Otto Kernberg - Lecture on Narcisism

Everybody, good morning, everybody. Can you hear me? Is that working? Yeah, okay. Today, we're going to study the subject of narcissism, both psychopathology and treatment. And I'll try to bring you an overview of the studies and developments about the subject of narcissism in our institute for personality disorders.

Um, and to start out with, I thought I should introduce you to the members of the institute. What I'm presenting to you is not simply what are my thinking, but the product of the work of the group of an institute for personality disorders that has been active for the last 30 years at the Cornell University Medical School. And you may know the names of some of the people who are quite well known internationally. Michael Stone is our expert on forensic psychiatry. Diana Diamond, our expert on attachment and early development. Mark Lenssenberger is an epidemiologist. He's the one who discovered that there's a genetic predisposition to schizotypal personality, but not to schizoid personality, which is important. Armand Lawrence developed the test for personality disorders for the World Mental Health Organization. And Lena Normandin directs studies on child and adolescents, particularly trauma and child adolescence in Quebec. And Ken Can Leave is an important researcher in the fields of psychotherapy and experts in research project developments. Um, and Eve Caligor, whom you probably have heard less from, is one of our most important clinical psychoanalysts and theoreticians. And Karon is my wife. We're sitting there at the corner. We have been, and she's a specialist in transference-focused psychotherapy, one of our senior teachers and supervisors. We have published the manual on transference-focused psychotherapy, third edition, about a year ago. And towards the end of this year, a free publication will come out, a book on narcissism. The first editor, which will be Diana Diamond, and which will contain much of the material that I'm going to summarize to you today. There will be a general text about psychological psychotherapy for all personality disorders, of which the main author is Eve Caligor, which I believe is going to be a classic. And there's a book of my own coming out, the selection of recent papers on personality disorders, narcissism, and erotic transference and countertransference. So I have mentioned to you, I think, the people who have been most involved in the narcissism work that I'm going to present you now.

What is narcissism? Um, it can be defined at a clinical level and a theoretical level within psychological theory. At the clinical level, narcissism is an essential and normal part of the personality. We all, hopefully, have adequate doses of normal narcissism, which means, first of all, the experience of an integrated self, an integrated self-experience of continuity between our past, present, and how we project ourselves into the future, and continuity about the different ways in which we are under different circumstances. It is the source of self-esteem, self-regard, of pleasurable self-affirmation, and, um, in short, pleasure living. This experience is based, as I said, on an integrated concept of self, as we yesterday started in some detail. But it is supported by other psychic structures. First of all, it is supported by an integrated system of values, our own superego, the fact that we live up to what we consider the ideal way in which we should be, being in harmony with ourselves, with our conscience. Second, it is strongly supported by the internal world of significant others that we have built up over the years, the total of integrated representation of the people who are close to us, whom we love, and who love us, and who give us a sense of sharing a world with friends and people who will love and understand with mutual understanding and to support us and support our self-regard, our good feelings about ourselves. And third, by the fact that we are effective in dealing with the environment, that we are effective in the major areas of work and profession, love and sex, social life, creativity, and in the process, gratify our basic needs in terms of self-affirmation, sublimated form of aggression, in gratification of our sexual needs in the form of sexual love, gratification of our attachment needs in terms of closeness, and our needs for play, bonding in terms of friendship, and enjoyable interactions with our wealth of close friends. So that all these psychological structures support the normal sense of pleasurable self-affirmation and self-regard.

From a theoretical viewpoint, Freud originated the concept of narcissism, conceived as the libidinal investment of the self. For Freud, narcissism was the expression of libido directed to ourselves, in contrast to libido invested in significant others, object love. So the destiny of libido is to be doubly invested in self and in others. This concept remained unchanged over many, many years, and only in the last 15 years, um, was challenged theoretically by Andre Green, the leading French psychoanalyst, who reminded us that in the constitution of a normal self is the integration of idealized and persecutory segments of experience. It means integration of both love and hatred, libido and aggression. So Andre Green suggested that narcissism constitutes the combined investment of libidinal and aggressive impulses, hopefully on the ordinary circumstances with a strong predominance of the libidinal investment of the self, pleasure in self-affirmation, rather a dominance of aggressive impulses in which our well-being depends mostly on the expression of aggression directed against others and ourselves. It is an important theoretical shift in psychological thinking, and of course, it has very important, meaningful practical consequences in the pathology of narcissism.

What is pathological narcissism? Um, the term narcissism used to be utilized for a number of concepts in older psychological literature. All this is gone by, and now we think about narcissism only at two levels of the most general level of psychopathology. One, a non-specific one, namely the getting fixated at a level of infantile narcissism. In other words, the infantile sources of well-being that were normal during infancy and adolescence, but are no longer normal for the adult with the development of adult values. And it turns out that in all neurotic developments, in all personality disorders, and all symptoms, um, that derive from unconscious intrapsychic conflict, at the same time with getting fixated and then the childhood conflict, one gets fixated at the childhood determinants of self-esteem. So, so a tendency of emotional immaturity and simplicity of values, somewhat childlike behavior in areas of conflicts. One's self-esteem being determined by childlike values of looking good, having many things, being centered on one's own pleasure in a childlike way. That's common broadly to all kinds of psychopathology. It has clinically no particular relevance except giving this element of emotional immaturity common to many types of pathology. And then there is a specific severe personality disorder, the narcissistic personality disorder, in which the entire pathology centers around our abnormality of self-experience, self-esteem, self-regard. Narcissism is severely distorted. Paradoxically, the narcissistic personality disorder was never discovered by Freud. It's, um, it's the only aspect, and very important clinical aspect of narcissism that derived from his findings, but was carried out by a number of other authors. I won't go through the history of the work of Carl Abraham, and then Riley, and Melanie Klein, and Ruben Berger, etc., etc., etc.

And, um, in them, in the last half, in the last 20 years of the past century, three major approaches to narcissism developed. One was originated by Melanie Klein, um, in her book on Envy and Gratitude, one of the most important clinical studies of pathological narcissism, on the basis of which Herbert Rosenfeld developed his more specific description of the narcissistic personality. That was one line. And Heinz Kohut in the United States developed another theoretical line. And myself, in also in the United States, developed the concept based in part on the Kleinian line of thinking that, as you may have already noticed, has profoundly influenced my own theoretical stance and the ego psychological development of the concept, um, and particularly the work of Margaret Mahler and Edith Jacobson. I may be considered a disciple of Edith Jacobson in a way. Um, and I tried to synthesize the ego psychological and Kleinian approaches and at the same time develop empirically the study, the clinical study of these personalities. So I think that in our institute, we are really, um, I hope I'm not exaggerating this, um, that we are the leading institution studying all the dimensions of narcissism, um, that really were not carried out on the basis of, um, of their other orientation. I should also mention a branch orientation based on Grunberger and others, but that has not developed into the study of this, of the specific narcissistic personality disorders.

So I'm going to give you an overview of where we are now. You know the background. I'm going to describe the clinical aspects of the narcissistic personality disorder, the descriptive features, then talk about the structural aspects of the personality, in other words, the underlying deeper psychological structures reflected in all the symptoms that I will mention, then about the dominant unconscious conflicts, the dynamics of those cases, and then describe to you the clinical syndromes, because the narcissistic personality disorder shows in many different ways that have important diagnostic and therapeutic implications.

Descriptive features. The most important one is the presence of what we call the pathological grandiose self. The pathological grandiose self is a kind of a hypothetical, exaggerated, abnormal sense of self, characterized clinically by self-centeredness and entitlement, an over-dependency on admiration, a dominance of fantasies of success and grandiosity, an inordinate ambitiousness, very often an ambitiousness that exceeds the capabilities, the realistic capabilities of the individual, a studious avoidance of realities that are contrary to that fantasies of success and grandiosity, and strangely enough, from time to time, bouts of intense insecurity when the pathological grandiose self collapses and leaves the individual with a tremendous sense of inferiority, insecurity, helplessness, extremely painful, devastating state, from which they try to escape as fast as possible to recreate the usual sense of assuring grandiosity. That's the pathological grandiose self.

Second, these patients are characterized by an inordinate amount of envy and dismissive behavior toward others. Um, let me say a few words about envy. Envy is a complex, normal affect that all of us, I imagine, have experienced. Um, it is a, it is a derivative form of, um, aggression, ultimately derived from the fight-flight affective system and from its development, not only as intense rage, but but the structuralization of rage into hatred. Hatred is a structural derivative of rage. It's a permanent, intense wish to destroy what is seen as dangerous or painful or threatening. So hatred is a stable, internalized object relation between self and a hated object, and of course, with the corresponding fears that others, people's hatred may destroy one. The difference between hatred and envy is that in hatred, you try to destroy what is bad and dangerous and threatening. Envy is a specialized form of hatred that is directed not against the bad object, but against something good that we want to have and that is being withheld, that we can't get. So that hatred is directed against something that at the bottom we love, but because we can't have it, we need to destroy, to eliminate the painful feeling that we can't have what we want. In discrete form, it is a normal sentiment, a normal affect, without any major dangerous consequences. But in these cases, it is very intense, and it is really a permanent motivational affect that is extremely dangerous because it's directed against what is good. So one destroys potential sources of gratification because one doesn't have them, and with this, in effect, one creates self-defeating deprivation. So these patients suffer under constant, intense envy.

And to give you a clinical example, a simple example. I have a patient, a physician with a narcissistic personality disorder, who in his specialty is in the university setting. He goes to professional meetings, and he's got who has more to contribute, who knows more. He can't in the discussions. He can't listen and learn from what's discussed about the subject because he's so concerned whether he has most knowledge, he has the best ideas, that there is no possibility of acquiring anything, and he suffers terribly because he has to be sure that he's the best. If he's not the best, it creates an intolerable situation. And the people who have something to say that he recognizes, by gosh, this this person knows more than I. Instead of being able to listen and learn or be grateful for what one has, one has to eliminate, erase what, what gets. When my patient goes to a conference, very often with the sense, let's see what this guy is going to tell us, with an attitude of depreciation that gives him a sense of security, and he listens attentively and dismantles what he hears. But if he hears something really valuable, and envy takes over, he thinks, how could this, how could this man know this? Where did he learn that? How old is he? Did I do the same at his age or not? And he's unable to hear anything. So learning suffers terribly. And you can see that from childhood on. In one of my patients, the youngest of a series of boys, the older brothers were excellent skiers, and so they took him along, and he started to learn to ski about about five, six years of age. But he realized all the older brothers did much better than he. He got into such a rage that he didn't want to ski. "I don't like skiing. I'm not a skier. No, this is nothing." And he never learned to ski in a family that lived in in a mountainous region where everybody practically was using. Well, I don't need to tell you people. So you see the devastating effect.

Students, a typical adolescent with narcissistic personality disorder has a strange school record. In some subjects, he's the best, was always the best, will always be the best. Studies and works hard because he feels he's the best. Everything he learns, everything to keep. In other subjects, fails totally because the others were doing better. So he drops them. So it's an irregularity of the school record, which is quite typical. I think I've given you enough examples of the destructive force of envy. And it is not only conscious, but it's unconscious. Very often, behind the conscious devaluation and dismissing people, ideas, things, is unconscious envy. And in the treatment, one has to get that out, and it makes the patients suffer even more in the in the early stages of treatment. So it makes real changing treatment a very painful experience.

These patients show intense greediness and exploitiveness. The devaluation of others, as I already explained. A typical incapacity to depend. They cannot depend on anybody because to depend means to acknowledge the value of the person on whom you depend, whom you need, and that runs against their need, their need to be self-sufficient, superior, and to be in a dependent position means to be inferior regarding the other person. All relationships become immediately one between one with superior and one who is inferior. And if the patients are not superior, it is an intolerable situation. And to depend puts them into this intolerable situation. And that incapacity to depend is a main issue in the psychoanalytic and psychotherapeutic treatment of these patients. And it is noticed immediately by the therapist in that one has the strange sense, rather than having a patient, one has a competing colleague or somebody who carefully evaluates everything he gets from the therapist, if it's good enough or not. The patient becomes the supervisor of the therapist. It's an expression of the incapacity to depend, and it's a major source of what is being, what has to be interpreted.

They show a lack of empathy with others, which is dramatic. These are sometimes very intelligent, um, sensitive, educated people who have an incapacity to put themselves into the feelings of others, which is a consequence of the destruction of their internal world of object relation. So lack of empathy, shallowness of feelings, incapacity to commit themselves because commitment is already a type of dependency. They have difficulty to commit themselves to a love object, great difficulty to establishing stable love relations, difficult to commit themselves to work or profession. Very often with the fear, if I do that, I will miss out on that. What should I be? Should I take this professional or that? This work or that? There's always a feeling there are others that are better, and if they commit themselves to one thing, they are missing out on what they could still put them in a superior spot. And so their own grandiosity is more important than they invest in the normal sense of pleasure of investment in a profession, in an art, in the in the work.

They present a typical form of negative therapeutic reaction. I don't think we talked about negative therapeutic reaction yesterday. So let me say that negative therapeutic reaction is an important complicating development in psychological psychotherapies. It's because it's not negative transference, but it is a worsening when the patient feels that he has been helped. It's a paradoxical reaction in which the patient feels worse right after having acknowledged that the therapist has been helpful to him. And it, this reaction, which if one is not used to it, at first, it comes as a surprise to the therapist, has three major sources. There are three types of negative therapeutic reaction. First, negative therapeutic reaction out of unconscious guilt. Typical for depressive masochistic personalities who have an attitude as if they don't deserve to be happy, they don't deserve to receive everything without paying a price. Unconscious guilt is a dominant psychodynamic of the depressive masochistic personality, not the narcissistic. The depressive masochistic personality. And one, one patient of mine with this person, as she was getting better, she said, "I think I should stop the treatment. My sister needs help more than I." I think, "Why don't you take her in psychotherapy at this point? I'll be glad to stop." Nice illustration of the mechanism.

