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Advance praise for Mentalization-Based
Treatment for Pathological Narcissism:
A Handbook
“Mentalization-Based Treatment for Pathological Narcissism: A Handbook

fills a critical gap in the clinical literature. This handbook examines the
nature of pathological narcissism, carefully outlines an innovative treat-
ment approach, and uses descriptive case material to illustrate the appli-
cation of mentalization-based treatment (MBT) to address the struggles
of these patients. Patients will recognize the expertise in MBT for narcis-
sism, feeling the validation of experience that can be motivating for those
who have not felt helped by other approaches.”
—Blaise Aguirre, MD, DBT trainer, author of Borderline Personality
Disorder in Adolescents, and co-author of DBT for Dummies
Founding Medical Director, 3East DBT Continuum, McLean Hospital
Assistant Professor, Department of Psychiatry, Harvard Medical School
“Now more than ever, psychotherapy needs a coherent and pragmatic

approach to the treatment of pathological narcissism. Not only does this
groundbreaking book introduce a novel mentalizing intervention for nar-
cissistic disturbances; it also provides clarity about how MBT is more gen-
erally implemented, in a practical and user-friendly manner. This book
will help any clinician improve their psychotherapeutic interventions
with patients who struggle with forming a clearer and more consistent
sense of self.”
—Lois W. Choi-Kain, MD, MEd, Good Psychiatric Management (GPM)
trainer, co-editor of Applications of Good Psychiatric Management
for Borderline Personality Disorder
Director, Gunderson Personality Disorders Institute, McLean Hospital
Assistant Professor, Department of Psychiatry, Harvard Medical School
“It is hard to imagine a book that could bridge so seamlessly the clinical,
empirical, and theoretical levels of discourse related to the treatment of
pathological narcissism. New students of psychotherapy and practiced

clinicians will benefit enormously from the specificity and breadth of
various levels of intervention. A book is remarkable when an experienced
clinician and a new therapist find genuine help and clarity regarding their
treatment of narcissistically disturbed patients. This is that rare text.”
—Steven H. Cooper, PhD, author of Playing and Becoming
in Psychoanalysis
Faculty, NYU Postdoctoral Program in Psychotherapy and Psychoanalysis
Training and Supervising Analyst,
The Boston Psychoanalytic Society and Institute
“Narcissistic tendencies are on the rise in this modern world of selfies,

manicured Instagram pages, constant self-promotion, and other artificial
means of increasing self-esteem. This exciting new book explores ways of
addressing pathological narcissism, based on one of the best supported
methods of addressing similar disorders: mentalization-based treatment
(MBT). This book is relevant not just to MBT therapists but also to those
interested in interventions from self-compassion to mindfulness, from
emotion-focused work to ‘third wave’ cognitive and behavioral therapy.
Comprehensive and well-written, this volume contains interesting and
useful ideas on every page. Highly recommended.”
—Steven C. Hayes, PhD, originator and co-developer of
Acceptance and Commitment Therapy (ACT), and author of
A Liberated Mind: How to Pivot Toward What Matters
Foundation Professor of Psychology, University of Nevada, Reno
“Our understanding of pathological narcissism has evolved and is con-

tinuing to become more complex and differentiated. Drozek, Unruh, and
Bateman’s Mentalization-Based Treatment for Pathological Narcissism: A
Handbook is an excellent example, taking up the challenge of showing us
how to work effectively with pathological narcissism. Perhaps the most
impressive aspect of this handbook is its clear and direct style, which
will make it appealing to seasoned clinicians (who might be familiar with
mentalization), as well as to students and early career professionals (who
are curious to learn about mentalization).”
—Elliot Jurist, PhD, PhD, author of Minding Emotions:
Cultivating Mentalization in Psychotherapy
Professor of Psychology and Philosophy, The City College of New York
and The Graduate Center, The City University of New York
“Integrating contemporary clinical theory and clinical science, this hand-

book fills an important gap by extending mentalization-based treatment
to patients presenting with pathological narcissism. Written in a straight-
forward and highly accessible style, the book provides clear clinical

examples and specific recommendations spanning all aspects of treat-
ment. Most importantly, the narrative easily transports readers into the
consulting room. The level of specificity in ‘how to’ assess and intervene
is outstanding, making it an essential resource for clinicians of all orienta-
tions who work with these challenging patients.”
—Aaron L. Pincus, PhD, developer of the
Pathological Narcissism Inventory (PNI)
Professor of Psychology, Pennsylvania State University
“This is by far the most up-to-date and comprehensive practical hand-

book for exploring and treating pathological narcissism. The focus on
mentalization as a technique and process opens a remarkable oppor-
tunity to engage patients to move from ‘reflexive’ towards ‘reflective’
functioning. The authors outline a non-judgmental, systematic approach
for recognizing and adjusting strategies for each patient’s individual
narcissism-related mindset. The detailed clarifying clinical examples
make this book exceptionally useful for psychotherapists and clinicians.”
—Elsa Ronningstam, PhD, author of
Identifying and Understanding the Narcissistic Personality
Associate Professor of Psychology (part-time),
Department of Psychiatry, Harvard Medical School
Psychologist, Gunderson Outpatient Program, McLean Hospital
“Drozek, Unruh, and Bateman illustrate how deficits in mentalization re-

sult in grandiosity, emotional vulnerabilities, and empathic deficiencies
in individuals with pathological narcissism. Myriad examples of thought-
fully worded interventions bring home the humble, evidence-based,
potent, and creative stance of mentalization-based treatment; therapist-
readers can immediately bring their suggestions to bear in sessions.
Theory, stance, and interventions are folded together in beautifully de-
scribed, full case examples. This book is a tour de force and a huge add-
ition to the clinical literature on treating pathological narcissism.”
—Charles Swenson, MD, DBT trainer and author of
DBT Principles in Action: Acceptance, Change, and Dialectics
Associate Professor, Department of Psychiatry,
University of Massachusetts Medical School
“Drozek, Unruh, and Bateman have written an essential book for clin-
icians who are treating, or wish to treat, those with pathological narcis-
sism. Beyond a sophisticated set of treatment principles and techniques,
the authors offer a compassionate guide to the often-difficult trajectory of
working with someone with this serious disorder. This book is a must-read

for anyone working with this intriguing, complex, and common group of
patients.”
—Mary C. Zanarini, EdD, author of In the Fullness of Time:
Recovery from Borderline Personality Disorder
Director, Laboratory for the Study of Adult Development, McLean Hospital
Professor of Psychology, Department of Psychiatry, Harvard Medical School

Mentalization-Based
Treatment for
Pathological Narcissism
A Handbook
Robert P. Drozek
Brandon T. Unruh
Anthony W. Bateman

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To Margaret Donnelly, for showing me another way.
—R. P. D.

Foreword
Peter Fonagy
It is indeed a heartwarming and substantial privilege to be asked to read and introduce

this book, which is one of the most exciting examples of the continuing expansion of
the mentalizing family. I will divide the space allocated equally to a brief overview of
mentalization-based treatment’s achievements and then highlight what Bob Drozek,
Brandon Unruh, and Anthony Bateman’s book has contributed.
While a relative newcomer, the treatment model and theory of mentalization-
based treatment (MBT) has acquired a certain standing within the community of psy-
chological treatment approaches and transdiagnostic models of mental disorder. The
origin of this work goes back (an unimaginable) 35 years, when we demonstrated for
the first time that the security of the parent–child attachment bond at one year of age
could be predicted from an interview with a parent regarding their own attachment
history prior to the birth of the child. This work, with Miriam and Howard Steele, now
both enjoying well-deserved senior positions at the New School for Social Research
in New York City, showed that parents’ capacity to make sense of their early experi-
ences and relationships in terms of their mental states (e.g., thoughts, feelings, beliefs,
emotions, intentions)—a capacity we referred to as “reflective function”—was a crit-
ical factor that shaped the quality of care parents provided to their infants and the
security of the evolving attachment relationships (Fonagy et al., 1991). This paper,
which according to Google Scholar has been cited in 2,800 publications, implied that
insecure relationships may be perpetuated from one generation to the next. Further
follow-ups by Miriam and Howard found parental mentalizing to have a long-term
predictive power (Steele et al., 2016). In collaborative work with Pasco Fearon, we
were able to show, using behavior genetic methods, that the transgenerational process
was indeed mediated by social (not genetic) transmission, and could be clearly linked
to the quality of care the child received (Fearon et al., 2006).
The idea that patterns of relating are laid down in early life, may be relatively stable
over time, and may be passed from one generation to the next is neither original nor
new. The specificity with which mentalizing explains this process is however im-
portant, when thinking about how mental disorder is generated, and how it may be
prevented with thoughtful intervention, thus breaking intergenerational cycles of
disadvantage. This book, as does the MBT tradition in general, stands on the three
decades’ old work linking early experiences, mentalizing, and unhelpful patterns of
organizing attachment representations that generate clinical outcomes. Much of the
translational work that followed the original studies based at the Anna Freud Centre
(celebrating its 70th birthday in 2022) adopted the developmental framework in
which the capacity to mentalize was seen as a developmental achievement partially

