Challenging Personalities: Understanding Borderline & Narcissism with Robert Drozek (307)

0:00The issue of borderline is that there's not enough self. The problem of narcissism is that there's too much self. That really matters for treatment. Because for folks with BPD, we're going to want to kind of help them see that their perspective matters. Help them have a sense of their own value independent of what's going on in their relationship. So we've got to kind of build them up in a way. Where with narcissism, there is a building up part of the process. But we really need to turn up the volume on other people. So clinically, that really, really matters. Other people need to get bigger in folks with narcissism sort of experience.

0:43And I would say that is actually helpful for the person with NPD because it's sort of to understand another person. Like if I have NPD and I'm understanding you better, you're going to then react better to me. I'm going to feel better in that relationship I'm going to have a sense of competence so this idea of kind of turning up the volume on other people actually like it helps folks with narcissistic traits sort of start to feel better and have a greater sense of meaning in their lives Welcome to Therapist Uncensored Building on decades of professional experience this podcast tackles neurobiology modern attachment and more in an honest way that's helpful in healing humans.

1:30Your session begins now with Dr. Ann Kelly and Sue Marriott.

1:40Hey, you guys. While we know relationships are wonderful, they are also really hard. Many of us believe that they shouldn't be, that if we have good connection and good communication, things will just go smoothly. But it's really that belief that can make us feel stubborn and even more hopeless. So relationships take work. It does for Sue and I. We can make it look easy. It's not. And one of the ways is because many of us, we differ. We differ in what activates us, what makes us feel threat, the expectation. And it's these differences that are held in our body, not our thoughts. And they influence how we talk, how we love, how we fight.

2:17So holding that belief, if he or she or they could just understand me, if they love me, they do something different, is not really true. and we're talking about relationships with your partner, your teenager, your mother-in-law. So Sue and I have created an online course that can help you understand yourself and those you love in a different way. This is not just for therapists, it's for everyone. Although the good news is if you're a therapist, you can get CEs along the way and all of you can use the visuals and the worksheets individually, or you could even use them in your own private practice.

2:51So while the course is based on our book, Secure Relating, Holding Your Own in an Insecure World, it is definitely not a replication of the book. We talk directly to you. You learn how to understand more deeply your attachment, those you love, the neuroscience behind it, and how to build secure types of connections right now in your everyday relationships. Rather than changing one another, y 'all can shift together in very important ways. It's very powerful. We're getting great reviews. Check it out. It's at therapistuncensored.com slash BAS, therapistuncensored.com slash BAS. The BAS stands for Beyond Attachment Styles, the Science of Growing Secure Adult Relationships.

3:39And by the way, the cost of the course is about the amount of one individual therapy session. And yet you get hours and hours and hours of what we think is extremely valuable information. So check it out. Hey everybody, this is the second of a two-part conversation that we're having with Bob Drozik and it is all about challenging personalities. The first conversation was more about the narcissistic personality disorder and borderline personality disorder and kind of a high-end overview and then this one goes into the what to do about it. Our guest, Bob Drosik, is an individual and group psychotherapist at McLean Hospital specializing in the treatment of personality disorders, trauma, dissociative disorders, and addiction.

4:23He serves as clinical director of the mentalization-based treatment, or what we call MBT, clinic at McLean Hospital. He's also a teaching associate in the Department of Psychiatry at Harvard Medical School and a supervisor of MBT through the Anna Freud Center in London. His clinical training spans dialectical behavior therapy, mentalization-based treatment, transverse-focused psychotherapy, and just good psychiatric management in general. Bob is also an author. His books include Psychoanalysis as an Ethical Process, Mentalization-Based Treatment for Pathological Narcissism, and his newest work, Mentalization, Using Reflection to Heal from Borderline Personality Disorder.

5:06One of the great things about these two conversations is that he gives a whole lot of free resources, downloadable links, tools and links and worksheets and apps to make these ideas actionable for our listeners. So we really encourage you to seek out the show notes and look at all those resources, therapistuncensored.com slash episodes, and you'll be able to find it right there. All right, let's get to it. Hey, everybody. Welcome to Therapist Uncensored. Welcome back. Welcome to those of you who are new. Today's episode is going to be so fun because we are going to get to geek out with all this research and science and separate myth from reality around challenging personalities.

5:49Our guest today is Bob Drozek. He is a social worker, which I'm proud to claim as a fellow social worker, and also an individual and group psychotherapist at McLean Hospital, specializing in the treatment of personality disorders, trauma, and dissociative disorders and addiction. He serves as clinical director of the mentalization-based treatment, what we're going to call MBT, at the clinic at McLean Hospital. He's also a teaching associate in the Department of Psychiatry at Harvard Medical School and a supervisor of MBT through the Anna Freud Center in London. His clinical training spans dialectical behavioral therapy, which I want to just touch on in our interview, kind of differences and similarities, mentalization-based treatments, transference-focused psychotherapy, and just good psychiatric management and psychological management in general.

