 Why should the narcissist attend therapy? What's wrong? Maybe it's just an a-hole or a jerk or maybe like Lens Perry says he has a narcissistic style But not a full-fledged narcissistic personality disorder So what so why should he waste resources this time his money on? utterly unnecessary treatments I Thought that I would give someone else the right to speak for a change It's a woman who had written to me Hello, Sam I'm watching many of your recent videos indeed as I type I had to pause halfway through one to write to you How the narcissist sees you as two women? Nothing has hit that bullseye with such clarity I have to tell you that I've written before at the beginning of leaving my fragile or covert narcissistic partner I thought I had enough resources to keep me determined in my run to the hills. I failed Seven months later. We reunited we then married Are the delicious blaring of reality in that back to the start phase of our resurrected relationship? I thought to myself How did I ever doubt this man? He loves me. He's so generous and kind and present He falls on one knee in a hebridean sunset and proposes of course the answer was yes Slowly ever so slowly Like the proverbial frog in that pot of water brought to boil. I Wake up after three more years and realize nothing has changed That feeling of being invisible That old niggle of disconnection feeling as though I'm irrelevant. I Mean nothing to him That void he can't physically touch me no laughter. No joy. He's like a kettle Furiously boiling inside where you can see the lead jumping, but you know you will be scolded if you try to remove it The verbal abuse where he totally lacerates my character wounds me deeply It's as though I'm nearly a household appliance functional I Attempt to discuss how I feel and he reacts with disinterested best at worst fury My feelings just don't matter He's the hero the provider. We both work by the way How dare I put him down when he's working so hard. I Feel ugly insecure Pointless and completely invisible. I Know that is not true. Of course, but I feel this in his company. I feel completely stuck. I Would not I would not like just to be free. This has gone on for 13 years. I Constantly tell myself how but he was kind to me then he bought me a meal out We had that holiday, etc. And I end up flailing between extremes Please feel free to quote my email if my words make others go me too and recognize that insidious sorcery That's subversion into the frog pan enough to act That's good My previous partner was a grandiose narcissist. It was evident who he was as he crashed around center stage There was nothing underhand about his aggression like blowing a trumpet in your face this one However, he's like walking barefoot in lush grass Not seeing the snake How do we get here? Well more to the point. How do we escape? I mean truly escape. I think this letter speaks for himself the nice assistant flicks in insurmountable Harrowing suffering on everyone around him and I'm not only referring to insignificant insignificant others or to non-intimate partners I'm referring to his business associates his neighbors Everyone around him suffers one way or another Ultimately the narcissist himself sets himself up for failure his Standards of perfection can never be attained. So he's constantly dissatisfied and tortured and then When he does succeed his sabotage is his own success. He undermines his self defeats. He self-destructs because of his inner critic sadistic superego the narcissist Is the narcissist? largest biggest victim The narcissist tends to regard the therapeutic relationship as yet another shared fantasy and Here too within the therapy the narcissist confuses internal and external objects via a process called transference He transfers his internal objects. He projects them onto the therapist some of these internal objects are parental figures So he begins to treat the therapist or regard the therapist as a surrogate father or surrogate mother and There is an almost psychotic confusion in the first stages of therapy My name is Sam Vakni. I'm the author of Malignan self-love narcissism revisited and your professor of psychology today, I'm going to offer you an overview of the psychotherapies and Treatment modes and modalities that had been proven to work with cluster B personality disorders most notably narcissistic antisocial and borderline personality disorders I Have omitted purposefully on purpose a few of these therapies for example, I Will not analyze or mention EMDR, which is a form of cognitive behavior therapy coupled with eye movements Generally, I will not dwell on body-mind therapies Although in the case of EMDR, for example, there's a good track record with cluster B Still, I'm excluding body-centered therapies I'm also excluding humanist humanistic therapies Carl Rogers. I'm excluding transactional analysis I'm excluding all psychodynamic therapies and psychoanalysis, etc. Etc. And the reason I'm doing all this is because there is insufficient data To prove or to show or to demonstrate conclusively or even just convincingly That these therapies with the exception of EMDR into some extent gestalt the these therapies are Efficacious with cluster B. So I'm going to focus only on therapies backed by studies and published peer-reviewed papers Now I encourage you To do your own research Go and read Go and read on EMDR EMDR go and read on gestalt therapy go even and read on psychodynamic or therapies or psychoanalytic psychotherapy It's all these are all laudable therapies and they make claims regrettably these claims are not supported by research So now evidence-based therapies First of all, I refer you again to Lens-Peris S P E R R Y Book handbook of diagnosis and treatment of the of DSM 5 personality disorders assessment case conceptualization and treatment published by Rutledge in 2016 it's a third edition previous to Relate to the DSM 4 text revision this one Incorporates the latest insights and changes in the DSM 5 and on we go We start with behavior therapy Behavior therapy is a group of therapies actually which replace problem behaviors with constructive behaviors via Conditioning or more precisely counter conditioning and Reinforcement so they use very primitive tools of operant conditioning and Reinforcement positive and negative reinforcement to sort of channel the patient Towards more constructive more productive Lace up less abrasive and less antisocial behaviors as a whole family and They date back to the 1950s out of behavior therapy this there came a second family of therapies They are known as cognitive therapies cognitive therapies seek to change negative automatic thoughts and Shemas that lead to attributional and other biases as well as to errors in thinking So cognitive therapy focuses on as the name implies cognition Cognition how to change your thinking by changing your thinking you change your frame of mind Change your frame of mind you change your state of mind remember all these therapies are used extensively in the treatment of personality disorders and most specifically in the treatment of Class to be personality disorders now the idea in cognitive therapy Is to alter to change problematic behaviors and dysfunctional feelings and behaviors by Focusing on the way you think about yourself the way you think about others and the way you think about the world It seems that you're thinking shapes molds your behavioral choices and these create reactions and the whole conglomerate the whole complex Generates negative emotions So there's a vicious cycle negative emotions Create actions create reactions create negative emotions and it's a self-perpetuating self-enhancing vicious cycle the latest The penultimate reiteration of cognitive therapy is of course the world-famous cognitive behavior therapy or CBT There is a third wave of behavior therapy It's a it's a wave that combines CBT with other elements. What are these other elements? Number one the primacy of the therapeutic relationship the therapeutic relationship for the duration of the therapy Becomes the main relationship of the patient Overriding even his intimate relationship Overriding his workplace overriding anything the therapeutic relationship becomes the main relationship because it is within the Therapeutic relationship the change is induced. Actually, it's the relationship itself that creates the change by having finally a Healthy relationship with another adult who happens to be therapist the personality disordered person experiences a monopoly of new Experiences so secure attachment. He feels safe He can express negative Affectivity and negative emotionality without being punished He can he can be dysfunctional the therapist will contain him and channel him and regulate him So he acquires regulation, etc. The the primary therapeutic relationship is a prototype for a healthy Functional relationship prototype Platform template that the patient can then take and apply to all his other Relationships remember we are talking about third wave of behavior therapy Combining CBT with other elements will discuss a few of these therapy shortly the second principle in the third wave is learning analyzing triggers analyzing environmental cues Exploring shamans will discuss shamans a bit later exploring emotions and then the third element is utilizing modeling Homework and imagery now. Okay, all these principles are 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 Marsha line 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 your regional was bright and brilliant There was no need to combine 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 shema therapy, they also have mindfulness shema therapy and so on these are Indian gurus and mystics translated via Western gurus and and one of the yogis who didn't understand the word of the of the original Indian teaching and it's a bloody mess So I'm going to describe the original dialectical behavior there line and develop it developed it 1993 to treat borderline personality disorders But gradually over the decades the efficacy of dbt had been proven with other personality disorders And with disorders of mood anxiety eating disorders and substance abuse disorders. So it is widely widely applied to a variety of disorders but the experience hitherto has been almost exclusively with female patients and in large part in Inpatient or residential settings in other words in hospital settings Mental asylum settings to be less politically correct people committed or hospitalized women committed or hospitalized and 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 narcissistic borderline Typical mostly to men not to women. This would explain Why dbt doesn't work well with men or has it hadn't been applied to men because men happened to Men gravitate more Towards the primary psychopathy poll while women Gravitate more towards the secondary psychopathy pole. In other words women borderline women borderlines would tend to become secondary psychopaths under conditions of stress and Men covert borderlines would tend to become primary psychopaths under the same conditions, for example Anticipating rejection humiliation and abandonment Or going through actual breakup or disintegration of an interpersonal meaningful interpersonal relationship so There is a substantial difference between the way 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 harks harkens back to the very beginning of behavior therapy when it was combined with emotive therapy so it is concerned dbt is concerned with how Your shema how the shemas of the patients were formed via dialectical conflicts shemas are simply combinations of beliefs Cognitions Emotions when you put them together in reaction to a set of specific circumstances Or a relationship is a set of specific circumstances And we have shemas that pertain for example to relationships. We will deal with shemas at length a bit later But dbt is asking the question. How did your shemas form? how how did How did you how was your affect? How were your emotions involved in generating these shemas dbt seeks to connect affect and need Because every shema responds to a need and involves emotions. So we have shema need affect emotions and dbt tries to connect all of them and There the dbt tries to demonstrate to the patient that there are processes of inference deduction analysis There are belief systems Which which put together with the need and the effect had generated the shema So suddenly everything becomes clear. You had a need you had a belief You had a reasoning process or a logical 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 this solution is a is a scheme or multiple solutions are shema So when these are reinterpreted when you become self aware of these background processes This self awareness begins to generate healing dbt identifies fixation or Perseveration example rumination caused by early developmental deprivation and by protective in attentional constriction So as a child have been deprived for example of maternal love in case you had a dead mother and You have learned gradually as a pay 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 You won't 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 your emotionality is regulated. 