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Two Ways to Handle One High Conflict Case with Dr. Anthony Mazzella · It’s All Your Fault: High Conflict People

• This transcript is produced using transcription software and reviewed for quality. Despite our best efforts, some passages may be incomplete or contain errors due to audio quality or software limitations. Megan Hunter Welcome to It's All Your Fault on TruStory FM, the one and only podcast dedicated to helping you with the most challenging human interactions, those involving someone with a high conflict personality. I'm Megan Hunter, and I'm joined by my co-host, Bill Eddy. Bill Eddy Hi, everybody. Megan Hunter We are the co-founders of the High Conflict Institute and ConflictInfluencer.com, where we focus on training, consulting, teaching, all kinds of methods to do with high conflict and how we can help people in any high conflict relationship. So today we're really pleased to be joined by Dr. Anthony Mazzella. We know you'll love hearing from him. He is going to talk about his approach to high conflict relationships, and whether treatment can be successful with people who may have narcissistic personalities, which I find very fascinating. I think a lot of people think there's not a lot of hope, so we're going to find out today. So welcome, listeners — thank you for joining us during your Pilates class. In most episodes, we break down concepts, answer listener questions, or talk through the patterns that we see in high conflict relationships or interactions. Today we want to get into the room with you and walk through an actual case, show you how we think about high conflict behavior, and then have someone discuss, compare notes, and tell us where things can be done differently. That someone is Dr. Anthony Mazzella, who is a psychoanalyst and psychotherapist in private practice on the Upper East Side of Manhattan. He's a training analyst and full member at the Institute for Psychoanalytic Training and Research, known as IPTAR, and a member of the International Psychoanalytic Association, which holds its members to the most rigorous standards for psychoanalytic training anywhere in the world. Dr. Mazzella holds fellow status at both organizations, serves as faculty and as a supervisor at IPTAR, and also teaches at the Metropolitan Institute for Training in Psychoanalytic Psychotherapy. Mouthful. He is an approved continuing education provider recognized by the New York State Education Department. And that's a lot of really impressive stuff, but he's also someone who believes, as we do, that people with high conflict patterns are not a lost cause — that with the right approach, real change is possible. That's a hopeful message, and one that we don't hear often enough. If you're a clinician, we think you'll find this practically useful. If you're someone navigating a high conflict relationship in your own life, we hope it gives you a new way of seeing what's really going on. So let's get into it. And first of all, welcome, Dr. Mazzella. I think we're going to call you Anthony going forward. So if you'd like to give us a little more background about how you got into this work in the first place, we'd be really fascinated. Dr. Anthony Mazzella Sure. Well, first, thank you both for having me here and giving me this opportunity. I was saying off air that I've always been a big fan of the podcast, so I'm truly honored to be here. So the way I got into this is, many, many years ago, I worked in a hemodialysis unit. That's where people go when they have kidney failure. Sometimes they have to go three or four times a week — well, they go three times a week for three to four hours, so it takes up a big part of their life. And one of the big problems, obstacles there, was that many patients would skip their dialysis treatment or shorten it. At the time, there was really no effective treatment approach to help patients become what they called more compliant. So, in short, I designed an intervention — which, quite honestly, is based on a lot of the things, the techniques, that the two of you discuss, and I'll go over today. I had a comparison group who got usual care, which was more like lectures and the risk of missing the dialysis treatment, and educational material. We compared the outcome between the intervention and the control group, and what we found is that adherence to the treatment protocol increased by over 200%. But more significantly, even after the intervention was done, at the three-month follow-up, their adherence continued to improve. So that's really what got me started, because when I sat with these individuals, what I discovered was that a lot of them had what we would call high conflict personalities, or what we call in my field, personality disorder or traits. So that's where I first started learning about narcissism and borderline personality characteristics. And from there, I took a deeper interest, because I started lecturing and teaching on this subject subsequently. Megan Hunter I did not expect it to start there. That's really fascinating with kidneys and dialysis. Bill Eddy It's fascinating that that's where you ran into high conflict personalities, because you would totally think of it as a social thing rather than a health and personal thing like that. So I'm excited to hear about the success of that and where you've landed in general since then. Dr. Anthony Mazzella But of course, one of the biggest things — I know the two of you are familiar with this — is that when they were skipping the dialysis or shortening the treatment, although it had severe negative consequences, when they were told, "You need to be compliant, you need to be here," it's sort of what we call the boomerang effect. Somebody with a personality disorder doesn't just internalize a positive message — they feel controlled or nagged. And then it's important that they get control back in whatever way is necessary. So one really wonderful way for them, a compromise to get control, is: "You want me to come? I'm not coming. I'd much rather be in Atlantic City gambling than sit here and get a lecture from you on how important it is for me to get my treatment." Because these were grown adults — they didn't need to be told what to do in terms of how to take care of themselves. Megan Hunter So when we talk about high conflict and high conflict personalities, you know our definition after listening to our podcast a lot: unmanaged emotions, extreme behaviors, all-or-nothing thinking, and focusing on a target of blame. I like to explain it to the person on the airplane next to me as — people take different approaches to conflict and to relationships and to interactions. And I think with the high conflict individual, their approach to conflict and relationships