Efficacy of Internet-Delivered Psychodynamic Psychotherapy

Research from Tomas Lindegaard PHD Ms.C. , Matilda Berg PHD Ms.C. and Gerhard Andersson PHD.

(2020). Psychodyn. Psi., (48)(4):437-454

Efficacy of Internet-Delivered Psychodynamic Therapy: Systematic Review and Meta-Analysis

Tomas Lindegaard PHD Ms.C. , Matilda Berg PHD Ms.C. and Gerhard Andersson PHD 

Recent years have seen an increase of internet-delivered interventions based on psychodynamic treatment models. To test the efficacy of internet-delivered psychodynamic therapy (IPDT), we conducted a systematic review and meta- analysis of randomized controlled trials. Following literature searches, we identified seven studies meeting inclusion criteria. The total number of participants was 528 in the treatment group and 552 in the control conditions. We found small effects favoring IPDT compared to inactive control conditions for main outcomes (g = 0.44), depression (g = 0.46), anxiety (g = 0.20), and quality of life (g = 0.40). There was significant heterogeneity between studies for main outcomes and depression. Within-group effects ranged from Hedges's g = 0.32-0.99. The effects of IPDT were maintained or increased at follow-up. Study quality varied but was generally high. No indications of publication bias were found. In conclusion, IPDT is a promising treatment alternative, especially for depression, although the small number of studies limits the generalizability of the findings.

Tomas Lindegaard, Ms.C., Ph.D. candidate in Clinical Psychology, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden

Matilda Berg, Ms.C., Ph.D. candidate in Clinical Psychology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Gerhard Andersson, Ph.D., Professor in Clinical Psychology, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden, and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Introduction

One of the first studies on internet-delivered psychotherapy was conducted in 1996 by researchers at the University of Amsterdam who developed a website through which they treated 20 students suffering from posttraumatic stress symptoms, 19 of which went into remission at posttreatment (Lange, van de Ven, Schrieken, Bredeweg, & Emmelkamp, 2000). Since then, more than 300 controlled trials have been conducted evaluating various forms of internet- delivered interventions for a range of different disorders and target populations (Andersson, 2018; Andersson, Titov, Dear, Rozental, & Carlbring, 2019).

Although many different versions and types of internet-delivered interventions have been developed and tested, they all share some common features, such as the requirement of a treatment software platform to deliver the treatment and facilitate interaction between the client and therapist (Andersson et al., 2019). The treatment programs usually deliver treatment content in the form of text, but use of audio and video is also common (Andersson et al., 2019). Most studies have evaluated programs involving some form of therapist guidance; there are also many instances of self-guided treatments, although the former type of program tends to be more effective (Baumeister, Reichler, Munzinger, & Lin, 2014). As noted by Andersson and colleagues (2019), cognitive-behavioral therapy (CBT) has been the dominant therapy model used thus far in internet interventions, with meta-analytic evidence indicating that internet-delivered CBT (ICBT) is as effective as regular face-to-face CBT (Carlbring, Anders-son, Cuijpers, & Riper, 2018) and more efficacious than control conditions for anxiety and depression disorders (Andrews et al., 2018). Research also suggests that there are long-term effects (Andersson, Rozental, Shafran, & Carlbring, 2018).

In recent years there have also been a number of internet interventions based on other theoretical models, such as interpersonal psychotherapy (IPT; Dagöö et al., 2014) and mindfulness (Boettcher et al., 2014), but also psychodynamic approaches. The first of these was a study by Andersson and colleagues (2012) that used an adapted version of the self-help book Make the Leap (Silverberg, 2005) in the treatment of generalized anxiety disorder (GAD). Since then, a handful of RCTs have been conducted investigating the efficacy of treatment programs based on a range of different psychodynamic treatment approaches, such as Luborsky's supportive-expressive model of psychoanalytic psychotherapy (Zwerenz, Becker, Gerzymisch et al., 2017) and the affect phobia therapy model (APT; Johansson, Björklund et al., 2013).

