Devaluation, Transference, Narcissism with Diana Diamond

In this episode, Dr. David Puder is joined by world-renowned psychologist Diana Diamond, PhD to explore devaluation, narcissism, attachment, and transference in psychotherapy. Together they examine why patients with narcissistic personality traits or narcissistic personality disorder (NPD) often devalue their therapists, how dismissing and disorganized attachment styles shape treatment, and why these cycles can be so painful for clinicians. Dr. Diamond shares clinical insights from Transference-Focused Psychotherapy (TFP), including how to recognize subtle and overt devaluation, how to hold boundaries, how to think psychodynamically about these behaviors, and how to respond without reenacting the patient's internal object relations. The discussion also highlights the role of trauma, reflective functioning, countertransference, and the deeper tragedy of pathological narcissism. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-250-devaluation-transference-narcissism-with-diana-diamond Link to YouTube video https://www.youtube.com/watch?v=oy-2eDCZaQY

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  Welcome back to the podcast. I am joined today with Diana Diamond. She is an amazing author who has written a book called Treating Pathological Narcissism with Transference-Focused Psychotherapy. She is also the first author on some really amazing articles like Attachment and Mentalization in Females with Comorbid Narcissistic and Borderline Personality Disorder, and also the first author of another great paper called Patient Therapist Attachment in the Treatment of Borderline Personality Disorder. She is truly a world expert in narcissism, borderline personality disorder,

• 0:53David Puder?

  transference-focused therapy, and I've heard about her for years, and it's great to finally meet you.

• 1:01Speaker 01

  Thank you so much, David, and thanks for inviting me to be on this podcast. I guess it's been very gratifying, the reception that the book has gotten. And I, you know, I spent five years writing it, some of which were the COVID years, and I was kind of like a monk in a medieval monastery, you know, I didn't have much contact with the world, and then, except my group, my co-authors, we kind of formed a pod, and that, it was really, I kind of miss it, you know, that time of just reflecting and thinking and talking about patients and writing. Then, of course, you send the book out into the world, and you have no idea

• 1:44Speaker 01

  what kind of reception it's going to get, and I think because it was written during the COVID years, that was doubly isolating. So it's been very gratifying that people have been so interested in it, and it's currently being translated into eight languages, which is also a big surprise. And interestingly enough, some of those languages are from countries like, I'm not going to put a label on them, but China. Iran and Turkey that have very different governments from what we have. And you know, there is a chapter on malignant narcissism in leaders and groups.

• 2:22David Puder?

  Hmm.

• 2:23Speaker 01

  So that's been very, very gratifying that people have written from those countries and said, this has been very useful to us. Okay, that's a long answer to a short question.

• 2:32David Puder?

  Right, and maybe we should put the caveat that all cultures and all countries have malignant narcissists, right? And I, I, I'm actually very gratified when this, when this podcast and these episodes go out to people in other countries too, and I get messages from, you know, people around the world. I was watching an interview where you had multiple questions from places like Iran and Egypt, and how wonderful for that sort of reach with ideas. And there's so many, so many lessons. I wanted to focus our time actually on one little area because I feel like I may have you back a couple of times and I was thinking about devaluation specifically.

• 3:13David Puder?

  And I almost feel like we could use that as kind of like a way of talking about multiple things. But you know, this podcast does go out to mostly mental health professionals, people in practice, therapists, psychiatrists, nurse practitioners, PAs. There's also other types of physicians as well. And I, I think, when I think about devaluation, and I, I think that it can be a uniquely painful thing that kind of sticks with the provider. Like, there's a couple of patients in my mind even as I'm thinking about this topic, where it's like, there's kind of this residue of this chronic devaluation that's happened towards me from them, that's subtle, that's insidious.

• 3:57David Puder?

  Anyways, do you want to kind of open up that topic and how it's linked to some of the things that you've written about?

• 4:03Speaker 01

  I would say that that is a very apt place to start and also to focus. Because that is one of the single most difficult things about treating these patients. And Otto Kernberg has a wonderful quote about that. The gist of it is that the single greatest challenging task in treating narcissistic patients is not to devalue the patient in response to their devaluation of you. And to be able to sit with that and hold that and work with that. And it often comes up again and again and again. It's not resolved necessarily in the earlier phases of treatment.

• 4:45Speaker 01

  And that's what makes, one of the things that makes treating these patients so incredibly challenging. It remains a primary defense. And there's a lot of reasons for that. But it's a primary defense that lasts well into even the later stages of treatment. Even into the termination phase, you can have devaluation of the treatment. What they expected, they didn't have the gains they wanted. And that has to be worked through. Now, that's not true of all patients. But it is, I think, the single most challenging issue. Do you want me to speak a little bit about where?

• 5:22David Puder?