Second form of negative therapeutic reaction: negative therapeutic reaction out of unconscious envy. That's the one that narcissistic personalities show, and it's the most frequent source of negative therapeutic reaction that we find clinically. That's the real major source of negative therapeutic reaction. They get worse. Um, I have a patient who session after session says, "This treatment is good for nothing. This treatment is useless. I don't know why I'm coming. You're giving me just clichés. I know all this. I've read it." Um, so in one session, we got to a real acute, deep problem of which the patient became aware, and there was a sense, "I never thought of that before. It is true that this is what happens in the relation with my wife." He's getting irritated at his wife just when she seemed particularly beautiful and attractive, and he would get irritated. And you can see the pathology of envy. He understood, and that irritation, which seemed to him kind of constitutional, became a psychologically significant issue. So I was impressed. He came to the next session. I wondered, "Now, are we going on?" And he started out, "Oh, again this treatment that leads to nothing." So one pointer said, "Do you remember our last session?" He said, "What about it?" "If you remember anything?" "Barely." His reaction was clearly immediately getting worse. Another patient of mine saw a book in a foreign language and it's possible to increase the level of the volume, the level of, yeah. So I have to have this very close. Okay. Turn it out to me. And the patient saw a book in a foreign language. He started resentfully thinking that I knew a foreign language, and immediately the effect was getting worse because the reaction was, "Oh, I, I must know more than he about the kind of things we were talking about." So all these are examples. And of course, as you study patients getting worse and what triggers it regularly, you find the dynamic of unconscious envy.

The third type of negative therapeutic reaction is an extremely severe one, only in the most severe personality disorders. And these are patients who have been traumatized, chronically abused, severely abused and traumatized, and had had almost no source of love or understanding and operate under the assumption that the only way in which anybody is interested in them is if they start a fight. Only in the middle of aggressive interaction is there any real interest. And they provoke, they transform the treatment into a battlefield and destroy everything that they receive as part of maintaining chronic warfare at the cost of self-destruction. So it is a, they are extremely primitive sadomasochistic transferences that at times are impossible to overcome in extremely, um, in extremely traumatized patients, and forced to shift the treatment into a supportive category. They cannot tolerate any deeper analytic approach that examines their emotional life.

And finally, these patients show a degree of fragile idealization, which means that they have people or things that they admire, something fantastic that they want to have. So that idealization is like a preliminary step to incorporate something or to incorporate it that runs counter the unconscious envy of what they admire. So it decomposes and disappears. One finds this in the sexual promiscuity of narcissistic patients. [Music] One, um, one woman, um, fell in love with the famous, um, who worked in the world of television and television and film, and she fell in love with, um, with attractive male actors. Intense love, managed to get involved, seduce them, had a relationship. After a few weeks, a few months, she got totally bored with this man, didn't know why she had selected them, dropped them, and went on to the next. You find this in both men and women, of course. By the way, let me say that it used to be thought that sexual promiscuity was a symptom of male narcissism, but not of male, um, narcissistic personality disorder, not of female. But that was a mistake. It was a product of a patriarchal culture that powerfully mediated against tolerating women's sexual promiscuity while fostering, is socially perfectly appropriate, male sexual promiscuity. And with women's liberation, women's becoming independent and not dependent on male power to the extent that male dominance was assured, have developed clearly that same sexual promiscuity that we find in men.

Another important feature of the narcissistic personality is deficient value systems, superego pathology. Together with the pathological grandiose self, there is a weakening of one's internalized ideal assumptions, moral ethical assumptions, and the higher functions that are controlled by the superego, the capacity for mature types of mourning. And a typical symptom is the incapacity to mourn. Very often, the closest relative of these patients die, and they have no mourning reaction at all. This shows also in the treatment, in that patients in analysis, the analyst goes away on an extended vacation, is otherwise maybe away for two months, and comes back. Patient has the first session after two months' absence and starts out saying, "Well, as I told you in our last session, we go on." There is no, no sense of discontinuity. And during all those two months, they never thought about their analyst. Out of sight, out of mind.

They suffer from severe mood swings. Instead of subtle feelings of sadness, of a kind of melancholic mood that all of us have from time to time for whatever reason, they don't experience that. But whenever there is a source of realism, unhappiness with self, or self-criticism, they cannot avoid a severe, sudden depressive mood, starting suddenly, ending suddenly, and going into its opposite. They typically present what sociologists have called the shame culture rather than a guilt culture. In simple terms, they don't behave anti-socially because they are afraid of being caught and put to shame, not because of a sense of guilt. They don't steal because they would feel guilty doing that, such as all other patients without superego pathology, but because they would be put to shame. And they are tempted to carry out anti-social behavior when they feel 100% safe and that nothing is going to stop that. It is, of course, as you know, a frequent phenomenon in industry and sometimes leads to scandals in persons who otherwise seem perfectly moral in their usual behavior. Value systems are childlike. In other words, they show the, the strange thing is, being so grandiose, they are in a way which is still determined by infantile values. For men, a five-year-old will be loved if he or she is clean. They will think fantastic if he has a collection of great toys, um, if all the friends admire the toys he has, and he shows his toys. And so to be admired for one's appearance, one's cleanliness, how nice one looks, how it's a normal manifestation of child, of narcissistic development in children, can go hand in hand with capacity for object relation in depth. Here, it becomes a noticeable characteristic. These are the patients who have to look shiny, have the best suits, the best way of presenting themselves. If they are part of a social subgroup that demonstrates by dressing in provocative ways and coloring their hair in provocative ways, they have to be those who do it the most within that particular culture. From the outside, sometimes they look the most observed. But in educated, high-level patients, the attention to their physical appearance, the interest in having them most dramatically shining, impressive cars, to illustrate by whatever means they can, what they, what is aimed with in their physical presentation and in their belonging is accentuated.

And are you indicating? Hello? Yeah, yeah. I can't see you. Yes, now I can. What on is difference between shame and guilt? Just a second. Let me. So, can you repeat your question, please? Yeah, I was wondering if you could maybe elaborate a little bit more on the the difference between shame and guilt. I find it such an interesting but very hard to grasp. Shame is a painful feeling of being caught in the position of inferiority that degrades it, theorizes one. It is a shameless and interpersonal experience. It indicates that one has shown something that one wouldn't want anybody to see because others will think that's terrible. Um, guilt, on the other hand, is an intrapsychic affect. It is having not lived up to one's own expectation or acted against one's own conviction. So it is a feeling of worthlessness that derives from one's own internal consciousness. Shame is a, is a primitive, early affect, which gradually gets transformed into guilt. I mean, a little baby soils itself, and nobody discovers it, it's okay. The mother says, "Shame on you." Baby is ashamed. [Music] In a child who uses control under circumstances where she should be in control, even if there's nobody watching, feels very bad about himself. That's not shame. That's this feeling of guilt of not living up to their own standards. Does that clarify it? Yeah, sure. Thank you.

So when the sociologists consider our normal functioning to be regulated by one's own conscience, we, the norm of culture is a guilt culture. And, um, a shame culture is one in which everybody can get away with it as long as it's not caught. It has a more primitive, regressive quality. And that's, of course, the sociological level is a social critique. Yes. Are you going to say anything more about how to work with this dynamic when a patient like, for example, I have a patient who finds it very difficult if I say something that he hasn't thought about before, who often says, "Oh, I knew you would say that. I knew you would think like that." And he finds it very difficult when suddenly something new comes. We are talking about psychopathology now. We'll go into treatment after I'm separating that out. Um, so, um, the incapacity to mourn, the severe mood swings, shame predominating over guilt, childlike values, these are the typical manifestations of deficient value systems.

Now, there are three more that are very important. One, the development of habitual anti-social behavior, which is a consequence of more severe destruction of an internalized system of value, a kind of superego deficit. Habitual anti-social behavior that can be reclassified under social behavior into passive, parasitic, and aggressive. Passive parasitic is all anti-social behavior is really an aggression against others and against society. Passive parasitic anti-social behavior consists in exploitative, extractive behavior, lying, stealing, writing false checks, irresponsibility with money. Aggressive behavior is frankly destructive behavior, attack on people, verbal or physical attack on property, destructive behavior to our property as well as people. So these patients show habitual, and I saw some narcissistic patients show habitual anti-social behavior, and combined with this, also an ego-syntonic aggression. In other words, their self-esteem doesn't depend only on being nice and good and correct, but their self-esteem also gets increased by a sense of power and being able to express their sense of power and superiority by attacking or by exploiting. And third, they show a paranoid attitude of hyper-alertness to attacks from others, suspiciousness, hypersensitivity. So these are really manifestations of severe superego deficit.

The combination, yesterday one of you asked me, what's the difference between narcissism and malignant narcissism? I don't know. Sitting over there. But in any case, now you are getting the answer. The combination of narcissistic personality, ego-syntonic aggression, anti-social behavior, and paranoid orientation. Those four features together determine the syndrome of malignant narcissism, which is the most severe form of the narcissistic personality, other than the anti-social personality proper, which is a chapter about. So malignant narcissism is an, is a syndrome of severity, a specific syndrome of severity of the narcissistic personality disorder. What I'm saying is that not all extremely severely ill narcissistic personalities show the syndrome of malignant narcissism. It's only a subgroup who shows that specific syndrome. But those are the most difficult to treat patients. It's important to make the diagnosis. And what is even more interesting is that this combination of narcissism, paranoid attitude, ego-syntonic aggression, anti-social behavior occurs at very different levels of behavioral limitation or regression. The most severe patients who show that look like borderline personalities, like ordinary borderline personality disorder, because they have a total breakdown in their social functioning, incapacity to work, incapacity of any relation, incapacity for any social work, a severe emotional dysregulation, practical breakdown, the capacity for ordinary living, severe anxiety, depression is accompanying symptoms. So very often these are misdiagnosed as borderline personality disorders, hospitalized with that diagnosis, and one misses that specific syndrome, which is much more severe than the ordinary borderline patient. On the other hand, there are some narcissistic personalities whose pathological grandiose self is sufficiently strong and powerful in making them capable of functioning in ordinary social life, that on the surface they don't show to be that ill, except they are individuals with the unusual nature of extreme grandiosity, extreme aggression, extreme anti-social features, and extreme paranoid orientation. We find such persons very often in leadership positions of organizations or political systems, particularly at times when there are natural sharp divisions in the social body between social in-group and out-group and political ideologies or parties that reflect that in their ideological formation. And they, under such turbulent situations, they become the leader of an extreme group that asserts its superiority, the need to fight its enemies. They lead the group, taking on a function of direction of the group toward triumph and exploiting the paranoid nature of the ideology, showing an extremely aggressive behavior and total absence of any guilt feelings regarding the attack of the enemy. So the search for the security of triumph, the security of the attack on the enemy, the suspicion of the danger of the enemy, and the ruthlessness and total abandonment of moral constraints make them ideal leaders for such a regressed social situation. So they become very dangerous leaders of institutions, school systems, hospital systems, political parties, or nations. And so we have these, don't become ordinary dictators, but they tend to establish totalitarian systems. They have to be loved and feared at the same time, not just loved. They are just not narcissists who have to be admired and they are happy. They have to be happy because they are superior, and the followers have to be afraid of them. It's, we have evidence that the personality of Stalin and of Hitler presented these four features. And I don't have time to give you more evidence at this point, but there are other historical dictators who didn't have those characteristics at all. Mussolini had a narcissistic personality, but not the syndrome of malignant narcissism. Same as General Franco in Spain. And of course, to these days, we have such leaders all over the world, India, mean, nice illustration in Africa, and so on. And, um, we don't have to look very far to find day-to-day examples of that. So at best, these can become very powerful and dangerous leaders of institutions.

Just as a note of interest, I did some research years ago about the effect of this kind of leadership on hospital systems. I've been medical director of hospitals over 20 years, and I had the chance of observing many other directors of many hospitals to test the hypothesis that I established that when such a person becomes the leader of the institution, immediately the institution gets organized into three levels of staff around the leader. There is immediate contour of individuals with anti-social features who can adapt perfectly to making the feel the leader feel loved, manipulate the leader, and at the same time know that they have to be subservient. So these are the dishonest courtiers around the leader. Then the second layer, the big numbers of the institutional staff develop strong paranoid features because there is aggression coming from the top, and one never knows when it will hit one. So one better be cautious. The morale of the institution deteriorates into a paranoid stance. And at the bottom, the individuals who develop depressive features and feel marginalized, critical, depressed about the nature of the institution, and tend to marginalize themselves and leave. That's the general hypothesis. And I even had a demonstration of it in my own hospital. After I stepped down, after finishing my term as medical director, somebody was appointed medical director with these characteristics. Three years later, he was surrounded by two or three totally dishonest people who were thrown out eventually because they were caught. There was a paranoid atmosphere which was very destructive, and the best people went out on the river. So it was an unwanted demonstration of a hypothesis.

All of this to indicate the complexity of narcissistic pathology, in which such a severe condition can show up as a severely hospitalized patient, or when the pathological grandiose self is sufficiently well put together, end up in such positions. Let me just finally, let me just add to this that of course, in the political process, that requires a sociological situation in which there is the crystallization of a social group that feels isolated, frustrated, with chronic dysfunctions or fears driving it into extreme, and therefore then becomes a consolidated as a, no longer is a huge number of people, but it's people who are joined by the very crystallization of the leader or an ideology or the combination, and who then feel the experience of mass psychology that Freud originally described in the 1920s. The fact that when individuals are part of an anonymous group that gets consolidated as a harmonious mass, one's thought process gets reduced, one's intelligence gets reduced, and one can only understand as part of the mass very simple messages and develops the kind of resentment of complexity that is signaled by high individualization. So it's an anti-individualization aspect, a tendency of submission to the leader, a tendency of liberation by being part and power by being part of a mass, and a sense of freedom from moral constraints. Everything is permitted because the leader carries the consciousness of the group. One projects one's morality into the leader. General immorality is tolerated. You have there the violence of masses, such as the Red Guards during Mao Tse-tung's times, the Shining Path in Peru, etc. So there is a correspondence between social conditions that produce mass movements and the ascents of leadership with malignant narcissism. Somebody was going to raise a question. Okay, now let's make use of this opportunity to discuss about the differential diagnosis of antisocial behavior. The importance of this differential diagnosis clinically is that it has immediate prognostic and therapeutic relevance. So I'm going to give you, I don't have this on this, on this slide, so bear with me as I give you a list that you won't find on the slide. I'm going to go from the most extreme, severe, and dangerous aspect of antisocial behavior to the mildest one in normality.

