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Cold Therapy: Treat Narcissism and Depression (30th World Psychiatrists and Psychologists Meet)

Uploaded 10/3/2018, approx. 21 minute read

Good day to all of you. My name is Sam Vaknin, and I'm the author of Malignant Self-Love: Narcissism Revisited, as well as a professor of psychology in Southern Federal University in Rostov-on-Don, the Russian Federation, and in the Center for Advanced Studies, CIAPS, SIAS-CIAPS.

I have spent about seven years developing a new treatment modality for a narcissistic personality disorder. I dubbed it Cold Therapy. The past 22 years, I dedicated to the study of pathological secondary narcissism, narcissistic defenses, and in the most extreme cases, malignant narcissism and narcissistic personality disorder, the full-fledged disorder of the spectrum. And I reach a conclusion that there are several misconceptions about pathological narcissism.

It is presented as a regression to an earlier childhood developmental phase, or a psychological defense, or an organizing principle or a schema, or in the more comprehensive form, is a personality disorder. And it may well be all these four, but not only these four. I think a much better way of looking and considering pathological narcissism is as a post-traumatic condition.

Pathological narcissism is elicited and provoked in a child. It starts at the age of three or four, during the formative years, in an abusive household, where the child's boundaries are not recognized, and individuation and separation are prevented by a capricious, sick or even malicious parent.

So this traumatic experience gives rise to a whole array, a whole amalgam of defenses, which we call pathological narcissism. It therefore behooves us to regard pathological narcissism as a post-traumatic condition.

The second thing that I notice is that when narcissistic patients, when narcissists finally attend therapy, having hit rock bottom, they are treated as adults.

Techniques borrowed from adult psychotherapies are applied to the treatment of the narcissism.

But narcissism is not an adult disorder. It is an attachment dysfunction, and it is coupled with arrested development. It therefore should be amenable to techniques borrowed from child psychology and from trauma therapy.

In other words, I regard pathological narcissism as less of a disorder of the self and more of an interpersonal disorder. Indeed, as Hazen and McFarland wrote in 2010, when alarmed, the child seeks proximity to a caregiver, a safe base, but proximity to frightening caregivers increases the alarm.

And I think the child attaches to an imaginary caregiver in this case, and this is the false self.

The false self is a god-like concoction. The false self is everything the child is not.

The child is helpless. The false self is omnipotent.

The child doesn't know what's going to happen next. The false self is omniscient.

The child is perceived as a bad, worthless object by the parent and introjects this perception. The false self is perfect and brilliant.

In a way, narcissism is a private religion with the false self as the deity worshiped by the narcissist. And so the child remains fixated.

And when a narcissist comes to therapy, he is nine years old, sometimes young. There's no point in applying adult techniques.

And this child is heavily traumatized. It's a child with no boundaries, a child with no organization for personality. It's a severe post-traumatic condition, complex PTSD.

And so Cold Therapy adopted a completely different approach to pathological narcissism, as I said, not regarding it as a personality problem or a character problem, but as an interpersonal issue.

And so what Cold Therapy seeks to do, going in the footsteps of Foa and Kozak in 1985, what it seeks to do is to re-traumatize the patient. The idea is that if the patient goes through the same trauma again, if he's re-traumatized, then this should be helpful in resolving the conflicts, in achieving closure, in countering avoidance, helplessness, and depression.

Of course, the re-traumatization is both controlled and tiered.

There is a process of triggering trauma stimulation or stressing, but the environment is a non-holding environment. It's absolutely hostile.

We are trying in Cold Therapy to generate a facsimile of the environment of the primary or originating trauma. And there's no way to generate such a facsimile in a holding setting. If the therapist is empathic, compassionate, genuinely emotional, concerned with patient, that is not a replica of the abusive parent and the re-traumatization process will fail.

The therapist needs to emulate the abusive parent, and that is why we encourage actually transference in Cold Therapy.

The idea is that as the adult patient emerges from the re-traumatization process alive, as he survives the re-traumatization, as he successfully copes with it, the patient's maladaptive narcissism, his cognitions, his beliefs, his emotions, all these will be rendered redundant. The patient will no longer need his pathological narcissism to cope.

Pathological narcissism starts as an adaptation. It's adaptive in childhood. But the adult patient needs to learn that even if he finds himself in an identical state of trauma, there are other mechanisms to cope. He does not need his narcissism anymore. It's unnecessary. It's obsolete.