  Maybe just to kind of give some, just some visceralness to this. Does any specific examples come to your mind of devaluation? Where you felt very devalued? Where it was hard for you? Where maybe you even saw it like supervision? Or you saw it like, I need to like, talk to some other providers about this?

• 5:41Speaker 01

  Yes. I mean, I just have to be careful about confidentiality, but.

• 5:45David Puder?

  I have the same fear. Like, I was, I'm even thinking like, like some examples, like, I know, like, what if, what if my patient were to listen to this? And then they were to feel, like, what would they feel towards me in knowing that I brought up their specific example? Like, would I get further devaluation? And would that even be worse? You know?

• 6:09Speaker 01

  Well, I can give you a general example of something that, you know, was going on with a patient I'm currently treating. And that is that.

• 6:20Speaker 01

  Let's call it a she, and she often tells me how much better she is. And she was so paralyzed, unable, she's a musician. And she was unable to perform in her graduate musical training because she was so self-conscious, also felt she wasn't getting the kind of exposure from her, the faculty that she expected. So she kind of retreated and also had tremendous envy of any of her co, her fellow students. They'll, they were getting more adulation, et cetera, et cetera.

• 7:01Speaker 01

  So a lot of the work was overcoming that sense of narcissistic injury, her sense of paralysis, her withdrawal, you know, from the world, which often happens with narcissistic patients. And that's an underestimated issue. But as she began to get better and began to be able to perform again and began to work through the envy, the sense of narcissistic vulnerability and so on. She would say to me, you know, I'm much, much better, but it, it doesn't have anything to do with the therapy. It's, it's really about the fact that I was able to go out and start performing again. And now I'm getting a lot of adulation that I had sought and so on.

• 7:42Speaker 01

  And so there's a kind of both, sometimes quite overt, as in that case, where the patient will, as they begin to get better, not be able to give any credit to the therapy. Um, that of course is very demoralizing for the therapist, even though you know that the therapy has helped them tremendously. And then, of course, that has to be taken up in terms of their object relations. Why does there always have to be someone who's superior, someone who's inferior? Because that's how we think in TFP. We think in terms of what is the dominant object relation that is being activated right now in the transference? So I find that very containing

• 8:24Speaker 01

  in terms of thinking about, now, why would this person need to devalue me at this particular moment? And let's talk about that and let's use it as an opportunity for understanding their internal world of self and other representations. And often the devaluation is a way into that, but it comes up over and over and over again. And You know, I think the other, so that's one example. The other thing is you get more kind of subtle devaluation. So the patient will set up almost like an adjunct of therapy. They'll say, well, you know, I have lunch with my best friend every week. And he or she is so insightful.

• 9:07Speaker 01

  And I learned so much from those discussions. Or I have a new trainer. And that person is really just, you know, I feel so salutary, so helpful for me. And you know that this is being set up as a kind of alternative therapy, therapeutic relationship. Or they will, they will say, you know, sometimes I think about my former therapist and I'm in dialogue with my former therapist, as though you don't really count. There are all kinds of subtle forms of devaluation that go on.

• 9:40David Puder?

  Or, or maybe like something like, um, you know, I read this new self-help book. And I feel like this has really made the difference for me.

• 9:48Speaker 01

  Yes.

• 9:48David Puder?

  And maybe it has helped to some degree, but like, how would that be different? How would we know it's devaluing? I mean, I think also like, we don't want to err on the side of like imagining devaluation when there's not devaluation, right?

• 10:04Speaker 01

  Yes, and that's a very good point because, you know, sometimes we're not as effective as we like to be. And sometimes the person is getting a great deal from talking to their friend or their trainer or, you know, um, sometimes it's, it's, if they're on medication, it's the psychopharmacologist, right? So one has to give that credence. One has to accept that that actually, you know, is helpful for them. The way I approach that is usually through clarification. Well, tell me what is particularly helpful there? And what is it about that person? And I don't immediately go into it as a devaluing comment.

• 10:47Speaker 01

  You want to know more about what is it about this other relationship? Or this other connection that's they're finding so salutary? But the bottom line is, these patients do feel that they have to do it and want to do it all by themselves. And in the beginning, you are a sounding board, for the most part. And they will, they will either reject or incorporate your interpretations, which is another form of devaluation. By that, I mean, when you make an interpretation, they will come back either in the same session or the following week, or they're in, in close proximity to tell you the very thing that you said to them, as though it came from them. It's a way of incorporating.

• 11:33Speaker 01

  We have to remember that interjection incorporation is a defense. It's a way of, you know, of withdrawing from the relationship. So we have to really think about why these patients need to do that.

• 11:48David Puder?

  Yeah, yeah. What about like, if you've ever had a patient, when you start giving an interpretation, they almost like dissociate, they almost like, it's like, the words don't even really register. You know what I mean? And then they're like talking at you. And then, you know what I mean? It's like their, their ideas are supreme. When you start talking, they kind of like almost go hazy or feel disconnected or separate. Like, is that kind of another form of this?