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 or in other ways and Also studies in adequate coping skills dbt claims that negative reinforcement emotional avoidance Inadequate coping skills. They are actually rewarded. There's something called partial reinforcement effects I will not go to it right now, but they are actually gratifying things while in healthy people emotional avoidance Inadequate coping skill is caused for for distress Healthy people don't like it borderlines actually do like it and not only borderlines. We're talking about plus the big but mostly borderline Now dbt dialectical behavioral therapy, which is used mostly for borderline involves individual therapy group skills training re-skilling you acquire new skills Phone contact to show you over, you know in between sessions and Therapist consult consultation, which is not for you. It's for your therapist Exactly like in psychoanalysis your therapist consults other 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 discontrol 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 damage goods This is dbt. dbt is an exceedingly successful therapy It has immediate effects On borderline patients well over 50 percent of borderline patients within the first year of dbt lose the diagnosis The dbt borderline can no longer be diagnosed in these people The next therapy I would like to discuss is cognitive behavior analysis system of psychotherapy or c-busp It was developed by McCullough And adopted by Sperry. It is not to be used with dbt. It's dangerous Exactly like cold therapy that we're going to discuss at the end. This is a therapy which is dangerous for borderline patients For borderline patients The clients of c-busp Learn to analyze life situations and manage daily stressors stressful events They evaluate 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 It and 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 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-trudging That every person seeks his own best interests. That's not always true with cluster b personalities At any rate one thing the therapy does for sure is it replaces emotional reasoning with consequential logical analytical reasoning and that's a major achievement because many cluster b personalities Engaging 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 in as I said earlier had become a modular if you wish Some of its techniques became integrated into dialectical behavior therapy EMDR even Shema therapy and so next therapy is pattern focus psychotherapy. It was developed by by sperry himself Sperry defined pattern as a predictable consistent self perpetuating style of thinking feeling acting coping and self defense It can be as a pattern can be adaptive And encourage you to be competent To be self efficacious To leverage your agency to secure favorable outcomes from your environment But the pattern can be maladaptive. It could be 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 it reduces your satisfaction with yourself and with your life A state called dysphoria. It generates dysphoria Therapy the pattern focus 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 this There's a commonality between all these they all that 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 there is a tendency to regard The 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 object. They produce an artwork But if they don't know how to do it or if they have their own problems The dead mother andray greens dead mother then The object art is deformed malformed and Is likely to behave in ways Which will not be conducive to health happiness Good relation 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 shema therapy shema therapy was developed by young Shema therapy changes these maladaptive patterns, which in shema therapy they're called shemas They're 18 shemas These are enduring and self-defeating ways of regarding oneself and others And the 18 shemas are arranged in five domains Shemas are perpetuated through you through coping styles There is shema maintenance shema shema avoidance and shema compensation And you can you can work with these shemas. You can reconstruct them. Which is very difficult takes a lot of time and investment But you can also modify them, which is a bit easier. You can interpret them insight 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 pole I'm going to read to you a list of all the shemas because it's a wonderful summary of summation of everything that's wrong with cluster B personality disorders So here are the shemas maladaptive shemas and shema domains Shema 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 and wanted or inferior in important aspects Social isolation alienation the belief that one is alienated different from others or not part of any group In period autonomy and performance is the next domain And within this domain we have the following shema Dependency 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 shema Next shema enmeshment and developed self the belief that one must be emotionally close with others at the expense Of full individuation or normal social development Next shema failure the belief that one will inevitably fail or is fundamentally inadequate in achieving one's goals Next domain impaired limits or boundaries Sh, 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 or 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 Shema therapy is a very powerful therapy and very intelligent if I may add Next Kernberg who else still active in his 80s amazing men The father of the field together a bit later with theodore miller transference focused psychotherapy developed by Kernberg Kernberg 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 effect a personality disorder occurs When positive representations and negative representations fail to integrate later in life echoes of melanin climb such splitting 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 Kernberg Very similar to cold therapy I'm doing this in cold therapy as well Kernberg encourages transference to the therapist because he believed that when the patient Engages in transference when the patient projects his inner it's 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 in insight. These are the two pillars So identity integration is accomplished As the patient experiences negative emotions, but in a safe accepting environment Beautiful if you 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 Have been Deemed have been deemed as efficient or efficacious therapies There is some 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 antivirus programs, you know So this one pass They they fought well the malware of the mind mentalization based treatment and the MBT developed by Bateman and from agi This therapy this treatment mode modality assumes that Um That you need to as a therapist you need to help the patient to experience secure attachment Because if the patient experienced secure attachment He can he can develop impulse control. They believed 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 percent to healing and this leads to improved relational skills finally developmental therapy the roadmap therapy was developed by quite a few people But the main figures are bloke bl o c h r blotcher Cartwright and spelling Cartwright blotcher and sparing developmental therapy regards problem 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 or hierarchy When you analyze this you shouldn't analyze them discreetly, but you should create a continuum a spectrum dimension And this dimension goes from disordered to adequate to optimal and i'm going to read to you Quoting from lence perry's book aforementioned i'm going to read to you how this looks with cluster b Select cluster b disorders, mainly the dramatic ones histrionic Optimal so everyone is a spectrum every cluster b disorder is a spectrum Every healthy person has a spectrum And the spectrum is optimal adequate 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 privileged or privileged 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 it's cluster a it's it's not class to be schizoid optimal Deeply grounded in themselves. They are emotionally connected to the world. That's optimal Adequate reasonably comfortable being around others provided. They are limited demands 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 The good grounds assume that schizoid personality disorder Is a facet of narcissism is 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 Anti-social or psychopath psychopath is an extreme anti-social Optimal have the gift of gab 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 psychos disordered A real psychopath a robot hair Harvey Cleckley psychopath primary psychopath Exhibits aggressive impulsive self-serving self-serving and irresponsible behavior Okay, borderline the queen of the of the 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 yeah, finally the paranoid Optimal highly observant and discerning they can defend themselves without losing control or becoming aggressive Adequate thin skinned they are rather sensitive to and hurt by criticism Which is very similar to narcissists One of the reasons I 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 call therapy developed by Vaknin Call 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. Yeah, don't you don't say here? Narcissists are actually the outcomes of arrested development and attachment dysfunctions consequently call 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 use To in order to deal with ptsd and cptsd Call therapy consists of the retraumatization 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 successfully tackles this second round of hurt And so resolves early childhood conflicts and achieves closure Rendering is now maladaptive narcissistic defenses Unnecessary redundant and obsolete This also improves his relational capacity Because the narcissists goes through the 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 Call 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 refraining guided imagery negative iteration other scoring happiness map mirroring escalation role play a similarity of confabulation hyper vigilant referencing and reparenting uh the very limited sample of Clients who had undergone cold therapy to its end level one two and three um the results have been Very positive it proves It's proving to be an efficacious trade effective treatment for narcissistic personality disorder and major depressive episode which seems to sustain an early belief That narcissism is a form of depression Call 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 yet the client should navigate this light motif and channel his or her creativity without a script As an exercising extemporarizing Improvising the twists and turns of the plot should come as a surprise First and foremost to the client himself Okay, now let's To some criticism of some of these treatment modalities start with mindfulness I said that mindfulness has been had been incorporated to various therapies modern treatment modalities Terror 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 This 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, corn auties You know, I don't like it. I seriously dislike it Next cognitive behavioral 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 And our repeated behavior patterns, learn behaviors and learn helplessness Where 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 no information Reframing is a shift from one narrative Of one's life and of others' plays and roles in one's life To another narrative with a bigger explanatory power And 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 ants But they are distortions They are not real, they are counterfactual They conflict head on with reality But when these negative automatic cognitions Thoughts conflict with reality The patient gives up on reality He is invested emotionally in the validity and truth Of these negative automatic thoughts So he is fighting tooth and nail to preserve them Cognitive restructuring is the main technique used in CBT Some elements of cognitive restructuring Like guided imagery are incorporated in cold therapy as well Psychodynamic theories reject the So this is CBT Psychodynamic theories reject the notion That cognition can influence emotion That's where there's a major conflict Between the metaphysical if you wish Pillar of philosophical pillar of CBT and psychodynamic theories The 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 It's 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 Reveal 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 So many therapies are very effective At modifying the behaviors of the narcissists But none of them Not even called therapy Heals or cures narcissism 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 They are forms of intensive psychotherapy Based on psychoanalytic theory Without the very important element of free association This is not to say that free association Is not used in these therapies Only that it is not a pillar of the technique You can go through a course of therapy in these therapies And not freely associate Dynamic therapies are usually applied to patients Not considered suitable for psychoanalysis For example, those suffering from personality disorders With one exception, the avoidant personalities Typically different modes of interpretation are employed And other techniques borrowed from other treatment modalities It's very eclectic actually But the material interpreted Is not necessarily the result of free association Or dreams like in psychoanalysis The psychotherapist is a lot more active Than the psychoanalyst The psychoanalyst provides a black screen On which the patient projects everything Via transference, via defense mechanisms and so on The psychotherapist in dynamic psychotherapy Psychodynamic therapy and psychoanalytic psychotherapy Is very active, is an active interpreter It's a collaboration Psychodynamic therapies are also open-ended A decommencement of a therapy, the therapist unlist Makes an agreement, a pact Alliance, therapeutic alliance With the analysand, 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 minutes 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 to Expressive versus supportive But it's a bit of a misleading In my view, 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 a strong ego can cope better And later on alone with external, situational Or internal instinctual related to drive's pressures Remember, the narcissist does not have an ego That's the narcissist's 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's The symptoms the conflict had generated Danish 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 therapies Make no use of insight or interpretation Although there are some exceptions Let's talk a bit about group therapies Class to be 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 called empathy The 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 Class to be personality disordered people regard coalitions with disdain Or contempt or as opportunities Or you know, it's not good They 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 class to be 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 Class to be patients is likely to deteriorate very fast Degenerate and fluctuate between short Very small size coalitions Based on superiority, interests, content And outbreaks, especially narcissistic outbreaks Acting out the compensation of rage, coercion, anxiety The most difficult patients by far in therapy Are psychopaths and narcissists In therapy, the general idea is to create the conditions For the true self, to resume its growth Provide safety, predictability, justice, love, acceptance A mirroring, reparenting, a holding environment Therapy is supposed to provide these conditions Of nurturance and guidance through transference Cognitive relabeling or other methods And the narcissist must learn that his past experiences Are not laws of nature That not all adults are abusive That relationships can be nurturing and supportive That love is fun Most therapists try to co-opt the narcissist's inflated ego His false self, his defenses They compliment 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 starts Bad dynamics These therapists make a contract with the narcissist The 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 absolving the narcissist from his responsibility And freeing his mental resources To concentrate, to focus on the therapy Confronting the narcissist's head-on And engaging in power politics I'm more clever than you My will will prevail and so on Is decidedly unhelpful And could lead to rage attacks And a deepening of the narcissist's persecutory delusions Bred by his humiliation in the therapeutic setting Same goes for borderline Same for... Same for psychopaths Successors 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, Neural Linguistic Programming Which many say is a scam Seem to somehow work Chemotherapy that I've mentioned Eye movement, desensitization, EMDR and so on But whatever the type of talk therapy The narcissist devalues the therapist The narcissist's internal dialogue is I know best I know everything This therapist is less intelligent than I am I can't afford the top-level therapist Who is the only one qualified to treat me As my equal, of course I'm actually a therapist myself Why am I here? What am I doing here? And so there's a litany of self-delusion grandiose self-delusion And fantastic grandiosity These are defenses, of course Resistances because In the therapy there's a kind of role-play I mentioned at the beginning of this video 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 to allocate Superior authority Therapist type