Treatment of the Patient with Narcissistic Personality Disorder by Arthur Freeman, EdD, ScD

well everyone welcome to the New York City CBT Association lecture series my name is Nathan Toma the president-elect of NYC CDT and I am here to introduce art Freeman will be giving tonight's lecture dr. Arthur Freeman is professor in the Department of Behavioral Science at Toro College where he is also the director of the school's graduate program in psychology he holds graduate degrees in science and education from New York University and Columbia University respectively and he earned the Doctor of Science degree from Babis and Bowie University he is past president of both the Association for behavioral and cognitive therapies and the International Association for cognitive psychotherapy he is a distinguished founding fellow of the Academy of cognitive therapy a fellow of the Association for behavioral and cognitive therapies and a fellow of the American Psychological Association in addition to well over 100 journal articles and book chapters dr. Friedman has published over 75 professional books that's a lot of books I have to say including work translated from English into 14 other languages dr. Freeman has been a consistent leader in the application of CBT to the treatment of personality disorders we are deeply honored to have him here this evening to speak on the topic of narcissistic personality disorder so dr. Frieden just to be clear this person lives in Forest Hills big white house on the corner like by the tennis dating thank you for inviting me you know I often start by saying I'm very pleased to be here I'm especially pleased to be here because I have recently moved back to New York after being away from many years I grew up in the Bronx and I moved back to the Bronx and you can take a boy out of the Bronx trying to told you can't take the Bronx out of the boy so when I went to I was living in Chicago people would try to be kind insane to me you know aren't you're so Eastern you mean New York yeah that so I'm especially pleased to be here um I have far more material than we have in our behalf so if you would like a set of the slides right to Lindsay I'll forward her a set of the slides and she'll give you the whole slide set as long as you promise not to start doing workshops with my slide set and put me out of business because they depend on this to pay my rent now here is a question to start it is narcissism a genetic predisposition pack animals like people have an alpha animal to be male or female but have an alpha and the alpha gets no choice of sleeping accommodations choice of mate choice of food so maybe being the special one in the pack is a genetic predisposition so that's something to think about and someday we'll find in our markers for these things now I know what it would look like this would be the one chromosome that's bigger than all the others and you know where to look is it adaptive is there good narcissism can it be functional is it gender related is it developmentally related at a call several weeks ago a director of an adolescent treatment facility said we'd like to invite you here to do a one-day presentation I said oh okay where are you located they told me it's all right when I said the other day is open what topic would you like so we'd like you to talk about treating narcissism and adolescents I said I can't do it it's developmentally appropriate you know young you know toddlers and adolescents are narcissistic it comes to the territory so no I'm not gonna come and talk about doing something that's quite impossible is it age-related is it a cultural characteristic and I'll talk more about that I went to the literature went through a number of books and papers on narcissism I found all of these terms self loving selfish excessive admiration lack of humility an infantile developmental stage erotic self-love lack of empathy uncaring for others vain self-absorbed egotistical conceited doesn't sound very nice this is like a bad thing and when you asked about the guy in Forest Hills the big white house when I lecture out of the country people in South American Europe asked that question is your president and narcissus and contrary to what some people are saying it's against the code of ethics to come up with a diagnosis for someone that I've never examined so you know does he have any of these characteristics may be how much sold with very positive self-esteem would you accept that in lieu of the term narcissistic if you like that they have a very positive self-esteem how many people like that one but basically we have a problem can anyone think of positive synonyms for narcissism well we have called someone special or gifted I don't think of any others a leader okay but not just no no if you say to a narcissist you're competent they'll kill you confident almost but we're hard pressed so we start off with an issue charming a lot of people with Charlie that doesn't make an enormous assist they make a mystery on it they're very charming but the problem we have is we start off with a given narcissism is bad it's negative we might question that not a phone call dr. Freeman I might want to see you for therapy okay who referred you I'd rather not say okay what's your name Alicia I'll meet you what I'd rather not say what reason would you be seeking therapy she said I'd rather not say how can I help I'd rather not say at this point I said then what are we talking about she said I have some questions ah okay you know she wants to ask about insurance my background my experience sure what are your questions okay question number one who wrote I'm kind of not music that's what I said huh let me repeat who wrote I'm planning on sick no I'm not that I do know the answer to that I said I'm sorry I don't understand the reason you're asking me that she said I'll take your lack of response to indicate that you don't know second question what is the current name of the country formerly known as Burma I read about that in the paper I said who is this Denise is that you come on no what is the current name of the country formerly known as Burma I'll take your lack of response to indicate you don't know third question I said you know this is a huge waste of my time third question who painted the screen in example two I said I'm hanging I'll take your lack of response to indicate that you don't know I said she said the answers are Mozart Myanmar and monk I said with the purpose of this and she said I'm incredibly smart and I need a therapist who's smart and you're clearly not the one now what does this prove to me this was incontrovertible evidence that there is a God because now I'll never have to see her and deal with her on a weekly basis and be angry a lot janna got that was it the actual call to bless time and it took my telling about it but for many individuals their narcissism is so obvious it's hard to miss it bite you on the butt for others it's not that clear and we have to do some searching if we look at it from a cognitive behavior perspective two of the main distortions that we see in our citizens