and interactions is going to be exactly what you described: I need to have control over this, and it's a very "opposites" world. So we're curious — do you have a definition of your own about high conflict personalities? I know you're coming at it from the clinical perspective, personality disorders, but do you have a similar or a little different definition? Dr. Anthony Mazzella No, I think the definition is very similar to the way the two of you describe it. I think what might be slightly unique or different is the approach that I take with these individuals. If we use the example of the dialysis patients — when I sat down to work with them, the focus was never on the behavior. It was on: what function does this behavior serve? In other words, even with high conflict individuals — the focus, and many people see this, right? It's the anger, the blaming, the conflict — "it's all your fault," right? Taking no responsibility, the dysregulation, poor impulse control. I can keep going; the two of you know about high conflict. But most people think, and this was the problem in dialysis as well, that we need to get this behavior under control. So that's something different in terms of the way I conceptualize the behavior. The way I think about it is the behavior is solving a problem. It's either there to solve a problem, or to protect the person from something, or to manage some sort of psychological function going on inside of them — perhaps an internal conflict, for example, of needing to be dependent on the staff and on hemodialysis to survive. Because, again, people with personality disorders like narcissism in particular do not do well with dependency or with needs. So, in short, I think the approach, or the way I conceptualize it differently, is that I want to get closer to the behavior. The goal is not to make the behavior go away — it's to understand the emotional inner conflicts, the attachment patterns, the defensive strategies they use to get rid of painful feelings. So the theory, in terms of the study I just mentioned, was that when we could get closer and help them understand all of what's driving the behavior — which is the manifest presentation of the problem — then, hopefully, over time, they no longer need that problematic behavior to solve an internal problem. I know that sounds like quite a bit, so maybe I could pause there for a second and see if that raises any questions. Bill Eddy Well, let me just respond, because I really like that. As a therapist, as a licensed clinical social worker — a lot of what we say, because a lot of what we're dealing with in mediation, human resources, legal cases, is we don't have much time. So we often are focusing on setting limits, imposing consequences, and not trying for insight. And what I was thinking is your work sounds like it leads to some really good insights, and we generally say, forget about insight — focus on what you have to do, what you can and can't do. Don't make people look inward; have them look outward at what their choices and consequences are. It's a more minimalist approach. And yet in the settings we're most often dealing with, we don't have that opportunity. So I'll be interested to see if there's some way to accomplish what you're doing in the kind of settings that we're often in. Dr. Anthony Mazzella No, Bill, I think to some extent the two of you have nailed it with your approach. I love all your acronyms. So even when I work with these individuals, to your point, which is well taken, the immediate goal is never insight — that's a long-term goal. When you're dealing with somebody who has a high conflict personality, or personality disorder, or these traits, they have no interest or capacity, by the way, to tolerate insight. So that's more of a longer-term objective. But the more immediate objective — which is something in my field we call containment, but it overlaps quite a bit with one of your acronyms, CARS, right? Was that one of them? Am I getting that right? Megan Hunter You got it. Bill Eddy That's the large one: connecting, analyzing, responding, and setting limits, and within that we have some smaller acronyms. Dr. Anthony Mazzella Yeah, so even in the connecting, if we just start with that one as an example — the main objective of connecting, I think, and here I hope to hear from the two of you, but this is my initial goal — is to move somebody from what we call a dysregulated state into a more regulated state of mind. So maybe that's where I think there's probably quite a bit of overlap, because the way we do that — I'm using some of your language, so please bear with me if I'm a little off — but I think you have something also called EAR, right? The EAR statements — you really need to sort of pull up a chair and listen. And that's part of containment as well. So when someone comes in, as they often do, in a very dysregulated state — the first order, they come in angry, overwhelmed, blaming, all the things that have to do with high conflict — the first goal is to pull up a chair, sit down, and then understand it very closely from their perspective, at least initially: "Can you tell me more about what happened?" We could go into specific examples of this, but I just wanted to respond quickly to your comment, Bill — yes, that is the most immediate goal: not insight, not going back to history. Because they're just not able to use that kind of information in that way, at that time. Bill Eddy Well, that's refreshing, because I think we really are on the same page with some of those principles. So that's great. Dr. Anthony Mazzella Yeah, so I guess the next step would be — I don't know if you bump into this — but the more challenging piece, I think, is: let's say, hypothetically, we do the connecting, right? We give the EAR statements, we do what I'm calling containment, we get them into a more regulated state, but things don't change. Maybe that's not something you have to encounter too much, but in my field, because people tend to come back over many months, sometimes years, sometimes things don't change. Even though you could get them into that state in the moment, the destructive patterns, the poor impulse control, the lack of frustration tolerance continue. So we'd really be thinking about — maybe a subset of what you see — but what I tend to see more often is people who are not initially, or even over time, responsive to what I would call these early-level, or foundational-level, interventions. If that part makes sense. Megan Hunter Yeah, yeah. So let's dive into a case. I think you came prepared with maybe a hypothetical case to talk about, and then we can break it down. And I agree with both of you. I often describe, when I'm giving a training, I have a nice little chart that shows the fear response — where they can't contain their own impulsive behaviors, the rage, the upset. The fear response comes in and isn't optional for them — it's just the operating system. Then their coping response is this whole bottom row I have on the chart. And I always point out that whole bottom row is just: we're all trying to get back to our default state of feeling okay. And for the narcissist, it's a feeling of superiority again. So I think it makes a lot of sense to people during trainings, to make it simple for them to understand and maybe gain some empathy and awareness. Okay, so let's get to the case. Dr. Anthony Mazzella So the case — I think you might be familiar with this. I'll do it in a broad enough way that many people can relate. We'll say someone presents in session, absolutely furious with her husband. She was supposed to go out to lunch with him, and when they were exiting the apartment, he took a different way out. So this escalated very quickly. We could fill this in with any example — someone has date night and one person shows up 10, 20, 30 minutes late; you send a text message to a loved one and they don't respond right away. But I'm leaving it more open-ended. But in this example, she becomes enraged, and she comes into session — not just with him in that moment, which of course she tells me about, because when he does come out, they end up fighting. They're having a big argument on the street. She's screaming at him: "You do this all the time. You're never there for me. A simple lunch that we were supposed to start together, and you're already separate from me. This is your selfishness." And then the blaming comes out. So this, by the way, is his narcissism, she's trying to tell me. So I think the two of you may be familiar with this a little bit. Does this sound familiar so far, in terms of— Megan Hunter Check, check, check, check, check. Bill Eddy High conflict couples. Dr. Anthony Mazzella Yeah. So we can hear all the things that are happening there, but Bill, to your point a moment ago, we cannot work with it until she has a capacity to get into a more reflective state of mind. So the goal, again, as I mentioned earlier, is just moving that — she's dysregulated, that's what we call it, just overwhelmed. So the initial goal is to help her get into that more regulated state. So the first thing I have to do is fight my own urge — this is what we call countertransference in my field — to take a side, either blame her or say she's overreacting, like, "What was the big deal, he went out a different door, but he was there literally 20 seconds later." We don't do any of that stuff. I don't try to figure out who was right and who was wrong. The only goal, right at this moment, is to get closer to her subjective experience. And the way we do that — and I think this is where there might be some overlap in our approaches — is to do the EAR thing: "Can we go over this again? I really want to understand what happened." And sometimes it may even mean that I'm repeating parts of the story, which, by the way, is okay to do — because that creates a little space for thinking, both mine and hers, because I need a little space to think too. Sometimes being with these people, as you know, is very intense, because you're flooded with affect. So initially I may even go over parts of the story, and then check: "Did I get that correct? Am I hearing you correctly?" And then slowly, if that's settling her even just a little bit, we go a step further. And I would want to inquire, at that moment — "When you realized that he was exiting through a different door, can you tell me what was going on inside of you? What were the thoughts and feelings?" So that part may be a little different, I'm not sure, but I want her to feel like she's being heard, because with many of these individuals, they cannot hear you until they feel like they're being heard. So that's the initial presentation: intense affect. Splitting — everything is the husband's fault, look what he did to me — dysregulated. Sitting down, slowing everything down, and getting as close as possible to her subjective experience. And that's it, Bill, period. Nothing about history, nothing about transference in the room, nothing like that. So that's where we start. So can I pause there just for a moment, to see if there's any reaction to any of that? Bill Eddy Well, first of all, I like it. The one minor difference, I think, is because we often say, "Tell me more, I want to understand" — we want to connect with their experience, but we don't ask them about their feelings, because we find that generally they become more dysregulated the more they focus on their feelings. So we try to focus on what's happening and understanding what's happening, and even saying, "I hear your frustration, I can see your pain" — acknowledging and labeling the emotion, but not opening up emotions — and then moving to, "Let's look at what our options are now." So that's the only difference. I think that essential connection is so important, and while I don't try for insight, we definitely work with that connection. Dr. Anthony Mazzella Okay, okay. Yeah, so let me speak to where we go next. But before I do — the feelings, I completely get it, because the environment we're working in is a little different. Your goal with these people, in that moment, is not to open up, because you don't want to open up these feelings. But for me, I do want to get very close, because I want to understand — not the feelings of, like, he's selfish, narcissistic. You could fill in the word there, right? Bill Eddy I can be playing fine. Megan Hunter Which is a blame, right? Dr. Anthony Mazzella Yeah. Yeah. It's more like what happened at that moment, and what I begin to hear as they settle, is a sense of: he rejected me, I felt abandoned, I was all alone, he wasn't coming back. So that's what I meant by feelings — not the angry presentation, what we would call the defense or the smokescreen, but what's really going on, and how hurt they feel, and how they need to get rid of those feelings so quickly by creating a conflict — there are many different ways to get rid of feelings, but one way is to create a conflict with her husband. And that's a wonderful solution, in the sense that now the conflict is no longer inside of her — it's no longer intrapsychic, it's interpersonal, between the two of them. And one of the reasons I like to get close to the feeling — another reason — is now we could work with her solution to the problem, but I could really understand why she needed to do it this way. So I'm still kind of in the EAR statement of listening, trying to understand her subjective experience. But it gives them a feeling, typically, if things go well, that this wasn't just — parenthetically — crazy behavior. It