Background

12 Treatments for Narcissists, Other Cluster B Personality Disorders (Borderlines, Psychopaths)

Uploaded 1/17/2021, approx. 47 minute read

Why should a narcissist attend therapy? What's wrong? Maybe he's just an a-hole, or a jerk, or maybe like Len Sperry says, he has a narcissistic style, but not a full-fledged narcissistic personality disorder. So why should he waste resources, his time, his money, on utterly unnecessary treatments?

I thought that I would give someone else the right to speak for a change. It's a woman who had written to me.

Hello, Sam. I'm watching many of your recent videos indeed as I type. I had to pause halfway through one to write to you how the narcissist sees you as two women. Nothing has hit that bullseye with such clarity.

I have to tell you that I've written before at the beginning of leaving my fragile or covert narcissistic partner. I thought I had enough resources to keep me determined in my run to the hills. I failed. Seven months later, we reunited. We then married. Are the delicious blaring of reality in that back to the start phase of our resurrected relationship?

I thought to myself, how did I ever doubt this man? He loves me. He's so generous and kind and present. He forms on one knee in a Hebridean sunset and proposes. Of course the answer was yes. Slowly, ever so slowly, like the proverbial frog in that pot of water brought to boil, I wake up after three more years and realize nothing has changed.

That feeling of being invisible, that old niggle of disconnection, feeling as though I'm irrelevant. I mean nothing to him. That void. He can't physically touch me. No laughter. No joy. He's like a kettle furiously boiling inside where you can see the lid jumping, but you know you will be scolded if you try to remove it. The verbal abuse where he totally lacerates my character wounds me deeply. It's as though I'm merely a household appliance, functional.

I attempt to discuss how I feel and he reacts with disinterested best at worst fury. My feelings just don't matter. He's the hero, the provider. We both work, by the way. How dare I put him down when he's working so hard? I feel ugly, insecure, pointless and completely invisible. I know this is not true, of course, but I feel this in his company. I feel completely stuck. I would not like just to be free. This has gone on for 13 years. I constantly tell myself, ah, but he was kind to me then. He bought me a meal out. We had that holiday, etc. And I end up flailing between extremes.

Please feel free to quote my email if my words make others go, me too, and recognize that insidious sorcery, that submersion into the frog pan, enough to act. That's good.

My previous partner was a grandiose narcissist. It was evident who he was as he crashed around center stage. There was nothing underhand about his aggression, like blowing a trumpet in your face.

This one, however, is like walking barefoot in lush grass, not seeing the snake. How do we get here?

Well, more to the point, how do we escape? I mean, truly escape.

I think this letter speaks for itself. The narcissist inflicts insurmountable, harrowing suffering on everyone around him. And I'm not only referring to insignificant others or to non intimate partners. I'm referring to his business associates, his neighbors, everyone around him suffers one way or another.

Ultimately, the narcissist himself sets himself up for failure. His standards of perfection can never be attained. So he's constantly dissatisfied and tortured.

And then when he does succeed, he sabotages his own success, he undermines, he self defeats, he self destructs because of his inner critic, sadistic superego.

The narcissist is the narcissist's largest, biggest victim. The narcissist tends to regard the therapeutic relationship as yet another shared fantasy.

And here too, within the therapy, the narcissist confuses internal and external objects via a process called transference. He transfers his internal objects, he projects them onto the therapist.

Some of these internal objects are parental figures. So he begins to treat the therapist or regard the therapist as a surrogate father or surrogate mother.

And there is an almost psychotic confusion in the first stages of therapy.

My name is Sam Vaknin. I'm the author of Malignant Self Love: Narcissism Revisited and your professor of psychology.


Today, I'm going to offer you an overview of the psychotherapies and treatment modes and modalities that had been proven to work with Cluster B personality disorders.

Most notably, narcissistic, antisocial and borderline personality disorders.

I have omitted purposefully on purpose a few of these therapies. For example, I will not analyze or mention EMDR, which is a form of cognitive behavior therapy, coupled with eye movements. Generally, I will not dwell on body centered therapies. I'm also excluding humanist, humanistic therapies, Carl Rogers. I'm excluding transactional analysis. I'm excluding all psychodynamic therapies and psychoanalysis, etc.

And the reason I'm doing all this is because there is insufficient data to prove or to show or to demonstrate conclusively or even just convincingly that these therapies with the exception of EMDR and to some extent Gestalt, that these therapies are efficacious with Cluster B.

So I'm going to focus only on therapies backed by studies and published peer reviewed papers.


Now I encourage you to do your own research. Go and read, go and read on EMDR, EMDR, go and read on Gestalt therapy, go even and read on psychodynamic therapies or psychoanalytic psychotherapy. These are all laudable therapies and they make claims.

Regrettably, these claims are not supported by research.

So now, evidence-based therapies.

First of all, I refer you again to Len Sperry's S-P-E-R-R-Y book, Handbook of Diagnosis and Treatment of DSM-5 Personality Disorders. Assessment, case conceptualization and treatment published by Rutledge in 2016 is the third edition.

Previous two relate to the DSM-4 text revision. This one incorporates the latest insights and changes in the DSM-5.

And on we go.

We start with behavior therapy.

It's a group of therapies actually, which replace problem behaviors with constructive behaviors via conditioning or more precisely counter conditioning and reinforcement.

So they use very primitive tools of operant conditioning and reinforcement, positive and negative reinforcement, to sort of channel the patient towards more constructive, more productive, less abrasive and less antisocial behaviors.