x Foreword
ensured by the capacity of the child’s caregivers to provide a reflective environment

able to build robust mentalizing capacity in the child. The model was described in a
hurriedly written book published twenty years ago, brilliantly edited by Dr. Elizabeth
Allison. With over 8,500 citations, the book became highly influential, laying out
the central hypothesis that attachment-related trauma impairs the development of
mentalizing. This subsequently leads to the patterns of emotional dysregulation and
self-disturbance that are characteristic of borderline personality disorder (BPD) and
related difficulties (Fonagy et al., 2002).
The relationship between attachment and mentalizing would not have had true
clinical impact but for the work of an extraordinary clinician, Professor Anthony
Bateman, one of the authors of the present work. The novel framework for psy-
chological therapy, on which I had the privilege of working with Anthony, had a
transformational impact on practice. In the United Kingdom and internationally,
this approach underpinned the development, evaluation, and professional appli-
cation of effective mental health therapies for several different psychological is-
sues that threaten the health and well-being of adults, adolescents, children, and
families (Bateman & Fonagy, 2010). The research, which evaluated the suitability
and effectiveness of the mentalizing approach in personality disorder and other
client populations where attachment and mentalizing difficulties are considered
important (e.g., adolescent self-harm, children in foster care, depression), has all
been based on the principles of treatment which Anthony Bateman’s work estab-
lished for individuals with BPD (Bateman & Fonagy, 2006).
The principles of MBT technique, brilliantly illustrated in the present book, are
not all that Anthony has brought to the MBT tradition. Accessibility is perhaps the
most important of these. Some of it goes back to the practical constraints that drove
the original development of the intervention. Anthony Bateman, in almost his first
clinical leadership role, inherited a psychodynamic partial hospital program (the
Halliwick Day Hospital), where clinical capacity for specialist intervention was far
exceeded by clinical need—a situation still not uncommon in public mental health
settings in the United Kingdom. His task was deceptively simple: to create a theory-
grounded intervention for individuals with severe (almost exclusively borderline)
personality disorders that would have therapeutic value, and could be adminis-
tered with minimal training by individuals who had not been psychotherapeutically
trained, but had experience in treating severe mental health problems through
their training in nursing, social work, occupational therapy, psychology, and even
psychiatry.
MBT, as established by Anthony Bateman, remains remarkable for taking a non-
stigmatizing approach toward a client group who suffer more from stigma linked to
their mental health condition than perhaps any other, giving hope to patients by pro-
moting kindness and understanding—the concepts that lie at the heart of mentalizing.
Perhaps it is this considerateness that makes MBT relatively easy to implement with
clinical groups who have often become suspicious as a result of the many disappoint-
ments they have experienced with support previously received.

Foreword xi
The approach Anthony, with some support from me, has developed turned out
to be massively successful both clinically, and in terms of popularity (Bateman &
Fonagy, 2004). It combined our psychoanalytic understanding of personality and its
disorders with understanding gleaned from the rapidly developing neuroscience of
social cognition (Frith & Frith, 2003). Inspired by developmental psychology and
neuroscience, a set of interventions were created that helped clinicians understand
the atypical thinking of those with a diagnosis of personality disorder, providing
simple rule-based interventions to address these in a way believed to be beneficial to
the individuals concerned (Bateman & Fonagy, 2006).
Half a dozen randomized controlled trials showed robust benefits of MBT relative
to treatment as usual for BPD and associated problems (Bateman & Fonagy, 1999,
2001, 2009, 2013a, 2019b; Bateman et al., 2016; Robinson et al., 2014, 2016). It is easy
to forget that Bateman’s work established MBT as the first therapy to offer clear evi-
dence of lasting patient benefit, including at five-and eight-year follow-up (Bateman
et al., 2021; Bateman & Fonagy, 2008). The evidence confirmed that those receiving
treatment enjoyed a more fulfilling and gratifying quality of life, in terms of reduced
use of services and greater likelihood of being involved in full-time education or
employment.
Mentalizing as a psychotherapeutic approach continued to grow under Anthony
Bateman’s stewardship (Bateman & Fonagy, 2012, 2019a), as did the developmental
neuroscience from which it drew some of its inspiration. But the two fields continued
to develop separately to enrich our understanding of development, cognition, and
psychopathology. Only relatively recently has neuroscience reached out to the clin-
ical mentalizing researchers to establish common understanding (Gilead & Ochsner,
2021). In the meantime, MBT grew as a treatment approach. In collaboration with the
Anna Freud Centre, Anthony Bateman oversaw the provision of professional training
to practitioners around the globe to incorporate this research-based intervention into
the widest range of practices. Over 15,000 practitioners from 36 different countries
have received training in one of the MBT family of interventions, with demand for
training places continuing to outstrip supply. MBT training centers have been estab-
lished in seven European countries and three North American locations, and training
sessions have been held in all the nations of the United Kingdom, as well as the United
States, Austria, Finland, Japan, Italy, the Netherlands, Germany, Chile, Spain, Hong
Kong, Sweden, and Canada. While both Brandon Unruh and Bob Drozek have con-
tributed significantly to this training effort, it is Anthony Bateman’s remarkable en-
ergy that has ensured that the dissemination of MBT has been so extensive. In a recent
follow-up survey of practitioners who received training in MBT interventions, 87%
of the almost 300 who responded reported that MBT had been “very useful” or “ex-
tremely useful” to their practice. 89% reported that MBT had been “very beneficial”
or “extremely beneficial” to their patients.
The MBT family is growing. The thinking around clinical practice now belongs to
a large and growing community of clinicians and researchers advancing our under-
standing of both mentalizing as a developmental process and its challenges in clinical

xii Foreword
groups. The MBT community’s thinking is remarkably coherent, linking attachment

and mentalizing to social functioning, and coupling these with the core elements of
MBT practice. MBT’s thinking has impacted the development of a range of psycho-
logical treatments. Mentalizing has become a word used by clinicians practicing many
modalities, and it is perhaps unsurprising that giant clinician treatment developers
claim MBT to be a subspecialty within their own preferred way of working. Both
Aaron Beck and Salvador Minuchin have suggested that MBT, on closer inspection,
was a development of cognitive behavior therapy and systemic thinking respectively.
The developers of MBT have never aimed to develop a new “school” of psychotherapy.
We consider MBT to be a set of techniques perhaps more comfortable within the
common factors approach than as a member of a family of psychotherapies, or as a
specialist orientation of its own. MBT clinicians and researchers, encountering clin-
ical problems and using the basic ideas of the original model, have developed adapta-
tions that are manualized. These adaptations were evaluated in randomized controlled
trials where possible, disseminated to the broadest number of potential practitioners,
and supervised by experienced trained clinicians in the subspecialty.
And this brings us to the most recent addition to the family: MBT for pathological
narcissism, or MBT-N. MBT-N is an ingenious, creative, and brilliant adaptation of
the theoretical and practical principles of MBT which genuinely advances the value
and relevance of the MBT approach. To restate in summary form, the two conceptual
advances that drive MBT-N are (1) the concept of the narcissistic alien self, and (2) the
novel concept of the me-mode.
The approach advanced in Drozek, Unruh, and Bateman’s book extends substan-
tially and helpfully the clinical model of the alien self. Those familiar with the work
will recall that the internalization of a non-contingently related mirroring figure can
create a vulnerability for instability within the self-representation of the child. The self
is constituted from interpersonal interaction experiences with others, as suggested
by dialectic philosophical tradition as well as interactional social psychological and
psychoanalytic models. If early mirroring is absent or inaccurate, the child, looking
for a representation of its subjective experiences in the outside world, internalizes an
absence or worse still a hostile representation into the experiencing self. The self then
includes within itself a representation of the other, which is nevertheless felt to be a
part of itself—albeit an incongruent part. As mentalizing is helpful in creating coher-
ence, the alien self remains a vulnerability rather than a pathology. The propensity
for disorder becomes evident at times when the illusory coherence of the self is lost,
as is likely to occur when there is a breakdown in mentalizing. At these moments, the
incongruence of the self becomes painful, and the fragmentation is experienced as an
existential threat.
We have argued that incongruence of this kind is acutely distressing, and is com-
monly managed by identifying a person in the social environment who can be
nudged or manipulated into adopting representations that belong to another (alien)
self—historically, the caregiver inaccurately mirroring the self. With trauma history
(as is common in borderline personality disorder), internalization of an abusive and