And as we know from the principle of economy of mental energy, if something is unnecessary and obsolete, it vanishes and fades away.

So this is the core precept, the core tenets of Cold Therapy.

Cold Therapy re-interprets the narcissist behaviors and actions in socially acceptable lights.

It emulates, it kind of combines cold empathy with emotional resonance tables. But we'll talk about it a bit later.

What are the goals of Cold Therapy?

The goals of Cold Therapy is to process trauma via skilled, relieving, foster more adaptive functioning, replace negative with positive coping strategies, integrate distressing materials, thoughts, feelings and memories in a way which would render them, neutralize them, lead to internal resolution and homeostasis and aid the growth of skills such as resilience, ego regulation, internal ego regulation and empathy.

Narcissistic replying is thereby rendered unnecessary because the main role of narcissistic replying is the regulation of the sense of self-worth, its stabilization and the fulfillment of certain ego functions which the narcissist is unable to provide from the inside.

At the conclusion of Cold Therapy, the narcissist ego construct, so to speak, is perfectly functional.

We all know that narcissists are difficult patients. We know that there's a variety of types of narcissists, overt, classic or grandiose, there's covert, shy, fragile, invulnerable, inverted narcissist, somatic, cerebral, etc. We know that narcissism is comorbid very often with other personality disorders and they're duly diagnosed with eating mood disorders, substance disorders and even autism.

There are various treatment modalities that have tried to cope with losses, with a core, with a nucleus. Enough to mention various cognitive behavior, emotive behavior, therapy, schema therapy, EMDR, dynamic therapy, psychoanalysis, Gestalt, you name it.

They have not been successful. There has been some success modifying behavior, abrasive behaviors, antisocial behaviors, socially unacceptable behaviors, all things have been modified to allow the narcissist to coexist with other people and to somehow function in various settings such as the workplace.

But this is far from healing.

This is far from tackling the core and the nucleus of narcissism. This deals with these techniques, these treatment modalities deal with some presenting symptoms or signs.

Indeed, even the process of clinical interview and a basis, a diagnosis, they are all heavily dependent on self-reporting.

Current existing psychological tests such as the narcissistic personality inventory are ridiculously premised on the assumption that narcissists would truthfully self-report.

And we all know that narcissists are pathological liars, confabulators.

So the patient's narcissistic defenses and resistances prevent proper therapeutic lights. They even prevent the proper diagnosis. Psychological tests are useless.

And the realistic therapy goals with current, with existing treatment modalities is some form of behavior modification.

As I mentioned, reconciling lifestyle and choices with pathological secondary narcissism and setting an extended timeframe, a measurement of outcomes that somehow will create a positive feedback loop.

These are very restricted, but realistic goals, but they are very restricted. That's a problem. They don't touch the core, as I said, and they are not long lost.

The rate of remission or relapse is enormous. Almost, I would say, universal.

And the therapist in this treatment modality suffers. The therapist suffers idealization and devaluation cycles. There's transference and countertransference, which is very pernicious. There's vicarious traumatization of the therapist.

The therapist's own narcissistic defenses are heavily provoked. Resentment, alienation, burnout, emotional exhaustion, trauma, very common.

And finally, there's a lot of cooperation and collusion the narcissist tries to buy or bribe therapists to victimize a therapist.

And so that very often we have situations where there is a shared psychotic disorder somehow emerging. There's paranoia as a form of narcissism, placing the narcissist at the center of some persecutory delusion in which the therapist plays the role of the persecutor. And cult settings are not uncommon, where the therapist actually admires the narcissist.

So it's all very problematic. And I would say with a sweeping generalization for which I hope to be excused, that all current existing treatment modalities have abysmal effect to deal with pathological narcissism.

It's not that Cold Therapy is devoid of its own problems.

For example, it needs to leverage the force of grandiosity. And this is not always easy.

And if the line is crossed, actually it could enhance the narcissist grandiosity. And grandiosity and fantasy are defense mechanisms and unhealthy ones, dysfunctional ones, maladaptive ones. So we seek to minimize them or to maximize them.

But Cold Therapy walks a very fine and thin line and sometimes actually ends up enhancing fantasy and grandiosity.

