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Seminars, conferences and online resources on psychotherapy and human relationships
Fragile Selves: Working with Narcissistic and Borderline States of Mind

Online module

This package of resources provides 19 hours of CPD on the subject of psychotherapeutic work with people who have received a diagnosis of a Narcissistic or Borderline Personality Disorder, or those who express personality traits often associated with those definitions such as difficulty regulating extreme affective states in relationships and of maintaining a stable, realistic view of the self and other. It combines a rich archive of:
  • Video lectures and presentations
  • Clinical role-play videos
  • Interviews and discussions
  • A comprehensive study guide
  • Research resources
  • Therapeutic skills
The experienced clinicians featured in this module have integrated the latest research on trauma, neurobiology, attachment and object relations into their therapeutic work.

Narcissism is one of psychotherapy's core concepts and the treatment of its pathological presentation has been a major focus of much research and theorising. These ostensible personality disorders are now understood to be the product of early emotional trauma, disturbed attachment relationships and, in some, early developmental arrest of the right brain. The various and distinct symptoms of both presentations are now generally thought to be the psyche's attempt to defend against and regulate the overwhelming embodied affects of rage and shame. The differences between NPD and BPD are here considered.

Along with Borderline Personality Disorder, treating pathological narcissism has traditionally been seen as difficult and unrewarding therapeutic work. Experimenting beyond the usual analytic and cognitive approaches has proved very effective in forming, maintaining and protecting the therapeutic alliance with these fragile patients as well as fostering their capacity for resilience and empathy. A range of contemporary therapeutic approaches and the most recent theoretical analysis is offered.


Module speakers

Susanna Abse, Dr Anne Alvarez, Dr David Celani, Dr Diana Diamond, Dr Jay Greenberg, Dr Jason Hepple, Professor Jeremy Holmes, Dr Frank Lachmann, Elizabeth Wilde McCormick, Dr Susan Mizen, Dr Phil Mollon, Dr Clara Mucci, Jack Nathan, Jenny Riddell, Dr Allan Schore, Ruthie Smith, Neville Symington and Marcus West.

Resources in this online module

Perspectives on Narcissism

Professor Jeremy Holmes
Audio A History of Narcissism and its Treatment: An Effective Clinical Approach

In this talk Professor Jeremy Holmes surveys the great analytic and literary thinkers on narcissism, providing a sense of the condition's unconscious origins, it's pathological development in childhood and giving examples of its appearance in life, the therapy room and in stories from Eastern and Western Culture. Following Kohut's notion of the parental task being to offer 'optimal frustration' to the child, Professor Holmes concludes that the therapeutic challenge in repairing narcissistic wounding is to 'walk the line' offering a deep empathy that is nevertheless tempered by challenging the patient's isolating self-centredness and illusion of self-sufficiency.

Audio lecture - 50 mins
The speaker Jeremy Holmes worked for 35 years as Consultant Psychiatrist and Psychotherapist in the NHS. He was Chair of the Psychotherapy Faculty of the Royal College of Psychiatrists 1998-2002. Now partially retired, he has a part-time private practice; set up and now teaches on the Masters/Doctoral psychoanalytic psychotherapy training and research programme at Exeter University, where he is visiting Professor; and lectures nationally and internationally. More >>

Dr Phil Mollon
Audio The Development of Pathological Narcissism as a Defence Against Psychotic Fragmentation

Pathological narcissism can be interpreted as a defence against the terror of fragmentation, a fear Kohut referred to as, 'the deepest anxiety a man can experience.' Drawing on ideas from Lacan, Bollas, Kohut and Buddhist philosophy, Dr Phil Mollon suggests that we all bound to make identities from the culture we are all born into, the images others have of us in their minds.

However, pathological narcissism develops because there is no negotiation at all between the infant's own nascent grandiosity and his mother's idea of her perfect baby. This causes the infant to split off his own grandiosity and a personality develops that swings between self-regard and self-denigration in an ongoing effort to avoid the psychotic outbreak of a still fragmented underlying psychic structure.

