Understanding Borderline Personality Disorder and Narcissism - with Dr. Frank Yeomans

foreign [Music] s and I'm here to give you an idea of what transference focused Psychotherapy is we refer to that as tfp transference focused Psychotherapy is one of the evidenced-based treatments for personality disorders the evidence base is specifically for borderline personality disorder but the application of tfp extends to the other major personality disorders including narcissistic personality disorder which is what our most recent book was about and is it seems an increasing problem both in our patient population and in society in general what does tfp offer and how does it differ from some of the other approaches when we think in the tfp world about personality and personality pathology our focus is first and foremost on one's sense of identity and we think about identity at the deepest level how is one in touch with and how does one combine one's emotional states and we talk about the desirability of emotional integration and yet what we find in people with personality disorders is fragmentation or splitting that different emotional states are very segregated in the individual's mind they don't come together they don't form a coherent whole they don't form a solid stable sense of self so one is always sort of torn between different emotional states that take over at one point or another and determine how the patient feels about himself and about the other person involved in whatever kind of interaction he has I'd like to refer briefly to what we call object relations Theory which is the branch of psychoanalytic theory that we base our ideas upon and in this Theory what is proposed is that an individual's sense of self and of others comes from the internalization in the course of development of key experiences emotionally affectively charged experience that become embedded as memory traces and then become paradigms or models for how one interprets or perceives experiences in life as one proceeds through life the idea is that if psychological development is successful the Mind puts together these multiple experiences of self and other and combines them into complex rich representations that have depth and uh correspond to the complexity of life but for the various reasons some people do not achieve this integration and some people do not get to the sense of complexity and they remain with a mind that is populated by superficial and two-dimensional images of self and others that are activated at different times by trigger events to be perfectly accurate about this model of the Mind I've described it as a developmental process but we should also realize that even somebody who has achieved the more healthy integrated state if they are under stress they might regress or revert to the fragmented State and we can talk about that a little bit later because it's relevant to our own functioning and how people function especially in groups and it has political implications but let me get back to our main topic our main topic is the patient how to understand him or her and how to help them I find it useful to think in terms of one's internal world the world that one has in one's mind the images that populate that world and how that connects or doesn't connect successfully to external reality the complexity of the world around us that was the title of one of the first books by the originator of transference focused Psychotherapy Otto kernberg internal world and external reality so I'd like to give you a couple of examples of how one might see the Gap that could exist between a person's internal world and the more objective external reality as I'm saying this I have to acknowledge that I don't think any of us has a perfectly objective grasp of external reality we're always reading a little bit into what's happening the question is if we read too much into it then we're not perceiving things accurately so I want to go back to a story about the first patient I treated in Psychotherapy after I finished my training as a psychiatrist and he was a middle-aged well 35 or so year old I guess that's middle age um man who had a combination of borderline and narcissistic personalities he could not get close to anyone comfortably he managed to function at work but he didn't have any close friends he didn't have a partner he was depressed a lot of the time and he was angry a lot of the time discontent angry blaming others for his unhappiness and I got used to a pattern in the Psychotherapy sessions where he would come in be angry and critical of me as it's very common with narcissistic patients finding fault and of course I'm sure my work wasn't perfect but his emphasis was on everything negative in this context after a couple of months he told me a story of something that happened to him when he was a child that was extremely sad it was hard for me to picture this child experiencing what he was describing and even though it's not my usual practice as a therapist it brought tears to my eyes sometimes that happens it's rare but that's what went on in this instance that was the trigger event so the man looked at me and said you have tears in your eyes and I said yes I simply wanted to acknowledge what he was observing then he looked at me really closely he kind of scrutinized me and he said you're mocking me and that's when I decided this was the way to proceed with helping patients if my patient could take what I thought was a hundred percent evidence of empathy and sympathy and because of an image in his mind that was so different from the external reality he could turn the external event into its opposite I said to myself I think we can help patients by helping them understand what they bring to a situation that doesn't correspond to the situation so let's get back to tfp tfp starts by carefully evaluating the patient because we have to know who we're dealing with I mean sometimes patients come