are selective abstraction if you remember that you have a body of data and you selectively abstract from that data only certain of the data the data that show that you're brilliant wonderful phenomenal and the idea of or nothing thinking they dichotomize the world it's black or white night or day if you're not the most brilliant than what are you the world's biggest loser so they dichotomize and they constantly scan the environment for evidence of their superiority if they find evidence and so on says you did a good job no really how they do solid average performance this suicidal no I'm not average and this year very proud to say is my 50th year of university teaching and in that time I've had all kinds of experiences about the Fishman is here she remembers the good old days back in Philadelphia the scent of a continent therapy we would get referrals from the law school that dr. Beck's wife was the associate dean and she would send us patients and with these patients they were law students at Penn law now to Kenneth to be one of the hundred and six law students at Penn what did your undergraduate record have to look like average solid C's B's you were number one in your class have swathmore Penn good places and now here there were 105 other law students and they were number three in the class and a suicidal and in fact some were homicidal they wanted to kill off the other two literally talking about how to get them when they're told that they're okay they respond with anger anxiety or over compensation and if they have poor problem-solving ability limited reality testing and lack of empathy it makes it even worse much harder to treat any indication that others are better than they are they're not the best of the best of the they're average they are in fact maybe even less than others they will do everything they can to destroy that offending view they will save you am I the most interesting patient you've ever had what do you say well you pull back on classic psychoanalytic technique you know on them we give them silence and what do you say to them now part of the difficulty is that they're often skill deficient no one's ever taught them the skill of empathy anybody have two kids or more you got two kids how old okay what you think way way way you're way back 31 to 28 three years apart so think back to when one was five make it six the other was three did you ever say to one of the other would you like it if your brother or sister did that to your toys you know how would you like it you teach them empathy for many of the people we see with narcissistic styled they've never learned empathy now the good news is as a psycho-educational approach CBT we can teach empathy that basically none of us can be fully empathic with our patients that they have experiences then we can never and we've never experienced and don't want it I had a schizophrenic patient say to me have you ever had to pull you dinner out of a dumpster then how do you know what I've had to go through the denigration of eating rotten food but we need to teach them empathy right now what's interesting and this is touted as something new in dsm-5 its dimensional rather than just categorical but Beck has talked about the continuity hypothesis forever you know from sad to depressed it's a continuum so some people aren't very mild and it's a style not a disorder it only becomes disorder when it's maladaptive it doesn't work but many people have a narcissistic style usually usually it doesn't interfere with success adaptation or functioning and when it does it's often limited so it says you know get off your high horse stop screwing around or maybe moderate and at times cause conflict or maybe severe the problem is the mild narcissists don't come for therapy so what we're left with on the moderate to chronic that are always in conflict and always unsatisfied with their lives so we can a very a poor version of narcissism bill we these are people we marry these people are friends with and once again we look at a continuum at one end is the altruist the other end is the narcissist and none of us is fully altruistic now there are people who are altruistic I remember my grandmother would come to our house in the Bronx many years ago and she would say to me play the song and there was one record we had that I play over and over again and she'd just sit there and cry and you know what the song was it's called my Yiddish yo mama my Jewish mother and in it the song I was buying out Sophie Tucker it says in water and fire would she run for her children uh she was the true altruist she risked her own life you know if there was food the children got it now for me water is fine so we need to look at narcissism as a continuum now many patients come into therapy saying my problem is low self-esteem how do you raise so and self-esteem what I would contend is you know how much self-esteem do you need if you have too much you know your enormous assist that self-esteem is a process not an endpoint okay you have adequate self-esteem that narcissism interestingly seems to be more of an endpoint than a process that has elements of both but self-esteem is something you go through on a day-to-day basis what will you think of me if now it's interesting the object relations people get leery ins psychodynamic folks see narcissism as compensatory armour talked about the so called superiority Compton I don't think I'm inferior I think I'm better but this is a compensation so the idea for many individuals many therapists is that the narcissist feels so little so unachieved the have to blow themselves up to the size of a Macy's Day Parade balloon to feel good to compensate for feeling little life now for some individuals this is true that the narcissism is compensatory but for others they're good at what they do and maybe they've always been good at what they do they have different set of rules basic rules you may have learned the meek shall inherit the earth they don't buy it you don't blow your own horn why not you don't call attention to yourself now for some individuals that's true but one of my basic schema is the importance of being noticed I think it's really important I'd like to get noticed so people say to me gee you've published so many books how do you do that well I discovered something years ago I'll share this when you publish a book if they put your name on every copy so if you want to get noticed that's a great way to get noticed now as a kid in school I remember assistant principal called me in and said Martha don't you realize that children aren't laughing with you what are they doing they're laughing at you and given that I was a history on the kid who liked being noticed I thought to myself yeah what's your point here now what's your guess am I an Elvis child middle child or youngest child how do you think I'm at and I'm not an only child how many think I'm an eldest child I'm sorry just one you're it how many think I'm a youngest child 1 2 3 4 5 6 7 8 so this I know how many think I'm a middle child well that's the majority why because middle children one of