seems like crazy behavior on the surface — you're in the middle of the street, fighting, screaming at your husband — but on the other hand, it doesn't seem so crazy if I understand it as: you're trying to get rid of something that's so much more painful than fighting with your husband. But anyway, I digress. So — yes, I think I heard the next step that you said, Bill, which was — coming up with solutions. Was that correct? Bill Eddy Yeah, so we analyze — so we connect, then A would be analyzing options, outside of themselves. So they don't have to reflect, they don't have to judge themselves or anything — it's like, okay, now let's look at what your choices are, things like that. Dr. Anthony Mazzella Yes, okay. So I think, yes, we're on the same page, at least in that initial one — but right here it's a little different, because before I can analyze or come up with a solution, it's more of the same. I'm trying to understand what made this moment so charged. Like, clearly you got very charged up about this, you got very upset, right? So that's the analyzing part, as I'm trying now with her — if she's in a more regulated state — to understand: what actually did get you so charged up? And I always have my mind on those central questions — I'm not interpreting any of this, but I'm always thinking: what problem is the behavior solving? Now, in this hypothetical example, the problem that this woman was solving is she didn't want to feel alone. One way not to feel alone is if she's attacking and aggressive and fighting — she's locked into something with her husband. Again, not the best way — I'm not saying it's a healthy way of not feeling alone — but you certainly get somebody's attention when you're behaving that way, because now they're locked in a fight. So: what problem is the behavior solving, and what is she protecting herself from? That's always in the back of my mind. And what I begin to hear is: the ultimate goal is for her to never, ever feel alone — that he left her, and she was abandoned or rejected, and she doesn't want to feel that way, and therefore this guy should always be perfectly synced up with her. So that's the analyzing piece — but again, not to her, yet, at this moment, because me telling her something like that would have no benefit. The more important goal is to try to help her get to the point where she could begin to see or recognize some of these things that are happening. Megan Hunter So in the therapeutic setting that makes a ton of sense. I wonder — let's shift it to an HR setting. And with "analyzing," the way we talk about it — I mean, it can be taken a few different ways, right? I'm analyzing what I should do, I'm helping them analyze what their options are and focus on choices or make proposals. But if we shift to HR, and that HR professional is faced with this, and they've got the EAR statements down — I've connected, I've helped de-escalate, contain, we're in a good space together — should they go in the direction you're talking about? Is it okay to go in that direction, or should it be more contained — just, "Here are the options that we have, and you need to focus on the choice between those options"? Dr. Anthony Mazzella It's a wonderful question. I would follow up with a few other questions. One of which is: is there a pattern, or some history? Has this HR person already sat down with this employee? Megan Hunter Let's say no. Dr. Anthony Mazzella Okay. Bill Eddy Sometimes yes, sometimes no. We've got a mix of it. Dr. Anthony Mazzella Okay. And then the follow-up — let's say they've sat down, and this is beginning to be a bit of a pattern. How important is this employee to the organization? Because we can always move in a direction — this is part of boundaries, I would imagine — we could do a disciplinary action, or write them up in some way, and if they get a certain amount of these, it would move towards termination, I would imagine. Something like that. The two of you are probably closer to this than I am, so I'm really just checking in with you — what would happen in that situation if there's a pattern? Is the goal to discipline and then remove? Bill Eddy Well, I'd say a lot of HR situations we may get involved in — I've been involved with high-tech companies, they have employees who are brilliant and they don't want to lose them, but they've got what they call sharp elbows — they keep bumping into each other, yelling, sending really hostile emails and things like that. They end up with HR saying, "You've got to do something about this middle manager, because they've got a pattern of this," or maybe there was one big blow-up. That's the kind of situation I see — you can't just say, "Well, let's terminate this employee, they're a nuisance." It's like — we've got to keep them, like a doctor or a surgeon, somebody like that. Dr. Anthony Mazzella Yeah, and that's what I was thinking too, along those lines, Bill — because that's a little closer to, like, if you actually have a relationship with somebody who's important in your life, and you may not be ready, or you don't want to just lose them. So, Megan, just to go back to your question — you give the EAR statements, you meet with this person. Let's hypothetically say we'll go somewhere in the middle of compromise — maybe it's not the first meeting with them, but it's not the fifteenth either, maybe you've met with them just a few times. At some point, if you're invested and want to keep them, and if there's a level of sophistication, you could go one step further. The one step further would be, like, to go back to this case example — the two of you could tell me if this could apply or not. What I did with this woman is she does get into a more regulated state by me saying things like: "Right now it feels like your husband is completely, or entirely, uncaring — as if there's no part of him that cares or loves you, he's entirely rejecting. Am I getting that correctly?" So, in terms of HR, I'd have to hear the nuances of how these things play out, but I can't imagine it's too far away from that, Megan — where they come in, and this is again what we call a split representation. They're splitting. So in that moment, if they're in the office, they probably perceive somebody as being very mean-spirited, or evil, or abusing them in some way. Am I close to the mark with the HR example? Because I'm trying to demonstrate what I would do with this woman — this would be the next-level intervention. What I'm doing now is identifying what we call a split, which is the biggest piece of working with high conflict patients, in my opinion, or personality disorder patients. Because the core of the self is fragmented. And when there's a fragmented sense of self, they are prone to what we call splitting — which basically