Download ebooks file Mentalization-Based Treatment for Pathological Narcissism Robert P. Drozek all chapters
Download ebooks file Mentalization-Based Treatment for Pathological Narcissism Robert P. Drozek all chapters
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本书版权归Oxford University Press所有
Advance praise for Mentalization-Based
Treatment for Pathological Narcissism:
A Handbook
“It is hard to imagine a book that could bridge so seamlessly the clinical,
empirical, and theoretical levels of discourse related to the treatment of
pathological narcissism. New students of psychotherapy and practiced
“Drozek, Unruh, and Bateman have written an essential book for clin-
icians who are treating, or wish to treat, those with pathological narcis-
sism. Beyond a sophisticated set of treatment principles and techniques,
the authors offer a compassionate guide to the often-difficult trajectory of
working with someone with this serious disorder. This book is a must-read
Robert P. Drozek
Brandon T. Unruh
Anthony W. Bateman
—R. P. D.
The approach Anthony, with some support from me, has developed turned out
to be massively successful both clinically, and in terms of popularity (Bateman &
Fonagy, 2004). It combined our psychoanalytic understanding of personality and its
disorders with understanding gleaned from the rapidly developing neuroscience of
social cognition (Frith & Frith, 2003). Inspired by developmental psychology and
neuroscience, a set of interventions were created that helped clinicians understand
the atypical thinking of those with a diagnosis of personality disorder, providing
simple rule-based interventions to address these in a way believed to be beneficial to
the individuals concerned (Bateman & Fonagy, 2006).
Half a dozen randomized controlled trials showed robust benefits of MBT relative
to treatment as usual for BPD and associated problems (Bateman & Fonagy, 1999,
2001, 2009, 2013a, 2019b; Bateman et al., 2016; Robinson et al., 2014, 2016). It is easy
to forget that Bateman’s work established MBT as the first therapy to offer clear evi-
dence of lasting patient benefit, including at five-and eight-year follow-up (Bateman
et al., 2021; Bateman & Fonagy, 2008). The evidence confirmed that those receiving
treatment enjoyed a more fulfilling and gratifying quality of life, in terms of reduced
use of services and greater likelihood of being involved in full-time education or
employment.
Mentalizing as a psychotherapeutic approach continued to grow under Anthony
Bateman’s stewardship (Bateman & Fonagy, 2012, 2019a), as did the developmental
neuroscience from which it drew some of its inspiration. But the two fields continued
to develop separately to enrich our understanding of development, cognition, and
psychopathology. Only relatively recently has neuroscience reached out to the clin-
ical mentalizing researchers to establish common understanding (Gilead & Ochsner,
2021). In the meantime, MBT grew as a treatment approach. In collaboration with the
Anna Freud Centre, Anthony Bateman oversaw the provision of professional training
to practitioners around the globe to incorporate this research-based intervention into
the widest range of practices. Over 15,000 practitioners from 36 different countries
have received training in one of the MBT family of interventions, with demand for
training places continuing to outstrip supply. MBT training centers have been estab-
lished in seven European countries and three North American locations, and training
sessions have been held in all the nations of the United Kingdom, as well as the United
States, Austria, Finland, Japan, Italy, the Netherlands, Germany, Chile, Spain, Hong
Kong, Sweden, and Canada. While both Brandon Unruh and Bob Drozek have con-
tributed significantly to this training effort, it is Anthony Bateman’s remarkable en-
ergy that has ensured that the dissemination of MBT has been so extensive. In a recent
follow-up survey of practitioners who received training in MBT interventions, 87%
of the almost 300 who responded reported that MBT had been “very useful” or “ex-
tremely useful” to their practice. 89% reported that MBT had been “very beneficial”
or “extremely beneficial” to their patients.
The MBT family is growing. The thinking around clinical practice now belongs to
a large and growing community of clinicians and researchers advancing our under-
standing of both mentalizing as a developmental process and its challenges in clinical
destructive figure into the self structure creates an experience of sometimes indescrib-
able self-hatred. The individual’s self-hatred can only be managed through identifying
a vehicle incorporating hostility toward the individual in the social world—someone
who adopts the attitudes of hatred and creates a relationship of persecution with the
(now serially victimized) object of maltreatment. Distressing and uncomfortable as
these solutions often turn out to be, they are preferred to the alternative of internal
persecution and instability in self-experience.
