17 Ways to "Cure" Narcissism (Compilation)

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 behavior therapy.

Dialectical behavior therapy was developed by Marshall Grannon 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 behavior therapy, but in numerous other, for example in Schema therapy, they also have mindfulness Shema 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 theory.

Levinahd 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 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 narcissist 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 would tend to become secondary psychopaths under conditions of stress and men covert borderline 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 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 DBT is concerned with how the patients were formed via dialectical conflicts. Schemas 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 Shemmas that pertain, for example, to relationships. We will deal with Shemmas at length a bit later.

But DBT is asking the question, how did your Shemmas form? How is your affect? How were your emotions involved in generating these Shemmas?

DBT seeks to connect affect and need because every Shemmah responds to a need and involves emotions. So we have Shemmah, 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 a need and the affect had generated the Shemmah.

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 Shemmah.

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, you've been 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 caused for distress, healthy people don't like it, borderlines actually do like it. And not only borderlines, we're talking about cluster B, but mostly borderlines.

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

Exactly like in psychoanalysis, your therapist consults other therapists.

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

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

This is DBT. DBT 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 CBASP. It was developed by McCullough and adopted by Sperry. It is not to be used with BBT. 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 CBASP learn 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, were 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 close to big 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 not only 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, even, schema therapy and so on.

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-effecacious, 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.

Therapy, 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 au jait 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 au jait d'art is deformed, malformed, and is likely to behave in ways which will not be conducive to health, happiness, good relationships, 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 Young.

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, Schema avoidance, and Schema 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, is 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 upper point.

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 met 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.

Imperial autonomy and performance is the next domain.

And within this domain, we have the following Schema, 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 Schema, 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 for 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 and 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.

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

Next, Kerenberg, who else? Still active in his 80s, amazing man, 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 climb. 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 believed 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.

Beautiful.

If you are an adherent of object relations, as I am, this is simply beautiful. It's the culmination of the field.

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 Fung.

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 Blochel, B-L-O-C-H-R, Blocher, Cartwright and Spevy.

Cartwright, Blocher and Spevy. 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, muscle 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 has a spectrum. Every cluster B disorder has a spectrum. Every healthy person has a spectrum. And the spectrum is optimal, adequate and disordered.

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. That's optimal. Adequate, reasonably comfortable being around others, provided there 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're good grounds to assume that schizoid personality disorder is a facet of narcissism. It's another name for a subtype of narcissists.

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, earn 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 psychophants.

Disordered, a real psychopath, a robot here, Harvey Blackley psychopath, primary psychopath, exhibits 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 are sometimes hurt and rejected in the process. Disordered borderline displays frantic efforts to avoid real or imagined rejection and abandonment.

And finally, I think, 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 too and hurt by criticism, which is very similar to narcissist.

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 Grannon. 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.

Nasties are actually the outcomes of arrested development and attachment dysfunctions.

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

Narcissists, according to cold therapy, are children in a post-traumatic state.

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

Cold 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 results early childhood conflicts and achieves closure. Rendering is 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 results 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. Cold 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, other scoring, happiness map, mirroring, escalation, role play, assimilative confabulation, hypervigilant referencing, and reparenting.

The very limited sample of clients who had undergone cold 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.

Cold therapy is also 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 weaving, 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 has 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-outies, 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 this 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 life 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 egos, 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's invested emotionally in the validity and truth of these negative automatic thoughts. So he's fighting tooth and nail to preserve them.

Cognitive restructuring is the main technique used in CBT.

Some elements of cognitive restructuring like guided imagery are incorporated in cold therapy as well.

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 of 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, has 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.

The nonsensical, 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 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. 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 me.

So we call this open-ended psychotherapy.

And sometimes these therapies are divided into expressive versus supportive, but it's 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 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. It's a 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, vanished 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, re-parenting, a holding environment. Therapy is supposed to provide these conditions of nurturance, in 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 counter-productive, 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 stance, 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 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 vulnerable, 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.

Schema therapy have mentioned eye movement desensitization, EMDR and so on. But whatever 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 role play.

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 therapists type, inferior supplicant narcissists type.

No, no, narcissists don't like this. And so they react with defense and resistance and they say a narcissist says to himself, "He, my therapist, should be my colleague. We are equal. In certain respect 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 psycho babble 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 Leoden.

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 is 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, is a zero, is 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.

Adornos 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 am perfect.'

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

Counter transference is a sign of this. The notion which first appeared in Heidt's co-host's work in the psychoanalytic treatment of narcissistic personality disorders 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 other 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 adverse 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 disorder 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, out-neal, 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 world, 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.

It takes nothing less than hitting rock bottom.

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

Esteemed colleagues, good morning or good afternoon.

My name is Sam Vaknin and I'm a visiting professor of psychology in Southern Federal University, in Westovan Don in the Russian Federation, as well as a professor of finance and professor of psychology in CIAPS, the Center for International Advanced and Professional Studies.

Today I would like to discuss the issue of codependency.

As we all know, codependency is not an official mental health diagnosis, at least not within the Diagnostic and Statistical Manual in its latest iteration, which is the fifth edition of 2013.

Instead, there is something called dependent personality disorder and there has been in the Diagnostic and Statistical Manual for well over 20 years.

So this creates a great confusion regarding the terms codependent, counterdependent, dependent, etc.

So perhaps before we proceed to study dependent personality disorder, we would do well to try to clarify these terms.

As Ligia Ghelovska observes, we all need to be needed. We all want to feel useful and able to give.

People resent the narcissist partly because his false self, the facade he puts out to the world, is so self-sufficient.

But codependents take this to a whole different level, to a new extreme.

Like dependents, people with dependent personality disorder, codependents depend on other people for their emotional gratification, the regulation of their emotions and moods, reducing lability, and the performance of both inconsequential and crucial daily psychological or in Freudian balance, ego functions.

Codependents seek to fuse or to merge with their significant others. By becoming one with their intimate partners, codependents are able to actually love themselves by loving others.

It is like loving yourself by proxy vicariously.

Codependents are needy, demanding, clinging, and submissive. They suffer from abandonment anxiety and to avoid being overwhelmed by it, they cling to others and act immaturity.

And in this sense, they are very reminiscent of some aspects of borderline personality disorder and some aspects of the complex post-traumatic stress disorder syndrome.

These behaviors are intended to elicit protective responses and to safeguard the relationship with a companion or mate upon whom they depend.

Codependents appear to be impervious to abuse. No matter how badly they are mistreated, they usually remain committed to the relationship.

In extreme codependents, this fusion, this merger with a significant other, lead to in-house stalking as the codependents strive to preserve the integrity and the cohesion of her personality and the representations of her loved ones within her mind.

So what I call in-house stalking is actually stalking perpetrated by the codependent on her intimate partner.

This is where the call in codependents comes into play.

By accepting the role of victims, codependents seek to control their abuses and to manipulate them.

It is a danse macabre in which both members of the dyad, collaborates.

It's a kind of traumatic bonding or trauma bonding.

In codependency, the codependents sometimes claims to pity her abuse. She cast herself in the grandiose roles of his savior or his redeemer or his mother.

Her overwhelming empathy imprisons the codependents in these dysfunctional relationships and she feels guilt either because she believes that she had driven the abuser to mistreat her or because she contemplates more and more seriously to abandon her.

There are various types of codependents.

Codependency is a complex, multifaceted and multidimensional defense against the codependents' fears and needs.

So I distinguish between four categories of codependency stemming from their respective etiologies, psychodynamic processes and psychological etiology.

So the first category is codependency that aims to fend off anxieties related to abandonment.

These codependents are clingy, smoldering and prone to panic. They are plagued with ideas of reference, differential ideation and the displaced side of the negating submissiveness.

Their main concern is to prevent their victims, friends, spouses, family members from abandoning and deserting them or from attaining through autonomy and independence.

These codependents merge with their loved ones and experience any sign of abandonment or autonomy, personal autonomy, where they're real, actual, friendly, magical. They experience these as form of self annihilation or even amputation.

They do not allow their partners to kind of separate an individual.

The second category of codependency is codependency that is geared to cope with a codependent sphere of losing control.