The psychodynamic internet-delivered treatment programs that have thus far been tested have generally been structured in a similar way as treatment programs based on CBT models, with weekly text- based modules, various homework exercises that the participants are encouraged to complete on a weekly basis, and e-mail support from a therapist. One could argue that some of these features, for example the use of homework assignments, constitute a significant difference between internet-delivered psychodynamic therapy (IPDT) and traditional psychodynamic therapy delivered face-to-face, given that use of homework assignments normally is considered a distinguishing feature between CBT and psychodynamic approaches (Blagys & Hilsenroth, 2002). However, in practice a majority of psychodynamically oriented clinicians report encouraging their clients to engage in between-session assignments (Kazantzis, Lampropoulos & Deane, 2005), perhaps making the discrepancy less important in the actual clinical reality. Another difference between IPDT and traditional psychodynamic therapy, according to Johansson, Frederick, and Andersson (2013), is the lack of explicit transference work found in the former. However, notwithstanding the differences noted above, IPDT and face-to-face psychodynamic therapy also share many similarities both regarding the treatment content and the role of the therapist in providing support and validation (Johansson, Frederick et al., 2013). For example, in the IPDT studies based on the affect phobia model, participants learn how to conceptualize their problems in terms of a psychodynamic conflict around feelings (Johansson, Björklund et al., 2013; Johansson et al., 2017). Participants are guided in how to restructure their own defenses, regulate anxiety, and face previously avoided feelings, which are purported to be the primary mechanisms of change (Johansson, Björklund et al., 2013; Johansson et al., 2017). Throughout this process, the therapist provides feedback and validation, mostly in relation to the homework assignments that the participants complete (Johansson, Frederick et al., 2013).

While recent years have seen a number of systematic reviews and meta- analyses regarding the efficacy of psychodynamic therapy in general (Abbas et al., 2014; Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017) as well as specific forms of psychodynamic therapy, such as experiential dynamic therapy (Lilliengren, Johansson, Lindqvist, Mechler, & Andersson, 2016), there is to our knowledge no previous review and meta-analysis regarding the efficacy of IPDT. Thus, the aim of the present study was to provide a first systematic review and meta-analysis regarding the efficacy of IPDT.

Results
Study Inclusion

Through our search strategies, we identified 73 articles from the PubMed/ MEDLINE, PsychINFO, and SCOPUS databases. After exclusion of duplicates, nonintervention studies, and studies of treatment approaches other than IPDT, 10 articles remained (see Table S1 in online supplemental material). These remaining articles were screened based on review of title and abstract, which led to the exclusion of three additional studies. Based on the full-text review of the remaining articles, all of the remaining seven studies met the inclusion criteria and were thus included in the study. For an overview of the study selection process, see Figure 1.

Study Characteristics

The study characteristics are summarized in Table 1. Of the seven included RCTs, one had depression as the primary target (Johansson, Björklund, et al., 2012), two targeted anxiety disorders (Andersson et al., 2012; Johansson, Björklund, et al., 2017), one targeted return to work (RTW; Zwerenz, Becker, Gerzymisch et al., 2017), and the remaining three had a transdiagnostic focus, targeting both depression and anxiety (Johansson et al., 2013; Lemma & Fonagy, 2013; Zwerenz, Becker, Johansson et al., 2017). The total number of participants was 528 in the treatment group and 552 in the control conditions. Only one of the seven studies had a bona fide intervention as a comparison (Andersson et al., 2012), meaning that we could only perform a quantitative synthesis comparing IPDT to the inactive control conditions. This study also had an inactive control condition and could thus be included in the analysis of IPDT compared to inactive controls.