Foreword xiii
destructive figure into the self structure creates an experience of sometimes indescrib-
able self-hatred. The individual’s self-hatred can only be managed through identifying
a vehicle incorporating hostility toward the individual in the social world—someone
who adopts the attitudes of hatred and creates a relationship of persecution with the
(now serially victimized) object of maltreatment. Distressing and uncomfortable as
these solutions often turn out to be, they are preferred to the alternative of internal
persecution and instability in self-experience.
Of course this model would not explain the typically grandiose and superior atti-
tude of the individual with pathological narcissism (PN). Drawing on developmental
literature, Drozek, Unruh, and Bateman identify the high prevalence of inaccurate
but positive interactions between parents and those who come to be at risk of de-
veloping PN. This creates an analogous but different challenge for self-organization
in these individuals. There is incongruity in the self structure but this feels alien be-
cause it is inappropriately, unrealistically, and excessively positive. The discomfort of
incongruity—its existential threat—is the same, but the alien part is not hateful but
excessively loving. Extrusion (projection) still has to happen to save the self, but it
comes with a loss of positive experience, as the extruded part of the self is loving ra-
ther than critical (as in BPD). Although finding external individuals to idealize (the
vehicle for this excessively positive stance) is a recognizable feature of PN, it is the ex-
aggerated value placed on the self which defines the disorder.
The brilliant insight guiding the model of treatment described in this book is
a recognition that the kind of extrusion or projection described in BPD can easily
be observed in narcissistic personality disorder (NPD), except that the incongruent
parts of the self are placed into the self-image rather than the external object. It is
the self-image that becomes the vehicle for the alien self, bringing with it relief in
terms of increased coherence, and also validation in terms of self-admiration and (in-
authentic) pride.
To make this simple idea work, the authors needed to bring in a second in-
genious extension to the basic MBT theory. They distinguish between the I-mode
and the me-mode, two developmentally sequenced categories of experience related
to the self. The I-mode, defined by philosophy of mind as the source of identity, re-
mains unchanged—the sum total of agentive self-experience. This is the sense of ex-
periencing that James recognized as the golden thread of sameness that continues
from infant behavior through childhood, and remains a core aspect of the human
mind across the lifespan: a sense of coherence and stability gifted to us (we main-
tain) by mentalization. As James (1890) wrote, “The mind can always intend, and
know when it intends, to think of the Same. This sense of sameness is the very keel
and backbone of our thinking” (p. 235). This sense sameness is located within the
I-mode. The I-mode, which contains agency, of course requires coherence. This is
why incongruent components that would compromise coherence of action need to
be projected. However, externalizing positive and favorable components of the self
into the external world opposes the pleasure principle, or the principle of reinforce-
ment learning. In common parlance, we might say, it does seem rather a shame,

xiv Foreword
particularly for individuals who for biological or social reasons are struggling with
enduring problems of self-esteem.
The solution which the authors suggest is both elegant and compelling. Where
better for a person with fragile self-evaluation to place such an inconvenient but
pleasing aspect of self than into the me-mode, the representational structure which
William James memorably named “self as object”? In the current model, the me-
mode is a self-representational structure based on the experience of the self in the
social context. It is an object that is described or narrated, rather than an entity that is
validated by its coherence and action, and consequently the I-mode is unable to tol-
erate incongruity. The me-mode belongs to a developmentally later stage, when the
capacity to construct an identity based on self-narrative emerges (McAdams, 2008;
McAdams et al., 2004). By creating a story and a set of meanings around personal
attributes, we create meaning around events in our lives. We interconnect past, pre-
sent, and expected experiences that collectively generate a unit of experience around
William James’ (1890) “self as object” or “me.” PN is not different in having a me-
mode. It is what the me-mode contains that differentiates PN.
The me-mode is the separate individual a person refers to when talking about their
personal experiences that feels sustainable over time. Of course it changes as the narra-
tive alters, but normally we deal with that through the usual flexibility that mentalizing
offers us. It is most likely that the me-mode comes to fruition as part of or after puberty,
when the demand for autonomy and the need to relate to and learn from peers be-
comes dominant (Debast et al., 2017). After the emergence of the metacognitive cap-
acity sufficient to create an integrated, evolving, coherent story of the self in interaction
with the social world, the individual becomes able to represent themselves to others,
drawing together their significant life experiences (Adler et al., 2016; McAdams, 2008).
The me-mode is a narrative identity that is more ideographic, dynamic, and contextual
than the I-mode can be, because self-agency demands coherence. You cannot do
two things at the same time, for example going at once left and right. Or you can, but
the result can be unattractive. As a narrative, the me-mode is therefore in most of us
more malleable to change—to change in psychotherapy, or perhaps even more likely,
through other social experience such as changed relationships (McLean, 2017).
Not so for the individual with pathological narcissism. If the me-mode is a vehicle
for a projection which safeguards the coherence of the I-mode, such luxury cannot
be afforded. In a person whose modification of their representational self structure
was enforced by the need to maintain coherence in the I-mode, any change in repre-
sentation signals the return of the extruded object back into the self. This gives rise to
incongruence and existential anxiety. For the BPD patient who creates a persecutor
externally and repeats again and again their history of maltreatment and exploitation,
there is no option of withdrawing the projection without generating the hatred within
the self, with self-harm and suicidal intent. The same challenge faces the person with
NPD. They cannot change. The grandiose self-love has to be part of their personality,
even if it ill-fits the reality of their life. For them, the flexibility of the me-mode repre-
sentational structure is unavailable.

Foreword xv
The dispositional traits characteristic of pathological narcissism are within the