There's an issue of overcoming psychological defense mechanisms like splitting, projective identification, projection, magical thinking. There's an issue of tackling cognitive deficits, cognitive distortions, thinking errors, fallacies, and failed reality tests. Example is the Dunning-Kruger grandiosity fallacy.

And then there's the issue in Cold Therapy of dealing with the narcissist victim's task, an internal working model.

They are challenged heavily in Cold Therapy on the one hand, but on the other hand, they are somehow supported and enhanced because the narcissist is really victimized in Cold Therapy, is really traumatized. It's not his imagination. His paranoia in this case is justified. And so is his victim's task. So how to modify his internal working model when we're actually ending up supporting it.

There's also risk of suicide at the very beginning. Retraumatization phase can be very dangerous and requires close monitoring. All kinds of grandiose, paranoid, schizoid, automatic thoughts are provoked. And contracting and aliasing are absent.

So there's no common goal, no kind of mutual horizon. It's all conflictive. Cold Therapy is very adversarial. And we need to manage and contain transference and countertransference very carefully, or it gets out of hand. And of course, the patients who are also on medication, the effects and side effects need to be taken into account.

Most importantly, I would say that because Cold Therapy is confrontational, because it fosters knowingly a hostile environment, because it imposes trauma on the narcissist, it fosters persecutory delusions. It creates intentional paranoia, narcissistic rage, narcissistic shame.

And so the aim of Cold Therapy is to distinguish primary originating trauma, trauma from secondary ones and from complex PTSD. So we have tools, proprietary tools, developed in Cold Therapy, aimed at doing exactly this.

Ultimately, we need to merge the patient's comfort zone with the hostile, non-holding, unsafe environment. And this merger, this fusion, lead at the beginning to some kind of repetition compulsion.

On the face of it, this sounds bad. Repetition compulsion is not a healthy thing, but it's far preferable to decompensation and acting out.

So here you are, I've been honest with you, about the disadvantages, shortcomings, shortfalls and dangers of Cold Therapy. But experience with several dozens of patients has shown that Cold Therapy is unusually, I would even say incredibly effective with narcissistic disorders, and to our complete surprise, with major depressive episodes. We are not sure why, perhaps because pathological narcissism is a form of depression. But that's a topic for another presentation.

So Cold Therapy currently comes with 25 proprietary techniques. And these techniques are highly unusual in various ways, and even I would say counterintuitive. They are divided to level one, two and three.

On level one, we have some basic, more basic techniques. And one of them is called erasure.

Erasure, again, builds on the work of Freud, Kozak, in the 80s. They said that fear memory, the memory of fear is combined with absent information.

So what we're doing in erasure is suppress expression. We suppress the speech of the patient.

Now this runs completely against anything done in any other kind of therapy. In all other kinds of therapy, we try to encourage the patient to share, to cogitate, to associate, to talk, etc., to communicate.

But in Cold Therapy, we actually encourage the patient to shut up. And we do it pretty aggressively.

We select a series of keywords, and we then filter for keywords which are heavily associated or describe a primary and original trauma.

And these speech suppression techniques are both active. We hush the patient when he tries to use the keywords.

Or they're also passive. When the patient uses a certain keyword, we ignore it or we treat it as irrelevant. We underestimate.

So then finally, there's a negative reinforcement mechanism which kind of suppresses these keywords.

And the idea is that the silences generated by the erasure technique tell us much more about the patient or as much about the patient as any form of communication. The silences are structured, but they reflect sentence structure and semiotic and semantic words of the patient.

So where the patient has to be silent, because he cannot utter a certain keyword, tells us that this silence denotes some quantitative field, tells us a lot about the inner world of the patient. So that's an example of a technique.

Then what we do, we recover the speech and we interpret the silence together with the patient. We have a look at the patterns of the gaps in the speech and the distribution in the context of the gaps, contextual gaps. And then we construct and deconstruct, reconstruct and deconstruct narratives so that the patient gains much deeper understanding of how the traumatic words reflect the structure of the trauma, reflect the infrastructure in the trauma, the cohesive trauma.

Another technique we have, and I of course won't be able to go through all the 25, but another technique we have is hypervigilant referencing. Trauma and abuse are a kind of perpetual narcissistic injury, and obviously they lead to hypervigilance. Obsessive compulsive behaviors, rituals, irritability, rage, sensory sensitivity, anxiety, arousal, exhaustion, and scanning constantly for threats and insults, often when there's none. So it's a kind of referential ideation.