With regard to theoretical orientation, three of the studies (Johansson, Björklund et al., 2013; Johansson et al., 2017; Zwerenz, Becker, Johansson et al., 2017) were based on the affect phobia model (McCullough et al., 2003) and more precisely on the self-help book Living Like You Mean It (Frederick, 2009). Two other studies (Andersson et al., 2012; Johansson et al., 2012) were based on the SUBGAP model as described in the psychodynamic self-help book Make the Leap (Silverberg, 2005). Of the remaining two studies, one (Lemma & Fonagy, 2013) was based on the brief dynamic interpersonal therapy model (BDIT; Lemma, Target & Fonagy, 2011) while the other (Zwerenz, Becker, Gerzymisch et al., 2017) was based on Luborsky's supportive-expressive model of psychoanalytic psychotherapy (Luborsky, 1984).

Regarding delivery format and structure of the treatment, in five of the included studies (Andersson et al., 2012; Johansson et al., 2012, Johansson, Björklund et al., 2013; Johansson et al., 2017; Zwerenz, Becker, Johansson et al., 2017) the treatment consisted of weekly text- based modules accessed through a web-based platform. The modules included various homework exercises that the participants completed on a weekly basis with e-mail support from a therapist. In one of the received feedback from their therapist on a weekly basis. Finally, in the study by Lemma and Fonagy (2013), participants were sent self-help material by e-mail once per week. The study made use of a group format in which participants had access to an online forum where they were encouraged to reflect on the treatment material via nonsynchronous communication with other group members. The group was facilitated by a therapist. The studies were carried out in either Sweden, Germany, and England, and the number of participants in each study ranged from 24 to 664.

Main Analysis—IPDT versus Inactive Controls

Between- and within-group results are presented in Table 2. With regard to the effect of IPDT compared to the inactive control conditions, we found small effects in favor of IPDT on all four outcomes; main outcome (g = 0.44), depression (g = 0.46), anxiety (g = 0.20), and quality of life (g = 0.40). For two of the outcomes, the main outcome and depression, we found a significant heterogeneity. After inspecting forest plots for the main outcome analysis, we decided to run a sensitivity analysis without the Johansson et al. (2012) study, which resulted in a nonsignificant heterogeneity (Q = 6.18, p = .29, I2 = 19.1%) and a lower effect size (g = 0.28, 95% CI [0.1, 0.45]).

In addition, we performed a sensitivity analysis removing the Zwerenz, Becker, Gerzymisch et al. (2017) study, since this study targeted participants with a somatic primary diagnosis. For the main outcome analysis, this also resulted in a nonsignificant heterogeneity (Q = 10.17, p = .07, I2 = 50.8%) and a moderate effect size of g = 0.52, 95% CI [0.22, 0.82]. Similarly for depression outcomes, removal of Zwerenz, Becker, Gerzymisch et al. (2017) resulted in a nonsignificant heterogeneity (Q = 8.98, p = .11, I2 = 44.3%) and a moderate effect size of g = 0.55, 95% CI [0.27, 0.83]. Finally, for anxiety outcomes, removing he Zwerenz, Becker, Gerzymisch et al. (2017) resulted in a nonsignificant heterogeneity (Q = 2.29, p = .81, I2 = 0.0%) and a small effect size of g = 0.32, 95% CI [0.12, 0.52].

With regard to follow-up, only two studies (Andersson et al., 2012; Zwerenz, Becker, Gerzymisch et al., 2017) reported follow-up data in comparison to an untreated control group.

Within-Group Effects

The analysis of within-group effects of the interventions pretreatment to posttreatment revealed effects between Hedges's g = 0.32-0.99 for the four outcomes. However, significant heterogeneity was found for the main outcome, depression, and anxiety. For the main outcome, after inspecting forest plots, we ran a sensitivity analysis without the studies by Zwerenz, Becker, Gerzymisch et al. (2017), Zwerenz, Becker, Johansson et al. (2017), and Johansson et al. (2012), which resulted in a nonsignificant heterogeneity (Q = 3.35, p = .34, I2 = 10.5%) and an effect size of g = 1.29, 95% CI [1.0, 1.58].