I-mode, but the story the person weaves around these occurs in the representa-
tional context, which demands a certain degree of mentalizing to ensure coherence.
Limitations in mentalizing will impact on narrative coherence, threatening well-being
and explaining clinical referral for the broad range of reasons which Drozek, Unruh,
and Bateman hypothesize (Lind et al., 2019, 2020). When fully functioning, the me-
mode—James’ self-as-object representation—effectively distracts, preoccupies, and
relieves from the disruption of self-experience threatened by incongruity within the
I-mode. When mentalizing fails, the threat to self-cohesion becomes real, and pre-
mentalistic modes of thinking come to dominate the me-mode. As the authors sug-
gest, at this point, the individual may no longer be able to distinguish the me-mode
from the I-mode. When in the concreteness of psychic equivalence, the person no
longer experiences the representational self as a construction, but as a reality. The
person imagines their representation (their self-image) as having properties of an
agent to guide as opposed to narrating action, and they will appear to all observing
them as grandiose. Escape to pretend mode may be a solution. It is tempting to think
that narcissistic pathology is the me-mode in “pretend I-mode.”
All this of course is new thinking which this book proposes, along with a step-
by-step comprehensive guide to helping individuals manage these problems, and to
navigate the issue of self-evaluation and self-esteem. The breakdown of mentalizing
causes a conflation of the representational and the agentive mode, whereby the person
feels crushed by their self-representation, as if it were an aspect of physical reality. But
the model brings a very clear and, once again, brilliantly insightful goal to the treat-
ment. Recovering mentalizing does not need to confront the exaggeratedly positive
self-experience which has caused difficulties in self-coherence in the first place. The
goal is the recovery of mentalizing that enables the representational me-mode to act
as container for the inflated sense of self-worth. In representational me-mode, the
self-narrative can be adjusted to contain both high self-worth and the exigencies of
life circumstance, which might at times challenge this assessment. The therapy, as in
the treatment of borderline personality disorder, is not focused on altering the alien
self. The mental economy of self structure is likely to make that a fruitless exercise. It
is aligning alien parts of the self with a coherent self-representation that is the chal-
lenge for therapy, but one which the authors make abundantly clear the patient needs
to achieve themselves.
What the book offers is an exquisite, brilliantly written, highly astute set of guide-
lines on how to manage the recovery of mentalizing with patients whose narcissism is
pathological. The inset boxes, the tables, and the case histories reflect the authors’ vast
and almost unique experience in navigating these patients through the crisis that has
caused the collapse of mentalizing. This crisis creates conflicts between the person’s
lived life and their imagination (their fantastic self-narrative), which they cannot by
themselves bridge. As described in the book, the trigger for the collapse of mentalizing
is an inconsistency (which the person cannot reconcile) between their experience of
themselves and the world’s experience of them. Normally the discrepancy, like cracks

xvi Foreword
in plaster, can be papered over by mentalizing, finding sometimes ingenious solu-

tions for fitting square pegs into round holes. The internal or external conflicts that
compromise this process and increase emotional arousal have to be negotiated in the
mind, but also outside, in the social world. The cognitive and emotional content of
the me-mode is often the focus of psychotherapeutic approaches, be it from a cogni-
tive behavioral or a psychodynamic tradition. The authors suggest an alternative: a
process-oriented approach where the therapist is committed to engaging the patient
in activities that validate their view of the world, without generating unnecessary con-
flict and endangering their capacity to mentalize. In this process, the separation of
the I-mode and me-mode is achieved without dramatically altering either. However,
changes will invariably arise through the emergence of more balanced mentalizing
that ceases to rigidly prioritize the self over the other, or indeed the other over the self.
I consider MBT for narcissism to be a major innovation. It clarifies the multilevel
nature of self structure, interfaces it with mentalizing, and offers what may turn out
to be vital help for individuals whose chronic struggle with self-esteem leaves them
vulnerable to depression, self-destructive acts, and sometimes suicidality. The book
also opens an opportunity for us to work with, and try to understand, a group of in-
dividuals who have previously perhaps received inappropriate treatment from MBT
practitioners. The increased subtlety of the MBT approach described here enables us
to respond accurately and contingently, in a gentle and marked mirroring manner.
This is ultimately what we hope for from the MBT approach in general—not quite
a school of therapy but perhaps more than a set of randomly assembled techniques,
somewhere in between. Perhaps a tradition?

Acknowledgments
We want to acknowledge a host of friends, colleagues, and organizations, without

which this book would never have come to be. MBT for narcissism was largely de-
veloped in the Mentalization-based Treatment (MBT) Clinic at McLean Hospital.
Established in 2011 under the guidance of MBT originators Anthony Bateman and
Peter Fonagy, the Clinic has grown and thrived due to the commitment and gener-
osity of John Gunderson, Lois Choi-Kain, Joe Flores, Shauna Dowden, George Smith,
Mary Zanarini, Michael Hollander, Amy Gagliardi, Diane Bedell, and Joseph Gold.
We are bolstered and enlivened by our staff, Ashley Beaulieu, Caleb Demers, and
Geoffrey Liu. We thank the scores of residents and trainees who have volunteered
their time and energy over the years to provide specialized, insurance-based care to
patients in critical need of their help. Perhaps most importantly, we are indebted to
our patients, who have been genuine partners in helping us learn how to adapt MBT
to the unique challenges of pathological narcissism.
Before any words were ever written about MBT for narcissism, Elsa Ronningstam
has long encouraged us to formulate and advance our ideas: “We need a therapy
geared toward reflectiveness in the treatment of NPD!” At Oxford University Press,
Martin Baum has consistently championed our vision for the book, with responsive-
ness and cheer. On both sides of the pond, our MBT training structures have served
as an essential “home base” that have enabled us to advance and disseminate the nu-
ances of this model. In the Gunderson Personality Disorders Institute at McLean
Hospital, we recognize Lois Choi-Kain, Ellen Finch, Gabs Ilagan, Evan Iliakis, Julia
Jurist, Grace Murray, and Vy Ngo. At University College London, we appreciate the
contributions made by our colleagues to the ongoing research on mentalizing. At the
Anna Freud National Centre for Children and Families, we acknowledge the con-
tinued work of all the staff who enthusiastically and efficiently support the teaching
of MBT to clinicians.
Bob Drozek
Many of these principles were initially developed and “road tested” in the MBT for
Narcissism psychotherapy group at McLean Hospital. I am thankful for the past and
current members of that group—for letting me be a part of your journey, and for
your courage and resilience in facing the most treacherous of all endeavors: evolving
your sense of self. In the Massachusetts General Hospital/McLean Adult Psychiatry
Residency Program, I have had the good fortune to supervise the PGY3s in the
Addiction Psychiatry rotation. You have long highlighted the need for a streamlined,

xviii Acknowledgments
“step-by-step” process of elaborating patients’ emotional experiences, which bol-

stered me to systematize the affect elaboration strategies outlined in this book. I am
privileged to collaborate with my colleagues in the Division of Alcohol, Drugs, and
Addiction at McLean, and especially in the Law Enforcement, Active Duty, Emergency
Responder (LEADER) program, where we have applied these ideas in a different con-
text, with the highest of stakes. Hilary Connery, Patty Diaferio, Kate McHugh, Rachel
Tester, and Ruth Reibstein—I love working with you all.
Amy Gagliardi, you are hands-down the best therapist that I know. Your pragma-
tism, flexibility, and abiding respect for patients as people have served as a guiding
light to me when working with these patients, shepherding me through many an im-
passe. Caleb Demers, thank you for co-leading the MBT for Narcissism group with
me for so many years. Your curiosity and incisiveness have challenged me to learn
and articulate these techniques at a greater level of depth. Brandon Unruh, you bring
a humility, thoughtfulness, and groundedness to everything that you do. This helps to
ground me in this work, keeping my focus where it belongs: helping our patients, and
serving a higher good.
Anthony Bateman, your benevolence, inclusivity, playfulness, and lack of pretense
are truly the embodiment of MBT. Since my first MBT training and my time at the
Veterans Administration, you have graciously given your time and mentorship to
me: expounding on the nuances of the model, and always being willing to interrogate
and rethink its implementation. I cannot express how much this meant to me at the
time—to feel connected to a broader community, despite my lack of status or affili-
ation in the world of personality disorders. It is an honor now to be partnering with
you to write this book.
To my family and friends: I feel grateful for all of your care and support, and for you
putting up with me talking about narcissism non-stop for the past four years. David
Klee, I am blown away by your painting for our cover. You have created a stunning
representation of the anguish of narcissism, as well as the hope and beauty of its trans-
formation, and ultimate healing.
My children Margaret and Kip: I have cherished our long walks discussing these
topics. With patience and perceptiveness, you have repeatedly helped me work
through conceptual problems whenever I got stuck. You now know more about
NPD than any other nine-and eleven-year-olds should! Kip, your humor, cre-
ativity, and tenacity provided me with constant joy and stimulation as I wrestled with
these matters. Margaret, your compassion, thoughtfulness, and consistent focus on
others’ needs inspire me and warm my heart. Nice work coining the term “relational
tracers”—a significant advance in MBT terminology.
My wife Rose: I truly cannot imagine this book without you. You read and edited
countless pages; designed all the figures in the book; and served as a personal, vo-
luminous, empathic thesaurus—always with an eye towards accessibility and practi-
cality. You endured my working long hours on the manuscript, while deftly managing
our shared burdens and responsibilities with generosity, kindness, and a continuous