Inferior supplicant narcissist 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 psychobabble Even better than he does I know terminology and I know his own field better than him At any rate, it's us, me and him Against a hostile and ignorant world Shared psychosis for the other And then there is this internal dialogue Just who does the therapist think he is Asking me all these questions What are his professional credentials, I wonder Which university did he graduate, if at all I am a success and he 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 is an authority figure in his own office And I hate this and I hate him And I will show him, I will humiliate him I'll prove him ignorant I will have his license reform Transference Actually, this therapist is pitiful 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 Agnes Oppenheim wrote the following In the International Dictionary of Psychoanalysis Mirror transference is the Remobilization of the grandiose self Its expression is I am perfect And I need you in order to confirm to me That I'm perfect When it is very archaic Mirror transference can easily result In feelings of boredom, tension and impatience In the analyst Whose otherness is not recognized In the analyst, in the therapist Counter-transference is a sign of this The notion which first appeared in Heidt's cohort's work In the psychoanalytic treatment of Narcissistic Personality Disorder In 1968 This notion of mirror transference Was further elaborated In cohort's analysis of the self in 1971 Mirror transference can take three forms Depending on the degree of regression 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 twin-ship or other or alter ego transference The other, the therapist, is experienced as being Like the self Lastly, in mirror transference properly speaking The analyst is experienced The therapist is experienced as a function At the service of the patient's needs If the patient feels recognized He experiences a sense of well-being Linked to the restoration of his narcissism Mirror transference can be primary The reaction to a broken idealizing transference Or secondary to one of these In The Restoration of the Self A book published in 1977 Heidt's cohort distinguished it From alter ego transference Some authors have refused to consider these transferences Being a result of the evolution of narcissism They've seen it merely as a defense Narcissists generally are averse to being medicated Actually, most patients with personality disorders Are averse to medication Resorting to medicines is an implied admission That something is wrong Narcissists are control freaks And they hate to be under the influence of Mind-altering drugs prescribed to them By inferior others Additionally, many of them believe That medication is a great equalize 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 medicines 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 disorders 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-neil, out-unique Either be special or don't be at all Narcissists are drama queens Exactly like borderlines And histrionics And some types of psychopaths Very much like in the physical one Change is brought about Only through incredible powers Of torsion and breakage Only when the narcissist's elasticity Gives way Only when he is wounded by his own intransigence Only then is there hope It takes nothing less than hitting rock bottom Real hard Takes a real crisis Multifaceted In all dimensions of the narcissist's life Samutaneously And we, boredom, failure Are not enough Esteemed colleagues Good morning or good afternoon My name is Sam Baknin And I'm visiting Professor of Psychology In Southern Federal University In Westovon-Dome In the Russian Federation As well as a professor of finance And a professor of psychology In SIAF's 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 that has been in the Diagnostic and Statistical Manual For almost, for well over 20 years So this creates a great confusion Regarding the terms Codependence, counterdependence, dependent, etc etc So perhaps before we proceed To study dependent personality disorder We would do well to try to clarify these terms As Lidia Rangelowska 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 codependence Take these to a whole different level To a new extreme Like dependence People with dependent personality disorder Codependence depend on other people For their emotional gratification The regulation of their emotions and moods Reducing lepility And the performance of both inconsequential and crucial Daily psychological or in Freudian parlance Ego functions Codependence seeks to fuse Or to merge with their significant others By becoming one with their intimate partners Codependence are able to actually love themselves By loving others It is like loving yourself by proxy Vicariously Codependence are needed Demanding, clinging and submissive They suffer from abandonment anxiety And to avoid being overwhelmed by it They cling to others and act in maturity And in this sense They're 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 release it Protective responses And to safeguard the relationship With their companion or mate Upon whom they depend Codependence appear to be impervious to abuse No matter how badly they are mistreated They usually remain committed to the relationship In extreme codependence This fusion, this merger with the significant other Lead to in-house stalking As the codependence strives 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 co- In codependence comes into play By accepting the role of victims Codependence seek to control their abuses To manipulate them It is a dals macabo In which both members of the diet collaborate It's a kind of traumatic bonding Or trauma bonding In codependency The codependence sometimes claims to pity her abuse She casts herself in the grandiose roles Of his savior Or his redeemer Or his mother Her overwhelming empathy Imprisons the codependence 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 abandoning There are various types of codependence Codependency is a complex, multifaceted And multi-dimensional defense Against the codependence 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 codependence are clingy, smothering in front of panic They are plagued with ideas of reference French ideation And they display self-negating submissiveness Their main concern is to prevent their victims Friends, spouses, family members From abandoning and deserting them Or from attaining true autonomy and independence These codependence merge with their loved ones And experience any sign of abandonment Or autonomy, personal autonomy Whether real, actual, threatened, imagined They experience these as a 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 the codependence fear of losing control By feigning helplessness and neediness Such codependence coerce their environment Into ceaselessly and seamlessly Catering to their needs, wishes and requirements These codependence are drama queens Their life is a kaleidoscope Of instability, chaos and liability They refuse to grow up They force their nearest and nearest To treat them as emotional or physical invaders They deploy their self-included efficiencies and disabilities They yield them and will them as weapons Both types of codependence, type 1 and type 2 Use emotional blackmail when necessary Guiltrate when necessary Threats to secure the presence of blind complies Blind complies, all their suppliers Anything less triggers anxiety The third category are vicarious codependence These are codependence who live through others More or less like the moons reflected somewhere They sacrifice themselves in order to glory In the accomplishments of their chosen talents They subsist on reflected light, as I said On second hand, applause And on derivative achievements and accomplishments They have no personal history Having suspended their lives Their wishes, preferences and dreams In favor of another's They live by proxy They live vicariously They live through another, a parasitic existence One subtype of such codependence Is what I call inverted narcissists The inverted narcissists is a form of covert narcissists It is a codependent who depends exclusively on narcissists A narcissist codependent If you are living with a narcissist If you have a relationship with a narcissist If you are married to one If you are working with a narcissist, etc This does not mean that you are 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 only 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 3 And category 4 is codependent or borderline narcissists 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 For their doom These are all outcomes of their overwhelming and Or pervasive abandonment anxiety They either smother their partner in an attempt to forestall desertion Or they creatively abandon sheep Thus avoiding her 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 deploys 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 co-extensivity The ventriloquist defense insisting to the partner Mind reads her And acts in ways that reflect her inner psychological states and moons 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 co-dependence 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, spouses, the law They are consummations The sense of self-worth and their very self-identity Are premised on and derived from In other words dependent on These acts on bravura and defiance They are personal autonomy militants Counter-dependence obviously militantly independent Controlling self-centered and aggressive Many of them are anti-social 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 behavior patterns are often the result of a deep-seated fear of intimacy In an intimate relationship The counter-dependent feels enslaved and snared, captive Counter-dependence are locked into an approach Avoidance repulsion repetition compulsion The hesitant approach is followed by Avoidance of commitment and then another Stilded approach and so on These people are lone wolves and they're very bad team players Counter-dependence is a reaction formation The counter-dependent dreads his own weakness He seeks to overcome these weaknesses By projecting an image of omnipotence omniscience Success, sufficiency and superiority Most classical overt narcissists are in effect counter-dependence And of course all psychopaths Their emotions and needs are buried Of the scar tissue which had formed and coalesced And hardened during the years of one form of abuse or another Grandiosity and sense of entitlement Lack of empathy and overwinning hotness Overwinning hotness usually hide Knowing insecurity and fluctuating sense of self-worth Another situational co-dependence Some patients develop co-dependent 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 emptiness One was once children embark on their own autonomous lives Or live home or together Such late onset co-dependence Forsters a complex emotional and behavioral chain reaction Whose role is to resolve the inner conflict By ridding oneself of the emergent undesirable co-dependent conduct Consciously such a patient may at first feel liberated But unconsciously being abruptly dumped and lonesome Has a disorienting and disconcerting effect Accompanied to intoxication Many patients rush headlong and indiscriminately Into new relationships Deep inside this kind of patient has always Dreaded being lonely Not alone Following a 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 She suppresses this dread Because she possesses no real effective solutions And antidotes to her sudden solitude And she has developed no meaningful ways to cope with it We are taught that denied and repressed emotions Often reemerge in camouflage as it were The dread of ending up on alone Is such that the patient becomes co-dependent In order to make sure that she never finds herself In a situation like this Never finds herself alone Her co-dependency 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 life-long 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 then they spectacularly expose his egregious misconduct So that they can get rid of them And of the newly acquired co-dependency In good conscious and at the same time So, to reiterate, the situational co-dependence Is characterized by a deep-set fear 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 endears At first, the newly found freedom is exhilarated 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 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 the 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 co-dependency As a coping strategy To attract and bond with the mate So as to forestall abandonment Yet the situational co-dependent is ecothistomic She is very unhappy with her newfound co-dependence Though at this stage she is utterly unaware of all this dynamics It runs contrary Her co-dependency runs contrary to her primary nature As a accomplished, assertive, self-confident person With a very well-regulated sense of self-worth She feels the need to frustrate this new set of compulsive addictions Her co-dependency 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, modeling, weak, out-of-control type All her life she has known herself to be strong A good judge of character, intelligent and in control Co-dependency does not become her But how could she get rid of this new co-dependency? Well, in three easy steps She chooses the wrong partner unconsciously And obviously it leads again to being alone She proves to the 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 co-dependent no more To make matters clear Co-dependency 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 her partner They use words such as humiliating, submissive But these are all subjective terms Either culture-bound or represent value judgments They open to disagreement They 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, the very old, the very young, deceived, the criminal and the mentally handicapped Are denied personal autonomy They are legally and economically dependent on others and company authorities Thus dependent personality disorder is diagnosed Only when such behavior does not conform To social or cultural or moral Co-dependences 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 Simplest everyday decision becomes an excruciating ordeal They go back and forth Approach avoidance This is why co-dependents rarely initiate protests Or do anything of their own Co-dependents typically go around the listing constant And repeated reassurances and advice From myriad sources And this recurrence solicitation of Sakura Is proof that the co-dependent seeks to transfer responsibility for his or her 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 and inner compass And a realistic assessment of their positive qualities on the 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 They ever criticize them They are afraid to lose their support And emotional large 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 disregulated Consequently The co-dependent wants himself or herself And bends over backwards to cater to the needs of his nearest and dearest And satisfy their every whim, every wish, expectation and demand Nothing is too unpleasant or unacceptable If it serves to secure the uninterrupted presence Of the co-dependent's family influence And the emotional sustenance that she can extract from them The co-dependent does not feel fully alive when she is alone She feels