There's a whole family and they date back to the 1950s.

Out of behavior therapy, there came a second family of therapies. They are known as cognitive therapies.

Cognitive therapies seek to change negative automatic thoughts and schemas that lead to attributional and other biases, as well as to errors in thinking.

So cognitive therapy focuses on, as the name implies, cognition.

Cognition, how to change your thinking.

By changing your thinking, you change your frame of mind, change your state of mind, you change your state of mind, remember, all these therapies are used extensively in the treatment of personality disorders and more specifically in treatment of cluster B, personality disorders.

Now the idea in cognitive therapy is to alter, to change problematic behaviors and dysfunctional feelings and behaviors by focusing on the way you think about yourself, the way you think about others and the way you think about the world.

It seems that your thinking shapes molds your behavioral choices and these create reactions.

The whole conglomerate, the whole complex generates negative emotions.

So there's a vicious cycle. Negative emotions create actions, create reactions, create negative emotions and it's a self-perpetuating, self-enhancing vicious cycle.

The latest, the penultimate reiteration of cognitive therapy is of course the world famous cognitive behavior therapy or CBT.

There is a third wave of behavioral therapy. It's a wave that combines CBT with other elements.

Number one, the primacy of the therapeutic relationship. The therapeutic relationship for the duration of the therapy becomes the main relationship of the patient, overriding even his intimate relationship, overriding his workplace, overriding anything. The therapeutic relationship becomes the main relationship because it is within the therapeutic relationship, the change is induced. Actually it's the relationship itself that creates the change by having finally a healthy relationship with another adult who happens to be a therapist.

The personality disordered person experiences a monopoly of new experiences, so secure attachment. He feels safe. He can express negative affectivity and negative emotionality without being punished. He can be dysfunctional. The therapist will contain him and channel him and regulate him so he acquires regulation, etc.

The primary therapeutic relationship is a prototype for a healthy functional relationship, a prototype platform, a template that the patient can then take and apply to all his other relationships.

Remember we are talking about third wave of behavioral therapy, combining CBT with other elements. We'll discuss a few of these therapies shortly.


The second principle in the third wave is learning, analyzing triggers, analyzing environmental cues, exploring schemas, we'll discuss schemas a bit later, exploring emotions.

And then the third element is utilizing modeling, homework and imagery.

Now okay, all these principles are now abstract. I'm going to show you how they are manifested, how they are used in specific therapies.

And let's start with my favorite by far, dialectical behavioral therapy.

Dialectical behavioral therapy was developed by Marshall Leibowitz in 1993. Recently, several elements were added to it, for example spirituality, mindfulness, not for me. I think it's a contamination, a contamination of the original. The original was bright and brilliant. There was no need to combine it with new age in order to make it more marketable and to increase profits. So I regret this development, not only in DBT, dialectical behavioral therapy, but in numerous other, for example in Schema therapy, they also have mindfulness Schema therapy and so on. These are Indian gurus and mystics translated via Western gurus and one of the yogis who didn't understand a word of the original Indian teaching, and it's a bloody mess.

So I'm going to describe the original dialectical behavior theorem. Leibowitz developed it in 1993 to treat borderline personality disorders.

But gradually over the decades, the efficacy of DBT had been proven with other personality disorders and with disorders of mood, anxiety, eating disorders and substance abuse disorders. So it is widely, widely applied to a variety of disorders.

But the experience hitherto has been almost exclusively with female patients and in large part in inpatient or residential settings. In other words, in hospital settings, mental asylum settings to be less politically correct. People committed or hospitalized, women committed or hospitalized have undergone dialectical behavior therapy.

So at this stage, we have no proof that it would be useful or applicable to men or to children. I have just come up with a new diagnosis for men suggested diagnosis for men covert borderline. If I'm right, the covert borderline is a combination of antisocial narcissists and borderline, typical mostly to men, not to women. This would explain why DBT doesn't work well with men or hasn't been applied to men.

Because men gravitate more towards the primary psychopathy pole, while women gravitate more towards the secondary psychopathy pole. In other words, women borderline, women borderlines would tend to become secondary psychopaths under conditions of stress.

And men covert borderlines would tend to become primary psychopaths under the same conditions, for example, anticipating rejection, humiliation and abandonment or going through actual breakup or disintegration of an interpersonal meaningful interpersonal relationship.

So there is a substantial difference between the way a borderline personality disorder is expressed and manifested in men and the way it is expressed and manifested in women, which would explain why DBT is much more efficacious with women. DBT emphasizes emotional and affect regulation, not cognitions. It in this sense diverges from classic cognitive therapy and goes back, harkens back to the very beginning of behavioral therapy when it was combined with emotive therapy.

So it is concerned, DBT is concerned with how your shema, how the shemas of the patients were performed via dialectical conflicts. Shemas are simply combinations of beliefs, cognitions, emotions when you put them together in reaction to a set of specific circumstances or a relationship is a set of specific circumstances. And we have shemas that pertain, for example, to relationships.

We will deal with shemas at length a bit later, but DBT is asking the question, how did your shemas form? How is your affect? How were your emotions involved in generating these shemas?

DBT seeks to connect affect and need because every shema responds to a need and involves emotions. So we have shema, need, affect, emotions. And DBT tries to connect all of them. And DBT tries to demonstrate to the patient that there are processes of inference, deduction, analysis. There are belief systems which put together with the need and the affect had generated the shema.

