grandiose fantasies that keep the person from having any real connection with others or the world around them. Example: a patient of mine came into treatment after 10 years in an unnamed major hospital in this city, and she was referred to me as I was embarking upon one of our psychotherapy studies for major personality disorder. So the lady sat down in front of me, and I started the assessment. "Tell me why you're here." "I have a refractory depression." I said, "Oh, to myself, we might have a little bit of a mismatch here." It turns out for the 10 years in which this lady was getting treatment, she had had every treatment under the sun for depression, including two unnecessary courses of ECT. And it's really terrible what a misdiagnosis can do. I think one of the points that underlies all of our experience clinically is that our mental health systems don't diagnose personality well and personality disorders well, and they're always treating patients with underlying personality disorders as bipolar or depressed, and those are lost years, treatments that weren't necessary and can be damaging.
So to get back to this, this lady who didn't seem like an unnamed presidential candidate that John referred to, but was the more modest and self-effacing type. When I asked her to describe her depressive episodes to me, thinking, you know, maybe I've got it wrong here, maybe she is a refractory depression. She said, in a rather convincing way, since we look for the neurovegetative signs and symptoms of depression, she said, "Well, I'm depressed. When I'm depressed, I just lie in bed. I just have no energy. I just feel so dead within me that I can't even get up to get a glass of water. Get up to get a glass of water, and I could almost die of dehydration." I was ready to say, "Back to the ECT room." So anyway, it occurred to me though to inquire a little further, and I said, "Well, what goes through your mind when you're lying in bed that depressed?" And unlike my expectation as a resident, you're taught if somebody has a melancholic depression, they think their guts are rotting out from inside. She said, "Well, when I'm lying there so depressed, I am thinking about how unfair the world is because I'm really a talented musician, and if this world had any justice to it, justice to it, I would be as successful as Madonna. I would be living on the Riviera with a villa and a yacht." I said to myself, "That doesn't sound like a depressive fantasy." So that's an example of the underlying grandiose fantasy where the person might look depressed to the rest of the world.
So what you have here are two different presentations, but as it turns out, both score high on entitlement and exploitativeness of others in self-report interview and ratings of significant others from the P-Lab. Both, we feel, share the same underlying structure that I've described: the grandiose self. And covert narcissism, not surprisingly, is more likely to be associated with acknowledging psychopathology. They're more likely to come for treatment than the overt, grandiose, and arrogant ones.
So the field has come questioning these subtypes. Are they subtypes or oscillating mental states? And it turns out that if you start studying these people, grandiose self states oscillate or co-occur with vulnerable self states and affect dysregulation. Again, P-Lab. Elsa has shown us that the narcissistic individual may fluctuate between assertive grandiosity and vulnerability, as your clinical example showed. And Kernberg has described NPD people as vulnerable to bouts of insecurity disrupting their sense of grandiosity or specialness. So when it comes right down to it, it seems as though they're two sides of the coin, that they're two facets of the same phenomenon.
So we have combined in our studies that John referred to a population of patients who have both. We haven't combined. We have from our study taken out as a subgroup those patients who have co-occurring NPD and BPD. And an important feature, an important clinical feature in this group is a deficit in mentalization within the individuals with combined NPD-BPD. We also had a deficit in mentalization with the BPD group, too. But how do we understand this deficit in mentalization in terms of the grandiose structure I've described? So one could argue that the rigid psychological organization around the grandiose self distorts and erases awareness of one's own mental states and the mental states of others, or even thinking itself. So this leads to a pseudo-stupidity or the syndrome of arrogance. If you are stuck in one way of thinking and feeling about yourself, there's just no wiggle room. You go back to Elsa's quoting Otto Kernberg: there's no observing distance. You are too identified with that one state, and there's no way to get any reflection on it. So the grandiose self is not recognized as one mental state among other mental states that characterize the self. Therefore, the individual cannot take an observing distance in relation to that grandiose self. And your job as the therapist is to begin to find a way to put a little wedge in there so there can begin to be an observing distance.
So modifications of technique. I'd like to introduce you to Diana Diamond. So, and we're right on time, so I'll try to keep going. Implications that this focus on psychological structure has for treatment. If you see this as the underlying problem, that structure, then therapy should tease apart the grandiose self. Help the patient relinquish his defensive retreat from reality and from relatedness. Therapy should uncover, sorry, uncover the underlying split structure and fragmentation that is very distressing to be in touch with. Therapy should promote normal identity integration by exploring the anxieties that keep the negative and positive intense affect realms apart that Dr. Kernberg emphasized yesterday. Yet, there are difficulties in therapy. Dismantling the grandiose self poses a great challenge. The grandiose self, as I've said, defends against these intense anxieties and provides a structured self-experience. Therefore, there is a life or death quality for the patient. His self is at stake. Without this grandiose self to hang on to, he really feels like he's dissolving into nothing. So we are attempting to treat these people with our transference-focused psychotherapy. And a reminder about the nature of that therapy, which Dr. Kernberg talked about at the end of the day yesterday. Rather than emphasizing changing or managing behaviors through skills, we set up a treatment frame with the following understanding: experience the problem in this controlled setting, in this treatment setting, and as you're experiencing it in vivo, in living color, let's try to observe and understand what motivates that.