helpless, threatened, ill at ease and childlike This acute discomfort drives the co-dependent to hope From one relationship to another And even sometimes lead to promiscuity The sources of nurturance are interchangeable To the co-dependent being with someone, with anyone No matter who is always preferable to solitude Well, parents of co-dependence Had taught their offspring to expect only conditional transactional love The child is supposed to render a service Or fulfill the parents' 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 furies 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 And 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 reserve of love Can be directed inward at himself and yield a narcissist Or it can be directed outward towards others And create co-dependence All these choices Retard personal growth Result in arrested development And are ultimately self-annihilating 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 For fear of incurring the wrath and the abandonment of the parent With whom he had merged so thoroughly, so early on When the co-dependent merges with the lab 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 love is An affiliation rest with the internalized parent Not with the newfound love Concurrently she punishes herself As she tries to pre-empt the merciless onslaught Of her sadistic parental interjects and superego She engages in a monocle of self-destructive reckless And self-defeating behaviors Acutely aware of the risk of losing her partner Owing to her abusive discontent The co-dependent experiences extreme abandonment anxiety She swings wildly between self-effacing and clinging Being a dormant behaviors on the one hand And explosive, recuperative invectives of 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 effect in contact Are often misdiagnosed As the hallmarks of a mood disorder May be bipolar disorder But where dependent personality disorder is diagnosed These pendulum-tectonic hospitals Are indicative of an underlying personality structure Rather than of any biochemically induced perturbations Accent to addiction Dependence on other people fulfills important mental health functions First, it is an organizing principle It serves to explain behaviors and events Within a coherent narrative, a fictional story A frame of reference I acted this way because I'm dependent Second, it gives me into life Third, the constant ups and downs Satisfy the need for excitement and thrills Fourth, and most crucially The addiction and emotional ability Plays the dependent to the center of attention Allows her to manipulate people around her To do her bidding Indeed, co-dependent is convinced That she cannot live without her dependence This is a subtle and important distinction She cannot, she can survive without him Or her ultimate 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 dependence 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 maid, 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 co-dependency Dependent personality disorder Borderline personality disorder They require professional help Luckily, dependency 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 a relationship does It is the dependence In you, in the patient That reacts with desperation Not the patient herself And 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 or her 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? Or, 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 plan of action She is bound to feel safer And more confident And she must share her thoughts, fears and emotions With friends and family Social support is indispensable One good friend And sometimes well A hundred therapy sessions And this is a secret That we should keep between us Or we'll all go unaccounted Clinging and smothering behaviors Are the unsavory consequences of a deep set Existential, almost mortal fear Of abandonment and separation But the co-dependent to maintain a long term And as the relationship She must first control her anxiety's head on This can be done by a 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 where the client can resume exploring And personal growth And form a modicum of self-autonomy In this, the psychiatrists may wish to prescribe Anti-exaggeration medication Transference should be encouraged In certain cases Self-help is also an option Meditation, yoga, the elimination of any And all addictions such as walk-out-lacing Winching 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 core dependence reflects the responses To where 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 worldview The world is hostile about to get hurt These are negative automatic thoughts Which can be easily eventful And profitably tackled In a variety of cognitive behavioral therapies She needs to sustain her captain's own Abuse and abandonment are familiar to At least I know the ropes And how to cope with them And this also is a form of complex negative thought This is why she needs to exit this realm Of mirror fears and fearsome mental tumors She should adopt new vocations New hobbies, meet new people Maybe relocate, move to a new place Engage in non-committal and dispensable Relationships and in general Take life much more lightly Some co-dependence develop a type of militant independence As a defense against their own Sorely felt vulnerability In dependence But even these daring rebels Tend to view their relationships In terms of black and white An infantile psychological defense mechanism No, the splitting They tend to regard their relationships As either doomed to failure Or as everlasting And they claim to regard their intimate partners As both unique and indispensable Soreness, twin Or completely interchangeable and objective These of course are misperceptions Cognitive deficits grounded in emotional maturity And thought and person of development All relationships have a life expectancy A sell-by could be for or expiry date No one is irreplaceable Or completely interchangeable Co-dependence problems are rooted In a profound lack of self-love And absence of object constancy She regards herself as unloved and unlovable When she is all by herself Yet clinging co-dependent and counter-dependent Firstly, independent, defined, intimacy, retarding, behavior All these can be motivated If you fear abandonment to the point of fogey-up I advise you to adhere to a regime of therapy And a series of steps Which can be easily implemented And I'll list it on my website Having implemented this mini-therapy You should then seek longer-term therapy In a structured, therapeutic alliance Co-dependency 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 co-dependent And you will find a mini-therapy Mini-therapy 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 There's spontaneous remission After age 40 or 45 There is DBT Which is a very effective treatment strategy And there is growing hope Day in and day out 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 Medical interventions open But even in the classical field Of psychotherapy There are mega developments Stay with me for this ride A literature review Of the most recent studies In the world of borderline personality disorder My name is Sam Vaknin I'm the author of Malignant Self-Love Narcissism Revisitive And a professor of psychology And let's delve right in And review a new study This study Upends 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 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 And 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 And so there's a study A recently published study And it's titled The Hidden Borderline Patients Patients with borderline personality disorder Who do not engage In recurrent suicidal or self- 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 And so what these people are saying But 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 chose 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. Etc. In other words These two populations Were identical Diagnostically and psychodynamically The only single difference between them Is that 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 In 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 Psychological, 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 Four, three and two This approach of making a list Of diagnostic criteria Prevailed over the alternative approach Which was 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 non-sysistic 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 One, two, three, four and five And then I could be diagnosed with criteria Five, six, seven, eight and nine 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 One to five My borderline personality disorder Realies on diagnostic criteria Five to nine 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 percent That's 90 percent Of all patients with borderline personality disorder Is effective instability Also known as emotional dysregulation Zimmerman says that effective instability Had a very high negative predictive value Meaning that if you didn't have effective 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 a subgroup of patients With borderline personality disorder Who are less borderline than patients with BPD Who do not manifest this criteria In short, the issue is this We know that 90 percent of patients With borderline personality disorder Have emotional dysregulation Aka effective instability We, 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, I don't know 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 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 criterion 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 Lower 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 Who of people who were of patients who were suicidal And self-harming And in the group of patients who were not suicidal And were not self-injuries All these parameters I repeat them Social functioning Adolescent social functioning Likelihood of persistent unemployment Or receiving disability benefits Childhood trauma or neglect Zimmerman 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 Repeated 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 Monika Karski Is the assistant professor of psychology In psychiatry and a senior fellow Of the personality disorders institute In Weil Cornell Medical College New York City She has a very long list of credentials She is also a postdoctoral manager Of the postdoctoral program in psychoanalysis Psychotherapy etc etc Karski suggested to stop using the model 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 It is regrettable that the insurance industry And the pharmaceutical industry Have both intimidated The diagnostic and statistical manual committee Into including the outdated and defunct Language of the diagnostic and statistical manual Edition 4 In the fifth edition and in the text revision Summary of this part You don't have to self-harm You don't have to self-mutilate And you don't have to be suicidal To qualify for a diagnosis Of borderline personality disorder If you are emotionally dysregulated And your effect 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 mobility Associated with borderline personality disorder It's under recognition Is a significant clinical problem BPD is likely underdiagnosed 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 recognized An important question is Whether the absence of this criteria Which might attenuate the likelihood Of recognizing and diagnosing the disorder Identifies a subgroup of patients With BPD who are less borderline Than patients with BPD Who do not manifest this criterion 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 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 of borderline Personality disorder Onward to the next article It identified a new treatment modality For borderline personality disorder Either to We have had mostly Dialectical behavior therapy DBT DBT has been extremely efficacious Well over 50% of patients Lost the diagnosis within one year A DPD involved a group element An individual therapy element To this very day DBT, dialectical behavior 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 Randomized clinical trial The lead author is Agnud Arns A-R-N-T-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. Agnud Arns 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. Arns 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 Medicine Association Medical Association Psychiatry The study characterizes borderline personality disorder A bit idiosyncratically I must say There 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 slides This kind of hyper vigilance 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 People, patients in the study were clearly borderline And 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 a primary treatment For people presenting with what appears to be Borderline personality disorder And so 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 DBT Schema therapy uses techniques from traditional psychotherapy But it focuses, as I said, on an experiential strategy It delves into early childhood experiences And 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 As early as childhood, 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 Nurture, 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 all the genes and all the brain abnormalities So schema therapy seems to be very relevant With this approach, therapies 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 Help to reduce BPD symptoms But what this study shows is that if you 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 improvement in multiple secondary outcomes Happiness, quality of life Patient reports enhance 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 hour 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 Said the investigators 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 the 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 question was Is group schema therapy for borderline personality disorder More effective than optimal treatment as usual And is predominantly group schema therapy Or combined individual in group schema therapy More effective The findings In this randomized clinical trial Which included 495 adult participants With borderline personality disorder in five countries Combined individual in 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 In group schema therapy Is the more effective schema therapy format 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 Chainon C-H-A-N-E-N And as usual I'll first analyze the study And then read to you from the 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 he the tool 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 a wrong approach You should focus on case clinical A clinical case manager 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 MOBI trial MOBI trial It showed improved psychosocial functioning And reduced suicidal ideation With early psychiatric intervention and case management So the results of this study suggest That psychotherapy is not the only or even first effective approach For early BPD Dr. Chainan is the director of clinical programs and services And head of personality disorder research at Origin Melbourne Australia And he told 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% depending on the country The condition is diagnosed in puberty or early adulthood And it affects about 3% 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 the diagnosis