the issues you often see is to talk to get notice so when Lindsay contacted me and said would you be willing to come and speak to our group you know I email back and say well there'll be people there and she said yes I said can I be the class clown and she said yes I said I'll be there and the only thing kept me away was 18 feet of snow otherwise I would have been here in Sweden and Norway there's anyone here Swedish or Norwegian background you wear goes way back yeah I was lecturing him room very much like this very first time I went to Sweden and I stopped I said any questions no questions nobody asks a question is there I said no but I'm OK and this was going on for a couple of days my first time in Sweden and I thought none of them understands English so all they hear is blah blah blah blah blah generally the word I'm talking about but during the coffee break people come over and ask questions so I spoke to my host I said what's going on and she said well we have some rules here Sundin was the basic the state religion in Sweden and Norway is Lutheranism and the basic tenets of Lutheranism is humility so he wrote ten new Commandments and we often think of Swedes and Norwegians as reticent know they have other commandments that most of us don't have - outland presumed there are as good as us you've got to keep your head down they'll shine I presume there aren't more knowledgable if you ask a question in class in Sweden or Norway you're showing off and you're putting the professor down so you're saying the professor wasn't clear enough so you have to ask for more clarity so as a group they are generally more reticent has that been your experience does that explain your whole life yeah and you had to come here to find out but this is very common so when I lectured in Norway or suite not then look they're different I always start the same way I'm very happy to be here in Oslo I have an announcement before I begin I for my hotel room this morning I spoke to the king and he told me to welcome you in his name and to tell you that for the length of my lecture the Optima even is put aside and you want to ask questions and they always laugh and they say to me how do you know about this it's a cultural rule it's a cultural schema that's not shared we know it what we don't talk about it but now you know the name of it now do New Yorkers share these Scandinavian rules and hide your head now they're parts of New York Bronx Staten Island where Scandinavian rules are more prevalent no you often a Bronx you stand up be something the Bronx so we may remember that it's a New Yorkers view of the United States talk about narcissistic if 9th Avenue Jersey and out here some old blue eyes he told us are narcissistic were raised to think we're special I could skip that give me an example I was a guy came in to see me 48 years old MBA from Wharton lived in expensive exclusive suburb of Chicago he was a vice president for a large multinational company outside of Chicago and the mistake he made they offered him a promotion in a large corporation if you turned down a promotion they don't say well just hang out a while we'll have something better if you turn down a promotion you have to leave they don't get a second chance um and he was very depressed because he made a mistake he turned down the promotion he was making $450,000 a year you know many workshops I have to do and the new job paid about 750 to run to be the CEO of their multinational in Canada why did he turn it down not that he did want to go to Canada but he said that's my determined that then he said Canada the only people who are on a Canada 35 million why could they give me China or India even Italy has more people than Canada so the idea of being CEO in Canada was so offensive to him that he has to leave his job everything was on the one I said well is there any way to recovery said no I said well what made you turn it down and he said Canada I said but think of how good it could have been your family wouldn't have to learn a new language says it doesn't matter it was Canada the often will join special groups they see kindred spirits when there's a mutual admiration society that they should only have to relate to special people they belong to the special church they belong to the special Country Club and a very conscious of the external trappings group narcissism is very common this political narcissism you know where the Republican with Democrats with Tea Party religious narcissism our religious better than your religion national narcissism or even Geographic narcissism narcissistic parents what narcissistic children so they don't even try to rein the kid in when the kid comes up with something unrealistic they say we can do it I had a eleven-year-old referred the question was was he on the spectrum and the answer I think was yes and the school a problem with his vocational goals at age 11 he wanted to be a professional baseball manager that he didn't need to go to school he just yeah I read everything there is to know about baseball so why shouldn't I be a manager you know he never played the sport didn't know how to catch the wrong role ground but he knows all the rules and that should be enough and the parents never said to him you know that may not be realistic honey are there other possum we don't want to make him feel bad we don't want to shake his world okay when he said that we can also look at narcissism using the model used for looking at children as internalizing or externalizing narcissism is it focused interpersonally or is it interpersonal the interpersonal or internalizing narcissist has their belief systems and often ends up very isolated but it's important because it will help us structure our therapy Freud's earliest and most important papers on narcissus in 1914 I was important because the idea of ego ideal and super-ego are developed now the idea of ego ideal is really important for us because one of the things that we want to ask the patient and we don't use these terms necessarily but what is their ego idea what is there was the ego ideal is composed of schema what does it you see for yourself what are your goals in life and you're very fortunate here in New York have someone like Bob Lahey who has broken all kinds of rules by using the language and constructs of them and applying them in CBT which I think was great now Freud in the early animus or the narcissism is transitional but for many narcissists it doesn't transition this is who they are we skip this so the narcissist spends huge amount of time looking for a knowledge meant of this specialness and it leaves them empty exhausted and often depressed when the desired positive reaction from others are received I feel great but then it goes away and I need another fix and there's a letdown resembling depression and then they have to go back into a drive state to reacquire what they feel they've lost the view of others that they are truly special now one way to differentiate that the narcissistic loss from depression the depressive has little energy to ease their losses and they suffer silently