Audio lecture - 45 mins
The speaker Phil Mollon PhD is a psychoanalyst and psychotherapist, with a background profession of clinical psychology. He has worked in the NHS for 35 years. The author of ten books, Dr Mollon has written and lectured widely on trauma, shame, narcissism, and Kohut's self psychology. Always searching for better ways of helping traumatised people, his enquiries led him to EMDR, and then to 'energy psychology'. More >>

Neville Symington
Audio Transforming Isolating Perceptions and Affects in Narcissistic Patients whose Self-Sufficiency Developed as a Protection from Malignant Parenting

Neville Symington's hopeful view of narcissism is linked to his spirituality. Narcissism is rooted in a turning away from that which should be nurturing. Paranoia, projection and self-destructiveness all stem from a quite reasonable rejection by the infant of the demands of the 'guilty adult'. His clinical examples show how the therapeutic encounter can convert isolating perceptions and affects into genuinely creative and transformative experiences.

Audio lecture - 50 mins
The speaker Neville Symington trained as a Psychoanalyst at the Institute of Psychoanalysis in London. He became Director of the Camden Psychotherapy Unit and later moved to the Tavistock Clinic, where he was Head of the Psychology Discipline in the Adult and Adolescent Departments. In 1986 he migrated to Australia and in the following year became Chairman of the Sydney Institute for Psychoanalysis and in 1999 President of the Australian Psychoanalytical Society, a position he held until 2002. More >>

Susanna Abse and Jenny Riddell
Audio The Role Of Echo or the 'Thin-Skinned' Narcissist in the Problematic Dynamics that Couples Encounter

In this joint talk, couples' therapists Susanna Abse and Jenny Riddell focus in on the mutual dependence inherent in the myth of Narcissus and Echo. Sharing examples from their clinical work, they detail how working with couples has led them to think more about the role of Echo, or the 'thin-skinned' narcissist in the problematic dynamics that couples encounter and seek to resolve.

Audio lecture - 45 mins
The speaker Susanna Abse is a couple psychoanalytic psychotherapist, executive coach and organisational consultant. She has worked in private practice with couples, parents and individuals since 1991. She was CEO of the charity Tavistock Relationships from 2006 until 2016 and is a Senior Fellow of the Tavistock Institute of Medical Psychology. She is a member of the British Psychoanalytic Council and serves on its Executive Board. More >>

Jenny Riddell is psychoanalytic psychotherapist working with individuals and couples. She is registered with The British Society of Couple Psychotherapists and Counsellors and The Bowlby Centre. She supervises and teaches on several psychotherapy programmes and CPD providers. She is also academic supervisor for MA and MSc dissertations. She has a private practice in London. More >>

The role of early brain development in Borderline and Narcissistic Personality Disorders

Dr Susan Mizen
Video Borderline Personality Disorder a disordered relationship with self, other and the body, arising from neurobiological or relational deficits and psychodynamic defences: A Relational Affective Hypothesis

Dr. Mizen presents her theory of a neurobiological and developmental pathway for symbolisation and its failures in those with borderline presentations.

Her 'Relational Affective Hypothesis' describes how neurobiological mechanisms promote mother infant interaction launching a developmental process through which the ability to symbolise emerges. Triangulation, which is key to developing the capacity to symbolise, may fail through relational or the psychodynamic defence mechanism of projective identification leading to a concrete emotional world and a disordered sense of physical and psychological identity.

The result is the emergence of two conflicted states of mind and patterns of interpersonal relating which give rise to the affective instability and impulsiveness of people with a diagnosis of borderline personality disorder and a disordered sense of what belongs to whom.

Video lecture with slides - 45 mins
The speaker Dr Susan Mizen is a Consultant Medical Psychotherapist and Jungian Analyst. Having trained at the Cassel Hospital and the Society of Analytical Psychology, she worked as a Consultant Medical Psychotherapist at Charing Cross Hospital Fulham before moving to Devon where she has developed a service for patients with Severe and Complex Personality Disorder working with a therapeutic team using a psychoanalytic model in a day and outpatient setting. More >>

Dr Allan Schore
Audio Borderline Personality Disorder as a Maturational Failure of the Right brain

Borderline Personality Disorder (BPD) is a severe disturbance of personality-functioning. It is characterised by affect and impulse-control disturbances associated with deficits in emotion regulation, as well as a pervasive pattern in self-image and persistent difficulties in interpersonal relationships. Current models of the aetiology and adaptive dysfunction of BPD are now converging as an attachment disorder that formed in the first years of life. These patients commonly experienced abusive and neglectful developmental backgrounds, a growth-inhibiting relational environment not only for social-emotional development but for early brain maturation.

Models of developmental psychopathology suggest that borderline attachment histories alter the development of regulatory cortical-sub-cortical limbic-autonomic circuits of the early developing right brain. In line with these models, a number of recent neurobiological studies now show right brain and orbitofrontal deficits in BPD patients. The clinical relevance of this documented maturational failure for diagnosis and treatment is discussed in the light of research.