of borderline personality disorder But these patients, young patients, they are volatile They are labile, they are dysregulated They are aggressive, they have enormous interpersonal difficulties And they are discriminated against by health professionals They don't get treated Those that are treated are often shunted off to some therapist Once a month or something And they receive individual psychotherapy A very small percentage of them end up in dialectical behavior therapy program The, and so 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 MOBI 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 Commobilities 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 With the patient 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 therapies were not specialist in BPD So the third approach is what we call as usual treatment Or treatment as usual approach Therapists, psychologists who are not experts in 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 Or 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 Chainham 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 Chainham 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 Or be it 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 Manninger Department of Psychiatry and Behavioral Sciences In Baylor College of Medicine, Houston, Texas Oldham says the general standard approach in psychiatry and 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 renome and track record Oldham is an example of a good scientist A scientist who is open to new information Scientists 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 study, 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 And a psychotherapy controlled condition Effective early intervention for BPD Is not reliant on availability of BPD psychotherapy In 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 there are very few people qualified to administer it 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 Sy Atezas Saeeden And Angela Kales K-A-L-L-I-S Publishing 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 In on multiple levels And in multiple areas of life Starting or 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 And so I want to review six studies very briefly So again the first one is titled Randomized control 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 this 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 programmatic however Due to cost and personnel constraints To resolve this issue Research has 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 Experience statistically significant improvements In all 10 endpoints and outcomes It seems that in patients with BPD Internet-based psychoeducation reduce symptom severity And improve psychosocial functioning With effects lasting up to one year Treatment group participants Experience 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 Guillemot and Boundhart So they said Standard dialectical behavioral therapy, DPD 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 skills Only treatment for BPD So while several clinical trials Examining this shortened or condensed version of DPD 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, DPD skills Only adjunctive treatment On the rates of suicide And NSSI episodes in patients with BPD I'll summarize this for you DPD is expensive DPD is costly DPD requires training DPD is not available everywhere to everyone So there's a sort of zipped or condensed version of DPD Which offers only skills training The authors tried to find out if BPD patients subjected to a bridged DPD The skills training component of DPD 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 DPD group Showed statistically significant greater reductions In the frequency of suicidal and NSSI episodes So the DPD group experienced statistically significant improvements In distress tolerance and emotion regulations But no difference on mindfulness The DPD 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 DPD It already has massive effects On multiple very crucial dimensions of BPD The DPD group showed significant improvements In social adjustment, symptom distress Borderline symptoms But no significant change in impulsivity Clinical improvements Were the statistics The statistical measures are very significant It's pretty safe to say that these outcomes are real The conclusions are Brief DPD skills training Reduced suicidal and NSSI self-injury episodes In patients with BPD Participants in the DPD 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 healthcare utilisation Social adjustment Symptom distress Borderline symptoms Diminished or did not differ from the other participants At week 32 That time, participants in the DPD 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 Adducted for Borderline Personality Disorder A two years' follower Was published in Psychiatry Research Psychiatry Research in 2016 The authors are Busatello and Belinno Ah, I love Italian, how musical The study was interesting It says that psychotherapeutic options For treating BPD Including DPD Mentalisation-based treatment Schema-focused therapy Transference-based psychotherapy And systems training for emotional Predictability and problems of it 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, Belinno et al. Published a 32-week study Examining the effect of IPT-BPD on BPD They concluded that IPT-BPD In other words, interpersonal therapy Adducted 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 Busatello et al. Examine whether the benefits of IPT-BPD Plus Prozac demonstrated in the 2010 study Persisted over a 24-month follow-up And so the outcomes were While the original study demonstrated That combined therapy had a clinically significant effect Of a Prozac alone on BPD This advantage was maintained only At the six-month assessment The improvement that 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 effective instability That combined therapy demonstrated Over Prozac monotherapy at 32 weeks When 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 Antonsen, Kvarsstein, 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 Where the 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 Were 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 And between years three and six The combined psychotherapy group Continue to show improvements in psychosocials Functioning So the outpatient psychotherapy group Worsened during this time The scores of these were 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 healthcare services over the last year Avoidant personality disorder Did not have a significant moderator effect In this case Comorbid avoidant personality disorder There was actually a negative predictor Independent of the group Both groups experienced a remission rate Of 90% at 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 start The next study is Eight-year prospective 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, Konstantino and Fonagy 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 And so the outcomes were That the number of participants Who met diagnostic criteria for BPD At the one-year follow-up Was significantly lower At the mentalization base 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 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 social care interventions Than the other group People in the MBT group Spent more months engaging purposeful activity Etc. They received 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 met 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 80-year follow-up period Was also significantly higher In the mentalization group So mentalization is a third option After DBT and schema therapy And finally A sigh of relief Finally The article An article titled Effectiveness and safety of the adjunctive views 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 B.M.J. Open Access B.M.J. 2021 The authors are Klein, Hauer and Berger 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 analysis Mental analysis Results for BPD are mixed In this study Klein and allies Examine the effectiveness and safety Of the adjunctive views 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 an internet-based intervention method And 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 It's interesting because many people resort to the internet As a first option You know, support groups, forums Even internet-based psychotherapy 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 had 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 Meaning, the role of meaning in therapy Now 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, how do we impose structure and order On people who decompensate Who defiantly and contumaciously react Reactence 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, are 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 but they're 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 as a Pathology Where I summarized 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 normal logical, 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 And 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 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 roots They went to the neighborhoods They went to homeless people They went to mentally ill people They went to mental as well 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 consider themselves frontline health workers And they collaborated with everyone who was fighting back Battling against the pandemic of mental illness Because that's by far a pandemic that's larger Than COVID or anything else we have known About one third of the adult population in most western countries Is diagnosed with a major mental illness So the power, threat, meaning framework And now I'm reading from their own publication Is a new perspective on why people sometimes Experience a whole range of forms of distress Confusion, fear, despair and trouble or troubling behavior And it is an alternative to the more traditional models Based on psychiatric diagnosis It was co-produced with service users And applies not just to people who have been in contact With the mental health or criminal justice systems But to all of us The framework summarizes and integrates A great deal of evidence About the role of various kinds of power in people's lives The kinds of threat that misuses of power Post to us And the ways we have learned as human beings to respond to threat In traditional mental health practice These threat responses are sometimes called symptoms The framework also looks at how we make sense Of these difficult experiences And how messages from wider society Can increase our feelings of shame Self-blame, isolation, fear and guilt That's a bit, I'm just cutting off right here To interject and say that it's very reminiscent Of Pete Walker's rendition of flight, fight, Form and freeze responses And I encourage you to have a look at that part of his work He got it completely wrong on emotional flashbacks And many other things But he expostulates very wisely and deeply And profoundly on these four types of responses Continue with the text The main aspects of the framework Are summarized in these questions Which can apply to individuals, families or social groups Number one, what has happened to you? How is power operating in your life? Number two, how did it affect you? What kind of threats does this pose? Number three, what sense did you make of it? What is the meaning of these situations and experiences to you? Number four, what did you have to do to survive? What kinds of threat response are you using? In addition, the two questions below Help us to think about what skins and resources people might have And how we might pull all these ideas and responses together Into a personal narrative or a story And this story comprises a few other questions Or answers a few other questions For example, what are your strengths? What access to power resources do you have? What is your story? How does it all fit together? So you see, this framework relies heavily on narrative construction And there's a firm underlying assumption That by constructing a reasonable, internally consistent And externally consistent narrative One can derive meaning And that meaning empowers and that empowerment Is the first step towards healing And the disappearance of what we call today In traditional psychiatry, symptoms I'm continuing from the text of the PTM framework Possible uses of the PTM framework The power-threat meaning framework can be used as a way of helping people To create more hopeful narratives or stories About their lives and the difficulties they may have faced Or are still facing Instead of seeing themselves as blameworthy, weak, deficient Or, quote-unquote, mentally ill The power-threat meaning framework highlights the links Between wider social factors such as poverty Discrimination and inequality Inequality along with traumas such as abuse and violence And the resulting emotional distress or troubled behavior The framework also shows why those of us Who do not have an obvious history of trauma or adversity Can still struggle to find a sense of self-worth Meaning and identity The framework describes the many different strategies people use From automatic bodily reactions, somatization To deliberately chosen ways of coping with overwhelming emotions In regulating emotions In order to survive and protect themselves And meet their core needs The framework suggests a wide range of ways That may help people to move forward For some people this may be therapy Or other standard interventions Including if they help someone to cope Psychiatric drugs But for other people the main needs Will be for practical help For resources, perhaps along with peer support Art, music, exercise, nutrition, community activism, and so on Underpinning all of this The framework offers a new perspective on distress Which takes us beyond the individual And shows that we are all part of a wider struggle for a fairer society One of the most important aspects of the framework Is the attempt to outline common or typical patterns In the ways people respond to the negative impacts of power In other words, patterns of meaning-based responses to threat When we are confronted with threat, we seek meaning This part of the framework, like all of it Is still a process in development However, the evidence summarizing the framework does suggest That there are common ways in which people in a particular culture Are likely to respond to certain kinds of threat Such as being excluded, rejected, trapped, coerced, or shamed It may be useful to draw on these patterns To help develop people's personal stories These general patterns can help to give people A message of acceptance and validation The patterns can also assist us in designing services That meet people's real needs, as well as suggesting ways Of accessing support, benefits, and so on That are not dependent on having a diagnosis In addition, the framework offers a way of thinking About culturally specific understandings of distress Without seeing them through a western diagnostic model So in other words, the framework is not culture-bound It doesn't crucially, critically depend on a cultural context A societal context, or a context of the period in history In which it operates The framework encourages, and I'm continuing from the text The framework encourages respect for the many creative And non-medical ways of supporting people around the world And the varied forms of narrative and healing practices