So suddenly everything becomes clear. You had a need, you had a belief, you had a reasoning process or a logical or analytical process, deductive process, inductive process, you had some process of thinking, cognitive process. And when you put everything together, you came up with a solution. And this solution is a scheme or multiple solutions are shema.

So when these are reinterpreted, when you become self-aware of these background processes, this self-awareness begins to generate healing.

DBT identifies fixation or perseveration, example, rumination, caused by early developmental deprivation and by protective inattentional constriction. So as a child would be deprived, for example, of maternal love in case you had a dead mother and you have learned gradually as a borderline personality disorder patient, you had learned gradually to react to this deprivation by kind of mentally insisting, by getting fixated, by being unable to move on until the issue is resolved, until your needs are met.

We all know these insistent children who keep nagging and nagging until they get what they want because they feel deprived.

Similarly, you develop protective attentional constriction. You filter out a lot of data and information because they're too painful. They're too hurtful. They threaten your inner precarious balance because you're emotionally dysregulated. You're very vulnerable. You don't have an outer protective armor or shield or skin.

DBT examines the effects of negative reinforcement through emotional avoidance or in other ways and also studies inadequate coping skills. DBT claims that negative reinforcement, emotional avoidance, inadequate coping skills, they are actually rewarded. There's something called partial reinforcement effect. I will not go to it right now, but they're actually gratifying things while in healthy people, emotional avoidance, inadequate coping skill is cause for distress. Healthy people don't like it. Borderlines actually do like it and not only borderlines. We're talking about class the big, but mostly borderlines.

Now, DBT, dialectical behavioral therapy, which is used mostly for borderline, involves individual therapy, group skills training, reskilling, you acquire new skills, phone contact to show you over in between sessions and therapist consult, consultation, which is not for you. It's for your therapist.

Exactly like in psychoanalysis, your therapist consults other therapies.

Actually, a typical DBT process involves as a minimum two therapies. One supervises the other, so to speak, consults the other.

DBT focuses on using validation and problem solving to counter severe behavioral discontol, issues of quiet desperation, problems of life, of living, and to reduce the borderlines perception, self-perception, as incomplete, incapable of experiencing happiness and joy, for example, missing, broken, damaged goods. This is DBT.

DBBT is an exceedingly successful therapy. It has immediate effects on borderline patients.

Well over 50% of borderline patients within the first year of DBT lose the diagnosis. The borderline can no longer be diagnosed with these people.


The next therapy I would like to discuss is cognitive behavioral analysis system of psychotherapy or CBAST. It was developed by Nicola and adopted by Sperry. It is not to be used with DBT. It's dangerous.

Exactly like cold therapy that we're going to discuss at the end, this is a therapy which is dangerous for borderline patients.

The clients of CBAST plan to analyze life situations and manage daily stressful events. They evaluate which thoughts, which behaviors prevent them from accomplishing desired outcomes.

So it's a very, very pragmatic kind of therapy, more like I would say management consultancy.

There are two processes, two stages. One is called elicitation and the other is called remediation.

In the elicitation phase, the therapist asks the patient questions about the situation, the client's role and functioning within the situation and the desired outcome.

And then the therapist demonstrates to the client that his behaviors, even his cognitions, are counterproductive, prevented him from accomplishing the desired outcome. And this leads to a revision of these self-defeating behaviors and cognition.

Of course, there's an underlying assumption that every client and every patient is not masochistic, is not self-defeating, is not self-destructive by nature, is not self-tracting, that every person seeks his own best interests. That's not always true with cluster B personalities.

At any rate, one thing the therapy does for sure is it replaces emotional reasoning with consequential, logical, analytical reasoning.

And that's a major achievement because many cluster B personalities engage in emotional reasoning.


The next therapy is mindfulness-based cognitive therapy, MBCT. It was developed by Tisdale. It fosters awareness, focus on thoughts, feelings, and experiences in the present with an attitude of acceptance and without analysis, even without judgment, but without analysis.

Now, MBCT had become, as I said earlier, had become a module, if you wish. Some of its techniques became integrated into dialectical behavior therapy, EMDR, schema therapy, and so.

Next therapy is pattern-focused psychotherapy. It was developed by Sperry himself. Sperry defined pattern as a predictable, consistent, self-perpetuating style of thinking, feeling, acting, coping, and self-defense. A pattern can be adaptive and encourage you to be competent, to be self-efficacious, to leverage your agency, to secure favorable outcomes from your environment.

But the pattern can be maladaptive. It could be inflexible, ineffective, inappropriate. And if it is maladaptive, it causes symptoms. It impairs your functioning in a variety of settings, including interpersonal relationships. And it reduces your satisfaction with yourself and with your life, a state called dysphoria. It generates dysphoria.

The pattern-focused therapy consists of replacing hurtful, painful, maladaptive patterns with helpful, adaptive patterns. And this is done by interpreting situations and behaviors in a certain way so as to throw light, shed lights suddenly on how maladaptive the pattern is.

You see, there's a commonality between all these. All these therapies assume that early on in childhood, we had become malformed. And this malformation, this wrong molding, wrong sculpting of who we are, I mean, there is a tendency to regard the newborn as a kind of raw material. And the parents mold and sculpt this raw material, kind of plastic art of parenting. And they produce an objet d'art. They produce an artwork.

But if they don't know how to do it or if they have their own problems, the dead mother, Andrei Green's dead mother, then the objet d'art is deformed, malformed, and is likely to behave in ways which will not be conducive to health, happiness, good, satisfactory relationships, attainment of goals, etc.