Audio lecture with slides - 1 hr 40 mins
The speaker Dr Allan Schore is on the clinical faculty of the Department of Psychiatry and Biobehavioral Sciences, UCLA David Geffen School of Medicine, and at the UCLA Center for Culture, Brain, and Development. More >>

How early attachment failures contribute to the root symptom of affect dysregulation

Dr Clara Mucci
Video The Influence of Trauma on the Development of Personality Disorders During Infancy

With reference to various theorists, Dr Clara Mucci argues that the most severe personality disorders develop when an infant is traumatised early in life. Trauma inhibits normal infant brain development, causing borderline symptoms of impulsivity and unstable mood. It also warps the infant's sense of self, leading to narcissistic symptoms of aggression, grandiosity and shame.

Video lecture with slides - 40 mins
The speaker Clara Mucci is a psychoanalytically-oriented psychotherapist practicing in Milan and Pescara, Italy. She is Full Professor of Clinical Psychology at the University of Chieti, where she taught English Literature and Shakespearean Drama. She received a PhD from Emory University, Atlanta, and was a fellow in 2005-2006 at the Institute of Personality Disorder, New York, directed by Otto Kernberg. More >>

Dr Diana Diamond
Audio The link between early attachment style and personality disorder presentations

In this talk, Dr Diana Diamond describes the attachment style underlying borderline and narcissistic disorders. These have been identified over a randomised control trial of patients who exhibit either or both personality characteristics. BPD is linked primarily to preoccupied and/or unresolved attachment and NPD with dismissing/or cannot classify attachment representations in which the individual oscillates between dismissing and preoccupied attachment strategies.

Audio lecture - 55 mins
The speaker Dr. Diana Diamond is Professor of Psychology at City University of New York, the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis and the Weill Cornell Medical College where she is a senior fellow in the Personality Disorders Institute. She has written numerous articles on personality disorders, attachment theory and research, mental representation and the application of psychoanalytic theory to the understanding of narrative and symbolism in cinema for which she has won several awards. More >>

Working with Narcissistic and Borderline Patients

Dr David Celani
Videos Fairbairn's Model of Borderline Psychic Structure as a Foundation and Guide for Work with Borderline Patients

In these talks Dr David Celani outlines Fairbairn's pioneering model which describes how object relations influence personality development. He has found this particularly useful in the treatment of borderline patients who are generally considered difficult and unrewarding to work with.

Fairbairn's Ideas

Video lecture with slides - 35 mins

Fairbairn's Structural Model and Examples

Video lecture with slides - 45 mins

Treating the Hysteric, Obsessive and Narcissist

Video lecture with slides - 45 mins

Case Study: Clumsy Guy

Video lecture - 10 mins
The speaker David P. Celani, PhD, is a licensed psychologist who practiced for more than 25 years in Burlington, Vermont. In treatment, he focused on his patients' "attachment to bad objects", which manifested through their inability to separate from parents, friends, or marital partners who demeaned, criticized, or abused them. More >>

Dr Jay Greenberg
Video The Challenge of Working with Narcissistic Patients

Referencing a detailed case study Jay Greenberg explains Freud and Winnicott's differing attitudes to the viability of working with and overcoming narcissistic defences. Greenberg outlines his encounters with a particular patient whose responses showed her need to remain unaffected by his interpretations. He suggests that whilst narcissistic patients are severely provoked by a therapist who can withstand their aggression, only therapists who are unafraid to differentiate from these patients really have anything to give them.

Video lecture with slides - 45 mins
The speaker Jay Greenberg is a Training and Supervising Analyst at the William Alanson White Institute in New York. The William Alanson White Institute of Psychiatry, Psychoanalysis & Psychology has distinguished itself as one of the world's most prominent and respected psychoanalytic training and treatment centres for more than 65 years. More >>

Dr Phil Mollon
Video The Fragile Self: Working with Narcissistic Vulnerability, Grandiosity, Shame, and Alienation

Phil Mollon uncovers the core feelings which are the source of problematic narcissistic behaviour. He uses illustrations from the work of Heinz Kohut, whose case studies show how patients' dreams, sexual fantasies and perversions can all provide clues to the childhood events that caused their narcissistic wounding.