with depression and it's a depression Sometimes they come with difficulty managing emotions and it's bipolar disorder you have to do a full assessment I'm emphasizing that because I don't think that enough therapists do that anyway once you have established that your patient has the kind of personality disorder that tfp is meant to help with we describe our impression to the patient it's very clear now that the patient should know about the diagnosis and how we understand it so that's the next step after the evaluation and then we go from there into the establishment of the conditions of treatment or the treatment frame and we call that part treatment Contracting therapy hasn't begun yet we have to evaluate we have to discuss our impression and we have to set up the frame before we actually begin the therapy and in the series of videos you may see if you watch what we've done here in uh sciflix we try to go through that process and then enter into the therapy when you have the frame set up we have a situation where the therapist is relatively neutral now that term is often misunderstood often people think oh a neutral therapist is a cold on caring therapist who never expresses any emotion that's not what we've been by neutrality what we mean by neutrality is seeing what the conflicts are within the patient letting those conflicts unfold and not taking sides with one or the other part of the conflict a patient might think you know I want to continue the relationship with this guy or I want to break up with him if you're just a friend of that person you might say well everything you've told me suggests it would be better to stay with him or be better to break up if you're the therapist in this model you think you're going to help more by helping the person solve the problem and find the means within themselves to solve the problem so neutrality is simply by say the patient might say to me what do you think should I break up with John and my response would be you know I could give you my answer and that might help you in the short term or it might not but actually I think I could help you more by looking at what makes it difficult for you to come to your own decision your own conclusion about that when we start the therapy we explain that it's a psychoanalytically based therapy sometimes referred to as a psychodynamic therapy what does that term mean the term psyche in Greek means the mind and dynamic of course means in motion so what we're dealing with in our patients and we of course have something similar in ourselves our minds are always in motion people have wishes and desires they have fears and anxieties they want to do something they're afraid about doing it they think they'll get into trouble if they do it so ultimately our goal is to help the person see all of that Dynamic movement in their mind how that leads to conflicts and how they might better understand and resolve those conflicts so we make it clear from the beginning that our work is to help further understanding to help the patient get to know things about himself that he's not aware of we make it clear that the lack of awareness isn't simply lack of knowledge it's not simply ignorance of those things it's because those things are difficult to know sometimes painful to know so let me get back to basic object relations Theory our understanding of the development of the mind is that in early childhood infancy in early childhood there are strong wishes that go in true directions there are wishes to attach and get connected and have warm loving relationships but there are also aggressive wishes and impulses you might say to me why would people feel aggressive it's nicer just to feel connected well think about it the infant is subject to lovely pleasurable experiences when their needs and desires are satisfied then there's a warm Loving Feeling but in every development and it's a good thing for this because otherwise the person wouldn't be prepared for reality there are moments of disappointment and frustration when you have a pain that is not being attended to a desire that's not being responded to in early development the developing child doesn't understand if you just be patient the person who helped you a little while ago might come back to help you again you haven't combined the images of the helping person and the non-helping person and the non-helping person is not simply experiences not helping you because of the Primitive way the mind is working at that point the non-helping person is seen as a persecutor somebody who's causing the pain and that's where the aggressive drives come from you want to orient yourself toward the source of satisfaction with loving feelings and you want to fight against the imagined source of painful feelings so every individual in their lifetime has to deal with the struggle in their mind between loving feelings and aggressive hateful feelings if we develop successfully we combine those and we appreciate others in all of their complexity they can be wonderful to us they can frustrate us we appreciate ourselves and our complexity we can love we can be angry we can sometimes even hate but let's talk about the person who has not achieved that integration they're left with a mind with strong loving feelings and strong aggressive feelings those aggressive feelings are not comfortable to experience so that organization of the Mind where the radical split between the positive and the negative is what a psychoanalyst named Melanie Klein called the paranoid schizoid position it's called schizoid because it's split it's called paranoid because the person experiencing the aggression is not comfortable owning it and seeing it as coming from them they seem to see all the aggression as from the outside so they can't feel comfortable in the world they see people as a threat people are going to hurt them or abandon them let me give you an example one of my patients and I had information