They all make these assumptions. This is the underlying assumption of modern psychotherapies in plural, which leads me to Schema therapy.

Schema therapy was developed by Jung. Schema therapy changes these maladaptive patterns, which in Schema therapy, they're called schemas. They're 18 schemas.

These are enduring and self-defeating ways of regarding oneself and others. And the 18 schemas are arranged in five domains.

Schemas are perpetuated through coping styles. There is schema maintenance, schemas avoidance, and schemas compensation.

And you can work with these schemas. You can reconstruct them, which is very difficult. It takes a lot of time and investment. But you can also modify them, which is a bit easier. You can interpret them in sight. It's supposed to generate internal dynamics of change.

Or you can camouflage them, disguise them so that they are no longer able to operate. Very similar, by the way, to how viruses behave with the immune system. Just an apropos.


I'm going to read to you a list of all the schemas because it's a wonderful summary or summation of everything that's wrong with cluster B personality disorders.

So here are the schemas, maladaptive schemas and schema domains.

Schema domain number one, disconnection and rejection. One, abandonment, instability, the belief that significant others will not or cannot provide reliable and stable support.

Number two, mistrust, abuse, the belief that others will abuse, humiliate, cheat, lie, manipulate, or take advantage of you.

Number three, emotional deprivation, the belief that one's desire for emotional support will not be made by others.

Number next one, defectiveness, shame, the belief that one is defective, bad, unwanted, or inferior in important aspects.

Social isolation, alienation, the belief that one is alienated, different from others, or not part of any group, impaired autonomy and performance is the next domain.

And within this domain, we have the following schemas, dependence and competence, the belief that one is unable to competently meet everyday responsibilities without considerable help from others.

Vulnerability to harm or illness, the exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it, catastrophizing.

Next scheme, enmeshment, undeveloped self, the belief that one must be emotionally close with others at the expense of full individuation or normal social development.

Next scheme, failure, the belief that one will inevitably fail or is fundamentally inadequate in achieving one's goals.

Next domain, impaired limits or boundaries.

Scheme number one, entitlement, grandiosity, the belief that one is superior to others and not bound by the rules and norms that govern normal social interaction.

Number two, insufficient self-control, self-discipline, the belief that one is incapable of self-control and frustration, tolerance.

Next domain, other directness at other people, subjugation, the belief that one's desires, needs and feelings must be suppressed in order to meet the needs of others and avoid retaliation or criticism.

Next, self-sacrifice, the belief that one must meet the needs of others at the expense of one's own gratification.

Next, approval seeking, recognition seeking, the belief that one must constantly seek to belong and be accepted at the expense of developing a true sense of self.

And then we have the domain of over-vigilance, hyper-vigilance and inhibition.

Scheme number one, negativity, pessimism, a pervasive lifelong focus on the negative aspects of life while minimizing the positive and optimistic aspects.

Next, emotional inhibition, the excessive inhibition of spontaneous action, feeling or communication, usually in order to avoid disapproval by others, feelings of shame or losing control of one's impulses.

Next, unrelenting standards, hyper-criticalness, the belief that striving to meet unrealistically high standards of performance is essential in order to be accepted and to avoid criticism.

And finally, punitiveness, the belief that others should be harshly punished for making errors.

Chema therapy is a very powerful therapy and very intelligent, if I may add.

Next, Kerenberg, who else? Still active in his 80s, amazing men, the father of the field, together a bit later with Theodore Miller.

Transference focused, psychotherapy developed by Kerenberg.

Kerenberg said that infants form internal representations of self and internal representations of others, of objects. And the infant connects these internal representations of self and others via emotions or more precisely affect.

A personality disorder occurs when positive representations and negative representations fail to integrate later in life, echoes of melanin decline.

Such splitting between all negative, all positive representations of self and of others, such splitting affects, of course, relationships, including the therapeutic relationship, including therapy.

So, Kerenberg, very similar to cold therapy, I'm doing this in cold therapy as well, Kerenberg encourages transference to the therapist because he believes that when the patient engages in transference, when the patient projects his innards, so to speak, his internal objects onto the therapist, the patient exposes these internal objects to scrutiny.

The patient delineates the faulty relationship template by engaging in a faulty relationship with a therapist via transference.

And if the therapist is empathic, the therapist can correct this faulty template via empathy and support and so insight, empathy and insight, these are the two pillars.

So identity integration is accomplished as the patient experiences negative emotions, but in a safe accepting environment.

Beautiful.

If you are an adherent of object relations, as I am, this is simply beautiful.


Okay, next one. Mentalization based treatment, MBT.

Remember, all these therapies have been deemed as efficient or efficacious therapies.

There is something called Division 12 of the American Psychological Association, and they measure the efficiency of therapies.

So all these got top marks. It's like these companies that measure the efficacy of anti-virus problems, you know, so this one passed. They fought well, the malware of the mind.

Mentalization based treatment and MBT developed by Bateman and Fornaji.

This therapy, this treatment modality assumes that you need to, as a therapist, you need to help the patient to experience secure attachment.

Because if the patient experience secure attachment, he can develop impulse control. They believe that impulse control is the outcome of insecure attachment.

So they empathically and insightfully, they provide insights, reflect on and label correctly the patient's state of mind. They believe that by analyzing this state of mind and giving it a label, this helps the patient to feel safe and secure as though the patient has a handle on his situation. And this allows him to control his impulses.

