Good afternoon, everyone. I'm Dr. David Stifler. On behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar, the third in our monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with the Oregon Health and Science University and the University of California at San Diego. We're excited you could join us today and to offer you these live trainings that will be held the second Wednesday of each month from 5.30 to 7 p.m. Eastern time. Our next presentation will be Wednesday, November 9th by Dr. Lisa Najavitz titled Seeking Safety and Beyond. Please check the AAAP website for updates on other upcoming speakers. A few housekeeping items before we begin the session. Please feel free to ask questions anytime during the presentation by clicking the questions button in the lower portion of your control panel and typing in your question. We will reserve 10 to 15 minutes at the end of the presentation for questions and answers. You can also contribute to the chat box during the talk for ongoing discussion if you would like. After the session, you can claim credit by logging into your AAAP account and accessing this course. Please complete the evaluation and follow the prompts provided to claim credit. And I'm Chris Blazes from OHSU. I'm the other course director and I'm excited to introduce Dr. Ramani Dravasala. She's a licensed clinical psychologist in Los Angeles, California, professor emerita of psychology at California State University in Los Angeles and the founder and CEO of Luna Education, Training and Consulting. Her academic research was focused on the impact of personality and personality disorders on health and behavior. She's an author of multiple books, including Should I Stay or Should I Go? Surviving a Relationship with a Narcissist and Don't You Know Who I Am? How to Stay Sane in the Era of Narcissism, Entitlement and Inactivity. Her work has been featured at South by Southwest, TED Talks, MedCircle, Red Table Talk, The Today Show and Investigation Discovery. And she's spoken around the world on the impact of narcissism on mental health, relationships and the workplace. She also operates a popular YouTube channel and podcast, Navigating Narcissism. Dr. Dravasala is also working with PESI on the development of an educational program on working with clients experiencing the fallout of narcissistic relationships. And narcissism is certainly a topic that we see so much in the world of addiction. And I'm grateful that you came to speak with us today, Dr. Dravasala. Thank you so much. Thank you to the American Academy of Addiction Psychiatry for hosting this, to Dr. Blazes for initially reaching out and to all of you for actually wanting to hear this because you're gonna feel kind of sort of depressed afterwards because it can feel hopeless, but hopefully we can infuse you with a little hope. So again, thank you for the introduction as well. I'm gonna, as always, I think we have to have these sort of standard disclosure statements and all of that. So I'm not glossing over anything big here, the things you already know. So let's go right to the elephant in the room. Anybody working, I think in any clinical setting, outpatient, inpatient, and certainly in addiction medicine, the antagonism of clients is the thing that often stops us in our tracks. It is, and again, this is not just restricted to the addiction space. So what has happened is in many ways, we just sort of said, okay, like maybe we can just sort of work around this, but that's a problem because in trying to work around these kinds of personality styles, it's almost a setup to fail because by acknowledging and integrating how these personality dynamics play a role in relapse prevention, treatment engagement, comorbid symptomatology and disorders is absolutely essential. And personality has long been given the cheap seats in our understanding of psychopathology, which is a huge mistake because I think that anecdotally, any of you will reflect back and say, yeah, some of the most complex, problematic, potentially even dangerous cases that had come up involved these personality issues, and yet we're not talking about it. And so today we'll just at least acknowledge that the elephant's in the room and hopefully have a better understanding of how instead of trying to work around the elephant, maybe kind of trying to cooperate with it for a little while. I'm gonna start simply, we have to start integrating personality into treatment planning. It's almost like there's no line in the EHR for this, but there almost needs to be because we don't account for it. And when you really think about it, even go to your own personal lives of familial relationships you might have had or intimate relationships or workplace relationships. Think about how influential personality is on the quality of those relationships. Think about traditional outpatient therapy you've done and how central a role that had. But it's really, really important when we think about addiction medicine and addiction treatment. It matters for so many reasons. Above all else is relapse. And we're gonna talk a little bit about the thin skin sort of poor frustration tolerance we see in people with these personality styles. It clearly impairs interpersonal functioning. It undercuts what we traditionally think of resilience, which is a strength characteristic we need to harness in individuals where we're trying to maintain sobriety. It has a lot to do with treatment engagement. If you're dreading seeing them, as much as we may not bring up dear old Dr. Freud, it's definitely gonna impact like even how we show up. And so engagement's hard on both sides. And obviously it also impacts emotional regulation, which again, is not only gonna be associated with poor outcomes in treatment, it's going to wreak havoc, for example, in group work, and it's going to create problems in the actual therapy, in the actual treatment. But let's focus specifically on narcissism. And people say, how did you even get into this? And I guess my question to everyone is how did we not all get into this? Because this has always been what has flummoxed us in doing this work. My own mentor in graduate school and postdoc said to me, oh, no, no, no, you're destroying your career, don't do this. I said, no, no, no, this seems like the important issue to take on. I mean, you'll notice I'm no longer in academia, so maybe it wasn't the best choice for me. But I do think that in terms of clinician training, it's been absolutely crucial. But why is it so important to consider this when we're working with individuals who are living with substance use disorders? It helps us understand much more clearly the motivations for substance use, maybe even some of the reasons for initiation of substance use, what maintains it, what makes it so complicated to do any form of assessment with these clients? As I said, we don't bring personality into the room, we don't think about it. Obviously, initiation of treatment, engagement in treatment, and above all, retention in treatment, long-term maintenance of sobriety. The impact, however, the two sets of impacts we don't always account for is how do people with these personalities affect treatment teams? And treatment teams are very diverse from people who are doing a lot of frontline work who often don't have a lot of elaborate training in psychopathology all the way up to senior attendings who don't have a lot of training, at least in personality disorders. And so, but the impacts on this is this can actually wreak havoc in treatment teams. You'll see a lot of triangulation and chaos and frustration and above all else, burnout. And then we also have to account for, and this is the focus of my work is very much on how narcissism affects people's partners, people's family members, because those are often supports that are harnessed in the sort of maintenance of sobriety. And if you often don't have that because these people are so burned out that they don't know which way is up, not to mention they're looking to you to be the miracle worker. They're thinking, oh, this is all addiction. This is because they're drinking too much. This is because they're using. And once my family member becomes sober, everything's going to be great. Let me tell you this, they're not pleased when that person comes home from rehab or long-term treatment or ongoing treatment and is still lacking empathy, is entitled and grandiose and abusive. And understanding that, that sobriety is not going to shift those personality characteristics. And so sometimes when you're doing sort of family group work you're going to see like, hey, wait a minute, this person is actually just as difficult. In fact, they may be more difficult now because they don't even have the, whatever effect the substances we're having on them, they don't even have that anymore. We have to account for clinician burnout. If I had to, if I, I mean, again, we don't have good data on this, but clinician burnout is high when you're working with these populations. Treatment resistance is also quite high. We see much, much higher likelihood of treatment dropout. And since most treatment isn't mandated treatment, it is not unusual in these clients to see sort of early departure from long-term residential care. You'll see dropout from outpatient care. So your risks of relapse increase. There are also a lot of shame dynamics present. And so the shame dynamics make it a lot harder unless you know what you're looking at. And that's part of the issue is that understanding how much shame is playing an issue, how sort of knowledge of their history of addiction or substance use or substance use disorder could affect their sort of social world or their professional world. And then the deeper shame dynamics associated with narcissism. Again, like I said, the triangulation and treatment teams and also blockages in the 12-step process. 12-step is actually not well set up to manage this. Some of the steps are actually in, you know, almost a complete direct variance with exactly the kinds of issues that are raised by these kinds of personality styles. And we'll get to that too. What is striking to me and has always been striking to me about this since I was doing research at the university level, since I have been writing books about this, working with clinicians, is actually how little research there is specifically on narcissism and substance use disorders. There's actually a relatively robust literature about antisocial personality disorder slash psychopathy and borderline personality and substance use and substance use disorders, far, far less when it comes to narcissism. And I think that those sort of, the noise of those and the clinical demand of borderline and antisocial personality disorders actually interestingly kind of quiet down some of what we look at in narcissism, which is a mistake. And I'm also gonna talk about how we probably shouldn't be chopping up this pie into pieces, but kind of viewing it all together. And we do see that persistent alcohol dependence is associated with narcissistic personality disorder. And this is a by-product of a very large epidemiological studies. This is not small sample research. Whereas borderline and antisocial personality were associated much more consistently with just about everything, alcohol, cannabis, nicotine use, which is what they were looking at in this study. But we don't have the data, which is another reason why I think we don't always take this on. So I'm just gonna very briefly present a case. This is a case actually I even talked with Dr. Blazes about just to sort of orient us to some of the issues. 