• 12:18Speaker 01

  That's another form of that. And I think that brings up something I know you're interested in, which is attachment.

• 12:25David Puder?

  Yes.

• 12:25Speaker 01

  Many narcissistic patients, not all, but many of them have what we call dismissing attachment. And those who have dismissing attachment. Really, you know, focus on their own strengths. They fear vulnerability. They avoid vulnerability at all costs. They avoid dependency. They have a sort of cool contemptuous attitude toward attachment. They often have lack of memory for their early attachment experiences. This is when they're given the Adult Attachment Interview, which is a 20-question semi-clinical interview about early attachment experiences and their relationships. And so they tend to not be able to remember very much

• 13:09Speaker 01

  or to give you very canned, idealized views of their attachment history, but often very truncated. And you realize that at some point, these are individuals who turned away from attachment figures. And they form these very strong defenses. And so I think when there's the give and take, therapy obviously challenges that because it's a relationship. There's a given tape between therapist and patient. They have a very, very difficult tone with that. So it activates their dismissing devaluation of relationships.

• 13:47David Puder?

  Hmm. But I was actually, I have that page turned open in my thing. And this section alone, it's worth, it's worth getting the book to read. This, this, this chapter on, where you go through the dismissing attachment style and then how the research on that. And it's, you know, for a long time, I was like, why do they call it dismissing? Because I, I think avoidant makes just so much more sense to me, right? Like, the child is left alone in a room at one and a half years of age. Mother comes back. The child doesn't show re-engagement with the mother. The child continues to play with toys. But the child is stressed. The child's cortisol is elevated.

• 14:29David Puder?

  The child's, you know, stressed out in the, in the mother's absence. But I like dismissing because it's the words of, that they use to negate the importance of attachment. And And but the but the the anxiety, the stress is still there. It's just like hidden.

• 14:51Speaker 01

  Yes, exactly. We just are finishing a study of fifty-two borderline patients in transplants-focused psychotherapy. And my part of the study was to give the adult attachment interview at the beginning of treatment and after eighteen months of TFP. And we're just looking at the data of this now. It's really, I don't want to go into a long thing about the research, but it's really fascinating. Because some of the most disturbed patients, those who have malignant narcissism at the beginning of treatment, which means that they have a grandiose self that is infiltrated with paranoia, antisocial features, and a lot of egosentonic aggression.

• 15:32Speaker 01

  And those individuals actually have, they can look very disorganized. They have lack of resolution of loss and trauma at the beginning of treatment, so their major classification is disorganized. But actually, after eighteen months, some of them look dismissing. So be careful with dismissing, because dismissing can also show the development of better defenses. And they tend to, instead of, you know, focusing on traumatic experiences and becoming disorganized, or being preoccupied with those experiences in a very disorganized way,

• 16:14Speaker 01

  they actually then can talk about their attachment figures in an idealized way. And for those patients to become dismissing shows better defensive structure. So we have to, dismissing can mean very different things at different points in the treatment, and depending on how severely disturbed the patient is. Generally, we find that people who have dismissing attachment do have better working defenses, better capacity for repression as opposed to splitting. And so one has to be careful about assuming that this is always negative. Does that make sense?

• 16:54David Puder?

  Yeah, yeah, absolutely, absolutely. And I'm wondering if the the reflective function is another way of kind of seeing the nuance in this. Like, are you measuring reflective function before and after? How is that shifting in your new study?

• 17:10Speaker 01

  I wish I could tell you that, but I mean, I can tell you based on a very small group of cases that I've looked at, those cases with malignant narcissism, but we're actually having a meeting today to go over the larger study findings. All I know from the statisticians is the reflective functioning is improving in our patients, but I don't know exactly how much. But I can tell you, based on these cases, these two cases I looked at who have malignant narcissism, at the beginning of treatment, their reflective functioning goes up substantially by 18 months.

• 17:46David Puder?

  Wow.

• 17:47Speaker 01

  To the near ordinary or above ordinary level. So I think this is a very good point because their capacity for mentalization, for understanding and imagining the thoughts, feelings, conflicts, motivations of themselves and others is improving, even though they might have, still have dismissing attachment, which is still insecure, but it's organized attachment. Does that make sense?

• 18:13David Puder?

  Right, right, right. Yeah, I, I like the word disorganized attachment. It's not used in the AAI. They use, they use like unclassified, they used unresolved. I wish they used disorganized as a kind of a continuation of the, you know, infant attachment studies. Why do you think they, they've changed the word? Why do you think it's different?

• 18:38Speaker 01

  Well, let, let me just clarify something about the AI, which is important. There's insecure attachment and there's secure attachment. Insecure is dismissing, preoccupied, and lack of resolution of loss and trauma. Okay? So those are the three insecure categories. Then, of course, there's secure. So those insecure categories and secure. But there's another way of looking at the AI, which is the organized categories versus the disorganized. And the disorganized categories are lack of resolution of loss and trauma, or what we call cannot classify, where the individual cannot mobilize any consistent attachment strategy.