means, I know the two of you know this, but somebody's all good or all bad, oftentimes all bad. Bill Eddy Yeah, I think the difference in what Megan's talking about and what you're talking about is with HR in a situation like this, I would see them referring to coaching or counseling. And that's where that kind of discussion you're talking about would happen. Dr. Anthony Mazzella I see. Bill Eddy And in many ways, that's why we really believe in coaching and counseling — we get lawyers and mediators and judges to say, "Wow, I can see how you're hurting, how frustrating this is, and here's what you need," so they're not necessarily doing beyond the EAR statement and setting limits. That's one of the options, and that's one we believe in a lot — like our New Ways for Work coaching model. So the question would be: would the coaches do what you're talking about, since the coaching's usually short-term? Say they have three sessions, like EAP — employee assistance personnel — have three sessions, we have a workbook, they teach some skills, very behavioral. But I'm curious — for the coaches, would they do what you're talking about? Dr. Anthony Mazzella Yeah, I mean, that sounds more appropriate — thank you for clarifying that. It sounds more like a job for the coaches at that point, because we're getting in just a little bit further now, by me labeling that split representation. So, in three sessions, to your point, Bill — three sessions is really tough. So, from my biased perspective, what I would try to accomplish in three sessions — and this is my own bias — is, at the very least, I would try to engage their curiosity. I would try to make them more curious about what's going on and how it quickly became this — and that's, again, in this prototypical example. Once they're settled and begin thinking — these people, by the way, I don't know if this is your own experience, but when they're in a more regulated state, they can become a little bit insightful and reflective. They do have some reflective capacity. And what this woman said, when she did calm down, is: "It felt like he left me." And this is just part of the nuance of working with these individuals — and this is, Bill, when you have a little more space and time, we could dwell on certain words, like "it felt like." And I would say, "Can we go back to that? I noticed you said, 'it felt like he rejected you.' But that implies something — I don't know if that's what you meant to imply, but maybe you could tell me. But that implies that maybe he didn't actually reject you and abandon you — do you think we could talk about that a bit more?" Megan Hunter A little reality testing. Dr. Anthony Mazzella Yeah, it's reality testing — it's helping them be a little curious. Is there a discrepancy here between the way that I feel and what actually happened? Because, in fact, oftentimes what I hear — again, prototypical example — is: "Well, what I meant was — I know, last week I was just telling you that he planned my birthday party for me, and that was really sweet of him." See, but I don't remind her of that — it's important that she comes to this herself. So yes, Megan, it's reality testing, and it's also helping her develop a capacity to create a little space and get into a more reflective state. And that's what I was starting to say — if I only had three sessions with somebody, my goal would be: can I engage their curiosity just enough that then they're interested in doing further work on this? Because we know people with high conflict personalities, or personality disorders — it's going to be very hard to put a dent in this stuff in three sessions. It takes a little more time to change patterns that are habitual, methods of attaching to people, inner representations of oneself — this stuff gets a little more complicated. Bill Eddy Yeah, it's interesting, because a lot of the situations we deal with, there isn't time — with judges, with mediators, in the middle of the mediation, someone becomes dysregulated, both people become dysregulated, and there's lots of heavy use of EAR statements, and also talking about analyzing options and such. What you're saying is important — I think that high conflict personalities, which we see overlap about 50-50 with personality disorders, can be reached, but not in those contexts, and that getting people to pursue that is maybe an ideal but also pretty hard. And it sounds like the way you do that is through that initial connecting process, and then starting to help them see what may be going on inside of them, and that it doesn't fit quite with what's going on outside of them. And I think I can see referring — telling the judge, "You need to refer them to Dr. Mazzella." Dr. Anthony Mazzella Yeah, especially if it's someone — I've acted as a consultant on high conflict divorce cases, where they think there's a personality disorder involved. So I try to always help them be very careful and mindful of the way they construct their sentences and the way they speak to these individuals. So — I didn't think about this before, Bill, but you got me thinking — the listeners may be saying, and Bill, you may be saying, this stuff seems helpful, but not really to the people, the situations that we're in. But I think the more mindful we are of all the dynamics that are going on, which I'm describing, it really does lend the potential to change the way that you talk to these people, which is, of course, something you know. And I think that's why I appreciate you said we don't have that kind of time, and I think your model — that's why I like CARS — is so appropriate for your audience. I was just thinking about the people, like in HR, what Megan was raising — we want to keep them around, there's a pattern here, and they already did the three sessions. What more can we do with this person if they're not responding to all the good techniques and tools that you and Megan use in your teaching? Right. So this is something that would just go a little bit further than that. That's the way I would see it. Bill Eddy Which is possible — the question that's often been there is, would they go there? In other words, personality disorders are fairly resistant to interest in therapy. You've got to get your foot in the door, like you're describing. But I think, Megan, you were about to say something. Megan Hunter Well, I was going to continue on a little bit with the CARS method through our initial case, after distracting you both with the HR discussion. So — responding, in the CARS method: responding to misinformation, responding to a hostile email — and then setting limits. And then we're going to get into the discussion around narcissism. I would assume and imagine that you often encounter misinformation — would you agree? And how would you handle