68 year old white male, very successful, largely retired, had tremendous financial success in his chosen field, was currently married and he presented at therapy. Before he even sat down in the seat, he's like, let's see if you can fix me, doc, I'm a narcissist. So there was a lot of swagger and arrogance coming in the room. He had an extramarital affair, which he was very transparent about from session one. And he was having turmoil, not only in his marriage, but also in the extramarital affair. What was interesting was he was 30 plus years sober. So he was very, very committed to sobriety. He had had a 15 year history of substance use disorders, polysubstance use, and had numerous personal and even legal crises because of this. He was very, very adherent to his 12 step work and punctuated throughout the sessions as I'm working my program, I'm working my program all the time, but there was also, and he was very committed to sobriety. He probably went to about four meetings a week. During the course of therapy, given a lot of the marital issues and relational issues raised, he then started attending SLAA meetings. And so that he added that to sort of his, his sort of spectrum of 12 step meetings he was attending. So at that point, he was going to six different meetings a week, four AA meetings and two of the SLAA meetings. Therapy with him would be, it would be a game of a bit of cat and mouse. There'd be moments when I was very idealized and aren't you brilliant, to moments when he was poking me and almost really sort of trying to break my resolve. But through the work, he actually wanted to address the narcissism. We talk a lot about mindfulness. We got to the core and the origins and the shame origins and all of that. We worked together in total 18 months. As we were coming towards the end of the therapy, lots of volatility between the, the wife, because of the wife and having the extramarital affair, they didn't have contact with each other. And it really kept coming back to this idea of maintaining, it's almost this work in mentalization. Can you understand why your girlfriend is hurt? Are you able to understand the issue that has come up with your wife? And the wife was also very, very narcissistic. And so it was, it got very messy. And we kept coming back to this idea of, can you put yourself in that situation? Can you hold space for someone else's emotional state? In essence, trying to build up the empathy and the self-reflective capacity. He came into therapy one day, again, about 18 months in. And he says to me, I'm very clear on what you're telling me. In order for my relationships to be successful, I have to bring them the kind of focus I've brought to my sobriety, which is I've got to do the work, go to my meetings, be very clear that I am never going to do this again, And he was very honest. He was open in therapy. He's like 30 years sober, and there's not a day I don't think about using. Makes sense. And so he said, so you're telling me I have to be present with their emotions. I have to be aware of their emotions. I have to hold space for their emotions. I have to be empathic with their emotions. And I have to do this anytime I'm with them. I'm like, well, yeah, I'm just basically saying you have to be empathic. Like you have to be self-aware with them. You have to hear them and validate their experience with you. And he said, okay, I'd like to take next week off and I'll see you in two weeks. Okay. So he comes back two weeks later and he's like, I just want to let you know I filed for divorce and I broke up with my girlfriend. And I said, okay, all right. So talk to me about that. And he said, I can't do this. He said, I have absolutely no interest in their inner worlds. I mean, he said, yeah, sure. I like the window dressing. And I sometimes like having someone to go to dinner with and I like the sex, but I'm not interested in the rest of this. However, I can see very clearly after our work together how much I'm hurting these women. And I've hurt many others before he had been divorced prior. He said, as part of making amends, I've reached out to women I've been with. And he's like, I didn't get this. Now I get this. And frankly, I can't do this. And so he disbanded all of it. And he said, I actually do have, he's like, I will miss sex. I love the SLAA. He had gone on a long break from having any form of sexual relations, including masturbation. And then he said, and when the time comes for intimacy, if anything, I'll bring something transactional into my life because I just don't want to hear about it. And that was it. And that was the end of the therapy. Was that a success? I personally, if I was in a room with you, I'd say, I see David nodding. So thank you. I thought it was a success because what he had done was he pulled himself out of these relationships that are actually quite harmful. He was no longer using sex as a means to regulate. He was remaining sober. And a lot of the shame started to alleviate by happenstance for a strange reason. He reached out to me about five, six years after the therapy was done. He said, I'm doing great. I'm writing a memoir. I've learned how to play the bass. My kids growing up, my other kids getting married. Like I'm really, really good. And I reached out, I said, it's good to hear from you. And I just wanted to check in on the relationships. And he's like, nope, you know, I co-parent my child with my ex-wife. And I never again spoke with the girlfriend. So talk about managing your expectations. Like, again, that was my win column on him. And to me, he's also very committed to his sobriety but he could bring something to sobriety he couldn't bring to his relationships. That self-awareness is about as good as it's going to get folks. So let's talk first about the, what is it? Because I want to make sure we're on the same page. Here's, I mean, to me here, right here is the problem which is the diagnosis of narcissistic personality disorder. If I had a sort of a DSM wish, it would be that we get rid of this. This has really, really muddied the waters. We know what the prevalence rates on this are maybe one to 5% in most epidemiological studies. You know the drill, you got to have five or more of these. You know, it's the grandiosity, the entitlement the need for admiration, the exploitativeness the lack of empathy, the envy and the arrogance. That's DSM. Five out of nine has to be interfering with their life in some ways. Well, it should often isn't because we also know from the research narcissistic qualities are often associated with higher income levels. So they're only noticing that there's a problem when there's actually a problem. And that problem is something they attribute to other people. The problem with the DSM definition is in no way, shape or form does it ever, ever, ever get an underlying dynamic. So like I said, this has muddied the waters because I think people are like, well, they haven't been diagnosed with NPD. And if you put NPD on an, again, in an EHR and there's insurance issues, this sets off red flags. So I think it's sort of something we avoid. The epidemiology of personality disorders. And again, we're going to see a lot more of this in outpatient and inpatient settings and far, far more in correctional settings, but you know, anywhere from four to 15% of any PD. But what we see is that I've focused here on the ones that old school cluster B, but you know, what we now are sort of hang out together. And we'll talk a little bit about how this is being framed differently now. But what we're seeing is one to 4%. Any of you working in addiction medicine saying this is more than one to 4% of the clients who are coming in. So this research is missing something, right? So again, in some of this research, like Stinson's work back from 2008, 13% of a narcissistic personality disordered sample presented with alcohol use disorders. So that personality disorder was quite prevalent when they were working with specific groups of clients and patients with substance use disorders. Again, old school, we all remember this, right? This is what we were originally sort of cut our teeth on. It's how we, and again, cluster B became its own sort of shorthand within the field. But let's sort of jump into what DSM-5 did. They said, okay, there's an I, it's almost like it was nostalgic that they wanted to keep the categorical designation. But now we're going much more dimensionally, but the new formulation of narcissistic personality now accounts for those vulnerabilities and self-esteem and notes it as being more of an issue with regulation, which the traditional five out of nine diagnostic framework didn't get. How do they regulate? They regulate through attention seeking, and grandiosity. So now it's at least a recognition of some of the defensive framework. So at least DSM has lifted their head long enough to say, okay, there is something sort of dynamic happening here that we should identify that. That's probably a bit more important than the laundry list. If you're not familiar, this is actually a model of personality that I can actually get a little bit more behind, which is the new alternate model framework, dividing functioning into self and interpersonal self, into identity and self-direction, interpersonal empathy and intimacy. And this is sort of now how narcissistic personality disorder gets framed in this new framework. A person to actually meet diagnostic criteria needs to only have significant difficulty in only two or more of these domains. So their impairments may be in the identity domain and the empathy domain. In almost every case, when you're working with a client who has a narcissistic personality style, you're going to see impairments in all four of these areas. The identity is very much defined by what other people will validate and value. So there's self-reference to others. Self-direction, same thing. The goal setting is based