• 19:22Speaker 01

  They ricochet between, say, being dismissing, idealizing.

• 19:28Speaker 01

  Cutting off all discussion of attachment, having lack of recall for early experiences of attachment, or on one hand, or being preoccupied, that is, they get very caught up in involving anger, current involving anger at attachment figures. So they're going back and forth between those two positions. And that's called, both that and lack of resolution of loss and trauma are called disorganized. So you have the disorganized categories, and then you have organized, which is dismissing and preoccupied and secure. And so if you look at it that way, individuals who move from being disorganized to organized, that's an advance.

• 20:09David Puder?

  That's a big advance, yeah.

• 20:11Speaker 01

  It's a big advance, yes. I know that's kind of a technical thing. Do you have any other questions about that?

• 20:16David Puder?

  Um, no, I think, I think, I want to get back to this kind of like idea of devaluation. And does someone with a different attachment styles devalue in different ways? Does someone with, for example, more of a disorganized attachment style devalue in a different way than a dismissing or a preoccupied?

• 20:39Speaker 01

  Yeah, it's a really interesting question. You know, I think the dismissing devaluation is more what the example I just gave. I'm much better, but it has nothing to do with our therapy.

• 20:53David Puder?

  Mm-hmm.

• 20:53Speaker 01

  Or, you know, I, I don't want to hurt your feelings, but it's not really about our therapy. It's about the fact that I was performing more, that I'm getting a lot of adulation for that, that I feel more confident. But the therapy hasn't had that much to do with it.

• 21:11David Puder?

  Hmm.

• 21:12Speaker 01

  So that's more the dismissing devaluation. I would say devaluation from a preoccupied patient, I, I think you're right, I think is a little bit different. And I think that would take more the form of a kind of angry vituperation. You haven't done anything for me. I've been coming here twice a week, paying you all this money. Therapy's been a waste of time. You know, I'm still having tremendous difficulties, you know, with my boyfriend. And now I think we're gonna break up. And so I don't know why I've been in this treatment. So periodic, you know, really trashing the therapist and the therapy.

• 21:55Speaker 01

  And blaming everything that's wrong in their life on or expecting, you know, a kind of perfect cure and being enraged when that doesn't happen. And so, and threats to quit, often all missing sessions, so it's more acted out in the person who's preoccupied. Often with with those individuals, you also get what we call a paranoid transference. So they not only are devaluing the treatment, but they're fearful that the the treatment could be harming them or might harm them. And because that's part of their internal world.

• 22:40Speaker 01

  Now, I know that the relational analysts will say, okay, but there's always co-construction. The therapist always makes some contribution, and I agree with that. I agree with that. I think we have to be very, very careful to always be examining our counter-transference, our capacity to stay empathically connected to the patient, no matter what they're bringing to us. We can get into that in a minute. And that's very difficult with narcissistic patients. But on the other hand, these patients have such a maladaptive set of internalized self and object representations that it often will override any situation.

• 23:22Speaker 01

  And also particularly in therapy, which is, you know, over time, where one develops, you know, a a relationship with the patient. So the therapist is going to get Those self and object representations are going to emerge in very powerful ways. And one has to to accept that and be prepared for it and hold those projections until the patient can tolerate examining them and exploring them and looking at them. And we have certain techniques for doing that. But the main thing is to accept what's happening at the affective level in the here and now. So that's the preoccupied patient.

• 24:06Speaker 01

  The disorganized patient who has lack of resolution of loss and trauma can also devalue the therapist. And it will very much, you know, when they have that classification of unresolved, they always get a next best spitting. So they're unresolved dismissing, unresolved preoccupied, or you can be unresolved secure. And that's very interesting. You can have lack of resolution of loss and trauma, but still have secure attachment, interestingly enough. And that just means that in the questions about trauma and loss, the person becomes disorganized in their linguistic, their capacity to give a coherent view of what happened.

• 24:49Speaker 01

  Because lack of resolution of loss and trauma is not about whether the person experienced trauma or abuse. It's whether they can talk about it coherently, whether they've put it in perspective, whether it disorganizes them in the current situation. And so in those situations, when somebody, say, is has lack of resolution of loss and trauma, but they actually have secure attachment, often that will come out in the treatment, again, with distrust of the therapist, fearfulness of the therapist, or fear of loss of the therapist. And and the devaluation could take that form as well.

• 25:33David Puder?

  So when when someone devalues you like when when are you gonna like bring that out into the open and what do you say and is that different I guess you know I imagine it's different for different patients different like where they are in the treatment but I'm curious like how you do that.

• 26:00Speaker 01

  Okay, I'm gonna give you a bit more of an extended case example now.