6:39Okay, so it is with great pleasure that I welcome you, Bob, to the podcast. Thank you, Sue. I'm really excited to be here and talk with you. So again, to just frame where you're coming from, can you say, I've kind of said your more official bio, but anything else you want to add about yourself and the books that you've published? Yeah, most of what I do is sort of like mentalization-based treatment, which is like an evidence-based therapy for borderline and antisocial personality disorders. So just do a lot of writing and teaching about that. And I'm here at McLean and Harvard. Yeah, and books, I have several different books, but the most relevant for mentalizing is we wrote a treatment manual for MBT for pathological narcissism.

7:22And then recently I published the first book for the general public about mentalization, and it's called Mentalization Utilizing Reflection to Heal from Borderline Personality Disorder. This is going to be good. So this was so juicy that we're going to break it into two sessions, the first one being for everybody. And we're going to do kind of a little bit higher level look at what's the difference, what's, again, myth from reality, social media from science, those kinds of things. and then the second session will be more clinically focused again it's still for everybody but I know that the therapists and other mental health professionals will love it and there's a lot of people that are just really into this material whether you have letters behind your name or not so everybody's welcome but we'll get more technical on that one so starting out then challenging personalities in general one of the things that we talk about on the podcast is this idea that anybody, no matter our personal histories, can go out of our zone, we call it the green zone, and behave badly.

8:26But this, we're focusing on something that's going to be more pervasive and more personality-oriented. So could you just sort of launch us by talking about the difference between that, between kind of temporary dysregulated states and the more pervasive features of both of these disorders. Yeah. And you both meaning specifically borderline and narcissism. Exactly. Yeah. No, it's a, it's a really, really great question because I do think that in the field, we're moving more towards this sort of thinking about personality more like dimensionally, you know, where we all have these traits and they're present at any given moment to a greater or lesser degree.

9:05Then for some folks, the impact of those traits on functioning can be more pronounced and then we start to see some trouble. So to kind of simplify it a little bit, just in terms of the two disorders that you're mentioning from a borderline personality disorder standpoint, borderline personality disorder or, you know, BPD for short is really a disorder of dysregulation where the person can really struggle with pretty pervasive challenges with stability in emotions, sense of self relationships and behaviors and really that's where the person can have less of a clear boundary between themselves and other people such that other people can really like hijack their minds and without that clear boundary that means that if you're feeling a certain way about me and i have bpd your feelings determine my reality they determine how i feel and then i can get thrown down very, very concerning roads where I feel like self-injury, suicidality is the solution to kind of really feeling like there is no sense of self.

10:15That's in the most kind of pronounced concerning state. There is a absence of self and then some of the more impulsive behavior that we see in borderline personality disorder. So just to go a little further with BPD, borderline personality disorder, can you separate that or cross it or whatever, lay it over attachment and preoccupied attachment and things like that? How do those relate? So tons of research showing that borderline personality disorder is associated with sort of attachment seeking behavior and specifically anxious attachment or what elsewhere in the literature is called quote like preoccupied.

10:55So by and large, like there's a huge correlation between those particular personality traits and that particular attachment style. That said, to note, it isn't sort of not, you know, not everybody with BPD has the same attachment style. And they're, you know, really the idea with sort of more traditional sort of quote textbook or like the stereotype of BPD, and the research supports this, is the person when they're in a state of dysregulation, copes with that by moving closer to others, to actually seeking out someone else to regulate them, and then they're able to feel connected again, and then we see sort of like increased stability.

11:37However, there are some folks with borderline personality disorder where they do have a more like avoidant approach to attachment, where emotions can get so overwhelming and they can feel sort of so unsafe in the context of a relationship that the only way for them to actually turn down the volume of their emotions is to actually remove themselves or pull back from the relationship. And so some proportion of folks have more of an avoidant attachment style. But when I'm working with sort of folks with these challenges, and actually that's part of what I have in the book, is questionnaires of how do you identify what your unique attachment style is?

12:18And a lot of patients will say, you know, really for me, I'm really more anxiously attached in these relationships but in these other relationships I'm more avoidantly attached and getting into the nuance of that I think that's really where the money is when we're trying to help people with these challenges and that's definitely how we approach it too it's almost like we're looking at again moments of attachment dysregulation and that it changes by relationship it changes over the course of a lifetime and I think what you're saying is yeah and not everybody that would measure if you were actually evaluated as preoccupied or as anxiously attached is borderline.

12:57And also not everybody that is borderline. They're independent, but they cross over. Is that right? Absolutely. Yeah, definitely. And of all the attachment styles, sort of BPD is most associated with anxious slash preoccupied attachment. Okay. And that's pretty robust. Unlike, well, then now let's move, if you will, to narcissism and kind of give us the big overview. Yeah, well, narcissism is really a complex construct. And there's a lot of controversy about what even narcissism is, there are a lot of ways to kind of frame it. But in the kind of most sort of scientifically validated kind of conception of narcissism, which is what we call the alternative model of narcissism in the DSM.