on approval seeking. Or they sort of play around with their personal standards so they can either view themselves as a victim or see themselves as exceptional. And again, we'll talk a little bit about that polarization within narcissism. Interpersonally, we know that empathy is impaired. They, however, here's the challenge. And this is something that you're gonna see even within your treatment teams. They'll say, however, this client sometimes seems really empathic. They can very much attune to the needs of others in a very transactional, performative manner. So that also muddies the waters because you'll see someone who actually can be quite connected, quite attuned at times. That variability is something that's more of a nuance. It's not just simply the absence of empathy that we might see more in psychopathy. And then intimacy is as we'd expect. Relationships are superficial. They're serving a regulation function. There's little interest in mutuality or reciprocity and very much about personal gain. So that's sort of the newer formulation of this. But now what DSM is going to, and this is actually where I think sort of the money shot is, is this criterion B, which is the trait formulation. So getting away entirely from you need two from here, five from there, but let's look at this as sort of these sort of trait, these sort of trait variances. If you will, for narcissism, they're saying what you need are grandiosity and attention seeking, both of which are antagonistic traits, okay? So let's talk a little bit about this because what they've done, and I think that this is actually a much more useful framework for clinicians, is using more of like a five level model. Some of it maps onto the five factor model. ICD-11 has now put out a model. And again, I'm hoping to maybe come a second time and talk more about this. So I don't want to belabor ICD-11, but they're doing it a little bit differently, but there's a lot of overlap. But when we look at all these areas, I'm highlighting antagonism because antagonism is the counterweight to what I would consider the far healthier trait of agreeableness, okay? It's a personal preference. I like agreeable people, not everyone does, but antagonism could be called disagreeableness. And with each of these blue boxes, you'll even see underneath it what that sort of more, that counterweight is. Where I do take some umbrage at this model is detachment, it's versus extroversion. And I think for folks who are sort of trying to work through the introversion of it all, it feels like it could be a pathologizing of introversion, but that's a conversation for another day. But this antagonism agreeableness piece, antagonism is actually what we should be talking about. The trait of antagonism, the way the DSM positions it, is that it's the behaviors that put us people at odds with other people. It's that grandiosity, the exaggerated sense of self-importance. It's the arrogance, it's the entitlement, it's the callousness and the lack of empathy. It's the lack of awareness of what other people need or feel, again, that's a lack of empathy and the willingness to be exploitative. These would be sort of the six sub-factors under that. This is what I want you to sort of burn on your brain. Because instead of us talking about narcissism, we really should be talking about antagonism. Because then we're not trying to make sort of these almost artificial, is it narcissism, is it psychopathy, is it borderline? Forget it, toss it and stay more focused on this pattern. Because this pattern is actually what is going to make your job more difficult in addiction psychiatry. And for any of us doing any form of outpatient therapeutic work with clients. When we break down the facets, so they take this big, this sort of six factors, much like they do in the five factor model of personality, and they break it down into sort of more of these sub-facets. And this is what we see as sort of the bigger picture of antagonism. Not just the manipulativeness and all the stuff I had above, but also we could expand this a little bit out of just the antagonism realm and start taking in some of the other territory that we see in things like negative affectivity and disinhibition. Because all of those things are playing a role in a narcissistic antagonistic presentation. The lability, the suspiciousness, the depressivity, the intimacy avoidance, and so on. So if we take that trait model and sort of put together the qualities that underlie what we would call a difficult personality, now you can say, yep, these are the qualities that are underlying the clients who are struggling the most. And I'm struggling with the most without it having to neatly fit into the borderline antisocial or narcissistic labeling system, but instead to recognize this from a model of traits. It's a regulation issue. And again, I'm going to be being mindful of time here because we have so much more we want to get to. The fact is we have healthy and unhealthy ways that we're going to regulate. We all are achievement striving. Human beings have a need for admiration. What happens is, is that that need for that is so much more pronounced in a narcissistic individual that we see these impairments in regulation when there's that need for admiration because it's so overwhelming. Another key element to keep in mind is that narcissism's on a continuum. It's not a yes, no, either, or. It ranges from far less severe presentations that may not even be that clinically significant to much more of a superficial, emotionally stunted, immature presentation, and it feels almost adolescent, all the way up to very severe presentations such as malignant narcissism, which feel almost more like a psychopathy antisocial personality presentation. With the less severe folks, you're probably going to have fewer of the kinds of treatment barriers that we'd see with a narcissistic personality. Some folks, you can frame them as fragile tyrants, and what we have to remember, and this is going to be really crucial in how you frame consideration of how to work with these clients, is that there's a grandiose presentation and there's a vulnerable presentation. Traditionally, almost everything that's been written about narcissism, not only in the clinical literature, but also in the research, the empirical literature, has focused on the grandiose presentation, pretentious, arrogant, assertive, attention-seeking. It's your kind of your textbook narcissist, I'm so great, I'm the king of the world, look at me, I'm so wonderful. The vulnerable narcissistic folks though, this is a really important issue to keep in mind when we think about, again, managing issues like substance use disorders. These are folks who are victimized, sullen, resentful, reactively hypersensitive, very fragile. The initial framing of them is often like, this feels like a mood disorder, this feels like an anxiety disorder, but you can't pull, you're not able to move the needle, you're using every evidence base you've got for depression or anxiety and nothing's changing, and they sort of remain in this resentful, sullen place. Vulnerable narcissism is more of how narcissism shows up in therapeutic settings, and also likely to show up in addiction medicine settings. Evaluation and assessment of personality, especially narcissistic and antagonistic personalities is tough. When we look at Elsa Ronningstam's work, she really lays it out as like, how do you assess someone who doesn't know their thing? I mean, when you're assessing substance use, and while it may take you a minute to sort of chase around the answer, in some ways you're looking for a behavior, a very clear behavior. And with mood disorders, anxiety disorders, there's enough subjective distress that the individual will relate that distress. I'm not getting out of bed, I can't stop worrying, it's getting in the way of my relationships. But here we see numerous impediments. The lack of self-reflective capacity means that they're saying, I don't understand, like my wife's like, go to therapy, or we're ending the relationship, so here I am, with a rather sort of arrogant, grandiose, resistant presentation. The lack of empathy, how do I affect others, this hypersensitivity, the defensive reactivity. And the difficulty in self-disclosure, where therapy becomes too much about storytelling. They almost feel like they have to regale the therapist with tales rather than actually be very present in the work. And that is incredibly frustrating when you're trying to bring them back and then they fall back into the storytelling. And that's how they maintain that distance between the emotional world, which brings up the shame, and how they present in therapy. They can keep that distance because they don't wanna go there. Lots of limitations in empathy, and then lots of contempt for any discussion that's emotional. Personality assessments, typically administered by psychologists, take a really long time. I mean, we don't really have great, quick instruments. There are some screening instruments that sort of kind of frame on to some of the DSM stuff, but it's not perfect, and it's, I mean, reliability, validity, eh, it's, but it's something. But the fact of the matter is the longer tests, like the Milan Inventory, the MMPI, these take hours, and it's often beyond the reach of a lot of treatment facilities. There's also a terminology issue, and you probably have heard the term covert narcissist, right? It's almost a bit of a misnomer. It was sort of a confusion in terminology. The way to make the distinction is between the grandiose and the vulnerable narcissist. As I said, the grandiose narcissist, pretentious and arrogant, and in many ways, that grandiosity, that pretentiousness, that arrogance, those are protective defenses. In many, they wanna say like, I'm gonna kill it at sobriety. You watch me, and you can actually harness those grandiose defenses to your, at least to winning in the sobriety space, if not in the interpersonal space. But with the vulnerable folks, they do not have those protective defenses. So what you'll see is when things aren't going their way, which is, as for any of us, quite often, you will see the fragility, the sullenness, the sulking, the victimhood, and a more of a quiet, passive-aggressive rage. The covert-overt distinction really goes down to, covert are the things that we ostensibly can't observe. They're the thoughts and the feelings. The overt are the behaviors and the words. And so as laid out in this sort of framework, it gives us a better sense of when that term vulnerable narcissist, or I should say when the term covert narcissist is being used, what they technically are often referring to is a vulnerable narcissist. The term covert really reflects the kinds of the