First, severe, very rare. Only those of you who work in the forensic system will ever have contact with that. It is the syndrome of pseudo-psychopathic schizophrenia. These are chronically schizophrenic patients with extremely dangerous aggressive behavior, bizarre forms of murder. And when you treat these patients with medication, you can normalize the psychosis, but they continue functioning like an antisocial personality. You don't know what's preferable. They need chronic hospitalization with medication. They look pretty normal as they are in institutions for life, but you let them out on the street, and they'll commit mayhem. So this is the most severe form that you probably won't see. By the way, it was discovered and described in 1954 by Goodman in the United States, but usually it's not in the texts. It's amazing how, how we gain knowledge and we lose knowledge at the same time.

Second, second category. The most important and frequent and dangerous in ordinary clinic, the antisocial personality disorder. The antisocial personality disorder is the most severe personality disorder that has zero treatment of any kind that we know. I'm, it is badly described in the official psychiatry texts. The best descriptions are those of the researchers in the field. Michael Stone is one of them. Hare has been probably, you know, most H-A-R-E has described the antisocial personality. Advice, important instruments. So Robert Hare's description and Michael Stone's description and my own, if you want to delimit clearly that syndrome, the antisocial personality proper, that is also goes under the name of this psychopath, although some authors prefer to call psychopath only those antisocial personalities whose behavior is the most dangerous, who are mass murderers, sexual murderers, serial murders of any kind. What characterizes the antisocial personality disorder is full development of the entire narcissistic pathology, or let's say 90% of them show typical narcissistic pathology. 10% show schizoid, paranoid, introverted personality. These are rare cases, usually very schizoid, isolated, and all of a sudden they jump out with violent, aggressive, and destructive behavior. These patients, so they show both their passive parasitic as well as aggressive antisocial behavior, chronic from childhood on, total lack of capacity for guilt feelings or concern, total lack of any investment in any value system, total lack of investment in any relationships with significant others, incapacity to project themselves into the future. They live into the eternal present, incapacity to learn from experience. A carelessness that is frightening, but in many cases, particularly those with passive parasitic antisocial behavior, can be hidden behind a charming exterior. And classically, they have been described as presenting a charming exterior, but that's only true for some of them. That's the antisocial personality problem. You, the diagnosis cannot be made in one or two interviews. It has to be made studying the entire history, observing these patients throughout time, studying them with third sources. They are totally incapable of investment. They show they don't have friends, they don't have anybody with the exception if they have pets, they can let the pet die without caring about it at all. That's the antisocial personality proper. It is whenever you have patients, I'm leaving that first group about pseudo-psychopathic schizophrenia out. Clinically, you have to differentiate them from all the others because all the rest are treatable.

The next category is that of the syndrome of malignant narcissism, that you already know. The next category is that of narcissistic personalities who show antisocial behavior, but they don't show the paranoid orientation nor the inordinate aggressivity. So they have a narcissistic personality with antisocial behavior, but without the intense aggression, without the paranoid features. This, I'll give you a simple example. Um, I had a patient, he was a professor in the arts and the narcissistic personality disorder and marital conflicts. And I asked him in the interview, which I ask routinely of all narcissistic personalities, um, "Have you had any other kind of difficulties, difficulties with the police or with the law, or activities that could, if discovered, run you into problems with the police or with the law?" And the patient said, "How do you know?" I said, "How do I know?" What he said, "I steal art books. I have an entire library of extraordinary art books, and I've never been caught. I look very respectful, and I know how to go and carefully select. And I think I have the right to do that because this usual bourgeois with money who buy art books without any real art appreciation, it's a social waste. I'm going to use it for teaching and learning." That's a nice illustration. Antisocial behavior, yes, but not the aggression, not the paranoid orientation in a typical narcissistic personality.

Next category, antisocial behavior in all other severe personality disorders, non-narcissistic. That has already better prognosis. The exception are infantile or histrionic personality disorders who show the Munchausen syndrome, who present pseudologia fantastica, um, in imaginary illnesses, um, that they produce, um, or other history. Only infantile patients who chronically lie to an extent that a major psychotherapeutic relationship is almost impossible, practically. But in general, the prognosis is better than when the structure is narcissistic.

Next category, neurotic personality organization with antisocial behavior. These were the patients that Freud described as criminals out of unconscious guilt. There exists such a category, very good prognosis. We had a physician in the hospital who was stealing magazines, sweets, and chocolates in the cafeteria of the hospital. If a physician, I mean, totally crazy and self-destructive, obsessive, obsessive personality structure, excellent prognosis. I once treated a researcher in the biological sciences who falsified her results and got quite attention, and then she corrected her own experiments to undo the false results that she had published. I mean, totally absurd antisocial behavior without any usefulness of any kind, and behind that, there was really unconscious guilt about her developing this and as a knowledgeable researcher in her field.

Next category, antisocial behavior is a part of adjustment reactions in adolescence, very good prognosis. By the way, there are some symptoms that are practically normal, at least in the United States. Stealing cosmetic objects in department stores. Adolescent girls very often take lipstick and all kind of women's cosmetics, sometimes in groups. It's with no other antisocial behavior, neither before nor after adolescence.

Next category, in the social syndrome described by English authors. These are patients who are part of a social subgroup of a gang that carry out antisocial behaviors. Being part of the gang, you get them out of the gang, and there's no more antisocial behavior.

Next group, people who steal without any psychopathology, simply because they are hungry, and that's the only way in which they feel they can survive. It's a sociological problem, not a psychiatric one. This list, as you can see, is very helpful because you can put your patients somewhere along, and you immediately have the prognosis for that aspect of pathology.

In final aspect of, I pressed the wrong button. Final symptom of the narcissistic personality disorder, a basic self-state of emptiness and boredom. These are patients who have a sense of meaninglessness of life and a stimulus hunger for things to keep them excited and interested. They are prone to addictions, sexual exploits, danger-seeking activities. They become the adventurers of foreign legions, explorers in dangerous sports, um, in the search for excitement that makes life worthwhile. And very often, sexual seduction appears of sufficient exciting interest and gratification to justify living. If they have none of these, they feel empty, bored, and restless. And this is a consequence of the lack of an internal world of object relation, the fact that there is really a destruction of the internalization of significant representations of representations of significant others. So the pathological grandiose self lives in an intrapsychic isolation, dependent on external admiration or exciting stimuli.

Perhaps this is a point where we should make a pause of the narcissistic personality disorder in general. We, we may classify it in very simple clinical way as the mildest cases, who are individuals who function very well, and the only problem they show are limited social conflicts at work. In spite of being very brilliant, they don't get promoted because they have chronic difficulties with others who feel that these patients are too self-centered, grandiose, pushing others aside. So the patients don't know why they are not selected to the top positions, are not aware of the rough edges of their personality. Or else, function very well everywhere except they have a chronic marital conflict. So couple conflicts, they can't maintain a relationship. And so, or they have some specific symptom. A patient of mine was a minister of a Protestant church in Middle America, and he had a mistress in every town where he went to preach. And one of these mistresses insisted that he had to leave his wife and marry her, if not, she was going to leave him. And he paid no attention, and she finally decided to leave him, and he got depressed. And he told his wife, asking why are you depressed? That he said, "There was this woman with whom I was involved, and she cut the relation because I didn't want to marry her. I mean, I'm married to you." And because he was very surprised that his wife got enraged and so on. Top of the depression at the marital conflict, he came to treatment because of the depression. So I saw him for about, um, eight or ten sessions, and he improved his depression and felt okay, and he said, "I think I'm all right. I could go back to normal." And what was normal for him? And I told him, "Yes, I could see that. But I predicted that he might have more problems in his marriage in the future, and if he had serious problems that he couldn't resolve, he should consider going back to treatment later on." I learned that in fact, a year later, he went back into long-term psychological psychotherapy, which surprised me because when I saw him, he just acted as if everything was fine, but

That's a nice illustration of a mild case, although it has the amusing quality that it was a religious man, where, of course, this behavior created more problems. But narcissistic pathology occurs in all professions, including extremely religious people, and we find issues of anti-social behavior widely spread in the personality.

There is an evaluation that about one percent of the population have anti-social personality disorders. That's extremely high. It means that if you are in a room with a hundred people you don't know, uh, and you leave some some some article of worth, it would not be impossible that it be stolen, even if the hundred people are psychoanalysts or nurses or extremely religious Jews or Catholics or or Muslims or whatever. So psychopathology is widely spread.

The middle range of psychopathology are the typical sort of typical syndromes that I described to you. They really require treatment. And the most severe level, those who function at a borderline level, which means with a total breakdown in their capacity for engagement in work and profession, love and sex, social life, creativity, those really cannot go without, cannot function without treatment.

The most frequent complications are, of course, the sexual promiscuity that I already mentioned, and interestingly enough, also extreme sexual inhibition. They don't get there to get involved because they are afraid of being rejected, which would be a terrible narcissistic blow. So there is a defensive inhibition against the threatening narcissistic trauma of being rejected. They are prone to drug dependency and alcoholism. And by the same token, when you talk about the prognosis of treating patients with addictions or alcoholism, those with narcissistic personality disorder have the most severe prognosis of all addictions.

There is a tendency to social parasitism. These are patients who very easily develop secondary gain of illness, and the secondary gain of illness may make treatment impossible. I saw a patient, a homosexual man without any financial support, who was living with his partners, with his partner, a homosexual who was extremely wealthy. And the partner offered to pay for his entire psychological treatment. Um, I insisted that the patient, who was an educated adult man who lived like a parasite, totally taken care of by his partner, he wasn't working, he was just enjoying life, he was like like a maintained sexual slave. So I insisted that if I was going to treat him, he would have to work, and he was, this was a man with a fully educated, trained, able to work, and that I expected him to pay at the level at which he could earn an income, and I wouldn't object to his partner helping him financially, as long as my patient did all he could of being independently responsible for himself. The patient indignantly refused. He said that was absolutely incredible that I should take such, make such demands, and no treatment.

Um, finally, there is the narcissistic suicidality. We already mentioned that briefly yesterday. Um, patients who threaten, um, to be deprived of their sense of superiority, prefer to kill themselves rather than going to the shame of failure. A businessman who was, because of his serious problems in the management of the business, um, was fired by the board, tried to get other high positions in industry, couldn't get any, would have had to accept an inferior position. Vicia was concerned, went into a depression, and killed himself. There are other patients who are driven into the corner because of threatening social developments that make their superiority and deficiency come in doubt and be rejected, prefer to commit suicide rather than face that failure.

Then there are other patients who have severe self-destructiveness. We'll come back to that group, and for whom physical self-destructiveness, deep cuts in their arms, in their body, not, not the slight superficial cuts typical for borderline patients, but who produce very serious lesions and defy all treatments, and show their superiority by triumph over all those who try to help, fund over medical science, and, um, very often are in a kind of long-range self-destructiveness that ends with their death. So it is a, a real danger, and very different from the impulse-ridden, temporal time from suicidality of borderline patients. That's all I wanted to say about descriptive features.

Now we come to the psychological structure, which is relevant for understanding the relationship among the symptoms and, of course, important for psychotherapeutic approaches. The most important is that at the bottom, these patients have borderline personality organization in the sense of identity diffusion, lack of integration of the idealized persecutory segment of early experience, lack of an integrated self, lack of an integrated view of significant others, who then is a secondary developer, as a secondary development, develop a pathological grand self. Namely, a kind of a structure in which they absorb in their self-representation, um, they aspect their of the ego ideal, the, the ideal representations of self that ordinarily would become part of the superego, of the internal value systems, and they incorporate them as if they were already living them.

Um, if a normal little child says, "I have to be good so my mother, my mother will love me," these patients develop the sense, "I am very good, so that I take it for granted that my mother loves me." And they incorporate into their self that loving representation of mother, become independent from the real mother, and depended from only from an internal one, which practically fuses with their sense of self. So the self becomes part of the real self and ideal fantasy self, and the corresponding object representation. At the same time, they project onto the outside all self-criticism or threats to their self-regard, the superego functions. So they see the outside mostly as people who are threatening them by making our demands, while if they remain independent, they feel well within themselves.

And, um, they project into the outside all the self-devaluating aspects of the self that they condensed with the representation of critical others. So they have devalued others, threatening others, and temporarily idealized others, whom they have to incorporate, imitate in their fragile idealization. So they expel their internal world while developing a sense of self-satisfying grandiosity. In the most severe cases that we've seen, then have contained in that self a sense of aggressive self-affirmation and the intensity of primitive aggression that is usually expressed as envy. And the psychopathology of envy becomes part of the self, the grandiosity of which is increased by the expression of power. So the grandiose self is infiltrated with an aggressive behavior and an antisocial potential, because they don't have the internalized value systems that would constitute a normal morality. That, in a nutshell, is the structure.

Now, the dominant psychodynamic features, as I over have already mentioned, conflicts around early aggression, and that they have in common with all patients with borderline personality organization. And all this is ideologically determined, same as with borderline personality organization, by a temperamental genetic, that means temperamental features, insecure attachment, abandonment, abuse, the same etiological factors for borderline personality organization, in other words, for severe personality disorders in general. But to this comes something specific: a remarkable lack of normal dependency and loving care. There is a weakness of all positive experiences, and therefore of the idealized segment, in contrast to the persecutory segment of experience. And at the same time, they are a source of admiration for some property or some circumstance, admiration replacing love.