the narcissist often exhibits incredible energy to re-establish their specialness so they get the energy somewhere it's unusual to get someone coming in saying I'm a narcissist and I'd like to stop they come in because their boss has said to them nobody here wants to work with you you're a jerk or a spouse has said if you don't change when even had a fellow come into my office this was when I was at Penn and offices were furnished with old furniture they put it that way University modern no metal desks things like that and he walked into my office they said four I'm paying you I would assume you'd have a much nicer office now wife's come to see mrs. wife said he had to he's driving a car that he can't afford because it's important for his business to look good and the reason he's come to therapy is he wants to hire me as a consultant to make his accounting practice more successful so in gathering information I say do you ever go out you know take clients out to lunch and he looked at he says why for why don't I want to have a meal with them problem was when he became homicidal he bought the biggest Mercedes they make the real big Mercedes in those days was something like seventy five thousand dollars and he would drive around the neighborhood my neighbor people have been in front of their houses very nice neighborhood he'd say hello to all his neighbors what was he doing showing off his Mercedes and he came in one day and he was furious and borderline homicide one of his neighbor's son of a bastard bought of Bentley you know what color gold and you know what this guy would do he'd ride around the neighborhood waving so my patient talked about how he was gonna kill the guy he was in a park his car in the driveway the rear end facing the street and had the engine on car in reverse and when this guy came abreast of his driveway floor and he went back into the driver's side door and killed this guy and then say terrible accident I meant to go for the brake and I hit the gas so what are you doing a situation like that what's a responsibility I'm say hospitalized him for what but driving his Mercedes he said they'll never convict me I'll get a good lawyer and it's an accident I said I already put it in my notes so I know it won't be an accident he said what I tell you is confidential no not if you're a danger to yourself or others so you would turn me in yes so you've got to find an alternate way of dealing with this but he was ready to kill someone who was making him look less good one of the problems we have the only place to find a pure narcissistic personality is in the pages of DSM or ICD they don't exist in the real world so what I'm going to suggest is that we don't even use the term we have to and to think of the patient is having an arousal spectrum disorder because while narcissus may be the major piece they usually have pieces of a little bit of histrionic little bit of antisocial little bit of borderline so to think of them as arousal spectrum so all the cluster B criteria combine to form this disorder and the best way to look at it because many of the cluster B disorders have similar criteria put them all down and then write them to that patient so you know where to start assess the component parts in order of severity availability for change with a client's motivation to change let's see probably the major issue in terms of diagnosis is that the problems are what our colleagues called ego-syntonic their self consonant didn't have a problem being this way is a good way to be I'm special what's wrong with being special in the words of the immortal Papa oh yeah I'm what I am okay their dramatic emotional erratic they relate to the world in through these lenses but the key for us from a CBT perspective we hear a cognition or behavior we need to immediately think of what schema so here's the behavior what schema get us to that point or they give us a schema and the question is what diagnosis would you come up with for that schema so when I told you about the woman calling me with these questions I don't think many of you had a question on what a diagnosis was we had examples of her behavior and yeah ideas for a scheme would she then made clear I was smarter than most people I need a therapist that's smarter than most people or if you're told a diagnosis it may be self-perpetuating that we know what schema to expect but the key ingredient for therapy is understanding the schema so there are four things that I need to look at temperament what we call genotype behavior the phenotype the environmental context the term I use here is socio type and the personality pattern and style which on the label schema type what in the basic scheme of that individual this is just dsm stuff one of the problems with DSM generally I almost spend much time at this point is that no matter how clear they try to make it it's still incredibly unclear terms like higher than average ideal special envious arrogant what does that mean we really don't have good operational definitions in fact some descriptors are so vague has to be unusable what we find is that the arousal spectrum disorders they're generally true to that cluster I find well he's a little bit schizotypal and a little bit borderline and a little bit dependent know most of us are generally true to us scheme it's a great scene from Alice in Wonderland she reaches the fork in the road as a tree there and the tree is the Cheshire Cat and she's standing in it says oh my which way to go and the cat says what do you want to get to and she says I don't know and the cat says well you're not sure where you going any road may get you there conceptually we've got to be very focused we can't take a round circuitous wandering free associative approach we've got to be much more focused in what we do we have to understand non system is not a unitary phenomena it has many manifestations and these expressions of the narcissistic style may be combined to form a complex pattern so here's what I see is the range of narcissus and this is not in any order or priority or hierarchy number one is positive self-esteem the individual views themselves generally in a positive way so if you say to Michael Jordan were you a great basketball player what what Jordan probably say to you yeah I was he wouldn't say huh was I great I was the greatest now some people say he was the greatest of all time but he'd say yeah sounds pretty good oh yeah I was very good this healthy narcissism we recognize that we're good at something but we don't flaunt it we don't walk around rubbing people's noses in it this group narcissus I mentioned earlier the problem with group narcissism is your special status is lost when you leave that group there's what I call helpful narcissism this is usually your mother-in-law she comes to visit and it's not looked to tell you how to be a better housekeeper a better parent better cook better wife better father so that you see you know I'm really tired honey I'm just trying to be helpful and they really are but what we recognize is they believe that they are the best there is real