patterns, like I said, thoughts and feelings, that you're only going to get at if you're able to sort of do an assessment and draw that out of the client. The overt, like I said, the bragging and the moping and the complaining, that's sort of quite visual. So it's interesting to me, and one thing I wanna bring up, I actually have to make this bar go, make this thing go away, which is so hard to do, to make this little slidey bar go away. Anyhow, step six, right? When we're thinking about these issues around, there we go, character defects, and you go to any rehab facilities website, right? And they've got step six laid out. So I went to several and I'm like, okay, they're all showing the same thing. These are the kinds of character defects that people are asked to bring and address. I've highlighted in red, everything that maps onto a narcissistic or antagonistic personality style. So now you can see that that's very personality style. The taking ownership of that, which is step six, good luck with that. It's a really, really hard place to get a client to, and yet it's everything. That's the whole thing. And I think that this is one place where I think that many times for clients with these personality styles, 12 step can either be a theatrical space for them, but they stumble at this level. And this had come up in my conversation with Dr. Blazes when we had talked about this initially and how this would play out. And so when I dug deep, I'm like, oh, how nice to completely overlap. Also, we have the issue of the overlap between narcissism and psychopathy. Like I said, I don't even know that we have to get lost in chopping all of this up. And it really depends on what kind of population you're working with, especially if you're working in anything that's sort of corrections adjacent or court mandated or anything like that. You might see more of these sort of psychopathic antisocial personality presentations. We see lots of overlap, the impaired empathy, the entitlement, the grandiosity, the manipulation and all of that. But with psychopathy, obviously we're going to see more of the lack of remorse, the coldness, the calculation, a lot more coercion will be present in their interpersonal relationships. The pleasure power motivation is almost singular with them. What you don't see in people with the psychopathy presentation is this insecurity. And remember insecurity is sort of the central pillar of the narcissistic presentation. It becomes an interesting sort of therapeutic point to have to hit and to explore, but that's not going to be an issue with this sort of personality style. The validation seeking isn't as important to them other than a way to get more power. The vanity, hypersensitivity, fragility, vulnerability, not as much, it might be on a case by case basis, but not as much. We also know that the issues around anxiety and autonomic arousal are very different. The research is pretty clear that in people who really are sort of using a model like Hare's model of psychopathy, you're not going to, what you do is you see that sort of attenuated autonomic arousal. And so you'll see that almost like sort of that stress resistance in these folks. That's very different than narcissistic folks who actually are very much, almost have a post-traumatic picture of autonomic arousal. We see a lot of folks using these terms interchangeably, so they are quite different. And then we also have a social class issue. This is something we saw on my data over and over again, was you have to be very careful because the way the DSM captures antisocial personality disorder, it's very behavioral. And so when you see, especially people, men from lower social class backgrounds, a lot of things there almost sort of load them right onto the ASPD factor. And if we were to really more carefully assess this, and when we've gone back and looked at some of my data, a lot of those folks who the DSM was sluicing into the ASPD really were much more on point with the narcissistic presentation. And just to remain aware of that, because you're gonna have slightly different approaches depending on what kind of personality style you're seeing psychopathy versus narcissism. But that social class bias is very, very much a part of that sort of a distinction. We also see that happening across the personality disorders and the ethnicity and personality disorder research is actually a very messy place. But what we see is that social class really undercuts a lot of this. The dark tetrad though is the other place. If you're not gonna, I think I spelled Machiavellianism wrong, I think there's two L's and one C, sorry about that. With the dark tetrad, I like this model because I think it takes antagonism and it really takes it into a place that acknowledges that all of this hangs together. And instead of talking about psychopathy or narcissism, this is more what we see on where the severe malignant narcissism and in psychopathy, it's where all of this comes together. The psychopathy, the exploitativeness, which is the Machiavellianism, the narcissism and the sadism. I'd argue for a dark Pentagon, because what I do think we see is a constant threat perception that presents as a little bit more of like a low grade, not psychotic, but a low grade paranoia. Looking at that constellation of traits, you can imagine the numerous barriers you're going to have to being able to engage a client like this in therapy. And while our depiction of this is we, again, this is the dark tetrad Pentagon, call it what you will, is something you're often going to see in correctional settings. You're going to also see this in a variety of addiction treatment settings, you are. And so it's to see this as the model that it is and not get us lost in the narcissism versus psychopathy versus borderline kinds of distinctions and see all of this as something that hangs together. And so I do think that talking about, do they have the personality disorder? Do they have the five out of nine? I really wish we could break out of that, because what we often don't see with folks with these personality styles is they don't have the social and occupational impairment. At least they're not endorsing it, right? Other people, this is rare. It's an unusual pattern of psychopathology where other people are being harmed often more than the individual who holds the quality versus other syndromal patterns like mood disorders, where obviously the individual is suffering and acknowledging that subjective distress. We're wasting so much time on semantics and trying to split hairs that we're losing an opportunity to talk about these personality styles. And in fact, the narcissism, because there's such a focus on looking good to the world, the grandiosity, the arrogance, being successful, the posturing, that they may actually look like they're quite high functioning and they may be using substance use to regulate, which is a key motivation, but they do not want that to be found out, right? That's the whole thing. I don't wanna be ashamed of doing this. And I'm not even gonna get into the ICD-11 of it because it's just too much. There's so much that co-locates with narcissism. That also complicates it. Most prominently things like ADHD. ADHD and narcissism co-locate probably at least 50% of the time, obviously what we're talking about today with substance use disorders, but all of these other things too, there are some overlaps in the sense that these overlaps can make diagnostic specificity more challenging. And again, I'm gonna come back to this idea of instead of saying, is it this or is it this, to be aware that these personality patterns are always in the backdrop for all of us. We all bring personality into whatever therapeutic setting we're in. So we're losing that in trying to kind of put everything into these little boxes, but there's overlap with all of these. I mean, most prominently with bipolar and narcissistic personality, we often see that overlap. And then the assumption is, well, the grandiosity is the mania, but when the person's in a depressive phase of their bipolar presentation, you're not gonna see the grandiosity and yet it may still persist in some unusual ways really and be observed in interpersonal relationships. So it's being aware that there are a lot of overlaps, which can make you still wonder. That's why this assessment is an issue. How do we know how much of this is narcissism? I know for all of you, you're already feeling that antagonism when you're in the room with a client. Again, I'm gonna pass over some of this if you wanna be mindful of the time, but we also have to be aware of these overlaps, right? There's tremendous overlap, how these different sort of classical cluster B styles overlap. We see that, and like I said, where all three styles are present, which is that whole laundry list of antagonism, and then those other sorts of difficult personality styles, that's where we see kind of this revolving doors and lots and lots of relapse and other high risk behaviors. What I'm gonna do is I'm gonna jump ahead. And if I have time, I'm gonna come back and then hopefully literally come back and we can talk about this some more. I do want us to be clear that there are these subtypes of narcissistic personality. We've talked about the grandiose and vulnerable, but the malignant narcissistic subtype is very much a sort of an overlap of almost more of the psychopathy in terms of lack of remorse, much greater likelihood of exploitativeness, sometimes even more physical violence. So it's more of a, it doesn't present as well. We won't have that usual, I've got to look good to the world of it all. There's something more menacing there. The communal narcissist, I'm gonna talk about in a moment when it comes to sort of performative recovery, but very briefly, and let's see if I, yeah, I didn't get there, so I'll get there next, but oops, sorry about that. The communal narcissist is, it's consistent with a style that's been called agentic extroversion, which is basically a way of saying that these are folks who attempt to get their validation from the world by doing good. So these are sort of your narcissistic humanitarians who are putting it out there that I'm saving the world, I'm rescuing the world, but continuing to wreak havoc with their antagonistic behaviors, usually with people who are closer into them, but the world has a different image. That's how they're sort of getting that narcissistic supply. And it's very interesting because for communal narcissistic folks, they will often their recovery process will be a means of getting validation, which can be actually quite treacherous for the people who are close to them, who will say we want to support their sobriety, but they're continuing to really treat us