• 26:05David Puder?

  Okay.

• 26:06Speaker 01

  Answer that question because it's it's it doesn't you have to kind of understand a little bit more about the process, right? And that will make it make it clear, I think, how when and how we we addressed evaluation. So this is a case actually from the book. So I don't have to worry so much about confidentiality, but because that person signed a release form and it's very well disguised. But this is a patient I was treating and he came to treatment, he'd had a very long analysis. And the analysis was very helpful in terms of him stealing with certain anxieties. He had tremendous performance anxiety. He

• 26:45Speaker 01

  was highly placed in an architectural firm and he was a partner and he had to go make presentations to international clients. He would get very anxious. The analysis was very helpful for him. He became got promoted to partnership, did very well. He was in a relationship with a woman that he had met. She was from a different culture and they were living together for a long time. But he chose her because she made him feel safe and she was from a different social class, not as well educated. But over time, he began to devalue her. Now, we did what we do find, by the way, initially, he idealized her was

• 27:30Speaker 01

  very sexually attracted to her. But over time, he felt she didn't really measure up. And he couldn't decide whether he should stay in that relationship or leave it. In the meantime, he was having relationships with women online. And um which she didn't know about. So the presenting problem, he was referred to me by the analyst. And the presenting problem was he's so much better in every respect. But he can't leave this relationship. Now, I always get very suspicious when there was like one thing being presented because he was so much better. He'd be able to do that on his own, right? So I agreed to take him on for TFP.

• 28:13Speaker 01

  And it's not unusual for a very narcissistic, grandiose manifestation of narcissism, patient with grandiose narcissism, to be in a relationship with someone they devalue. And they feel stuck in that relationship because they project the devalued part of themselves onto the other.

• 28:33David Puder?

  Hmm.

• 28:34Speaker 01

  And that holds the devalued part of themselves. And so they can't understand why they can't leave. But that's because that's projection. When one projects an aspect of one's own experience that one dreads and is trying to get rid of onto the other. That other holds a part of the self, it's not so easy to separate. So it was pretty clear to me early on in the treatment that this is what was going on. And, you know, he came in saying, I've had a long analysis. I don't really, I just want to deal with this one thing. This one thing about whether I should leave my, my relationship. So I said, okay, well, let's give it a try. Usually I tell patients that TFP, they could commit for a year.

• 29:17Speaker 01

  That our research, this, we're doing research on this is very useful. Our research shows that there's real change after a year.

• 29:25David Puder?

  Yeah.

• 29:25Speaker 01

  Um, so I can't, you know, they don't have to sign on the dotted line, but we make a contract that they will, you know, try to see the treatment through if they feel like quitting, they'll come in. Okay, so this patient chronically devalued the treatment in the first two or three months. Would evaluate every intervention or observation I made. This session was good on interpretation, but not so good on empathy. You know, and so

• 29:55David Puder?

  Wow.

• 29:56Speaker 01

  He'd read a lot. And, um, and he would sometimes say it sort of in an off the cuff way as he was walking out. Well, that interpretation actually was very helpful to me. But you know, I didn't feel that you were so connected to me emotionally in this session. So it was like always, always a kind of evaluation.

• 30:16David Puder?

  Interesting, interesting on the way out the door, right? As well, because that, I mean, for me, when I hear that, it's like, man, maybe it's like painful to leave. There's something about it's so painful to leave that you might, it might be easier to get angry at me while you leave. Or to, to, to be unsatisfied or to, as, as, as a kind of way of coping with the distress of leaving.

• 30:40Speaker 01

  I think that's a really, really good point because this person did have trouble leaving. But I think it's also about reasserting his superiority.

• 30:51David Puder?

  Oh, okay. And I, I, I don't want to devalue your thousands of moments of this with this particular person. You probably know him a lot better than I, I do, of, of, obviously. Yeah. Okay. So the superiority was kind of being exerted of like intellectual, psychological mindedness.

• 31:11Speaker 01

  Exactly.

• 31:12David Puder?

  Okay.

• 31:12Speaker 01

  Right. And that just to make sure that I knew that, you know, that he had his own sort of tape going on of evaluating the treatment, right? And so this went on for, you know, I'd say the first two or three months of treatment. And then I actually was feeling kind of restless. Like, you know, this treatment isn't taking off. And maybe it was just hubris to think that I could treat someone who'd had this long analysis and really make headway in this. And so I made an interpretation and the interpretation, well, it was the first major interpretation that I made. He came in.

• 31:56Speaker 01

  He was talking about the woman he'd met online. He'd met a particular woman, was trying to decide, should he actually meet her in person? Should he actually venture out and try to have a real relationship with her? Not just a virtual relationship. And I said to him, it seemed to me that that was the conflict. The conflict was not between two women, his long-term partner and this person he'd met online, but it was whether he wanted to have a real relationship in depth with somebody versus staying sequestered in a fantasy world. And he said to me, wow, I think that really makes sense. I'll have to think about that.