By feigning helplessness and neediness, such codependents coerce their environment into ceaselessly and seamlessly catering to their needs, wishes and requirements.

These codependents are drama queens. Their life is a kaleidoscope of instability, chaos and lability. They refuse to grow up. They force their nearest and nearest to treat them as emotional or physical invalids. They deploy their self-inputed efficiencies and disabilities. They yield them and will them as well as both types of both these types of codependents, type one and type two, use emotional blinding when necessary, guilt-free and when necessary threats to secure the presence of blind compliance, all their suppliers, anything less, triggers anxiety.

The third category are vicarious codependents. These are codependents who live through others, more or less like the moon's reflected sunlight. They sacrifice themselves in order to glory the accomplishments of their chosen targets. They subsist on reflected light, as I said, on second hand applause and on derivative achievements and accomplishments. They have no person, on history, having suspended their lives, their wishes, preferences and dreams in favor of another. They live by proxy, they live vicariously, they live through another, a parasitic existence.

One subtype of such codependents is what I call inverted narcissist. The inverted narcissist is a form of covert narcissist. It is a codependent who depends exclusively on narcissists, a narcissist codependent.

If you're living with a narcissist, if you have a relationship with a narcissist, if you're married to one, if you're working with a narcissist, etc, this does not mean that you're an inverted narcissist, to qualify, so to speak.

As an inverted narcissist, you must crave to be in a relationship with a narcissist regardless of any abuse inflicted on you by him. You must actively seek relationships with narcissists and oddly with narcissists, no matter what your bitter and traumatic past experience has been. You must feel empty and unhappy in relationships with any other type of person, only then, and if you satisfy the other diagnostic criteria of dependent personality disorder, only then can you be safely labeled an inverted narcissist.

So this is an example of a vicarious codependent, the category three. And category four is codependent or borderline narcissist.

These are narcissists who oscillate between periods of clinging and other codependent behavior patterns, which they interpret as intimacy, and eras of aloofness, detachment, and emotional neglect and abandonment, which they regard as legitimate and only possible manifestations of their personal autonomy and need for space.

They also tend to form with their intimate partner a shared psychosis or a shared psychotic disorder, the aphoria do.

These are all outcomes of their overwhelming and pervasive abandonment anxiety.

They either smother their partner in an attempt to forestall desertion or they preemptively abandon sheep, thus avoiding hurt and maintaining an illusion of control over the situation.

They say, I walked out on her, I dumped her, not the other way around. The codependent deploy strategies such as merger becoming one with her intimate partner while renouncing all personal autonomy and all independence of both of them up to a point of shared psychosis.

Another strategy is coextensivity, the ventriloquist defense, insisting the department might raise her and acts in ways that reflect her inner psychological states and moves.

And then there's the classic strategy of shifting, ever shifting or shape shifting boundaries, using behavioral unpredictability and ambient uncertainty to induce paralysis and a paralyzing dependence in the partner.

There's another form of codependence that is so subtle that it eluded detection until very recently and that's counter dependence.

Counter dependence reject and despise authority and often clash with authority figures such as parents, bosses, the law. They are contumacious.

The sense of self-worth and their very self-identity are premised on and derived from, in other words, dependent on, these acts of bravura and defiance, they are personal autonomy, militants, counter dependence, a fiercely militant independent, controlling, self-centered and aggressive.

Many of them are antisocial and they use projective identification. They force people to behave in ways that buttress and affirm their view of the world and its expectations.

These behavioral patterns are often the result of a deep-seated fear of intimacy.

In an intimate relationship, the counterdependent fields ensnared, captive.

Counter dependence are locked into an approach avoidance repetition compulsion. The hesitant approach is followed by avoidance of commitment and then another stifled approach and so on.

These people are long-winded and they're very bad team players.

Counter dependence is a reaction formation. The counterdependent dreads his own weakness. He seeks to overcome these weaknesses by projecting an image of omnipotence, omniscience, success, sub-sufficiency and superiority.

Most classical overt losses are in effect counter dependence and of course all psychopaths. Their emotions and needs are buried up the scar tissue which had formed and coalesced and hardened during the years of one form of abuse or another.

Grandiosity, a sense of entitlement, lack of empathy, overwinning haughtiness, overwinning haughtiness usually hide knowing insecurity and fluctuating sense of self-worth.

Another situational codependency.

Some patients develop codependent behaviors and traits in the wake of a life crisis, especially if this crisis involves an abandonment and resulting solitude.

So in the wake of a divorce or an empty nest, one must once, children embark on their own autonomous lives, only wrong or together.

Such late onset codependents foster a complex emotional and behavioral chain reaction whose role is to resolve the inner conflict by reading oneself of the emergent undesirable codependent conduct.

Consciously such a patient may at first feel liberated but unconsciously being abruptly dumped and lonesome has a disorienting and disconcerting effect akin to intoxication.

Many patients rush headlock and indiscriminately into new relationships.

Deep inside this kind of patient has always dreaded being lonely, lonely not alone.

Following the divorce, the death of a significant other or an intimate partner, passing away of parents or other loved ones, children relocating to college, following similar episodes of dislocation, the patient suppresses this dread because she possesses no real effective solutions and antidote to her sudden solitude and she has developed no meaningful ways to cope with it.

We are taught that denied and repressed emotions often re-emerge in camouflage as it were.

The dread of ending up all alone is such that the patient becomes codependent in order to make sure that she never finds herself in a situation like this, never finds herself alone.

Her codependency is a series of dysfunctional behaviors that are intended to fend off abandonment and loneliness.

And still, patients who develop situational co-dependence unlike classic light-lock co-dependence are fundamentally balanced and strong personalities who cherish their self-control.

So they always keep all their options open, including the vital option of going alone yet again.

They make sure to choose the wrong partner and that they spectacularly expose his egregious misconduct so that they can get rid of them and of the newly acquired codependency and good conscience and at the same time.

So to reiterate, the situational codependent is characterized by a deep set here of being lonely, an abandonment anxiety, a form of attachment disorder as an underlying dormant inner landscape.

This lurking abandonment anxiety is awakened by life's tribulations, divorce and emptiness, death of one's nearest and dearest.

At first, the newfound freedom is exhilarating and intoxicating, but this feel-good factor actually serves to enhance the anxiety.

The inner dialogue goes something like this.

What if it feels so good that I will not opt to remain by myself for the rest of my days?

This prospect is terrifying.

So a conflict erupts in an internal conflict between conscious emotions and behaviors, liberation, joy, pleasure signal and a nagging unconscious anxiety.

I'm not getting any younger. This can't go on forever. I've got to settle down to find appropriate mate not to be left alone. I shouldn't get addicted to being alone.

To allay this internal tension, the patient comes up with situational codependency as a coping strategy to attract and bond with mate so as to forstone abandon.

Yet the situational codependent is egodystonic. She's very unhappy with her newfound codependency, though at this stage she's utterly unaware of all these dynamics.

She feels the need to frustrate this new set of compulsive addictions, her codependency, and to get rid of it because it threatens who she is and who she thinks she is, her identity and self-perception.

Surely she is not the clingy, maudlin, weak out-of-control type. All her life she has known herself to be strong, a poor judge of character, intelligent and in control.

Codependency does not pick up her.

But how could she get rid of this new codependency?

Well, in three easy steps.

She chooses the wrong partner unconsciously and obviously it leads again to being alone. She proves to her satisfaction that he is the wrong partner for her. She gets rid of him, thus re-establishing her autonomy, her resilience, self-control and demonstrating credibly that she is codependent no more.

To make matters clear, codependency is a much disputed mental health pseudo-diagnosis. We are all dependent to some degree or we all like to be taken care of.

When is this need judged to be pathological, compulsive, pervasive and excessive? And who decides?

Clinicians who contributed to the study of this disorder use words such as craving, clinging, stifling, both the dependent and apartheid. They use words such as humility, humiliating or submissive.

But these are all subjective terms, either culture-bound or represent value judgements. They are open to disagreement. They are open to differences of opinion.