And so hypervigilant referencing strives to learn from the content of the delusional thinking about the locus of the primary originating trauma. It deconstructs the disparity between emotional and reality states in a highly specific way.

Another technique we have is called grandiosity reframing. And it's a bit unusual in that it treats grandiosity not merely as a psychological defense mechanism, but also as a cognitive distortion, extending the work of Dunning, Kruger, and their effect.

Grandiosity is justified only in as much as it is an adaptation or a survival strategy, but with a narcissist it is neither. Neither. It's not an adaptation because it's maladaptive. And ultimately it leads to the narcissist's downfall and implosion. It's a self-destructive strategy.

Grandiosity provides capabilities to overcome traumas, that's true. And in this sense, it's a kind of skill and it results in winning in various settings. But what we do, we leverage the narcissist's grandiosity in order to get rid of it.

For example, we tell the patient when you are grandiose, you are not acting optimally or efficiently, you are not perfect. So we use grandiosity against itself. If you tell the patient when you're grandiose, you're not perfect, you're actually making a statement about grandiosity.

This is very similar to the way we strengthen the host personality in dissociative identity disorder.

Another technique, which of course is borrowed, is the technique of guided imagery. But again, it's proprietary in the sense that we have modified it very considerably and we call it imaginable technique.

So what we do is we encourage the patient to catastrophize, actually. We leverage catastrophizing. We ask the patient to imagine the worst and in a controlled way, but to imagine the worst and to live through the worst.

We control the patient's malignant optimism. We imagine the fantastic. We have something called mid-link and that is to locate the middle ground and to render the adult side of the patient the winner.

By meeting a strict, rigorous reality test, we have controlled depersonalization. When we deconstruct the false self, the patient remains basically exposed, naked, vulnerable. And so what we do, we encourage the patient to depersonalize because if the patient does not depersonalize and derealize, the patient is in such pain and hurt that it could lead to suicide. Depersonalization and derealization, which are encouraged in this phase, are intended to protect the patient and against the hurt and the pain that the false self used to cater to, used to block out.

But ultimately, we validate reality. We acknowledge the patient's transference and the client's own language. We echo it. We mirror the patient and we acknowledge his state of mind. But we compare it to reality in such a way that reality intrudes and replaces all these.

Another technique we have is called negative iteration.

In negative iteration, what we do is reframe situations and events as traumas.

We design special coping strategies, winning strategies, and defenses for various situations and events instead of catastrophizing. We observe, we hold, we freeze. We use a lot of techniques from cognitive processing therapy.

And we try to engender personal safety, trust, a dynamic of power control, which is not out of control. We try to foster esteem or self-esteem, intimacy, by reconsidering or reframing negative thoughts about self, others, and the world and the environment, exactly as is done in many, many types of cognitive behavioral therapy. We encourage assertiveness, communication, social support.

But we do all this by forcing on the patient and encouraging the patient to develop a kind of repetition compulsion. This repetition compulsion is then brought to awareness, it is mastered, and it is used, its power, its energy is used to obtain different outcomes. It actually leads to resolution and reconciliation.

So one of the most powerful techniques we have, and we use utterly independently of Cold Therapy, patients who don't undergo Cold Therapy, is the happiness map.

Happiness map is a kind of happiness space. And what we do, we ask the patient to list everything that makes her happy. And then we narrow it down by finding common denominators.

We reduce the number of happiness-inducing factors by finding common denominators. We drill down in a way. We reduce. And we do this in the face of reactivity and denial.

There's a lot of resistance to the happiness map. Because the happiness map yields counterintuitive results.

You may think that your children make you happy. But by the time you are finished with the happiness map, we discover that it's not your children at all.

You may think that some activity makes you happy. But then you discover that actually it's not the activity, but it's excelling at the activity.

And so what we try to do is we try to create new intuition in you, new ways of thinking about your happiness.

Of course, we use mirroring in Cold Therapy.

The patient or client is requested to play the devil's advocate via dialectic, Hegelian dialectic.

Thesis, which is the abuse and the trauma.

Antithesis, which is not abuse, not trauma.

And then synthesis. Trauma is not an objective scientific factor or event, but a subjective reaction to an objective or scientific factor or event.

