The most selfish person you know is at

therapy being told they're allowed to be

selfish sometimes. Somewhere out there,

the worst person you know is being fed

an Instagram graphic on their algorithm

telling them it's okay to put themselves

first, right? So, do therapists know

when their patient is actually the

vision villain? One of the most toxic

people I know has been seeing the same

therapist for about 5 years with no

change in their behavior/ life, mind

you. And I just have to wonder if this

therapist secretly knows that her client

is actually the problem. The person I

know, M, is just truly awful to everyone

around her. But she's constantly raving

about her therapist and how her

therapist tells her that everyone else

is the villain in her story, that her

mom is a narcissist, her sister is a

sociopath. I've never heard of a

therapist casually diagnosing family

members with personality disorders. Does

this therapist likely know that M is the

actually the villain? So, this is a

really great question, right? So, if

you're a therapist, do you know when

your patient could be the villain? It's

kind of an interesting question, right?

like do we do we know and this is where

I would say a couple of things. The

first is that I think it's like super

scary but I have had so many patients

who have people in their life who are in

therapy for years and it appears that

from my lens of working with my patient

that the person in their life is

basically not their that their therapist

is missing this person's personality

disorder. And it's shocking like I would

say the most common example of this is I

will be working with someone who is

dating someone who has borderline

personality disorder and that person is

in therapy but the therapist seems to

think that they have severe anxiety.

Bipolar disorder is a very common

misdiagnosis of borderline personality

disorder. And so it seems like they just

are working with them for years and like

nothing is getting better. Now is that

actually what's going on? Like I don't

know, right? Because the problem with

that is is in my shoes is my patient is

in a relationship with someone with BPD.

They have a therapist and I'm like, "Oh

my god, the therapist is misdiagnosing

them." But maybe it's my patient who is

narcissistic or borderline or whatever

and represents this other person in a

bad light. So I I'm going to I'm going

to go ahead and say that as a therapist,

I believe that there are many therapists

who misdiagnose their patients. They

misdiagnoses in their patients. Now the

other scary thing is that when I say

therapists do this, do I do this? Almost

certainly, right? So there's like no

reason to think that I am impervious to

what my colleagues may experience as

well. But what I can say is that when I

work with people, I often times find

personality problems. Like I see a lot

of narcissism. I see a lot of

sociopathy. I see a lot of borderline

characteristics. And there are certain

signs. So like if you I mean this is

maybe me being arrogant here, but it's

not just me. I think I was taught by

many therapists to detect people who are

narcissistic. Right? So, one key thing

that I've learned is that if I have a

patient who is surrounded by people who

are problematic, this person mistreats

me, this person mistreats me, this

person mistreats me, the patient is

somehow responsible for that. Now, I

want to be clear about this because it

doesn't necessarily mean that the

patient is personality disordered. Okay,

this person is abusive, this person is

abusive, this person is abusive. The key

thing there is that it could be that my

patient is narcissistic and thinks that

everybody is abusive or it could be that

my patient has certain relationship

patterns where they enter into

relationships with people who regularly

abuse them. That when someone treats

them kindly, they actually freak out.

They don't know what's going on. They're

waiting for the other shoe to drop and

they run away from the good

relationships in their life. So one of

the key things that I sort of think

about as a therapist is how is my

patient responsible for their situation

in life. Even when if if it's someone

who's like let's say I have a patient

who says this person is taking advantage

of me in a weird way I still kind of

blame the patient in the sense that okay

you are doing something that allows them

to take advantage of you. I think very

heavily from a lens of what is my

patients role and responsibility in

their life and even if other people are

bad to you may be able to do something

that can change that because ultimately

we can't control them right so the field

that we play on is like what what the

two of us can figure out and how my

patient can actually change so that's

what I kind of focus on the interesting

thing is I do have a lot of patients

that I think are you know have features

of sociopathy narciss narcissism, BPD,

and I see those things. I can see and

like I'll give you guys a couple of

examples of what this looks like. I keep

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in the description below. So number one

is if I have a patient who has a very

strong external locus of control, this

is a big problem. So what is external

locus of control? When I have a patient

who comes in who says the things in my

life happen because things outside of me

control my life. So that's an external

locus of control. Where is the center of

control in your life? Society is this

way. Your boss is this way. Your parents

are this way. your wife is this way,

your husband is this way, where is the

power in the relationship? And now

sometimes that can be narcissism, but

it's not always. So that's kind of what

I think about. Does the patient feel

empowered or are they just a victim to

everything going on around them? And

then the second thing is even if they

sort of play the victim, I think this is

a really important point to understand.

A lot of people think that therapy is

about talking about your feelings. So

you come in and you talk about, oh, this

person did this and this person did this

and I feel this way and I feel this way.