13:40The DSM defines narcissism as sort of variable self-esteem, where there is actually difficulties regulating self-esteem. And the kind of two traits on this sort of model, and again, research shows this, that are most associated with narcissism are what we call grandiosity and admiration seeking. And the grandiosity is really this idea that it takes a couple different shapes. For some folks with the more grandiose subtype of narcissism, it's this idea that I am great. I'm better than you. There's an elevated sense of self. That said, not everybody with narcissism has that particular kind of flavor of grandiosity.

14:27There are some folks with narcissistic traits where it's actually more, I should be great. I should be better than I am. And there's this constant kind of questing. And if I'm not great, then I'm nothing. Something like that. Exactly. And that's what's so powerful and useful about the new conception of narcissism in the DSM is that it's actually is able to capture those sorts of folks, which those are the folks who are presenting to treatment, like folks who are holding themselves to desperately high standards, but feeling really horrible about themselves when they don't meet them. And then we start to see depression, we start to see anxiety, and we start to see dysregulation.

15:09So that's the grandiosity piece. And the attention seeking is, or sort of, sorry, the admiration seeking is really where there's a need for other people to see them in a positive light in order for them to feel okay. That's where self-esteem is regulated by other people's positive views of them. So in order to kind of for somebody to have these traits of narcissism on the new model of narcissism in the dsm there needs to be grandiosity and the seeking of admiration and so then i think you call it vulnerable narcissism yeah yeah for some reason we had got we were calling it negative narcissism i don't know if we made that up or well it's funny i mean it's a pretty confusing literature our narcissism because everybody defines these subtypes differently.

16:00But the most widely used measure of narcissism, like in like research is called the pathological narcissism inventory. So I would encourage your listeners, look it up. It's a very useful measure. It's fun. We can all complete it because the point is that really it's, we all have narcissistic traits and it's really in And there are some instances where that actually really gets people into trouble, right? But we all have these traits. You can complete the measure, and this measure will tell you, what are my narcissistic traits? So it's actually really useful. Totally. And we will link that in the show notes for sure.

16:37I'm just kind of smiling about, you know, how many people after a breakup get the lay diagnosis of, oh, that person was a narcissist, you know? So true. And this is something that can really sort that out. So just in general terms, what does it look like kind of in real life? And I really love the distinction with the grandiosity. That one seems easy. People kind of get that. We can think of public examples of that. Right. Oh, yeah. It's very easy. You know, the fragility, you know, the bluster. But the vulnerable narcissism, or what we were calling negative narcissism, the vulnerable narcissism, like let's dig into that a little bit more and also sort of separate that out from BPD.

17:19Because I think that they can look similar. Very thoughtful question. So the reason I mentioned the pathological narcissism inventory is because what it does, it tells you what are your traits of grandiose narcissism? What are your traits of vulnerable narcissism? And it's actually empirically validated. It actually maps on to sort of people's personalities. It's a measure that can actually kind of tease out these distinctions. So to answer your question, what is vulnerable narcissism? Vulnerable narcissism centers on this construct of contingent self-esteem. And what that means is, I am only valuable if.

17:59I am only valuable if. And what's the if? It could be achievement. It could be intelligence. It could be effectively performing a task. It could be status. It could be appearance. It could be sex. So the idea there is that self-worth is earned, not endowed. You know, I have to always work to have value. That's the idea of narcissism, a vulnerable narcissism. And there are different other traits that are associated with vulnerable narcissism. And one of those is, interestingly, avoidance. Because if all of my worth is based on these outside things, then I've got to stay away from anything that's going to make me feel bad about myself.

18:44So there's a lot of avoidance in there. Also, it's associated with anger. Because if you threaten my self-worth, I'm going to get mad at you, right? Like, who are you to threaten my self-worth? So there's the sort of the two subtypes that are most supported scientifically in the literature. Ours is a grandiose subtype, which is this need for pursuing these grand ideals. And then the vulnerable narcissism, which is the person experiencing dysregulation when they're not able to achieve kind of these external markers of recognition. That's great. And you mentioned avoidance. So can we also talk about mapping it on top of attachment, how much it correlates or not with dismissive attachment or avoidant attachment?

19:29Well, the attachment literature, that's another thing I love about your show that you're so interested in attachment, like you put it really in pride of place. So I love these questions. I wish I could give you an easy answer when it comes to vulnerable narcissism. The attachment literature on vulnerable narcissism is very messy. Some studies show that it's associated with sort of anxious or preoccupied attachment. Other studies show that it's associated with more avoidant attachment. And then even others will associate vulnerable narcissism with dismissive attachment. and so there's not a clear literature and i would propose what i really this is this is anecdotal but i think what that's about is that there's such a vacillating sort of set of states for folks with vulnerable narcissism they can present folks with vulnerable npd can present quite differently and it's really hard to kind of put them in a clean box that said the attachment literature for grandiose narcissism does associate the grandiose subtype with dismissive attachment and, you won't believe this one, secure attachment, which is fascinating, but it's because a lot of these are like self-report measures.