narcissism these are the individuals who go around rubbing everyone's nose in it that I'm better I'm smarter on bigger I'm stronger compensated narcissism where the whole self is blown up the vengeful narcissist they spend their time getting even for real or imagined slights example I'm seeing a man for therapy he came and he said I don't want to do about this to do about this what happened he got a new boss knew God was hired and his boss invited this fellow and his wife to dinner and the boss fourth gorgeous house sterling silver flatware crystal beautiful dishes and someone to serve the meal and he said and the meal was excellent I said well sounds great no on the way home his wife was furious they were just showing off they wanted to show that they had what we don't they're just rubbing our nose in it but I fixed them he said what did you do the gentleman's a purse and takes out a salad fork she said they used to have service for 12 he says what do I do the boss's wife called and said did you by accident I mean that didn't fall in your cough how dare you intimated that ie your anything I stole it but if what he did but that would be the vengeful narcissus they're gonna get even now can that salad for be replaced what do you think of course if you have all that money to get a new salad fork but that will be the vengeful narcissist you've got a problem you've got a problem with me you don't like it get that the paranoid narcissist is constantly scanning for data that challenges their high regard for themselves the violent narcissists will use anger threats medicine gestures awards intimidation expressions of violence and the psychotic narcissist loses reality who is the fellow who tried to assassinate Reagan John John Hinckley now why did he want to kill the president because Jodie Foster would then fall in love with him that I mean he was that special Jodie Foster makes the practice of being attracted to violent psychotic narcissist how to call woman said I'd like to make an appointment for my son okay I you know I get parents had lessons calling I said how old is your son she said 52 I said have your son call me no no he's under a lot of pressure he's very depressed he's very depressed it's a guy who graduated from Penn when he was 22 for the last 30 years he's lived at home then was a cardiothoracic surgeon made a lot of money let's go a lot of money and he doesn't do anything he's he's retired the something so I said no I won't make an appointment your son has to call me couple minutes later yeah I said who's this my mother told me to call you okay when should I come in Syd will have an opening Wednesday at 3:00 he hangs up we're done he comes in with his mother and she has a file about three inches thick and she hands it to me so what is this she said these are copies of reports from previous therapists and they all end the same way untreatable non-compliant and they had taken him to therapists from Boston to Washington he had seen every major psychiatrist psychologist in that corridor many people who taught me and he's sitting there now the way my office was set up and the patient chair on the side and across I had two chairs in case of crowd came in where does mom sit I guess in the patient chair and he's sitting across the desk and when I asked the question what happens she answers please don't put pressure on it he's so depressed he's been depressed for years I looked at all these reports I said no medication was prescribed for your depression have you ever taken it mom said it's you know I don't take it for a couple of days it doesn't work so he stops and it's not going to go anywhere so I said you've seen a lot of therapists haven't you and all the reports say that you haven't been helped and the first time he looked up made eye contact with me and said do you think you can help me does that sound like a request for help there's a challenge so what do you say to that I said no no you've seen all these great therapists some of them my teachers and if these great therapists couldn't help you I certainly can't something says you're not gonna even try I said no that's unethical you can't do that I said yes I can in fact the code of ethics in psychology says if I don't think I can help someone I shouldn't see them and I don't think I can help you and his mother's crying please dr. Freeman please and he's yelling at me how do I dare not see him he is what I call the helpless narcissist the yes buck patient they often come to therapy with refractory depression low self-esteem but the problem is not their depression the problem is their narcissism typical schema for this individual if I surrender my symptoms I'll be like everyone else if I appear we can help us a strong person will appear I am special my weekly meeting with my special therapist proves that some of the best-known therapists this area failed to cure me I always win so that rather than treating him as depressed I treat him as a narcissist I said I will see you for five sessions we'll set some goals for those five sessions and if you don't meet the goals we stopped he said that's not the way therapy is done okay then I won't see you at all you have two choices want to do it my way or the others to put a sharp stick in your arm which would you prefer I didn't say it that way so he assumed for about six months in five session modules I finally said I'm not going to do any more I said that's fine my mother wants to know if you give her a report for the next therapist very often there on SSI and the reason you can't help them is because we're treating the wrong problem mister review now when we challenge schema anxiety is going to result so when we challenge their view of themselves their world in the future but been called the cognitive triad they could become very anxious so the first thing I want to do with narcissists is teach them and anxiety reduction techniques so when they start to get upset they're able to stay in therapy but we're going to have to work on the schema and there are five possibilities some individuals have schematic paralysis their view of themselves is ossified and nothing you do will bring about change this sucker for others I call schematic rigidity they're very dogmatic change may come but it's going to be pulling teeth for most of us we live in here we know what the schema are the internal rules are clear predictable and we know what to expect schematic flexibility is a create key ingredient in creativity because they believe rules can be bent or changed as needed here and the other end of the continuum what I call schematic instability this schema are chaotic you know I feel so isolated alone I'd love to be close to some so I can feel secure when I get too close to you I feel vulnerable have to move away but then I feel isolated alone so I never know what schema to follow I don't have time for this but this is something we're developing we're developing a questionnaire for this looking at three elements for change motivation skills and abilities and systemic a situation of support now whether or not you need an equal