Very often, very narcissistic parents, incapable of real interest in their children's personality, use the children for narcissistic purposes of their own. Look for the beautiful child, "I have." So the child becomes an object of narcissistic gratification. And so far as the child has wonderful things that increase the gratification of mother, the child is admired. Or if the child has unusual talents. A patient of mine was a born piano player. He, at age seven, he was able to play complex, um, musical theses. Um, a brilliant career as a, for concert pianist, and when rapidly ascended, went into the best schools, finally into the top music school of New York. And then when what he had to do was to practice many hours, when he realized there were other people equally talented, working to become a concert pianist, he lost interest. He couldn't, he was a natural genius. You have to work for many hours. When it was natural for him to be perfect, he couldn't tolerate that. So he started failing and finally had to leave, just before graduation, and had to resign himself not to become a concert pianist, but probably a piano teacher or in a pianist in an orchestra, but, but not of the position which he had dreamt, given his time. So he dropped that completely. And so the, the admiration fostered the development of the pathological grandiose self, but by the same token, that for which he was admired was not motive enough to accept having to learn and compete, rather than being automatically at the top, as he thought he always would be. And he went after that, uh, from one effort to maintain his grandiosity with changes of profession to another, ending up with serious incompetence to maintain himself and the social failure that brought him to treatment.

Very often, these are patients who are also overstimulated by the parents. Parents who cannot put limits, who treat the child, they, who project their own narcissism into the child, and to treat the child as the perfect being that could do nothing wrong. And the child learns through temper tantrums to have his will all the way. Personal grandiosity is fostered in an atmosphere there is no basic love and no basic limit setting. And that leads them to a kind of grandiosity. Very often maintenance of serious splitting. One parent, one parent who caters after the child is idealized, the child rewards the parent who lets him get away with everything. The other parent, the aggression is projected, or the parent is devalued. So that there is parental devaluation when there is not a parental collusion with grandiosity, which then perpetuates this structure. So the, the, the effect is that they don't have the normal basis for narcissistic support that we've seen is essential for normality. And they try to obtain it by admiration from others, desperate search for admiration, while at the same time they look for incorporating whatever they feel will contribute, um, to their own grandiosity, or if they don't have with limited, and the psychopathology of envy, then the hatred of what is needed and denied is set up. They tend to spoil. They tend to, well, I see somebody raising a hand. What's your question?

I just have a clarification question, uh, concerning what you talked about about parents or splitting. It was not clear for me whether you said that there would be a typical pattern of the parents being divided into one parent over admiring the child and and [Music] giving the child love, and the other one being punishing and and neglectful or devaluating, or if it was inside the child there was a tendency to just split or think of the the parents in that sense.

Usually, it's an interaction. To start out with fostering grandiosity, not setting limits. Both parents tend to differentiate themselves because if both parents admire the child continuously, um, and the child becomes more and more demanding, eventually one of the two of them says, "Enough is enough." And the other one says, "No, no, he needs that." The child, the child notices this their potential split and then tries to reinforce that. So one parent becomes his slave, the other parent serves as an object of projection. So it's an interaction between, between the behavior of the parents, the reaction of the child.

So the, the projection of the devalued aspects of the self onto others to maintain only a sense of superiority are an ongoing effort. And they have to defend themselves against dependency for the reasons that I already mentioned. And one very important con typical conflict is profound envy of the other sex. Um, there are two true situations which a child doesn't have. One, it doesn't have the power of their diets. But the child can have the fantasy, eventually he'll get to that power. And narcissistic children have a capacity to become very powerful. And some of their managers manage to to establish a regimen of terror and oblige parents to do what they want. Is a condition for a child doing the essential things that need to be done.

Um, one, one of the narcissistic children treated by one of our therapists, a 10-year-old, refused to go to school. And the parents insisted. And they said, "Okay, but I need more space at home." And so the parents left him. It was a very limited family in terms of financial resources. They left him their living room area for all the toys, and the parents withdrew to their bedroom. So at home, the parents were in the bedroom, the 10-year-old boy controlled the big living room, and would go to school. And that was a stable arrangement by the time the treatment started. And the parents wouldn't dare to to change that. One symptom of antisocial personality is that sometimes aggressive anti-social personalities are threatening to the parents, who become afraid of their child. It's a very important early symptom in severe cases.

But anyhow, the, um, um, it, it profound, as I said, one, then is the envy of their lives, that is compensated knowing the type is going to be on a diet too. And the other is the envy of the other gender. And one never will become part of the other gender, except if socially it is, it becomes tolerable or fashionable that one can change one's gender. And the increase that we have at this point in a transsexuality, intersexuality, is an opening for the unconscious envy of the other gender that can now be expressed, um, socially. And it's a typical, um, for a segment of the intersexual, be bisexual or transsexual, um, population to contain this kind of narcissistic personality. I'm not saying that all transgender patients are narcissistic personalities. No. Um, on the contrary, there are patients who are, for, we don't know exactly, we don't know. We know that, of course, gender is determined, is determined genetically. But one sexual identity is a combination of genetic dispositions and psychosocial influences. This, um, sense of when whether one is a boy or a girl. There are four components to the sexual response. Um, the intensity of sexual excitement, whether one selects men or women sexual objects, in the, the extent to which one experiences oneself as man or woman, and one's psychological behavior that acquires characteristics socially associated with one or the other gender. These four components together make for one's sexual identity. We talk about core sexual identity, which is the core conviction that one is man or woman. We talk about secondary sexual characteristics for the, uh, for the behavior, usual behaviors associated with boys and girls. That's partly genetically determined, partly cultural. Intensity of sexual excitement, partly hormonally determined, partly psychologically. And the selection of the, of a person, male or female.

Um, I don't have time to go into detail about this, but I'm mentioning this here because one of these components, whether one is basically male or female, is determined in the first three years of life. Probably some genetic component, but there's evidence that is mostly determined psychologically, whether the baby is considered to be a boy or a girl by the parents. If you have an hermaphrodite child, the sex is clearly determined how the child is being treated by the parents. Um, so there are persons who grow up with a conviction with that they are in the wrong body because their early determination of gender predates the final biological development of their physical body. So there are people who have the conviction for childhood on their in the wrong body and want to change gender. And these are indeed indications for hormonal and surgical intervention and are a source of then transsexuality, which is a perfectly appropriate therapeutic intervention. But one, and by the way, just as a personal note, I was a fellow at John's Hopkins, Hopkins, John's Hopkins Hospital, 1959 to 1960, where those operations were done, very early operations. And there were a number of patients coming in from Cuba to Baltimore for sex change. And I had to, because I spoke Spanish, I had the opportunity of examining all these patients who came in for gender change and had the opportunity of seeing that very impressive group of patients who, in fact, ended up without any major conflicts, very happy once they changed gender. So that transgender has many origins, but one of them, and particularly a multi-gender oriented attitude, very often is an effort to overcome that envy of the other gender.

Freud, as you know, discovered what he called penis envy in women, before thinking that that was the profound source of psychopathology in women. And it only later became the awareness in studying narcissistic pathology that male patients unconsciously have as intense envy about women than women may have about men. And, and that this is a profound source of the unconscious resentment and envy toward the other gender.

And finally, regarding psychodynamic features, the syndrome, the syndrome of negative narcissism, the symptom of negative narcissism described by Andre Green, in which self-directed aggression becomes a dominant motivational force, and that affects patients who chronically self-mutilate. Very often, there are traumatic circumstances which originate the syndrome, which then is maintained and can end up really with with terrible consequences and suicide. These are patients who whose major objective is self-destruction. Um, it doesn't need to be a momentary act of suicide. It may be a long-range slow death that they aspire. One of our patients took rat poison, which produces internal hemorrhages. Hospitalized, she was searched for rat poison, we never found it, and her blood picture got worse and worse, trumping time longer and longer, and finally we had to transfer her to internal medicine because of it, the severe internal bleeding. That patient probably died weeks or months later. We tried to, initiate treatment, she swore that she took no rat poison, she never was able to become honest with the therapist.

Another case I saw, a patient in, in another city, who at age 10, her father, who was an alcoholic and who she loved dearly, raped her one night as he came home alcoholic, and then left. He left home and was never seen again. And from that age on, that patient, had great difficulty touching her body between neck and pubis, and could only soak herself using gloves, and started eventually cutting her finger, her arm, her fingers. And she had episodes of severe cutting with blood loss. In between, she felt perfectly alright, smilingly went through daily life, never got involved with a man, never had any sexual feelings, never had any further thought about her father, to just, just started self-cutting. By the time I saw her, she had already lost two fingers. Later on, she destroyed one of her eyes. Then she put her, she poured gasoline over her bed, put it on fire, threatened the fire threat of the entire building. She got to the legal system and finally was condemned to be in the hospital for the criminally mental illness. I have followed her case over the years. What impressed me in my interview for was the awareness of that experience with the father, and behind that, a kind of intense rageful reaction against feeling betrayed, the mixture of guilt and sexual excitement, sex with the beloved father. It was something she could not tolerate, and a sense of destroying him, the memory, and every other relation, including her mother, who had failed to to protect her, ended up with the sense of an aggressive grandiose self that then acquired the sense of of self-destruction. I don't know whether that patient is still alive. She probably, I haven't heard anything about her for about a year. She may be dead by now. But even in that hospital for the men, the injured prison hospital for the mentally ill, she was able to continue with severely self-inflicted lesion, in between with a friendly openness, "Everything is fine, never again again the same thing will happen," which could not be touched, in spite of the fact that you are seeing a very experienced therapist.

And now I'm going to this, well, the psychodynamic. So we have seen descriptive symptoms, psychological structures, the unconscious conflicts. [Music] And we are going now in the dominant clinical syndromes. And you see there are a number of them. First, strangely enough, they surface timidity. Patients are timid, anxious, insecure, they are sexually inhibited. They look like inhibited personality disorders. And first one thinks in erotic level of personality organization until one studies the fantasy life, in which the one finds the inordinate grandiosity, superiority, um, devaluing of others, um, the struggles with ongoing envy, and makes the diagnosis.

Second type: sexual promiscuity and the incapacity to love. Here it's important to differentiate sexual promiscuity of a narcissistic type from a masochistic type. [Music] Then severely masochistic personality disorders may also go from one unhappy love relationship to the next because they don't tolerate a good love relationships and destroy because of unconscious guilt. And they finally get stabilized in a relationship in which they are chronically mistreated or suffer terribly. In other words, they have a capacity for emotional investment, except that the heavy price has to be paid for it. The prognosis for treatment is much better than that in the case of narcissistic kind of sexual promiscuity. But the important to make that differentiation.

The typical sexual promiscuity is that the, the dog, one pathology in men. Men who are extremely seductive and idealize a woman, get involved with her, last a few months, then they get tired, drop her, on to the next. And clinically, one sees this very self-centered, exhibitionistic, dramatically exaggerating their attractiveness men who are very successful, usually with women, manage to get the woman whom they are seducing, convince her, the woman of their life, with an intense from trans transitory idealization that then is rapidly dismantled. You find the same personality in women, and there it takes a different form, a kind of cold exhibitionism, um, which has to be differentiated from the seductive, extreme exhibitionistic behavior of hysterical personality, which are a high-level personality disorder. Both in men and women, and then women often take the direct form of of seductive, of sexual seductiveness, accentuated in their presentation, their dress, and their emitting kind of sexual vibration, so to speak, all the time, but whose capacity for committing themselves to relationship in depth is radically different from what we find in narcissistic women with these characteristics, who are also accentuating their sexuality and exhibitionism, but without the emotional warmth. So there, it is, there's a kind of enigmatic coldness. It, it seems a very seductive, attractive, and attraction-seeking woman, who, in in fact, has very limited capacities for internalized object relations, and who presents temporary idealization of men, gets involved, and then drops them, and on to the next.

It is, it is a pathology that, of course, shows maximum intensity in, in at an early age. And insofar as these patients are gratified by this pattern, um, they don't look for treatment. So in their 20s, they are on top of the world. That is true, still in the 30s, a little less than the 40s, and then they start getting concerned over their perceived incapacity to establish a family. Their friends get married, have families, and they end up more and more alone. And then it, when they get into their 50s and 60s, there is a loss of interest and dilute general disillusionment. They know that every new affair will be a repetition from the past. And as they lose the interest in that outlet, what predominates is that chronic sense of emptiness and a secondary sense of depression having to do with their psychological isolation, sometimes their social isolation. And then they come into treatment. And the, the treatment of narcissistic patients in the 50s and 60s, it's easier. It's a better prognosis than in the 20s and 30s, because of the normal secondary gain, particularly of the symptom of sexual promiscuity.

Then another syndrome is the so-called thick-skinned and thin-skinned narcissistic personalities. That is also described as self-assured, is against the fragile narcissistic personality. So it goes under, under different names in the literature, grandiose versus the insecure. And at the bottom, the difference is the effectiveness of the functioning of the pathological grandiose self. The thick-skinned narcissistic personality usually are individuals who are self-assured, self-assertive, seem very comfortable with themselves, very secure, usually with no emotional introspection at all, and totally adverse to any emotional introspection. They have great difficulties in treatment, and they don't understand the logic of feelings, of subtle aspects of interpersonal relationship. So it's a perfect functioning without any intimacy, without any empathy, and in, it's like trying to twist glass, uh, in the sense of the difficulty of touching them psychologically.

In contrast, the thin-skinned narcissistic personalities have a much weaker self-structure. So they are hypersensitive to any slight, any any mistreatment, any little failure, um, and of course, they react immediately with getting depressed when they feel mistreated, attacked, devalued, and not ratified in their grandiosity. Have rage, may have rage attacks alternating with sense of depression, show great emotional lability, decrease of the capacity to function in work and profession, and intimacy, social life. They look more like borderline patients without having the syndrome of malignant narcissism. So the thin-skinned narcissistic personalities are really narcissistic personalities. The underlying borderline structure shows in lack of affective control, severe emotional switches, hypersensitive, some paranoid tendencies together with chronic anxiety and depressive features. They are much sicker clinically than the thick skins, but paradoxically, psychologically easier to reach, because the pathological grandiose self doesn't present that tremendously powerful defense against any psychological involvement.