That are used across cultures And in concluding remarks, they say Taking the PTM framework further It is important to note that power-threat meaning Is an overarching framework which is not intended To replace all the ways we currently think about And work with distress Instead, the aim is to support and strengthen The many examples of good practice which already exist While also suggesting new ways forward The framework has wider implications than therapeutic or clinical work The main document, and referring to a specific foundation document Suggests how it can offer constructive alternatives In the areas of service design and commissioning Professional training, research, service user involvement And public information There are also important implications for social policy And the wider role of equality and social justice It is a work in progress offered as a resource For any individuals, groups, or organizations Interested in developing it further And I add that this framework Has, is proving its value and its relevance Especially now during the pandemic When traditional tools have been taken away from us When we have been isolated and alienated from the familiar When everything, including loved ones, can be perceived as a threat And where whatever happens outside makes no sense whatsoever And so our lives are rendered increasingly more meaningless So the framework can help you restore meaning Create a new narrative which will empower you in different ways And allow you to reintegrate with people Familiar people and new people I strongly encourage you to delve into this Everything is available online They welcome contributors and contributions Contributions that don't mean money Intellectual contributions Ideas, observations, shared experiences They welcome all of you So I strongly encourage Now, the second treatment modality I would like to discuss Typically, immodestly, is my own I had developed a treatment modality Called, dubbed, called therapy Called, like in Coldberg Called therapy Cold therapy now with its extension Nothingness, nothingness narrative construction Cold therapy and nothingness narrative construction Is all about meaning I actually started my work on cold therapy By re-reading Frankl's writings We'll come to Viktor Frankl a bit later But cold therapy is about me A cold therapy is a therapy That eliminates grandiosity It eliminates grandiosity in narcissistic disorders of the self Including narcissistic personality disorder And it eliminates grandiosity in depressive narratives A big source, perhaps the biggest source Of depression, dysphoria, anhedonia in people Is the discrepancy between their expectations Their self-image, their self-perception Which is often inflated illusory delusional Grandios and reality And I call these the grandiosity gap Cold therapy works well with narcissists And with people with depressive people People with depressive illnesses Precisely because both narcissism and depression Share a common etiology The grandiosity gap The gap between reality and how you would have liked to see yourself What Freud called the ego ideal Now here's the thing Grandiosity is a cognitive deficit It impairs reality testing Of course, it distorts input from the outside To fit into the grandios narrative So in this sense Grandiosity and its agent, the false self They provide the narcissists and the depressive With meaning The false self is a narrative It's a piece of fiction It's a story It's a movie And it provides meaning, context, purpose, direction, goal It has explanatory power And organizing, structure, organizing power To generate structure and order in the narcissist's life So when we take away the grandiosity When we take away the false self We actually dismantle the false self Call therapy is about dismantling the false self in narcissism And to some extent in depressive patients So when you take away this You take away the main engine of meaning in the narcissist's life The narcissist is left with a life That appears to be arbitrary, capricious, threatening, hostile, meaningless No context, no sense, no direction, no purpose, no nothing No structure, no order The narcissist drifts like a feather in a hurricane He loses his bearings He has no inner compass The false self is an exoskeleton It's an external skeletal Very similar to an addiction It has the same psychodynamic function Functions of an addiction Provides a narcissist with an external skeletal Something that holds him together We take away this skeleton Take away this scaffolding And the whole edifice of the narcissist crumbles Because it's a house of cards So when we take away the false self in call therapy We take away meaning Now this meaning is delusional It's pathological It's based on a severe cognitive deficit It has little to do with reality So it impairs reality testing It's not healthy, it's not good The precondition for healing is to take away this distorted meaning And the generator of this meaning Which is the false self So when you take away the false self By dismantling it, the narcissist re-experiences Lives through You remember the video about flashbacks? Revivedness Relives his traumas But this time he's an adult I take away his false self He re-experiences his traumas Because he has no protection left It's like taking away the shell from a turtle He becomes a tortoise Turtle without a shell And so he re-experiences the harshness of reality The injuries The mortifications The traumas The narrative The disparaging narratives The sadistic hateful introjects He experiences suddenly all this And he has zero protection Because he has no grandiosity And no false self But this time he's an adult And so this time he can try To make sense out of his harrowing Horrible life experiences He can construct a new narrative That is not delusional That is reality-based That makes sense and gives his life Structure, order, direction, meaning and purpose This is the core of cold therapy It's forcing the narcissist Forcing the depressive patient To let go To let go Of a dysfunctional delusional, sick, constricting, crippling Meaning-generating narrative Get rid of it Trash it And then bravely and courageously Faced the pain The fountain, the tsunami of pain And hurt and damage and shame And guilt to some extent Have to face it And have to integrate it in a new story In a new narrative that makes sense And would continue to make sense Now in AA, Alcoholics Anonymous They more or less Force you to do the same To go through the same path Of letting go of your grandiosity And then having to face the people you've hurt During your alcoholic bouts The damage you have caused And then to integrate all this Into a narrative of healing and recovery It all boils down to the same Effectively Get rid of dysfunctional pathological defenses Deficits, biases Get rid Stop renouncing reality Stop as collectively called it Rejecting life Embrace life Embrace who you are Flood and invalid as you are Accept yourself Nurture and parent yourself Or reparent yourself Extricate yourself this time With your own power Out of the trauma Of your early childhood And heal Heal via meaning Which leads us To the last treatment modality And by far The most dominant and important And that's logotherapy Logotherapy Was invented by Viktor Frankl Viktor Frankl had the most amazing story He was He survived in Auschwitz The indescribable hell on earth An inferno-raified and embodied In Poland A concentration and extermination camp Most people were lucky Were lucky or unfortunate To survive six months in Auschwitz This guy Viktor Frankl survived for three and a half years Three and a half years in hell With devils and demons in human form SS guards and so on And he has emerged With lessons He has emerged with his mental health Largely intact A bit of grandiosity there But largely intact And he leveraged his experiences To help humanity And he invented logotherapy Logotherapy I'm quoting now from the Website of the Logotherapy Institute Viktor Frankl's logotherapy is based on the premise That the human person Is motivated by a will to meaning An inner pool to find a meaning in life The following list of tenets Represents basic principles of logotherapy One, life as meaning under all circumstances Even the most miserable ones Even in Auschwitz Number two Our main motivation for living Is our will to find meaning in life Number three We have freedom We have freedom to find meaning in what we do And what we experience Or at least in the stand that we take When we are faced with the situation of unchangeable suffering How we react to suffering Is in itself Meaning or generates meaning The human spirit Referred to in logotherapy Is defined as that Which is uniquely human Though in no way opposed to religion The term is not used In a religious sense So how do we discover meaning? According to Frankl We can discover this meaning in life In three different ways Number one By creating a work Or doing a deed Creativity Number two By experiencing something Or encountering someone And number three By the attitude we take Toward unavoidable suffering Everything can be taken from a man But one thing The last of human freedoms To choose one's attitude In any given set Of circumstances On the meaning of suffering Frankl gives the following example Once An elderly Elderly Old general practitioner Consulted me An old medical doctor Consulted me Because of his severe depression He could not overcome the loss of his wife Who had died two years before And whom he had loved Above all else Now how could I help him? What should I tell him? I refrain from telling him anything But instead I confronted him with a question What would have happened doctor? If you had died first Then your wife would have had to survive you Oh he said For her this would have been terrible How she would have suffered Whereupon I replied You see doctor Such a suffering has been spared her And it is you who have spared her this suffering But now you have to pay for it By surviving By mourning her He said no word But he shook my hand Her calmly left the office Viktor Frankl vignette All psychotherapies Make a base of course On implicit or explicit assumptions Usually implicit philosophical Even metaphysical assumptions We make assumptions When we create a new psychotherapy When I created my treatment modality We make assumptions About what it is To be human And more importantly What it is to be a person In other words In other words What it is to have a personality To be distinguished To be an individual Is there such a thing? Some treatment modality is disputing They say individuals are not atoms They are not divorced from their environment There's no such thing as individual That's a western invention So there's a lot of debate And psychotherapies clash In their description of their subject matter The patient or the client None of these assumptions Can be proven with certainty It's not a science It's literature at best And bad metaphysics at worst The assumptions of logotherapy Include the following The human being is an entity Consisting of body, mind, and spirit So that excludes logotherapy for me For example Because I would never I'm a scientist by training My original academic degrees are in physics I cannot accept the concept of spirit Things I cannot define Don't exist for me But it may apply to the vast majority of humanity Who do believe in souls, spirits, ghosts, demons, and I don't know what else So this is one assumption of logotherapy Sumption number two Life is meaning Under all circumstances Even the most miserable Even when millions of people are exterminated In front of your eyes In a horrible wintery camp In the middle of nowhere in Poland Auschwitz Number three People have a will to meaning They want meaning Like Adler's will to power And Freud's will to pleasure Indeed, Frankl suggested that this is the third school of psychoanalysis This will to meaning And number four People have freedom Under all circumstances To activate the will to find meaning Number five Life has a demand quality To which people must respond If decisions are to be meaningful And number six The individual is unique Which of course reflects Biosys of western thinking Of the enlightenment Biosys that started in the 17th and 18th century And reached their apex in the 19th and 20th century The concept of the individual Which is alien Alien to cultures and societies For example in Asia And in some parts of Africa So this is highly western Western-centered The first assumption Deals with the body, soma The mind, psyche, the spirit, noose According to Frankl The body and the mind are what we have And the spirit is what we are Assumption number two is ultimate meaning This is difficult to grasp But it is something everyone experiences And it represents an order In a world with laws That go beyond human laws It's not the laws of nature These are metaphysical Laws Sometimes translated Sometimes they appear in the form of religion But even when you're not religious Even when you're agnostic like me Or you have the religion of atheism You're a non-theistic religious person Or your religion is science Even then There are these unspoken laws Kind of ambient Ambient canon Codex Of how the world behaves The etiquette of existence, if you wish The third assumption is seen as our main motivation For living and acting When we see meaning We are ready for any type of suffering This is considered to be different Than our will to achieve power and pleasure Assumption four is that we are free To activate our will to find meaning And this can be done under any circumstances This deals with change of attitudes about unavoidable fate Frankel was able to test the first four assumptions When he was confined in the concentration camps And successfully saw Let me tell you this Any psychotherapy that helped someone survive Auschwitz It's worth considering The fifth assumption The meaning of the moment Is more practical in daily living than ultimate meaning Unlike ultimate meaning The meaning of the moment can be found and fulfilled This can be done by following the values of society Or by following the voice of our conscience Not much of a difference, by the way Our conscience is internalized society It's an introjected via the process of socialization The sixth assumption deals with one's sense of meaning This is enhanced by the realization that we Are irreplaceable, unique In essence, all humans are unique With an entity of body, mind and spirit We all go through unique situations We are constantly looking to find meaning We are free to do this at all times In response to certain demands Victor Frankel, like Zygmunt Freud, was a neurologist But unlike Zygmunt Freud, he was also a psychiatrist And he believed that the primary motivational force Is meaning in life He believes that if you're motivated by money If you're motivated by sex or power Your motivation will not last long And it will not sustain you As a functional, integrated entity Meaning does this Meaning is the glue that holds everything together And when you look at models, models of the psyche When parts in these models interact And I'm not only talking about Freud's tripartite model I'm talking about Jung's model I'm not only talking about psychoanalytic or psychodynamic models Or object relations models Any model, including behaviorist models They necessitate meaning A leads to B This teleology is to some extent embedded A leads to B Because A needs to do something to B Or with B in order to achieve C