20:49Exactly. I was just going to say that. The adult attachment literature probably associates it with secure because it is self-report. There's a lot of different stuff out there, but in general, grandiose narcissism in very studies associated with secure attachment, but vulnerable narcissism is not. But I'll tell you, you spend time with these patients with grandiose narcissism, it makes sense because at some moments they're like, oh, I'm fine. It's other people who are the problem. So it makes complete sense from their self-experience. If the narcissism is working well, I'll put that in quotes, they actually feel fine.

21:26The problem is outside the self. Yeah, no, I totally get that, that people can often misidentify. If the measures are conscious self-report, it's one thing, versus when you do the developmental attachment assessments, where that you're really getting around the unconscious, then it looks really, really different, I think. Yeah, yeah. And I'm not actually sure. It's a good question. Like, what are the different measures associated with these different results? I think I kind of know the results, but I actually don't know which one goes with which, but it's a really, it's a good question. Yeah, it's so often that it's the adult literature because it's just so easy to test.

22:04You know what I mean? It's not like this hours and hours of projective testing and stuff like that. So this is interesting. And then you said anger is associated with the vulnerable. Anger is also often associated with borderline personality. Can you say a little bit about what you know from the literature that creates this kind of personality style, these styles of personality? And sorry, do you mean for both borderline and narcissism? Yeah, just what do you know that can set somebody up to have these more rigid personality structures? Yeah, definitely. So from a borderline personality disorder standpoint, more so than any of our other personality disorders, BPD is associated with trauma.

22:48Very, very clearly, very, very definitively. And there is, you know, basically it's a sort of emotional abuse, emotional neglect, physical abuse, physical neglect, sexual abuse. So it's very, very clear. or these adverse childhood experiences are associated with some folks with borderline personality disorder. Also, it's notable, you know, I think the prevailing models of the development of borderline personality disorder, we call them trauma vulnerability models. So it's the idea that there are genetic and neurological differences, tons of research on this, I'm showing that folks with BPD have these genetic and neurobiological vulnerabilities to emotional dysregulation.

23:38And this is a really important point because the behaviors can feel so intentional. You know, when we mentioned attachment earlier, I think, and again, this is, you're much more in this literature than I am, but borderline is also associated with disorganized attachment. Disorganized? It's a good question. So disorganized tends to be an attachment of, there's so many different lenses for it that we'll use sort of more for like younger folks versus like kind of some. A fearful avoidant. Yeah, yeah. But there definitely is sort of, there's adult research on that as well. But yeah. Yeah. So we think of an overwhelmed nervous.

24:18I mean, part of what's so important about this is because used to when people would throw the word borderline around, it was a way of, it's a dismissal. It could be a dismissal of the person and like, oh, they're just borderline, like, like, don't listen. They're just this. Right. And I do think that it's changed a lot over the years where that people are recognizing it as a neurological vulnerability, that the reactivity is physiological. It's not a choice. Definitely. And there is so much research sort of supporting that, that the brains of folks with BPD are different. But the idea in sort of the trauma vulnerability models is that there are these kind of vulnerabilities or predispositions.

24:59Some will call it temperament mixed with genetics. And that that plus trauma significantly increases the chance that somebody is going to be developing, you know, notable borderline traits. And then what about the history of folks that end up developing narcissism look like? My next book is actually, I'm working on my next book is actually going to be a self-help book for people with narcissistic personality disorder. So I was just writing about this the other day is like, what is the developmental literature for folks who end up kind of developing narcissistic traits? And in terms of contributions to the sort of the chance that somebody is going to develop narcissistic traits, about 40 to 60 percent of that is genetic, actually.

25:46Really? Yeah, which is interesting. Yeah, they sort of have twin studies and all that sort of stuff. 40 to 60 % is genetic. So the simple way to think about it is about half genetics, half environment. Wow. Yeah, yeah, no, it's interesting. It's not as definitive as the research on BPD. There's much more research on BPD than narcissism. But yeah, 40 to 60 % is like the current empirical literature for narcissism. And does that break out at all with the subtypes? Or is it just kind of narcissism in general? That is a good question. Like all the research that I've been reading, it's sort of just to quote narcissistic traits, but that's a really great question is like, do we, oh, I have some, I know some stuff about that for the parenting styles, which I can get to, but genetically I don't know the answer to that.

26:31That's a really good question. So about 40 to 60 % genetic, then the rest sort of, we see it as more environmental. And in terms of the environment, so also tons of research showing that folks with significant narcissistic traits, that that's actually correlated with childhood trauma and adverse childhood experiences. But it's also associated with two different types of parenting styles. And those parenting styles, the most widely researched one, there's a lot of empirical support for this, is what we call parental overvaluation. and that's the idea that the child is more special unique skilled or talented or entitled than other children which that may not be a surprise um that that wouldn't potentially lead to narcissism so it's basically parental permissiveness is the best predictor um in terms of parenting styles in the development of narcissism interestingly that parenting style predicts both vulnerable and grandiose narcissism.

