Pathological Narcissism: Effective Treatment with Mentalization-Based Therapy (MBT)

In this episode, Dr. David Puder, alongside experts Anthony Bateman, Dr. Brandon Unruh, and Robert Drozek, delves into the complexities of treating pathological narcissism with Mentalization-Based Therapy (MBT). They explore practical strategies to help individuals with Narcissistic Personality Disorder develop self-awareness, emotional regulation, and healthier relationships. Learn how MBT can transform the therapeutic journey for those who often feel misunderstood or resistant to change. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. ../../../cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-227-narcissism-mentalization-based-treatment-effective-strategies Link to YouTube video. https://www.youtube.com/watch?v=fJ3fVZ0GegI

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

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with a team of people. We will be talking about narcissistic personality disorder. We'll be talking about mentalization-based therapy for patients with narcissistic personality disorder, narcissistic traits. This is kind of like probably the world's best team for this that I'm bringing on. If I can be grandiose myself, this is, you know, I was, I was thinking about it and like, okay, if you were really, really narcissistic, where would you want to get your, where would you want to go, you know, to be like, to get your treatment? You would want to go to Harvard, right? And who would you want to go to? You'd want to go to the world's best founder.

• 0:58David Puder?

  So we have Anthony Bateman. He is the founder of, co-founder of Mentalization-Based Therapy. We have Bob Drozak, who has been kind of huge in, in bringing together a team to write this book, Mentalization-Based Treatment for Pathological Narcissism. And then we have Brandon Unruh, who is in the trenches treating borderline personality disorder, narcissistic personality disorder. And I kind of want each of you to introduce yourselves. Maybe, Bob Drozak, you could start. Just a little bit like, what is, what does life look like at this point? How much clinical duties? How much research? And so, yeah, give us just kind of a brief intro.

• 1:43Speaker 01

  Okay. All right. Thanks, David. Thank you for having us. It's really fun to be here. We love your podcast. So, um, yeah, I'm a clinical social worker and I'm clinical director of the Mentalization-Based Treatment Clinic here at McLean. Brandon's the medical director. And I'm working a bunch of different programs here, but a lot of, a lot of what I do is sort of helping folks with narcissistic personality disorder, borderline personality disorder. Doing like individual and group treatment and very sort of squarely focused on MBT. So, um, you know, sort of most of what I'm doing is sort of helping folks with these challenges with doing sort of individual therapy. And then we have a narcissist, uh, MBT group for folks with narcissistic personality disorder.

• 2:28Speaker 01

  And then just do have a private practice where I do a lot of, you know, helping folks with narcissism and, and do like consultations, it's diagnostic consultations of like, how do we give the diagnosis to folks with narcissistic personality disorder?

• 2:41David Puder?

  Okay. And so, um, some of the audience will be wondering like, why?

• 2:49David Puder?

  Like, why is that your unique passion in life to work with patients with narcissism? Maybe we'll, we'll, we'll kind of come full circle to this. And then Brandon, uh, you want to introduce yourself?

• 3:01Speaker 02

  Hi, and thanks, David. It really is a joy and treasure to get to be part of this, um, great podcast. Thank you so much. You know, like Bob, I practice, uh, I'm a psychiatrist and psychotherapist. I've been based at McLean Hospital outside of Boston since I finished my training there. And, and at the Mass General Hospital in Boston, a number of years ago, and got interested in personality disorders right in the middle of my training when I was being mentored by John Gunderson. You know, the, one of the so-called parents of the borderline personality disorder diagnosis. And since then, I've just fallen into a variety of different, um, clinical and administrative roles. Was involved with the founding of the MBT Mentalization Based Treatment Clinic at McLean right from the get-go.

• 3:45Speaker 02

  And it's, it's just been a joy to see that, um, be a place that's still hanging on and continuing to be a place where clinicians can come across different disciplines and modalities and degree channels to get treatment, uh, and, and training rather in MBT. And where we're continuing to actually deliver insurance-based, specialized, evidence-based care for personality disorders, which is a bit harder to come by, at least in this country. And then my other hat that I primarily wear is I'm the medical director of the Gunderson Residence, an intensive residential program that is different from our MBT program. And that it's a more integrative evidence-based personality disorder treatment program where we're integrating

• 4:26Speaker 02

  elements of dialectical behavioral therapy, elements of mentalization, elements of transference-focused psychotherapy, and some elements of John Gunderson's approach of good psychiatric management. So it's a bit of a mysterious eclectic place in that way.

• 4:42David Puder?

  It sounds, it sounds world-class. It really does. I mean, I, um, when I, I've done an episode where we talk about like all the treatments that work for borderline personality disorder. And I feel like when I went through training, you know, it was DBT, right? That was, that was the thing. And now it's, it's become a lot broader. And so it's, it's great to see that you are like really bringing together all these fields. And I want to, I want to hear, learn a lot from you on those things. And then Anthony Bateman, you're, you're in England and you are someone who was on the podcast before you with Fongi, which was one of my favorite episodes. So thanks for coming back.

• 5:25Speaker 03

  Okay, yes, I'm Anthony Bateman and I'm Visiting Professor at University College London. And whilst I may be one of the co-founders of MBT, I'm certainly a hanger-on in this podcast because the bulk of the work and studying pathological narcissism and mentalizing has been by Bob and Brandon. So I'm kind of joining from behind here and I kind of steer occasionally, but the creativity is there. It's not, not mine, I should say. I'm actually a psychiatrist. I currently just, I better say, I do not do any private practice. I've never done any private practice.

• 6:04Speaker 03

  So I do not accept referrals from outside our national health system here in the UK. Yeah, just in case. But I primarily now advise the Anna Freud for clinical work and training in mentalizing. And mostly other than that, generate and write up research projects which are coming to fruition. Most recently about mentalizing and antisocial personality disorder, which we'll shortly be publishing a large trial about.

• 6:37David Puder?

  Okay, nice. That's, that's, I'm excited to hear about that. Okay, so I was thinking we'd just kind of like launch into what is narcissism. Bob, maybe you can kind of direct us towards like grandiose versus vulnerable narcissism. And speak specifically what you're finding in terms of the high percentage of patients with borderline precise disorder who also had narcissistic tendencies and maybe the differential like what makes, what stresses lead to someone maybe decompensating who's more narcissistic versus more borderline precise disorder. I think that's really interesting.

• 7:14Speaker 01

  Okay, all right, great. Well, I think we'll probably all have stuff to say about this. But in terms of like the prevalence of sort of narcissistic personality disorder, at least in the United States, it's around 7%, which is pretty high. In terms of the sort of percentage of folks with both BPD and narcissism, I don't know tons of research on that specifically. I can kind of speak a little bit about some of the symptomatic overlaps, but basically narcissism is, you know, seen as there being like two different subtypes, grandiose and vulnerable. Both tend to have, we can really think about narcissism as like a disorder of self-esteem

• 7:51Speaker 01

  regulation, you know, and really the sort of the excessive reliance on what we call self-enhancement in order to regulate self-esteem. And that can take a lot of different shapes for folks with sort of more the more grandiose subtype. There's this idea that I am great, I am better than other people. Sort of, you know, to be honest, in terms of the percentage of sort of those folks presenting for clinical care, it's much lower than folks with vulnerable narcissism. So the folks, you know, it's a lot of times there's this sort of saying in narcissism treatment that like, sort of like the grandiose folks come to treatment because their family wants them in treatment. There are other people want them in treatment where the vulnerable

• 8:35Speaker 01

  folks will be coming in because they're actually, they're kind of suffering subjectively in a way. So in vulnerable narcissism is really this idea, not that I am so great, and this may be overly simplistic, but that I should be so great. I am only valuable. If, so it's this construct of, it's called contingent self-esteem, which correlates with vulnerable narcissism and is basing the sense of self on external factors like, like achievement, um, uh, success, money, attractiveness, attractiveness of romantic partners. Um, so a lot of folks with vulnerable NPD can really, you know, their self-esteem and their mood can rise and fall

• 9:18Speaker 01

  based on whether or not they're getting that external kind of positive feedback in a way. So, um, so that's kind of the broad distinction. Both are joined by what they call, it's called different, different things in the literature, but essentially some people call it entitlement. That's been shown to correlate with sort of both subtypes. Some folks say antagonism, some folks say self-centeredness. So the idea is that there is a unifying thread for those two subtypes and it tends to be sort of some elevation of self over other. I don't know.

• 9:53David Puder?

  Yeah, beautiful. No, appreciate it. Brandon, that was the best ever, Bob. That was awesome. I'm, I'm gonna be making like some, some just fun grandiose statements during this whole interview, so just be ready.

• 10:05Speaker 03

  Can I add to that as well? Because Bob's, uh, um, uh, mentioned and you were asked about borderline personality disorder and narcissism, but in fact you find a much greater overlap, I think, generally with antisocial. So, uh, the problem with narcissism to some degree in the grandiose subtype is that it can get expressed through that entitlement and antagonism. And that leads, of course, to social disruption. And, um, once you feel grandly entitled to things, you tend to start potentially committing crimes and so on. But more importantly, um, and it's problematic for treatments, is that you narcissistically have overcome your, your developmental traumas.

• 10:51Speaker 03

  So, uh, you may have had considerable developmental trauma leading to antisocial dysfunction in adolescence, but actually you narcissistically

• 11:01Speaker 03

  You've overcome it. So when you're questioned about your capacities to manage yourself, manage your emotions and all these things. They say, well, that's not a problem for me. I got over that years ago. Um, no, not at all. So they then use their narcissism, in fact, to deny any developmental problem that may impact on treatment, for example. So um, that, that then becomes a major problem of engaging that group of people in treatment.

• 11:30David Puder?

  Nice. Brandon, do you want to, is, how about envy? Is, how does envy play a role here?

• 11:37Speaker 02

  Well, envy can be particularly toxic in association with narcissistic vulnerabilities. I mean, because it's inherently, we would say, a challenge to one's self-esteem needs to kind of preserve a stable sense of oneself as measuring up to what one expects or senses other people expect. But the experience of envy inherently contains within it a sense of myself as lacking something. It's outwardly directed in the sense of looking at someone else who's got the thing that I think I want or had better have. So there's an inherent vulnerability in sitting with the experience of envy. I tend to actually think that envy may be the most challenging emotion, or one of them, to actually manage within ourselves for many of us.

• 12:23Speaker 02

  But it's certainly a problem in NPD. And the problem is really about sitting with the more vulnerable aspects of that experience of envy. It's, it becomes toxic rather than a kind of healthy motivator that's adaptive for, well, if I see someone who has a reputation I kind of admire, well, maybe I could work on myself and go do the work over time in a stepwise fashion and tolerate the uncertainty and be incremental in my approach to build myself up in that direction. But people with narcissistic vulnerabilities can't do that. And we sometimes call this the narcissistic staircase of doom, where they, they feel they have to pull vault themselves to the top of the staircase.

• 13:03Speaker 02

  Um, rather than being able to tolerate the incremental steps along the way, which has gone to involve tolerating uh, that sense of not having something that other people have. And people with NPD tend to just opt out of that process altogether, rather than it's kind of staying on the path and allowing envy to function adaptively.

• 13:25David Puder?

  That's really, that's good. I really appreciate that. That's good. Okay, so let's go into the problems in mentalizing associated with narcissism. So what kind of, maybe let's start with diminished emotional awareness or alexithymia, kind of this inability to maybe identify emotions as well.