So, moving on with that basic understanding of the treatment model, as Dr. Kernberg emphasized, transference is the activation of internal object relationships paradigms of self-in-relation-to-other, imbued with a very intense affect. And we feel this brings the work to a very experience-near quality. We're talking, we're thinking about what is being felt in the moment. There isn't that intellectualized quality of many exploratory therapies. You've got the raw material and the reflection hand in hand. So this is just a simple, I hope simple, but this is a little diagram that's supposed to put into, you know, pictorial form what I've just said. That the images from the patient's mind are experienced as though those images are in the therapist. So the patient makes of the therapist what the patient has in their repertoire of internal representations of others. And the therapist, in the first phase of therapy, lets that happen. You don't say, "Wait a minute, I'm not really a horrible person." If the patient says, "You're a horrible person because you end the session on time," you say, "Well, tell me more about it." You want to elaborate those internal representations rather than put a lid on them.
Summarizing our overall treatment approach: through the contract, we create a strong frame that allows the experience of intense emotion to take place in the patient-therapist interaction. Then we observe, we experience, observe, and reflect on these emotions that emerge in the sessions. We clarify the experience the patient is having of self in relation to other that corresponds to those intense emotions. And we help the patient understand that other emotional states that the surface state may be defending against could be present but are kept out of awareness.
So to look at the typical experience of self and other of the narcissistic patient, what we call the object relations dyad. In general, the narcissistic patient comes in with a grandiose, self-sufficient, "I need nothing" self-representation, and an object representation of you, the other, as depreciated, devalued, having nothing to offer. And the affect is of contempt and derision. The problem is that the poles of this can shift, and as I said earlier, that attacking part of the psyche can turn against the patient, and that's what they're trying to protect themselves from. I'll give you an example shortly. Now, also in our model, we see how different object relations paradigms or dyads defend against their opposite. In the narcissist, that grandiose-devalued relationship paradigm is defending against what might be an ideal positive dyad of dependency based on love, nurturing, and caring, which the narcissist doesn't dare even begin to think of because they're so convinced it's not there. That's where the mistrust comes from. If you begin to hope for that, your hopes are going to be dashed. So we try to create a treatment relationship in which this might be accessed, that positive part that the grandiose self defense against.
So in any case, in treatment, there is this dissolution of the grandiose self. You empathize with the psychic refuge. You empathize, as I said, with that retreat from unwanted emotional states. You help take apart this grandiose self and see what's underneath it. And, okay, just beginning to wrap up. So I'm going to talk about three treatment modifications that we use for narcissistic patients. First, the treatment contract. In general, we have to be more flexible with our narcissistic patients because their structure is so rigid. Secondly, we have to, what we call, hold the negative affect for the patient longer. They cannot tolerate the experience of the negative affect within themselves. So the patient clings to an identification with the grandiose self and an identification with the other part of that relationship experience, the devalued one, comes in much more slowly than with borderline patients, who, as you know, have affect states that are shifting all over the place, even within the same session. These narcissistic patients are much more rigidly stuck in one relationship paradigm. And finally, that identification of the opposite libidinal dyad, where there's true dependency based on nurturing, love, and caring, is much slower with the narcissistic patient.
Now, just a few more slides than a brief final example. This stance, referred to as therapist neutrality, where we are a participant but also that neutral observer, is an implicit confrontation of the inferior-superior model of relating that is so central to the narcissistic patient. In other words, by not responding, by not taking the bait, we're getting the patient to begin to think, "Hmm, this guy isn't defending against my attacks. This guy is in counterattacking. How do I experience this?" So this stance, the participant-observer, is an invitation to experience and reflect on a relationship that involves limitations but also mutuality. That's in contrast to the superior arrogance of the grandiose self or the magical solutions that the other side of the narcissistic coin is that wished-for ideal magic. So the therapist neither supports the grandiosity nor retaliates to devaluing attacks. You experience, observe, and try to engage the patient as a co-observer.
Just moving on. As grandiosity and devaluing are addressed, it becomes possible to interpret the deep anxieties that have maintained the retreat into the grandiosity, as I've said, anxieties including possible abandonment, insignificance, annihilation, the fear of a rage that's related to envy, very central to narcissism, related to disappointment, the ideal expectations the narcissist has. So as therapy progresses, the patient gradually experiences a conflict between his refuge into the grandiose self and some awareness that begins to emerge with us of the more complex reality of self and other. The richness of a more complex experience of self and other becomes an appealing alternative to the exquisite isolation of the grandiose self.