that? Dr. Anthony Mazzella So the responding, I think, is maybe a little different — I alluded to this before, so this is just a little review. My response would be more on the lines of — once I do my own connecting, and the analyzing, the A, which was a little different — I'm trying to understand the emotions behind the outburst, how they felt rejected or abandoned or whatever it might be. So that last step, the responding, is I'm responding only, Megan, to their subjective experience. And when their subjective experience is way off the mark — to your point, you mentioned denial before — part of containment, believe it or not, is not just holding somebody and validating them. A big part of containment that a lot of people leave out, because this part's harder, is confrontation — confronting them that there's a big discrepancy between what they imagined happened, or what they felt, and what was actually happening. And I don't mean confronting them in an aggressive way — it's always with curiosity, to try to understand how they make sense of these two things. Like in that example, when I said, "Well, right now you feel like your husband is the enemy — he's uncaring, he's narcissistic, he's selfish, and that's all, right?" And then, if she didn't come to this on her own — "Oh, by the way, last week he did plan a birthday party for me." I might try to evoke a memory, and see how that goes. Now, that's tricky business, because when they're in this sort of frame of mind where things get split, they can't recall the other piece of reality that happened just a week ago — sometimes just 10 minutes ago, by the way. But I will try to evoke a memory, with curiosity, and say: "Hey, listen, can I go back to something you said to me last week? Is it okay? Because I do remember you talking to me about your husband putting together this wonderful party, and how good you felt. So how do these two things go together? How can we make sense of this?" So, Megan, that would be another intervention, another way to go with it. Megan Hunter And thank you for that. Then — on to setting limits — where does that fit in for you? Dr. Anthony Mazzella Yeah, setting limits — and again, I appreciate this part of your treatment model as well, because it's not that it doesn't exist. I'll just give you a quick example. I was treating a woman who was homebound — middle-aged, not working, living an anaclitic life, depending on her mother. And her mother, over the course of about a year — this is longer-term treatment — she started to get better. She started going out. And her mother could not tolerate this. So she would send me scathing emails — that I'm not helping her daughter, that I'm the worst therapist she's ever had. So finally it got to the point, Megan, where I had to say to her — because these were pages, I don't mean a few words, but pages of emails about what a failure I am, and it was all because the mother felt so threatened, because the daughter was showing signs of change, probably for the first time in her life. But I had to set a limit and say to her: "You can't send me these emails anymore, and if you continue to send them, I'm going to block you. Any further correspondence will need to come through your daughter — if you need to talk to me, you can go through her." So I don't know if that exactly fits your definition of a limit or a boundary, but that's the way I've had to handle it with this mother. Bill Eddy That's a perfect example, because you're setting a limit but also saying what the consequence is. And that's what we've learned — with high conflict people, just setting the limit, they often ignore: "Please don't send me these long emails." "Yeah, right, I'll just do whatever I want." "If you do, then I'll have to block you." So that's a perfect example. I think what's interesting is some of what you do — I think our processes are somewhat parallel, that ours is really more of an intervention, and yours is more of a therapy. And there's a place for each, including — some of our interventions are to get people into therapy where you can do that. So, for example, analyzing and responding — for us, it's analyzing options outside of the person; for you, it's analyzing what's going on inside the person. So it's parallel — I think it's very interesting and encouraging, because I think you're having success with people that a lot of people we run into have given up on. Dr. Anthony Mazzella Yeah, and I think a lot of what we all discuss today — I want to keep in mind that I don't want to say anybody, but most people — if anybody's listening to this who's also in a relationship with somebody who fits these characteristics — in terms of the EAR statements, the connecting — all of these are things that anybody could do. These are what I call the early-level interventions. But — let me give a caveat — anybody who themselves can be in a regulated state of mind, because that's not easy either. Remember, my first thing — the first part of my intervention — was I had to check myself, because when intense affect is coming at you directly, it could be a little overwhelming. Then you lose your own capacity, your own reflective capacities. Megan Hunter I call that losing your mind, Dr. Mazzella. You call it countertransference — I call it mind blown. Dr. Anthony Mazzella Yes. No, I like that — if you do lose your mind, because your mind is where we think, right? So you lose your — you lose your mind. I actually had an episode on that, Megan, not too long ago — "Why Do I Lose My Mind?", or something along those lines. Megan Hunter Yeah, that's a perfect way to put it. And then people feel so guilty, because they've lost their temper, they've said something they shouldn't, they dropped an F-bomb and they're not proud of themselves. But I like to say, look, you need to see this as probably pretty normal — it doesn't mean you have to beat yourself up, but just try something different next time. Dr. Anthony Mazzella Well, there's something different, Megan. Let me ask you this question. We're talking about a lot of these tools and techniques that people can use, even in relationships. If we went a little bit further, where we started to diverge in our approach — when Bill just said mine is more like a therapeutic process — do you think the people that you encounter — the next step, instead of attacking back, like losing your mind, like we were just saying, and then feeling guilty — is this too much to ask, for someone to say, if they're encountering this intensity, "What's going on? What's happening right now? What are you doing?" And then to stay very close, not to the content of whatever's being argued about at that point. But to what I would call the process — "What's going on? What's happening? How come you're getting so