• 13:49David Puder?

  More vulnerable emotions like sadness, shame, insecurity. Yeah. Do you want to, Bob, do you want to jump in?

• 13:57Speaker 01

  Yeah, no, this is, I think, a really, this is sort of where M B T, mentalization-based treatment. Folks listening to this podcast, because David has done such an amazing job covering mentalizing and reflective functioning in this podcast, which is really, I think, exciting for us. But just to kind of make sure people are kind of on, you know, top of what this idea means of mentalizing, it's really the ability to reflect on mental states in ourselves as well as other people. So what a lot of times people, when they think about narcissism, they'll think like, okay, they have, folks with N P D have difficulties putting themselves in other people's shoes. They have equal difficulties with putting themselves in their own shoes. And that's something that can often be missed. So like, if, you know, in terms of what's

• 14:42Speaker 01

  been shown through research is narcissism is correlated with alexithymia, difficulty putting words on emotions, difficulty finding emotions in the self. So these are the patients, you want to start thinking, like, when you're sitting with them in session and they're describing lots of scenarios, you know, very externally focused, talking about whether or not other people are right or wrong around something, you know, and then you ask them a question, well, what was that like for you? And they continue to just describe the situation. You want to start wondering, is this, this is what we often see with the alexithymia kind of connected with narcissism? And the idea is that it's just hard, there's not quite a language for emotions in themselves.

• 15:26Speaker 01

  And so, and that's been shown, you know, I think you cited some of the research, David, that, you know, specifically sadness, insecurity.

• 15:34Speaker 01

  Shame, dependency on others has been shown through research to that folks with narcissism really, they don't spontaneously put words on those emotions. So there's a bias in what they mentalize in themselves. And so a lot of the treatment is actually, the early stages of treatment is helping them find a broader array of emotions in themselves.

• 15:57Speaker 01

  Anything you, Brandon and Anthony, you would add around that, the difficulties? No?

• 16:02David Puder?

  I, I think it was, it was so superior how you put it. It was just so good.

• 16:07Speaker 01

  I'm gonna be getting so much validation in this podcast.

• 16:11David Puder?

  Sorry.

• 16:12Speaker 03

  Stoke his grandiosity soon be kept.

• 16:16David Puder?

  I need to not like have a placating tone here. I gotta work on that. No, I really, I really think it's good.

• 16:24David Puder?

  I, I think there's something about that, like, it's like, what do they have? They have anger, they have superiority, they have this kind of detached demeanor. Is it like in your work with them? Like you really do see like, okay, people probably, this is what I'm imagining the audience is thinking, wait, you see people move past that? Like, is that what you guys actually see happening?

• 16:49Speaker 02

  Well, I mean, I think we wouldn't sort of be at this place of having sort of invested enough in wanting to kind of develop a bit of a model and set of techniques if we didn't feel there was, we were able to get leverage around this and some progress with, with at least some of our patients. And that's really what kind of galvanized, you know, rewriting this up. But yes, it, it is a touch and go process and that initial stage of alliance formation, that's so, such a critical, universal element in psychotherapy for any, any cause, targeting anything. It is a more fraught process. The treatment dropout rates, as I think you've reviewed in your podcast previously, are much higher in NPD even than, than for BPD.

• 17:34Speaker 02

  Because there isn't that kind of natural dependency seeking, you know, that, that, the primacy of connectedness and wish to kind of stay in. And manage connectedness with the therapist. That isn't there in the same way. It's not there as an adaptive motivator. Even though that's disordered in BPD, it can really be kind of co-opted in a productive way by the therapist. If you lean in with interest and you're basically empathic and validating, that goes a long way and a lot can be forgiven by somebody with BPD more easily. But in NPD, it is a much more fraught process, I think. So we're doing a lot early on to stay very contingent to our patients' experience.

• 18:18Speaker 02

  And then the kind of subsequent moves are often, as Bob's describing, around trying to enhance an affective vocabulary. But it's really the mentalizing capacity to look inwardly with reflectiveness into oneself. And that takes, we believe, this affect elaboration pathway that maybe Bob can speak more about. It is inherently a challenge to the patient's certainty about what they see or don't see inside themselves. And so it is a kind of narcissistic challenge in and of itself to be pushed to look for more within oneself. You know, what more might be there beyond your immediate angry reaction or that sense of being diminished? You know, what other feelings might be around?

• 19:01Speaker 02

  And that's why we developed more of a kind of instructive pathway for clinicians to walk through that a bit more carefully.

• 19:10Speaker 03

  And just to add to that, if it does, it might be important to emphasize that actually the kind of empathic sort of joining that Brandon's mentioning in a sense has to be around the idea, their experience, that they look inside themselves and they're very uncertain what they find. And that in itself is dangerously painful because you can't then formulate a really your inner experience all that easily. And at least not in a flexible, rather generalized way, or even in a specific way. So you tend to then start operating along very narrow, rigid sort of ways and so on. So you have to be empathic to that, not to the anger as such, or anything.

• 19:54Speaker 03

  Like that in a way first and in the and if I can just put that in the M B T perspective. We've rather, I suppose, if I'm allowed to use the word sort of bastardized I mode. Um, which is the the inner experience of I and alexithymic or the inability to look inside. To actually, as it were, integrate bodily experience into an emotion and and label it. Is actually what they have problems with. And you're asking about their mentalizing problems. Well, this is one of the first components. That I mode isn't really working very well. So we call it that for clinicians.

• 20:36David Puder?

  I mode, can you can you explain I mode? Like, what does it mean?

• 20:39Speaker 03

  Well, I mode is is truly the experience of existence. Um, um, it work goes back to the eighteen nineties and a sort of Jamesian consciousness and awareness of consciousness. But we've sort of developed it in a sense clinically, simply to get this self reflective capacity. The ability to actually integrate inner interceptive bodily experience into a representational level of meaning. Uh, of oneself. Uh, and that is a self that's then continuous across time and doesn't require self. Uh, doesn't require referencing with the world. You're on your own. You can carry this self wherever you go.

• 21:18Speaker 03

  Um, it eventually interacts, obviously, with others. And when it's interacting with others, we call that me mode. And Bob's added you mode to it because we have to read other minds. Uh, and read them accurately to some degree, which is what mentalizing is about. So that becomes me mode. Uh, as it were, you me mode anyway. And we tend to personalize that. We simply read other people, but in reference to ourselves and we compare. Do they represent our mind accurately? Do they see us as representing their mind accurately and so on? So then you're into the self and other interactive. We call that me mode. But that's also somewhat problematic for in narcissism, just to put this component in context.

• 22:03Speaker 01

  And David, along the lines of what Anthony's saying, are do you want us to talk about like the treatment techniques for this now? Or we just are we sort of holding that for later?

• 22:12David Puder?

  Um, yeah, I'm just, I'm just going through questions one by one and then, you know.

• 22:18Speaker 01

  Well, so I guess even to the point of what Anthony's saying, it's a real important part of like how we go about helping folks with this because a lot of times when folks are treating folks with NPD, they'll want to say, well, what do you think what that was like for your wife when you said that to her? And we would really not recommend that at first, right? So what Anthony is talking about is that we really need to be prioritizing like an infrastructure of selfhood prior to moving to other. So the idea would be like, how did that make you feel when your wife said that to you? So I was so pissed off, you know, so you explore the pissed off feeling. But then to Brandon's point, we got to expand it, you know? I'm curious, what about when she said to you that you weren't, you're not really a good husband?

• 23:04Speaker 01

  Did that bring up anything other than just pissed off? So we're just trying to horizontally expand the person's experience of themselves. There's anger, there's hurt, there's shame, right? That is all working from within their own perspective first. So that is a core kind of element of what we're kind of thinking about here before kind of going to the helping them mentalize other people.

• 23:28David Puder?

  Got it. Okay. So yeah, it's the deepening of their experiential self. And then it sounds like also like also trying to help them find who they are outside of other people. And other people's like external validation.

• 23:46David Puder?

  Is that, I'm getting some nods.

• 23:47Speaker 01

  That's, you all don't hear us nodding? Yeah, yeah.

• 23:52David Puder?

  I need, I need some vocal validation.

• 23:55Speaker 01

  Thank you.

• 23:57Speaker 01

  Anthony's done a ton of these. Brandon and I have no idea what we're doing. Yeah, yeah. So, yeah.

• 24:02David Puder?

  You guys are, you guys are doing great.

• 24:06David Puder?

  Yeah. And so what I would say is like, let's go through the, the areas of where they struggled with mentalizing. And then I love, let's already incorporate kind of like how you approach it. I love that. So how about the overconfidence and perspective taking and impaired empathy?

• 24:23Speaker 01

  It's fun. This is a good one. Yeah, I don't want to be the first one to respond. So Anthony, why don't you take that?

• 24:29Speaker 03

  No, no, you go, Bob. This is your rap. You know, you should be, we can chip in.

• 24:36David Puder?

  Anthony, that's very non narcissistic of you, by the way, to allow your young protege to have the floor so much.

• 24:45Speaker 03

  But that's what you have to do as you get older. It's a narcissistic hurt, but it's something that you have to come to terms with.

• 24:52David Puder?

  No, I love that.

• 24:53Speaker 03

  I'll stick things on.

• 24:54David Puder?

  Yeah. Dr. Tarr, one of my mentors, we co-taught for like 10 years together. And he was far superior to me in his understanding of psychology and psychotherapy. But he would always like, he had that spirit about him of like, you teach first and then I'll jump in and kind of slightly correct you, which I appreciate it.

• 25:19Speaker 03

  I learned from them. That's, I hope. That's my youth. I want to learn from them. Then I keep young.

• 25:27David Puder?

  Yeah, that's good.

• 25:29Speaker 01

  Also, you said kind of two things, David. You said sort of the certainty in perspective taking and then the problems in empathy. We kind of put those in different camps. You do kind of deal with a little differently clinically.

• 25:40David Puder?

  Okay, let's start with the overconfidence in perspective taking.

• 25:46Speaker 01

  That is really so crucial here. And so that's the idea is that oftentimes, this is what MBT calls psychic equivalence mode. If I think it, that makes it so. It's really, really relevant for narcissism. And it's not always, sometimes it's like, I know that I am a certain way. Sometimes it's, I know that what that person did was wrong and this person's horrible in some way. Sometimes it's like, I know I'm bad and not good enough. So it's a bunch of different forms of certainty. And so this really comes out of Anthony's formulations about treating personality disorders more generally. So we didn't really do anything

• 26:27Speaker 01

  new on this one. But like, one is the sort of the most Common form of certainty that you'll see with a lot of folks with narcissism is like a negative judgment of the other person. You know, so some version of like my um, my wife is too critical of me. You know, like something like that. So that'll be like a negative judgment. And so in M B T, we would never take issue with that on first pass. We would want to be saying like, okay, well, so tell me more. In what ways is she so critical? You kind of like help them kind of make their case to you. And then you explore the impact on the patient. And so, okay, wow. So when she's treating you in that way. Well, how's that impact you? What does that bring up for you?

• 27:12Speaker 01

  So again, not in any way sort of challenging. But the problem is, is that if we only do that, we're not really helping patients to see things from a more flexible perspective. So we've got to do more. And what Anthony has sort of envisioned.

• 27:30David Puder?

  So let me, let's, let's, let's jump into this. I'll be, I'll be the narcissist here. Okay?

• 27:35Speaker 01

  Okay, cool.

• 27:36David Puder?