Similarly to the between-group analysis, we also performed a sensitivity analysis removing the Zwerenz, Becker, Gerzymisch et al. (2017) for the same reason as stated above. For the main outcome analysis, this also resulted in a significant heterogeneity (Q = 39.50, p < .01,I2 = 87.3%) and an effect size of g = 1.17, 95% CI [0.55, 1.79]. For depression outcomes, removal of Zwerenz, Becker, Gerzymisch et al. (2017) resulted in a significant heterogeneity (Q = 40.47, p < .01, I2 = 87.6%) and an effect size of g = 0.98, 95% CI [0.36, 1.61]. Finally, for anxiety outcomes, removing Zwerenz, Becker, Gerzymisch et al. (2017) resulted in a significant heterogeneity (Q = 15.5, p < .01, I2 = 67.7%) and an effect size of g = 0.83, 95% CI [0.47, 1.2].

With regard to follow-up, only five of the studies reported follow-up data for the treatment group and only two studies included measures of quality of life at follow-up; this outcome was therefore not included in this analysis. The analysis of posttreatment to follow-up revealed effects between Hedges's g = 0.06-0.3 for the three outcomes. Significant heterogeneity was found for the anxiety outcome.

Discussion

This systematic review and meta-analysis most likely constitute the first review of the efficacy of IPDT. In total, seven studies were identified that met all inclusion criteria. Overall, we found small effects in favor of IPDT compared to inactive control conditions regarding overall effects of treatment (g = 0.44), as well as on depression (g = 0.46), anxiety (g = 0.20), and quality of life (g = 0.40) outcomes. No comparison in relation to active control conditions was possible, since only one of the eligible studies included an active control (Andersson et al., 2012). With regard to study quality, four of seven studies were rated as having low risk of bias across all rated criteria. We did not find evidence of publication bias.

The effect sizes obtained in the present study appear to be lower than those found in meta-analysis of internet interventions based on CBT models. For example, Andrews et al. (2018) found an overall effect of ICBT of Hedges's g = 0.80 compared to control conditions. They are also somewhat lower than those found in meta-analyses of face-to-face psychodynamic therapy where, for example, Abbas et al. (2014) found effects in the medium range for general psychiatric symptoms (SMD, 0.71), anxiety (SMD, 0.64), and depression (SMD, 0.61). However, a more recent meta-analysis by Cuijpers, Karyotaki, de Wit & Ebert (2019) found an effect of Hedges's g = 0.39 for psychodynamic therapy for adult depression, which is more in line with the findings of the present study. Due to the limited number of studies and the large heterogeneity between studies, the findings of the present study have to be viewed as highly tentative. In addition, the sensitivity analysis, which excluded Zwerenz, Becker, Gerzymisch et al. (2017), resulted in moderate effect sizes for both overall outcomes and depression, more akin to the findings by Abbas et al. (2014).

With regard to within-group effects, the effect sizes found in the present study are again somewhat lower than those found in face-to-face studies of psychodynamic therapy. For example, in their meta-analysis of experiential dynamic therapy, Lilliengren et al. (2015) found within- group effects ranging from d = 1.11 for general psychiatric symptoms to d = 0.86 for quality of life/ global functioning, which is also similar to within-group effects found in the meta-analysis by Town et al. (2012). Overall, the findings of the present study do not exclude the possibility that IPDT might result in slightly lower treatment effects than face-to- face psychodynamic therapy. However, similarly to the between-groups effect mentioned above, removal of Zwerenz, Becker, Gerzymisch et al. (2017) resulted in within-group effect sizes more similar to those found by Lilliengren et al. (2015) and Town et al. (2012). Regarding follow- up, we found evidence for continued improvement on anxiety symptoms (g = 0.3) while the other outcomes remained stable.