And there are forms of psychotherapy

that are like that. So something called

supportive psychotherapy is an example

of psychotherapy that's just supportive.

So patient comes in every week. You just

try to do your best to support them. Now

sometimes this is what people need. Like

if their life is genuinely falling apart

and they have nowhere to turn to. They

just need one place to go for 1 hour a

week where they just vent everything out

where we're not working on what what's

your responsibility. We're not working

on what to change. they're just carrying

so much weight that they need to

unbburden it some, they need to vent

some, then supportive psychotherapy is

fine. The other thing is if you look at,

you know, patients with a history of

something like Down syndrome or patients

who have lower IQ, supportive

psychotherapy is one of the most

effective forms of psychotherapy for

those people. That doesn't mean that if

it's effective for you that means you

have low IQ, but there are certain

populations where supportive

psychotherapy is very effective. But for

me, when I work with people in their

emotions, the goal is to decompress the

emotion so that the emotion no longer

clouds your thinking. And then you

should be able to see the situation,

right? So yeah, this person you got get

this person a gift and they never give

you a gift and that hurts. You feel

angry, you feel frustrated, so be it,

right? Let's let's get those emotions

out. But then what? So what comes next?

Now that we understand that you feel

taken advantage of, and sure you're

entitled to your feelings, but then

what? What are we going to do about it?

What comes next? And there are some

therapists who don't push for that. And

this is the really tricky thing. So,

it's easy for me to say, "Hey, I don't

think that that is effective." But

that's wrong. See, this is important to

understand. I suck at that. I'm pretty

bad at supportive psychotherapy. So, one

of the key things about being a

therapist is you have to understand that

just because you're not good at a

modality doesn't mean that the modality

isn't effective, right? So it could be

that oh it's like sushi is disgusting

because I don't know how to make good

sushi. So it's very possible that other

psychotherapists are being supportive

with their narcissistic clients and they

are making progress. So I I had a a

brilliant supervisor who once told me

you know was after 3 years that we made

a breakthrough and my reaction was what

the hell were you doing for the first

two and a half why does it take 3 years

to make a breakthrough? Because there's

this presumption in especially fields

like psychoanalysis and and psychonamic

therapy that like therapy is kind of

like a long-term intense slow fertilized

growing kind of process. And I'm not

saying that it isn't, but I have to

wonder like from a almost like a

randomized controlled trial standpoint

out of those 3 years of therapy like how

much of that is really necessary. And

there are therapists who are far more

experienced than me, arguably far more

clinically superior. I don't know cuz

I've never compared my outcomes to their

outcomes who will say, "Yeah, like this

is the way that it has to be done." I'll

be the first to admit that maybe this is

the arrogance of having a little bit of

information. But when it comes down to

it, I think that most of us know when

our patient is the villain. I think most

of us can tell because there are

conspicuous things that are absent from

their stories, right? Oh, this person

cut me off. Like, this person blocked

me. This person complains about me. my

boss doesn't recognize my credit or

people at work are ostracizing me. I'm

being bullied. And then if we tunnel

down into it, is there something missing

from that story? So, what I what I

really look for is like a sense of like

do things stitched together in a way

that is that makes sense? And one of the

the trickiest things is, you know,

everyone says nowadays that people are

entitled to their feelings, like you're

entitled to feel that way. This is where

I got to respectfully disagree a little

bit. I think some of the emotional

reactions that we have, especially with

narcissistic patients, are inappropriate

to the circumstance. Like I know this is

wild, but this is a a key, you know,

teaching from Buddhism. So in in western

psychology, we have this attitude that

all feelings are healthy, all feelings

are good, you know, and this is like a

good neuroscience evolutionary argument.

Our brain has the capacity for anxiety.

Our brain has the capacity for shame and

guilt. These are important

evolutionarily selected emotions. But if

you look at sort of the Buddhist

perspective, some of them are good and

some of them are bad. Compassion

[clears throat] and appreciation are

superior to envy and jealousy are

flatout better than envy and jealousy.

And that ideally it is not good to feel

envy or jealousy ever. We want to get

rid of that completely. Now, where I

kind of settle is that in many of my

patients, what I find is that they have

what I would call inappropriate

emotional reactions to situations. Now,

this isn't their fault because they have

a template where this emotion is

activating, but they're actually like

that's not the right thing to feel,

right? So, in a sense, like we can't

blame you for it, but I think something

is really scary where a lot of the

language that we're using around sort of

the democratization of mental health

where like now everyone's being em like

emotionally supportive and mental health

aware and things like that. I think

that's a generally a good trend, but I

think it's really scary because you have

this subop of people who have become

incredibly predatory like the

narcissists who are now weaponizing the

language of therapy to continue to

traumatize other people. I'm entitled to

my feelings. Well, like sort of, right?