Of course this model would not explain the typically grandiose and superior atti-
tude of the individual with pathological narcissism (PN). Drawing on developmental
literature, Drozek, Unruh, and Bateman identify the high prevalence of inaccurate
but positive interactions between parents and those who come to be at risk of de-
veloping PN. This creates an analogous but different challenge for self-organization
in these individuals. There is incongruity in the self structure but this feels alien be-
cause it is inappropriately, unrealistically, and excessively positive. The discomfort of
incongruity—its existential threat—is the same, but the alien part is not hateful but
excessively loving. Extrusion (projection) still has to happen to save the self, but it
comes with a loss of positive experience, as the extruded part of the self is loving ra-
ther than critical (as in BPD). Although finding external individuals to idealize (the
vehicle for this excessively positive stance) is a recognizable feature of PN, it is the ex-
aggerated value placed on the self which defines the disorder.
The brilliant insight guiding the model of treatment described in this book is
a recognition that the kind of extrusion or projection described in BPD can easily
be observed in narcissistic personality disorder (NPD), except that the incongruent
parts of the self are placed into the self-image rather than the external object. It is
the self-image that becomes the vehicle for the alien self, bringing with it relief in
terms of increased coherence, and also validation in terms of self-admiration and (in-
authentic) pride.
To make this simple idea work, the authors needed to bring in a second in-
genious extension to the basic MBT theory. They distinguish between the I-mode
and the me-mode, two developmentally sequenced categories of experience related
to the self. The I-mode, defined by philosophy of mind as the source of identity, re-
mains unchanged—the sum total of agentive self-experience. This is the sense of ex-
periencing that James recognized as the golden thread of sameness that continues
from infant behavior through childhood, and remains a core aspect of the human
mind across the lifespan: a sense of coherence and stability gifted to us (we main-
tain) by mentalization. As James (1890) wrote, “The mind can always intend, and
know when it intends, to think of the Same. This sense of sameness is the very keel
and backbone of our thinking” (p. 235). This sense sameness is located within the
I-mode. The I-mode, which contains agency, of course requires coherence. This is
why incongruent components that would compromise coherence of action need to
be projected. However, externalizing positive and favorable components of the self
into the external world opposes the pleasure principle, or the principle of reinforce-
ment learning. In common parlance, we might say, it does seem rather a shame,
particularly for individuals who for biological or social reasons are struggling with
enduring problems of self-esteem.
The solution which the authors suggest is both elegant and compelling. Where
better for a person with fragile self-evaluation to place such an inconvenient but
pleasing aspect of self than into the me-mode, the representational structure which
William James memorably named “self as object”? In the current model, the me-
mode is a self-representational structure based on the experience of the self in the
social context. It is an object that is described or narrated, rather than an entity that is
validated by its coherence and action, and consequently the I-mode is unable to tol-
erate incongruity. The me-mode belongs to a developmentally later stage, when the
capacity to construct an identity based on self-narrative emerges (McAdams, 2008;
McAdams et al., 2004). By creating a story and a set of meanings around personal
attributes, we create meaning around events in our lives. We interconnect past, pre-
sent, and expected experiences that collectively generate a unit of experience around
William James’ (1890) “self as object” or “me.” PN is not different in having a me-
mode. It is what the me-mode contains that differentiates PN.
The me-mode is the separate individual a person refers to when talking about their
personal experiences that feels sustainable over time. Of course it changes as the narra-
tive alters, but normally we deal with that through the usual flexibility that mentalizing
offers us. It is most likely that the me-mode comes to fruition as part of or after puberty,
when the demand for autonomy and the need to relate to and learn from peers be-
comes dominant (Debast et al., 2017). After the emergence of the metacognitive cap-
acity sufficient to create an integrated, evolving, coherent story of the self in interaction
with the social world, the individual becomes able to represent themselves to others,
drawing together their significant life experiences (Adler et al., 2016; McAdams, 2008).
The me-mode is a narrative identity that is more ideographic, dynamic, and contextual
than the I-mode can be, because self-agency demands coherence. You cannot do
two things at the same time, for example going at once left and right. Or you can, but
the result can be unattractive. As a narrative, the me-mode is therefore in most of us
more malleable to change—to change in psychotherapy, or perhaps even more likely,
through other social experience such as changed relationships (McLean, 2017).
Not so for the individual with pathological narcissism. If the me-mode is a vehicle
for a projection which safeguards the coherence of the I-mode, such luxury cannot
be afforded. In a person whose modification of their representational self structure
was enforced by the need to maintain coherence in the I-mode, any change in repre-
sentation signals the return of the extruded object back into the self. This gives rise to
incongruence and existential anxiety. For the BPD patient who creates a persecutor
externally and repeats again and again their history of maltreatment and exploitation,
there is no option of withdrawing the projection without generating the hatred within
the self, with self-harm and suicidal intent. The same challenge faces the person with
NPD. They cannot change. The grandiose self-love has to be part of their personality,
even if it ill-fits the reality of their life. For them, the flexibility of the me-mode repre-
sentational structure is unavailable.
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