Moreover, virtually in all cultures and societies, dependency is encouraged to varying degrees, especially in women. Even in developed countries, many women, very old, very young, deceived, the criminal and the mentally handicapped are denied personal autonomy. They are legally and economically dependent on others and of the authorities.

Thus, dependent personality disorder is diagnosed only when such behavior does not conform to social or cultural or morals.

Codependents, they are sometimes known, are possessed with fantastic worries and concerns. They are paralyzed by their abundant anxiety and fear of separation.

And this inner turmoil renders them indecisive. Even the simpler, everyday decision becomes an excruciating ordeal.

They go back and forth, approach avoidance. This is why codependents rarely initiate protests or do anything of their own.

Codependents typically go around eliciting constant and repeated reassurances and advice from myriad sources.

And this recurrent solicitation of Sakura is proof that the codependent seeks to transfer responsibility for peace over life to other people, whether they have agreed to assume this responsibility or not.

It's coercive. It's blackmail. This recoil and studious avoidance of challenges may give the wrong impression that the dependent is intimate or insipid, yet most dependents are neither.

They are often fired by repressed ambition, energy and imagination. It is the lack of self-confidence that holds them back. They don't trust their own abilities and judgment.

Absent an inner compass and a realistic assessment of their positive qualities of one hand, and a realistic assessment of their limitations on the other hand, dependents are forced to rely on crucial input from the outside.

Realizing this, their behavior becomes self-negating. They never disagree with meaningful others, never criticize them. They are afraid to lose their support and emotional nurturance, but also their calibration, their place in the world.

Knowing and realizing what's right and what's wrong crucially depends on input from others. They don't have self-regulation, they are dysregulated.

Consequently, the codependent wants himself or herself and bends over backwards to cater to the needs of his nearest and dearest and satisfy every every queen, every wish, expectation and demand.

Nothing is too unpleasant or unacceptable if it serves to secure the uninterrupted presence of the codependent's family and friends and the emotional sustenance that she can extract from them.

The codependent does not feel fully alive when she is alone. She feels helpless, threatened, ill-at-ease and child-like.

This acute discomfort drives the codependent to hope from one relationship to another and even sometimes lead to promiscuity.

The sources of nurturance are interchangeable to the codependent being with someone, with anyone, no matter who, is always preferable to solitude.

Parents of codependency had taught their offspring to expect only conditional transactional love. The child is supposed to render a service or fulfill the parent's wishes and dreams in return for affection and compassion, tension and emotion and so on.

Inevitably, the hurt child reacts with rage to this unjust, capricious, arbitrary, conditional mistreatment.

With no recourse to the offending parent, these theories either directed outwards to others who stand in for the dead parent or inwards.

The former solution yields a psychopath or a passive-aggressive, negativistic personality disorder.

The second solution, internalizing the aggression, results in a matter-case or in a person with depressive illness.

Similarly, with an unavailable parent, the child reserved with love can be directed inward at himself and yield a narcissist or it can be directed outward towards others and create codependent.

All these choices, retard personal growth, result in arrested development and are ultimately self-annualistic, self-defeating at least.

In all four paths, the adult plays the dual roles of a punitive parent and an eternal child who is unable and unwilling to grow up for fear of incurring the wrath and the abandonment of the parent, with whom he had merged so thoroughly so early on.

When the codependent merges with a love object, she interprets her newfound attachment and bond as a betrayal of the punitive parent. She fully anticipates the internalized parent's disapproval and dreads its self-destructive disciplinary measures.

In an attempt to placate this implacable divinity, she turns on her partner and lashes out at him, thus establishing where her true loyalty and affiliation rests with the internalized parent, not with the newfound love.

Concurrently, she punishes herself as she tries to preempt the merciless onslaught of her sadistic parental introjects and superior ego.

She engages in a panoply of self-destructive, reckless and self-defeating behaviors.

Acutely aware of the risk of losing her partner owing to her abusive misconduct, the codependent experiences extreme abandonment anxiety.

She swings wildly between self-effacing and clinging, being a doormat, behaviors on the one hand, and explosive vituperative assaults on the other, the former being the manifestations of her eternal child and internal child and the latter expressions of her punitive parent.

Such abrupt shifts in affect in conduct are often misdiagnosed as the hallmarks of a mood disorder, maybe bipolar disorder, but where dependent personality disorder is diagnosed, these pendular electronic upheavals are indicative of an underlying personality structure rather than of any biochemically-induced perturbations.

I came to addiction. Dependence of other people fulfills important mental health functions.

First, it is an organizing principle. It serves to explain behaviors and events within a coherent narrative, fictional story, a frame of reference. I acted this way because I'm dependent.

Second, it gives meaning to life. Third, the constant ups and downs satisfy the need for excitement and thrills. Fourth, and most crucially, the addiction and emotional ability places the dependent at the center of attention, allows her to manipulate people around her to do her bidding.

Indeed, codependent is convinced that she cannot live without her dependence.

This is a subtle and important distinction. She cannot survive without him or her intimate partner, but she believes profoundly, erroneously as it happens, that she cannot go on living without her addiction to her partner.

She is in love with love, not with the partner. She experiences her independence as her best friend, her comfort zone, as familiar and warm and fitting as an old pair of sleepers. She is addicted to and dependent on her dependence, but she attributes the source of his dependence to her boyfriend, to her mates, spouse, children, parents, anyone who happens to fit the bill in the plot of her narrative.

But these people come and go. Her addictions remain intact. They are interchangeable. Her addiction is immutable.

So extreme cases of codependency, dependent personality disorder, borderline personality disorder, they require professional help. Luckily, dependence is a spectrum and most people with dependent traits and behaviors are clustered somewhere in the middle. They can help themselves by realizing that the world never comes to an end when our relationship does. It is the dependence in you, in the patient that reacts with desperation, not a patient as so.

Next, the patient can analyze her addiction. What are the stories and narratives that underlie the addiction? Does she tend to idealize an intimate partner? And if so, can she see him in a more realistic light? Is she anxious about being abandoned? Why? Has she been traumatically abandoned in the past as a child perhaps?

She should write down the worst possible scenario. The relationship is over, she is abandoned, is her physical survival at stake? Of course it's not. She should make a list of the consequences of the breakup and write next to each one what she can do and intends to do about it.

And so armed with this blend of action, she is bound to feel safer and more confident. And she wants to share her thoughts, fears and emotions with friends and family. Social support is indispensable. One good friend is sometimes worth a hundred therapy sessions and this is a secret that we should keep between us. We will all go on and on.

Clinging and smoldering behaviors are the unsavory consequences of a deep-set, existential, almost mortal fear of abandonment and separation.

For the co-dependent to maintain a long-term, healthy relationship, she must first control her anxieties head-on. This can be done via psychotherapy. The therapeutic alliance is a contract between patient and therapist, which provides for a safe environment where abandonment is not an option.

And thus, when the client can resume exploring and personal growth in former modicum of surfotology, it is a psychiatrist may wish to prescribe anti-anxiety medication.

Transference should be encouraged in certain cases. Self-help is also an option when meditation, yoga, the elimination of any and all addictions such as walk-out racing, binge eating, feelings of emptiness and loneliness at the core of abandonment anxiety and other dysfunctional attachment styles. These feelings can be countered with meaningful activities, maybe altruistic, charitable, and with true stable friends who provide a safe haven and are unlikely to abandon the patient and therefore they constitute a holding, supportive and nourishing environment.

The co-dependence reflexive responses to your inner turmoil are self-defeating and counterproductive. They often bring about the very outcomes she fears most.

But these outcomes also tend to buttress her world. The world is hostile about to get hurt. These are negative automatic thoughts which can be easily and profitably tackled in a variety of cognitive behavioral therapies.

She needs to sustain her cochlear zone, abuse and abandonment are familiar to them. At least I know the rules about to cope with them. And this also is a form of complex negative thought. This is why she needs to exit this realm of mirroring fears and fearsome mental tumors. She should adopt new vocations, new hobbies, meet new people, maybe relocate, move to any place, engage in non-committal dispensable relationships and in general take life much more lightly.

Some codependents develop a type of militant independence as a defense against their own solely felt vulnerability and dependence.