They believe that impulse control is possibly the biggest problem in relationships.

And so if the state of mind is insightfully reflected on and correctly labeled, especially powerful emotions, especially cognitive errors, if they're pointed out, it's 50% to healing. And this leads to improved relational skills.

Finally, developmental therapy.

Developmental therapy was developed by quite a few people, but the main figures are Blocher, B-L-O-C-H-R, Blocher, Cartwright and Spary.

Developmental therapy regards problems in personal growth and needs satisfaction on a dimensional continuum from disordered to adequate to optimal.

So when you analyze the patient's personal growth trajectory, you know, we have this phrase that we no longer use, by the way, arrested development. It's taboo. Don't use it. It's like the N word.

So when you analyze personal growth, when you analyze the satisfaction of the patient's basic and not so basic needs, you know, Maslow hierarchy, when you analyze this, you shouldn't analyze them discreetly, but you should create a continuum, a spectrum, a dimension. And this dimension goes from disordered to adequate to optimal.

And I'm going to read to you, quoting from Len Sperry's book, aforementioned, I'm going to read to you how this looks with cluster B, select cluster B disorders, mainly the dramatic ones. Histrionic, optimal.

So everyone is a spectrum. Every cluster B disorder is a spectrum. Every healthy person has a spectrum. And the spectrum is optimal, adequate disorder. So histrionic, optimal.

Having found the love they seek within themselves, they are altruistic and giving without expecting reciprocity. That's the optimal, adequate.

While fun loving and often impulsive, they can delay gratification and be emotionally appropriate much of the time. The disordered version, which is histrionic personality disorder, the disordered version is uncomfortable in situations in which they are not the center of attention.

By the way, the histrionic personality disorder together with schizoid personality disorder and others had been removed from the alternative model of the DSM-5. And they will not exist in the DSM-6.


Let's talk about narcissistic.

What's the optimal, adequate and disordered versions of narcissism?

Narcissistic, optimal, energetic, self-assured, without expecting special treatment or privilege. Adequate, confident, yet emotionally vulnerable. They favor special treatment or privilege.

Disordered narcissistic personality disorder manifests a grandiose sense of self-importance and demands special privilege.

Schizoid, optimal, deeply grounded in themselves. They are emotionally connected to the world.

Adequate, reasonably comfortable being around others, provided they are limited amounts for intimacy or emotional connectedness.

Disordered version? Neither desire nor enjoy close relationships.

Now, the reason I inserted schizoid into this is because I recommend that you watch three of my previous videos, the series about schizoid narcissists. They are good grounds to assume that schizoid personality disorder is a facet of narcissism. It's another name for a subtype of narcissist.

Dependent, codependent, optimal, may seek out the opinions and advice of others when making major decisions, but the decisions they make are ultimately their own, optimal.

Adequate, have the capacity to be responsible and make decisions, but still seek out and rely on others for help and advice.

Disordered, codependent or dependent personality disorder needs others to assume responsibility for most major areas of their lives. Antisocial or psychopath?

Psychopath is an extreme antisocial. Optimal, have the gift of gap and easily befriend others, although they may not offer much depth to these relationships.

Adequate and respect by acting honorably and with compassion, by using power constructively and by promoting worthwhile causes.

Remember, in previous videos, I kept telling you that many, many activists, social justice activists and so on are actually psychopaths, but they are adequate psychopaths.

Disordered, a real psychopath, a Robert Hare, Harvey Keckley psychopath, primary psychopathexhibits aggressive, impulsive, self-serving and irresponsible behavior.

Okay, borderline, the queen of the roost. Borderline, optimal, sensitive, introspective and impressionable individuals who are very comfortable with their feelings and inner impulses.

Adequate borderline, they quickly and easily engage in relationships and on sometimes hurt and rejected in the process.

Disordered borderline displays frantic efforts to avoid real or imagined rejection and abandonment. And finally, the paranoid.

Optimal, highly observant and discerning, they can defend themselves without losing control or becoming aggressive.

Adequate, thin-skinned, they are rather sensitive to and hurt by criticism, which is very similar to narcissism.

One of the reasons I keep saying that paranoia or paranoid personality disorder is a subtype of narcissistic personality disorder.

Paranoia is narcissism.

Disordered, suspicious, without sufficient basis, that others are exploiting, harming or deceiving them.


Okay, and now we come to the last one, number 12, Cold Therapy developed by Vaknin.

Cold therapy is based on two premises.

One, that narcissistic disorders are actually forms of complex post-traumatic conditions. And two, that narcissists are the outcomes of arrested development. Narcissists are actually the outcomes of arrested development and attachment dysfunctions.

Consequently, cold-therapy borrows techniques from child psychology because narcissists are children.

Nasties, according to co-therapy, are children in a post-traumatic state.

So co-therapy borrows techniques from child psychology and from treatment modalities used in order to deal with PTSD and CPTSD.

Co-therapy consists of the re-traumatization of the narcissistic client in a hostile, non-holding environment, which resembles the ambience of the original trauma, recreates the original trauma.

The adult patient successfully tackles this second round of hurt and so resolves early childhood conflicts and achieves closure, rendering his now maladaptive narcissistic defenses unnecessary, redundant and obsolete. This also improves his relational capacity because the narcissist goes through the trauma second time, but this time the conflict, the early childhood conflict, so he doesn't need to do this with his spouse or his next girlfriend or his intimate partner or lover.