There is If I were religious, I would say there's a mind, a designer But of course evolution gives a sufficient answer for this And God is, as Pascal said, an unnecessary assumption So logotherapy is in many respects existential I mean belongs to the school of existentialism And it is openly, I mean, Frank Lloyd meets That he derived it from Kierkegaard's will to meaning And Alfred Adler was influenced by Nietzsche Nietzsche's will to power While Frankl was influenced by Kierkegaard and his will to meaning Freud was influenced by Gloiler and others And he came with a will to pleasure Logotherapies says that you must, you always strive to find meaning in life This was primary, most foundational, most powerful Motivating and driving force And I advise you to read the book Men's Search for Meaning Which is the accessible Because Frankl has many technical, highly obtuse and complicated books Which I also recommend to read I mean they're very, very important But if you want to get the gist of it And how shall I say the spirit of it Then Men's Search for Meaning In this book he outlines how his theories Helped him to survive the Holocaust And how he developed his experience And how he generated his theories Logotherapy, of course, these are two words Logos and therapy So logos is reason, logos is also word So logos is language, logos is reason Logos is the mind of God in action If you read the New Testament The first sentences about the logos So he says that people are motivated by the logos When they look at the world, when they look at the universe There are two ways to look at your environment Either you look at it and it's totally chaotic Totally random, totally meaningless Has no direction, purpose And you say to yourself When I see meaning, when I see direction, when I see purpose I'm imposing myself on the universe The universe is not like that It's a delusion These narratives are BS Because it's me, I'm inventing them And if I'm the source of these narratives They don't give real meaning These narratives reflect more about my inner state About my inner landscape About my mental structures, constructs, introjects Then about reality, they say nothing about reality And if I force reality, shoehorn reality To conform into these narratives I'm just lying to myself So that's one way of looking at the universe And another way of looking at the universe Is the way Frankel does Saying that, yeah, humans are the source of meaning But that doesn't mean that meaning is meaningless The fact that we are the source Doesn't vitiate, negate or undermine The power of meaning, the importance of meaning And above all, the validity of meaning We can come up with narratives Which are meaningful And these meanings will be sustained by reality Science What is science? Science is a set of narratives Who creates science? We do, only we do I have yet to come across a giraffe Who creates, who creates relativity theory Humans create science And yet science resonates with the universe The universe agrees, complies, obeys, follows science Of course, it's a way of looking at it The science makes sense of the universe Imbues it with some form of operational meaning Charts it, maps it Creates maps of meaning to borrow from Jordan Peterson So science is an example of a meaningful narrative Which is essentially human, only human, exclusively human But still has its own standalone validity Independent of the source And so if we can do it with science Why can't we do it with metaphysics Or philosophy Or you know what, perish a thought, religion The human spirit imbues the work of Franco But his use of the word spirit is not spiritual It's not religious Spirit is the will What Kierkegaard called the will That's the spirit It's the search for meaning It's not a search for God It's not a search for any supernatural being It's not a search for the paranormal The search for meaning on the contrary Is very pedestrian Is very quotidian Is very detail-oriented It's very You search for meaning in your routine In your daily life In the people that surround you day in and day out Or zoom with you day in and day out You search for meaning in the virus You search for meaning in the sick wards In hospitals You search for meaning in the trenches Where millions of people die You search for meaning in hunger You search for meaning in love You search for meaning in your children And your spouse And your boring and dull work You don't search for meaning in heavens You don't search for meaning in the kingdom of heaven That is about to come Or in the second coming Or in any guru or prophet Or public intellectual Or you don't search for meaning in these places You search for meaning within yourself Within yourself He Frankl warned against affluence hedonism Materialism In the search for meaning He said that these are These are gods With a fit of clay They are idols in the biblical sense And their prophets are false prophets All these cultures and so on Frankl observed That it's actually psychologically damaging When our search for meaning is thwarted Blocked, frustrated, deformed Manipulated Althusser Louis Althusser With his interpolation So positive life purpose Positive meaning is Could be associated with strong religious belief Or membership in some group Or dedication to a cause Or upholding certain life values And reifying them in your behavior Having clear goals Purpose of life Adult development Developing into an adult Maturing into an adult Implies having a purpose Having a structure Channeling Having a direction And yes In many respects it implies Narrowing your life Channeling means being limited to a channel And this is what Clackley describes in his book Mask of Sanity Psychopaths Even gifted one Even geniuses And he dedicates a whole chapter to gifted psychopaths Their problem is not that they're stupid Or even that they are insane Although he claims that they are Functionally insane Their problem is that they reject life They reject life in the sense that they refuse to adhere To any purpose And any meaning in any direction In any order they are defined In psychopathy we call it reactants Psychopaths are reactant They have defiance And they sacrifice their own Then they would rather die Than succumb Than accept The mores and edicts And expectations of society Of peers Of family Of institutions They'd rather die And they often die So psychopathy is the rejection of meaning The rejection of meaning The rejection of maturation And the rejection of life Because to do this You must comprehend life's purpose You must direct it You must have intention Life is intentionality Intentionality creates the feeling that life is meaningful And there were many other scholars like Crumbo Maholic And they designed even something called the purpose of life Purpose in life test The PIL test It measures individuals' meaning and purpose in life And they found that in various studies that Meaning in life mediated Relationship between religiosity and well-being, for example Between stress, uncontrollable stress And substance abuse Depression and self-derogation Etc, etc They discovered that meaning is super critical Seeking of noetic goals tests Song It's another measure that they had designed And song measures the orientation towards meaning So PIL measures the existence of meaning Song measures orientation to find meaning The drive to find meaning So when you have a low score on PIL You have low meaning in your life Or no meaning in your life And you have a high score on song That predicts a better outcome in treatment Than the opposite Franklin himself suggested various ways of obtaining meaning And I quoted I referred you to this And I described the case of the general practitioner The medical doctor and so on and so forth But like Jordan Peterson much later Franklin emphasises suffering And of course Jordan Peterson continues a very long tradition Of debate about suffering Buddhism is one way of considering suffering Christianity, of course, is founded on suffering Christianity is suffering reified It's institutionalized suffering Especially in its more original forms Which is Catholicism Strangely orthodox Christianity Is centered around life and meaning While Catholicism chose suffering And the negation of life The denial of life One could argue that perhaps Catholicism is far more psychopathic Than other variants of Christianity But let's not go into this It's another video But Franklin similarly Realized the value of suffering And he said that And he said that suffering is meaningful Only And here he's distinct from Peterson He disagrees with Peterson He said suffering is valuable But only when first two creative possibilities Are not available In other words, when nothing else is available When you can't create When you can't be with people When you can't socialize When you can't do anything When you're in a concentration camp in other words When your locus of control is totally external Your life is not your own Only then your suffering becomes meaningful When Roman legionnaires March you through Jerusalem And then crucify you You are utterly powerless You're utterly helpless You're utterly impotent At that point Your suffering becomes meaningful But only at that point Because prior to that point You have alternatives And all alternatives Are preferable to suffering Franklin said that Suffering is not meaningless If it can be avoided Only when suffering is inevitable He becomes it becomes meaningful So he was very He was dead set against suffering And in this sense he was a Buddhist Of course we'll talk about it In one of our next videos He wrote another book Which I recommend to you It's it's a bit more complex And it's called The Will to Meaning Foundations and Applications Of Logo Therapy That's the philosophy And metaphysics Of Logo Therapy He makes some Some amazingly basic Observations in this book That have eluded and evaded The greatest minds in psychology For example His opening sentence is essentially There's no psychotherapy If we don't have a theory of the individual He was Remember he was an existentialist And he disagreed with behaviorism He disagreed that people are machines Or that they are Evolved rats Like if you experiment on rats in a laboratory You learn everything You have You learn everything you need to know about About humans He disagreed He said that difference between rats and humans Question of quantity It's a question of quality And he said that behaviorism is anti-human It undermines the human quality of humans He was a neurologist And he was a psychiatrist And so When you couple These essentially mechanistic Disciplines Because neurology is mechanistic It's a machine It's studying the machine The machinery The hardware of the brain So when you couple this with existentialism You come up with the equivalent of determinism But how do you reconcile determinism With freedom of will Or the will to freedom Or the will to meaning So there is an inherent time bomb In logotherapy Frankel admits That a person can never be free From every condition People are subjected to To start with physiological Biological Medical conditions And then they're subjected to sociological Cultural conditions And then they're subjected to psychological determinants I mean People are under so many constraints And that it's very difficult To assert yourself To exert yourself separately from these constraints With many many people The constraints and the limitations and the rules Become their identity Their identity is comprised of what they cannot do Not what they can do So he says that people are capable of resisting And braving Even the worst conditions He said you must You must rebel Against these constraints You must detach from the situation You must choose an attitude You must determine your own determinants You must shape your own character You must become responsible for yourself You must fight Fight back Echehomo Is a method used in logotherapy And it requires the therapist to note the innate strengths That people have And how they have dealt with adversity and suffering in life Despite everything a person may have gone through They made the best of their suffering And this is the Echehomo Behold the man The man And his story Behold the meaning That each and every one of us generates To a lesser or greater degree Okay Assignments remind you All your studies are meaningless Without assignments And what's even much worse I'm meaningless without your assignments So don't make me lose my job in this pandemic Because, you know, the only one I have Is the thing that gives my life and dows my life With meaning They wouldn't want to take this away from me Thank you for listening I received complaints from some Shoshanim That they had been discarded and replaced With baby seals and baby silets Worry not, my Shoshanim You're always in my heart You're the first and foremost So here goes Okay Shoshanim Today we're going to deal with narrative Narrative is our core identity And what happens when narratives fail In how to fix them My name is Sam Vakny I'm the author of Malignan Self Love Narcissism Revisited I am also a professor of psychology in CIAS Center for International Advanced Professional Studies The Outreach Program of the CIAS Consortium of Universities That was long wasn't it Okay Disorders of the self Narcissism borderline can be easily construed As failures of narratives Failures of self stories Now you know my view I don't believe there is such a thing as a unitary Stable immutable self Across the lifespan I believe that people have an assemblage Of self states which respond to and resonate with Environmental stimuli and changes But whichever the case may be Self states, self They have to be organized in a way Which would make sense to the individual They have to be put together somehow According to some script Some story And this story about yourself Who are you? Where are you headed to? What's the meaning of your life? What are your greatest aspirations? What are your hopes? What are your fears? All these put together in a coherent Cohesive framework Is what is known as self narrative In narcissism The narrative breaks down There's a failure of narrative Because the narcissist adopts a story About himself or herself Which has little to do with reality The story is unrealistic It's counterfactual It's fantastic Very often grandiosly fantastic But not only For example, the shared fantasy Is a narrative failure The narrative, the self-narrative Has to be self-efficacious It is intended to help us to survive It has an evolution It is an evolutionary positive adaptation Narratives that divorce us from reality For example, a psychotic narrative Or a narcissistic narrative These narratives are narrative failures It's the same in borderline Borderline we have identity disturbance There is no fixed core There's no identity It's like a cloud A femoral Ever-changing shape-shifting You can't pinpoint Or pin down The borderline There's nobody there In the sense that everybody is there The borderline changes Sometimes within hours Everything about her Including her values And beliefs And hopes And wishes And dreams Everything changes And the borderline Switches between self-states Rapidly cycles To the point that she is not In both narcissism and borderline We have a situation of absence These are disorders of absence The in both of them There's an empty schizoid core Kind of black hole Which does not contain Any continuous contiguous Jointed information Everything it's as if some Improvised explosive