• 32:36Speaker 01

  And then he came to the next session and said he was thinking of leaving treatment. In fact, and this is an interesting thing about your point about leaving, he came early to the next session. And he knocked on the door to let me know he was there, but I was with another patient. He came early in the morning, but I was at a very early session that day. And so, you know, I told him I was with another patient. We still had another five minutes. Then he came in and he was just bursting at the seams to tell me that he was going to quit treatment. And I was so confused because I thought we had gotten somewhere.

• 33:12David Puder?

  Ah.

• 33:14Speaker 01

  And so I thought, why, why now? Why, why is he going to quit now, just when we're starting to make progress? And, um, and so I, I held on to that. And I basically just said, made a comment about the non-verbal. I said, well, I understand that you want to leave and we'll talk about that. But, you know, it seems interesting to me that you came early to tell me that. So maybe there's part of you that really wanted to come to the session and talk about what's going on. So let's try to understand this. And then, as the session went on, he said, told me I had missed something very important in the last session. That I hadn't understood that his girlfriend was actually beginning to push him away.

• 33:59Speaker 01

  And he was quite anxious about that. And instead, I'd focused on this conflict that he has about a real relationship versus a fantasy relationship. And I said, well, fair enough, you know, I did remember him mentioning that earlier in the session. Before he was obsessing about the girlfriend that he'd met online. I said, well, fair enough, you know, I'll have to really think about that. Um, why I didn't pick up on that and necessarily explore that, and that's something we can talk about today. Now, this is very important. It, it sounds like a minor thing, but one has to be willing to accept the projection. One has to be willing to also acknowledge one's own, um, uh, you can call them technical.

• 34:44David Puder?

  Culpability, right? Culpability, like.

• 34:48Speaker 01

  And so I acknowledged, yes, that could be the case. That I didn't hear the distress that he was expressing, because he mentioned it in a very matter-of-fact way. Um, and without much affect, uh, that she was visiting, the girlfriend was visiting her family and she hadn't gotten back to him and he was getting very anxious about. Okay, so we, we talked about that and I said to him, it must be very difficult to have a therapist. Who didn't hear your distress. Now, this is called a therapist-centered interpretation. So we really focus on the immediate affect that the person is feeling towards the object.

• 35:31Speaker 01

  Whether it's the therapist or somebody else, and validate that that must be very difficult and very painful. To have a therapist who didn't hear his distress. And so if he, and perhaps that was similar to how he was feeling with the girlfriend. That she was pushing him away and he felt in some way pushed away by me, the therapist as well. And so that's something that he's very vulnerable to. And then I said, you know. When feels rejected or he feels not attended to, it just, you know.

• 36:06Speaker 01

  arouses all these feelings and no wonder he came in and said he wanted to quit. Perhaps that had something to do with it. And then it was a very long silence and he turned away from me. And he turned and I thought to myself, well, this is the moment when he's going to tell me that he's going to quit. And, you know, I gave it my best shot. And but he, when he turned back, he said to me, well,

• 36:33Speaker 01

  I was very anxious about coming today because I have to do a major presentation this morning. And I'm really worried that I'm not going to do a good job. And I really wanted to talk to you about that. But I felt since you missed this important thing last week, that maybe you wouldn't be able to hear me.

• 36:53David Puder?

  Hmm.

• 36:53Speaker 01

  I realized that that's the moment when the treatment began. When the treatment really took off. And then I said to him, you know, it sounds like you're telling me that you felt really vulnerable. And you felt, you know, exposed and fearful that I wouldn't be able to hear that, that I would dismiss that. And so instead you came in and you said you wanted to dismiss me. And, um, and, and, and, you know, fire me as a therapist. And then what we wound up in that session was talking about how that seemed to be the way his relationships went. That there was always a superior one, always an inferior one.

• 37:37Speaker 01

  Somebody who was humiliating someone or who felt humiliated. And he had felt humiliated by me. And so he came in and said, I'm going to quit treatment. And that's when the treatment took off. So does that begin to address the issue about how do you address devaluation? You address it by getting into the internalized object relation that it's connected to. And trying to help the person see, and this is the beauty of the object relations model. Is there's a self-representation, the one who's being rejected. And there's an object representation, the one who's doing the rejecting. Let's just stay with that particular representation and a linking affect of distress.

• 38:23Speaker 01

  Or fear or anger about it. And you try to show the person that that is an object relation that exists as a model in their mind. And sometimes they live out one side of it and other times they live out the other side of it. And that's most effectively done when you have an in vivo situation like that with where it's alive in the transference and you can work with it.

• 38:50David Puder?