  Well, it brings up rage for me, Bob. It brings up absolute rage.

• 27:40Speaker 01

  Okay, all right. Tell me more. What's the rage?

• 27:43David Puder?

  Well, it feels so disrespecting.

• 27:47Speaker 01

  Yeah.

• 27:48David Puder?

  And it's like, I'm, I'm, I'm working my butt off, you know? And then I do the dishes and then it's like, yeah, and then more crit. And then I hear a critical word and it's like, hey, I'm, I'm doing a lot here.

• 28:03Speaker 01

  Absolutely. So it's like, you're literally working so hard so much of the time. And so it's enraging that she sort of would even, she would speak to you in that way.

• 28:14David Puder?

  Yeah, that's exactly what I said, Bob. Good. You're repeating back to me exactly what I'm telling you. Is this, is this what I'm getting from Harvard? Like, is this what I'm getting?

• 28:23Speaker 01

  Well, it's fair. It's fair. I don't know how much sort of new I have to offer here, but I'm just curious. Is she always?

• 28:29David Puder?

  Are we laughing at my comment here? I'm, I'm, I'm trying to pour out my heart here, Bob. And I feel like you're like making light of this.

• 28:37Speaker 01

  I'm sorry. I apologize. I, you know, I was, I was laughing. I was laughing. I thought, I thought you were kind of joking a little bit with the Harvard thing. I appreciate that.

• 28:44David Puder?

  No, I was. I was.

• 28:48David Puder?

  I was messing with you, Bob.

• 28:50Speaker 01

  Well, so let me just ask you, just to be clear.

• 28:52David Puder?

  Wait, can we pause? How's my character here? I'm like heating up here. I don't know. This is like getting too hot.

• 28:58Speaker 01

  No, no, let's, let's stay with it. I want to.

• 28:59David Puder?

  Okay, okay. Let's, let's keep going.

• 29:01Speaker 01

  Well, so I'm just curious, though, has she always, has she, has she always been this way?

• 29:09David Puder?

  No, I mean, I think when we were like initially, you know, maybe the first six months, it was kind of like, you know, I felt like she was like very supportive. And then something, something flipped. Yeah.

• 29:23Speaker 01

  I see. Okay, okay. And then just curious, like, yeah, so but when she was more supportive, how did she treat you?

• 29:32David Puder?

  Oh, like, everything was gratitude and positive and, you know, warm and,

• 29:42David Puder?

  and yeah.

• 29:43Speaker 01

  Okay. And I'm just curious now, like this past week, has there been, have there been any days where she's been any like better than others?

• 29:55David Puder?

  Yeah, maybe.

• 29:56Speaker 01

  Okay, what, what did she do that day?

• 30:01David Puder?

  She greeted me with a hug. That was nice.

• 30:05Speaker 01

  Yeah, what was that like?

• 30:09David Puder?

  Well, I don't know. It's just, you know, it's like, nice.

• 30:13Speaker 01

  Yeah. It sounds nice. I mean, I really appreciate what you're putting words on here because there's a really way in which you work tremendously hard. And it doesn't seem fair that she would just come and criticize you. And yet there are these other moments where it sounds like you see a different version of her and where she's kinder, she's warmer, she hugs you, and there is something nice about that.

• 30:39David Puder?

  Yeah. Okay, we can pause there.

• 30:42Speaker 01

  All right, okay, so.

• 30:43David Puder?

  Well, can I like, can I have, because I would like Brandon to become the patient now? What do you think?

• 30:53Speaker 01

  Can we, David, not to be too controlled, but everybody put Brandon's thoughts on that. So.

• 30:57Speaker 02

  Do you want a bit of commentary on what I thought was happening there?

• 31:00Speaker 01

  Is it okay, David, if Brandon gives some commentary about that? Because this is, yeah.

• 31:04David Puder?

  I want to have increased envy on Brandon being a better patient than me. No, I'm joking. Okay, yeah, let's hear Brandon's commentary.

• 31:11Speaker 02

  You set the bar, David, I think. You set the archetype.

• 31:14Speaker 01

  You're amazing. Yeah.

• 31:16Speaker 02

  No, I think just a brief, brief commentary, I mean, and kind of just pulling out some elements of the model. So I think what you saw there was Bob was responding to you, David, with, without any sense of challenging or really questioning your initial experience. I mean, that's the first thing. You know, in M B T in general, and this is really Anthony's, he sort of, you know, I mean, insight from the beginning. First place is to just get impressionistically alongside the patient as best as we can. And that can sound like psychotherapy 101, but it really is starting point for M B T. And it's important to be very contingent to the, the subjectivity of a narcissistic person, just as a get go. So you saw Bob just trying to join you in that. He wasn't questioning, he wasn't criticizing.

• 32:02Speaker 02

  But then, then he starts to just take up that experience without questioning it itself. And he may be thinking in his mind, well, this sounds a bit overly certain or rigid, or maybe that's, this is psychic equivalence, to use the jargon. But he doesn't press on that, the certainty or rigidity about it. He doesn't go after that at first. He just starts asking elaboration questions. And he's interested in, you know, how did you get to this sense that she's critical all the time? And he starts to use his own reflective power, his own mentalizing, to just ask clarifying and elaborating questions. And what I think happened there was that those questions, without him really challenging, you know, your experience, started to expose some areas of.

• 32:48Speaker 02

  Potential nuance and potential gray area. And these would be things that we'd seize on and come back to work with later in our pathway for managing this certainty. Problem, because these would be potential footholds where we may be able to turn on some mentalizing. Get some curiosity going, get, get out of that all knowing stance and actually introduce some uncertainty. So I think you saw Bob doing that, saying, she always been like this? And then he got interested in kind of, well, what was it like when she greeted you with a hug or earlier in the relationship when she was? Seemed a little less critical. So what we hope we've achieved so far is we've got a patient. Actually, that's moved out of that position of complete certainty. They're a little more interested and uncertain about.

• 33:34Speaker 02

  Has this changed over time? You know, maybe even now in the past week, does this change over time? Do I have different experiences that fluctuate or don't I? And it's introducing that uncertainty. That's really priming the mentalizing pump. That's the first few steps.

• 33:50Speaker 03

  Yeah. So in the model, it's very much expanding the field of sort of discovery. Um, because you start off with such a narrow line, which is a wife who is critical. But actually you just simply expand it, well, from what we call the exploratory or not knowing stance really. Uh, where you're not actually challenging the validity. That's really important. You're, you're accepting it as seen from their perspective. And, and getting it expanded. And interestingly, people worry about it, but you're in a way, as Bob and Brandon have said, landing. Actually alongside the patient and looking at the whole thing through their eyes, not trying to get them to see anything different at first.

• 34:32Speaker 03

  And that's where we actually end with an empathic validation. So in a way, we're scaffolding the narcissism first here. We're not trying to demolish it. You're just scaffolding it so that actually here we are, this is where we are, now we're together. And you could get empathically validating already to some degree about this person who actually. Can't quite work out how his wife now can see appears so different across time in the one and she's like this, but then she's like that. What do you make of that? Do you sort of mean you're just continually opening up the field of sort of exploration here?

• 35:11Speaker 01

  And I'm curious for you, David, like as, because I had to go, when I asked that question, has she always been that way? You stopped and you looked and you had a couple pauses that sort of end up having, I was curious, what were you feeling like in those moments?

• 35:26Speaker 01

  I don't know if you remember.

• 35:27David Puder?

  Yeah, I think, um, I think I was, I was trying to imagine my person that I was embodying, not from a place of my own experience and not from a place of, uh, like an identifiable patient.

• 35:51David Puder?

  So it's like, I wanted to tell a story that was like unique and not necessarily like something that was, you know, I wanted to stay in character. So I was like, trying to imagine this character.

• 36:04Speaker 03

  Beautifully in character here, just to point out that you came back at Bob in a wonderfully sort of dismissive way. You said, well, you've just repeated what I've said. And that's exactly the sort of area that you need to get in because it was so sort of pithy and direct and say, well, what's new here? Have I got anything to learn from you? It doesn't seem that I have really. And so you're straight back into the sort of narcissistic management of whatever your experience was, which was disappointment or really, I thought I'd come to Harvard, but what I'm getting is some kind of echo chamber. Hell, you know, what is this? And so.

• 36:45David Puder?

  Yep. Yep. Yep. Yep. No, that's, and I think those moments, and this is why I wanted to illustrate this for my audience, those moments are some of the most painful, difficult moments to manage. And so, yeah, okay, let's, let's slow it down right there. What, what could be some other ways of approaching a patient when, when they do kind of that direct attack, right? Cause I'm curious, Brandon, maybe you could speak to like, I know you've also trained some transference focused therapy. Because I think they would jump on that as like a transference moment, right? But I'm curious as well, like how mentalization would differ in your approach to that specifically?

• 37:22Speaker 02

  Well, this is a good question and with, you know, full appreciation for transference-focused psychotherapy, which I use as well and value in my practice. I think there are some, some real differences here in both theory and technique. And just to keep this on the briefer side, what I think you saw Bob doing was just the of still standing sort of firm in the not knowing stance. He didn't actually use too much of, you know, his own mentalizing, I thought, in that moment to come up with some idea about what might be going on in the patient's mind. He didn't do anything interpretive. He wouldn't do that in TFP either, right out of the gates.

• 38:04Speaker 02

  But in general, MBT really views the, the, the experience as really quite co-constructed. I mean, a real, I think, Anthony, correct me if you wouldn't agree with this, but really a two-person model in that sense, to use Nancy McWilliams' language. And so, so Bob sort of stays with the sense of, I don't know if I can be helpful to you. It is kind of like, well, let's see, I really don't know. He doesn't get defensive and he doesn't get interpretive. He just kind of rolls with it. And he also doesn't stop and take it up immediately and kind of do a deep dive on exploring the relationship in the here and now. And I think he's done that, Bob, tell me if this is not how you were thinking in that

• 38:47Speaker 02

  role play, but I think he's doing that because Bob senses there's so much certainty here already operating. And I think he's kind of made a clinical assessment. This patient's mentalizing is quite fragile and may even be rather offline at the moment. There's so much certainty that's operating. So in general, we may not use that as an, as an opportunity to move into a kind of depth exploration of what's going on in the representational, you know, object relations diet, as you might do in TFP. Bob just stays really contingent to the patient's experience and continues to explore. That I think in the hopes of trying to get some mentalizing going first and foremost,

• 39:29Speaker 02

  knowing that if he goes to analyzing the relationship in the moment, that's generally a higher order mentalizing challenge for all of us, really. So I think he's trying to stay with, okay, we've got a patient who's overly certain. Let's just try to get some uncertainty and curiosity into the mix around this area before we go to what's likely to be a more fraught challenge to mentalizing. Does that make sense?

• 39:53Speaker 03

  And the other bit may be important a little bit there is is that, and I don't know that this is a differentiation, it may not be, but just for the importance of it is that Bob was the creator of that problem. So in a sense, he was the source rather than the patient being the source. And very often, when you're talking about transference, at least, the patient is seen as the source. And in this case, actually, MBT would see this as a as a joint sort of creation, but it started in a sense with Bob, who created an anxiety in the patient unwittingly, unknowingly, as it were, of which destabilizes the patient.