amount of each one or one can compensate for others we have yet to see in our research okay um now magically I gave a DVD to God and if I speak to God she will answer me God can you put on the DVD please hello thank you for being here thank you good relationship one what has been just a few things and I still don't understand why she left me okay it's that the first time that a relationship [Music] [Music] we all that so what we hear immediately are very dependent schemer I'm not capable of living alone and my relationships they keep running away so my first thought is oh this guy sounds really dependent ok let's move on for a long time so your ideas I can't live alone and but the question you have is that like having relationships because we hold it when do you run I'm sorry fight or flight but when do you run you scared you know do we run if those are scared or was scared cause we run but when you run me these women don't just leave him nothing to say abandon him they run from him okay that's one when it happened the first time yes did you wonder at that point what was going on yes but you've got no answer what happened the second time is you wonder to get yes but no answer no one's and now it's a third time yes no it's so one of the things that itself that you want to do is see if you can find that answer to why this happens names problems instead I sometimes I understand that I have some influence of people sometimes I don't know why but people is here I hold it is anyone scared of Alfred you're scared of him at all no okay that's curious not going scared poor guy a little bit scared of them okay let's continue in just a bit aside from the relationship massive problems are there other reasons that bringing the therapy I think that's the main problem because if I don't I don't get didn't answer I don't see and I see how I lived my life he may be suicidal because I can remember a million with my sister for two months because I live alone after my sister convinced me getting some help because I think see any future for myself hopelessness a key ingredient and thinking about maybe I'll be better off when I when I finish it when you tell yourself this is that something that's very active state your job yourself at the moment I will try to give myself another chance when the first relationship program is did you think of ending it better children yes but did you think yourself after the first relationship and maybe I'd be better off dead when the second relationship is yourself because can you stop I'm sorry I missed that what do you say had thoughts of killing her let me ask again anybody scared of this guy now he becomes very spooky is thought of killing his girlfriend something you typically find in a dependent individual no they'll do anything they can do to keep them and I heard him say this uneven oh my god but you know I I can identify with that I have empathy because well my wife left me she took my truck and my dog and my guitar and then did a very successful Country and Western career you don't believe that but I would never think of killing her the mother of my children I would loved each other so much we looked so beautiful at the wedding how could I kill her but I for the thought of killing her let's continue that relationship but are yourself relationships we hold it he's a university graduate he's employed as the night manager of a hotel in downtown Amsterdam he doesn't see anybody the only time you'd see people would be a late check-in or if you need batteries for the TV remote otherwise he would sit in his office behind the front desk phone calls to his girlfriend 15 17 times a night and her job was to wait up for his phone calls because he'd sleep during the day okay you sister as she alter-ego mrs. or to oldest sister are you folks around okay and what do they do what does your father do my father Pesce work doesn't work your mother hold it his mother must be severely debilitated maybe some neuromuscular problem where she doesn't do anything of course it may be a schema about women let's continue nothing at all we begin to see a schema about women to work outside that their value or lack thereof when you were a teenager did you date Jim well the girls yes did you have relationships I spent time alone but you did have dates this did you have a regular girlfriend when was the first time how old were you when you started dating someone as a special person okay can we hold it so it's going to now I didn't know what the culture this was in the thumb of the Netherlands maybe you know you know start dating till twenty three twenty four and they said no thirteen fourteen just like in the US so he's ten years behind the curve of having a real girlfriend and listen carefully to the women he picks let's continue what happened so the next relationship relationship next real relationship you stop see handling about 23 okay let's hold it here afternoon how do we explain that seven years to the next girlfriend how would you explain that okay good good what else waiting is someone good enough now what's a very convenient and again I I think Bob Leahy for doing things like this it was a very interesting psychoanalytic idea it's called the narcissistic injury or the narcissistic insult she did what took him seven years to get back up on that horse and that would be an example of the narcissistic injury can't I mean how could they do this to me it's a very useful idea let's continue and that she had she but she can say why she did what she did no she said this is how he sees it then she saw your intense love s be very possessive yes how did you live with Carlo we relive them what do you get to get them so you stopped seeing quality of about 32 then who is next who's the next one 3530 was counting in Dutch how long you and you live with her hold it they met and that day she moved in with him now what kind of scheme at the she evidence very dependent and the people the kind of woman that Alfred would be attracted to would be someone very dependent who would take his great love or control as Carl called it okay so you're with her all this time what did she say did she say to you anything like heartless at human with too possessive afterwards I have some things [Music] [Music] [Music] the therapists do that the therapist forced someone to break a relationship yeah we do under what condition what's that if you as a therapist save yourself or say to this to sashka if you stay with him he may kill you now the therapist didn't know anything about his threat against Carla but he'll tell you what he did with sashka and the therapist when he was at work had her move out into an abused women shelter and refused to give him her location and he screamed and he came into her office kicking furniture around he says no way never kicked any furniture towards her so I don't know what she was scared about okay let it come back offer to something you said that something about people being stared at a scary way sometimes it's in people that'd be nice in my face sometimes I know but I know about myself and very angry sometimes but