  One thing that occurs to me is kind of you are also a real person to this, but you could have been at the beginning of treatment, a fantasy. Oh, here you are, an expert, many books, many, with high respect from this analyst that referred, right? And so you're kind of in this idealized place, which is kind of a fantasy, right, of sorts. And then by saying to him, you know, this is really a conflict between, do you want to live in a fantasy versus a real relationship?

• 39:31David Puder?

  And there was something about that and maybe also missing this other piece that he said, right? Like, you're not perfectly attuning to every bit of his distress that popped him out of that fantasy model with you into a real relationship.

• 39:49Speaker 01

  Yes. It made me a real person and a person who was fallible, right? And who also could hold that imperfection. I mean, this is very hard for narcissistic patients. They either highly idealize you, or of course, the side of that is a devaluation. And so for you to say, hey, I can acknowledge, maybe I missed something. You know, I'm imperfect. I'm not that idealized figure.

• 40:20Speaker 01

  Or I can acknowledge that but not feel incredibly distressed or, you know, devalued. This is very important for them, that they can see you model for them, that you can have imperfection and still go on with the relationship or whatever. And, you know, this person was highly perfectionistic, highly self-critical. I mean, there are no patients, in my experience, who are more self-critical than narcissistic patients. Yes, they devalue others and they are severely critical of others. But when they turn that on themselves, they can be absolutely scathingly devalued. And, I mean, to the point of self-annihilation.

• 41:06David Puder?

  Mm-hmm.

• 41:06Speaker 01

  Or we have to think about that part of narcissistic pathology. And that, of course, is in the myth of narcissus.

• 41:16David Puder?

  Hmm, tell me. I know you wanted to maybe read this, so.

• 41:21Speaker 01

  Yeah, I mean, I can read you just one passage.

• 41:24David Puder?

  Let's go, yeah, I love it.

• 41:25Speaker 01

  Narcissus, and it's from the Ted Hughes translation.

• 41:29David Puder?

  Okay.

• 41:30Speaker 01

  And by the way, it's interesting, there's different versions of the myth, but I'll go into that in a minute. So, uh, and you all know the myth of narcissus, right? And it's, uh, narcissus was the son of, it's very interesting, actually. The son of a nymph and the river god. And the river god raped the nymph, which is really very interesting. So narcissus was the product of a traumatic experience. And people rarely talk about that, but you know, there's a lot of interesting material now about, um, trauma and narcissism. And in fact, we know that if you look at the histories of these individuals, quite a few of them have a particular kind of abuse.

• 42:14Speaker 01

  It's, it's not so much sexual and physical abuse, it's emotional abuse and, and, and neglect.

• 42:22David Puder?

  Oh.

• 42:22Speaker 01

  So.

• 42:23David Puder?

  And what's like, is there any unique identifiers of the type of emotional abuse, would you say?

• 42:30Speaker 01

  Yes, um, I, yes, there is. Uh, parental, using the child as an extension of themselves. I mean, basically, investing their own narcissism in the child where the child's real self is overlooked and their real need for nurturance, and they become a narcissistic complement to the parent. And I mean, it's it's kind of a, not not to move to popular culture, but you see, for example, in Succession, if you know that mini-series, so you see a patriarch whose children were just narcissistic extensions of himself.

• 43:09David Puder?

  Hmm.

• 43:10Speaker 01

  Had very little sense of them as real people. So there's the over-involvement, but in the context of using the child as a narcissistic extension itself, sometimes there's just rejection.

• 43:23David Puder?

  Hmm.

• 43:24Speaker 01

  Cold, um, coldness, lack of warmth, um, not so much, that's the opposite of over-involvement, under-involvement. And, you know, I mean, I've had patients whose, one patient whose mother was severely narcissistic, would have tea parties and and entertain her friends where, as a child, the patient was left outside in a wet diaper just to run around on her own, or left alone in the house while the mother went out. Uh, so these are parents who can be quite neglectful, the physical and the emotional level.

• 44:05David Puder?

  Hmm.

• 44:07Speaker 01

  Anyway, let me just read you this passage, which is very short. But, so the myth of narcissus, so narcissus was the product of this, this, this rape, um, between, um, of the river guard and and and the nymph. And, um, he was particularly attractive. And, you know, as he got older... The river goddess, his mother was quite concerned about him and went to see a seer, the seer god, I think it was Thereseus, and said, "How will he fare in life? Will he be okay?" And Thereseus said, "He will be okay if he never comes to see himself." Because the mother was worried that he was so attractive

• 44:52Speaker 01

  that, you know, he would never be able to get beyond that. He said, "But if he never knows himself, he will be okay." So then, of course, we know that Narcissus had all these admirers, including Echo, who he kept spurning. And then there was one, there was one male admirer. And the male admirer was spurned by Narcissus, and he went to the god who does revenge. I'm sorry, I can't pronounce his name. And basically, what he said is, "We're going to give him a taste of his own medicine and know what it feels like to be spurned."