angry right now? I know, yes, I did exit through a different door, but I'm here right now — but what's happening?" Megan, is that too much, do you think, to expect, or to imagine people can do at that moment, if following the content isn't going anywhere? Megan Hunter I think it's a two-part answer, and I know Bill has a response too. I'd say for some, they can do that — it takes some discipline, it takes some reminding oneself, maybe daily. Others, I think, it will be more difficult, and they get hooked by the emotion — and sometimes we are just hooked by that emotion. And on the other hand — I don't know, I'm taking a risk saying this out loud — but maybe there's a benefit to losing your mind sometimes. A benefit to the relationship. In a way, it's a setting of a limit. I don't know — I'll ask you two about that. Dr. Anthony Mazzella Wait, let me just respond to the last point — I liked it, it kind of emerged spontaneously. I would say, to that, my immediate association is: sometimes with patients who are really challenging, I get upset and I lose my mind, Megan. But then I say to them, "How come you can only hear me when I yell at you?" Now, I don't actually yell at them, just so you know — but I may get a little short, or a little louder. But then I say to them, "How come you can only hear me when we do it this way? This is something we really need to think about together." Why does this interaction need to constantly play out with this particular dynamic? So, Megan, to your point — yeah, maybe there's a certain necessity of pulling you into something. And it could be that they're recreating something from their earlier childhood, or whatever they may be recreating. Bill Eddy My thinking with this — because I'm thinking of not ongoing relationships, that in most of these settings, whether it's HR or mediation, or even a lawyer talking to their client — we discourage pushing for insight, which is what you're talking about, in that category to me. And the reason why is because a lot of the people we're dealing with, when you try to say, "Can you see how you're doing this?" they become enraged. And any kind of pushing to look inside means taking responsibility in the conflict, which is all the other person's fault — "How dare you suggest that there's anything I need to do differently?" And since a lot of the context for what we're dealing with is conflict with another person, and not in a counseling setting, I try to teach people: don't try to do that. Because what happens is not only do you activate their defensiveness, they become more dysregulated, but they also won't work with you as much — they like you less. And I learned a lot of this in mediation — it would be kind of on-the-spot situations. I would say, "I think it's good if I meet separately with each of you for a few minutes," and I'd sit down with one of the people, and I know I've got like 10 or 15 minutes, then I've got to get back to the other. When I would say, "You know, there's this thing you're doing — if you just stop that and do this other thing instead, you'll probably be more successful and get more of what you want," the response I've gotten is, "Why don't you like me, Bill?" Dr. Anthony Mazzella Yes. Bill Eddy And feeling a rejection from me. Dr. Anthony Mazzella Yes. Bill Eddy And not having the opportunity to do the kind of processing that you're talking about. But what I'm wondering is how much of it's the time, and how much of it's the clients — that they may really be at a higher level of resistance, a higher level of anger, and a more severe personality disorder. Because I think a lot of these folks are personality disordered, which to me means they're not going to have insight and behavior change unless there's some really long-term ability to work with them. So I think what I'm seeing is it's the amount of time we have, but also the level of severity — because some of these folks, I've seen them come back, and they say they've been in therapy for a year, and they're the same, if not worse. And I often think it's because the therapist does a pure supportive therapy, which supports their distorted thinking. So anyway, that's my thoughts here. Dr. Anthony Mazzella Oh, can I just jump in really quickly? You got me thinking about so many things, but I'll limit it. Bill Eddy Yeah. Dr. Anthony Mazzella So, one — you are right, by the way, I think there's research that demonstrates that supportive therapy with personality-disordered patients or individuals is not effective. So you're on the mark there. The other thing is the language is so important, and I'm glad you picked up on this — and I may have misrepresented myself, so I want to go back to something. When I switch from content to process, it's never like what you just described, Bill, which is "Can you see what you're doing here?" Because you're absolutely right again — the defenses will go up, they'll feel blamed and criticized, because, again, they don't have that reflective capacity, so it comes in as just another person judging or criticizing, or, to your point, "they don't like me." So, Bill, I just wanted to be very careful, because words are so important — you have to select your words so carefully. So that's why I said more like, "Hey, what's going on here? Something is happening," rather than "Can you see what you're doing?" I tried to be a little more neutral. But Bill, you may have gone in that direction because it may not have sounded neutral enough — it may have raised their hackles, in other words — because that's why you described that defensive response, which is absolutely true, that anytime you imply that they have motive, that there's unconscious motivation, they're going to feel very guarded, defensive, and may even leave treatment. Bill Eddy Well, that's interesting. I like that — what you're saying is just say what's happening. Dr. Anthony Mazzella Yeah, so — if I could just do a really quick recap — that's the beginning level of intervention: stay so close to their subjective experience, and usually that's enough, and you both know that, because this is what you teach. That's typically enough, at least to settle them. But then the next step is: can you help them transcend the immediate situation, and even have an inch, an ounce of reflection? Which is what I tried to demonstrate in that case I was just reviewing — when I said, "So your husband is all bad right now, he doesn't care," and then she said, "No, wait a minute — last week he threw a birthday party." So now they're transcending the immediate, and that's a little bit of reflecting. And this is the very beginning of what we could call change, because now they're developing a little bit of capacity for reflective functioning. Bill Eddy And that's where I see it really as a therapeutic