Then there is the syndrome of arrogance. The syndrome of arrogance takes, is again fluctuates a long broad spectrum. At the sickest level, we talked yesterday about them. They look like borderline patients, and they have intense aggression in the recognition in the transference. Intensadism, they show that combination of aggressive evaluation of the therapist, curiosity, and pseudo stupidity that I referred to. On at a higher level of functioning, they may be function much better, except that they simply clinically have such a degree of arrogance that in any conflict, anything that doesn't go the way they want to, they have an arrogant, dismissive way of dealing with it, which runs them into serious trouble. One of our patients was an art teacher who whenever she had some conflict with the principal of the school, treated the principal with the degree of arrogance and inappropriate behavior that got her to be dismissed from the school, although she was a gifted art teacher. So, and these are patients who, who come to see a therapist. And say, one patient came the first session with the therapist says, "I've told that you are supposed to help me. I'll confess to you, you don't look like somebody who is really to help anybody else." It was the first greeting.

There is a, there is a story about Maxwell Gitelson, who was a very famous psychoanalyst in Chicago. He was a small man, bored, kind of insignificant looking figure. One evening, he's in his office late, the doorbell rings. So he opens the door a little bit, and there is a man, tall, blond, elegant, elegant tie, perfect suit, an athletic posture, who looks down on the little Gitelson. Looks up at him. Some seconds go by, and then Gitelson opens the door and says, "Come in, anyhow." [Music] This very often, these patients really cannot be treated because their arrogance interferes with the possibility, even the minimum dependency of going to their therapist.

Then they are a type described by Arnold Cooper in our own department, and now generally accepted, the narcissistic masochistic structures. These are complex patients who have a very complex structure, both narcissistic and masochistic. Very often patients who have the fantasy they are the greatest sufferers of the world, they carry the greatest way. So their grandiosity is because of their victimization status, and they make sure that everybody knows how they have been victimized. And, and that's the most important aspect of their life, period, and a source of moral, uh, and personality superiority.

Um, in there are other patients who alternate between periods of a narcissistic grandiose aggressive self-affirmation, and other times of projecting this self-affirmation to others in the form of paranoid features. And then other times the aggression is directed against themselves, and they become depressive. So in the treatment, this very often shows in that they alternate between periods in which they are very aggressive and dismissive of the therapist, which then shifts into the opposite. They are perceiving the therapist as aggressive and dismissive of them. And then still other periods when they get depressed and become self-aggressive and self-devaluing. So it is a confusion until one realizes that it is an ongoing struggle between a pathological grandiose self and the devalued part of the self, which is sufficiently unstable so that they can alternate between the identification between grandiosity and inferiority, and during inferiority, project the grandiosity outside, which creates this chaos, and the fact that sometimes they seem severely narcissistic and other times severely masochistic. So these are difficult, usually severe cases.

Then there is the syndrome of severe suicidality, self-mutilation, a primitive negative therapeutic reaction. When I say primitive, I mean not simply because of unconscious envy, but because of the sense that only the relationships that are aggressive have any meaning. Then there is a strange syndrome described by Drag Queen, very few cases and very unusual, because there is a self that directs aggression. There's a sense that affects aggression against itself, as well as against the, in whatever there is of an internal world that remains a general effort to dismantle all object relations after having achieved a certain level of it, and which shows clinically as individuals who have a chronic sense of emptiness and meaninglessness of life. They are not depressed. They just have a sense that nothing interests them, nothing has any particular meaning. And life is a burden that they want to get rid of. Some of these patients end up with suicide simply because they cannot tolerate an existence that makes no sense to them. In the clinical contact, they appear sometimes as valuable, nice person. They don't have the narcissistic grandiosity, self-depreciatory behavior. They just have a kind of emptiness that they experience and fully acknowledge. It's not like the usual narcissistic person. These are patients who tell the therapist, "I understand what we're saying. It makes a lot of sense, but it doesn't do anything to me. So, so, so what?" And not so much in a grandiose way, but they regret that they cannot use anything that the therapist is saying. They are usually quite isolated socially. They may function, be functioning okay at work. They have a superego function. Their social behavior is appropriate. They may have social friends, except in their intimacy, which they don't have the capacity for in terms of stable love. Left, but they don't have any particular sexual interest either.

I hope I've given you the, the picture. And, um, usually in the background of this patient, in the first few years of life, there was a chronically severely depressed mother, and there is an unconscious fantasy that they want to return or maintain the relationship with this dead mother, as they experience it, the non-available mother. But that's the dead mother. After that's the matter that there is, and there's an unconscious wish to get back to her by becoming eternally dead. They dismantle their sense of self, their sense of significant others, in an effort to refuse with that their mother, that dead mother. In the treatment, this becomes almost intolerable. It takes many months, at best, in which one discovers behind that indifference, the profound sense of frustration, because they see the therapist as empty, is unavailable, as that early depressed mother. And if they are capable of of deactivating the deep frustration and resentment that originally caused that deep level of activation of aggression, then there is hope for change. If not, very often after years of treatment, therapists feel like giving up. I only know other than the cases of unregreen, three or four of these patients. My colleagues as well, of my, my own experience. So it's an extremely difficult, challenging, and frustrating syndrome, very rare.

And finally, the anti-social pathology that I have already outlined to you. Narcissistic personalities that now you can understand very quickly have to be subdivided in narcissistic personality with anti-social features. My art professor who was stealing books, the syndrome of malignant narcissism, that patients who are hospitalized and thought of as being ordinary parliamentarians, and on the other hand, the politicians, like you know, who, and, and finally, the anti-social personality proper. They already mentioned the importance of the differential diagnosis.

A few words about prognosis. You just want to make sure that what did I do here? I did something. I pressed something. No. Okay. Thank you. A few words about prognosis. In first of all, the general prognostic factors that override all others, as I mentioned yesterday, anti-social behavior, secondary gain of illness. For antisocial behavior, you make your differential diagnosis. For secondary gain of illness, you control it and make it a condition for treatment that patients stop being parasites. Remember that, um, personality disorders are not a reason for not being fully employed. Work, profession, studies, whatever. It is, there are in the United States thousands of patients who exploit either the state or private agencies or the family, living a parasitic life, and which mediates against being treatable, and that can be corrected. So secondary gain and antisocial behavior, prognosis. First, future antisocial behavior and total irresponsibility. And of course, those patients who are in capacity to engage in any treatment situation, the, the very thick, extremely thick-skinned narcissist. Second, secondary gain, already analyzed. Third, severe regression against the self, against others. And in addition to what I've mentioned, there are two types of patients who are very difficult. Those who show the symptom of perversity. Perversity is not perversion. Perversity is a clinical condition in which love is recruited at the service of aggression. The patient uses what you are trying to give the patient to help the patient for destructive purposes, destroying what you are giving them, or using what you are telling them to attack other people. So it is a misuse, this self-destructive misuse of what patient receives, a subtle but important manifestation of of aggression. It, um, sometimes it takes a woman comes to treatment because she has severe conflicts with the boyfriend. Um, behind this is an unconscious submission to her mother. Her mother has a horrible marriage. She tells her daughter, "Has been always telling her, don't get involved with men. It's only a source of suffering. Stay by yourself and your family. Don't let yourself get involved." The patient has fallen in love with a man who loves her as a lovely person, and then she started to get wild jealousy attacks for nothing, and that proved at the bottom ways in which was trying to destroy the relationship out of unconscious guilt. She didn't dare to stand up to her mother. So gradually during the treatment, and she uses that for saying, "I'm feeling much better. No more rage attacks with him. It's just that I'm really no longer interested in him." This was not enough, not a narcissistic personality, but I'm feeling much better. I've decided this has been a bad relation. Let's continue the treatment to see how I'm going to react getting involved with other men. And then this patient gets involved with men and rejects them one after another, happily, happily telling the therapist, "Good that I didn't get involved in this one," continuing to be submissive to mother unconsciously, which now has been the conscious content, which she acknowledges, but at the bottom pays no attention. And then she comes one day and says, "I've decided I'm going to buy semen and have children. I feel like having children right now." So under the pretext of getting help, she uses the help for dismantling the relationship and and acts in submission and protest with the predominance of the kind of an enjoyable protest and destruction, whatever the therapist is trying to do to help. That's the kind of situation in which an unconscious pleasure of destructiveness, subtly disguised in the form of quote unexpected developments, a lack of response, incapacity to this, or else using what the therapist says for destructive purposes becomes important. One of my patients learned in the treatment that he cannot depend on a narcissistic personality. He cannot depend on anybody because if he did depend, he would miss the person so terribly. When he lost that person, that he couldn't tolerate it. Therefore, he cannot depend. A totally empty statement that uses what he learns to rationalize his total interest in dealing with the symptom of dependency. That's the syndrome of perversity. It has a very prognostic quality if it doesn't get resolved.

And then there are the tedious patients. We have, in the United States is a litigious country, people sue each other for nothing. And so there are patients who get into conflict with the therapist, they sue the therapist, and take a second therapist to deal with the trauma that they experienced with the first therapist. Then the, this, then they get into conflict with the second therapist, sue the second therapist, and get into treatment with the third therapist. So they use litigation as a chronic attack on the people who are trying to help them. A very severe syndrome, they complicating productive factors. And we make it as a principle, when anybody consults us who is in a legal process involving another mental health professional, we tell them, "First, you settle all your business with the previous mental health professional. Then we'll evaluate whether we start training."

Then primitive negative therapeutic reaction, the third most severe type that already mentioned. While negative therapeutic reaction out of unconscious envy is daily bread in the treatment of narcissistic personalities. Then the existence of drug, drug and alcohol dependency that requires, when there's true dependency, you make a clear differential diagnosis to simultaneous treatment of drug dependency and alcoholism. The syndrome of the extreme arrogance that I mentioned to you. Then there is the syndrome of microcosis. I, um, I would like to refer to this very briefly. I already mentioned it yesterday. It's a rare personality disorder, but not so rare an infrequent personality disorder that is not mentioned usually in the nomenclature. Together with all the other problems, these are personalities who are chronically concerned about the functioning of their body, hypersensitivity to normal sensory perception of the body, withdrawal from social contacts to be concerned with their body, imaginary illnesses, prone to health foods, protective behavior against illnesses, use of crystal and magic to protect oneself against various illnesses, and who have projected aggression into their own body. You start them in treatment, and the projection shifts onto the therapist. They become very paranoid. Severe paranoid. The transferences include the psychotic features. They may become chronically psychotic, and the treatment is to be stopped and transformed into supportive treatment. So these are, these are very severe cases.

And finally, patients who because of their illness have already severely destroyed their social resources. And so when the negatives, one businessman who developed alcoholism, lost the dominant position in business, instead of being CEO, became section chief, then he lost that, finally he was no longer employable. A successful business woman, wife, whom he envied and resented bitterly, starting of sexual affairs with worsening of the alcoholism, he became unemployable. Wife decided to divorce him. There he was, alone, limited resources, and I would call it about 56 years old, at an age from being the top executive, he was practically on the street and struggling with severe suicidal impulses. Here you have the double problem of treating the narcissistic personality and the, the social, disastrous situation that he had provoked. So that destructiveness becomes prognostically negative.

On the positive side, when narcissistic patients age, they get from their 40s into 50s, reach retirement, their narcissistic triumph goes, they lose power, youth, influence, and are faced with the depression of living up to the limits. The differences between their fantasies of grandiosity and reality. If they can tolerate this and start treatment, the prognosis becomes better, and they can be helped to redo their life. One thing that I didn't mention here is the main extremely difficult symptom, and will stop after that, is the incapacity to love. Many patients come to treatment, and they recognize their incapacity to love. It is a major challenge, and there are treatments in which we manage to resolve that in resolving the pathological narcissism, and it becomes a very gratifying treatment situation. And in other cases, in which we can't, the negative prognostic elements are too powerful. This is something that I am very involved in studying right now, but we don't have as yet sufficient knowledge, understanding, research, and publication to be able to tell you more than it is very difficult to treat, and very, and we don't know exactly the prognostic indicators when will we succeed, when not. It's still an open question. Let's stop here.

And we start with treatment. In the upper room, can you hear me? Yeah, I apologize for the delay. We are now starting with treatment for the mildest cases. Patients will come because they have specific symptoms. Remember that a protester minister whose mistress left him, these kind of cases. We use a supportive psychotherapy, or if there's a specific symptom that may respond to cognitive behavioral therapy, DBT for the middle range cases. The ideal treatment is psychoanalysis or transference-focused psychotherapy. For the severe cases, including those with over borderline functioning, transference-focused psychotherapy is the treatment of choice. Um, if there is a contraindication for the transference-focused psychotherapy, for example, for excessive secondary gain that cannot be controlled by treatment contract, or anti-social behavior that requires ongoing information from other sources, maintenance of behavior control of the patient, the education would be supportive psychotherapy. So that supportive psychotherapy is the treatment for the lightest cases, and for the extremely severe one. The intermediate range is a choice between psychoanalysis and transference-focused psychotherapy. I think that in general, patients who function at a higher media level probably would be benefit most from psychoanalysis, but transference-focused psychotherapy is a possibility when psychoanalysis seems either contraindicated or not possible, because it requires such an intensive commitment to three or four sessions a week. Transference-focused psychotherapy only requires two sessions a week. And psychoanalysis is such a long-range development, and there may be urgent life programs that require, um, fast operating treatment. Transference-focused psychotherapy may be preferable. Cases where the main problem is the incapacity to love, probably as much as possible should be treated in psychoanalysis, because it's very difficult to bring about that change in individuals whose capacity of of loving stable engagement is so severely contained.