badly. And they have become sort of the the poster child for all things recovery, and that that gets to be a very complicated space for the survivors. I'm going to get jumping ahead because I really, really want to make sure I get to the core of what we're going to be talking about here. Substance use disorders are what often get narcissistic people into treatment because we have to think about why would somebody this grandiose, who is so shame driven and doesn't want to sort of experience that what they consider the weakness that would get them into therapy, substance use disorders, there might be work impairments that result interpersonal impairments, even court mandated therapies that come from substance use that would get someone with this personality style into therapy. Like I said, DUIs would be sort of most prominent amongst that a family may attempt to do an intervention. And what's interesting is those families may be doing as much an intervention around the antagonistic emotionally abusive behavior as they are around the substance use, but they will be trying to house all of the behavior. The reason they're like this is because they're drinking or they're using. And like I said, that's often a heartbreak moment for the family. When they do go for treatment, and they come home sober, but still quite emotionally abusive. They may get into treatment to save face, especially if they have more of a public presence. And they're like, look at me, I've committed to rehab, but they've committed to it, not from a place of recovery, as much as I need to do this, so the world isn't mad at me. We see significantly 55% more likely to drop out of therapy. And that's going to also likely extend to rehab settings. Personality in general, is associated with poorer treatment outcomes across the board. In fact, I can summarize this treatment literature quite easily for you. There are not there's not ever been a single randomized clinical trial that has done been done with clients with narcissistic personality disorder, or significant narcissistic personality styles. And the case literature out there is really sort of a literature and exceptionalism. And by and large, what we don't see is large sample research showing a way to create consistent change in large and diverse samples of individuals. I mean, sure, you'll see a study where it's like the client went to therapy for two years twice a week with a highly skilled therapist who knew all about whatever therapy they did. And we were talking now about what again, we're talking about means we're talking about access, we're talking about motivation, and that's not going to be normative. And so the case based research, it's almost like again, it's like reading about a unicorn. But what we're not seeing is any consistent evidence that there that these personality styles can be changed enough to cause visible sort of behavioral, social and occupational improvement. So treatment feels impossible. There's a big file drawer problem in this research that I think the negative findings are not published, because good luck trying to publish those. It's very case based. And I love this quote from one of the articles where I'm from Ellison was talking about treatment dropout, where one of the individuals in their research stated if mental health means I have to be nice to the idiots of the world, then I would rather be crazy. And this is a client who actually had documented narcissistic personality, that contemptuousness is what's brought in to therapy. So narcissism really interferes with relapse prevention. Why? Because many times, the dysregulation issues are not addressed in treatment. Now, here's a place where dbt can actually be a really useful adjunct to any form of therapy that's being done with these clients. Because the focus in dbt is so much about real time regulation, and dysregulation and disappointment, because the frustration tolerance in individuals with these personality styles is so low, is often a real predictor of relapse. So giving these individuals some form of tool to be able to, to be able to manage those moments becomes a really key issue. Once substances are off the person, they're no longer using, they've lost a major coping tool. And all of those issues around shame, they no longer have a way to numb that, whether it's the grandiosity that's induced by stimulants, or whether the numbing effect of whether they're using cannabis, or they're they're drinking, now they've lost that. So that raw emotion, if it hasn't been handled in treatment, that has nowhere to go, and you'll see a tremendous amount of agitation. There are a lot of narcissistic injuries they'll run into, they don't get the promotion, they don't get the relationship they want the relationship they want ends, they don't get the house they don't want, they don't get the thing they wanted, it feels very spoiled childy, but they experienced this as narcissistic injuries. Those narcissistic injuries are experienced psychologically as being quite cataclysmic, and then can be oftentimes will often presage a relapse. What's really interesting is in doing this work with clients and clients who have co located substance use and narcissism, is that when it's framed, like these disappointments seem to be associated with relapse. I remember one client specifically pushing back and saying, No, no, no, I have to fully take responsibility. So really holding on to 12 step, this is me, I have to take responsibility. But what it took us away from us was we he wasn't willing to do the work of connecting the dots of these disappointments are setting him off. He didn't like the well, that can't be about the disappointment, because that's outside of me, I have to take responsibility. And so it was an interesting sort of, we weren't able to have that really important conversation to help him with that element of relapse management. Some, some folks with narcissistic personality styles may feel othered by sobriety. la is a different city, because, you know, I think that for a lot of folks in the entertainment industry, substance use disorders are, have been a big issue, actually. And sobriety is a bit of a badge of honor there. But I don't think that that's going to be a trend you're going to see nationally. And so there is a lot of sort of feeling othered in those settings, and then feeling unsupported. And that's where that victimhood that's so classically narcissistic arises. Well, what do we want for these clients, obviously, that they they detox, and they, they, you can prevent relapse, that's the goal, right? Giving them coping tools, but that's really hard, because those coping tools have to hit that nexus that we struggle even with narcissistic clients who have never had a substance use issue or disorder to maintain because they can't manage frustration. We're working on better and social and occupational functioning, but the tendency of narcissistic folks to blame shift, this isn't my fault. This is them, this is them, this is them, the unwillingness to take that responsibility, that if we can work on that with these clients, it's actually a really protective factor for them is taking that responsibility. Obviously, emotional regulation is a huge treatment target with these individuals, because the greater the regulation, not only will we see improvements in social and occupational functioning, there will also be this sort of this kind of protection against the risk of relapse, because that dysregulation is often what does sort of presage a relapse episode. The issue is how much you can bring in character and personality issues, when you have already overtaxed staffs, and you're trying to get people through and you're in overwhelmed systems. I just don't think there's an option, because if that element is not addressed, especially the regulatory impairments, and the shame issues, I just think that you're going to have a client that's constantly cycled through. It's not addressed in substance use treatment, we're just not talking about it. I mean, I think in many sort of in case conferences, and, and rounds, it's just not discussed. And yet, it's almost as though it's a it's a bad word, you shouldn't be saying this as though you're sort of assailing their character. It's just a word, you know, just like antagonistic is a word. And I think those are some of our own sort of internalized biases as though this is a bad thing. I mean, it's not it's not a healthy thing. But depression is also not a healthy thing for our clients. But we use that word all the time. So I think that there are certain biases within the field that we need to be willing to address, because this word is actually quite useful in substance use treatment. Even if it's brief screens, and they're out there, there are five and 10 and 15 question personality assessment tools that can be built into intake assessments. Yes, the reliability and validity is certainly not at the highest levels, but it at least and it can sort of lift our heads to say, okay, some stuff is going on here, we need to be aware of this and prepare treatment teams. We need better vocabularies around this. But it's all acknowledging the reality is that we don't always have the time in these settings. There are so many competing clinical agendas. And then there are also these other co-occurring clinical patterns. Remember to narcissism and again, beyond the scope of today's talk, because of the time we had, but we could do it if I come again, etiologically, narcissism is very much believed, and I think it's upheld by a lot of the literature to in the theory to be a very post traumatic pattern. So at a minimum, a trauma informed approach to working with these clients becomes really important. So to break some of that down, and I'm going to go backwards to that. So when we look at just sort of the fundamentals of trauma informed practice, safety, choice, collaboration, and so on. Because that is that those trauma origins are, are there for probably a good 75% of narcissistic clients could be attachment. Usually there are attachment disruptions, chaos, neglect, sometimes frank abuse, to integrate that into the treatment planning, to make sure that trauma informed practices are being sort of brought to bear. Where we see narcissism, we should also be looking and thinking about trauma. narcissism is very multi determined. And as I said, beyond sort of today's one hour, but we have to balance that the trauma informed practice and enabling the client's behavior, and it really becomes a back and forth. There's also a tremendous amount of shame evoked when the conversation shifts to one's traumatic origins. And it is amazing how much storytelling narcissistic clients, especially grandiose clients will engage in to avoid almost