27:42That is interesting. So parental permissiveness, you know, you think of helicopter parenting, you know, versus like lighthouse parenting, I think they've called it, where you're steady and then you let them kind of come and go. But overvaluation feels a little different than permissiveness. Are those different things or is that the same thing? Permissiveness is like the umbrella term, which basically kind of refer, because they have different measures for this stuff. It's not all the same measure, but permissiveness is the kind of catch-all term for a bunch of different constructs in the parenting literature that basically means promoting or valuing the child in a way that is imbalanced.

28:25Like too much child, if that makes sense. Oh, it totally 100 % makes sense. too much child. And then you grow up if you've been given messages of that specialness, because initially your parents are God and you are, in a sense, by extension, but that you also get the nicks and blows of being in this group of bodies called humans. Absolutely. And it just makes me think I had a nephew that his birthday happened to fall on Thanksgiving, and he was real little and he was like, and he really like had this idea that the parade was for him, you know? Absolutely. Yeah, that's right. So that's healthy narcissism.

29:08But if that sticks, absolutely, then you're either going to be vulnerable as in if it's not for me, then therefore I'm nothing or that this is what I should be for me. Yeah, right. Where's my parade? Yeah, exactly. So that parenting style is associated with both subtypes. There is one parenting style that's associated only with a vulnerable narcissism, actually. And that's called parental psychological control. That's where the caregiver uses shame and criticism to control and constrain the child's emotional experience. So that's like, you're bad. You're not good enough. You know, you should be a certain way, right?

29:54where there's a lot of criticism or ascription of negative value to the child. And that completely makes sense because with vulnerable narcissism, it's like, I'm not good enough. In order to kind of have value, I need to meet these standards. So the child will take in this kind of negative view of them from the parents. And then that leads them to have this kind of vulnerable self-structure.

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33:22You know, in our next one, I want to talk a little bit more or talk a lot more about what to do about this and what the treatment looks like. But I'm also thinking about folks that might be listening, just like, is my husband a narcissist? You know what I mean? Like, am I narcissistic because I think about myself, that kind of thing. So if we can bring it to where it's like, this is what it looks, this is, if you actually have pathological narcissism, it looks more like what in adult life? Yeah, because so many of these traits we all have to some degree, right? So I would say, if you're asking yourself this question, the first key question to start, and this is also consistent with the alternative model for personality disorders in the DSM, which is, you know, highly supported by science, is start with the functional impairment.

34:09Okay? That's really what matters is does the individual struggle with notable impairment really in love or work? So then how that would translate in the most simple terms would be fighting with your boss, getting fired a lot, going through relationships or having trouble in relationships? So at work, it can be a bunch of different things, but definitely fighting with your boss. But often it can be the shape of like, I know the way that things should happen at work. Like I'm right about this. There can be a rigidity interpersonally where it needs to be my way. There can be withdrawal or conflicts when work doesn't do what kind of the person wants it to do in some way work is like one of the most powerful kind of revealers of narcissism because we go to work we want recognition we want people to tell us we're doing a good job and what you see with folks with sort of significant traits of npd as long as the environment does that they feel okay when the environment stops doing that when there's a negative performance review when they are judging their own performance on an assignment or something like that.

35:27When other people don't do things their way, they can take it more personally. And they want, in some ways, this is where the functional impairment comes in. They can't stop thinking about it. Like it really dominates their mind. They start to feel really, really badly about themselves. And so it's usually fluctuates. If it's a vulnerable presentation, it's like they flip flop from either feeling really bad about themselves for things going poorly versus, but my boss should still be doing it differently. But if things were different, then I would be feeling better. This need to change the environment.

36:02So this flip flop of I'm bad, they're bad. So if you see that flip flop, I'm bad, they're bad, we start to think about it as like a vulnerable narcissism presentation. Now, what about when you see that? Because to me, I associate that with borderline. Well, because of splitting and stuff. Yeah, it's a good question. I mean, this is the thing in the research. This is where things get a little complicated. I don't want to overcomplicate it, but this is what the kind of research shows is that there is 90 % symptomatic overlap between borderline personality disorder and vulnerable NPD. Okay. 90%. That's high.

36:45And what's the difference? What's the fundamental difference? There are certain kind of markers of behavioral impulsivity that if you're seeing a lot in the picture, that's definitely going to be more associated with borderline personality disorder, like self-injury, for example. That's not in the traits of vulnerable narcissism. But the main difference, I would say, just like in a simple kind of defining principle that your listeners could kind of like hold on to. With borderline personality disorder, the person primarily seeks emotional regulation through attachment. It's like, you love me, you're connected to me, I can breathe.