Concerning study quality, there was a considerable variance between studies with regard to their risk of bias. All of the four studies conducted by the research group led by Professor Andersson were rated as having low risk of bias across all rated domains, whereas the other three studies were rated as having unclear or high risk of bias in at least one of the rated domains. Due to the small number of studies, it was not possible to investigate whether and how study quality related to the reported effects of the treatment under study.

With regard to the limitations of the present study, one major limitation concerns the limited number of eligible studies, which limits the generalizability of the findings. Due to this limitation, it was not possible to examine the effects of IPDT for specific disorders; instead, we calculated an overall effect on the main outcome measures of the studies. The secondary analysis of depression, anxiety, and quality of life mixed studies targeting the same outcome as either a primary or a secondary outcome, which could potentially lead to lower estimated effect sizes. Also, due to the small sample size, it was not possible to conduct subgroup analysis based on, for example, study quality or treatment model. Another limitation concerns the fact that we calculated within-group effects using the formula for independent groups. This procedure was chosen because the included studies did not report correlations between pre- and postmeasurements, however this might have led to a slight overestimation of effect sizes (Dunlap et al., 1996).

Conclusion

The results of the meta-analysis suggest that IPDT is more efficacious than inactive control conditions, with small effect sizes in favor of IPDT with regard to main outcomes, depression, anxiety, and quality of life. Moreover, the effects of IPDT seem to be maintained or increase at follow-up. Existing IPDT studies are based on a variety of theoretical models, with Leigh McCullough's affect phobia model being the most common. Study quality was generally high and we found no indications of publication bias. However, due to the small number of eligible studies, the findings in this present review and meta-analysis has to be considered highly tentative; further research is needed.

Acknowledgement

The present review was funded in part by a professors grant to the last author.

Micro-separations: How to traumatize your partner on a daily basis

We’re talking death by a thousand cuts. We’re talking frog in boiling water situations.

In my last post I wrote about the capacity to be alone. Once I wrote about that, I started seeing the issue everywhere, both in myself and in my patients and friends.

I just came across an article by Brett Kahr, a prolific psychoanalytic writer, titled, Micro-separations: how to traumatize your spouse on a daily basis.

Basically, our reactions to smaller separations experienced inside of a romantic couple are linked to our childhood separations and misattunements from our parents/caregivers.

Kahr lists a great deal of research showing how toxic of an impact a depressed, deceased, and/or very preoccupied parent can have on their child. A parent who leaves to go to the store and never comes back, a parent who emotionally neglects their child’s need and vulnerability saying, “___ is so independent. He really takes care of himself.” Those parents negate the needs of their child, and the child goes on to be quite sensitive to feeling dismissed and disregarded or forgotten.

‘Separations’ are described in four different categories:

Traumatic Micro-Separations: “Two members of the couple become separated, both physically and psychologically, for merely a brief period of time, albeit with profound consequences.”

Finding your partner masturbating/watching porn. The author calls this ‘infidelity via sexual fantasy’.

Of course, not everyone will feel disturbed by that. For some, it’s a big issue, even it only happened once. They may have an issue with their partner having sexual thoughts about others, and it takes quite a psychological toll on them.

Like for someone who happens to be having a bout of insecurity, it could be the thing that sends them into further depths of despair.

They know that in that moment, they weren’t the person on their partner’s mind, and that affects us all differently and sometimes quite significantly.

Justifiable Micro-Separations: But many micro-separations don’t involve anything overtly sexual. This might be in a couple where one person travels very frequently for work — maybe it provides a great deal of income for the family, but the partner feels resentful of the time left alone. The constant travel might be OK for a month or a year or more, but the separations accumulate, as does the trauma from it.

There are so many missed moments if one is traveling constantly. You start to feel like you know less and less about each other and your ability to track each other’s feelings and states of mind starts to decline greatly, which leads to an atmosphere of disconnection.