Video lecture with slides - 50 mins
The speaker Phil Mollon PhD is a psychoanalyst and psychotherapist, with a background profession of clinical psychology. He has worked in the NHS for 35 years. The author of ten books, Dr Mollon has written and lectured widely on trauma, shame, narcissism, and Kohut's self psychology. Always searching for better ways of helping traumatised people, his enquiries led him to EMDR, and then to 'energy psychology'. More >>

Dr Frank Lachmann
Video The Transformative Power of Working Affectively and Empathically with Narcissistic Patients

Frank Lachmann believes that infant research shows that how we perceive, remember, feel and behave are relationally co-created between child and caregiver. He argues that when we combine this understanding of early development with knowledge of the organisation of the mind and transference, new therapeutic possibilities emerge. Deep, enduring change occurs when therapist and client are affectively related. This is especially true for narcissistic patients who have difficulty connecting to and bonding with others. Working with such patients can also evoke negative feeling in the therapist which can sabotage the process.

Despite the challenges of working with affect and showing empathy, Lachmann argues that integrating these aspects into treatment is deeply transformative, especially so for these patients who have deep early developmental deficits and who have been traditionally seen as 'treatment resistant.'

Video lecture - 55 mins
The speaker Frank M. Lachmann, Ph.D. is a teacher, supervisor and member of the Founding Faculty of the Institute for the Psychoanalytic Study of Subjectivity, New York; and a Clinical Assistant Professor, in the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis. More >>

Ruthie Smith
Video Disorganised Attachment as a Reframing of Borderline Personality Disorder

In this talk Ruthie Smith explains how a person with a disorganised attachment (Type D) has suffered from wounding and complex attachment trauma in early infant development, which adversely affected their subsequent personality development. Such clients attract less empathy than those with other emotional difficulties or behaviours, not least because as a result of their fragmentation and weak ego boundaries, they unconsciously project painful and uncomfortable feelings into others. Clients who exhibit disorganised attachment patterns have traditionally diagnosed as suffering from 'borderline personality disorder'.

Ruthie proposes that it is helpful to view and work with this client group through the lens of trauma, working with the body as well as the mind. Good results in facilitating affect-regulation and gradually transforming relational patterns have been found using Energy Psychotherapy techniques in combination with talking therapy, which can also be used as self-help tools by the client. Since these methods work at the level of cellular memory in the body they have the capacity to help break down otherwise seemingly intransigent patterns, although this is long term and complex work. Ruthie's talk is informed by neurobiology.

Video lecture - 1 hr 30 mins
The speaker Ruthie Smith is a Psychoanalytic Attachment Based Psychotherapist and Energy Psychotherapist with 30 years' experience in private practice and 10 years as a Principal Individual Psychotherapist and Supervisor in the NHS. More >>

Jack Nathan
Audio The Use of 'Benign Authority' with Borderline Patients: The Need for Interpretive Attunement and Limit-Setting

In this talk, Jack Nathan describes how BPD symptoms present and how therapists can best support those with these behaviours. He makes the case for the use of benign authority - an approach where the practitioner attunes to the 'logic' of the borderline's internal experience, whilst also attending to challenging persistent acting out behaviours, through limit setting. There is always a dialectical tension between these two functions.

In the face of the challenges the borderline patient can pose, benign authority can support the therapist in not succumbing to the twin dangers of, on the one hand a 'maternal' masochism, and on the other, 'paternal' sadism.

Audio lecture with slides - 30 mins
The speaker Jack Nathan is a psychoanalytic psychotherapist and Consultant Adult Psychotherapist at the Maudsley Hospital Psychotherapy and Self-Harm Out-Patients Service. He is particularly interested in how to work with this patient group - which was once openly referred to as 'the patients psychiatrists dislike' - what countertransference difficulties they arouse and the meaning attached to their self-destructive behaviours. More >>

The Cognitive Analytical Approach

Dr Jason Hepple
Videos A Demonstration of The Cognitive Analytic Approach to Working with Narcissistic and Borderline Personality Disorder

Working with Borderline Personality Disorder (Lola)

In this video, Dr Hepple demonstrates the main features of Cognitive Analytic Therapy when working with a Borderline Client. CAT has been taken up widely within the NHS as although it is time-limited it has shown itself to be very effective in alleviating these patient's distress and promoting improved self-management and self-care.