And here's the clinical example just to finish off. A lady comes into therapy, referred by her parents, age 33. She has been in treatment for literally half her life, since age 17, again for refractory depression. And this lady didn't look that depressed, but she was very suicidal. So that might seem to lead one to think she was depressed, but she was stuck on having a certain goal in life, and if she couldn't achieve this rather ambitious and grandiose goal, she was going to kill herself. So that's why everybody thought she was depressed. So in any case, I started the therapy by doing an assessment. She had not had this diagnosis before. As I say, she'd been treated for refractory depression, ECT, transcranial magnetic stimulation, every medication known to man, inpatient, outpatient, day hospital, what have you. So we talk, first of all, about our diagnostic impression. Then we involve the family to see if they can share in this more psychological, as opposed to biological, appreciation of the patient's difficulties. That was all said and done. I'm going to take one more minute to finish the example, okay, because I have a rather massive superego. So the therapy begins. We have this brief little honeymoon idealization period because the patient was referred to me by Glenn Gabard, and everybody knows Glenn's name, and he's a big, you know, star. So she thought for two weeks that maybe I would be a good therapist. That stopped in the third week. So starting in the third, I just get this chronic massive devaluing. "I thought you might be good. You're no better than any of the rest of them. All of you are terrible psychiatrists, psychologists. You don't know anything." So I'm sitting there taking all this and trying not to react, trying not to retaliate, trying not to defend myself, and also, and very importantly, trying not to dissociate myself and just zone out because the patient would sense that. So I'm trying to be present with this negative affect. You just first have to contain the affect. And then, oh, I forgot to say, this patient wouldn't agree to a contract. You know, I said, "Well, we meet twice a week." "Why should I meet with you twice a week? I don't know if you're going to be any good." So I said, "Okay, let's just schedule another meeting." "Okay." Second meeting, "Let's schedule a third meeting." Third meeting, "Let's schedule." By the time we're at the meeting, I said, "You know, we spend, we waste a few minutes in every session scheduling the next meeting. Why don't we just schedule two regular meetings?" She said, "Okay." So that's an example of being more flexible. So you don't seem, you know, because anything else would be a power play on your part.
But getting to the interpretation part, one day the patient comes in and was particularly barbed in her criticism of me. "This is a waste of time. You know nothing for me." So anyway, but I was used to that by now. Then she lifted me up for she said, "There is one thing I admire about you psychiatrists. At least we have something." "One little thing." "What is it?" I'm thinking. She said, "You all of you, as a profession, have managed to convince the world that you have something to offer that's worth people paying enormous amounts of money for, and you have nothing to offer. That kind of fooling the whole rest of the world, that's clever." So, so I'm just feeling smaller and smaller and smaller. So I thought I'd do a classic interpretation and said, "You know, I think we can agree that in these sessions, there's a kind of a pattern where you kind of come in and you attack me all the time, and I receive your attacks. I said that's okay. I said, you know, I sit here twice a week with that. But I think maybe the reasons you're so depressed and feel like killing yourself is that goes on within your own mind all the time. What you do to me, you do to yourself, and that's 24/7." I thought that was a reason, a good interpretation. She said, "I can't believe you just said that. That's straight out of one of your books. Can't you ever think of anything new and different to say?" At that point, I thought of this concept of therapist-centered interpretations. And I think Elsa would like this. I said, "It must be frustrating to come to a therapist as limited as I am." No, I'm serious. And I had to say it sincerely and without irony. But what you're doing there, even though it seems simple, is you're modeling for the person somebody who doesn't have to be perfect to go on living, breathing, and existing. And that is counter to the narcissistic idea that you're perfect and grandiose, or you shatter into a million pieces. I'll just stop there.
Question: We have time for a question. Okay, we have time for a question. Yes. This is fascinating. And when you're working with a person like this, how do you talk to them about what you think is going on? How do you, do you offer a diagnosis or what do you, what do you say to someone?
Oh, yeah. I, I went over that very quickly. But after our assessment, we do do a discussion of diagnosis. So, and even with they're in our group, we're divided. I just tend to put it all out there and say, I think they have a narcissistic personality disorder. But I don't say it like that because I agree with Elsa. I say, you know, "Given my assessment of you," and you always say, "Would you like to hear my impression?" So I think what you have falls in the category of what we call personality disorders. Okay. Now, to understand that term, first of all, we think have to think of what a personality disorder. You go through a little layman's definition of personality in general, and they say, "If that's a personality, what's a personality disorder?" Well, that's when your personality traits are both very extreme and very rigid. They aren't flexible. You don't adapt to different circumstances. It makes life very difficult for you. Then, if you dare do so, you take the next step, which is to say, "Among the different personality disorders out there, I think you have what we call a narcissistic personality disorder." And as you brace yourself, you say, "But I want to make sure you understand that's not the way we mean narcissism in plain English. I don't think you're a horrible, stuck-up prig." I say, "It means you're suffering because you have within you a system where you can't exist without being so grand and superior that it just makes life miserable for you." I mean, I would take a little longer with the patient, but that gives you an idea. Okay. So, thank you. [Applause]