• 40:36Speaker 03

  So they actually have a vulnerable self at that point. So in order to create a more stable self, you actually create a stable self by dismissing the other mind. So you recreate your own mind. So I think we'd probably see a lot of that reaction as secondary, say, rather than actually being, I don't know, indicative of primary aggression or something, whatever, you know, that other people may see things in a slightly different way. And then that alters, of course, your technical intervention as well, as well as seeing the other mind as actually being ineffective mentalizing, therefore not open to exploration so easily. You actually see the source of the problem as being triggered, in this case, by the clinician.

• 41:20Speaker 01

  That probably is the most important technical distinction, I would say here, which is that in our kind of model for mentalizing, we do a lot of relationship work in MBT, lots. I think that's one thing, I think that there's a sense that, oh, TFP does the, in the relationship work, MBT sort of just does the reflective work. I don't know how you both see it, but I definitely do tons of relational work. But the difference is if we presume that it's co-constructed, then that expands our interventions. Because I think what I said there, because I was a little bit, uh-oh. And part of it was like, oh, is this going to make me look bad because I'm role-playing on a podcast, right? So that was one part of my experience, right? But what I said is

• 42:01Speaker 01

  like, oh, I'm sorry. I thought you were joking, right? Which is, sounds like a very quick move, but if it's two-person, I can apologize for my contribution. And that's so important in the treatment of narcissism because that regulates the patient.

• 42:16David Puder?

  Right. I think, I think you were laughing because you were stepping out of the...

• 42:19Speaker 01

  I was. That's true.

• 42:21David Puder?

  You were stepping out of the role-play and you just thought like, okay, this is getting really comical, like the amount of like, how this flipped so quickly. And then, instead of like, pausing the role-play to like, laugh with you, I decided to like, dig into it even more.

• 42:37Speaker 01

  That's true. You got me, David. You got me.

• 42:42David Puder?

  Oh, man.

• 42:44Speaker 01

  Brandon, were you gonna say something?

• 42:46Speaker 02

  Just underscoring, I think there is a difference in the models here. You know, we're really quick to kind of, as we say, take it on the chin sometimes. We're quick to sort of own whatever we think may have been our potentially real contribution to the problem for the patient in the moment. So we're, you know, it's not that we're not interested in how this, some of this, what just happened between us may be an expression of the patient's psychopathology, but we're explicitly, I think, verbally showing that we're quite open to how we impinge on the patient's mind in real ways.

• 43:31David Puder?

  Brandon, but don't you want to narcissistically defend against that you are the cause of their suffering? Like, isn't that like, a deep, profound desire of ours as clinicians? Like, that I am not the problem. It's your parents, right? It's your parents, it's the transference. You're not really angry at me, you're angry at your parents right now. I didn't cause any of this anger, right?

• 43:53Speaker 02

  Well, I think Bob will have something to say, because this is some of his other work on the ethics in psychotherapy and prioritizing sort of awareness of where is the clinician's self-esteem at. But I think you're getting at that, David. This is an important piece of counter-transference or counter-relationship, as we'd say in M B T. In working with narcissistic individuals, we do have to actually kind of be able to manage that sense of, gosh, am I going to be useful to this person? Gosh, I'm feeling quite inadequate and powerless to help and de-skilled and unskilled. And where did all my training go? And feeling quite helpless to be helpful here. So those are common counter-relational experiences that are, I think, more unique,

• 44:35Speaker 02

  are more prominent in treating N P D than even B P D. So yes, we do have to be able to manage that. But in M B T, we don't, you know, we're going to be a bit more forthcoming about some of some of that in the moment. But Bob, you may have more to say about this.

• 44:52Speaker 01

  Yeah, I love the question, David. And you're, it's really, I think it's such an important point. And if we think about it, what is, what are the parenting styles that have been shown to kind of be correlated with the development of narcissism? Parental psychological control. It's been shown that folk, that parents with N P D are more likely to have kids with N P D. So that's, that is a really important thing. That's why I love M B T as a model for treating narcissism, because the not-knowing stance and taking it on the chin, as Brandon says, is kind of anti-narcissistic. Like, we need to be willing to own our part first. And this is consistent with like contemporary psychoanalytic thinking.

• 45:33David Puder?

  Right.

• 45:33Speaker 01

  And sort of inter projectivity, inter subjectivity theory. And, but the cool thing is, is we do that, folks down-regulate. And, but then, the thing is, you can't stop there. Because if you stop there, then it's like, well, I'm glad you've, I'm glad you've sort of figured out that you've done something wrong, right? We can't stop there. Then we gotta say, I hear you. And, you know, I think we can both have a part. So can we also take a minute to look at what your part might be? So it's, it's two minds in the room. And I think my experience is if I'm willing to own my part, that makes patients much more interested and willing to actually look at their own part. Anthony, what do you think about that? It's so central to the model. Yeah.

• 46:16David Puder?

  Thumbs up from Anthony. That's okay. Yeah, that's fine. Man, I feel like, I feel like there's so much here to get through. And I'm like, so wanting to get through all of it.

• 46:33David Puder?

  So I feel like we're just scratching the surface, you know, it's like, it's good. Okay, so let's, let's get, there's, there's so much more around like the mis-mentalizing. One of the, one of the things is like externalization of blame. How do you, how do you help people in the midst of that? And I think it's kind of similar to what we've been talking about.

• 46:59David Puder?

  Do you see it as the same as what we've been talking about? Do you see it as different? Like the overconfidence and perspective-taking, externalization of blame, are those two separate things?

• 47:07Speaker 01

  I mean, just for like, in terms of ground to cover, it kind of, the techniques kind of go into the same area because they're both certainty, right? Certainty that it's your fault, certainty of whatever it happens to be. So broadly speaking, we are going to get alongside the person, find nuance, and then share our own perspectives. I do think technically, there's, it covers relatively similar terrain.

• 47:33David Puder?

  Okay.

• 47:33Speaker 01

  You want to hear more, more about it?

• 47:35Speaker 03

  The aphorism for it in a way is, is what we've said, which is, see it from their perspective and scaffold the whole thing. So you get the content, as Bob always talks about. Scaffold the whole thing so that they experience a sense that you do see it as they see it and as they experience it. So you're then joint in some form. Once you think that's established, you can start chipping and then chip away. But you don't demolish, you don't explode the whole thing and show them that really they're dismissive and they're misinterpreting and it's their narcissism and they're to blame. This is, this would be disastrous. But you then just technically chip away within the frame of your now-stable

• 48:20Speaker 03

  and rather empathically sort of organized relationship. So you just question slightly, you say, do you know, it occurred to me? Something else here and pop it in and see how it's taken. Do they bite? Do they say, well, why do you see it like that? I told you it wasn't like that. He said, well, I think it came to my mind just when you were saying this. And so, so they have to consider your mind and your perspective. You've just a hundred percent done theirs. Now, hang on a minute, we're two of us. What about my perspective? We can only do that once you've actually, as it were, engaged with them. And, and, and they experienced, she was seeing it from their perspective.

• 49:03David Puder?

  So with borderline precise disorder, I see it as like there's an interpersonal stress, which leads to destabilization. And so when I look back through someone's history, you see these like breakup and then the cutting and the suicidality that comes after. Do you see similar events in narcissism? And I think you mentioned it's like these like self-esteem challenges, right? Which could be a loss of a job or a boss saying a certain thing or, you know. But how do you specifically work with these insults?

• 49:35Speaker 01

  Yeah, that's, that's definitely that. That requires a sort of different set of techniques. I'm glad you're asking about it, David. So this gets to a construct that we cover in the book, which we kind of. So Anthony has developed this idea of teleology, which is sort of interpreting mental states in terms of what's visible. We've kind of expanded that to sort of think about the sense of self in narcissism. So it's teleological self-esteem. So my self did sort of rests on external things. And for that, like absolutely, what are the kind of precipitants to treatment for narcissism? It's sort of problems at work, problems in relationships, other people not treating them in the way that they feel like they deserve.

• 50:17David Puder?

  Okay, okay. Slow that. So explain that to a third grader.

• 50:22Speaker 01

  So it's the idea is it's sort of it's often stays very externally focused, but there is some situation in life that I don't say makes them feel bad about themselves, that they just find upsetting. And that leads to sort of psychiatric decompensation. That's not a third grader language, but.

• 50:43Speaker 03

  Okay, so I can put it in second grade language.

• 50:45Speaker 01

  All right.

• 50:48Speaker 03

  But but in a way, I am, you know, what I do, or I myself, I am what I do, or what happens to me. So if I lose a job, I'm nothing. If I fail in some way to do something I expect of myself, then my self-esteem plummets because I didn't do it. I didn't manage it.

• 51:10Speaker 01

  Definitely. And that entails two parts, though. What Anthony's saying, the first is I should be blank. And the second is if I'm not, then I'm bad.

• 51:22David Puder?

  Right. I almost like feel like some Karen Horni here, like neurosis in human growth, like the shoulds that define the person and they have like the I should be this, and I should be that, and I should be this. And then it's like when they come into life and life shows them that they're not that way, then they kind of decompensate, right? So they have this like false self, the shoulds create this like false persona, just the true persona, which is kind of hidden there, right? It's, I don't know if you guys are fans of her work, but that's, that's what I'm hearing in kind of a way.

• 51:54Speaker 02

  I think of it as also a sense of there's some kind of expectation or should, or this is how I have to see myself or be seen. And this is of course, you know, not entirely conscious, generally speaking, but it's some, some way in which I'm not aware, but may actually be behaviorally quite insistent on being seen a certain way by others or seeing myself a certain way through my own mind's eye. It's, it goes to that I mode, what kind of person am I? But there's an insistence on, you know, this is my worth, this is, you know, I'm competent because I'm intelligent because I'm.

• 52:31Speaker 02

  Attractive because of the number of followers I have on Instagram. I'm I'm capable of vocationally because of the number of graduate schools I got into. And when there's some concrete disturbance in that that that channel of sort of self stabilization, then it throws the whole sense of self off. It just capsizes, as Anthony is saying. So that can be a threat coming at the self esteem in in virtually any channel. It can look like an interpersonal, you know, disturbance. But it's a it's a narcissistic disturbance because it actually it's it's not so much about being connected

• 53:11Speaker 02

  to that person and having that disrupted as it is about kind of being connected to or living out or, you know, expressing actually this image of myself. And that's what kind of get destabilized. Would you agree with all that, Bob and Anthony?

• 53:26Speaker 01

  Oh, absolutely. And the thing is, that's interesting about these patients is often they are not saying it in these like really, you know, clean ways that Anthony or Brandon are describing. They're just saying, I'm just depressed. Or I'm just I'm just so anxious and I just feel so horrible. Right? You have to kind of explore and get at those external triggers.

• 53:46David Puder?

  Yeah, this this is really good. Yeah.

• 53:48Speaker 02

  Or there's been a suicide attempt. I mean, it's usually people with NPD don't talk about their suicidality. There just will be a serious higher lethality, higher risk, you know, suicidal suicidal behavior. And that's the downstream behavioral consequence of the capsizing of that sense of self. That's more abstracted, that's healthier, mentalizing. That's gone. It's all become concretely fused with, you know, the professional failure or the marital failure or having a double life exposed or whatever it was that happened concretely. But the injury is to how I see myself.

• 54:27Speaker 01

  And David, I would say here, this is really where this I think is crucial for treatment. Because, and we would propose, in order to help somebody with narcissism, we need to get a, what are those conditions that they base their self-esteem on? And we've got to put that front and center in the treatment and help them begin to kind of reflect on that, rather than just running with it.

• 54:51David Puder?