But even these daring rebels tend to view their relationships in terms of black and white, an infantile psychological defense mechanism known as "splitting".

They tend to regard their relationships as either doomed to failure or as everlasting and they tend to regard their intimate partners as both unique and indispensable, soul-made, twin or completely interchangeable and objective one.

These of course are misperceptions, cognitive deficits grounded in emotional maturity and thought and personal development.

All relationships have a life expectancy, a cell bind could be for or expiring it. No one is irreplaceable or completely interchangeable.

Codependent's problems are rooted in a profound lack of self-love and an absence of object constancy. She regards herself as unloved and unlovable when she is all by herself.

Yet clinging codependent and counterdependent, firstly independent, defined, intimacy, retarding behaviors, all these can be modeled.

If you fear abandonment to the point of phobia, I advise you to adhere to a regime of therapy and a series of steps which can be easily implemented and I'll visit on my website.

Having implemented this mini-therapy, you should then seek longer term therapy in a structured therapeutic alliance.

Codependency can be overcome, can be cured if you wish, can be altered and changed into a much healthier pattern of attachment, bonding and relationships.

So I advise you to head to my website www.narcissistic-abuse.com and there's a search engine there, type the word codependent and you will find a mini-theraporetic self-administered regime which should be perhaps a first aid kit in your case.

Thank you for listening. I wish you a very good conference.

Some good upheaval in the world of borderline personality disorder.

Many things we thought we knew were disproven lately and others have emerged. All in all, more optimistic news.

If I had to choose between borderline personality disorder and narcissistic personality disorder as a diagnosis, I would choose borderline.

The more we believe or the more we convince ourselves that borderline personality disorder is actually a form of hereditary brain abnormality, the more treatment horizons and medical interventions open.

But even in the classical field of psychotherapy, there are mega developments.

Stay with me for this right, a literature review of the most recent studies in the world of borderline personality disorder.

My name is Sam Vaknin and the author of Malignant Self-Love: Narcissism Revisited and a professor of psychology.

And let's delve right in and review a new study.

This study appends our perception of borderline personality disorder.

Before I go there, there is enormous ignorance, enormous ignorance, even among people who are supposed to know better.

I just returned from a trip in July to Vienna where I've met 13 psychologists and psychiatrists, 12 of whom had insisted that borderline personality disorder is actually bipolar disorder, not borderline personality disorder as the name implies is a personality disorder.

Bipolar disorder has absolutely nothing to do with it. It's a mood disorder and yet these top-notch professionals didn't know the difference.

In another country, Hungary, I've heard of the most credentialed, prestigious diagnostician there misdiagnosing borderline personality disorder or actually the absence or lack thereof egregiously. He hands down diagnosis to people telling them they do not have borderline personality disorders because they don't self-mutilate or self-harm.

This is a level of profound ignorance in every civilized country. This man would have lost his license.

Let me elucidate a bit.

The absence of self-harm does not preclude a diagnosis of borderline personality disorder.

There are new findings and they have enormous implications when it comes to the diagnostic criteria for this disorder.

There's a recently published study and it's titled The Hidden Borderline Patient: Patients with Borderline Personality Disorder Who Do Not Engage in Recurrent Suicidal or Self-Injurious Behavior. It was published by Cambridge University Press in July 2022 and the authors are Mark Zimmerman and Lena Becker.

I will summarize the study for you and then as is my habit, I will read to you the abstract.

So what these people are saying, what these investigators or scholars are saying, is that you don't need to self-harm or self-mutilate or cut in order to gain the diagnosis of borderline or qualify for the diagnosis of borderline personality disorder.

They selected 400 psychiatric outpatients diagnosed with borderline personality disorder. About half the participants were suicidal and they engaged in recurrent self-injury, self-mutilation and self-harm. The other half didn't.

Then they studied these two populations and the results showed no difference between the two groups in the degree of impairment in occupational functioning, social functioning, comorbidity of psychiatric disorders, history of childhood trauma, severity of depression, existence, presence of anxiety, anger, emptiness, etc.

In other words, these two populations were identical diagnostically and psychodynamically. The only single difference between them is that the people in the first group self-injured, self-harm and self-mutilated intended to have suicidal ideation.

And people in the second group didn't.

When yet clearly both members of both groups qualified abundantly for a diagnosis of borderline personality disorder.

Mark Zimmerman, who is an MD and a professor of psychiatry and human behavior at Brown University, Providence, Rhode Island, said just because a person doesn't engage in self-harm or suicidal behavior doesn't mean that the person is free of borderline personality disorder.

Clinicians need to screen for borderline personality disorder in patients with other suggestive symptoms, even if these patients do not self-harm, just as they would for similar patients who do self-harm.

Zimmerman is also the director of the outpatient division at the partial hospital program in Rhode Island Hospital.

Anyhow, he published his findings in the journal Psychological Medicine.

The problem with borderline personality disorder and with all other personality disorders is that they are polythetic, at least in the Diagnostic and Statistical Manual 4, 3 and 2.

This approach of making a list of diagnostic criteria prevailed over the alternative approach, which is descriptive and dimensional.

So we ended up having lists. Each diagnosis had its own list of criteria and in the case of borderline personality disorder and narcissistic personality disorder, it was sufficient to meet five of the nine criteria in order to be diagnosed with a disorder.

But this created a major problem because for example you could be diagnosed with criteria 1, 2, 3, 4 and 5 and then I could be diagnosed with criteria 5, 6, 7, 8 and 9 and both of us would qualify to receive the diagnosis of borderline personality disorder, yet we have almost nothing in common.

Your borderline personality disorder relies on diagnostic criteria 1, 2, 5. My borderline personality disorder relies on diagnostic criteria 5, 2, 9. We have extremely little in common and this is called the polythetic problem.

So there were scholars and researchers and experimenters and psychologists all over the world who have spent past two decades trying to find the single criterion which would apply to all patients with borderline personality disorder regardless of which other criteria they had met.

And they found that the only criterion which applies to 90% of all patients with borderline personality disorder is affective instability, also known as emotional dysregulation.

Zimmerman says that affective instability had a very high negative predictive value meaning that if you didn't have affective instability you didn't have the disorder.

Given the clinical and public health significance of suicidal and self-harm behavior in patients with BPD an important question is whether the absence of these criteria which might attenuate the likelihood of recognizing a diagnosis of this disorder and they identify the subgroup of patients with borderline personality disorder who are less borderline than patients with BPD who do not manifest these criteria.

In short, the issue is this. We know that 90% of patients with borderline personality disorder have emotional dysregulation, aka affective instability.

These scholars wanted to find out whether self-harm, self-injury, self-mutilation occupies the same hallowed space in other words whether it was also present in the vast majority of borderline cases and what they found is no.

The answer is no. You could definitely be borderline without any hint or trace of suicidal ideation, self-harm, self-injurious behavior or self-mutilation.

Similarly, there was no difference between any specific axis one or personality disorder and borderline personality disorder. In other words, the comorbidity of borderline personality disorder with other mental health disorders did not have a predictive diagnostic value. You couldn't say if this person doesn't have depression, if this person doesn't have some other issue, for example, grandiosity, if this person doesn't self-harm and self-mutilate and doesn't have suicidal ideation, this person is not a borderline. You can't say this, it's wrong.

The only two comorbidities which have some predictive value when it comes to borderline personality disorder are generalized anxiety disorder in patients under age 45, especially very young patients and histrionic personality disorder. Both were more frequent in the patients who did not meet the suicidal self-injury criteria.

So it seems that there are two groups of borderline.

Borderlines who are suicidal and self-injurious, these borderlines would tend to have anxiety and histrionic personality disorder and borderlines who are self-destructive, self-harming and these borderlines would not have usually or normally or would have less frequency of histrionic personality disorder.

The patients who met the suicidality self-injury criterion were significantly more likely to have been hospitalized and reported more suicidal ideation at the time of the evaluation.

Wrote the researchers, there were no between group differences on severity of depression, anxiety or anger at the initial evaluation. There were no differences in social functioning, adolescent social functioning, likelihood of persistent unemployment or receiving disability benefits, childhood trauma or neglect.