Example: A woman was in a very healthy relationship overall. During a stressful time in the relationship, however, she and her partner were deciding about the lease on their car which would soon end — they had to choose whether to continue with the same model or choose a different make and model. There were six months left on the lease, and they were in disagreement over what car to choose, so they were taking a good amount of time to research.

Suddenly, the husband tells the woman, “Hey, I just located one of those cars we thought looked good, and I’m going for a test drive.”

Woman says, “Uh…I can’t go right now. I have to work. You’re doing that without me?”

He says, “Yeah, but it’s just a test drive. If I like it, we can go back together and check it out.”

She says, “OK. Just take a lot of photos and take a video of the inside.”

Husband sends one photo of the exterior and says it’s cute. Wife agrees but says it seems small. Husband gets home and announces he actually purchased the car.

She becomes very angry in response but still holds out some hope that once she sees it, she’ll be happy he did it. In the meantime, however, her anger grew. Her awareness of how she’d been dismissed and disregarded and excluded created rage within her, and it brought up all the old feelings of being unimportant and invisible, her thoughts and opinions ignored.

They worked their way through the issue, but that feeling didn’t leave her for quite a while. For months she was hyper-aware of being forgotten, ignored, or taken for granted.

Anticipated Micro-Separations: Sometimes just knowing that you and your partner are going to be separated (a work trip; a solo adventure; etc.) at some point in the future starts to really weigh on you.

It’s like if you know you’re moving in 6 months, maybe you start to pull away from your surroundings and the people in your life a bit. You start preparing yourself to feel distance with them, to need them less. While completely understandable, it means you miss out on more heartfelt time with the people and place you’re leaving behind.

Same with a couple — if you’re anticipating distance, you start to prepare yourself accordingly. Some couples start to fight when they know a separation is coming — feeling angry feels easier than feeling the pain of parting.

Invisible Micro-Separations: This is best described through an example, so I’ll get right to it.

A patient I treated had a very neglectful and cruel mother. Miraculously, he ended up in a very healthy and enduring marriage. However, he finds that he at times can become quite sad and detached the more he reaches for his partner only to be met with someone who’s totally absorbed in their phone.

He asks a question, partner doesn’t respond or responds minutes later. It got tedious and hurtful over time.

What this means for you: Most of us do not set out to hurt our partners, yet we are all capable of inflicting these little tiny hurts that accumulate over time.

My take on the topic is that all of us need to take the small tears in the fabric quite seriously. It’s often these small, unnoticed or unspoken items that lead to bigger problems and bigger relationship traumas down the road.

It’s also important that we learn how to tolerate more of our feelings of separateness, aloneness, loneliness, and isolation in order to have a stronger foundation that buffers against these micro-infractions.

And…I guess all of us have to decide at some point whether it’s worth it to keep going, or maybe there’s a way to build a bridge between the two separate beings?

Dear Ashley: Don't narcissists need love like everyone else? They're not evil.

Dear Ashley:

I think that people very often demonize narcissists. Do you actually understand that narcissists are human beings who need love like anyone else?

— Tim

Hi Tim:

I can’t help but wonder if you think you’re a narcissist, so you’re feeling a bit defensive? Or maybe you’re in the middle of a relationship with one, and you’re feeling defensive/doubtful about your choice to stick with them?

The problem has historically been that people prioritize their love of the narcissist over all other troubling evidence. Don’t worry, the narcissistic person is still being loved by people, but they could care less about love; they’re purely seeking validation of their power.

For many of us who’ve also been in relationships with them — whether romantic partner, family member, parent, friend, or boss — we learned over time that there wasn’t actually a lot of good in there that could be reliably felt or experienced from them.

Your question is totally negating of the experiences of so many people who’ve been hurt by a narcissistic type of person: lied to, manipulated, competed with, dismissed again and again, disregarded and ignored, abandoned emotionally or even physically when there are difficult things to discuss or address.