  Okay, so, so this is really good. So it's like, um, I, I, I hope other people who are listening to this have epiphanies as well. I'm like thinking of some patients, I'm like, oh gosh, that makes so much sense. But I don't know if I tell them that they're narcissistic. And it sounds like, that's like part of the label of your program. It's like, how do you get true narcissists to go to a program with narcissist in the label? You know, like maybe, I would have like spouses of people sending their husband there. Yeah, any thoughts on that? Just brief side note.

• 55:28Speaker 01

  Well, so we do it a very, it's a big part of the treatment. We provide them a claim. I think Anthony, I'll be curious here what you think, and if it's any different in the UK. But, um, you know, one of the groups that I run is M B T for narcissistic personality disorder. And when I started that group, the feedback that I got from every, you know, a lot of people around the hospital was like, you can't call it that. Can't call it, you know, M B T for narcissism. Call it M B T for people with interpersonal problems. And so, but there is a stigma that's associated with narcissism that is really, I think, can like hinder these folks. So in terms of giving the diagnosis, I would say, and we have a whole chapter in this on the book of how to give the diagnosis in an experienced near way.

• 56:13Speaker 01

  But I would propose, it's really, really important because so often with these patients, you're going to reach a point very soon in the treatment where they're going to be insisted that the problem is outside of them.

• 56:28Speaker 01

  And often we need the diagnosis in play and agreed upon to have enough therapeutic leverage to actually look at it in treatment. So that's why we give the diagnosis.

• 56:40Speaker 03

  Well, in fairness, M B T itself, and mentalizing, doesn't require a diagnosis in a sense, because it's a transdiagnostic concept anyway. And what it requires us to do in the early phase, as Bob's explaining, is to actually get the assessment done so they begin to recognize what the mentalizing areas of difficulty are. And then we might be able to say, and I think Bob always mentions this, we tend not to necessarily say narcissistic personality disorder, but we do say that there's a pathological narcissism operating here. And it's pathological because it's leading to trouble for them and their self-esteem management, and also

• 57:20Speaker 03

  in their lives, in their relationships. And it really is what we mean. So we can then actually normalize narcissism. It's a perfectly legitimate experience for all of us. We have to have a level of narcissism. The problem here is it either become vulnerable or over soufflé, you know, there's too many eggs in the soufflé and so on. So we've just got to moderate and help moderate. So it's not something that we need to put across as you're pathological here in a way like, you know, so on. But we do say it's a P N, pathological narcissism, I say, but not a category of personality disorder necessarily.

• 58:00Speaker 02

  Very quick coda on that. You know, this is really a standard piece of M B T is that we're not just looking for the patient then to be parroting back to us, okay, I have pathological narcissism, or I have this disorder, but that we deliver a formulation that's very experienced near to the patient. And that's part of standard M B T. We've just kind of, you know, airlifted that into M B T for narcissism. But it has a few tweaks because we're going to be sure that we are saying something in our formulation after the first four weeks of assessment about what are the conditions for self-esteem and self-worth that this individual holds. We have to get to that as clinicians. So we do specifically assess that.

• 58:42Speaker 02

  And we want to give it back to the patient in language that's experienced near empathic. And as Anthony says, it's on the continuum of what we've all got to manage in ourselves. And that normalizing component is really at the, at the heart of M B T for me anyway. It's got to be talked about explicitly and we do need the patient to see it in some way within themselves. And agree and agree that it's got to be worked on in this treatment to move forward.

• 59:10David Puder?

  So shall we, shall we do a role play on that, Brandon? And I'll be, tell me, tell me what the scenario is. Tell me who I am.

• 59:18Speaker 02

  I'll tell you who you are.

• 59:21David Puder?

  What are my, what, what is the insult?

• 59:24Speaker 02

  That's your eye mode. You need you to stabilize who you're going to be.

• 59:29David Puder?

  No, Brandon, I need you to tell me what is my failure that I've had that has led me to see you. Cause I, I don't know what it is.

• 59:36Speaker 02

  It's like, it's like when you and I were talking about, you know, how you became suicidal after you were waiting for that, you know, 14th letter from that 14th graduate school that you applied to. And I think you told me in our assessment sessions that as each of those, as you're coming to the end of your undergraduate, you know, final year. And you were, you had this certainty that you were going to get in at least to one of these programs. And, you know, it seems to me that actually something really important happened there with each rejection letter that you got as it rolled in. You told me that you felt more and more nervous. You didn't want to think about it. But you just kept, part of you kept waiting for that, that, that next letter to roll in.

• 1:00:19Speaker 02

  But when that 14th out of 14 letters came in and you took that overdose. You know, I think you and I have been trying to, to understand together how those things might be connected. And one of the things I think I've understood in trying to get to know you this last month is that something intolerable happened for you there within your sense of yourself when you got that 14th rejection. And you couldn't see a way forward.

• 1:00:44David Puder?

  Yep.

• 1:00:44Speaker 02

  You couldn't feel there was anything left in yourself worth hanging on to. So you just had to end it.

• 1:00:50David Puder?

  The, I think that the thing, the thing that jumps out to my mind. Brandon, if I can call you by your first name.

• 1:00:57Speaker 02

  As my patients do.

• 1:01:00David Puder?

  I, um, the thing that comes to my mind is, is, is my best friend got in everywhere. And to all the graduate programs that I didn't get into. And so here's the guy.

• 1:01:09Speaker 02

  And what was happening for you when you saw your best friend getting all these acceptances that you weren't getting?

• 1:01:15David Puder?

  Oh, I was so, I, I was just irate. I was like, we studied together. We took all the same classes. We were in research lab together. Pretty much the same identical person in terms of like grades and extracurriculars. And here he gets in everywhere and I don't get in anywhere. And I'm just like, what the heck?

• 1:01:36Speaker 02

  I mean, really getting a picture of that, the irate-ness that you said, you know, I can see that quite clearly, actually. Was it, what else was going on around that? I was just reminded of what you said earlier about how you were banking on. You, you had your whole sense of your future kind of mapped out based on getting in. And, and what was, what happened when you, when you saw that that, that door was closed for you? What else was going on, if anything?

• 1:02:03David Puder?

  Um.

• 1:02:07David Puder?

  I think I just started waking up in the middle of the night with my fist clenched. And I would just think about like, like, how could they not see? You know, how awesome I would be. Like I.

• 1:02:25Speaker 02

  So when it was challenging your sense of whether people could see how awesome you are, how were you feeling about yourself?

• 1:02:35David Puder?

  I was feeling

• 1:02:38David Puder?

  rage at them. I don't know if I was feeling at myself at all. I, I.

• 1:02:45Speaker 02

  Well, you did, you did go on to then, I think, do something pretty serious to yourself.

• 1:02:51Speaker 02

  Well, what else? Were there any other emotions around that? There's the anger at them. But I wondered if there was anything.

• 1:02:58David Puder?

  Yeah, and I think this is. I think this is why I went to my stepdad's house because that was where. It was like a fuck you dad, stepdad, uncle, person I barely know. You know, like, I mean.

• 1:03:15David Puder?

  I know, I know what he expected of me, but I think like I took the pills right there in his. In his bathroom as a big fuck you.

• 1:03:26Speaker 02

  What were you hoping that that would change within yourself?

• 1:03:30David Puder?

  I, I just was hoping it would, it would.

• 1:03:34David Puder?

  Let him take the. You know. Let, let him actually feel some guilt for the harm he called me, caused me over the years.

• 1:03:43Speaker 02

  Did you have a sense of how that would feel differently for you if you were able to cause him to feel guilt?

• 1:03:56David Puder?

  I, I, I'm noticing I said, instead of caused me, I said, called me. You know, and I think it was him calling me all sorts of names when I.

• 1:04:07David Puder?

  Wouldn't amount to shit.

• 1:04:10David Puder?

  I'm sorry, I forgot your question.

• 1:04:11Speaker 02

  Well, anyway, we could keep going.

• 1:04:13David Puder?

  No, this is good.

• 1:04:14Speaker 02

  And I think it's, I think this so far, I mean, if I can tag out.

• 1:04:18David Puder?

  Was it getting, was it getting too real there? Was it getting too uncomfortable?

• 1:04:21Speaker 02

  No, I think Bob and Anthony would each do that a little differently, I think. But, um, you know, it's around exploring suicidality. You know, we're particularly interested in NPD or pathological narcissism and getting a hold of. You know, what's going on within the sense of self, feelings about self? And so we've got a piece of the anger there that's really clear, but I was trying, you know, not so successfully. But to kind of push the curiosity about how's this person evaluating and feeling about their sense of worth? Competence, their sense of having a future.

• 1:04:54David Puder?

  Yeah.

• 1:04:55Speaker 02

  Sense of measuring up expectations, but Bob would probably do it differently.

• 1:04:59David Puder?

  And I want to hear Bob's debrief here. Bob looks excited.

• 1:05:03Speaker 01

  I love that. Brandon, no, I wouldn't have done it differently because I think Brandon was doing the right moves there. You were asking, you got at the impression about reality in the situation that was triggering. And said, how did that make you feel about yourself? But you're very externally focused, David. So I think I, and this may not work what I'm about to do, but I think one last gasp I would try at this. And I would just sort of say, I'm just curious, you know, David, as we're talking about this, I keep asking about your emotions around self and self-esteem. And all I'm hearing is like the anger at other people, which is fine. But I'm just curious, do you have any negative feelings about yourself around getting rejected and all these ways?

• 1:05:47David Puder?

  Yeah, and I think this is where I was, what I think I've, it's kind of entered into my mind while we're here.

• 1:05:56Speaker 01

  Okay.

• 1:05:59David Puder?

  And I don't want to go easy mode on you, Bob, and difficulty mode number 10 on Brandon here. But we'll consider you guys the same person.

• 1:06:10Speaker 01

  Brandon's interventions were great, so I'm riding on them right now. Yeah.

• 1:06:17David Puder?

  Okay, let's let me get back into it.

• 1:06:20David Puder?

  What I was saying was that I was like, when you asked me that question earlier, I think I thought about my stepdad and his role in this. Because I think, I think I was, I internalized some of his anger and need for me to do things perfect.

• 1:06:41Speaker 01

  Okay.

• 1:06:42David Puder?

  And I think that's part of why my anger was turned towards him.

• 1:06:49Speaker 01

  So you're kind of explaining it, David, which I totally appreciate. But I just generally want to know, how did it make you feel to get rejected by those 14 grad schools? Like, other than anger, what else was in there for you?

• 1:07:04David Puder?

  You know, embarrassment.

• 1:07:07Speaker 01

  Okay.

• 1:07:08David Puder?

  I was incredibly embarrassed. I didn't want to tell anyone and I thought it would be better to kill myself than to tell anyone that I didn't get in. So I actually burned all of the letters before I killed myself. So that no one would find if I successfully killed myself, no one would know.

• 1:07:23Speaker 01

  Wow. Well, yeah, absolutely. Like it literally would be better to not exist than it would be to have to feel that sense of embarrassment. Yeah. I wonder, I mean, what do you think if we were to use this treatment to kind of work on this? Cause that's what stood out to me is kind of.

• 1:07:40David Puder?

  It was a, it was a, it was a punch in the gut.

• 1:07:43Speaker 01

  Yeah.

• 1:07:43David Puder?

  Yeah, I felt, I felt a literal punch in the gut. Like it was, it was like someone had hit me.