Both all these parameters were identical in the group of patients who were suicidal and self-harming and in the group of patients who were not suicidal and were not self-injurious. All these parameters, I repeat them, social functioning, adolescent social functioning, likelihood of persistent unemployment or receiving disability benefits, childhood trauma or neglect.

Zimelan says, "I suspect that there are a number of individuals whose BPD is not recognized. Because they don't have the more overt feature of self-injury or suicidal behavior."

He calls this hidden BPD, hidden Borderline Personality Disorder.

"Reputed self-injurious and suicidal behavior," he says, "is not synonymous with Borderline Personality Disorder and clinicians should be aware that the absence of these behaviors does not rule out a diagnosis of Borderline Personality Disorder."

Monica Karski is the Assistant Professor of Psychology in Psychiatry and a Senior Fellow of the Personality Disorders Institute in Weill Cornell Medical College, New York City. She has a very long list of credentials. She is also a manager of the postdoctoral program in psychoanalysis, psychotherapy, etc.

Karski suggested to stop using the diagnostic and statistical manual edition four text revision model. In other words, she says, "Don't use the list of nine diagnostic criteria."

This list is very misleading. It's very misleading. It's also culture-bound. It includes gender bias and it's polythetic. It leads equally to comorbidity with other disorders. It's a mess.

The diagnostic and statistical manual edition four, including the text revision, are a bloody mess. And they are a mess because they rely on lists and categories.

Whereas the human psyche and the human mind are not categorical. They are dimensional and they are on a spectrum.

So Karski suggests to use the alternative model or the alternate model for personality disorder in the diagnostic and statistical manual fifth edition text revision.

In the alternative model or alternate model of Borderline Personality Disorder, first you rate the severity level of personality. You assess identity, relationship problems, intimacy issues, self-regulation. You note specific traits of personality disorders.

And she says, "This will help clinicians who dread telling patients that they are borderline."

I concur wholeheartedly.

The alternative model in the DSM-5 is vastly superior to anything DSM-4 has to offer.

Summary of this part, you don't have to self-harm, you don't have to self-mutilate, you don't have to be suicidal to qualify for a diagnosis of Borderline Personality Disorder.

If you are emotionally dysregulated and your affect is unstable, you probably have borderline features and in all likelihood a borderline personality disorder.

So this is the article. Go to the description for a bibliography.

I'm going to read to you what the authors said in the article itself.

Background. Despite the significant psychosocial morbidity associated with Borderline Personality Disorder, its under-recognition is a significant clinical problem.

BPD is likely under-diagnosed in part because patients with BPD usually present with chief complaints associated with mood, anxiety and substance abuse disorders.

When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to be recognised.

An important question is whether the absence of these criteria, which might attenuate the likelihood of recognising and diagnosing the disorder, identifies a subgroup of patients with BPD who are less borderline than patients with BPD who do not manifest these criteria.

The results are this. Approximately half of the patients with BPD did not meet the suicidality self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in terms of occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma or severity of depression, anxiety or anger upon presentation for treatment.

And just correcting one thing, the only exceptions are generalized anxiety disorder in patients under age 40 and histrionic personality disorder throughout the lifespan. These two are correlated with borderline personality disorder.

The comorbidity is significant statistically speaking.

The conclusions of the study, repeated self-injurious and suicidal behavior is not synonymous with borderline personality disorder. It is critical for clinicians to be aware that the absence of repeated self-injury in suicide threats or gestures or attempts does not rule out the diagnosis for borderline personality disorder.

Onward to the next article.

It identified a new treatment modality for borderline personality disorder.

Hereto we have had mostly dialectical behavioral therapy, DBT. DBT has been extremely efficacious while over 50% of patients lost the diagnosis within one year.

The DPD involved a group element and an individual therapy element.

To this very day, DBT, dialectical behavioral therapy, is the gold standard for treating borderline personality disorder.

And here comes another possibility.

Another possibility. I'm referring to an article titled The Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder. A randomized clinical trial.

The lead author is Anund Anz, A-R-N-Z. And I will read to you the key points and findings from the study itself, but I want to discuss it a bit beforehand.

What the study shows is that if you were to combine individual schema therapy with group schema therapy, you would accomplish a reduction of symptoms, a substantial reduction of symptoms in patients with borderline personality disorder.

That's a new tool in our arsenal. Schema is a form of psychotherapy that focuses on the experience, on experiential approach. It's not so focused on behavior change. It teaches you how to manage your experience in ways which render you more functional and definitely more self-aware.

This study, again, the lead author was Dr. Anund Anz. This study was an international, randomized control trial.

And what the study found was that it's not enough to offer individual schema therapy. You need to couple it with group schema therapy.

And so what Dr. Anz says is, in the Netherlands, there's a big push from mental health institutes to deliver treatments in group therapy only because people think it's more cost effective.

But these findings question this idea.

The findings were published in a very prestigious academic journal, Journal of American Medical Association Psychiatry.

The study characterizes borderline personality disorder a bit idiosyncratically, I must say.

Many scholars would disagree with some of the characteristics of borderline personality disorder as incorporated in this study.

The study says that patients with borderline personality disorder exhibit extreme sensitivity to interpersonal self-schema.

This kind of hypervigilance is actually much more typical in narcissistic personality disorder, not in borderline personality disorder.

The study says that patients with BPD have intense and volatile emotions, which is true, as we've seen in the previous study.

Impulsive behaviors, also true. Many of them abuse drugs, self-harm or attempt suicide.

Wrong, it seems. About half of them do, not many of them.

At any rate, borderline personality disorder is by and large captured appropriately in the study.

So we can't disqualify the study as having explored other mental health disorders.

Patients in the study were clearly borderline.

When we look at evidence-based recommendations by various psychiatric and psychological associations around the world, the usual first venue or first resort is psychotherapy.

Psychotherapy is the primary treatment for people presenting with what appears to be borderline personality disorder.

We need many more therapies.

Classical therapies such as psychoanalysis or even cognitive behavior therapy have proven to be inefficacious with borderline, hence the modification of BPD.

Schema therapy uses techniques from traditional psychotherapy, but it focuses, as I said, on an experiential strategy. It delves into early childhood experiences.

In the case of borderline personality disorder, this is very relevant because in the vast majority of patients with borderline personality disorder, we do find adverse childhood experiences, trauma, abuse and neglect in early life.

That is not to say that borderline personality disorder is not a brain abnormality. It's not to say that there is no genetic or hereditary component in borderline.

It seems that people who go on to develop borderline personality disorder in childhood or adolescence are people who have a propensity, a proclivity, a predilection to develop borderline personality disorder genetically or cerebrally in the brain.

In other words, these people are somehow predisposed to develop borderline personality disorder because they have defective genes or brain abnormalities, but the trigger is environmental, nurtured, not nature.

In the absence of abuse, trauma and neglect in early childhood, you're very unlikely to develop borderline personality disorder even if you have older genes and older brain abnormalities.

So, schema therapy seems to be very relevant.

With this approach, therapists take on a kind of parenting role and they try to meet the needs of these patients that were not met in early childhood.

The patient is perceived as a frustrated child and the role of the therapies is to help the patient grow up and mature by acting the parent.

Previous research had suggested that both individual and group schema therapy helped to reduce BPD symptoms, but what this study shows is that if you were to combine individual and group schema therapy, the benefit becomes exponential.

Treatment retention is also higher when you combine the therapy. There's the improvement in multiple secondary outcomes, happiness, quality of life, patient reports, and enhanced sense of well-being.

Still, just to put things in perspective, outcomes in society or in work are more improved in DBT than they are in this combined approach.

I want to be clear, combining individual schema therapy and group schema therapy does improve societal and work functioning patterns and outcomes, but not as much as DBT.

So, Arndt says that group therapy seems to offer something that is important for learning to cooperate with other people.

At work, you often have to collaborate with people who are not necessarily your friends.

It's the same approach in DBT, by the way. There's a very strong, dominant group element there.

The number of suicide attempts among patients exposed to combined schema therapy, the number of suicide attempts declined over time. The combination proved to be significantly superior to treatment as usual.