In here is just the comparison of the various utilization of the techniques that we talked about yesterday. Interpretation, transference analysis, technical neutrality, and countertransference. You can see that psychoanalysis and transference-focused psychotherapy are practically similar in their technical approach to patients, except that psychoanalysis has a higher frequency. The use of the couch, usually technical neutrality can be maintained in more stable ways in psychoanalysis proper, and there's a much more intense utilization of countertransference analysis in transference-focused psychotherapy. The DP PFP is the German Tiefenpsychologie Physical Therapy, which is very similar to in to the American expressive supportive psychotherapy, a kind of a mixed approach, which is not of interest in this context. And supportive psychotherapy uses mostly supportive techniques that are not mentioned here, which is cognitive support, emotional support, ab reaction, environmental intervention. Supportive psychotherapy is not pat on the shoulder treatment. It can be a very intense treatment, but its instruments are then those supportive techniques that I mentioned, with very little of the analytic techniques. They use the limited use of interpretation, particularly of manifest negative transference, and of course, intense utilization of countertransference analysis, which I think is true for all psychodynamic psychotherapists.

Now I'm going to talk about the technical approach combining psychoanalytic technique proper with that of transference-focused psychotherapy. For practical purposes, you may consider what follows a specific application of what we discussed yesterday, transference-focused psychotherapy to the treatment of narcissistic personalities. We see these patients twice a week, face to face. And here it really becomes essential to maintain that as a minimum frequency because of the great difficulty of transference regression of these patients who have as a main symptom their intense struggle against dependency, the incapacity for establishing a dependent relationship, the great difficulty in engaging in treatment of these patients requires this minimum frequency. This patient give the impression as if they did not develop any transference at all, because they maintain, they try to maintain the relationship so reality-oriented, so equivalent to a kind of a commercial interaction, so to speak, in terms of coldness and distance, that it's very difficult to see any particular distortion of the interpersonal relationship that would give one cues to what is dominantly going on in the transference, except the intense maintained effort on the part of the patient to avoid coming in a dependent relationship. However, at a deeper level, there is a dominant transference pattern in what I described, namely the patient's unconscious efforts to maintain himself in the superior level by trying desperately, so to speak, to maintain a relationship of equality with the therapist, not patient-therapist, but as if two core therapists were treating the patient. And the, if there is subtle effort on the part of the patient to control the treatment and maintain a sense of superiority, while unconsciously tending to project onto the therapist the devalued aspects of their own self, that part of the patient which is envious and devaluing, and that the patient is defending against by maintaining the dynamic of superiority. These patients have an attitude, but that it's very significant. You'll notice it from the beginning. Ordinary patients, as we saw yesterday, talk to you, to the therapist, about themselves with an effort that you should gain knowledge about them, understanding of them beyond what they themselves know about themselves, in order for you to use that understanding, share it with a patient, who in turn takes over from you the knowledge, the understanding that you are providing the patient, and use that for improving their own understanding, dealing with their own conflicts. This is the normal therapeutic relationship. Here, to the contrary, patients talk to themselves. They use free.

Association to express their superiority, their grandiosity, and experience. The therapist is a kind of admiring audience who should be impressed by them, or else the patient speaks to the therapist, but not to communicate what his difficulties are in order for the therapist to increase the understanding of them beyond that of the patient, but to influence the therapist and convince the therapist the way the patient is thinking. So that the use of language here is either for self-demonstration or for establishment of control. And the therapist experiences that in that is being controlled, and that that the patient is talking to him to convince the therapist rather than sharing information. Or else that the patient is talking without any consideration of the therapist as a real person with whom is having a dialogue. The impression this produces in the countertransference is a sense of unavailability of, uh, of of a communicative partner. So the therapist feels alone in the room while the patient is talking to him. It's a disturbing sensation that brings usually a defensive reaction of the therapist of disengagement, because the therapist senses that the patient is not engaged, so the therapist disengages and feels bored and uninterested. So you listen to the patient, hear what he's saying, but you are not involved. You are strangely distant. This is the countertransference by which you defend yourself against this dynamic of superiority and inferiority. And of course, there are times where the patient feels he has failed or there's something traumatizing that has happened to him. He really needs help. And at that point, for moments or a period of time, the patient feels inferior, despicable, worthless, and the therapist seems grandiose, superior, and dividing of the patient. So every, the typical reversal occurs between superiority and inferiority.

So the, the most important consequences of all this is that treatment becomes a kind of self-analysis, a cognitive learning on the part of the patient. The patient is willing to learn new things from the therapist in order to absorb them immediately. Knowing something new, yes, he knows that now, he can forget it, he has already acquired it. At the bottom, it's an unconscious evaluation of what the patient receives from the therapist. It's both an incorporation and is spoiling. So that patients have a sense on the one hand, they have to learn gimmicks, they have to learn formulations, interesting theories. Once they know the theories, they can help themselves. And there is a sense that the value of this disappears. They feel empty. They are not receiving anything. They want to get more. And there is a typical feeling of the patient, the setup is not saying anything new, he knows this already. What else the new thing is that setup is going to say? And the therapist gets the feeling he has to come up with interesting new things. So it's the patient not to get disappointed. At the bottom, it's the manifestation of the mechanism of omnipotent control. The therapist has to be good enough, be not to be totally devalued, because if he's totally devalued, becomes useless, the treatment becomes useless. On the other hand, he doesn't have to be so good that the patient feels, oh, he knows something more than I, he's really the superior one, by which the patient would feel deflated. He cannot tolerate that. So he has to make sure that the therapist functions within a limit, good enough, but not too good. And this is then the effect of omitted control.

Um, I had a patient in times at which people were still permitted to smoke during the sessions. Now smoking, smoking during the sessions is not socially permissible. And whenever I made an interpretation, if the patient was in analysis, and the ashtray on top of him. [Music] And so whenever I made an interpretation, the patient's reaction, so I was being quickly scanned and evaluated. How good was what I was saying? The, it was an evaluation of me, not the use of what I was saying for any other purpose. And these patients cannot avoid experiencing consciously envy of the therapist, in addition to the unconscious envy that is provided by the development of negative therapeutic reaction out of unconscious envy. And sometimes the development of perversity complicates the situation further. Um, in there are subtle defenses against dependency. Now I'm giving you a real micro analysis of how patients defend themselves again being one is a distortion of pre-association that I just mentioned in the, the way the patient is communicating to himself, uh, talking to himself or to influence the anarchist. Then there is an organizational pre-association. Patient says, oh, I, I mentioned that later, now first let me say. So they transform free association in a kind of an organized discourse, and they establish the order rather than being interested in spontaneously communicating whatever comes to mind. It has to be according to an order they established for publication. So to speak, a concern about the value of each session. I wonder whether this was a good session or a bad session. I think this wasn't a good session. There's a kind of a commercialization of of the value of each session. So to speak, we had a patient, uh, who's, uh, a 10-year-old again, um, who, um, the, the patient told the therapist, I know my mother pays you $200 per session. Let me tell you, the child says to the setup, is this session was worth $2 at most. And so the therapist picked that up and, um, and with some frequency said, so what was the value of this session? And pay for $20.50. So the 10-year-old showed clearly a mechanism that's much more subtle and hidden in the dives, and here was so open on the surface.

Um, there is an elaboration of the therapist comment. Can you repeat what you told me? Ah, what did you mean? Can you explain it a little better? So one is put in a position of a bad teacher who has to clarify what can't be understood. Um, and, um, then the, the tendency that the patient devalues what he learns from the therapist shows up in the fact that the same problems, the same issues come up. The patient hasn't learned anything because he has devalued the contribution of the therapist. So the therapist is seduced into repeating the same things. And the patient says, I know you have told me a thousand times the same thing. Whenever a patient tells the therapist, you've told me that 20 times, I know, I know. The important issue is not the content, what is being discussed, but the unconscious evaluation that's going on, and that has caused this to happen. And there is a tendency of patients to repeat associative consequences without any depth of understanding. It's just repeating a learned text. And what is sometimes frightening is an incorporation of the therapist's theories. The patient learns the theory and starts repeating the theory. That means nothing except an empty statement. I, I mentioned to you that patient who would say, it is true, I cannot depend on anybody because if I depended on anybody, I would miss the person so much. If I lost the person, I couldn't tolerate that. That was said by a patient who had never missed anybody in his life. It was a, it sounded like a perfect analytic understanding and was empty talk. These patients also usually show a very stereotyped view of others. They have everybody else is fixated by them, with a fixed way of looking at them. So you get a frozen family history, nothing. The fun, this is the way the family was, that's a period. There is no change, no evolution throughout time. Then it is a frozen picture.

Another element in which the superiority shows is patient speculation on the intentions behind the analyst's comment. Why is this? Why is the therapist telling me that? So the patient tries to guess the theories in order to learn the theories behind the therapist's statements. So he can really learn all that the therapist knows. Of course, there is great indifference and ignorance regarding the therapist. It is impressive that the patients who will be having treatment for many months know nothing about you. I mean, every other type of patient learns things about you. Patients have lots of time to think about their therapists and to get an image and think, construct pretty realistically the picture of the therapist. These patients have got the slightest inkling after years. They have no view of the therapist except that determined by the immediate transference. The patient may find that times the therapist must be impressed by what the patient is saying. The therapist must be very interested or not interested at all, or very critical. The therapist must be fed up with the patient. They attribute all kind of reactions based on projective identification, but they can't put together a representation of the therapist as a real person. Um, and in the ignorance is combined with indifference. They have not the slightest interest in what's going on in the life of the therapist, except if they know about things that might evoke envy, and then this becomes extremely interesting and has to be controlled. Very often these patients tell one important things that have happened in their life. Um, there may be, um, brilliant or impressive stories, but in all of these stories, in the description of what's happening in the patient's life, there is no emergence of the patient and his own internal experience and reaction to the situation. So that very often sessions are filled with brilliance or ironic or critical or amused description of important things they have experienced without any information about the patient proper. And, um, often these patients, um, repeat issues that came up in the last session in a conscious effort to indicate they still have the same problem and nothing has affected it. It's a provocative demonstration of the incompetence of the therapist, as they see it. In often these patients have an attitude, um, as if free association were a kind of event, as if they were a vending machine. So the patient of the pure trump says, okay, I've said all that I have to say, now it's your turn to talk. The patient has done his work, so now the therapist to do his work. There's no sense of an ongoing working relationship. The countertransference with these patients is very intense, and at the same time is I already sometimes simply one of detachment, of indifference, of distance. So we stop listening to a patient who talks to us without experiencing us more than an admiring audience. Sometimes narcissistic patients in analysis on the couch after 20, 30 minutes talking, all of a sudden the analyst says something and the patient startles. He has completely forgotten that there's something else, somebody else in the room, and which shows the attitude that provokes the distancing. And of course, these patients may make the therapist feel very insecure, controlled, having the feeling that he has to watch himself, be at his best all the time, because it's being evaluated critically by somebody ready to depreciate him for whatever reason. So there is some manifestations of omnipotence, omnipotent control, and sometimes diversity. And sometimes patients unload experiences. They tell about bad experiences, not because they want to be held, but they unloaded. Rosenfeld said they used the therapist as a toilet to get rid of bad experiences. Once they've told the therapist, they don't need to think about it anymore. It has been taken care of. It's not a source for new learning. I hope I, I have given you a good illustration of the dominant transferences, and we systematically have to interpret what the patient is doing, that he's using free association to keep himself in control, that he's afraid if he doesn't watch it, he'll show weaknesses, or if he has to listen, if he has to accept that the therapist helps him to gain a new understanding, he will feel defeated. Uh, to be helped means to be defeated. It shows the triumph of the therapist. We have to interpret that consistency until gradually the patient becomes fully aware of his need to keep a level of superiority, because he's afraid that other than that, a sense of an inferior, chaotic, threatened, isolated, lonely self will emerge, with sense of being rejected, rejectable, of the emptiness that can't be compensated with, and, and that he has to accept the shameful feeling of having to rely on the therapist to help the patient out of this mess.

And at that advanced stage of the treatment, several things happened. First, the pathological grandiosity begins to dissolve into its component internalized ideal object representations, and the patient activates the specific primitive conflictual idealized and persecutory relationship at the borderline level that are underneath that layer of the pathological grandiosity. So there is an activation of a specific constituent object relations, and the emergence of primitive defenses, projective identification, emotional distortions, paranoid development in the transference, and a kind of dramatic ways of splitting contradictory experience that that happens one after another without the patient being able to establish contact between them. The typical primitive borderline idealized and persecutory specific relationship come into a picture. I'll give you an example. In I had a patient in treatment in a psychiatrist in the small town in which I then worked, the Mainer Foundation to pick up Kansas, population 140,000. Everybody knew everybody in the professional field, obviously. And I was one of the candidates for becoming director of the Mainer Hospital, and there was, I represented the analytic group, and there was another candidate who represented the classical, um, neuropsychiatrist orientation. And, um, my patient, aware that there was a political struggle in the psychiatric field, became very alert. And as he was my patient, he knew me, and he started to tell gossips about me, to tell stories about me, that put me in a somewhat ridiculous position. So he started telling these stories over a period of weeks, and then the story started circulating in the city, and finally they told him the same stories that he had originally circulated, and he got very anxious. And in the middle of the session, he told me that he had to confess that he was upset about the fact that something that he had told somebody about me came back to him from a completely different source. And I found out that he had been spreading rumors about me for weeks. As you can imagine, I didn't feel very happy, and it was, it was very upsetting to me. I was at that point at the relative early stage of my professional development as the specialist in personality disorders. I was enraged, and I was ready to end the treatment. And I had supervision for that case by one of the leaders in the fields, Roman van der Waals, who told me to hang in there and to find out why the patient had to treat me this way. This was highly unusual for patients to to circulate gossips about their therapists. So not highly unusual, but not frequent. And I gradually found out that the patient's mother had this attitude of being gossipy, having what people who knew her called a poisoned tongue. She came from a very poor environment, had married in this very small town, a local physician who was from the upper level environment of that small town, and she felt insecure regarding the person of his social environment. And by spreading rumors and gossip, she tried to devalue people and put herself into a position of superiority. So the patient had activated his identification with his powerful mother, his powerful gossipy mother, that was had been part of his pathological grandiosity, and now, um, was kind of crystallized as one specific relation, while he projected into me himself as the controlled victim of that dangerous mother. That's an illustration of the activation of the dissolution of the grandiosity into its component object relation and their enactment is object relations in the transference that permits specific interpretation resolution, like with all borderline structures.