37:26Or I don't think you love me, I don't think you're connected to me, I'm very upset, but the solution is reconnect. Like what's driving me is to reconnect. Exactly. So it's really connection is the significant kind of determines a lot of the movements of BPD. Like I want it, you know, and I don't get it, then I'm dysregulated. And the way I think of it, like nurse, I mean, borderline is a little bit where there's not enough self, then narcissism being kind of a little too much about oneself. Is that fair? Absolutely. Yeah, yeah. so so that's sort of the bpd piece the kind of simple defining factor of narcissism is that sort of dysregulation comes not necessarily related directly from connectedness but really is my self-esteem being threatened so it's more insular it's more like i need this to feel good about myself and then you're getting in the way so it's a little more inward in the sense that if you threaten my self-esteem then i'm going to devalue you so um and there um definitely like it ends up being associated with problems of empathy right and there's tons of research on this particular issue is narcissism both subtypes are associated with problems with emotional empathy is the person can know that another person is feeling a certain thing but they don't necessarily care or they can't empathically resonate with it, that's not the way that borderline personality disorder works.

39:06So if you're thinking about it, that kind of presence or absence of these empathic deficits, I think can also kind of help us to understand, is this more of a narcissism picture or is this more of a borderline picture? And does it matter? And how does it matter? That's a good question. Yeah. Yeah. So because, again, I'm just imagining listener saying, oh, no, I think he is or I think she is. I think it's more pervasive. I'm running around circling them, trying to get them to stay regulated. And so kind of speaking to them, it's like, do these distinctions in real life make a difference? Is there more hope in one than the other, that kind of thing?

39:46Oh, that's such a good question. Yeah. I mean, I'm biased because I do a lot of this sort of work and I'm giving the diagnosis all the time or these both these diagnosis to people all the time. So I do think the distinctions matter. But the question would be how and why, right? It matters really, I would say a couple of reasons. One, from an evidence-based treatment standpoint, all of our evidence-based therapies, we have extensive evidence-based therapies for borderline personality disorder. So if your listeners or their loved ones have borderline personality disorder, there is extensive reason that's been shown through research to be hopeful.

40:28Like we have very specific things that sort of folks can avail themselves of in terms of particular forms of treatment that yield tremendous benefits for people. Like what? Can you go ahead and give some examples? or yeah and i would just say like this is sort of what i see every day here at mclean because we're it we kind of offer like all of these forms of therapy here so we see a lot of people who've been who have these disorders haven't really been getting better and then they come and things start to really transform so basically from borderline personality disorder standpoint your listeners will i'm sure have heard about dialectical behavior therapy dbt that is the most scientifically supported therapy for borderline personality disorder.

41:15There have been more studies and randomized controlled trials for DBT than any other evidence-based therapy for BPD. So that's DBT. Coming in a close second in terms of empirical backing is mentalization-based treatment, which is the, you know, the type of therapy, obviously I'm very biased, but that's the type of therapy that I'm a trainer in. And tons of studies showing that MBT has significant benefits for people with borderline personality disorder. But even like some pretty remarkable ones that I don't know of any corollaries for other forms of therapy for BPD, eight-year follow-up studies in MBT showing that eight years after treatment, the gains are maintained.

41:58That's fantastic. Yeah, it's really quite something. And the gains are not negligible. They're their decreased self-injury, decreased suicidality, decreased depression, decreased medication usage, decreased hospitalizations. So those gains are maintained eight years at follow-up for MBT. That's fantastic. And we're going to, just for folks who are excited about, oh, what is that? I want to get more of that. As we go into the next episode, we're going to talk a lot more about this specific kind of treatment. So hang in there on that. cool and so then just quickly then the other ones transference focused psychotherapy or tfp is also an evidence-based therapy for borderline good psychiatric management which was developed by john gunderson here at mclean and sort of now spearheaded by lois choy kane that's also an evidence-based therapy for borderline personality disorder and also schema therapy so those are those five are the ones with significant empirical support for treatment of borderline personality disorder.

43:00Now I have to ask, you know, this is the world of empirically validated studies. There's a lot of therapy, long-term talk therapy, things like that, that aren't in that realm, that don't, you know, consider it more of an art, consider it like it's this analysis, which is, doesn't lend itself to evidence-based evaluation. And I don't mean to take us off on a tangent, but I wonder what you think about that, because I can tell you, I know that folks that aren't in those realms, like cognitive behavioral, there can be tension between those groups. And so I'm just curious, from your perspective, long-term talk therapy, is that, how do you view that?

43:41I really appreciate that point. And it would be a problem, in my opinion, to just presume that everybody needs specialized care, because it's expensive. It sort of takes a lot of training. It's not as available in other areas of the country. So I think it's hubris on the part of any therapist to be like, this is the only way to get better, you know? So I appreciate that perspective you're giving voice to. I guess what I would say is that they're especially important when people have tried general talk therapy, but the symptoms are still not getting better. That's when it really matters because, you know, not to, you know, use a like a glib saying, but like the proof is in the pudding.