During the study period, three patients died of suicide, one in each treatment arm. Another third one was not, it wasn't clear that it was suicide.

So, these are three out of hundreds. It's a major improvement in the statistics of suicide in typical borderline groups.

Overall, the results suggest that group and individual sessions address different needs of patients.

While patients may learn to get along with others in a group setting, they may be more comfortable discussing severe trauma or suicidal ideation or thoughts in one-on-one sessions with a therapist.

So, let me read to you from the study. And again, go to the description, there's a bibliography with a list of all these studies and where to find them.

Let me read to you the key points of the study.

The findings.

In this randomized clinical trial, which included 495 adult participants with borderline personality disorder in five countries, combined individual and group schema therapy was significantly more effective than optimal treatment as usual and predominantly group schema therapy.

So, the combination was much more effective in reducing BPD severity.

The findings add to the evidence for the effectiveness of schema therapy for borderline personality disorder and indicated the combination of individual and group schema therapy is the more effective schema therapy for month.

Okay, let's go on to the next study.

And the next study kind of challenges the common orthodox wisdom in all the treatment guidelines that I'm aware of all over the world.

If this study is replicated and supported by other studies, we have been doing things wrong for decades.

According to this study, and in a minute I'll read to you the title of this study, give me a minute, effect of three forms of early intervention for young people with borderline personality disorder.

The MOBY, Randomized Clinical Trial, the lead author is Andrew Chanen. And as usual, I'll first analyze the study and then read to you from this study.

What the study says is that early interventions that focus on clinical case management and psychiatric care and not on individual psychotherapy are more effective for young patients with borderline personality disorder.

You remember that we can diagnose and do diagnose borderline personality disorder as early as 12 years old. It's not the case with narcissistic and antisocial personality disorder, which are diagnosed only after age 18 or sometimes 21.

Borderline can be diagnosed very early on in life. And so we have patients, they're underage and we need to treat them somehow.

And hitherto, all the treatment guidelines all over the world said that what you do with such a young patient is give him or her psychotherapy.

And what this study says, it's the wrong approach. You should focus on case clinical, a clinical case management. You should focus on psychiatric care, including medication.

And there is this trial, big trial called Monitoring Outcomes of Borderline Personality Disorder in Youth, the MOBY trial. It showed improved psychosocial functioning and reduced suicidal ideation with early psychiatric intervention in case management.

So the results of this study suggest that psychotherapy is not the only or even first effective approach for early BPD.

Dr. Chanen is the Director of Clinical Programs and Services and Head of Personality Disorder Research at Origin Melbourne, Australia. And he said, "We can say that early diagnosis and early treatment is effective and the treatment doesn't need to involve individual psychotherapy, but does need to involve clinical case management and psychiatric care.

Patients with BPD have extreme sensitivity to interpersonal slides and exhibit all kinds of volatile emotions and impulsive behavior. As we said, many self-harm, abuse drugs, attempt suicide. The suicide rate among patients with Borderline Personality Disorder to remind you is anywhere between 8 and 11 percent depending on the country.

The condition is diagnosed in puberty or earlier adulthood and it affects about 3 percent of young people. Luckily for humanity, many of these young people grow out of their Borderline Personality Disorder.

There are two ways where you can lose the diagnosis between ages 12 and 21 and then after age 45. Only one-third of young adults or adolescents diagnosed with Borderline Personality Disorder go on to become adults with a diagnosis with Borderline Personality Disorder.

But these patients, young patients, they are volatile, they're labile, they're dysregulated, they're aggressive, they have enormous interpersonal difficulties and they're discriminated against by health professionals. They don't get treated.

Those that are treated are often shunted off to some therapies once a month or something. They receive individual psychotherapy. A very small percentage of them end up in dialectical behavioral therapy program.

Let me be clear, individual psychotherapy is a good thing. These therapies, especially DBT, teach you healthy ways to cope with stress and to regulate emotions. And so these therapies are highly effective.

But the MOBY trial examined three treatment approaches, not only one.

The first treatment approach is called the Help Young People Early model, Hype. The second is Hype combined with weekly befriending. And the third was a General Youth Mental Health Service, YMHS model, combined with befriending.

So a key element of Hype is cognitive analytic therapy. It's a psychotherapy program focused on understanding problematic self-management and interpersonal relationship patterns.

The model also includes clinical case management, for example, housing, vocational and educational issues, other mental health needs, comorbidities like depression and anxiety, medication, physical health needs.

In the second model, psychotherapy of the Hype program is replaced.

You have all the elements of clinical case management, but instead of psychotherapy, you have befriending.

Befriending means chatting with the patients. The chats are about neutral topics. I don't know, sports. Avoiding emotionally loaded topics, avoiding actually not discussing interpersonal problems.

And the third approach was YMHS plus befriending. It's when the experts trained young people. They gave the young people therapy, they managed the patients, but these therapists were not specialists in BPD.

So the third approach is what we call as usual treatment, or treatment as usual approach.

Therapists, psychologists who are not experts and scholars of BPD, but treat BPD as well. All patients across all three groups had marked and sustained improvements in ways you wouldn't expect for borderline personalities.

Interventions have a true effect, especially in childhood and puberty.

The results suggest that early diagnosis and not very complicated treatment or even just chatting to someone drastically improves the lives of these young people, says Cheynum.

The results also imply that there are effective alternatives to mere treatment as usual psychotherapy.

The insistence of the field by many scholars and many institutions and many treatment guidelines, the insistence that only therapy works in BPD is wrong.

Cheynum says this study turns things upside down and says actually that psychotherapy is not the single modality. It's the basics of treatment that are important, not which treatment.

When a patient presents at an emergency department following, for example, severe overdose, clinicians reflexively refer that person to a psychotherapy program.

But the problem is these programs are not built to service the needs of suicidal borderline personality disorder patients. They are kind of canvassing programs and most of the workers in these programs, albeit with academic degrees in psychology, are not experts in the extremely convoluted and complicated dynamic of borderline personality disorder.

The skills for clinical case management and psychiatric care are very specialized.

So this is the study.

John Oldham, who is a distinguished emeritus professor in the Meninger Department of Psychiatry and Behavioral Sciences in Baylor College of Medicine, Houston, Texas, Oldham says the general standard approach in psychiatry in the diagnostic world has been to not even consider anything until after somebody is 18 years of age, which is a mistake because these kids can become quite impaired much earlier than that, he says incorrectly.

Oldham was not involved in this study. Ironically, he was one of the main contributors and authors of the very treatment guidelines which are undermined by this study.

And yet, amazingly at his age and with his renomé and track record, Oldham is an example of a good scientist. A scientist who is open to new information, a scientist who is capable of modifying his views very substantially when exposed to new findings.

Oldham says there is an emerging trend towards good psychiatric management that focuses on level of functioning rather than on a specific strategy requiring a certificate of training that not many people out there have, Oldham says.

"You're not going to make much headway," he concludes with these kids. "You're not going to make much headway with these kids if you are going to be searching around for a DBT certified therapist.

What you need is to bring them in, get them to trust you and in a sense to be a kind of overall behavioral medicine navigator for them.

Let me read to you from the study, as I usually do, by the way, the study comes with a beautiful graphic.

And so the key points are, question, what combination of treatment components is sufficient for early intervention for young people with borderline personality disorder?

And the findings in this randomized clinical trial with 139 youth with borderline personality disorder, a dedicated BPD service model and a specialized BPD psychotherapy were associated with superior retention in care but not a superior rate of change in psychological functioning by 12 months.

And this is compared with general youth mental health care in a psychotherapy controlled condition.

Effective early intervention for BPD is not reliant on availability of BPD psychotherapy. This is a major change in orientation.

It means that when we are confronted with a young BPD patient, we should immediately take care of all the aspects of his functioning and his life. We should befriend him and we should offer a complete or total solution, not focus on psychotherapy, which often doesn't work or works less effectively.

And so now I want to review six studies of psychosocial interventions. It is an article titled "Borderline Personality Disorder: Six Studies of Psychosocial Interventions".

By Saeed and Angela Callis, K-A-L-L-I-S, is published in the Journal of Current Psychiatry in 2002.