So these patients acquire a borderline quality, which gives the impression that they are worse when in fact they are getting better. There is a risk of very severe acting out of these problems, disruption of the treatment, very painful activation of envy at its worst, the possibility of developing severe depression, as the patient is again recovering the capacity to recognize and identify with moral value systems. The patient starts, my patients start to feel honestly guilty over having treated me this way, who after all was trying to help him. So there's a capacity for the development of guilt. The risk is that a very primitive and severe superego develops with severe guilt, depression, even suicidal tendency. At the same time, on the positive side, one notices that the patient are starting to have the capacity for more sophisticated and complex relationships with others. As they discover the complexity of their own emotional life, they become alert to the complexity of the the life of the people with whom they are involved. I had a patient who, after complete indifference and depreciation of his wife, started to get interested in her in in strange ways. She started to admire her taste, was interested in what she was thinking, what she was interested in, dared to share with her his own insecurities, and found out that she had a lot of understanding of which he had been completely unaware, because he was never interested in. So development of the capacity for love and investment are an important aspect. Sometimes very dramatically, I had a narcissistic patient who, um, got involved, it was American, went to Germany, got involved with him. He was a physician, some medical specialty, went to Germany, met the girl in the small village where he spent the summer, who admired a really beautiful woman, but of the most humble, simple condition. He married her, and she admired him and was willing to be his slave. He was ashamed because he had no education. They got him to go through college in the United States. She went to college, got an education, and so gradually she became successful in her own and, um, finally was able to establish a profession. He couldn't tolerate that. So his feeling, he developed more and more resentment and more and more dissatisfaction, lost all sexual interest in her, and finally suggested to her that they have open sex. Those were years where there were group sex and open sex quite fashionable in certain air, in certain segments of the population. And that escalated to his humiliating her sexually, and finally forcing her at one occasion to have sex with five men simultaneously while he was watching. And after that, she divided her completely as a piece of meat. End of the relationship. I, I think I've demonstrated to you the destructive aspect, that the cruel, destructive, depreciative aspects of of his behavior. To return in the course of the treatment, he was able retrospectively to feel very bad about having destroyed that relation, reconstructing it in his mind with how he met her and the first years of their relationship, and that he had only received good things from her, to which he responded in this sexual degradation, felt terribly guilty about that. Met another woman at that point and was able to get married and to have a good marriage with a woman whom he loved. I had a 15 years follow-up, and that was a very good marriage. Now that's a successful case. Some cases fail, but when they are successful, it is very impressive how you can change totally the life of a person.

Specific problems with specific syndromes. First, the thick-skinned narcissist. We should have a break around two. We should stop around two for 10 minutes. Yeah, the thick-skinned narcissists. Here, their incapacity for developing any deepening of the relationship forces one to very carefully focus on the relationship of the patient outside the treatment situation and find out in the subtle difficulties in external life, the manifestations, the subtle manifestations of transference development that then can be developed in the relationship with the therapist. It is fundamental to systematically work through the superiority-inferiority issues in the transference because here they are maximal. Here the grandiosity is, um, is maximum. One has a little Napoleon in treatment that one has to transform into an ordinary human being. The thin-skinned narcissists offer a different situation. Here the sessions are chaotic. They alternate between sadistic and masochistic and paranoid transferences. Here one has to treat suicidal threat with structuring of the treatment, typical structuring, and interpreting at the same time the unconscious functions of this recital behavior. One has to maintain the treatment frame against the threat of severe in acting out. And particularly in in very severe cases, there is a transference complication that indicates an extremely severe regression of the patient, a total intolerance of triangulation. What I mean is that the patient starts, uh, getting enraged whenever the therapist has a different view from the patient. The therapist has to totally agree with the patient, 100%, because if the therapist disagrees, it means he's depreciating the patient, he's abandoning the patient, or that he's trying to control him. Statistically, patient can't tolerate that. So you either agree 100% or you become a danger. And that is what it is. It is it is a situation where no third person is tolerated. Third person in the sense of independent thinking of theory by the therapist. And that has to be interpreted systematically. Um, but I, I don't think it needs an example. A little example. A woman, her sister dies. She's at the cemetery. My patient, my patient is a patient of the colleague. The patient, um, develops a dramatic, seeing of suffering about. So where everybody, everybody's standing around the coffin, the patient recries and makes gesture and big theatrics to an extent, then she has to be conducted away and comes to the session enraged. Nobody understands real mourning, real suffering. All of these people really didn't feel anything about the deaths. She was the only one who really felt about the death of her sister. So I start pointing out to the patient that for what she tells me, her behavior was really rather out of the ordinary. I forgot to say that at one point she tried to throw herself after the coffin and had to be held back. And the patient got enraged that any, that that the therapist should question her suffering, her deep suffering, the fact that she was the only person in the morning. So then for weeks, the therapist only dedicated himself to analyze with her the threat of his having any different way of thinking or reacting than she did. It is a relatively rare, almost psychotic regression. And the importance is then to keep track of the intolerance of your triangulation more than the specific issue. Yes.

Can I just have a question about that? I was wondering what about when you talk about a thin-skinned narcissist, and I'm wondering is that a need for a deep validation rather, you know, recognizing that or if they feel like there's a difference of opinion from a therapist to themselves that I don't know if I make myself clear, but I'm wondering what's validating, how hard this would not be more helpful rather than analyzing there's a difference of opinions. If if patients react realistically to a situation and they don't dare to affirm themselves in that, we point out to them, it seems that you acted very appropriately. So we are validating normal behavior. But if they behave crazily, we have to confront them. We try not to validate crazy behavior. I mean, I, if I had told that patient, yes, you are right, you were the one who marked most, that indifferent family, good for you, that would have been crazy. I'm not talking about the behavior validation behavior, but the pain underneath it. The the pain underneath it. She felt like this is so terrible for me to lose this person, but the pain underneath here, that she was not the most important person in the cemetery. Everybody worried about that shitty sister was being buried. I mean, this was a person with intense competitiveness with the sister. So behind behind such extremes, there is not simply normality, but conflicts. The concept of validation is helpful in cognitive behavior therapy when the effort is to reinforce normal behavior of the patient that the patient didn't have the sense of the right or the power to assert. So we help, we, we help the patient with normal narcissism. Here we deal with total distortion, and so there's nothing to validate to begin with. Okay.

So the syndrome of aggregates in, I already mentioned yesterday that the secret there is to analyze the patient's intolerance of the pleasure in destroying everything that comes from the therapist. In in this is the one situation where the patient can be free to attack, to depreciate, to behave impossibly within the frame of the treatment. We don't let the patient attack us physically. We don't let the patient destroy objects in the office, but within that, and the patient can yell if he wants to, as long as other people on the same floor are not disturbed. So that's the, that's the limit. So we are always considered with it, but within the treatment frame, we analyze the defense against sadistic pleasure, which tends to reduce that pseudo-stupidity and normalize the behavior of the patient. The importance is, of course, to control one's countertransference, because these are extremely provocative behaviors. In the case of patients with severe self-mutilation, usually, and let me see for a moment. I want to, can I just ask a question? I maybe we should stop at this point, um, and then we go on, and I want to leave some time for questions and answers. So I'm trying to complete this about by 2:30. Okay.

Cases. [Music] Now cases with severe self-mutilation. First of all, one has to differentiate the self-mutilating behavior of patients with borderline personality disorder from that of patients with narcissistic personality disorder. Generally, the narcissistic personality disorder patients have, as I mentioned, much more severe self-destructive features. Borderline personality disorder usually either burn themselves or cut themselves superficially, but without any real danger to themselves. Um, and sometimes there is a kind of a discrete cutting that doesn't even leave scars. So whenever we see patients who have chronic self-mutilation, we look at the scars. We want to know, do they have significant scars? Are they deep scars? Or are they really trivial? In terms of the structuring of the treatment, if patients self-cut or self-burn in a very superficial way, very often we simply interpret it as a symptom, but don't do anything to control it, because it doesn't seem to be important. And very often patients, when there's no external reinforcement and nobody's concerned about it, stop that dramatized aspects of their behavior. If the self-destructiveness is more severe, then we use the usual approach of setting limits, telling the patient this behavior cannot take place, and at the same time immediately analyze this behavior in the transference. My, my wife is not here. I hope she will not mind if I mention a patient of hers. She had, she had a patient, a woman, who was chronically cutting her vagina with a knife, with the development of severe infections, the pelvic infections and genital infections. And so this patient had a very sadistic mother who had been severely forbidding her sexual behavior and punishing the patient for sexual escapades during her adolescence. So, um, the, the treatment contract was that this patient was not cutting her vagina anymore. If she couldn't control it, or she had cut herself, she had to immediately go to see the gynecological surgeon to be treated, and with the indication whether she could continue functioning on an outpatient basis or not. As long as she fulfilled that condition, and she came to the sessions with, with the authorization of the, um, and having been seen by the gynecological surgeon, the treatment could proceed. If she, if she could control it, then of course the wish, the intense wish for that could be discussed in the sessions. The patient got enraged about this invasion. They accused the therapist that the therapist wanted to to humiliate her and expose her to those, if it's having to spread her legs so that all these male physicians could examine your genitals. It was shameful. It was intolerable. You can see how the patient was defending her symptom. And what the therapist did was to immediately interpret that she was now perceiving mother, the the therapist as the mother who was, um, attacking her sexuality, forcing her to exhibit herself shamefully to this leering man, while she was the victim of mother's mistreating her sexuality, while at the same time she herself was identifying with mother who was doing the cutting and destroying her sexuality, while the therapist was the healthy part of the patient who was supposed to be helpless while the patient's genitals were being destroyed. So you see the combination of limit setting and interpreting of the transference element and the meaning of the symptom and the, but insisting in the conditions under which treatment would be carried out that the patient finally accepted. And the working through of this problem over a period of time then resolved the symptoms. So this was a serious symptom. We had another patient who was cutting her arm, a criss-crossing. She cut deeply in one direction and then she cut deeply across, kind of in a quarticulate fashion. The result was a total destruction of the forearm, so that the plastic surgeons were unable to intervene. It was their arm was just a fostering wound that had to be bandaged and chronically bandaged. That patient examined, she was seen in the unit, she was proudly showing her arm and looking at everybody with a sense of triumph, enjoying the fact that everybody else was horrified. And other than during such a time, the patient seemed perfectly happy and tranquil. So the treatment consisted in the systematic analysis of the sadistic pleasure in controlling the world and showing her superiority by not being afraid of pain, infection, illness, death, while maintaining medical control of the wounds. That again, at that stage, there was no way of doing any corrective surgery, just an open wound to be maintained. And the patient was treated for a month in such condition, but systematically analyzing all the psychological implication of this ongoing triumphant self-destructiveness. So again, in this case, she was identifying both with victim and perpetrator, repeating a dominant family dynamic in treating her body and in the relation to the therapist. So the important technique is the analysis of the double victim perpetrator identification, protection of patients, protections of the limit of the treatment, and of course, in the middle of this, asserting the safety of the therapist. So the therapist should not be tempted to abandon ordinary medical responsibility if there are serious medical consequences, and accepting the limit of treatability of certain cases that simply cannot be handled. I mentioned the woman with the rat poison. We were just incapable of of controlling where she had the, this patient was observed, nursing staff were becoming like a secret police, and we never were able to to find how she was getting that the rat poison, and we had accepted limits of of the treatment. So these are extremely severe cases, but the combination of techniques that I mentioned may help in many cases, not in others.

The date mother syndrome. I described it to you in the morning. Here, perhaps the most important issue is the tolerance of a countertransference of the patients whose superficial friendliness hides a deep devaluation of self and everybody else and all human experience. And in the analysis of the deep meaning of her coming to the therapist over many months without any effort to explore what made were so indifferent toward everything else, including a refusal to explore what would be the consequences in the counter in the therapist mind, in the countertransference is fantasied by the patient in response to that interaction. And at the bottom, the therapist of such a patient with the dead mother syndrome is put in the position of the patient, while the patient's indifference enacts the chronic depression of the mother. So the patient is the dead mother. I mean, the therapist is the dead mother. The patient is the deaf mother. The, the patient is the, the dead mother, and the therapist, the child, confronted with a depressive, depressive mother. And that relationship has to be examined in all its meanings to the, to the point where the patient is recover her own corresponding experience and the frustration and the disappointment and the hatred that all of this would have engendered. And very often, before that, there's a time when the patient has found us is about the therapist being deeply frustrated and angry and resentful. So the therapist begins to project onto the, the patient begins to project onto the therapist what the patient has not been able to tolerate in the relation with her own mother. So it is working through of the dead scene that is the, the treatment situation parallel in working through with the therapist, within the therapist, of the countertransference with being sub, with being with such a dead patient. In France, again and again and again and again.