Co-therapy makes use of proprietary techniques such as erasure, suppressing the client's speech and free expression and gaining clinical information and insights from his reactions to being stifled this way.

Other techniques include grandiosity, reframing, guided imagery, negative iteration, otherscoring, happiness map, mirroring, escalation, roleplay, assimilative confabulation, hypervigilant referencing and reparenting.

The very limited sample of clients who had undergone co-therapy to its end, level one, two and three, the results have been very positive. It's proving to be an effective treatment for narcissistic personality disorder and major depressive episodes, which seems to sustain an early belief that narcissism is a form of depression.

Co-therapy is also a philosophical, really metaphysical framework.

I suggest that the client should regard his or her life as a movie.

The main goal in life, the core task and the engine of meaning is to direct this movie, to direct this film so as to render it an accomplished hit, a work of art and a masterpiece of narrative.

At every inflection point and faced with any critical decision, the client should truthfully answer the question, would I have paid money to watch this movie?

This yarn that I'm with him, the flick that is my life. If the answer is no, a transformative change, of course, is called for.

Directing the film should be the client's overriding priority. Every other thing should be subservient and secondary to this role, to this chore.

Everyone in the client's life should feature in this movie.

And if the client should navigate this leitmotif and channel his or her creativity without a script, as an exercising, extemporizing, improvising, the twists and turns of the plot should come as a surprise, first and foremost, to the client himself.


Okay, now let's do some criticism of some of these treatment modalities.

Start with mindfulness.

I said that mindfulness had been incorporated to various therapies.

Modern treatment modalities, psychotherapies, emphasize the present over the past and the future.

Mindfulness. There is a clinical diagnosis for the kind of people who are focused on the moment, care little about the past and others in the past, and cannot foresee or take into reckoning the consequences of their actions in the future. These kind of people are called psychopaths.

Mindfulness, in my view, and that's only my view, fosters entitlement, grandiosity, disempathy, recklessness. I am dead set against it. It's also too closely allied with new age, fake gurus, con-autists, you know, I don't like it. I seriously dislike it.

Next, cognitive behavioral therapies, CBT.

The CBT is this group of therapies, this family of therapies, postulated insight, even if merely verbal insight, intellectual, analytical insight, is sufficient to induce an emotional outcome. Verbal cues, analysis of mantras of negative automatic thoughts that we keep repeating, for example, I'm ugly, I'm afraid no one would like to be with me, I'm bound to fail.

If you analyze these sentences, the itemizing of our inner dialogue or monologue, our inner narrative, our repeated behavior patterns, learned behaviors and learned helplessness, when they're coupled with positive and rarely negative reinforcements, so if you put all this together, the inventory list of your thoughts, your behaviors, your beliefs about yourself, and the therapist then uses negative and positive reinforcements, if you put all these together, this induces, according to CBT, cumulative emotional effect, emotional, tantamount to healing.


Here's the problem, cognitive reframing is not a technique in any treatment modality, it refers to a mental process of shifting thinking.

The inner conversion of positive thoughts regarding oneself, one's mind and others into negative cognitions or vice versa.

Cognitive reframing can be induced in therapy or by shifting circumstances of one's life as well as by new information.

Reframing is a shift from one narrative of one's life and of others' place and roles in one's life to another narrative with a bigger explanatory power, an organizing principle which imbues one's personal history with meaning and direction, creates goal orientation, goal direction.

So the technique used in various psychotherapies is known as cognitive restructuring of cognitive distortions.

Cognitive distortions is automatic negative thoughts or ends, but they are distortions, they are not real, they are counterfactual, they conflict head on with reality, but when these negative automatic cognitions, thoughts conflict with reality, the patient gives up on reality. He is invested emotionally in the validity and truth of these negative automatic thoughts. So he is fighting tooth and nail to preserve them.

Cognitive restructuring is the main technique used in CBT.


Psychodynamic theories reject the notion that cognition can influence emotion. That's where there's a major conflict between the metaphysical, if you wish, pillar, or philosophical pillar of CBT and psychodynamic theories.

Psychodynamic theory says your thinking cannot influence your emotions.

Healing requires access, access to and the study of much deeper strata by both patient and therapist is not enough just to think, you need to dig deep.

Psychodynamic therapies starting with psychoanalysis, they are a form of archaeology. Let's say that CBT is tourism and psychodynamic therapies are archaeology.

The very exposure of these deep layers to the therapeutic process is considered sufficient to induce a dynamic of healing.

The therapist's role is either to interpret the material revealed to the patient, for example, in psychoanalysis by allowing the patient to transfer past experience and superimpose it on the therapist.

Another option is to provide a safe emotional and holding environment conducive to the patient changing himself.

So either the therapist is active as an active role or he just provides the environment within which he activates the patient and then it's the patient who is doing the work.

The sad fact is that no known therapy is effective with narcissism itself.

There are quite a few therapies, treatment modalities, which are reasonably successful as far as coping with some of the effects of narcissism, some of the abrasive and antisocial and self-defeating behaviors.

So many therapies are very effective at modifying the behaviors of the narcissist. But none of them, not even cold therapy, heals or cures narcissism.

The nonsensical concept of recovered narcissism or recovered narcissism, it's a scam. I'm sorry, anyone who uses this phrase is a con artist pretending to be a professional.

No textbook supports this.


Let's talk a bit about dynamic psychotherapy, psychodynamic therapy and psychoanalytic psychotherapy, the old school.