Acknowledgments xix
spirit of discovery and play. You have kept me centered, allowing me to feel safe, con-
nected, and loved throughout this process.
Brandon Unruh
I am deeply grateful to those who galvanized my earliest quests with storylines and
soundtracks that helped me blend ambition with surrender, swords with walking
sticks, a searching heart with knowing my true place in the world: J.R.R. Tolkien, C.S.
Lewis, Bono, Robert Coles, and Armand Nicholi, Jr.
Thanks to Lois Choi-Kain and the late John Gunderson for trusting me to steward
MBT at McLean and strengthening my spine by catalyzing sorely needed integra-
tion of aggression. Thanks to Joe Flores, Joan Wheelis, and Frank Yeomans for sup-
port in unifying diverse ways of being. I pay special homage to the late John Terry
Maltsberger, elder dragonslayer, for nurturing my therapeutic core and getting me to
admit its source to myself and to the world.
I thank Anthony Bateman and Peter Fonagy for taking an interest in me when I had
just been tasked with founding the McLean MBT Clinic and yet could barely contain
my idealization toward them, judging by the five highway U-turns made before finally
delivering them safely to the airport.
I thank Bob Drozek for our abiding friendship and our partnerships in writing,
teaching, and leading our Clinic. Thanks to Shauna Dowden, who helped build the
Clinic through her spirited and Spirit-led mentalizing. Thanks to my long-time com-
rades at the Gunderson Residence for their camaraderie and sharpening of my clinical
sensibilities: Karen Jacob, Kelly Gunderson, Brad Reich, and Claire Brickell. Thanks
to my friend, Kyle Smethurst, for helping me keep lit the fire of faith.
I owe so much to my parents Dennis and Cinde, sister Taryn, and grandparents
Verda, Arthur, and Elva, for anchoring a family culture in which I could grow to know
both humility and high hopes, stretched between Kansas farmland and California
dreams. Thanks to my uncle Greg, my original and ongoing musical, literary, and
philosophical “influencer.”
To my wife Katherine, my FCT and FPTTT, whose daily acts of faith, love, and
devotion plunge me into depths far beyond my own dreaming or making. Thanks to
you, my world is wide, and none of my comings and goings within it are ever a solo
act. Together we “kick at the darkness ‘til it bleeds daylight.” To our children, whose
very essences temper narcissistic struggle: Lily, how lovely is your empathy; River,
your spiritual vision exceeds your years and enriches us all; and Greyson, may you
always have the capacity to seize joy and relish playing the ham. This book is an effort
toward a brighter future for you three.
But for me this book is really offered up to the Logos who walks between the worlds
of Real and Ideal. There may be a final “mode” beyond those discussed in these pages
offering truest hope for the ultimate resolution of narcissistic contending. From I,

xx Acknowledgments
to me, to we, to I-and-Thou: Come, Lord, turn us away from Narcissus’ pool, unto
Yourself . . . “till we have faces”!
Anthony Bateman
My colleagues will recognize many of their ideas in this book, and I am profoundly
grateful to them for sharing their thoughts willingly and without ownership. It is my
hope that others in turn will take the ideas and suggestions in this book, try them out,
and make them their own. First and foremost, I would like to thank Peter Fonagy, who
has more ideas in a short time than most of us do in a lifetime, throwing them out to
see if they land on fertile ground. Many of them do. Generously, he later sees them
as the other person’s idea rather than his own, as exampled in his Foreword to this
book. My role has primarily been to translate developmental research into practical
and effective clinical intervention. I am supported in this by the many patients and
clinicians with whom I have worked over the years.
It would be invidious to start naming people, but two of the clinicians from whom
I have learned extensively are the other authors of this book. Bob and Brandon, whose
“not-knowing” attitude and clinical skills led to the development of the approach out-
lined in these pages, are without doubt the real developers of MBT for narcissism.
I thank them for persuading me that it was a journey worth going on with them. It
certainly was, as this book attests. I would like to mention the late John Gunderson,
with whom I worked closely over many years. Without his mischievous intellect and
breadth of thinking, mentalizing and MBT would not so easily have found fertile
ground in the United States, and perhaps this book never would have come about.
I miss him and thank him for his friendship and collaboration of many years.
Finally, of course I would also like to thank my family and close colleagues who
continually put up with me writing books and chapters, and who have always been
kind when puncturing my own narcissism, as and when necessary!

Contents
About the Authors xxv
PART 1 MENTALIZATION AND PATHOLOGICAL NARCISSISM
1. Introduction to Pathological Narcissism and Mentalization-based

Treatment 3
MBT for narcissism: The rationale 6
Introduction to mentalization-based treatment 8
What is mentalizing? 9
The healthy development of mentalization 10
I-mode: Focus on internal states in self 10
Me-mode: Reading others’ mental states 11
Personalized me-mode: Reading others’ mental states about self 12
We-mode: Co-mentalizing and epistemic trust 13
Core processes of MBT 14
Managing anxiety 15
Empathic validation 15
Democracy, equality, and collaboration 15
Authenticity and the not-knowing stance 16
Stimulating patients’ own reflectiveness about mental states 17
Exploring relational processes 18
Conclusion: An outline for the book 18
2. A Mentalization-based Model of Pathological Narcissism 23

Symptoms and characteristics of pathological narcissism 23
Mentalizing and the development of pathological narcissism 26
A mentalization-based model of pathological narcissism 29
Attachment-related inhibition of mentalization 29
Re-emergence of non-mentalizing modes 30
The narcissistic alien self 32
Conclusion 33
PART 2 BEGINNING THE TREATMENT
3. Assessment and Diagnosis of Pathological Narcissism 37

The importance of diagnosis-giving in MBT for narcissism 37
Assessment of narcissism in MBT-N 38
Patients’ perspective on presenting problems 40
Discussion of the psychosocial landscape: Functioning and precipitants 41
Exploration of narcissistic processes 43
Giving the diagnosis of pathological narcissism 47

xxii Contents
4. Structure and Aims of MBT for Narcissism 54

Domain-based conception of mentalization: Content, context, and process 54
Aims of MBT for narcissism: “Reflect rather than reflex” 58
Early stages of treatment 60
Establishing shared treatment priorities 61
Assessment of mentalizing 65
Developing and delivering the mentalization-based formulation 69
Orienting patients to the therapy sessions 79
PART 3 THE THERAPEUTIC APPROACH
5. Therapeutic Stance and Clinical Principles 85

Core features of the therapeutic stance in MBT for narcissism 85
Trajectory of mentalizing interventions: Content, context, and process 88
Establishing and managing the experiential contexts for mentalizing 95
Structure of sessions in MBT for narcissism 100
6. Content-focused Interventions 107

Clarification 108
Affect elaboration 110
Affect elaboration inquiries 112
The affect elaboration interventional pathway 115
Affect elaboration of vulnerable emotional states 121
“If all else fails”: What to do when affect elaboration is ineffective 126
Affect elaboration of other people’s mental states 131
Empathic validation 135
Technical principles of empathic validation 136
7. Context-focused Interventions 142

The context of events 144
The context of behavior 147
Context-mentalizing of past behaviors 148
Context-mentalizing of patients’ current experience of agency 149
Context-mentalizing of broader behavioral and interpersonal patterns 151
Context-mentalizing of future behavioral possibilities 155
Context-mentalizing of other people’s behaviors and mental states 159
Providing feedback about patients’ challenges with behavior-focused
mentalizing 162
The context of emotions 165
Consecutive emotions 166
Simultaneous emotions 168
Nascent emotions 169
General context-focused inquiries 174
The context of history 176

Contents xxiii
8. Process-focused Interventions: Pretend Mode 180

Introduction to process-focused interventions 180
Clinical manifestations of pretend mode in pathological narcissism 181
Process-focused interventions for pretend mode 183
“If all else fails”: Challenging the pretend mode 189
9. Process-focused Interventions: Psychic Equivalence Mode 195