Traumas are reactions, not reality. They are a subjective form of exegesis, of interpretation. They are reactive, as I said.

There are many other things.

There's escalation where we construct a scenario. What could have been worse? What could have been even more wrong?

There is role play where the patient is encouraged to be the abuser.

There is other scoring where the patient is actually encouraged to develop empathy by placing herself or himself inside the mind of meaningful or significant others in his or her life in ever more complex nesting algorithms. So I'm thinking about the other, then I'm thinking about how I'm thinking about the other, then I'm thinking about how the other is thinking that I'm thinking about the other, et cetera, et cetera, et cetera. So it's ever evolving tree, nested tree, until the complexity is such that it breaks down defenses and absolutely forces the client to become someone else and develop a form of empathy, rudimentary, but there.

And then we have a simulated confabulation where we encourage the patient to identify gaps in his memory, dissociative gaps, and ask himself, why did he repress these memories? And that's very similar to some techniques in psychoanalysis, psychoanalytic and psychology.

And where the gaps are invisible, where the memory is gone totally gone, you don't want to have an ab reaction. In that case, we construct confabulations, and that's why it's called the simulated confabulation, this technique.

We construct confabulations to bridge the gaps, and then we pass the patient to rank the plausibility of such confabulation.

And we demand that the patient owns the confabulations and assimilates them. And then once the patient tries to assimilate the confabulation, we monitor, we observe the reaction.

Does he react with egodystony, unease? Or does he react with egosyntony, happiness?

Egodystony teaches us that there is a discrepancy or discontinuity or disjointedness in the patient.

And egosyntony, of course, indicates congruence, narrative coherence.

So we assemble gradually, lego-like, a healthy core, narratives about functioning and happiness that can be assimilated by the patient, the patient can be accepted.

And in one thing we do, for example, in this therapy, we share our therapy with the patient. The process is completely transparent. The patient is a partner, not an ally, like in our classic therapeutic alliance, but a full-scale, full-fledged partner with equal status to the therapist with some of the techniques.

We're talking about the phase after retraumatization. Very important technique is reparenting. And that's why we encourage transference.

And we actually foster, and engender with a kind of shared psychotic disorder, a kind of folie at the beginning. We encourage so that the patient can feel that we are his abusive parents and shift the potential focus of trauma from himself to the therapist.

And the therapist is the one who owns the bad object. The therapist owns the pain, owns the trauma in the hurt. Splitting is encouraged, even leveraged. And the patient now ends up owning only a good object.

When this good object is introjected, the patient can begin to feel good. Projective identification and introjective identification are very powerful tools. The therapist picks up and contains via projective identification what the patient cannot think about, the unthought known.

We have also emotional re-regulation. We encourage patients to externalize, externalizing to internalize. We encourage a patient to shift from grievance to task orientation to avoid rumination.

We encourage a patient to move from counter-dependence defiance to co-dependence in some respects.

We encourage a patient to move from social withdrawal to social functioning.

And from child psychology, we borrow techniques like emotional intensity control, behavioral control, or termination, interpretation of modes of emotional cues, including his own cues, interpretation of social cues, avoidance and aggression balancing, focusing on the positive attention and focus control, impulse control, modeling and not demanding desired behavior, freedom versus constraint and self-regulation, no overstimulation, no excessive frustration, identifying and countering discriminating thoughts and emotions, and moving from internal construction to external representation.

All these, I must emphasize, are after the initial stage of re-traumatizing.

In the initial state of re-traumatization, the therapist is the abusive parent and the patient is the child.

Emerging from the re-traumatization phase, the therapist is the bad parent holding the bad object and the patient is rendered a good adult, identified with a good object.

Cold Therapy is a highly unusual treatment modality in that it actually makes use of all the artifacts in other therapies which are considered negative and to be avoided.

And in that it does not coddle or cuddle the patient or the client. On the contrary, it's adversarial. It's much more like a court of law than a classic therapy setting.

But through this conflict, through this repetition compulsion, a new adult emerges with firm boundaries, with healthy core, and with absolutely no need for narcissistic supply or any other forms of external ego function regulation. A healthy, stable sense of self-worth, totally regulated in all environments and all settings.

And isn't this the very definition of a healthy, normal individual, socially functional and happy in his interpersonal relations?

This is the aim of Cold Therapy.

Thank you very much for listening.

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