44:26If somebody really is suffering and have been trying general therapy for a while, if we have these kind of scientifically supported forms of therapy, I think it benefits us all for the person to just kind of give it a shot. Because the worst case, God forbid, the worst case is that they are suffering needlessly. That's such a great point. And it's easy, you know, to just get in a automated realm and then you're just, you think you're in there, you know, you think you're doing it and there's not a lot of change, but you don't know what the choices are, which is part of why we want to highlight these studies in this new, you know, this material.

45:01So now what about narcissism when we, when we talked about, does it matter and how does it matter? So basically from a narcissism standpoint, it matters in a couple of kind of pieces. One, there are no evidence-based therapies for specifically for narcissistic personality disorder. So there just hasn't been enough research on that. A couple forms of therapy show benefit for people with both borderline and narcissistic traits. And that's MBT, the type of therapy that I do, and also TFP. So that's just an important thing to consider. So there's not as much research on how to treat narcissism, which I think is really, really important that we're having conversations about it teaching the public about it just so we can kind of bring more attention to this under studied concept that sort of really like people are really suffering from and you know they they do need you know they deserve evidence-based and or sort of treatment that we know will work but the other reason why it matters is exactly what you said which you said i love that kind of way of putting it that the issue of borderline is that there's not enough self.

46:09The problem of narcissism is that there's too much self. That really matters for treatment because for folks with BPD, we're going to want to kind of help them see that their perspective matters, help them have a sense of their own value independent of what's going on in their relationship. So we're going to kind of build them up in a way where with narcissism, there is a building up part of the process, but we really need to turn up the volume on other people. So clinically, that really, really matters. Like other people need to get bigger in folks with narcissism sort of experience. And I would say that is actually helpful for the person with NPD because it's sort of, you know, to understand another person.

46:59Like if I have NPD and I'm understanding you better. You're going to then react better to me. I'm going to feel better in that relationship. I'm going to have a sense of competence. So this idea of kind of turning up the volume on other people, actually, it helps folks with narcissistic traits sort of start to feel better and have a greater sense of meaning in their lives. You know, we can take the shame out of it and everything. But when you said that for them to feel better for grandiose narcissism, they're not feeling that bad, I don't think. It's true. But even with its more grandiose traits, even if they're, what they are feeling bad about, at least if they're coming to treatment, is that they do know their relationships are not going the way that they want them to go.

47:45And so by kind of considering others more, trying to be more curious about their own perspectives, a little less dogged or rigid in their thinking, other people will react to them differently. and their lives will sort of start to feel better. So it's an interesting point that even if the person isn't formulating themselves as the problem, the treatment and the forms of treatment we use can still really make their lives better. Well, and you know, you just said that you, there wasn't nearly as much evidence-based positive impact in treatment, but I've heard you also talk about just this real hopeful stance related to narcissism.

48:26So I want to get that in before we stop and go to the next session. Can you say a little bit about the hope of change? Oh, I mean, this is my favorite topic, Sue. I really like, it's a really, really inspiring thing. I feel very grateful for what I get to do because most of what I get to do on a daily basis is helping folks with significant traits of narcissism. So two kind of things I'll say along those lines. One is I work in, it's called the Gunderson Outpatient Program, which is a day treatment program for folks with severe personality disorders. It's here at McLean. So many of the folks we're helping have narcissistic personality disorder.

49:05And it's a very, very powerful thing to be part of a treatment program where that's what we're working on. All these folks, they've struggled in their lives. They have struggled with significant shame a lot of the times where things are not going the way they would want in their lives. They enter treatment and we see dramatic improvements. Like in the course of six to 18 months, it's like a transformative experience and it's their lives are getting better. They're able to succeed more at jobs. They're able to have higher quality relationships, but also they feel better about themselves. They start developing a sense of self-worth that's not just determined by outside things.

49:48So I find that very, very inspiring. And then the other thing is I do have a group here at McLean, mentalization-based treatment for pathological narcissism or for narcissistic personality disorder. And that's like just a weekly group, 90 minutes, all for patients who themselves, they've been diagnosed with narcissism and they want help for it. And that is one of my favorite moments of the week, go into that group. These are very earnest, sincere, motivated, and curious people who are just, they recognize these traits and they want help for them. And I personally, I don't know if this is a little cheesy, but like for me, like for those of us who we all struggle with empathic deficits, right?

50:33But for those of us where it's not the main thing we struggle with, it's not as big of a deal to sort of work on these things, right? But for somebody where that's kind of the main area of trouble, but they want treatment for it anyway, and they're motivated to change, I personally find very, very inspiring. So obviously this is all very anecdotal, but I would say our experience from this work at McLean is that yes, there is reason to be hopeful. and now kind of the work is how do we help folks gain more knowledge about how to kind of basically help these folks get better but also ultimately we're going to have to start doing more research on how to treat narcissism that's good i love i too love your hope and especially when you add the genetic piece you know it becomes less willful it becomes less patriarch you know like oh it's just benefiting from the patriarchy and just sitting back and enjoying you know like those kinds of things, but also for folks that are in relationships with someone with pathological narcissism that are not in treatment, that are not interested in treatment, can you speak to them before we go?