Introduction: Clinical manifestations of psychic equivalence in
pathological narcissism 195
Process-focused interventions for psychic equivalence mode 198
“If all else fails”: What to do when process-focused interventions for
psychic equivalence are ineffective 203
Clinical illustration: Process-focused interventions for psychic equivalence 206
10. Process-focused Interventions: Teleological Mode 210
Introduction: Clinical manifestations of teleological mode in pathological
narcissism 210
Process-focused interventions for teleological mode 214
“If all else fails”: What to do when process-focused interventions for
teleological mode are ineffective 220
Clinical applications: Process-focused interventions for teleological self-
esteem 223
11. Mentalizing the Therapeutic Relationship: Auxiliary Relational
Techniques 229
Introduction to mentalizing the relationship in MBT for narcissism 229
The “don’ts” of mentalizing the relationship in MBT for narcissism 230
Relational tracers 234
Interpersonal affect focus 242
Affective self-disclosure 247
12. Mentalizing the Therapeutic Relationship: The Interventional
Pathway 259
Direct focus to relevant relational process 261
Collaborative exploration and elaboration 262
Context-focused interventions 266
Empathic summary of patients’ experience 269
Exploration and acceptance of therapist contribution 270
Identify form of non-mentalizing 273
Domain-specific interventions 273
Potential content-focused interventions 276
Potential context-focused interventions 278
Potential process-focused interventions 282
Review, reflection on new understanding 288
Clinical illustration: The interventional pathway for mentalizing the
relationship 292

xxiv Contents
PART 4 CLINICAL APPLICATIONS
13. Moving Forward in the Treatment 305

Contrary moves and mentalizing polarities 305
Classic polarities of mentalizing 305
Additional polarities assessed in MBT for narcissism 307
Contrary moves: General aims and techniques 308
Contrary moves with special relevance to pathological narcissism 311
Self → Other /Other → Self 311
Certainty → Doubt 311
General → Specific 313
Fantasy → Reality 313
Suicidal behavior in pathological narcissism 314
Unique empirical features of suicidality in pathological narcissism 315
A mentalization-based model of suicidal behavior in pathological narcissism 317
Mentalizing functional analysis: General aims and techniques 319
Mentalizing functional analysis of suicidal behavior: Specific techniques in
Clinical illustration: Mentalizing functional analysis of a suicide attempt in
Therapeutic progress, pauses, and termination 330
14. Case Example: After the “Accident” 334
Background information 334
The start of the treatment 336
Months 6–12 of treatment 342
The second year of treatment 345
The third and fourth years of treatment 348
Termination 353
15. Case Example: I-mode, Me-mode, and We-mode in Clinical Process 354
Initial sessions 357
Addressing the fragility of narcissism 358
Affective self-disclosure to address narcissistic processes 360
Strategies to address pretend mode 361
Conclusion: The groundwork for we-mode 363
16. Case Example: William the Firefighter 364
Background information 364
Months 6–12 of treatment 370
The second year of treatment 373
The third year of treatment 377
References 383
Index 399

About the Authors
Robert P. Drozek is a staff psychotherapist in the Personality Disorders Service

and the Division of Alcohol, Drugs, and Addiction at McLean Hospital in Belmont,
Massachusetts. He serves as a supervisor in the Mentalization-based Treatment
(MBT) Clinic at McLean, a teaching associate in the Department of Psychiatry at
Harvard Medical School, and an MBT trainer and supervisor through the Anna Freud
Centre in London. His publications examine the interface between psychotherapy
and ethics, with an emphasis on the role of ethics in the patient’s therapeutic change.
He is author of the book Psychoanalysis as an Ethical Process (2019). He maintains a
private practice in Belmont, Massachusetts.
Brandon T. Unruh is the medical director of the Gunderson Residence and founding
director of the Mentalization-based Treatment (MBT) Clinic at McLean Hospital in
Belmont, Massachusetts. He is an instructor in psychiatry at Harvard Medical School,
and an MBT trainer and supervisor through the Anna Freud Centre in London. His
clinical approach is anchored in the practice of evidence-based treatments for per-
sonality disorders, including MBT, dialectical behavior therapy, transference-focused
psychotherapy, and good psychiatric management. His core academic publications
and interests are in the areas of personality disorders, suicidality, spirituality, and
flourishing. He is co-editor of the book Borderline Personality Disorder: A Case-based
Approach (2018). He has a private practice in Cambridge, Massachusetts.
Anthony W. Bateman is a consultant psychiatrist, psychotherapist, and MBT

Consultant to the Anna Freud National Centre for Children and Families; a Visiting
Professor at University College, London; and an Honorary Professor in Psychotherapy
at the University of Copenhagen. With Peter Fonagy, he developed mentalization-
based treatment (MBT) for borderline personality disorder, studying its effective-
ness in research trials. He has authored, co-authored, and edited 17 books, including
Mentalization-based Treatment for Personality Disorders: A Practical Guide (2016),
and Introduction to Psychoanalysis, Second Edition (2021). He has published nu-
merous book chapters, and over 150 peer-reviewed research articles on personality
disorders and the use of psychotherapy in psychiatric practice.

PART 1
MENTALIZATION AND PATHOLOGICAL
NARCISSISM
Part 1 examines the relevance of pathological narcissism (PN) within contemporary

culture and psychotherapy practice, as well as the potential utility of mentalization-
based treatment (MBT) in treating PN. The construct of mentalization is introduced,
and the main principles and applications of MBT as a modality are outlined. Utilizing
research on parenting styles, attachment patterns, and empathy in PN, the authors
propose a theory of PN that centers on impairments in mentalization.

1
Introduction to Pathological Narcissism
and Mentalization-based Treatment
As a clinical and theoretical construct, narcissism is currently receiving an unprece-

dented amount of attention. Multiple authors have highlighted the relevance of nar-
cissism to broader “self-focused” patterns in contemporary culture (Lunbeck, 2014;
Malkin, 2015; Twenge & Campbell, 2009), and the term “narcissism” is now employed
liberally in discussions of celebrities, reality television, social media, “selfie” culture,
and political figures. Within psychology, research on narcissism has proliferated ex-
ponentially over the past several decades. According to the database PsychInfo, while
only around a dozen empirical papers on narcissism appeared before 1980, several
hundred studies on narcissism are now published every year in peer-reviewed aca-
demic journals. This research has revealed that narcissism is not simply an annoying
personality trait, but a valid psychological construct with real public health costs.
Narcissistic personality disorder (NPD) has a lifetime prevalence of 6.2% (Stinson
et al., 2008), and narcissistic traits are associated with a range of debilitating psycho-
social challenges, including affective instability (Fava et al., 1996; Stinson et al., 2008;
Tritt et al., 2010); substance use disorder (Coleman et al., 2017; Echeburúa et al., 2007;
Preuss et al., 2009); vocational impairment (Schwarzkopf et al., 2016); violence and
aggression (Lambe et al., 2018); corruption (Julian & Bonavia, 2020); lethality from
suicide (Blasco-Fontecilla et al., 2009; Giner et al., 2013); and dysfunction and distress
in interpersonal relationships (Cheek et al., 2018; Miller et al., 2007; Ogrodniczuk
et al., 2009).
As other authors have noted (Caligor et al., 2015; Ronningstam, 2005), patho-
logical narcissism (PN) encompasses a wide array of psychological, emotional, inter-
personal, and functional challenges. In popular culture, the term “narcissist” calls
forth something of a caricature: the arrogant, self-involved man who spends most of
his time bragging about himself and devaluing others. “It’s all about him.” “He thinks
he’s always right.” In everyday clinical practice, clinicians regularly encounter more
three-dimensional, sympathetic examples of narcissism: the perfectionistic, inse-
cure college student who spends all of his time on his schoolwork, seriously consid-
ering suicide when he is unable to meet his rigid standards for himself; the physician
struggling with frequent interpersonal conflicts with colleagues and supervisors, be-
coming defensive and argumentative whenever she receives constructive feedback;
the poised, well-dressed advertising executive plagued by obsessive ruminations
about her attractiveness, wealth, and how other people in the office are seeing her and