device Detonated amidst What should have been a core A kernel of identity And these are narrative failures Now there is something called narrative psychology And there is something called narrative therapy Where we try to fix narratives It's a form of psychotherapy We help patients to identify Values and skills Which are associated with it We provide the patient With some kind of knowledge or ability To experience these values And to exercise these skills In order to confront problems And so the way we do this Is we encourage self-authorship We encourage the patient to co-author With a therapist A new narrative about themselves And the patient does this By investigating the history Of his or her values The continuity of his or her skills Narrative therapy is closely associated With other therapies For example collaborative therapy And person-centered therapy There are several techniques In narrative therapy We start with re-offering identity The narrative therapist Focuses on assisting the patient To create a story about himself I'm going to use the male gender pronoun But of course it applies to women as well So the patient is encouraged To write a story about himself About his identity But the story has to be helpful in some way It has to cope with some issue Or problem or repetition compulsion And the work of this Re-offering one's identity Helps the patients to identify values Skills, knowledge to exercise In order to leave these values And so on so forth The therapist just listens and questions And directs this process of authorship Having identified or having pinned down Or realized the personal history And the values attached to this personal history Now the patient is able to write A new narrative or to co-author a new narrative The problem usually starts when there is a discrepancy Between the narrative that a person tells himself And the stories that other people tell about the person When there is a clash or a conflict or dissonance Between what people say and think about you And what you say and think about yourself This is very common in narcissism And that's why narcissists have a grandiosity defense Grandiosity is a cognitive distortion Intended to uphold a fantasy Intended to prevent a dissonance Between self-narrative and narratives about you From other people And so the story of someone's identity Determines not only who you are At any given moment But also your potential for self-actualization What you believe is possible for yourself In other words, your self-narrative defines your horizon The narrative process allows you to identify values That are important to you Use your skills and integrate your knowledge But it is always focused on unique outcomes It's a phrase coined by Irving Goffman Unique outcomes Expectations or exceptions to the problem That wouldn't be predicted by the problem's narrative or story Whenever we are faced with a problem And I recommend that you watch my previous videos Video about solving dilemmas Whenever you are faced with a problem The problem itself is a narrative And usually embedded in the problem There's some form of catastrophizing The problem actually communicates to you I cannot be solved or you are not good enough to solve me And so rewriting or re-authoring your story Creates unique outcomes In the sense that you find a way to solve the problem You find an exception to the problem's overriding message I am unresolvable Another technique is called externalizing conversation Narrative therapy is about constructing self-narratives But of course a self-narrative is a very important part A very important component of core identity So the approach in narrative therapy Is not to conflate identities with self-narratives And not to mistake problems with identities That is very reminiscent of the way cognitive behavior therapy Treats automatic negative thoughts Automatic negative thoughts are narratives in effect Or mini narratives But the message of automatic negative thoughts is You cannot cope with your problems They're never going to go away Because your problems are who you are Your problems are not just mistakes you have made But they reflect on who you are And so in narrative therapy we teach the patient To separate narrative about who they are Self-story from problems and issues in life Which have to do more with actions choices and decisions Not with who you are The approach seeks to avoid actually The notion that the self is kind of biologically determined That there is something like a true nature Equity and essence that you cannot escape It's a bit deterministic It's a bit fatalistic And narrative therapy is the opposite Of deterministic and fatalistic It tells you you can rewrite yourself You can reinvent yourself You can become someone different Just by sheer willpower imagination and creativity We separate in narrative therapy Identities, self-narratives from problems And we do this by externalizing conversations The process of externalizing Allows people to consider their relationships with their problems And so externalizing focuses on your strengths On your positive attributes And allows you to construct and perform A new preferred identity Which is essentially a kind of positive psychology If you wish And externalizing emphasis is about naming a problem Getting a handle on it So that a person can assess the problem's effects In his or her life Can analyze how the problem operates or works In his or her life And can end the relationship with the problem They can simply choose to disengage from the problem Ignore it in a way Or engage with it in a totally new way From a point of strength Emphasizing assets rather than liabilities And this leads usually to something Which the prominent narrative therapist Michael White Had developed is called a statement of position map The therapist is collaborating with the patient It's a therapeutic posture He doesn't impose ideas on the patient He doesn't give the patient advice He just together with the patient explores The patient's life and history Personal history, autobiography Together they uncover and examine A life unexamined They remember things past to borrow From another Jew, Marcel Proust Michael White developed a conversation map Which by the way is somewhat reminiscent To the map of happiness in cold therapy So he developed a conversation map called A statement of position map It is designed to elicit the client's Own evaluation of the problems And the developments in their life The therapist and the client are perceived as Having some kind of valuable information Relevant to the process And they create together They co-create They're co-creators They co-create the content of their Therapeutic conversation By imbuing it and suffusing it With this valuable information The therapist has valuable information About healing The patient has valuable information About the patient So there's a position There's a position of curiosity The therapist is curious about the patient The patient is curious about what the therapist Might have to say May have to say And they collaborate And there's an implicit message You already have everything you need To transform your life You have all the skills You have all the values You have all the knowledge To solve the problems that you're facing Even if you have identity disturbance You can leverage You can leverage your kaleidoscopic nature You can leverage this instability This constant shape-shifting These are not necessarily liabilities These could be construed and used as assets In a new self-narrative or self-story Which is not deprecatory Not self-critical And does not necessarily adhere Or conform to social mores and so When people develop solutions to their own problems Based on their own values On their traits On their decisions, choices and behavior On their personal history They own the process They become much more committed To implementing these solutions A common practice in narrative therapy Is remembering The therapy identifies identities That are somehow sublimated Identities that are socially conformant Or reflect somehow Or denote social accomplishments and achievements And the practice of remembering Kind of puts together these identities Which are socially condoned It tries to coalesce them To support a person's preferred story About themselves It disengages the identities That do not support the person Again, very reminiscent of how Cognitive behavior therapy deals with Automatic negative thoughts And similarly in Gestalt Michael White was actually Is actually a proponent of Jacques Derrida And he draws on his work White was curious about the values Were implicit in people's pain Sense of failure And actions which are self-destructive And self-defeating What kind of values can motivate these Why would anyone have a value Or set of values Which causes self-destruction Why would anyone seek pain in a way By adopting certain values Where does a sense of failure come from If you do follow your values You should feel great You should feel egocintonic You should feel accomplished Because you have been following your values So why don't you? Why don't you? Why do you feel so bad? Ultimately People feel pain or failure In relation to their values Or how they would prefer their Relationships of life to be These are kind of stalled initiatives That people take in life And they are also guided by implicit values By rendering the hidden text overt The implicit text explicit By doing this We actually bring to awareness Conflicts, dissonances and internal problems Another map in narrative therapy Not that therapy is very big on maps So another map is called the Outsider Witnesses Map It's a, again, everything in narrative therapy Is a conversation between the therapist and the patient This is a narrative practice It's a practice of telling stories to each other Sometimes outsider witnesses are invited As listeners in the consultation It could be other than parents Good friends Enemies Spouses Spouses are enemies Okay, you know what I mean People from the outside So they are brought into the Into the room Into the counseling process And then they They are asked to contribute They are asked to contribute to the weaving Of this yarn Of this quilt To the weaving of this emerging story And it is beautiful, beautiful to behold The narrative process as it gives rise To a totally new identity And self-story Which are much more helpful and beneficial to the client When outsiders are invited To the counseling or consultation room And, by the way, outsiders could be, for example, Other clients of the therapist Who have gone through the process And they have knowledge and experience Of the problem at hand There's no limit or limitation On who is allowed into the room During the consultation And so these people participate And it becomes a community effort Very similar to group therapy, in a way And during the first interview Between the therapist and the patient Even during the first interview Sometimes there's an outsider The outsider listens without commenting It's in order to be seen The outsider's gaze helps the patient See himself or herself through an outsider's gaze Maybe for the first time The patient is really seen The usual protocol for the involvement Of outsiders in narrative therapy Is to instruct them not to criticize the patient Not to evaluate the patient Not to rank the patient or give him over marks And not to make proclamations Opinionated proclamations About what they've just heard Or what they've just seen Outsiders are simply asked to say What phrase or image stood out for them In the narrative Or the newly emergent narrative They ask to follow resonances Between their own life struggles And the problems and issues They have just witnessed The outsider is asked in what ways They may feel a shift in how they experience themselves From when they first entered the room It is intended to demonstrate to the patient That every human interaction creates a shift Every human interaction is an effect Every human interaction hurts or elates Nothing and no one is isolated We're all relational And so any narrative and self-story we may come up with Has to take into account other people The therapist turns to the consulting to the patient The patient has been listening all the while to the outsider And then the therapist turns to him And interviews him about what images or phrases stood out in the conversation just heard And what resonances have struck a chord with the patient So there is a kind of intermediation The therapist becomes a facilitator or a moderator Between the inputs of the outsider and the inputs of the patient And the resonances and interactions between these two inputs In the end An outsider witness conversation is very rewarding It's very rewarding not only for the patient But for the outsider as well The outcomes are often remarkable where the patient is concerned They learn that they are not the only one with this problem for example They acquire new images and knowledge about the problem And they can they choose an alternative direction in life The main aim of narrative therapy is to engage people with their problems By providing them with alternative better or best solutions Which are essentially new self-stories, new identities, new self-narratives And everything is document, everything is written down exactly as an author would do Only this is a process of self-authorship with a guide or a facilitator So the person and the counselor they co-offer certificates There is for example a graduation from the blues certificate About overcoming depression Sometimes case notes are created collaboratively with clients To provide documentation as well as markers of progress I do the same in cold therapy Rewriting who you are is a first step not a last one When you are faced with situations in life Which are intractable, when you feel hopeless When you feel there's nowhere to go When you feel that it is your essence that is compromising your life When you feel that who you are is the problem Then of course you need to change who you are And here's the good news, you have the power to do so Because you are nothing but a dream You are nothing but a storyline You're nothing but a movie or a script or a theater play You can rewrite yourself You are the author of yourself and you are the exclusive author of your own life And people are out there and they can provide you with sufficient input To guide you, calibrate you Even evil people, people with ill intentions They provide you with valuable input They part and parcel of the learning curve and experience It's a teaching moment every moment So trust your ability to become someone else And trust the world to provide you with inputs and feedback Which will keep you on track Which will allow you to gauge whether you are doing the right thing Do not discard anything information or data that comes from the world All these stimuli, all these inputs are critical for your self-betterment Healing or at the very least enhanced self-efficacy in solving problems Gradually you will discover that you do have stable values Even as a borderline Gradually you will find out that reconstructing your narrative has amazing effects Not only on who you are but on what's happening to you And this is true even for narcissists Call therapy is actually a variant of narrative therapy Where we write out grandiosity and replace it with a self-narrative That is realistic and allows for enhanced self-efficacy in interpersonal relationships Thank you for listening