So the first study is by Zanarini, Konki and Temes.

But before we go there, a reminder of what is borderline personality disorder.

Borderline personality disorder is a serious impairment on multiple levels and in multiple areas of life, starting with emotional dysregulation and affect instability.

But psychosocial functioning is severely affected. There's an ongoing pattern of mood instability, or ability, cognitive distortions, problems with self-image, impulsive behavior that often results in problems in the workplace and in relationships.

Patients with BPD tend to utilize more mental health services than patients with any other mental health disorder or even with major depressive disorder.

Many clinicians believe that BPD is very difficult to treat. This is no longer true, this hasn't been true for decades, but the stigma lingers on.

Historically, there's been little consensus on the best treatments for these disorders. And currently we use pharmacologic and psychological interventions in combination.

So I want to review six studies very briefly.

So again, the first one is titled "Randomized Controlled Trial of Web-Based Psychoeducation for Women with Borderline Personality Disorder". It was published in the Journal of Clinical Psychiatry in 2018.

The authors are Zanarini, Konki and Temes. I'm reading the abstract.

Research has shown that BPD is a treatable illness with a more favorable prognosis than previously believed.

Despite these, patients often experience difficulty accessing the most up-to-date information on BPD, which can impede their treatment.

A 2008 study by Zanarini and allies of younger female patients with BPD demonstrated that immediate in-person psychoeducation improved impulsivity and relationships.

Widespread implementation of this program proved problematic, however, due to cost and personnel constraints.

To resolve this issue, researchers developed an internet-based version of the program.

In a 2018 follow-up study, Zanarini and his collaborators examined the effect of this internet-based psychoeducation program on symptoms of BPD. And the outcomes were pretty astonishing.

In the acute phase, treatment group participants experienced statistically significant improvements in all 10 endpoints and outcomes.

It seems that in patients with BPD, internet-based psychoeducation reduced symptom severity and improved psychosocial functioning, with effects lasting up to one year.

Treatment group participants experienced clinically significant improvements in all outcomes measured during the acute phase of the study. Most improvements were maintained over one year.

So this is pretty interesting.

A pretty interesting study.

The next study is a randomized trial of brief dialectical behavioral therapy skills training in suicidal patients suffering from borderline disorder, was published in Akta Psychiatry, Scandinavia, Scandinavia 2017.

The authors were McCain and Guimot and Bountiful.

So they said standard dialectical behavioral therapy, DBT, is an effective treatment for BPD.

However, access is often limited by shortages of clinicians and resources.

Therefore, it has become increasingly common for clinical settings to offer patients only the skills training component of DPD, which requires fewer resources.

While several clinical trials examining brief DPD, DBT skills, only treatment for BPD. So while several clinical trials examining this shortened or condensed version of DPT for BPD, these studies have shown promising results. It is unclear how effective this kind of intervention is introducing suicidal or non-suicidal self-injury episodes.

So the study explored the effectiveness of brief DPD, DBT skills. Only adjunctive treatment for the rates of suicide and NSSI episodes in patients with BPD.

I'll summarize this for you.

DPD is expensive, DBT is costly, DBT requires training. DBT is not available everywhere to everyone. So there's a sort of zipped or condensed version of DBT, which offers only skills training.

The authors try to find out if BPD patients subjected to abridged DBT, the skills training component of DBT, if these patients responded favorably to the treatment by reducing rates of suicide and self-injury, which was not suicidal.

And so the outcomes were that the DBT group showed statistically significant greater reductions in the frequency of suicidal and NSSI episodes. So the DBT group experienced statistically significant improvements in distress tolerance and emotion regulation, but no difference on mindfulness. The DBT group achieved greater reductions in anger over time.

So it seems that yes, there are impacts, even if we use only a single component of DBT, it already has massive effects on multiple very crucial dimensions of BPD.

The conclusions are brief DBT skills training, reduced suicidal and NSSI self-injury episodes in patients with BPD.

Participants in the DBT group also demonstrated greater improvements in anger, distress tolerance and emotion regulation compared to the control group. These results were evident three months after treatment.

However, any gains in health care utilization, social adjustment, symptom distress, borderline symptoms diminished or did not differ from the other participants at week 32.

At that time, participants in the DBT group demonstrated a similar level of symptomatology as the control group.

So this was the second study.

The next study is titled "Combined Therapy with Interpersonal Psychotherapy Adopted for Moclipid Personality Disorder".

A two year follow-up was published in Psychiatry Research in 2016.

The authors are Bozzatello and Bellino. I love Italian, how musical.

The study was interesting. It says that psychotherapeutic options for treating BPD, including DBT, mentalization based treatment, schema focused therapy, transference based psychotherapy and systems training for emotional predictability and problem solving. All these are psychotherapeutic options, but they are not widely available.

More recently, interpersonal therapy also has been adopted for BPD. It is known as IPT-BPD.

However, thus far, say the authors, no trials have investigated the long-term effects of this particular therapy on BPD.

In 2010, Bellino and allies published a 32-week study examining the effect of IPT-BPD on BPD. They concluded that IPT-BPD, in other words, interpersonal therapy, adopted for BPD.

They concluded that IPT-BPD plus Prozac was superior to Prozac alone in improving symptoms and quality of life.

The present study by Bozzatello and allies examined whether the benefits of IPT-BPD plus Prozac demonstrated in the 2010 study assisted over a 24-month follow-up.

And so the outcomes were, while the original study demonstrated that combined therapy had a clinically significant effect over Prozac alone on BPD, this advantage was maintained only at the six-month assessment. The improvement of the combined therapy provided over Prozac monotherapy with regards to impulsivity and interpersonal relationships, as well as factors of social and psychological functioning at 32 weeks, were preserved at 24 months. No additional improvements have been seen.

The conclusions of the study are that the improvements in impulsivity, interpersonal functioning, social functioning and psychological functioning at 32 weeks, seen with IPT-BPD plus Prozac, compared with Prozac alone, persisted for two years after completing therapy.

But no further improvements were seen. The improvements to anxiety and affective instability that combined therapy demonstrated over Prozac monotherapy at 32 weeks were not maintained after 24 months.

So the next study is favorable outcome of long-term combined psychotherapy for patients with borderline personality disorder, six-year follow-up of a randomized study.

Again in psychotherapy research, 2017, the authors were Anchonsen, Kvashtai, Stein and Ernest.

While many studies have demonstrated the benefits of psychotherapy for treating personality disorders, say the authors, there is limited research of how different levels of psychotherapy may impact treatment outcomes.

There is something called the Uleval Personality Project. It compared an intensive combined treatment program with outpatient individual psychotherapy in patients with personality disorders.

The combined treatment program consisted of short-term day hospital treatment followed by outpatient combined group and individual psychotherapy.

The outcomes evaluated included suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress and interpersonal personality problems.

A six-year follow-up concluded that there were no differences in outcomes between the two treatment groups.

However, the authors examined whether combined therapy, the combined psychotherapy, produced statistically significant benefits over the outpatient therapy in a subset of patients with borderline personality disorder.

So you remember that the group included many types of personality disorders.

So these authors wanted to home in to focus on patients with borderline personality disorder and to see whether combined therapy was superior to outpatient therapy in the case of BPD only.

So they discovered that when it comes to BPD, borderline personality disorder, compared to the outpatient group, the combined psychotherapy group demonstrated statistically significant reductions in symptom distress.

At year six, in between years three and six, the combined psychotherapy group continued to show improvements in psychosocial functioning.

So the outpatient psychotherapy group worsened during this time.

The scores of this group worsened during this time compared to the outpatient group.

Participants in the composite group also had significantly better outcomes on multiple domains of self-control and identity integration.

There were no significant differences between groups on the proportion of participants who engage in self-harm or experience suicidal thoughts or attempts. There were no significant differences in outcomes between the treatment groups in all these domains.

Participants in the composite group tended to use fewer psychotropic medications than those in the outpatient groups over time.

But this difference was not statistically significant. The two groups did not differ in the use of health care services over the last year.

Avoidant personality disorder did not have a significant moderate effect in this case.