The well-being of the victims of this abuse weren’t considered for even a second by the narcissist. They were gaslighted, making them feel crazy and like they can’t trust themselves; they were given the silent treatment; insulted with more and more cruel remarks; subjected to knowing their partner was living some kind of double life but could never get them to admit it; had to lower themselves by agreeing to do everything on the narcissist’s terms; experience such little interest in themselves as a human from the narcissist that it makes them think they’re really not worth knowing

So they’re supposed to look past that and see the good in their cruel friend/parent/partner?

I don’t think so. That’s what got them into trouble in the first place. You see, most of us have the tendency to want to see the good in the people we love and care about, so we are most likely to ignore or explain away bad behavior and focus on the good things. We often forgive the bad behavior far too early, keeping us stuck in a relationship that’s actively hurting us.

Too often there are people like you out there who insist we must love these people and focus on their needs and the love they deserve. Do you see how that’s a total repetition of the issue at hand? Their needs are always the most important ones anyway, so the hurt and abused person is supposed to tolerate the hurt and keep focusing on loving them?

Again, I don’t think so.

That’s a cruel thing to ask of the victims. I’d rather see them get to a point where they can easily state what the narcissist did to them and feel confident about it. Not second-guessed by someone like you.

Further, I want to make something very clear — narcissistic, borderline, and psychopathic personality traits are on the same spectrum. Some people can be narcissistic and borderline but be fairly benign, albeit very annoying, in how they affect the people in their world. But some tend more toward the psychopathic end of the spectrum — little or no empathy, a total disregard for the feelings of someone else and how they might affect them, a willingness to do whatever they want and feel entitled to it with little regret. Now, unlike a truly psychopathic person, a narcissist will worry about being caught because they will be quite concerned with how they appear to others, BUT they won’t care about the act itself and the hurt it caused.

So tell me again why we should prioritize their needs over ours?

"Blindsided" - The Anthem of the Narcisissist

I work as a therapist, I watch reality tv, and I’ve known many narcissists in my personal life. If I had a nickel for every time I heard this annoying word…ay, jesucristo. Narcissists will often gaslight you by saying they’re “blindsided” by your confrontation, your boundary, your anger, your hurt, etc… This is a very handy way to put the blame back on you. ‘You should’ve done x, y, or z before saying that!’ ‘How can you do this to me like this? This is out of nowhere!’

Sound familiar?

Really feeling himself until he gets grazed by a vehicle on the road. He screams, “How the f*** did that happen? What the f***’s wrong with you?!”

[Ok, actually, first let me make the disclaimer that I’m probably not talking about you. Many of us can be blindsided, and it’s far more innocent than what I’m explaining here.]

If you’re dealing with a narcissist (or someone with those tendencies) please swat this claim of blindsided away as you would a fly headed straight for your plate. Don’t take it seriously. Don’t contemplate whether it’s true or what you could’ve done differently. Chances are you’ve brought the issue up one hundred times, and it’s as though every time is the first time, as though the earlier conversations never happened.

While it’s probably an unconscious process for them, they have blocked out whatever the issue is because to think about it would mean facing that they did something wrong or something they may need to change. Narcissists have an almost 0% capacity for tolerating (accurate & appropriate) guilt. As such, those conversations you’ve had have been pushed right on out of awareness until you bring it up again.

It is not your job to make them remember 3, 5, or 40 more times. It’s their responsibility to hold on to that conversation you had and do their part to address the issue.

And even if you had never had one single conversation about it, to be “blindsided” is still a stretch.

Let me give an example to illustrate.

I know a man whose wife keeps telling him his reclusive behavior and substance use is causing problems for her and their family as a whole. He pays lip service to the concern, or, more often, he criticizes her for her feelings. He continues as normal. Cut to him ending up in a very life-threatening situation related to his continued patterns/choices, and his wife and children are witnesses. He brushes it under the rug. When wife confronts the issue again, and his closest friends also confront what they’re seeing, he claims he’s blindsided. Really?