portraying their story as one characterized by this, the vulnerable narcissistic folks will actually be much more forthcoming with traumatic histories, but the grandiose folks not as much. And so you almost have to do a little bit more digging. But I also think it's important to keep in mind, even again, from a treatment planning standpoint, in a study that came out in 2021. And I think this was actually it was one of the biggest in the field. This was like 435 studies that they did a meta analysis, consistently across all forms of aggression, narcissism was a really, really strong, powerful correlate of aggression. And that has implications for treatment planning around awareness of domestic abuse, awareness of how they manage themselves, if you're working in any settings that are again, correctional adjacent, or this is court ordered, it's remaining aware of this. And obviously, substance use, adding on to the existing emotional dysregulation and impulsivity has often increased the likelihood of aggression. But it's being aware that this is an issue, this is very much part of how narcissism presents. And that's now been very much substantiated by the literature, your staff is going to burn out that and in fact, if we don't have the data, and heaven help us, I wish we could get it because this these antagonistic personality styles are what are doing stuff. And this is actually where my empirical research in this area got work got initially going, we were working in urban clinics in Los Angeles focusing on HIV. And it was our observation of how the staff was getting exhausted by the antagonistic clients. And I thought, why isn't anyone looking at this? So that's how where that came from. But these clients can tip the balance through boundary testing through their entitlement, through their you know, through their inappropriate conduct and inappropriate language with staff and therapists, the limit testing is a constant, and it's in it is having really, really clear procedures and giving staff permission to exert those is really, really important. There is the you're often wasting resource on rule enforcement, that becomes a big one. Because for a narcissistic individual, the idea that a rule is being placed on them can really pull for oppositionality. And it punctures those entitlement defenses, which again, you have that sort of shame reactivity. clinicians will often be left feeling incompetent, like I should quit because I'm getting absolutely nowhere. This client has now relapsed multiple times, they keep getting into more trouble, what am I doing wrong? Having this frame of antagonism for so many clinicians, ranging from interns, residents, staff, fellows, I think even senior staff will say, okay, now that I have this framework, at a minimum, you can engage in some of the ratcheting of expectations, knowing that you're not going to get you're not going to get very far with personality stuff in 28 days. So oftentimes, you're focusing on sort of focus nodes, things like emotional regulation, and things like that, shoring up other defenses, working with family, like whatever you can find you can do, because you're not going to address the bigger, the spectrum of personality. But this isn't just about people who are getting medically trained, or even graduate students who are working with you. This is also your frontline staff, the people who are, you know, doing the overnights, the people who are the other team members might even be in paraprofessional statuses, they need this framework. And this becomes a really important part of in service work. But again, I know, and I know we're coming to time. So it's gonna, we're going to go over to questions. But we have to understand narcissistic vulnerability, and not just view this as a grandiose presentation, since that's what gets people in the in the door. You have this sort of constant, they're either provoking the therapist or alienating the therapist, neither one feels good. All of its exhausting, but to be aware that of the various dynamics at play, when you're in a therapeutic situation with somebody who has these personality styles, and that fluctuation is really confusing for clinicians who will go from they seem socially anxious to now they're verbally abusive, what is happening here. And a lot of this has to do with that concept of narcissistic safety. When the narcissistic client feels safe, and yes, you can establish rapport with these clients can go a long way to sort of managing that. And so now you sort of again, it's about giving people that roadmap. So there's less of that clinician sort of self blame again, beyond what we can do here. But your key goals and treatment, working with these clients on distress tolerance, getting clients okay with the ordinary self ain't doing that in 28 days, managing the comorbidities is obviously crucial, addressing reactivity, responding to suicidal crises, especially with vulnerable narcissistic clients, there is a risk their grandiose defenses, helping them become more functional in their relationships, doing some of that mentalization work, having them practice coping skills, wherever you have them roleplay anything you can, they can often be quite contemptuous of that, but that can be useful. And as work goes on, especially if you're able to do longer term work with these clients on an outpatient basis, you may be able to start elevating work to things like meaning and purpose, they, many of these clients will ultimately resonate with that. But there's a lot of bedrock work you have to do first, and it takes time. But this work also has to recognize contextual factors, such as other things that might actually undercut those, those grandiose and protective defenses, including aging, understanding cultural factors, how is this enabled within their culture? How are these patterns understood within their culture, and also with gender, vulnerable narcissism occurs at the rates are equal between cross genders, but that's not what we see is grandiose, where it's much more prevalent in men. Same with malignant narcissism, much more prevalent with men. So again, I'm going through this, because I really want to make sure we get to the high points, what works with these clients, therapeutic alliance works, it's work, but I think sometimes understanding it understanding some of their vulnerabilities, understanding the core insecurities, understanding that shame dynamic can foster the alliance, keeping those expectations reasonable, because this is likely to be a few, you're going to go a few turns around the block with this person, understanding that this is going to be a longer term treatment game with them. It's not just about establishment and maintenance of sobriety, but it's really going to be about how do we create more of this sort of self reflective capacity within these clients, addressing some of their maladaptive schemas, which can be longer term work, regulation becomes important. But it's also about issues around the analysis of not only the transference, but the counter transference. Some of us grew up with some of this, some of us have been married to some of this. And let me tell you, it's going to bring some of that up for you and to manage our own reactivity in these treatment in these treatment settings. And so it's a chess game. And so accounting for all of that, making space for things like boundaries, being aware, again, that there's going to be constant boundary violation. So you almost need to have a very, very, very tight treatment contract between yourself and these clients, which at times can even feel excessive, you're going to be tentative and testing their defenses. And also, we have to be very aware and seeking out consultation where we need it around issues related to any intersectional issues, domestic abuse, whatever we feel we need that reach on. And even if there's, for example, other issues at play here around child abuse, or divorce and family court issues to seek out the consultation that you need. Let's leave suffice it to say that this really, really takes a toll on clinicians who will often feel incompetent, devalued, humiliated, inadequate, exploited. And especially when you're working with trainees, people get med student intern resident fellow level, it cannot be this like, Oh, come on, figure it out. It's to understand that this is very, very real, that these are difficult clients. And that it is it's this is this is a them. This is a client thing. This is less a clinician thing, because nobody's really kind of getting through here. And being aware, especially in communal narcissism, this issue of virtuous recovery, the recovery being embarked on for validation, great in terms of if that maintains sobriety, which is obviously a primary goal, but it can be shallow recovery. And then to be aware of what that shallow recovery looks like. And this whole concept of spiritual bypassing and concepts that you'll read more, it's sort of in the popular literature. But these clients will sometimes harness to be able to say, See, I'm better, and I'm great. And now there's a grandiosity around their sobriety, which can also sort of be chafing for the clinicians. And some of the hacks and I, I'm going to say with a to Dr. Blaze is he's responsible for the be smart, but I'm responsible for the but not too smart. Because if you try to be smarter than them, they may get really angry, and it'll pull up the defenses. So it's, they need they like your diplomas on the wall, they like thinking like, I've got the best addiction medicine person on my team. But they also don't want you to be so smart that they feel humiliated. So it's that's a dance. You want to stand your ground and don't get snowed by them. Because they may say you're the best. I can't believe I have the best doctor. No fawning. You just have to you have to stand your ground, be very clear of those boundaries in the game that they're playing charm and charisma is very much a forward facing quality here. You may be much need to be much more directive and treatment than you're accustomed to. It's like sort of harness your inner life coach to work with these clients. Use your their adherence to 12 step to your advantage. Focus on mindfulness approaches and meditation. There's a real sort of like sexy meditation mindfulness community out there where it's like, it's interesting and look how great I am, I meditate. The nice thing about that is you can use some of that to your advantage because as these buzzwords become so sort of, again, sort of virtuous and validation seeking, those tools can actually be really useful for these clients. It's harder when you have the co-located attention deficit sort of presentation. That's where I've seen it not work as well. And you have