about this event her husband had forgotten their wedding anniversary she got really angry at him and she picked up the television and threw it across the room at him I knew that because the husband had left a phone message for me saying doctor what should I do my my wife got really angry I forgot our anniversary and she threw the TV at me anyway let's get to the session my patient comes in and says doctor can you believe I've told you how insensitive and awful my husband is can you believe he forgot our wedding anniversary he knows how much that matters to me you know he should have been aware how hurtful that would be to me that he forgot it I said well I do understand that but I also understand that you through the television at him what are your thoughts about that and she said what what else could I do I was upset this is an example of the person who is feeling aggressive and acting aggressive but doesn't register it consciously as aggression she was just discharging an emotion that's what we call acting out acting out isn't just misbehaving it's putting a feeling into action when it's too intolerable to experience so when we proceed in our work with the patient we're going to experience extremely different states sometimes the patient feels really good with us sometimes the patient feels really awful with us sometimes the patient thinks we're mocking them even when we might not be well I would say we never are I hope no therapists ever marks a patient so my job getting back to the first example was not to convince the man that I wasn't mocking him because his feeling is too intense I could say to him please trust me I wasn't mocking you I was sympathizing with you when somebody is feeling something as intensively as he was my reassurance wouldn't go very far so we do something and this is where it comes to the transference we enter into the transference what is the transference it's the transference of what's in the person's mind onto the experience they're having in the external world so he was transferring a critical sadistic image from within his mind onto me seeing it is outside of him and not seeing it as part of his internal world so the difficulty with this man as with most of our patients is he didn't have any of awareness of his own capacity to be angry aggressive sometimes hateful and hostile always seeing it in the other that's why this sad individual couldn't get close to people he was always seeing that unacknowledged part of him in the other so our task over time is to help the person get to know better all that is within them emotionally I'll make reference just to one more patient and then I'll begin to wind up the talk this was this next example was a young woman around 23 years old in most instances she was very nice young woman she had a lot of things going for her but unfortunately and conceivably tragically she had made a number of suicide attempts so in a therapy session with me I was trying to help her understand what was going on inside of her I was curious about it I was doing what we call clarification just let me know more about what's going on in your mind and she banged her fist on the chair she was sitting in and she said you know I'd rather be dead than think I have anything in common with that horrible abusive Father of Mine and I said to her you just summarized your problem very well you'd rather be dead than think you have anything in common with him it's almost inevitable we have something in common with him because we all have Angry feelings some of the time we all have aggressive feelings some of the time but what you just said is that if you have any trace of any of those feelings then you feel you're totally defined by them you're totally overwhelmed by them and you'd rather end your life than to get to know those feelings within you it's very likely well let me put it this way it's very unlikely that you would ever have those feelings to the extent you describe them in your father but you're so uncomfortable with the slightest bit of that kind of feeling that once it emerges in you rather than feel it and get to know it you make a suicide attempt to turn it off so our goal would be to try to get in touch with things in you that are extremely painful and hard to tolerate and I just wanna sort of ask once again if if you want to do this kind of work with me I realize it's painful I realize it's difficult but I don't know any other way to help you not just get beyond your self-destructive behaviors but live in a way that allows you to feel more at peace with yourself and more comfortable with others so just to summarize we go through a process that goes from clarifying what the patient feels to confronting what seems inconsistent or discordant within them through things that don't add up being curious about that which leads us then to be able to interpret motivations for these different appearances and ways of feelings that they can have from one moment to another and once the person becomes more aware of the motivation that keeps these extreme feelings in them split off from one another they can begin to put them together they can they can begin to experience themselves with more complexity they can appreciate the richness of their emotional world and they can appreciate the richness of the other people in their lives and we feel at that point we've done our job and they can usually find satisfaction in a relationship or a range of relationships in a productive activity in life and they get beyond the radical Extreme Ways of feeling that have led to such discontinuity and pain in their lives so that's a brief explanation of transference focused therapy and how we try to help our patients using it [Music]

Channel: Psyflix

Views: 71,113

Keywords: psychotherapy, psychology, therapy, borderline, narcissism, borderlinepersonalitydisorder, psyflix

Id: _WsEjccAc1U

Length: 22min 14sec (1334 seconds)

Published: Thu Jul 27 2023