you say he was scared you become so angry that you hurt people it's very simple question Alfred yes or no visit guess your numbers with the label please we sister though was scared you were physical with her yes sir that once [Music] okay let's hold hmm she get an idea he's physically violent is anyone not scared of him and what I didn't know at this time they didn't find out for the second session is his girlfriend sashka was pregnant and maybe I'm an old-fashioned kind of guy throwing your pregnant girlfriend to the floor is not nice that's just the kind of guy I am but he has no problem doing that he knew she was pregnant and it's why the therapist said you better get out of there the video goes on and we didn't have time for all of it can I get back to the slides please I'm gonna have let me finish this and a lot of time for questions so with Alfred getting to learn empathy caring being asserted rather than aggressive looking at consequences self-regulation being proactive not always reactive building skills now the typical narcissistic pattern is is a stimulus and we respond the ideal pattern is is a stimulus and a response but the more of these pieces we can interpose the better functioning we're going to get the use of mindfulness being aware of what you're experiencing being aware of what's around you recognizing the schema problem-solving what am I going to do about this making a decision and then responding Alfred goes from here to here I was asking her a question she wouldn't give me an answer so I threw it to the floor and he stopped for a moment she might still be there and later in the session I asked him about that and he is unyielding about that I said you know how much of your love would you have to dial back he said how much love would sashka be able to take and he said 65% I said would you be willing to dial back the 65% he said no I wonder why she doesn't want the hundred-percent well maybe she's scared she needs to take a hundred okay basically we're dealing with very narrow schema or very luminous scheme ideally ideally what we have to think about is enlarging the schema giving him more room within which to move just want to cover one more thing patient comes in we say here's what you look like but after cognitive therapy boy are you gonna look different it's not what happens with the narcissist if we can knock the sharp corners off so they're easier to live with we'll have done them a huge favor now the question we have is how are we going to do that and the easiest way to show that is how severe is the problem the greater the from the greatest severity the greater the preponderance on behavior award the less severe the greater the preponderance of cognitive work so without ffred what are we going to be doing more cognitive or behavioral be well behavioral he's bright he's articulate but I wouldn't want to do that we've now again never goes down to zero but most of what I'm going to do without for it is working on behavioral interventions okay what we want to do is sit out a problem list what patients come in with our list of complaints not problems so our first job is to turn these complaints into a problem list and then figure out how we're going to help them reduce that problem list by q1 for another several hours but people are yawning so take that as a subtle cue and Lindsay told me you only had an hour and a half and then we'll have time for questions so I've done an hour in 29 minutes I don't want to push it so I'm gonna stop here and ask has there any questions you had a question sir without ffred yeah I don't well he doesn't fully meet criteria for any of these I'm gonna again I'm gonna cop out and say arousal spectrum he's got antisocial features he's got borderline features he's most of what he has is his narcissistic features you must take everything I give you so I think that's the major element though I think they're elements of all the others yes little louder there was no now what let me tell you Alfred's not a patient he's a professional actor you know that yeah that he they the hospital use a simulated patient process that they trained this professional actor to play various diagnoses to train the psychiatric residence he's very good he watched videos of the real Alfred and there was no evidence of any neurological issues I think the tics the movements are much more psychogenic than neurogenic questions coming I'd like to find a DBT group form because the DBT group his skills focused how many friends does he have how many human contacts does he have none and he says he doesn't much care for them i i'd like to seem in a group that can give him some support because he has no support other than his sister in the second session he tells me that his sister has thrown him out that he was living with her his sister her two children and her husband and coming home one night drunk he fell down the stairs in our home woke up the kids woke up his sister and brother-in-law as brother i said you're a drunk i don't want you in the house my kids are crying and he says you promised I could stay here the brother-in-law said give me the key I don't want you here it was very indignant in the session I said let me see wait get this clear your sister is more concerned about our children that about you and he said exactly but why would why would we be surprised he said she promised me I could stay here and now she's more concerned about her precious family than me and the second session I asked him I said if you met another woman tomorrow would you still be suicidal over sashka he said no I must admit where I got that idea was from an old song that you probably all sang at camp Oh My Darling Clementine how I missed her how I missed her how I missed my Clementine how I missed her I met her sister I don't miss my Clementine so if he met another woman tomorrow he'd be as good as could be as long as she take now we put him on eHarmony or match.com or DD Dutch day we put him on some no website narcissistic forty year old University graduate very controlling and demanding would like woman willing to accept all of his loving control do you think there any women who would answer that head yes or no no I got a shiny nickel up at the whole thing that they'd be people would respond to that you probably have them in your practice now questions one two highly successful we want to change that he has a choice but the question is what's his motivation to change it I did a series of workshops many years ago and I called it's for executives like that it's called changing what you do without changing you are they don't want to change where they are unsuccessful because of what I do now you want me to be just like any jerk I don't want to be that so the biggest issue we have with that individual is how to make a small change to knock off one of those corners and see what effect it has it's really therapeutic experiments yes sir nice and loud the old men's death sorry I was wondering if you could talk a little bit more about ego idea and its role in this kind of rigidity we all build an ego idea you know what