So, like, yeah, I understand that you

feel that way, but is that an

appropriate feeling? Oh, this person

lost weight and came to my wedding. How

dare they? I feel attacked. They're

doing it to make me look bad. And that

emotional reaction you're having that

emotional reaction isn't an appropriate

emotional reaction. If you feel bad,

does that mean that someone is trying to

hurt you? So, one of the key things that

I look for when it comes to like, is my

patient the villain? Is something called

theory of mind? So, what we see in

people who are narcissistic is the way

that they feel projects out onto the

people around them. So if my friend lost

weight and now I feel ashamed of myself,

I feel hurt. I feel like, oh my god, my

friend was able to do it. I used to be

the attractive one, now they've become

the attractive one over the last 10

years. I've let myself go, whereas they

have really taken care of themselves.

And that shines a light on my own

failures and their successes. But then

what I will do, what people who are

narcissist, this is what I pay attention

for, is do they attribute their hurt to

the other person? this person lost

weight to make me look bad. That's the

nature of narcissism. Everything that

happens around me is pointed at me,

right? And then I'll ask a couple of

questions. I'll be like, "Oh, so you

know, this person really tried to put

you down. What did that look like? What

did they say?" So, I'll be inquisitive

because I think this is the really

important thing to remember. I like

working with cluster B patients a lot.

My job is to help them be less

narcissistic cuz narcissism causes an

immense amount of suffering in their

life. Screws up their relationships,

screws up their mood, is a high risk

factor for substance use. Right? So my

job, like my goal is to help this person

become less narcissistic to help them

realize that the world is not all

pointed at them, that they take things

too personally. And so I'm on the

lookout for those kinds of features

because if I miss that, then I'm doing

my patient a huge disservice. And

[clears throat] then we do the slow work

of sort of helping them understand,

right? And like that's what the work is.

Do we know that our patient is the

villain? Oftentimes, yes. And then it's

like, okay, let's understand what other

motivations could this person have. How

do you feel about their choices versus

your choices? Cuz that's where the money

is. This person did this to make me look

bad. That's not helpful because what's

the what's the action then? Are we going

to cut this person out of their life and

then someone else shows up and makes you

look bad and then we're going to cut

that person out of their life? And this

is what happens with people who are

narcissistic. They leave a trail of

burned bridges behind them. And as a

psychiatrist, like my goal is to try to

prevent that, unless that's what they

really want to do. If they're acting

with full awareness and they want to

burn bridges right, left, and center,

like that's their choice. My goal is to

give them the choice. And then as we

examine, okay, what does it feel like

when someone shows up and has really

gotten their life together and you've

let your life slide away? What does that

feel like? What's the emotion there? How

do you feel about yourself? Right? And

this is the this is literally the

deficit in cluster B personality

disorders is a failure of mentalization.

They're not able to separate out

separate out if I feel bad someone did

it to me. No, I can feel bad and this

person can be a completely independent

entity and it is literally in the

failure of that understanding. Oh, and I

hear this so much from like parents who

have been cut off suddenly by their kids

with no warning. It came out of nowhere.

My my daughter blocked me. And that's

what their experience is because their

brain is not registering that when this

person a really good example of this is

when someone complains to you about

something that you do. A narcissist does

one really interesting thing. If they

don't agree with your complaint, they

don't accept your complaint. They

frequently think that people who

complain towards them, hey, I think

you're doing something wrong, they say,

no, I am not. If they don't agree with

it, if it doesn't make sense to them,

the other person is wrong. This is the

key thing about narcissism. When you're

narcissistic, if you don't understand

something, that means it doesn't exist.

Whereas someone who is capable of

mentalizing spins around and tries to

okay, that that's confusing to me why

you would be upset about what I'm doing.

Can you help me understand it? Like I'm

I'm lost. I don't see it, but that

doesn't mean it doesn't exist. So for a

narcissist, if they don't understand it,

that means it doesn't exist. Whereas if

a non-narcissist gets some kind of

feedback, it's not that it doesn't

exist. It's that I have a blind spot.

that's why I don't see it. There's a

differential diagnosis for the things

that I don't see. Either that I don't

understand. Either they don't exist or I

have a blind spot. And so, these are the

kinds of things that we pick up on. I

want to say that most psychiatrists and

therapists pick up on this stuff. But

this the tricky thing is I could have

all kinds of patients that, you know,

maybe I'm missing diagnoses on and I

don't realize. And I that's what's

really hard about psychiatry is like we

don't always know.