4 MBT for Pathological Narcissism
her work; the military veteran with alcohol use disorder and depression, which he
attributes to a long history of mistreatment by others—getting fired from his job, his
wife divorcing him, and his adult children refusing to speak to him.
What links these diverse sorts of patients to each other? While different theories
answer this question from different perspectives (see Campbell & Miller, 2011), a sig-
nificant body of empirical literature frames PN in terms of an excessive reliance on
narcissistic self-enhancement, understood as internal and interpersonal efforts “to in-
crease the positivity of one’s self-concept or public image” (Wallace, 2011, p. 309; see
also Grijalva & Zhang, 2016). On this view, across its various manifestations and sub-
types, PN is marked by the tendency to seek out and amplify internal and external
factors that augment the person’s sense of self-esteem, while simultaneously avoiding
and minimizing those factors that diminish the person’s sense of self-esteem.
Despite our increased understanding of narcissistic challenges, therapists treating
these patients often feel poorly equipped to the task. Patients with PN are notoriously
“difficult to treat,” often dropping out of treatment precipitously (Campbell et al.,
2009; Ellison et al., 2013), and leading therapists to experience a range of uncomfort-
able emotional states in themselves, including frustration, boredom, and inadequacy
(Tanzilli et al., 2017). The psychotherapy literature on PN provides little assistance
along these lines. With no randomized controlled trials completed to date, this lit-
erature consists of mainly of case reviews, theoretical formulations, and quantitative
evaluations of clinical reports (Dimaggio et al., 2008; Kernberg, 1975; Kohut, 1977).
Apart from some recent exceptions (Diamond et al., 2022; Weinberg & Ronningstam,
2020), authors discussing PN tend to approach these topics at a high level of abstrac-
tion, articulating broad therapeutic principles that leave significant ambiguity about
how to actually implement the approaches in question. Clinicians thus may under-
stand patients with PN better, but they still feel quite uncertain about what to actually
do when they are sitting with these patients: what to say, how to guide the sessions,
and how to respond to the confusing and often frustrating difficulties that occupy
these patients.
In this book, we will attempt to employ the principles of mentalization-based treat-
ment (MBT) to develop a comprehensive approach for understanding, assessing, and
treating patients with pathological narcissism (Drozek & Unruh, 2020). MBT is an ac-
cessible, easy to learn, and resource-sensitive therapeutic approach that is second only
to dialectical behavior therapy (DBT) in empirical support for treating borderline
personality disorder (BPD; Cristea et al., 2017; Oud et al., 2018; Storebø et al., 2020;
Witt et al., 2021). The term “mentalization” refers to the fundamental psychological
capacity to “read,” access, and reflect on mental states (e.g., thoughts, emotions, de-
sires, attitudes) in oneself and other people. As a psychotherapeutic treatment, MBT
works to strengthen patients’ ability to initiate and maintain mentalizing under cir-
cumstances of emotional and interpersonal stress, resulting in increased stability
in patients’ emotions, relationships, behaviors, and overall sense of self (Bateman
& Fonagy, 2017). The core tenets of MBT have already been elaborated elsewhere
(Bateman & Fonagy, 2016, 2019a), illustrating its broad applicability to personality

Introduction to Pathological Narcissism and Mentalization-based Treatment 5
disorders, eating disorders, posttraumatic stress disorder, and substance use dis-
orders, among other psychiatric and psychosocial challenges. Rather than supplant
Bateman and Fonagy’s more comprehensive formulations, we hope to tailor and re-
fine these insights to address the unique challenges associated with narcissism.
We approach this task with significant experience in the practice and training of
MBT. Anthony Bateman is one of the developers (along with Peter Fonagy) of MBT,
having spearheaded much of the research and writing that has established MBT as
a leading psychotherapy for personality disorders. Brandon Unruh is the founder
and director of the MBT Training Clinic at McLean Hospital, and a trainer of MBT
through the Anna Freud Centre in London. Robert Drozek serves as a therapist and
supervisor in the MBT Training Clinic, also serving as a trainer of MBT through the
Anna Freud Centre. As we have gained increased experience facilitating and super-
vising the treatment of patients with PN, we have come to regard MBT as a useful
intervention.
Our interest in narcissism developed somewhat accidentally, through our experi-
ence treating patients with BPD in the MBT Training Clinic. Part of the Personality
Disorders Service at McLean Hospital, the clinic currently stands as the only out-
patient clinic in the United States providing standardized, systematic, insurance-
based individual and group MBT. Over the years, we began to notice a certain
subgroup of patients presenting for care. While these patients often had experienced
some level of success and stability in their lives, they ultimately encountered a signifi-
cant life disruption—interpersonal challenges at work, disruptions in relationships,
change in financial status—that precipitated their difficulties with depression, anx-
iety, and suicidality. Given the characteristic interpersonal hypersensitivity associated
with BPD (Gunderson, 2014), this understandably led referring providers to see them
as having “borderline personality disorder.”
However, whereas patients with BPD tend to be overly seeking of attachment with
others, these patients exhibited much more self-reliance, selectiveness in interper-
sonal relationships, and at times, avoidance and isolation from other people. They
seemed to crave connectedness, but they did so more indirectly, namely by making
insightful comments, sharing about past successes, and in the context of therapy,
being the “star patient.” While patients with BPD struggle extensively with emotional
dysregulation, these patients often seemed more disconnected from their emotions.
They had extensive insights about themselves and their histories, which they were
happy to share, but they struggled to access and express their emotions in an au-
thentic, rich way.
As these treatments unfolded, we gathered a more complex picture of these patients
and their challenges. We observed tendencies toward defensiveness, argumentative-
ness, superiority, entitlement, externalization, self-centeredness, and aggression, as
well as empathic deficits, especially when their self-esteem was threatened by others.
Thankfully, we were treating these patients during the renaissance of empirical re-
search on narcissism (Campbell & Crist, 2020), which includes studies showing a
striking symptomological overlap between BPD and a certain subtype of narcissism

referred to as vulnerable NPD (Miller et al., 2010; Pincus et al., 2009). As we digested
the vast and growing empirical literature on PN, we began to understand that this sub-
group of patients was likely better understood through the lens of narcissism. Similar
to the treatment of BPD, we started to directly give the NPD diagnosis to patients: re-
viewing diagnostic criteria, exploring relevant symptoms from their history, and pro-
viding psychoeducation about this widely misunderstood and stigmatized construct
(see Chapter 3). To our surprise, patients were usually grateful for this information.
“This explains me in a way that nothing else ever has. I don’t like the word narcissism,
but I just feel so relieved that I finally know what has been going on with me.”
Following in the footsteps of other modalities for treating PN (Diamond et al.,
2022; Gabbard & Crisp, 2018), we began applying the principles of MBT to address
these patients’ unique challenges, with surprising effects: they tended to get better,
in a manner that differed from their previous experiences in treatment. Functionally,
patients reported decreased avoidance, improved work performance, and fewer
interpersonal conflicts with other people. More internally, they described decreased
depression and anxiety, improved ability to empathize with other people, and an in-
creased sense of self-esteem and self-worth. Heartened by this progress, we started
an MBT psychotherapy group specifically for patients with PN, where members had
the opportunity to learn more about the diagnosis, and to engage in mutual sharing
and reflection around their shared challenges with self-esteem and interpersonal
instability.
Admittedly, these gains are anecdotal and highly provisional. However, they have
led us to consider the possibility that MBT’s principles could have genuine utility in
helping patients with pathological narcissism. This book represents our efforts to dis-
till our clinical experience with these patients, in a pragmatic way that is accessible
for the practicing clinician. We offer this volume as a usable handbook which might
shed some light on how to treat these patients: how to structure the treatment; “what
to do and say” in response to patients’ characteristic challenges; and how to facilitate
sessions—and the treatment as a whole—in order to maximize the potential for real
and enduring change. By clearly outlining our specific techniques and interventions,
we try to formulate our proposals in a manner that lays the groundwork for future
empirical investigation and clinical applications.
MBT for narcissism: The rationale