• 1:07:49Speaker 01

  Yeah. Yeah. It, I don't know what you think about this, but it does strike me, there is a way in which you can really base your sense of self-worth on these, these external things. I don't know if you would agree with that.

• 1:08:03David Puder?

  Yeah, because that's what matters in life. Like if I can't get through school, grad school, then I can't become, you know, um, an aerospace engineer in the way that I want to.

• 1:08:17Speaker 01

  Okay.

• 1:08:18David Puder?

  And so what, what do, what else do I do? There's no plan B for me. There's only plan A.

• 1:08:24Speaker 01

  So I need to succeed? I need to kind of have professional success in order to even have a life, actually?

• 1:08:32David Puder?

  I mean, does, doesn't that make sense to you?

• 1:08:36Speaker 01

  Well, so.

• 1:08:36David Puder?

  Isn't that what's happened? I mean, you obviously have success and are here and have got through grad school and.

• 1:08:42Speaker 01

  I guess just throw this out there. I'm not trying to disagree with you, but I'm worried about it. Because I'm worried that, that it's like you're putting all your eggs in that basket and what happens when the basket topples? So you, you want to kill yourself. So I'm interested in like using this treatment. I don't know what you think to help you with that. So you're less vulnerable. And what do you, what would you think about like trying to use this treatment to kind of help you with that?

• 1:09:11David Puder?

  As much as I don't like the word vulnerable, I think, yeah, maybe, maybe give it a shot.

• 1:09:19Speaker 01

  All right.

• 1:09:19Speaker 03

  So what's it like, David, then, if you are coming into treatment, sort of seeing someone like me, who you just said you see as really quite successful, comparing, as you're saying to yourself, who I understand it even in the middle of the night, it begins to sound like you're thinking yourself as unsuccessful, not worthy of anything.

• 1:09:39David Puder?

  Yeah, you know, I just don't think there's any way that you could know how this feels, because you have obtained the pinnacle of success.

• 1:09:50Speaker 03

  Yeah. So what's it like, can I put it back to you again, what's it like you actually sitting, discussing this with me, because we're gonna have to sit here quite regularly to try and work on this.

• 1:10:02David Puder?

  I feel like you have no clue what this is really like. I think you are, you're trained and you know kind of what to say, but deep down inside, you have no idea what it feels like to really fail like this.

• 1:10:16Speaker 03

  Yeah, you're quite right, in a sense. So that's why I'm trying to find out how it does feel for you just at the moment, especially being in a world where you see me as successful and yourself as unsuccessful. I don't know what that's like.

• 1:10:30David Puder?

  It feels horrible, gut wrenching. It feels like

• 1:10:41David Puder?

  therapy is the most painful thing, and I question if I should even do this.

• 1:10:47Speaker 03

  Yeah, absolutely, yeah.

• 1:10:49David Puder?

  I just read this book called Something Like Awful Therapy, and it said therapy isn't helpful, and I'm wondering if this is gonna be helpful.

• 1:10:56Speaker 03

  Yeah. But that's quite an elephant for us, isn't it? I mean, I think we might have to sort of put that on the table and sort of know that actually every time we're meeting, that actually there's a dangerously painful sort of place around potentially, particularly created a bit by you seeing me as so successful as well and yourself as unsuccessful. Can we put that down as something we need to really watch out for?

• 1:11:25David Puder?

  Great. Yeah. I mean, another thing that I'm failing at, I guess.

• 1:11:33David Puder?

  Sorry, I'm just like, it's kind of comical because I'm like, I know. No, no, and I know, I know that you.

• 1:11:40Speaker 03

  Saying tries to get it to sort of the relational area, particularly right at the beginning. I think Bob was taking up as well and Brandon a little bit, but initially what we call pretend mode. You have these sorts of explanations for things which were rather, in my view, rather sort of over explanatory. Try, well, it's because my stepfather was like this and therefore I've learned to do that. And that's why I'm like, I am, you think, oh, well, that's fine then off we go home. We've explained it all, but actually this is what we call pretend mode where you actually over explain things. It's not really rooted in reality. It's not grounded in a sense. It doesn't link really through to coherent memory, coherent narrative of one's history and so on.

• 1:12:24Speaker 03

  It's just sort of thrown out into the world and so on. And we then have a problem because pretend mode is very common in narcissistic function.

• 1:12:35David Puder?

  Interesting. Okay. So this is, um, wow. And both all three of you guys, awesome. Just awesome. Like I, I don't want you to feel like I'm like, I, I, I was, I was being very difficult.

• 1:12:48Speaker 01

  David, you're awesome. You need to like go into acting. I mean, amazing.

• 1:12:53David Puder?

  Can I tell you, Bob, like, I mean, and I've, I've, I've told this before, but like, I tried out for Berkeley acting class and I could not get in.

• 1:13:01Speaker 01

  What?

• 1:13:02David Puder?

  Yeah, I did not get into their.

• 1:13:04Speaker 01

  Write a letter.

• 1:13:04David Puder?

  I did not get into their intro to acting class. And so whatever my patients tell me that I feel like you're acting, I'm like, no, I'm not a good actor. I like my.

• 1:13:18Speaker 02

  That's that genuineness of MBT. And I just, you know, you saw that, I think, in Anthony's sort of final response there, the patient says, you can't know what this is like. He just says, quite right. You have to tell me. I am trying to find out what it's like. I need your help with that. Can we do some of that together? Can we try? And that's so central in MBT in general, just giving the patient the experience. Someone's trying to find out about my mind, even if they can't possibly get it exactly right. There's a lot of that BPD work, but I think it comes out in a different way with NPD tolerating these inevitable misalignments. We're never going to get it exactly right.

• 1:14:00Speaker 02

  And that itself is more of a trigger, I think, in NPD than BPD. So we have to be very ready to just roll with that and actually lean into it, as Anthony did. You, you, you got me pegged. I can't understand it. I don't understand it. Can you try to explain it to me?

• 1:14:17Speaker 01

  Um, I see that Anthony has to go shortly. David, you had asked the question about problems in empathy. And Anthony has done so much work with this around the antisocial stuff and it's so treating narcissism. I don't know if we could hear about that.

• 1:14:30David Puder?

  I'm super curious. Yeah. And I'm specifically curious because I've always thought that some people with narcissism also have like dark triad psychopathy. And psychopathy, I think, is a deficit of affective empathy. And so I'm curious, Anthony, your thoughts on this? Like, it seems to me that once you go beyond a certain level of psychopathy, there's, there's not a lot of help that therapy can bring you. And I also think, Anthony, just to kind of deepen this, just to give you kind of download my, my thoughts as we go into this.

• 1:15:06David Puder?

  When you did the, when Foneggi did the reflective manual, the people who were in the prison had the lowest scores on the reflective function, uh, lower than the psychiatric hospital. And so I found that specifically interesting when you think about, a lot of them are there for violence. A lot of them are not putting to words their aggression, but they're acting it out on the world. So, okay.

• 1:15:33Speaker 03

  Yeah, yeah, I mean, your question is unanswerable, but I'm going to slightly reverse it. But I think you're quite right, and it's in the literature about the absence of the affective empathy sort of component as you move towards the psychopathy sort of way of the mind, the psychopathic way of the mind functioning, in a sense. It has no concern of other minds at all, to a large degree. And that's a big problem. But I think the thing that people might like to think about is that this sort of reverse occurs, that in a sense you have a counter-relational problem to this. So that they're not curious about your mind, in a sense.

• 1:16:17Speaker 03

  And actually, they also, you can be with someone with strong psychopathic traits and realise that, this is going to sound odd, that their mind is not transmitting. So it's really difficult to read what's in their mind. In fact, and I think whether they are deliberately covering up what's in their mind, say, or actually they simply don't naturally transmit their mental states to others, in other words, they're walled off, they're kind of secret, in a sense, is incredibly discomforting for the other person. So you're kind of with someone who actually doesn't seem to want to read you, but you equally can't read them.

• 1:17:00David Puder?

  Hmm.

• 1:17:02Speaker 03

  And you try, and you ask them, and you get a blank, in a sense. You may get verbalisation, but it's cold, it's, it doesn't seem to root in some way. So you have quite a problematic counter responsiveness in these situations. So then it's very hard for you to be empathically validating to them.

• 1:17:22David Puder?

  Hmm.

• 1:17:23Speaker 03

  Because you can't read it.

• 1:17:24David Puder?

  Yeah.

• 1:17:25Speaker 03

  Um. So I I think uh in general, the antisocial with with uh who also may have some levels of affective empathy problems, they don't care about the other in a sense, or they don't then feel guilty about how the other experiences something, for example, they don't get the feedback system, they do tend to actually transmit, so they're they're not very good liars of mental state, if you see what I mean. They tend to be able, they tend to say, no, I don't feel like that, and yet it's kind of obvious they that they're they're that's what they're expressing, and so you've got something to hook into uh when you're kind of working with them. And that's rather different.

• 1:18:08David Puder?

  Okay, so we're talking, uh I think, like, when I think antisocial personality disorder, it's like, I'm thinking DSM five, like, we're charac-, you know, people who end up in prison, they're doing illegal activities, they could have some psychopathy. They could, they could have lower levels of psychopathy and just be kind of more of the the baked in a bad environment, um but surrounded by by people who are like, you know, doing criminal acts and they themselves get kind of pulled into it. Um, are you are you treating um which which category of people do you normally come across? Are you doing a psychopathy checklist?

• 1:18:46Speaker 03

  Trial, we were treating those with uh uh well, the issue is aggression in a way, isn't it? Or the the the uh violence um that ensues, uh and that was what we were really asked. So it so it was the group with antisocial who were recidivist violent uh criminals. Uh, so so they were uh responding to um uh provocation or general stressors, if you like, in life, simply through violence, so they were re- repeated violent offenders.

• 1:19:18David Puder?

  And was it more impulsive violence, or was it like a predatory violence?

• 1:19:23Speaker 03

  It was more impulsive violence, but we measured their psychopathic sort of levels.

• 1:19:29David Puder?

  Uh, okay.

• 1:19:30Speaker 03

  And that was a range, uh actually, from low levels to much higher, up to twenty nine Europeans, which is thirty two, thirty four. Um, US measure on the PCL.

• 1:19:43David Puder?

  Okay, okay. So then, wow. Okay. So you're dealing with some true psychopathic individuals at that point.

• 1:19:49Speaker 03

  Well, yeah, yeah. To be honest, we were trying not to.

• 1:19:53David Puder?

  Okay.

• 1:19:55Speaker 03

  You know, but we were measuring the PCL because we had a cutoff of twenty nine.

• 1:19:59David Puder?

  And then so what did, what, what did you find in the research?

• 1:20:03Speaker 03

  Well, I'm not at liberty to say what we found in a sense because it's not yet published, but for the antisocial violence, we can say that were positive outcomes for improving their mentalizing. So uh, in a sense, we were working on the basis that the problem with aggression is that aggression is a necessary survival phenomenon and so on. Um, and mentalizing is inhibitory in that sense. So we block being violent in the main. We may experience a sense, oh, I want to, you know, get rid of someone or hit them or whatever.

• 1:20:41Speaker 03

  Uh, when we're five and we bash them a bit, you know, but gradually mentalizing takes over, we socialize and we actually inhibit. And the problem is that um, uh, mentalizing therefore is, is a partial mediator towards aggression and violence. Uh, and it's an inhibitory mechanism. So if it's not working well, you know, impulsivity comes through and so on. So we improve.

• 1:21:06David Puder?