• 45:34Speaker 01

  So then Narcissus looks into the river, the pool, and sees himself. And he falls in love with his own image. So what's interesting about the myth is he falls in love with his own image, but in the beginning, he does not know that it's his image. He really, truly believes it's a being in the water, a separate being. So here's the lines from the myth. "He lay like a fallen garden statue, gaze fixed on his image in the water, comparing it to Bacchus or Apollo, falling deeper and deeper in love with what so many had loved so hopelessly. Not recognizing himself, he wanted only himself.

• 46:18Speaker 01

  He had chosen from all the faces he had ever seen only his own. He was himself the torturer, who now began his torture."

• 46:27David Puder?

  Hmm.

• 46:30Speaker 01

  He mistakes this image for a stranger who could make him happy. But it turns out, and he, there's all kinds of lines in the, in the, in the poem about, he couldn't believe the beauty of the eyes that gazed into his own. But then, of course, what happens is that he realizes after a period of time that he cannot grasp this other being, it is an image of himself, but this becomes a torture. And he winds up just collapsing on the riverbank, not eating, and he turns into the narcissus flower. Right? That's in one version of the myth. There's another version of the myth where he actually stabs himself in the breast and dies.

• 47:15Speaker 01

  And as he crosses into the river Sphinx, which is the river that, you know, separated the land of the living and the dead in Greek mythology, he continues to look himself, look, look for, for his image, still believing he can find that other. So I often say the myth expresses the tragic life course and the tragedy of narcissistic pathology. But I don't think we focus on enough. We focus on the grandiosity of these patients, how we know that this, of all the personality disorders, we know that narcissistic personality disorder is the personality disorder that most harms other people

• 47:56Speaker 01

  or distresses other people around them. There have been studies in social psychology of this, even more than borderline patients. So we know it's the people around the narcissistic patient who are distressed. Feel it more often than the narcissist themselves, but narcissistic personalities have, have, you know, a rate of completed suicides greater than that of borderline patients. So they can be very self annihilation, annihilating, very self abnegating. And so you see in the myth. All these kinds of things that we know about narcissism.

• 48:37Speaker 01

  You see the exaltation of the self and then the plunge into paralyzing states of rage and shame and loss when the narcissistic illusions are shattered. And the extent to which the self-exaltation or self-aggrandizement that you see in the grandio states often can be accompanied by states of severe disappointment, self-criticism, even self-torture and self-destruction.

• 49:05David Puder?

  Yeah. Powerful. Powerful. I am cognizant of the time and you have an appointment in like five minutes and I wanted to give you a little bit of a break. I want to fully value your expertise and I really have appreciated hearing all of this and I want to continue this conversation ideally in the future and so maybe we'll do a part two. Not Too Long in the Distance.

• 49:32Speaker 01

  Sounds good. Very happy to do that.

• 49:35David Puder?

  Yeah, there's like so much to go into and it's like, it's exciting to meet you and to get a little bit of a taste of this. So yeah, any final comments as we kind of wrap up our time?

• 49:50Speaker 01

  Well, I think that what we didn't get into in depth, we began to get into it, is how do you work with these patients?

• 50:00David Puder?

  Yeah.

• 50:01Speaker 01

  I think that that is the biggest challenge. And this is why we wrote the book. We wrote the book because in our, we, all of us are part of a research group and that includes treatment of patients with personality disorders at the Personality Disorders Institute at Wild Cornell. And we all are in supervision groups and we found that as we were presenting cases to each other, it was the cases with pathological narcissism that were giving us the most trouble, interestingly enough. And so we formed a study group about 15 years ago. And the book really came out of the study group. And so it comes right out of our clinical experience. And I imagine there are many people out there who will listen to this podcast

• 50:45Speaker 01

  because they have a lot of narcissistic patients in their practice at all levels of organization. They can be high functioning and on the cusp of neurosis. They can be at the borderline level, or they can be more severely disturbed, like patients with malignant narcissism, where they can actually lose touch with reality. So I think maybe if we continue, we should talk more about how do you treat these patients? And what are the dilemmas? You asked me about the devaluation. That was a very good question for the beginning stages of treatment, because that's often what you run into. But you can also run into extreme idealization.

• 51:23David Puder?

  Yep.

• 51:24Speaker 01

  Another, you know, a whole other trajectory. So much to talk about, and thank you for inviting me.

• 51:31David Puder?

  Much to talk about. Okay, thank you so much for your time. And we will, maybe, maybe a good place to leave this is if you're listening to this and you have specific, specific things that you would like sort of drawn out in terms of the treatment, maybe a case that we could de-identify and kind of ask her, you know, shoot me an email. You can find me on psychiatrypodcast.com. And we'll leave it there for today.

• 51:58Speaker 01

  Thank you.

• 51:59David Puder?

  All right.

• 52:00Speaker 01

  Bye-bye.