technique — that to do what you're talking about, I think, means having an opportunity to work with someone over time. But I can see — I'm picturing my mediation caucus, where I'm meeting with someone and saying, "Wow, I hear your frustration and all of that," that I may — rather than make a suggestion — say, "Tell me more, what's happening." But even there, I know I've still got to get back to the other person, and we have an overall time limit of two hours, so my time's very limited with that. But I think, in a way, where we're overlapping here is really emphasizing the empathy, the attention with the person — and that "what's happening" is part of the attention, as I see it. But not going for that little bit of reflection in that kind of setting. But I could see — and I'm sure this happens sometimes — say a lawyer who's going to be working with a client for six to twelve months on their divorce might be able to say a little more, "Well, what's happening right now for you?" And certainly therapists need to know that. Dr. Anthony Mazzella Yeah, like these cases that I consulted on that I mentioned earlier — we consulted for months, Bill. So this went on for months, in terms of how to speak to who was labeled, you know, as the narcissistic husband, in this example. But yeah, this went on for a long time. Megan Hunter I'm going to interrupt here — as much as I'd like to just continue this part of the conversation, I think we're going to have to have you back. I know for sure we are, to talk about narcissism. But because we did make a promise at the beginning that we would talk a bit about narcissism — if you want to just do a simple breakdown: number one, is treatment of narcissism ever effective? Because I think the noise out in the universe says no, it never — there's no effective treatment. So let's start there, and then, if there is any treatment possibility, what is that? Dr. Anthony Mazzella So I'll answer this very quickly, because I appreciate that we're pressed for time, and we're hoping and planning a part two to this, if we could call it that, where you'll come over to my show — so we could definitely pick this up more, or whatever direction you and Bill would like to go. But the short answer is: there is evidence now out there that suggests that yes, treatment can be effective. It's not that it's easy, and, to Bill's point throughout, this is the thread that runs through — it takes time. People don't usually change in a matter of weeks or months. Typically, what we find, and this is my own experience as well, is around nine months to a year. It doesn't mean there's not little movement along the way, which I tried to illustrate with that case example — there's little movement along the way, of course. But it depends on how you measure change — if you want to be able to really see a significant amount of change, then yes, it is possible, but it takes months, sometimes years, to be quite honest with everybody who's listening, which sounds a little bit shocking. And I'll tell you one thing that sounds shocking too: I meet with these patients, very different from what you and Bill are doing, anywhere from once a week to four times a week — my profession, in training, is psychoanalysis, where people come in frequently. But then you have to remember, those are the most motivated people — who really want to change, that they would dedicate that time and money to do something like that. Bill Eddy There's hope. Megan Hunter There's hope. Dr. Anthony Mazzella Mm-hmm. Megan Hunter There's hope. Would you say — and this will be the last question, then we'll wrap it up — would you say there's a difference between the types of narcissists and the hope for treatment? Dr. Anthony Mazzella Oh, there's no doubt. That's a whole other discussion, but it's commonly known that there are different clusters, or presentations, of narcissism. And some of them you will never even see in private practice — you know, when you have more of what we call the malignant type of narcissism. A leader in the field, Otto Kernberg, who writes about this extensively, says the prognosis for somebody who has the malignant type is far lower than your typical garden-variety narcissistic presentation. Bill Eddy You've seen him speak, and that's one of the things — this is the personality that maybe there isn't hope for. Dr. Anthony Mazzella Yeah, I'd say it's guarded — the prognosis is guarded at best. Megan Hunter Yeah, sadly. Well, thank you — that's really fascinating, and I know our listeners are going to have loved hearing this entire presentation and discussion. So, Dr. Mazzella, if you wouldn't mind telling us your website, your podcast, anything else you want us to know. Dr. Anthony Mazzella Sure, it's really simple — everything's on the website, it's just Dr. Mazzella. I can give you the link, if you like. And the podcast is actually called Narcissism Decoder. So that's the podcast. And the thing that distinguishes it from most of the podcasts or YouTube channels out there is — Megan Hunter I love that. Dr. Anthony Mazzella We're not looking to vilify or blame the narcissist and call them the enemy, or say they're evil and they'll never change. We look at it in a more compassionate way. So usually the people who come there are the ones who are fed up with all the sensationalism, and they want to try to really understand all of what's going on, either with them or with a loved one. Megan Hunter Excellent. Well, we'll put those links in our show notes, and look forward to seeing you in part two on your show. Dr. Anthony Mazzella On my show, yes — I will have the two of you on. So, for your listeners, stay tuned. Well, thank you both — it was a pleasure. Bill Eddy It's been wonderful to meet you. I enjoyed the discussion, and not only your thinking, but the optimism that you carry with you. I think that's very powerful. Dr. Anthony Mazzella Well, thank you. Megan Hunter Yeah, and rare. Dr. Anthony Mazzella Thanks again. Megan Hunter Powerful and rare — so wonderful. It's a hopeful, optimistic approach, and we love that. If today's conversation has resonated with you listeners and you need some help in the professional field, contact us at HighConflictInstitute.com. If it's in your personal life, contact us at ConflictInfluencer.com. We have lots of solutions and things for everyone. Until next time, keep learning and practicing the skills. Be kind to yourself and to others while we all try to keep the conflict small and find the missing peace. It's All Your Fault is a production of TruStory FM. Engineering by Andy Nelson. Music by Wolf Samuels, John Coggins, and Ziv Moran. Find the show, show notes, and transcripts at TruStory.fm or HighConflictInstitute.com/podcast. 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