  Wonderful.

• 1:21:07Speaker 03

  Reduce their violence.

• 1:21:10Speaker 01

  So I just want to make sure to speak to this because Anthony is sort of talking about antisocial and when, when we're like in terms of the folks that we're more likely to see at McLean. And I don't know if this applies, if you would agree with this, Brandon, but the, whenever I give this sort of narcissism diagnosis, the most common response that I get is, but I can't be narcissistic because I don't really, I, it's not that I lack empathy. So, and I really think it's important to not like to basically to think about this more dimensionally. And so the way that sort of we explain it to patients is like, absolutely. I'm not in any way saying that you don't have empathy. The challenge is though, is that sometimes it seems to me that when your sense of self-worth is threatened,

• 1:21:55Speaker 01

  it can be harder for you to empathize with others. You're more likely to go to a place of anger than empathy. I don't know what you think of that. And then patients usually will be able to see themselves in it. So we sort of see it as more context-dependent and pathic deficits rather than countercultural empathic deficits.

• 1:22:12David Puder?

  Do you, do you think we all have that to some degree? And I like, cause I feel like when I'm really tired or like, you know, after nine hours of seeing clients and I'm hungry, it's like, sometimes I'm just like, can I just eat before we have this discussion? I need my brain to like, come back on, you know?

• 1:22:33Speaker 01

  Absolutely. And I would say that's really in service of like, we would say that to patients directly. Like this is not a, this is not just a you thing or a narcissism thing. This is a human thing. When our self-esteem is under threat, it can be harder for us to put ourself in other shoes. And so hopefully like normalizing that can make it feel less like a dig or something. Brandon, what do you think about this?

• 1:22:56Speaker 02

  That's exactly how we normalize it. It's just, yeah, when, when any of us at the core of how we see ourselves are destabilized or dealing with some really rotten, disappointed sense of ourselves. You know, it makes total intuitive sense really that we're not in, gonna be in the optimal circumstance for paying close, curious, caring attention to what's going on in other people's experiences. You just kind of normalize it like that. And without wanting to explain away what's kind of unique about narcissistic problems. But it is on that spectrum of that continuum of normal human experience. We had a very poignant example, actually of this, just at the Gunderson residence earlier this week.

• 1:23:38Speaker 02

  In our M B T group, one of our patients had been given Formerly the diagnosis of NPD. And this is her mentalizing question that she opened the group with. It wasn't so much a question as a statement. I I can't be NPD because, as Bob said, because I I can be quite empathic sometimes. Isn't that how all of you experienced me, kind of looking around to others in the group? And what was actually really poignant is that other group members, as we focused on her for the course of an hour or so, were able to actually empathically and gently give examples where they could see both at moments she could be quite empathic and interested and attuned.

• 1:24:19Speaker 02

  But at other moments, and it was in these moments where there was these threats to self-esteem. In those moments, others' experience of her was that she was not interested or curious about them. And that could be happening when she was quite aggressive and really doing damage in these relationships. And other people would feel totally kind of, you know, bewildered by, you know, angry with her. And but she's kind of left in a vacuum of really dealing with her own feelings about herself and just missing other people's experience. So it was quite poignant. And I I think that by the end of the group, it just shook up that sense.

• 1:24:56David Puder?

  Let me, I just want to say, Dr. Dr. Baiman, thank you so much for coming on. I really appreciate you. And it's it's a, I think there was a comment earlier like, oh, we're so glad you guys are talking. My podcast is talking about mentalization. And and honestly, like, it's it's an honor just even talk to you face to face. That's the way I feel as someone who like has read your book since I was a resident, you know, appreciate you so.

• 1:25:22Speaker 03

  That'll that'll fuel my narcissism for the time being. Thank you very much for having me.

• 1:25:28Speaker 01

  Thanks for coming, Anthony, making the time.

• 1:25:32Speaker 01

  Um, David, I think that what Brandon's saying also, just from a technical standpoint, because I know so many of your listeners are psychotherapists who want to know how to treat narcissism. I think that what happened in in Brandon's group really illustrates a key part of treating empathic deficits and narcissism, which is that at the start of treatment, we write up, I don't know how much, you know, you sort of folks are aware, but we write up what's called an MDT formulation, which is a, which is a written document, itemizing patients' problems and mentalizing. And this is where we put.

• 1:26:03David Puder?

  And is that, is that for yourself or is that for sharing with the patient?

• 1:26:07Speaker 01

  We write it up, we give it to patients, we get feedback about it and we.

• 1:26:11David Puder?

  Oh.

• 1:26:12Speaker 01

  As a focus for treatment, it kind of guides the whole treatment.

• 1:26:15David Puder?

  Is this what you do in a like a one-on-one private practice or is this what you do in like a group therapy setting?

• 1:26:21Speaker 01

  Yeah, all the research on MBT's outcomes include having a formulation and for individual MBT includes a formulation. So even in our private practice, we're writing formulations for people.

• 1:26:32David Puder?

  Okay, so you write the formulation, you give it to the person, how does that go?

• 1:26:37Speaker 01

  Well, so just for, well, we can talk about that, but I just want to make sure the empathy point isn't missed is that we gotta put the problems of empathy in the formulation. And it'll be, sometimes it seems to me when you disagree with people, it can be harder for you to put, put yourself in their shoes. And or you can see what they're feeling, but you don't always fully care. That's your point about affective empathy, put that in the formulation. And then where's, there's a reaction, how does it go? There's often pushback, disagreement, we're curious about it, we kind of play with it together. But, um, but we end up sort of using the treatment to actually help with those issues.

• 1:27:18David Puder?

  Hmm, okay. Yeah, that's really, that's good.

• 1:27:24Speaker 01

  Ready to know any more about how it goes?

• 1:27:26Speaker 02

  Well, just to emphasize, we set that up as again, within the kind of two-person intersubjective model. So we usually will preface this, well, first of all, we tell the patient that we're going to have, you know, a series of four or so assessment sessions. I'm just going to be asking you questions, trying to get to know you as a person, what problems you're coming in with, what your goals are for treatment, like you would with any new case. But then we tell them early on, you know, there's some structure to this. After a month or so of meeting, I'm going to actually, you know, go through this exercise of writing down as best I can see it. My understanding, what I think I've heard from you about your difficulties, your symptoms, you know, how they kind of make sense and connect to challenges in mentalizing.

• 1:28:10Speaker 02

  And some predictions about how it might go if we begin formal treatment together. And so you had an example of that earlier where Anthony's saying, we've got to keep an eye out for that, that elephant in the room between us that. You know, there's a sense that I can't possibly understand you because I'm too successful and you're too much of a failure. So those kind of things we would put in, in writing, along with the kind of catalog, as we've understood it, that's experienced near of the patient's difficulties in their functional realities, you know, how they are in relationships. If people regard them as unempathic, if their spouse, their partner, their friends, their boss, we're gonna have gotten that information and we're gonna put that into the formulation. This is a goal for treatment.

• 1:28:55Speaker 02

  We're going to work on your capacity to tune in with curiosity and interest to the experiences of others, especially when your sense of self is threatened or you're feeling rotten about your accomplishments. And so all that's made explicit, it's on paper, and patients usually get interested in this. Well, oh, that's coming. Okay, maybe I'll stick around for that and see what this person's got to say about me. And even if they see it with a very critical kind of scrutinizing lens, we just welcome that. You know, we say to people, get your red pen ready. You know, I would like you to come in and tell me what you would correct, what you would change, what you think I got wrong. So we really just invite that, you know, help me understand better.

• 1:29:39Speaker 02

  That doesn't mean we'll necessarily change everything, but we will. What we think this does is it accelerates the process of, it gets some of those implicit relational processes that maybe we don't usually talk about so early in treatment with these patients for fear of upsetting them too quickly. It gets those up to the surface and it gets us talking about them, we find, more quickly, earlier in the treatment. Helps with treatment dropout.

• 1:30:05David Puder?

  That's good. Yeah, no, it, it, it, it sounds like it really makes sense, especially with this population. And, but you're also doing this with like borderline precise disorder, all your patients, right, at that center?

• 1:30:17Speaker 01

  Yeah, it's one of the distinguishing features. What makes it different from just traditional psychodynamic psychotherapy because we're putting stuff in writing, revising, and then that becomes the, the target of treatment. Yeah.

• 1:30:28David Puder?

  Interesting. Okay. Yeah. And then also like there's difficulty in tolerating ambiguity, black and white thinking, that's another mismentalizing thing that you commonly see, right? Is that correct? Brandon, you don't look like.

• 1:30:46Speaker 02

  I'm agreeing, I'm letting Bob take this one, but absolutely, black, I mean, there's particular forms of black and white thinking and that manifest characteristically in NPD, supposed to be PD.

• 1:31:00Speaker 01

  A lot of this falls under the kind of category of the certainty that we talked about earlier, you know, different versions of the certainty. The only thing that I would add to it that we didn't get to in the role play that's really, really important is that we're trying to help the patient see their perspective, as Anthony described it, broadening it, but at the end of that, we're also going to share our distinct perspective.

• 1:31:25Speaker 01

  And so that's a really crucial piece. A lot of times clinicians can feel afraid of being forthright with these patients because of the devaluation that you've so expertly kind of role-played today, David, and so we can hold back our truth.

• 1:31:41David Puder?

  What, you're calling me an expert on devaluation, are you?

• 1:31:45Speaker 01

  An expert at role-playing devaluation. Yeah, yeah. But, but, but basically, but the point is, we can hold back how we see things out of fear of getting a negative reaction. So we have to be willing to actually say at the end of it, once we've explored their perspective, what's their perspective, what supports it, help them hopefully see things from more nuance, like that patient we talked about earlier, who was devaluing his wife and he's, oh, she's okay on Tuesdays, not on Wednesdays. And then at the end of that, I am going to have to say something like, well, I gotta admit, I know your wife can sometimes be critical of you. I've, it's also stood out to me sometimes that you can actually be quite critical of her.

• 1:32:30David Puder?

  Ooh.

• 1:32:32Speaker 01

  What, what did you just feel?

• 1:32:34David Puder?

  But I'm only critical of her because she's critical of me.

• 1:32:38Speaker 01

  I hear you.

• 1:32:39David Puder?

  No, I'm joking.

• 1:32:40Speaker 01

  Yeah, so that's the idea. So we gotta bring in our perspective and it often does hurt a little bit, but that's how we help people, that's how we help patients begin to consider these other perspectives. And the idea is if they can do that with us, they're going to be able to do that more easily with people outside their room.

• 1:32:59Speaker 02

  And think about that, what that requires the patient to do, actually, and why we put this at the end of the interventional pathways. Once we've already kind of got mentalizing, restabilized somewhat, only then would we do something like what Bob just did. Because that's, again, inherently more challenging for all of us to grapple with this kind of input or feedback, you know, how we're seen from the outside. That's really different for how I see myself. That's hard for all of us. It's maybe harder if you've got NPD. So that comes at the tail end of all these more contingent interventions to flesh out horizontally the nuance, the gray area, the uncertainty within the patient's current

• 1:33:41Speaker 02

  perspective. And then we think, there's a bit more mentalizing online, maybe there's room now to at least, it's not to try to get them to agree with us. We're never trying to just persuade, like a cognitive therapy, like persuade of an alternate perspective. We're trying to get mentalizing going, which is all about just perspective-taking and reflecting on the myriad coexisting perspectives that exist at any one time. And can this patient do something, reckon with the fact that Bob has this additional thing that he's throwing in, whether or not I see it in myself? So what do I do with that? Can I, can I consider it? Can I take it up reflectively or not? That's what we're aiming for.