51:44Thank you so much for asking that question, because I am talking about a subset of folks who recognize that they are playing a role in their challenges in life and want help for that. But yeah, there are also tons of folks, and there's sort of research on this as well, showing that folks with narcissism struggle more with like treatment dropouts and not actually sticking with treatment. So I have the, you know, the privilege of getting to work with folks who see the traits and want help for them. There are many people who will actually not be in that spot and they won't actually see like themselves as playing a role in the problem.

52:22And in that case, it's actually pretty important that like, I would say to your listeners, there's tons of literature out there, like really, really wonderful books about how to protect yourself and make sure that your needs and rights are actually, that you're kind of, you know, are being respected. And sometimes that means by setting boundaries and learning how to set boundaries, but obviously sometimes that means actually leaving the relationship if it turns out that the person doesn't want help. So yeah, that's a huge part of the picture here. And we need to, you know, take that very seriously because there can be obviously with the empathic deficits of narcissism.

52:59There could be a lot of harm done at the same time. That's right. That's right. So I love both the hope and also the, and if folks aren't willing to get on board and see one, recognize that they have a problem to be willing to work on that problem, you know, like there's steps so that you're not alone. And like you said, if somebody doesn't identify themselves as part of the problem, what's the problem, you know, what, why should I work on if you would just be better than so and you mentioned resources we always like to put lots of resources in our show notes do you know of any of that literature off the top of your mind or do we want to gather it and just put it in oh good question you mean for about about like the books and the narcissism people that are with someone yeah oh yeah it's a good question i mean i think one of the kind of best general books for narcissism for the lay person just like learn about some of the distinctions that we talked about today, because the literature on it, as you can probably tell, it's complex, it's not kind of clear, is called The New Science of Narcissism by Campbell.

54:03I think it's Keith Campbell. Keith Campbell is a researcher on narcissism, actually, and he wrote a book just to introduce the general public about like all of these kind of concepts. So I would say that's like the best starting point to like learn about the disorder based on kind of science, I would say. Another thing, your listeners, is we have a world expert in narcissistic personality disorder at McLean. Her name is Elsa Ronningstam. She's a clinical psychologist. She has written this brief pamphlet, and we can definitely give you the link so you can put it on your website. It's just called NPD Basic, and it's just a free resource that people can sort of get to learn about narcissism, and so we give that to a lot of our patients.

54:47The other thing I would mention that is really useful if you are, if you have a loved one that you think might have narcissism and you're kind of concerned about your own experience and should I stay in the relationship? Should I go? How do I kind of respond to it? I would definitely say the book, It's Not You. It's a really, really good book. And it's probably my favorite book for family members. And I love just the saying, it's not you for, you know, that really that's often what sort of family members need to learn is that they may be being devalued by the person with narcissistic traits, but it's not their fault.

55:23So it kind of helps them hold on to their own reality. That's great. Romani has been on our podcast before, actually, and talked about. Oh, good. Is that true? Okay. Yeah, it's been a long time. But yeah, I didn't even know that she had that out. That's great. And then also, again, just as wrap up, are there any other books that come to your mind for the lay public related to borderline? Borderline personality disorder. Yeah. Well, so I would say if you're just looking, if you're looking for like a general information to the sort of general book about borderline personality disorder, the one that's probably like most famous that most people will talk about is Stop Walking on Eggshells.

55:59It's a very, very helpful book. So many of our families read it. I also really like Borderline Personality Disorder Demystified, which is a kind of a very kind of straightforward. It's a little bit more like learning about the kind of concepts and stuff like that, but really, really like broad ranging in its scope. And then I'm, you know, not to kind of self-publicize, but my recent book, which I guess I can mention as well. I was going to do it for you. Go ahead. Yeah. Is that coming up on the screen? Yeah. Yeah. So this is mentalization utilizing reflection to heal from borderline personality disorder.

56:35You know, it's basically the first book for the general public about mentalization based treatment, which I mentioned here. The benefit of that book is it gives strategies for patients, but also sort of the hope is families can utilize these strategies as well. So that's a little more if you want to know, what do I do about the symptoms? And we always do, right? We don't want to just be able to identify it. We want to be able to act. So I highly recommend it as well. It is chock full. And as you go through it, there's charts. It's very hands-on. Far away, it might look intimidating, But once you get your hands in it, it's a handbook.

57:12It's a really rich resource. So again, that will be linked as well in our show notes. And stick around or hit play again. We're going to continue this conversation and get more into mentalization and to the clinical aspects. All right. Thank you very much. You've been so generous. And thank you, listeners. If this has been helpful, please do share this episode. Leave us a rating and review. That helps other people find it. This is a free catalog of all of this wealth, 10 years of, you know, bringing light to all of these kinds of treatments and mental health. And yeah, thanks for listening and we will see you around the bend.

57:55Therapist Uncensored is hosted by Ann Kelly and Sue Marriott. This podcast is edited by Jack Anderson.

58:06Thank you.