Comorbid avoidant personality disorder was actually a negative predictor independent of the group.

Both groups experienced a remission rate of 90 percent a six-year follow-up.

Compared with the outpatient group, participants in the composite group experienced significantly greater reductions in symptom distress and improvements in self-control and identity integration at six years.

So this is the this study.

The next study is eight-year perspective follow-up of mentalization-based treatment versus structured clinical management for people with borderline personality disorder.

It was published in the Journal of Personality Disorders 2021 in the authors of Bateman, Constantino and Phonology.

They say the efficacy of various psychotherapies for symptoms of BPD has been well established. However, there is limited evidence that these effects persist over time.

In 2009, Bateman and others conducted an 18-month study comparing the effectiveness of outpatient mentalization-based treatment MBT against structured clinical management for patients with BPD.

Both groups experienced substantial improvements, but patients assigned to mentalization-based treatment demonstrated greater improvement in clinically significant problems, including suicide attempts and hospitalization.

In a 2021 follow-up to this study, Bateman and allies investigated whether the MBT group, the mentalization group, the gains in this group, in the primary outcomes, absence of severe self-harm, suicide attempts and inpatient admissions in the previous 12 months, the gains in social functioning, the gains in vocational engagement, mental health service usage, whether these gains were maintained throughout an eight-year follow-up period.

So the outcomes were that the number of participants who met diagnostic criteria for BPD at the one-year follow-up was significantly lower than the mentalization-based group compared with the other group.

To improve participant retention, this outcome was not evaluated at later visits. The number of participants who achieved the primary recovery criteria of the original trial, to remind you, absence of self-harm, suicide attempts and inpatient admissions, the number of patients who achieved these primary recovery criteria and remained well throughout the entire follow-up period was significantly higher in the mentalization group compared with the other group.

The average number of years through during which participants failed to meet recovery criteria was significantly greater in the other group compared to the mentalization group.

When controlling for age, treatment group was a significant predictor of recovery during the follow-up period.

Overall, significantly fewer participants in the mentalization group experienced critical incidents during the follow-up period, which was a very long follow-up period.

The other group, the non-mentalization group, used mental health services for a significantly greater number of follow-up years than the mentalization group.

The likelihood of using crisis services did not statistically differ between the groups, but the first group, the non-mentalization group, used these services much more.

MBT group participants spent more time in education, were less likely to be unemployed, were less likely to use social care interventions than the other group. People in the MBT group spent more months engaging purposeful activity, etc., etc. They had fewer months of psychotherapeutic medication compared with the other group, and so on.

The study demonstrated that patients with BPD significantly benefited from specialized therapies such as mentalization-based therapy.

At the one-year follow-up, the number of participants who made diagnostic criteria for BPD was significantly lower in the mentalization group. The number of participants who achieved the primary recovery criteria and remained well during the eight-year follow-up period was also significantly higher in the mentalization group. So mentalization is a third option after DBT in schema therapy. Finally, the sigh of relief. Finally, an article titled "Effectiveness and Safety of the Adjunctive Use of an Internet-Based Self-Management Intervention for Borderline Personality Disorder, in addition to care, as usual, results from a randomized controlled trial" was published in the BMJ Open Access, BMJ 2021. The authors are Klein, Howard and Bergen.

They say fewer than one in four patients with BPD have access to effective psychotherapies. The use of Internet-based self-management interventions developed from evidence-based psychotherapies can help close this treatment gap.

Although the efficacy of Internet for several mental health disorders has been demonstrated in multiple mental analyses, results for BPD are mixed.

In this study, Klein and allies examined the effectiveness and safety of the adjunctive use of an Internet-based self-management intervention based on schema therapy in addition to care, as usual, in patients with BPD.

So the outcomes were there were large reductions in the severity of BPD symptoms as measured in various ways.

In people who used Internet-based intervention method, this difference was statistically significant. There was no statistically significant difference in the number of serious adverse events between the two groups.

So the conclusion was that treatment with an Internet-based intervention module did not result in improved outcomes over care, as usual.

Although the average reduction was greater in this group compared to the reduction in symptoms was greater in this group compared to the control group, this difference was not statistically significant.

The authors believe that because many of the patients were receiving psychotherapy, the study should be taken with a grain of salt.

But it's interesting because many people resort to the Internet as a first option, you know, support groups, forums, even Internet-based psychotherapies.

This study seems to indicate that it's not working. Many groundbreaking and earth-shattering discoveries. I thought I'd bring them to your attention. Thank you for surviving. We'll see you next time. Good afternoon, dear students. This is a half-credit lecture for the CIAPS, Outreach Program of CIAPS, Center for International Advanced Professional Studies, those of you who had forgotten during the pandemic. And another thing you've forgotten is to hand in your assignments. Half of you, more than half of you, haven't done so. I don't know, you're twiddling your thumbs. Or shudder the thought, twiddling some other part of you.

So quit twiddling and start handing in, submitting your assignments from the last lecture. Last lectures, actually. Okay, enough with hectoring and preaching.

Today we are going to discuss meaning, the role of meaning in therapy. We are going to use three examples, three treatment modalities, three therapies, which have based themselves explicitly on the meaning of life, on introducing meaning, context and sense into the client's life, or deriving meaning, context and sense out of the patient's or client's life and the way he describes his life, also known in clinical terms as personal narrative.

Meaning is a very important thing.

I tend to agree with Viktor Frankl, who had suggested that Freud got it essentially wrong when he said that life revolves around pleasure, that Adler got it wrong when he had suggested that life revolves around power and that life actually revolves around making sense, significance, meaning, direction, goal, purpose, structure and order.

In this sense, Jordan Peterson is right when he posits chaos against order and claims that order is the key to mental health.

And so today we are going to discuss meaning.

How do we introduce meaning into a life that ostensibly is chaotic, is all over the place, discombobulated, disintegrated? How do we impose structure and order on people who decompensate, who defiantly and contumaciously react, reactance, on people who confuse external objects and internal objects?

In short, how do we make sense of mental illness? And once we make sense of the lives of the mentally ill, do they stop being mentally ill? Is this the key?

Were these people simply anomic? Were people with mental illness simply people who fail to make sense of the world, of their lives, who find no meaning, no purpose, no direction, no structure, no order? Is this why many of them end up in hermeneutic, explanatory and organizing systems like religion, because they're defined by their missing?

And are these solutions like religion not much worse than the problem?

Swapping one delusion for another, one illusion for another, is this an acceptable mental health strategy?

But we tend to do this a lot in our daily lives.

What is love? What is love, if not a delusional disorder?

By the way, biochemically in the brain, it resembles very much a mental health disorder.

I refer you to my video on this YouTube channel titled "Love is a Pathology" where I summarize the latest findings.

Love is indistinguishable, or more precisely the stage of limerence, the stage of infatuation, is indistinguishable for mental illness.

And I'm talking about the brain, functional magnetic resonance imaging.

So here we swap one, one intolerable situation, a meaningless life, for a delusion called love, because love structures our lives.

Love gives us direction, purpose, goal, etc.

In extreme cases, love deteriorates into stalking.

Similarly, substance abuse, drugs, alcohol, they provide an exoskeleton, they imbue life with meaning, and that's why they are so difficult to eradicate, to reverse, that's why rehab, rehab is a spectacular failure, because rehab tackles the psychological and physiological elements of addiction, but does not tackle the nomological, the axiological aspects, the lack of meaning in the addict's life.

So today I would like to discuss three treatment modalities, which leverage meaning, use meaning as a healing tool.

Let's start with the power threat meaning framework, PTMF or PTM framework.

And I want to read to you what these people say about themselves.

The PTMF framework was developed by both psychologists and psychiatrists, this is what was one group of psychologists and psychiatrists, and they teamed up, they teamed up with social workers, neighborhood activists and so on.

So they went down, they went to the grass grassroots, they went to the neighborhoods, they went to homeless people, they went to mentally ill people, they went to mental, I mean they dirtied their hands, they didn't stay in the lab or in this lecture hall and just theorize, and you know they didn't consider themselves public intellectuals, they considered themselves frontline health workers and they collaborated with everyone who was fighting back.