to work collaboratively. These clients are always looking for those triangulation kinds of opportunities. I love my psychologist, but my psychiatrist is the worst kind of thing. That triangulation is really, really common here. So we're not gonna get to case two, but try to get through the end of that as quickly as I could so we could open up for questions. And so I think we're close enough, 37, sorry. But so are there any questions? There are. Thank you so much. That was an amazing presentation. And I'm sure there's a lot of questions. Some of them have already been put on into the Q&A box. So I'll read the first one and then Dr. Blazes will take over after that one. The first one was going back to the grandiosity you were talking about, I think, also with like the fragility and vulnerability. And Sunil is asking, isn't the grandiosity itself also quite fragile? Like when someone is being very confident about being the best in recovery, how there's often a lack of substance behind that and therefore it's an easy setup for failure. It absolutely is. And I think that's a really, really astute observation. All of these defenses are fragile. You know, the entitlement, the arrogance, the grandiosity, they're all very fragile sorts of defenses. And so I think the key though is to see it coming, and I always say, and as hard as this is, is to almost, if we can, receive the grandiosity with empathy because what's right underneath that is the vulnerability. And so it's not our job to chop that down but almost file it away and reflect on what a failure would actually do to this person because it would puncture that grandiose defense. And imagine it's like pulling the middle of a scaffold out, the entire structure is going to fall. So I absolutely do think that that's the case. And I think that it does set up this sort of, this kind of, the more grandiose the defense, the more catastrophic it's going to be for them if they do slip and have a lapse. And I think that for us as clinicians, we have to catch ourselves. This is where the mentalization and the mindfulness is important for us, which is to monitor our reactions and even use that as a therapeutic framing saying, you know, you really are committed to this. So let's jump off to say, you know, lapses are common. So what are some ways you could approach this? It's almost like you're saying, you're really view their grandiosity as a commitment rather than as posturing. We may know what the function is serving is, but to meet them there to say, okay, let's keep giving you tools so we can keep you invested in this. Because I do remember working with one client and every single week it's like, doc, doc, 21 days today. Next week, doc, doc, 28 days today. Like, you know, I was sort of his little personal chip and he was so important. And that's where the session started every single time. He's like, don't you think I'm going to get to six months? And instead of saying, well, don't get ahead of yourself, say, wow, you are really committed to this, this time. So let's see what we can work on to make sure you can make that goal. Harness their defenses instead of sort of, we can't sort of roll our eyes at them, which is tempting to do, but it's not compassionate. So, yeah. So Jonathan had a very interesting comment. I conceptualize the increased prevalence of narcissistic features in patients with addictive disorder to result from the profound narcissistic wound of having lost one's autonomy to an inanimate substance which leads to a desperate need to assert control and restore self-esteem by maladaptive strategies. I think much of the narcissistic personality features we see with addiction are substance-induced, do not resolve with sobriety and may resolve with recovery, in quotes, especially when mediated by the 12-step process. So I have some further comments, but I'd love to hear what you have to say. I'd actually love to hear your comments first, Dr. Blazes, because you have so much good insight here. Well, I mean, I think that this, it brings up for me that I think that there, it's almost like there's two categories of people, one of which have the real deal narcissistic personality disorder that may not respond as well to the 12 steps. But then there's another category of people who their primary issue is addiction, but it seems to manifest as somebody with narcissistic personality disorder. And they seem to respond very well to kind of 12-step programming and whatnot. I mean, the framing that this person who laid this out, who laid this out, it's so elegant and it's so on point. And this is the kind of sort of framing that the way this person, the person, I forgot their name. Jonathan. Jonathan. Jonathan's actually a very, very wise clinician. Now, the trick with what Jonathan said is that that is something we put in, because I completely agree with it, is to sort of gently put that in our back pocket, because as the work continues with a client, especially with a motivated client that is able to sort of engage at this level of therapeutic engagement, is to slowly let them have that interpretation. I think if you open up with that, it may be sort of, again, it may be sort of that contemptuous disregard for it. But as the rapport and the respect is established, I do think that that kind of interpretation really helps contextualize the sense of powerlessness that this individual feels. And again, how nihilistic that feels for a person with this kind of a style, that they don't have that person, that they don't have that power. And that idea of autonomy is a huge one. What's so fascinating is that people who are in relationships with narcissistic people will really characterize it as a hijacking of their autonomy, that if they are not living in service to the narcissistic person in their defenses, that they're going to get destroyed by the relationship. But what we forget is that it's a mirrored process, that the narcissistic individual themselves is struggling for their own autonomy, because right now they're basically doing a dance. Their goal setting, their regulation is all based on what they think the world wants for them so they can keep getting admired and validated. That's a horrible position to be in, because there's no, the search for the authentic self gets completely thwarted. So I think that that slowly letting out the line of giving them permission to be themselves, that that is valuable and to substantiate that. I mean, I love Jonathan's analysis. It's so spot on, but it's something that you have to gradually give to the client and to recognize with this continuum, some clients are never going to be ready to hear that, some will, and that inversion of sort of addiction over NPD versus NPD over addiction can really have some bearing on how they're able to navigate that 12-step process. Okay, thank you. Jennifer has two questions. I'll ask the first one. Wondering about the morphology across the Ericksonian stages. How do you see differences in functioning or the manifestation between young adults versus middle-aged versus the elderly? That's a great question. And when we look at a lot of the research just on personalities and personality disorders as well, what they generally do talk about is a softening of some of these patterns over time. Now, whether that softening is due to actual changes in personality or the amount of social supply a person has, especially with an antagonistic personality, whether that abates over time, divorces happen, adult children become isolated and have no interest in the parent, they're no longer working, that what may seem abated may also be that they're not sort of not wreaking as much havoc. But what we do see with, in terms of personalities, narcissistic personality is a developmental stuckness. Now, some folks would have said that it's actually a relatively primitive style because it's so projective in how it manifests, but it is that there's such a dependency built into the style. So one of the big debates in the world of personality and personality disorders is when do you even use these sort of maladaptive personality designators developmentally? I am a big believer that emerging adulthood, which I think we can sort of spitball out to about 25, 26 years of age, putting the heavy, like this is a maladaptive personality style thing, there can be some stigmatizing that happens because, I mean, by that model, every adolescent person out there is narcissistic. It's just the nature, going back to that Ericksonian conceptualization, it's a stage of individuation. And in individuation, there's a lot of oppositionality built into that phase. As the frontal lobes develop, all that happens by the age of 25, now you have the sort of the jello mold that is called personality, it's now sort of in shape, it's gonna hold its form. And so I think that now, and I say that, and I'm gonna say it in another breath, there's increased focus on the idea that borderline personality is actually a very useful diagnosis to give if all conditions are met in adolescence, because what it's doing is instead of the hurry up and wait, it's the hurry up and treat and bringing DBT in a much more assertive, aggressive way to those clients at that age. And instead of viewing it as some melange of mood disorder, anxiety disorder, bipolar disorder, see that frame properly, and then be able to actually, because by waiting from adolescence into early adulthood to start treating borderline pattern can be disastrous. Narcissism is a little different. And so I think in young adulthood, what we'd wanna do is almost break that down by defensive patterns, entitlement, grandiosity, oppositionality, that antagonistic stuff. As you come into middle age, that's sort of the revelation. Do these patterns persist? So now do you have the 40-year-old who's acting like the 17-year-old or the four-year-old, as the case may be, or has that evolved out? Now, I think in middle age, there's actually sometimes where we see some of the worst of it, because it's a place where a person is getting a lot of career validation. Marriage is a much more high pressure situation where long-term committed relationship might be that. So I do think that what you see is you may very well see a stuckness and a bridge burning. So that then, as you get into older age, you may see sort of the antagonism coming out as burn bridges across family. And sometimes if the antagonism persists enough, it can actually make assessment of other conditions like dementia more difficult, because you're wondering how much of the agitation and the aggravation might be related to a dementia-related process, how much of it is related to this personality process. And we often don't think of that differential. And so I do think that the severity of the