All of them are not psychoanalysis, just to be clear. All of them are, they are forms of intensive psychotherapy based on psychoanalytic theory without the very important element of free association.

This is not to say that free association is not used in these therapies, only that it is not a pillar of the technique.

You can go through a course of therapy in these therapies and not freely associate.

Dynamic therapies are usually applied to patients not considered suitable for psychoanalysis, for example, those suffering from personality disorders, with one exception, the avoidant personalities.

Typically, different modes of interpretation are employed and other techniques borrowed from other treatment modalities. It's very eclectic, actually, but the material interpreted is not necessarily the result of free association or dreams, like in psychoanalysis.

The psychotherapist is a lot more active than the psychoanalyst. The psychoanalyst provides a black screen on which the patient projects everything via transference, via defense mechanisms and so on.

The psychotherapist in dynamic psychotherapy, psychodynamic therapy and psychoanalytic psychotherapy is very active, is an active interpreter. It's a collaboration.

Psychodynamic therapies are also open-ended and the commencement of the therapy, the therapist, analyst, makes an agreement, a pact, alliance, therapeutic alliance, with the analyst and with the patient or the client.

The pact says that the patient undertakes to explore his problems for as long as may be needed, which is, of course, very good for the therapist's bank account.

This is supposed to make the therapeutic environment much more relaxed because the patient knows that the analyst is at his or her disposal no matter how many meetings will be required in order to broach painful subject matter.

In other words, there's a blank check. The therapist is telling the patient, no matter how long this is going to be, even if it's years, I'm going to be here for you at your disposal for as long as you want to be.

So we call this open-ended psychotherapy.

And sometimes these therapies are divided to expressive versus supportive, but it's a bit of a misleading division. It might be a bit of a misleading division.

Still, expressive means uncovering, making conscious the patient's conflicts and studying his or her defenses and resistances.

The analyst interprets the conflict in view of the new knowledge gained and guides the therapy towards the resolution of the conflict.

The conflict, in other words, is interpreted away through insight and through the change in the patient motivated by his or her insights.

So insights come from both the therapist and the patient.

The supportive therapies, as opposed to the exposure, the expressive therapies, I'm sorry, the supportive therapies seek to strengthen the ego.

Their premise is that a strong ego can cope better and later on alone with external, situational, or internal instinctual related to drives, pressures.

Remember, the narcissist does not have an ego. That's the narcissist problem, ironically.

Supportive therapies seek to increase the patient's ability to repress conflicts rather than bring them to the surface of consciousness.

When the patient's painful conflicts are suppressed or repressed, the attendant dysphoria, the symptoms the conflict had generated, vanish and are ameliorated or reduced, so does the anxiety.

This is somewhat reminiscent of behaviorism. The main aim is to change behavior and to relieve symptoms, never mind what.

And it usually makes no use, the, this kind of behavior of the therapist make no use of insight or interpretation, although there are some exceptions.


Let's talk a bit about group therapies, cluster B patients in group therapies.

Start with narcissists. Narcissists are notoriously unsuitable for collaborative efforts of any kind. They're not team players and they're not built for group therapy.

They immediately size up other people as potential sources of narcissistic supply. They use cold empathy or they decide that someone is a potential competitor. It's a power play immediately.

They idealize the suppliers and devalue the competitors. This obviously is not very conducive to the dynamic in the group.

Moreover, the dynamic of the group is bound to reflect the interactions of its members.

Narcissists are individualistic. Borderlines are anxious. Psychopaths are ruthless and callous.

And so cluster B personality disorder people regard coalitions with disdain or contempt or as opportunities or, you know, it's not good.

The need to resort to teamwork, to adhere to group rules, to succumb to a moderator and an agenda and to honor and respect the other members as equals is perceived by Cluster B patients as either humiliating and degrading or as contemptible weakness or as something to be exploited and leveraged.

And so a group containing one or more Cluster B patients is likely to deteriorate very fast, degenerate and fluctuate between short term, very small size coalitions based on superiority, interest, content and outbreaks, especially narcissistic outbreaks, acting out the compensation of rage, coercion, anxiety.

The most difficult patients by far in therapy are psychopaths and narcissists.

In therapy, the general idea is to create the conditions for the true self to resume its growth, provide safety, predictability, justice, love, acceptance, a mirroring, reparenting, a holding environment.

Therapy is supposed to provide these conditions of nurturance and guidance through transference, cognitive relabeling or other methods.

And the narcissist must learn that his past experiences are not laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive, that love is fun.

Most therapists try to co-opt the narcissist's inflated ego, his false self, his defenses. They complement the narcissist, challenging him to prove his omnipotence by overcoming his own disorder.

They appeal to the narcissist's quest for perfection, brilliance and eternal love, and to the narcissist's paranoid tendencies in an attempt to get rid of counterproductive, self-defeating and dysfunctional behavior patterns.

And by stroking the narcissist's grandiosity, these therapists hope to modify or to counter cognitive deficits, thinking errors.

The narcissist's victim starts bad dynamics.

These therapists make a contract with the narcissist, they contract with the narcissist, in order to alter his conduct.

And some therapists even go to the extent of medicalizing the disorder, attributing it to a genetic hereditary or biochemical origin, and so absorbing the narcissist from his responsibility and freeing his mental resources to concentrate to focus on the therapy.

Confronting the narcissist's head on and engaging in power politics, I'm more clever than you, my will will prevail and so on, is decidedly unhelpful and could lead to rage attacks and a deepening of the narcissist's persecutory delusions bred by his humiliation in the therapeutic setting.