In patients with antisocial behavior, the first of all, it is important to set clear limits. Let's say you have gone through the differential diagnosis about prognosis. It's not an antisocial personality proper. If it's an antisocial personality proper, the prognosis is really zero. And I'm, I don't have time to go through the literature and the empirical effort to try to treat these patients. It is a major unresolved challenge. You will find research showing that antisocial behavior in children can be treated and improved. That is true because there is no good differential diagnosis done between the antisocial behavior in the antisocial personality proper and all the other syndromes. So that it looks better than the situation is. So you have, unfortunately, you have to distrust statistics that show you improvement because it's not a pure selection of cases. But in cases with significant antisocial behavior, who have a syndrome of malignant narcissism, narcissistic personalities with antisocial behavior, all other kind of personality disorders with antisocial behavior, the prognosis is acceptable. And then you have to make sure that you stop the patient's antisocial behavior during the treatment. That's the commitment, that's the contract. Um, sometimes there are extremely difficult decisions because you can't really make the differential diagnosis accurately. And if you can't make the differential diagnosis accurately, and the patient's behavior is highly dangerous, it is preferable not to engage in the treatment of such a patient. I'm sorry to say that therapists should not be heroes, but realistically treat patients who can be treated. And I think it's an important limitation of our profession. Um, we have to accept inacceptable cases, and that sometimes we can't accept responsibility. One very important general rule is that the therapist has to feel safe and in control. First law of treating these extremely difficult patients, particularly with antisocial behavior, is that the therapist feels safe, physically safe, emotionally safe, socially safe, legally safe, not having to be afraid of the patient. The therapist has to do whatever he can so he is assured of not being afraid of the patient. If you are afraid of the patient, you shouldn't treat him. And second, whenever there is a threat to therapist and patient and other people, first law of the therapist, his own safety before the safety of the patient comes the safety of the therapist. It's like in the airplanes, if the oxygen mask falls, first you put it before your face, then the child. So this is the basic principle to because if you are not in control, and remember that all narcissistic pathology deals with patients who have need for extreme control and want to preserve their superiority. Let me give you, um, example. One of our patients was a man, homosexual, who used to seduce homosexuals from the Times Square area, very central area in New York City, and get them to a hotel, and there at gunpoint, rope them and leave. And usually this homosexual men didn't dare to to protest or call the police because of the semi-illegal quality of, uh, homosexual, published promiscuity or engagement in public places. So that patient had hypochondriacal symptoms and came to treatment, severely paranoid personality with antisocial features. And he was seen by one therapist who felt afraid of that therapist, of that patient. Asked him to give him his gum. The patient had all kind of explanations why couldn't give the gun. The therapist ended the treatment, sent him to another therapist. The patient gave that therapist the gun, but the therapist remained afraid of that patient. And we decided to recommend the patient not be treated through experienced therapists being afraid. The diagnosis wasn't their personality was that an antisocial personality of the rare schizoid paranoid features of the 10 of inhibited ones. Second example, we had a patient, HIV positive, huge understanding because HIV positive periphery, who would seduce children or very young adolescents to sex. Narcissistic personality with antisocial features and pedophilia. Condition for the treatment, he had to stop any engagement with a minor and had to stop any engagement in which he didn't wear a condom and warned the person with whom he was involved about his HIV status. And we just didn't trust that the patient was going to follow this instruction enough to be able to end to go to enter psychotherapeutic treatment. Again, we decided not to trade. Third case, a man who was a professional man, who was in a business, who whose father was in the business, a narcissistic personality with strong power features. He paid a criminal $10,000 to kill his father, and that was discovered. Legal authority, the criminal campaign, and the patient came to be examined by various institutions, and nobody could decide, was that an antisocial personality or or severely narcissistic personality? We examined the patient, and we couldn't decide either, and we decided that this was a patient who possibly was psychotic, but it would need long-term hospitalization to make video differential diagnosis, and it ended up in this way, and the criminal system was in agreement with that. I've given you all these are extreme cases, and I just wanted to mention them for you to keep in mind, be open to cases where you feel insecure enough of the diagnosis or of the capacity to control them, not engage in treatment. So clear limit setting, external control is necessary, and you believe that it can be carried out, assurance of the safety of the therapist, and then systematic working through of, uh, psychopathic transferences, dishonesty in the transference, and its function as a defense against underlying paranoid defenses. It is important to tolerate the intense negative countertransference that these patients produce, so that one doesn't get excessively paranoid in the countertransference, nor deny the severity of the situation. So you have to accept the patient is a human being that possibly can be helped, and you are willing to help without any illusion about the certainty of it.

One important antisocial feature is the use of sexual seduction as a way of destroying the treatment. This is an important aspect of violation of professional boundaries. You must be familiar with the fact that severely narcissistic therapists are tempted to get involved sexually with their patients. The large majority of involvement of therapists, sexual involvement of therapists with patients is a narcissistic therapists with misogynistic patients. It's more proportion are masochistic therapists with narcissistic patients who seduce the therapist, and the therapist becomes a victim of the patient's efforts to destroy the treatment. These are the cases where there is a risk of an erotic or an aggressive error decision in the transference. Sometimes it's so obvious and so infiltrated by aggression that it's really no danger for the therapist. I don't know whether I mentioned to you the case we have of Dr. Yeomans, one of our most experienced authors in setup is a patient who insists that she had to kiss him and throw off his shirt and start to kiss him while the video was running. That's what is not a sexual seduction for the patient who came to my session without, I think I mentioned, a patient without underwear. But there are cases that are much more subtle and effective, and where patients can create very destructive havoc. I mentioned to you, I think, my supervisee who was afraid that her narcissistic patient was a kind of man who she wouldn't be able to resist. The female in the body. We had one case of a narcissist, of a patient whom an examined, and I believed it was a narcissistic personality with severe features. This patient was treated by an experienced masochistic therapist. The patient started out the treatment in the hospital. She left the hospital, continued the treatment with the therapist, called him one night because she had terrible problems, um, and, um, in short, she managed to seduce him and got involved sexually with the therapist. This patient had a lesbian relationship with another woman. The patient, this patient committed suicide a few weeks later, left in her diary information aboard all the sexual interactions with the therapist, and send it to her lesbian friend who was enraged, of course, blamed the therapist, started the legal process. I was medical director of those times. We had to dismiss the therapists, reorganize the section. The entire hospital was internal. It was a terrible situation. You notice the patient ended up with suicide, but not before a massive destructive behavior. Those involved. So it is very important to watch that where men may become afraid heterosexual men of open homosexual provocation or effort and seduction in sessions. One of our patients in analysis, patient analysis with the male therapist, during the session, uh, hit an erection, took out his penis, and, um, and invited the therapist to try to be more directly helpful by touching him. And the therapist got extremely anxious, had difficulty continuing that case. So it was very, if you want to openly aggressive, but it was threatening. Okay.

I think I've told you enough about the problem in the treatment of patients with severe social behavior. Finally, some common challenges for therapists who treat narcissistic personalities. First, the lengthy stage of pathological grandiosity dominance. We have to be prepared to let patients try to dominate with their superiority and their dismissal of us for extended periods of time. It's difficult to tolerate it. It may create intense hatred in the countertransference. There's nothing wrong if you hate your patient, as long as it's a countertransference reaction that you're willing to explore to a point of resolution that permits you to use it for transparency interpretation rather than being controlled by it. It is important in all those cases to scan continuously what's going on in their external reality, because severe acting out may occur in other areas regarding love and sex, work and professional social life, and destructive destructivity in all those areas. And finally, these patients tend to have a destruction of time, by which I mean that the narcissistic grandiosity makes them feel that they are going to live eternally. Time doesn't pass by. They don't need to be concerned about aging, death. They'll keep themselves eternally the way they are. And they may communicate that in their behavior in the treatment, and see endless triumph of the therapists of a month and years as a sufficient life goal to continue in treatment. Treatment itself becomes a defense against changes in life. So one has to to watch that. I have a note here about the diagnosis in DSM-5. And it's basically all right in terms of stressing the impairment itself, functioning problems, and identity and self-direction, impairment in personal functioning, lack of empathy, lack of intimacy, and pathological personality, particularly grandiosity and attention seeking. But you can see that it's a very superficial description that misses the particular type of self-structure, the pathology of envy, the different types, the antisocial feature. But at least it recognizes for the first time subjective experiences part of the diagnosis of a personality disorder. For many many years, nobody give a damn about the subjective experience of these patients. And that in that regard, there has been improvement and progress. Thank you for your attention. [Applause] Time for some questions. Yes.

Um, yesterday you mentioned as well the lack of, like, a lack of empathy for self and others. Uh, and I just wondering how do you deal with that lack of empathy from the client for others or for themselves, like self-compassion or, or kind of empathy for self or others? The lack of empathy, yeah. The lack of empathy, yes. What about it? So I was wondering that you said that that would be a trade that you would see as well in clients that come and see you. So I was wondering how do you deal with that? How do you work with that? Well, the lack of empathy is a consequence of the internal destruction or unavailability of the internalization of significant others, a dismissal of others except as sources of animation and gratification. So you can't deal with that directly, but by analytically dissolving the pathological grandiosity and bringing out in the open the deep conflicts. So as a result of that, empathy can be restored. I mentioned that case who destroyed his marriage and had his wife have sex with five men, zero empathy, who is consequences of the treatment, retrospectively developed some understanding of her in the capacity for empathy, now that he understood what his problem had been and how it had destroyed his capacity to relate to people. So there is no direct treatment of lack of empathy, but you have to transform deeply that structures. It's a consequence of treatment. Yes, sir.

Um, I was wondering, you were talking about countertransference reactions, and one of those, um, things you were mentioning quite some several times today, yesterday, was that one had to tolerate one's own countertransference reaction. And as I've got it, um, that involves that one has to be quite honest with oneself, that the therapist has to be capable of seeing his own or her own reaction. So I was wondering, you mentioned supervision yesterday. I was wondering how is your take on on training therapy or training analysis? Yeah, I think that it is ideal when psychological psychotherapists have themselves an experience of psychological psychotherapy or psychoanalysis. It is not indispensable. There are some people who have a tremendous capacity for empathy and for psychological understanding and self-reflection. Other people have very little of it. People who have very little capacity for self-reflection certainly should have a.

period of psychologic psychotherapy or psychoanalysis other than that they won't be able to treat these patients. you raise a very important point, the need for the therapist to really acquire a self-awareness with exceeds that used in ordinary social life, and that requires ideally training in a psychotherapeutic experience or a personal analysis. not everybody needs it. there are some people who are excellent therapists without any treatment even in their lives. i have seen them, but men in majority really require that kind of experience.

yes sir. narcissism isn't exactly a word associated with a lot of positive emotions. if you have any tactical tips regarding how to deliver the diagnosis, how this patient should live with the diagnosis, communicating their diagnosis. i communicate to the patient what i think they are able to understand, um, and then very direct with patients. patients who have no psychological knowledge whatsoever, i tell them, i think you have a severe personality disorder. what's a personality disorder? it is a lack of a good integration of one's self-concept and serious difficulties in the understanding of other people, which seriously interferes with in demodulation, with work relation, with social life, and you need a treatment for that. that would be the simplest explanation. if somebody is in is a sophisticated said, okay, i have enough, i have imported personalities or what kind do i have? i ask the person what is i find out what is your knowledge about personality disorders and if the, let's say it is a, it is a psychologist to say, so what diagnosis do i have? i tell him, if you had a patient with such and such and such characteristics, what's your diagnosis? and it was a, that's a narcissistic personality. i said, i agree. so i adjust, but i try to be as honest as i can within the knowledge of to avoid that what i'm saying is misinterpreted in some conventional direction.

other questions? yes, just just a question interpretation, um, because as i understand your interpretation would be the main tool to deal with what is happening in the interaction. so i was thinking when a patient has sort of a tendency of kind of sadistic ways of putting down the therapist, or for example, shifts a lot between some degree affectionate feelings and then trying to strike the therapist, hurt the therapist. how how would you interpret that or what kind of interventions do they use to deal with that? i don't think it's such a broad answer so that the patient can be very friendly and then all of a sudden he hits out and becomes very aggressive. yes, one affectionate and then yes, yeah. well, i would point out to the patient that he has shifted from one extreme to the other. what's the reason? what's going on? by saying what is he angry about? what's what's the fantasy the patient has about what's going on with the therapy? what makes him aim with the therapist? what's on his mind? if the patient was very friendly and then he has to hit the therapist, he may feel the therapist feels superior because he likes the therapist and he has to tell the therapist that's not at all true. he wants patient may feel guilty over being so friendly and then try to rule the relationship because it doesn't. they are very good for 10 different reasons. i i just confront the patient with something that doesn't make sense and invite him to think about that and and to to think about what it implies and particularly what it implies and what's going on between the two of us.

yes, um, i have another question concerning, um, session frequency. you were saying that the the transference analyzer based treatment has twice a week sessions. um, i was always of the impression that the more severe the patient is, um, the more it would be recommended to go up in frequency. what is your take on that? like increasing number of sessions per week. um, i think that treatment can be carried out two or three times a week. um, the most severe cases can also be treated twice a week with transference focused psychotherapy. in general, increase of the frequency of sessions is not necessary. i'm aware that there's a tendency to do that, but very often what happens is that one increases frequency of sessions in patients who destroy everything they get in the session. so one increases the frequency to compensate for that and rather doing that, better to interpret the destructive effects, the the of the patient's transferences. so we always are interested what happens after the session, with what the patient learned in the session, what is the patient doing, if anything, with narcissistic pathology, particularly what remains and what consequences does it have. and so dealing with self-destructive devaluation of the session is very important in such cases. there are some cases where an increase of frequency to free session which might be helpful, not more than that. the cases where patient says, i had to see this patient six times a week, that hasn't been handled right regarding psychoanalysis, by the way, you know, this psychoanalysts fight among each other. what's the ideal frequency? the french say three times a week, the americans four times a week, the british five times a week. i think that there is no real empirical study practically, and this is the conclusion that now the international psychological association is coming to. psychoanalysis can be carried out between three and five sessions. the ordinary, the usual case, free session is sufficient. narcissistic pathology in analysis, four sessions a week. in alternative patients who can't come forward, they live too far, it's to have two double sessions may be sufficient. excellent for both tfp and psychoanalysis. when there's distance or other difficulties, it is not orthodox, but it's done more and more, particularly in enormous countries where patients to get to therapists have enormous distances. in brazil, the distance is just extraordinary.

uh, i think it is three o'clock and we should stop. i appreciate your interest and attention and this has been a pleasure. honey, dr kernberg, we just want to, as a thank you for this amazing two days, uh, with the extreme richness and clarity, we just want to give you a little something to thank you. and we also look forward to learning more about your personality this evening. thank you very much. [Applause] hmm.