narcissism, I think the more severe, the more you're going to sort of stay on a steady track. But I think that in the milder levels of it, that lower grade that I was speaking of, you might actually see some correction, especially as life slaps them a bit. And then there may be some correction, especially if the person is in high-quality psychotherapy. So I think that's a very astute observation, but I actually do believe that narcissistic people are sort of forever stuck in this Ericksonian individuation struggle for most of their lives. That actually kind of also ties into this next question. In the recovery world, there's a label King Baby, which is actually a pamphlet that was created by, I believe, the Hazelden Foundation. And it's actually, if I remember correctly, it's based on one of Freud's papers on narcissism, where he described His Majesty the Baby. But anyway, that's just background. And this word King Baby gets slapped on to obvious narcissists in recovery institutions. The program seems to think the 12 steps can overcome it if the alcoholic is truly motivated. It sounds like they can learn to mimic, but maybe not have the true conversion if the character defects are too numerous to count. Could this be a distinction between disorder and traits? It's a really good question. And I think it cuts probably more to severity, right? So not even getting into disorder versus traits, but severity, level of impairment in life, in the difficulty with regulation, all of those things. So if we look at it in terms of severity, I've never heard that King Baby designation. It's actually really interesting here because we, in the folks I was working with in sort of narcissism, actually working on teams, focusing on with clients who had also co-located addiction, we'd call them baby men and baby women, because it was like, again, this absolute dysregulation and sort of these very immature defenses. I do think that the, you know, that, here's the thing, I've actually seen, the client I told you, the 68-year-old guy, he did beautifully with 12 step. His investment in that, his investment of ego in that was so high that he made a very successful 30 years of sobriety, where his lack of success, for lack of a better way to put it, was an interpersonal functioning. It's as though he parked all of his psychological resources into sobriety, into 12 step, and some of the other pieces around character defects and accountability taking and all of that, that was always lagging for him. And so he ended up, though, making some interesting choices in that space. But I do think instead of trait versus disorder, it's easier to view it as severity, using that larger antagonism adjacent trait format, how much of that is present, the more of that that's present, the more you're gonna have, again, really smart framing of it, that emulation, the emulation of what this is to look like. Because what is so interesting about this is, there at times can seemingly be a very high emotional intelligence in these individuals, because they know how to work the room. And unfortunately, it's a transactional emotional intelligence, because they know how to work the room. But there's not, again, that mentalization capacity of how do the people in the room feel? So over time, people feel manipulated, used, preyed upon, instead of feeling heard or seen, though initially in the encounter, they do actually feel like, whoa, this person's got it. So I think that also relates a bit to this emulation, and I think it relates a lot to severity. Okay, next question. Do you have any advice about negotiating with narcissistic personality types? I've used success with these patients, like the work of a dissociative identity disorder patient learning to negotiate successfully with alters. Oh, that's interesting. So what I just, I guess I'd want a little clarification is that the negotiation in terms of, negotiation in terms of treatment engagement, or like what is the, I'm trying to understand that frame of reference. I understand the negotiating between the alters, but how they, what they're negotiating for with the narcissistic client. This question came from Jeremy. Jeremy, I'm gonna try to click on allowing you to talk and you can further clarify. Yeah, so I just find it challenging to negotiate with patients when they're so disagreeable. And I think I do a lot of group work, and so it can impede the work of the group if it becomes a focus of the disagreement. So I think you have to adaptably negotiate with those patients that come to resolutions. I guess I understand what you're saying. So negotiate, it's like, you know, say sort of negotiating with a narcissist is a sort of masochistic endeavor for sure, because they are gonna need to win the negotiation. So in a way, it's almost like, how do you frame it that they don't feel chided, they don't feel shamed, but, you know, and then some of it might, some of that then may end up being process work instead of sort of outcome focused work. I think that in sort of this so-called negotiation would be the process work of, you know, what is the temperature of the room? How are people feeling? Can this other individual, maybe another individual in the group who was likely affected by this, can you weigh in on this and give, you know, and recognize, again, I think one of the big issues in narcissism is that maintenance of multiple truths, right? Multiple things can be true at the same time. You know, the narcissistic person can feel, you know, the way they do, and this other person can have a feeling at the simultaneously at the same time. And so I think that process work can go a long way to that. So it's less an indictment of them, again, a chiding of them, as much as it's what's happening in the room. But then if there is a negotiation, it's how can you help them understand it? Again, this is that mentalization work. There is an interesting literature on the use of mentalization techniques with narcissistic clients in the sense of how can we help them sort of reflect on what might be happening for another person? But it is, ultimately, if you're trying to negotiate and they feel like you're trying to negotiate an outcome that's advantageous for you, Jeremy, that's not something that they're not going to wanna do. So it's really about keeping your eye on the prize of what's going to be best for this group. And it may mean punting over to a more process-oriented framework so there can be that reflection. They may react to that with contempt, but then that becomes further process work you can do. Interesting. All right, one last question, and I'm gonna ask one of my own. So back in the Sopranos, his psychiatrist, actually, when they were meeting with other psychiatrists, they were, you know, one of the other psychiatrists said, well, you really shouldn't do good psychotherapy for somebody with narcissistic personality disorder, or maybe this is the crossover between antisocial personality disorder because you can actually make them worse and they can be more destructive because of what they learn in therapy. Yeah, you know, I've heard that criticism leveled, and this is where, that's why I was saying that balance between standing your ground and enabling them, right? Because what we have to ask ourselves is when I give you that Hills and Roth statistic where 55% of them are dropping out of therapy prematurely, we may get ourselves trained on the prize of keeping them in is the win, right? But if keeping them in means that we are having to basically enable them, embolden them, and sort of become a source of supply, we ain't doing them any favors. So this is work at the group format, as Jeremy raised, at the individual format, where boundary and frame become everything. And that needs to be worked on the way in with the entire treatment team or the individual, depending on the setting, where you stand by those rules. They may very well drop out of treatment, but if the choice is making them worse by engaging them in the treatment, by trying to puff them up, this is not, again, this is not an individual with a mood disorder where you're trying to shore up their defenses so they feel strong enough to get out of bed or get through a work day or get through a day. This is quite different when you start doing that. So it's the, we have to be very careful to not fluff our clients just to keep them in therapy. And that, and then to understand that if we do set limits, they may drop out. That's the tipping point because that's often what's going to happen. I agree with the quote, it really depends on how we approach the treatment. But I think enabling these clients is something that's happened to them. And I have to say from a cynical perspective, and maybe it's the Los Angeles in me, is that some of these narcissistic clients are high net worth individuals. And they'll want to keep a therapist on retainer and write these literally monthly checks to just have the therapist on speed dial. And I've seen more than a few therapists keep these clients because, I mean, again, they're literally, they are so lucrative for these therapists and are constantly enabling them in every which way and are available to them 24 seven. Heaven help you if you're the therapist who receives this client and says, how come you can't come to my beach house? Why are you not available on Christmas Eve? And it's, I'm not joking. I mean, this is literally the conversations I've had and it's because I'm not, we've gone through the emergency plan, and then there's some verbal abuse at that point. And then we have to say, okay, that's, yeah, this isn't going to work, but now we've lost the client, if you will. But I think it beats enabling them. Well, I just wanted to thank you so much for this really awesome presentation. And I can tell you that we are going to invite you back for another session next year. And thank you again for taking the time to share your knowledge and wisdom with us. Well, I really appreciate it. And I appreciate the brilliant questions and framing that came from this group. It certainly has led me to think about things in a different way and it's wonderful. So thank you, Dr. Blazes. Thank you, Dr. Stifler. Thank you for organizing this. And again, thank you for your attendance and your questions. I really appreciate it. Thank you, yeah. All right. All right, we will see everybody. Looking forward to seeing you next month for Seeking Safety and Beyond. Hope everybody has a good month and a good Halloween. Thank you. Bye. Bye-bye.

Dr. Ramani Durvasula

webinar

narcissistic personality styles

addiction treatment

personality disorders

narcissistic personality disorder

treatment outcomes

antagonism

psychopathy

borderline personality disorder

empathy

trauma-informed care