• 1:34:27David Puder?

  Well, I'm having some transference developing with you guys where I feel like I would really enjoy. A dual relationship of going out to a good meal or something.

• 1:34:37Speaker 01

  I know it's too bad you live in Florida. I mean, not too bad. For us, it's too bad.

• 1:34:42Speaker 02

  Tell us when to come, David.

• 1:34:45David Puder?

  Man, would you guys fly down?

• 1:34:47Speaker 02

  It's going into wintertime here.

• 1:34:49David Puder?

  There's some really good food down here. We should, we should make that happen and we could do our next one in person.

• 1:34:57Speaker 01

  I really appreciate it. I didn't expect, just to be frank, I mean, I, I was a little worried about joining just because I'm sort of, you know, don't sort of tend to do these sorts of podcasts, but it was genuinely fun actually talking about this stuff with you.

• 1:35:11David Puder?

  Yeah, well, I mean, you guys are like, you guys are in the trenches, right? So it's like, it's my job to make, to try to pull out your, the wisdom of being in the trenches with this population. I feel like, you know, you guys have a lot of, a lot of experience, a lot of wisdom on treating this population. I appreciate having this conversation where other people, you know, across the world can hear it.

• 1:35:36David Puder?

  And hopefully it can spark their curiosity where they want to continue to learn more. And so kind of as we wrap this up, like, are, what are, are there any big categories, any pearls that you have that we haven't really hit on that you want to just reemphasize?

• 1:35:51Speaker 01

  Hmm, uh huh. Good question. Oh, yeah, yeah. I do, actually, I do, I do have, I have one thought, actually, yeah, yeah. And it relates to the stuff you were asking about the ruptures in self-esteem.

• 1:36:05David Puder?

  Okay.

• 1:36:05Speaker 01

  So that for me is, in the teleological self-esteem stuff, we also need to actually put very, very clearly in the formulation, something like, you tend to base your sense of self-esteem on blank.

• 1:36:19David Puder?

  Okay.

• 1:36:20Speaker 01

  Okay. Really, really important. And inevitably, as you're moving through the treatment, there are going to be moments of emotional disruption that are linked to that. And then those, those are like crucial moments for the treatment because then I've got to be able to say, okay, so we get there. It's like, it almost, it sounds like that your, your boss seeing you that way really made you quite, feel quite bad about yourself.

• 1:36:45David Puder?

  Yep.

• 1:36:46Speaker 01

  This reminds me of what we kind of talked about before, how you can kind of base your self-esteem on achievement and other person's views. Can we look about that a little bit? This idea that you're bad because she sees you in a negative light.

• 1:37:01Speaker 01

  Could we look at that? And so you actually then have to transition to actually try to stimulate reflection about this idea that their value rests on outside things. And without that, I would say these narcissistic processes just continue because the person just keeps feeling horrible about themselves when the world doesn't kind of meet them where they're hoping it will meet them.

• 1:37:28David Puder?

  Yeah, yeah, that's, that's really helpful. This is really good. It makes me think of so many things with so many things I'll have to say offline. I can't say on the podcast type of things.

• 1:37:40Speaker 01

  Okay.

• 1:37:40David Puder?

  But, um, okay. But yeah, okay, Bob, one more question before, before we get off with, with, with this for you. Like, what led to you getting so excited about this field? Like, what, what drew you in?

• 1:37:53Speaker 01

  Well, interestingly, so I worked, when I was first trained in MDT, I worked at the VA. I was at the Veterans Administration and I was doing a lot of individual MDT with patients. I started up like three MDT groups. We knew these folks had characterological disorders. I think at the time, I probably put them more in the BPD camp because there was a suicidality that Brandon had kind of mentioned. But then, when we started learning more, there's a huge amount of research done in the past 10 years on treating narcissism. I came back to McLean, met Brandon, sort of we were working together, and we started realizing, oh, gosh, these patients likely meet criteria for

• 1:38:35Speaker 01

  NPD. So, but what was kind of interesting about it is that I realized that a lot of those patients I was treating at the VA who was very disconnected from their emotions, they leave the military, they're feeling horrible about themselves. There's a big emphasis on strength, power. A lot of them had NPD. And so, sort of a lot, you know, in that, in that respect, I'd kind of been working on this without even knowing it. And Brandon and I started kind of developing these principles for these patients in the MDT clinic. And it just sort of all kind of sprung from there. And we started finding that using the kind of adapting the principles somewhat like there's some differences between MBT for narcissism and standard MBT.

• 1:39:21Speaker 01

  These patients we found were really getting better. First patient that we diagnosed with NPD formally in the clinic. I won't get into, you know, great details on it. We know we got to stop shortly, but this is a patient who is in four times weekly psychoanalysis. Very suicidal inpatient, multiple inpatient admissions and came to us for once weekly MBT. Brandon did this person's evaluation and we ultimately diagnosed him with narcissism and gave him the treatment that we do in the clinic. And this is going to sound really out there, but within a year, Brandon did the group therapy. I did the individual therapy. Then a year of him being in treatment with us, he was no longer suicidal. He was no longer inpatient. He had no inpatient admissions.

• 1:40:06Speaker 01

  He was excelling at work. He was finally reporting feeling good about himself. And now he's sort of probably no longer meets criteria for NPD and is in his first romantic relationship of his adult life. So like when we started seeing, whoa, this is really working, we started wanting to write the treatment manual.

• 1:40:27David Puder?

  You know, a side note on that, when I think about, and I, I think that's just, first of all, it's awesome that you guys collaborated and worked with it and get to work with Bateman. I mean, how amazing. And, and I think giving him clear feedback and direction, like, hey, here's the things you need to work on. I can, I can imagine that that was very actually helpful and not as amorphous as maybe other therapy could be.

• 1:40:56David Puder?

  Okay, the, the second thought I had was I see a lot of these patients who are successful, who continue to be successful. But it's the fantasy of losing the success that actually is the distress.

• 1:41:12David Puder?

  Yeah. Brandon, what do you think about that? I love that question. Yeah.

• 1:41:15Speaker 02

  Oh, yeah, that's a really provocative question. I mean, I mean, honestly, where I go just in my heart, listening to that question is, gosh, yeah, I mean, do we all have that a bit? I mean, I mean, it just, it makes me go to where I was going to close my piece, just to say that I think one reason this work is so gratifying is because, and I think Bob McRae feels the same way, just like with borderline patients, you know, with narcissistic patients, we can really see parts of ourselves that are on this continuum. These are, these are human problems that are quite ordinary. You know, the fears of losing, whatever it is, we've been able to accumulate for ourselves in this life, you know, we clutch it. I know I do clutch it too tightly sometimes. So that's not to minimize, you know, what's unique about having a personality disorder, but

• 1:42:01Speaker 02

  just like with borderline patients, you know, I can see in myself those, those idealizing desires for a perfect relationship, to be perfectly connected and understood. Well, in narcissism, I can also, you know, really relate to that sense of, gosh, if everything I valued that fueled my sense of self was suddenly taken away or threatened, how would I do with that? Yeah, that is a scary thought. So that doesn't answer your question necessarily, but I try to, I think both Bob and I are, try to be grounded as humble as we can in a sense of, you know, so to speak, there but for the grace of God, go I, you know, we're, we're with our patients on this kind of human adventure. It sounds a bit cheesy, but I think it does anchor us in the clinical moment

• 1:42:45Speaker 02

  when we don't know what else to do, you know, it grounds our empathy for these patients. And it's quite gratifying to see that these are universally human problems we're sometimes able to help people with in some powerful ways.

• 1:42:59David Puder?

  Very, very good. And, and that, that statement there, but by the grace of God, there go I, Paul, right? And in the midst of,

• 1:43:13David Puder?

  In the midst of trials and in the midst of success, right?

• 1:43:18David Puder?

  And I think it's almost like, I was actually thinking more of like the Stoic solution to the fantasy. But that seems like the Christian solution to the ego, right? It's the grace of God, it's not my own ability in all things. The Stoic solution is actually to imagine losing it all and to be peaceful.

• 1:43:47Speaker 01

  Well, but this is key, David, and this is how we end up treating the teleological self-esteem. Because it's like, I am only good if I have professional achievement. So then you got to ask the question along those lines. I'm just curious, if you got everything that you wanted, like, you know, can you ever imagine yourself still feeling bad? Of course I would feel bad, of course I would, I would be stressed about this, I would be stressed about that. So, oh, interesting, okay. What about had there ever been, you know, can you even try to imagine the possibility that even without this thing, you could actually have value as a person?

• 1:44:29Speaker 01

  Just try to consider that. And that is, that parallels the Stoic solution, right? The sense that we have a sense of worth and a sense of connectedness, independent of the externals. As patients begin to wrestle with that possibility, we see improvements in self-esteem and improvements in functioning.

• 1:44:48David Puder?

  Yeah.

• 1:44:49Speaker 02

  Less contingent self-esteem and sense of identity. And I don't know whether that's Stoic or Christian or what it is, but I think that's a really essential element in ultimate recovery, living with narcissistic vulnerabilities and really diminishing them over time. This is, we think this is core for this model.

• 1:45:10David Puder?

  Yeah, and I think about the other thing that kind of makes me think about is Viktor Frankl, right? And so one of his quotes, "We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man. But one thing, the last of human freedoms, to choose one's attitude in any given set of circumstances, to choose one's own way."

• 1:45:41Speaker 01

  Wow.

• 1:45:41Speaker 02

  And that's a freedom, an internal degree of mentalizing freedom that someone with NPD does not usually feel they have. If it's all taken from me, if I get those 14 rejections from graduate school, I don't have that freedom to define myself or feel worthy in any other way. And that is, that really does speak, I think, to that, that final, ultimate freedom we're trying to actually kind of grow as a nascent quality in our patients alongside them.

• 1:46:14David Puder?

  Yeah. Yeah. So I think, yeah, it's, it's, it's like, can you imagine, if you are successful, losing, but then being like Viktor Frankl and, and seeing it as a path, it's part of the hero's journey. And, you know, taking the role of the, you know, the giver, like how he chose to help out, I think, typhus patients at one point, which saved his life, actually.

• 1:46:44Speaker 01

  Well, on those lines, David, the patient that we mentioned that like was, you know, had such a tremendous recovery in, from narcissism in the MBT clinic, one of his sayings that he implemented in his relationships, which is interesting, and it's non, for him, it was not religious, but it was this question, he said, "How can I be of service to this person?" That was what, that was his mentalizing prompt.

• 1:47:11David Puder?

  Beautiful.

• 1:47:12Speaker 01

  How can I put myself in the other person's shoes and try to actually contribute to their experience? And he's found that the more that he's done that, he actually experiences an internal freedom, which I think is also related to your quote.

• 1:47:26David Puder?

  Beautiful. Well, I think that's a good place to wrap it up right there. Thank you, guys, for coming on. I appreciate you. And I do extend the offer when you come out to Orlando. Um, knows how to phrase that, to uh, to come, to come grab some world-class sushi, or steaks, or whatever you're into, or both. And we'll leave it there for today.

• 1:47:47Speaker 01

  This is really fun.

• 1:47:49Speaker 02

  It's really amazingly fun, and what an opportunity. Thank you.

• 1:47:53David Puder?

  Awesome.