OK, now say a conversation had never happened between them. She’d never brought it up. For me, and I know for many of you reading this, if my partner brought major concerns to me and told me how my choices were negatively affecting him, I’d sure as s*** be listening. It would be burned into my brain.

What’s highly unlikely is that I wouldn’t have seen it coming at all. If I’m paying attention AT ALL, I would notice that things aren’t right or that I had a nagging feeling I was messing up somehow. Maybe I was caught up with my focus being elsewhere, but when brought to my attention, I’d admit (begrudingly, perhaps) my partner was right, and I had work to do. I’d be holding myself accountable.

Saying you’re blindsided is tantamount to denial.

That’s untenable in a relationship. I encourage you to have a boundary around accountability. If that person can’t tolerate accountability for themselves, you can expect to have the same patterns repeat over and over and over…

#1 Way to Deal with a Narcissist

It can be summed up in one word: indifference.

Young woman indifferent to the deluge of water coming at her.

Indifference is when we don’t care one way or another about someone or something. For a narcissist, it feels horrible for anyone to be indifferent toward them. What they want most is to be seen and heard and praised. For many of us, others’ indifference would be painful but not soul-crushing; for a narcissist, it feels absolutely crazy-making.

You’re wondering why you’d want to make your loved one, the narcissist, feel horrible? Well, for your own sanity and peace of mind.

I lived with and around very narcissistic family members growing up who teased, mocked, and criticized me (my mother, grandmother, aunt, and uncle — if you’re thinking it’s unbelievable that there would be that many in one family, I agree). If I fought back, it got worse, and I felt worse. And if I let their compliments in, it meant I had to let all the other stuff in as well.

Then I started studying psychoanalytic theory and counseling and became a practicing psychotherapist.

Here’s what I’ve learned so far:

1. Take every tiny bit of communication from a narcissist with a grain of salt, emotionally-speaking. Whether it’s an insult, a threat, a compliment, or agreement with and support of you, always remember that there’s an agenda behind it. As such, stay as neutral as possible.

2. Stay calm even if you don’t feel calm. Keep your face and voice neutral. My narcissistic patients hate that they can’t read me. If they could sense what I was thinking and feeling, they’d guide themselves accordingly, whether to gain my approval or to provoke me and gain a felt sense of power over me. Staying calm has the added benefit of making sure there’s still room for me to think my own thoughts.

3. Be absolutely ruthless in sticking to the point of the conversation. Be callous. They could distract and deflect by trying to make you feel guilty or sorry for them.

Woman happy to be relentless.

In psychoanalytic circles, narcissists are usually likened to a fragile shell. There’s nothing inside to buffer them against everyday, ordinary ups and downs or the insults and hurts we all suffer.

1. Because of their brittle shell, they will collapse emotionally if they start to feel the hurt or disappointment or disgust at themselves. HOWEVER, do not be drawn into their spiral. It’s temporary and usually leads nowhere; they’re back to their normal grandiose selves as soon as they can feel better or more powerful than you or someone else.

2. You may never know what’s real or true for them. You might think you know, but it’s more likely that you don’t.

3. If you attempt to insult them back, they will feel profoundly powerful at having provoked you and, unfortunately, your energy will be drawn from you, leaving you as the one who feels empty. If we show too much empathy or approval, they immediately take us less seriously, and now we’ve offered something of ourselves that will not be reciprocated. Of course we’re not monsters and want find the empathy for this person in our lives, but it’s all too common that providing empathy to a narcissist comes at a cost to ourselves. We tend to have to negate our views and perspectives in order to provide that empathy and move forward with them.

4. EVERY. SINGLE. THING. they say to you is a projection from their internal world. It has less than zero to do with you. Operate as such.

5. Do your own work on yourself. The more you see and understand and work through inside yourself, the less likely you are to be destabilized and pulled around by a narcissist.

It’s hard work, but if you can wrap your head around it, you’ll gain a lot of confidence in yourself. Good luck.