Same goes for borderlines, same for psychopaths.

Successes have been reported by applying 12-step techniques as modified for patients suffering from antisocial personality disorder, and also with some treatment modalities.

Even NLP, neuro-linguistic programming, which many say is a scam, seem to somehow work.

Shema therapy, as I mentioned, eye movement, desensitization, EMDR and so on.

But whatever the type of talk therapy, the narcissist devalues the therapist.

The narcissist's internal dialogue is, I know best, I know everything.

This therapist is less intelligent than I am. I can't afford the top-level therapist, who is the only one qualified to treat me as my equal, of course. I'm actually a therapist myself, why am I here? What am I doing here?


And so there's a litany of self-delusion, grandiose self-delusion and fantastic grandiosity.

These are defenses, of course, resistances, because in the therapy there's a kind of roleplay.

I mentioned at the beginning of this video, a long time ago, when we were all much younger, that the narcissist approaches therapy as he approaches a shared fantasy, and he allocates roles.

Now, the problem with therapy is that at the very inception of the therapy, there are roles allocated. Superior authority therapist type, inferior supplicant narcissist type.

No, narcissist don't like this. And so they react with defense and resistance, and they say, and narcissist says to himself, my therapist, should be my colleague. We are equal. In certain respects, it is he who should accept my professional authority and learn from me.

Why won't he be my friend? After all, I can use the lingo and the psychobabble even better than he does.

I know terminology and I know his own field better than him. At any rate, it's us, me and him, against a hostile and ignorant world.

Shared psychosis for the other.

And then there is this internal dialogue. Just who does the therapist think he is? Asking me all these questions.

What are his professional credentials, I wonder? Which university did he graduate, if at all?

I am a success and he's a nobody therapist in a dingy office and he is trying to negate my uniqueness. I'm making 10 times more money than he does. He's an authority figure in his own office.

And I hate this and I hate him. And I will show him. I will humiliate him and prove him ignorant. I will have his license revoked.

Transference. Actually, this therapist is pitiable. He's a zero. He's a failure. And I will smear him everywhere I go after all this is over.

Such reactions are even much more common among borderlines and psychopaths.

And this is only in the first three sessions of the therapy.

This abusive internal exchange becomes more vituperative and pejorative as therapy progresses.

Agnes Oppenheim wrote the following in the International Dictionary of Psychoanalysis.

Mirror transference is the remobilization of the grandiose self. Its expression is, I am perfect. And I need you in order to confirm to me that I'm perfect.

When it is very archaic, mirror transference can easily result in feelings of boredom, tension and impatience in the analyst, whose otherness is not recognized in the analyst, in the therapist.

Counter-transference is a sign of this.

The notion which first appeared in Heide's co-host's work in the psychoanalytic treatment of narcissistic personality disorder in 1968, this notion of mirror transference was further elaborated in Kohut's analysis of the self in 1971.

Mirror transference can take three forms, depending on the degree of regression and the nature of the point of fixation.

Fusion transference is the most archaic form and it refers to a primary identity relationship in which the other, the therapist, is completely a part of the self, an extension.

It shows itself when the analyst is taken to be omnipotent and tyrannical and is experienced as an extension of the self.

In twinship or alter ego transference, the other, the therapist, is experienced as being like the self.

Lastly, in mirror transference, properly speaking, the analyst is experienced, the therapist is experienced as a function at the service of the patient's needs.

If the patient feels recognized, he experiences a sense of well-being linked to the restoration of his narcissism.

Mirror transference can be primary, the reaction to a broken, idealizing transference, or secondary to one of these.

In The Restoration of the Self, a book published in 1977, Heinz Kohut distinguished it from alter ego transference.

Some authors have refused to consider this transference as being a result of the evolution of narcissism. They've seen it merely as a defense.

Narcissists generally are averse to being medicated.

Actually, most patients with personality disorders are averse to medication.

Resorting to medicines is an implied admission that something is wrong.

Narcissists are control freaks, and they hate to be under the influence of mind-altering drugs prescribed to them by inferior others.

Additionally, many of them believe that medication is a great equalizer. It will make them lose their uniqueness, creativity, superiority, and so on.

It's a form of social control.

Unless they can convincingly present the act of taking their medicines as heroism, they don't want to take medicine.

Sometimes with, for example, pioneering vaccines, the narcissist can tell himself what he's doing is heroic. It's a daring enterprise of self-exploration, which is intended to benefit humanity.

It's part of a breakthrough clinical trial, and so on and so forth. But these are exceptions.

Narcissists and personality-disordered people often claim that the medicine affects them differently than it does other people.

Or that they have discovered a new exciting way of using the medicine. Or that they are part of someone's, usually themselves, learning curve, part of a new approach to dosage, part of a new cocktail which holds great promise.

Narcissists, borderlines, histrionics, they must dramatize their lives in order to feel worthy and special.

Outneal, out, unique. Either be special or don't be at all. Narcissists are drama queens, exactly like borderlines and histrionics, and some types of psychopaths.

Very much like in the physical one, change is brought about only through incredible powers of torsion and breakage.

Only when the narcissist's elasticity gives way, only when he is wounded by his own intransigence, only then is there hope.

He takes nothing less than hitting rock bottom.

Real heart takes a real crisis, multifaceted in all dimensions of the narcissist's life simultaneously.

And we, failure, are not enough.

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