Video Role Play - 30 mins

Working with Narcissism (Kenneth)

In this video, Dr Hepple demonstrates the main features of Cognitive Analytic Therapy when working with a Narcissistic Client. CAT has been taken up widely within the NHS as although it is time-limited it has shown itself to be very effective in alleviating these patient's distress and promoting improved self-management and self-care.

Video Role Play - 30 mins
The speaker Dr Jason Hepple MA FRCPsych was born in Somerset and studied medicine and then psychiatry and psychotherapy at Oxford. More >>

Elizabeth Wilde McCormick
Video Borderline and Narcissistic Clients in Cognitive Analytic Therapy

In this interview, Elizabeth Wilde McCormick explains the characteristics of the borderline personality within the framework of Cognitive Analytic Therapy (CAT). Grounded in the cognitive revision of object relations theory, a central tenet of CAT is that from birth we all internalise a complex web of relationships which CAT names as reciprocal roles. Until revised these roles may dominate our adult relationships and are likely to be acted out in therapy, which is where the valuable work of noticing and choosing to change may be invited. Patients who are described as borderline tend to have reciprocal roles related to neglectful early care such as abusing/attacking in relation to abused and attacked. The resulting deep emotional states may shift suddenly in response to perceived threat and this is likely to be enacted during a therapy and is an essential form of communication. It is the therapeutic work to contain and name the different states and create safety and this is challenging for therapists who often feel deskilled, confused, afraid or angry.

Elizabeth elaborates her understanding of how these states operate within the psyche as ways of managing difficult feelings that cannot be otherwise described. In the early stages, the therapeutic work is simply that of recognition of what is being felt or enacted. By developing an observer-self, who learns to recognise these emotions, it becomes possible to find language for them - the key to containment. Ultimately, clients become more able to tolerate relationships, to be less reactive and more responsive.

Video lecture - 35 mins
The speaker Elizabeth Wilde McCormick has been practicing as a psychotherapist for over 30 years in both private and NHS settings. Her background is in Transpersonal and Humanistic Psychology, Social Psychiatry, Cognitive Analytic Therapy, Sensorimotor Psychotherapy and Mindfulness Based Stress Reduction. More >>

Panel Discussion

Dr Anne Alvarez and Marcus West
Video A panel discussion on the treatment of Borderline and Narcissistic presentations

Marcus West and Dr Anne Alvarez discuss contemporary questions around the diagnosis and treatment of so-called Narcissistic and Borderline Personality Disorders. They also share some of the therapeutic tips and pitfalls they have learnt from their extensive but different experiences of working with adults and adolescents.

Video discussion - 1 hr 5 mins
The speakers Dr Anne Alvarez, PhD, M.A.C.P is a Consultant Child and Adolescent Psychotherapist (and retired Co-Convener of the Autism Service, Child and Family Dep't. Tavistock Clinic, London, where she still teaches.). She is author of Live Company: Psychotherapy with Autistic, Borderline, Deprived and Abused Children. She has edited with Susan Reid, Autism and Personality: Findings from the Tavistock Autism Workshop. A book in her honour, edited by Judith Edwards, entitled Being Alive: Building on the Work of Anne Alvarez was published in 2002. More >>

Marcus West is a Training Analyst of the Society of Analytical Psychology and the UK Editor-in-Chief of the Journal of Analytical Psychology; he is also a trained EMDR practitioner. He is author of three books, Into the Darkest Places: Early Relational Trauma and Borderline States of Mind (2016), Understanding Dreams in Clinical Practice (2011), and Feeling, Being and the Sense of Self: a new perspective on identity, affect and narcissistic disorders (2007). More >>

Grey Oval, Kandinsky (1917)

  • Self-funded: £200
  • Organisationally-funded: £300
  • Institutional account (4 or more): £90 per user
  • Teaching licence (10 or more): £75 per student
  • Test and Certificate of Attendance: £36

This module includes:

  • 17 hours of video and audio presentations illustrated with captions, diagrams or images
  • Supporting notes, slides or references
  • Study guides
  • Bibliography linked to relevant articles and books
  • Additional resources relating to each speaker
  • Discussion forum
  • A Certificate of Attendance through which you can acquire up to 19 hours CPD on the basis of a multiple choice questionnaire assessing your knowledge of the module.

Study guides

  • Brief history of the concepts of 'personality types' and 'personality disorders'
  • The symptoms and clinical presentation of narcissistic and borderline personality traits
  • Aetiology of borderline and narcissistic traits
  • Therapeutic approaches to working with fragile selves
  • Controversies
  • Key people and theoretical developments
  • References
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