we want to look like the first course I took in graduate school at NYU in 1964 the instructor teaching the course was a felon of claude grant visiting professor from youth I remember he would wear tweed jackets button-down collar shirts striped eyes and funny and he you know had crew-cut which was appropriate in those days and I thought boy if I ever become a psychologist that's what I want to look like and I've got tweed jackets no difference is I can never do the patches used to have patches on the elbows we all build this ego ideal the narcissist built and he going feel like everybody else but in it then the center of attraction Family Therapist Florence a daughter was president of APA I remember she does a an interesting thing she does what she calls a projective genogram says draw a picture of your family structure and she wants to see where they start they start to grandparents parents where do they start with themselves north system we start with themselves and the world circles around them so I asked you know what is your ideal of the perfect life and I you and started asking about this guy in Forest Hills and the big white house he has idea of a perfect life where he has the best the most the biggest of everything and anything that is at variance with that idea is unacceptable and he surrounds himself with people who say yes Mike you're the best yes Mike you're the best and they are until somebody else becomes the bestest best questions comment yes there are a couple of people I wouldn't put in groups narcissists I generally would not because they tend to overwhelm the group intimidate the group yawen for example will not put suicidal patients in a group because he says their suicidality itself is so self focused so narcissistic they take up they suck the air out of the group they take all the energy out of the group so I'm not real keen to put narcissism groups even with other narcissus it never concluded cause alfred was an exemplar i saw him twice he was seen by a number of therapists so he was interviewed by marsha linehan by kernberg by a number of mostly psycho I want to submit Benjamin so a number of people interviewed him and he always as an actor gave us a fresh patient yeah and I don't know what the outcome was with the real outfit they never gave me that told me it with the real Alfred on they didn't do anything behavioral because the hospital the director of the hospital was president of the Dutch psychoanalytic Association so everything they did was psychoanalytic what I would have done is asked a very simple question would you like to get more of what you want because they go through life people trying to knock them down a peg or two so I say you know I'd like to help you get more of what you want would that be okay with you example had a patient come in he was referred by the federal probation office requirements were then he had to come in once a week for a year that's the condition of his probation and I he walked into the office with five minutes left to the session he said hey Doc how are ya just check it in I'll see in a year that's not the deal you have to come in every week they don't make you do that and try to convince me that make you come to therapy was a violation of the first 993 112th amendments to the Constitution I told them this may be true and no being merely a psychologist not a constitutional scholar this will have to go to the Supreme Court in the meantime he has to go back to jail well for the first two or three sessions he didn't say a word he just sat there and read either magazine or newspaper so what am I going to do so I thought let me deal with him schematically like I teach so he came in and he sat down took out a newspaper I said you know I was thinking about you over the week that kind of attention he looked up I said I was thinking out wr's he said I'd like a punch in the face that's why I don't want to punch in the face but I was still thinking I'd dumb you hard it's a stupid that's different than dumb he said what makes you so smart it's a no-no I didn't say I was smart I said you were dumb he said what makes me dumb I said I charge $100 an hour you can see me for free see those books on the shelf whose name is on all the books that you I said yeah so I'm an expert on changing behavior is there any one's behavior you'd like to change says you could change people's behavior I said yeah whose behavior you don't want to change so my girlfriend okay tell me her name and now he's give me all kinds of data sitting and what would you like to change well she's a lazy then what makes you a lazy well she never cooks and she's not sexually available those are not his exact words but you know she's not available can you make her I said of course and he said how you gonna do that I said well let's in company oh how old is she if you ever hit her oh no I wouldn't do that that's as bad stuff I don't do that I said you insult her he said yeah or lazy okay let's make on a plan if you ever buy her gifts what do you mean it's a precedence he said you mean like birthday Christmas I said yeah no I said what would happen if you did but four it's a scientific experiment what would she like she loves flowers all right what would happen if you came home today with flowers for her or what happened here no I said would you be willing to do an experiment so I enlisted him as a coach scientists came the next week no magazine no newspaper I said well how did it go he says fantastic on his way home he stole some flowers we did he said he was walking along by some time and they had you know flowers by a fence line they just pulled down flowers he came home and he said here for you she's what's this for is it I know you like flowers oh honey and they got smoochy and she became available and after she was finished being available you know what she said to him you're hungry I said so why join he says so all I got to do is be nice to her now you say well so you make him a better psychopath no I'm making like the rest of us if you are nice to someone they may reciprocate and then I taught him how to get over on his parole is probation officer now to get over on your probation officer show up on time in fact 10 minutes early I know I'm early is that you know mountain the waiting and you only have to come every other week so I could help him think of how not to piss people off because he was an interpersonal problem person say again yeah anything else questions comment contact Lindsey and she'll give you a copy of the slide set and all the things that we did enough time for if you're interested in the full video of Alfred you can contact victory album at a psychotherapy dotnet and they've got three videos about for me Marsha Linehan and Otto Kerner it's really interesting to see the difference thank you very much for inviting me [Applause] [Music] [Music] [Laughter] so I think I could just send them out to whoever was registered that way

Channel: NYC CBT

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Id: 3JCd32GQoas

Length: 108min 26sec (6506 seconds)

Published: Sat Jun 02 2018