Why think that MBT might work for narcissism? Given the aforementioned symptom-
atic commonalities between BPD and vulnerable NPD, as well as MBT’s established
efficacy in treating BPD, there is value in considering the potential utility of MBT’s tech-
niques in addressing the symptoms and traits of PN. Similarly, recent research supports
the efficacy of MBT in treating antisocial personality disorder (ASPD; Bateman et al.,
2016), a diagnostic category with a similar mentalizing profile (e.g., involving concrete-
ness, alexithymia, and empathic deficits) as NPD. In the absence of evidence-based

treatments for PN, an approach yielding benefits for multiple neighboring diagnoses
merits consideration as a candidate treatment. Furthermore, in an 18-month trial of
outpatient MBT, MBT was more effective than generalist treatment for patients with
greater Axis II comorbidity, including comorbid BPD and PN (Bateman & Fonagy,
2013a). This suggests that MBT may have particular efficacy for those whose BPD is
embedded within other personality problems, including narcissism.
Furthermore, as we explore in detail in Chapter 2, patients with PN exhibit sig-
nificant and pervasive challenges with mentalization. Research shows that PN is as-
sociated with impairments in empathy (Urbonaviciute & Hepper, 2020)—involving
difficulties mentalizing others—and alexithymia (Fan et al., 2011; Jonason & Krause,
2013)—implying troubles mentalizing oneself. Consistent with the aforementioned
tendencies toward self-enhancement, patients with PN also often overestimate their
mentalizing abilities (Ames & Kammrath, 2004; Duval et al., 2018; Ritter et al., 2011).
One recent study found that reduced generosity was mediated by reduced perspective-
taking abilities in narcissism (Böckler et al., 2017), raising the interesting possibility
that inhibited mentalizing could be related to the typical “selfishness” associated with
PN. More anecdotally, in clinical work with patients with PN, we regularly see many
of the transdiagnostic “mentalizing impairments” that MBT targets, including overly
rigid and certain views of Self and Other (psychic equivalence mode); tendencies to-
ward concreteness and externalization (teleological mode); and problems with intel-
lectualization and disconnection from emotions (pretend mode). If these challenges
with reflectiveness are part of the characteristic symptom profile in PN, it is reason-
able to utilize a treatment approach that directly addresses those challenges.
Along similar lines, one recent study discovered that deficits in mentalizing me-
diate the relationship between childhood trauma and narcissism among adolescents
(Duval, Ensink, Normandin, & Fonagy, 2018). In the event that mentalizing impair-
ments are part of the “pathway” for the development of narcissism, strengthening pa-
tients’ mentalizing could impact the impact the severity of narcissistic pathology.
Finally, improvements in reflective function and mentalization appear to be im-
portant mechanisms of change for personality disorders, including in samples of pa-
tients with comorbid BPD and PN (Diamond, Clarkin, et al., 2014; Diamond, Levy,
et al., 2014; Diamond et al., 2013). One important recent study confirms the correl-
ation between PN and mentalizing deficits (Euler et al., 2022), also finding that the
capacity to mentalize mediates the relationship between PN and outcomes in psy-
chotherapy. The authors propose: “Enhancing the capacity to mentalize might thus
be a promising endeavor in the treatment of patients with pathological narcissism”
(p. 288). These conclusions are consistent with research suggesting that mentalized
affectivity—the capacity to access one’s own emotions while simultaneously reflecting
on them—mediates the connection between PN and the capacity for self-compassion
(Goodwin & Luchner, in press), a trait that is often compromised in PN (Barry et al.,
2015; Kramer et al., 2018). In light of all of these findings, we suggest that there could
be significant value in utilizing MBT to understand and address the symptoms of
pathological narcissism.

Introduction to mentalization-based treatment

The construct of mentalization was originally formulated by Peter Fonagy in psy-
choanalytic terms in 1989 (Fonagy, 1989). Fonagy then collaborated with Anthony
Bateman to manualize and research MBT in the United Kingdom in the 1990s, pub-
lishing the first randomized controlled trial on MBT for BPD in 1999 (Bateman &
Fonagy, 1999). The first MBT treatment manual was released in 2004, and subsequent
editions have followed (Bateman & Fonagy, 2006, 2016), further developing MBT’s
technical strategies in light of its expanding evidence base and clinical applications. At
present, MBT’s focus has expanded far beyond personality disorders, with random-
ized controlled trials conducted on a wide range of clinical challenges, including sub-
stance use disorder (Philips et al., 2018), addiction among mothers (Suchman et al.,
2017), eating disorders (Robinson et al., 2016), depression (Jakobsen et al., 2014), and
adolescent self-injury (Rossouw & Fonagy, 2012).
MBT’s efficacy has been illustrated in partial hospitalization programs (Bales et al.,
2015, 2012; Bateman & Fonagy, 1999; Laurenssen et al., 2018; Smits et al., 2020); out-
patient treatment (Bateman & Fonagy, 2009, 2013a; Bateman et al., 2016; Jørgensen
et al., 2013); and group-based protocols (Bo et al., 2019, 2017; Griffiths et al., 2019).
Studies suggest that the positive outcomes for MBT are significant and wide-ranging,
including reduced depressive symptoms, decreased suicidality and self-injurious
behavior, less inpatient usage, and improved social and interpersonal functioning
(Bateman & Fonagy, 1999, 2009). These gains are durable, with follow-up studies
suggesting that progress is maintained 5–8 years after the conclusion of treatment
(Bateman & Fonagy, 2008; Bateman et al., 2021).
When investigating an 18-month day hospital MBT program for patients with
BPD, Bales and colleagues (2012, 2015) similarly illustrated that MBT results in
decreased symptomatic distress, suicidality, self-harm, and care consumption, as
well as enhanced self-control, identity integration, responsibility, social cooper-
ation, and stability in relationships. In the treatment of patients with comorbid BPD
and ASPD (Bateman et al., 2016), MBT led to diminished anger, hostility, para-
noia, and frequency of self-harm and suicide attempts, as well as improvement of
negative mood, general psychiatric symptoms, interpersonal problems, and social
adjustment.
The reach of MBT is ever-expanding. Clinicians and researchers have begun to de-
velop more novel adaptations of MBT, including short-term MBT (Juul et al., 2022,
2019); virtual MBT in the context of the COVID-19 pandemic (Fisher et al., 2021;
Ventura Wurman et al., 2021); and integration of MBT with other evidence-based
psychotherapies for BPD, such as DBT (Edel et al., 2017; Swenson & Choi-Kain,
2015) and Good Psychiatric Management (Unruh et al., 2019). Similarly, MBT is
being applied to address non-clinical problems as well, including law enforcement
violence (Drozek et al., 2021), parents undergoing divorce (Hertzmann et al., 2016),
children in the foster system (Midgley et al., 2017), bullying in schools (Twemlow
et al., 2005), and families of patients with BPD (Bateman & Fonagy, 2019b). In these

ways, MBT has emerged as an empirically informed treatment approach that targets
transdiagnostic mentalizing processes across a wide range of clinical, psychosocial,
and cultural challenges.
What is mentalizing?
Access to and accurate reading of mental states in self and others is the core of
mentalizing. We are all more or less good at it, and the process serves us well as groups
of human beings engaging in constructive and progressive affiliation. It gives us
the sense of who we are, how we feel, who others are, and what we are like together.
Mentalizing helps us understand motives and what lies behind action. It allows us to
undertake joint tasks and participate in group interactions in which an individual’s
role and function is shared by all and, most importantly, accepted by them. We “read”
each other. A sense of belonging is generated; loneliness and isolation are vanquished.
Of course mentalizing can go wrong, be inaccurate, or lack balance. So self-
correction when misunderstandings occur is a key aspect of our mental flexibility and
success at mentalizing. Just as we right ourselves when we stumble physically, we do
so mentally. Without flexibility and reflection, individuals insist on their perspective
as the perspective, rigidifying the process and forcing others to think as they do, or
believe what they believe. Conflict and relational inequality result, and relationships
may become strained, if not broken.
Mental states are by definition imaginary and infinitely creative, and so anything
can happen. Things are not as they seem. We fool ourselves and can be fooled by
others. We can trick ourselves and others unwittingly, but it is also possible to make
someone believe something for our own selfish purposes. This can be done clumsily
and without guile, the other person quickly realizing the misunderstanding. But it can
be also done with cunning and charm; the person experiences unwarranted trust and
becomes vulnerable to exploitation and manipulation. The accomplished trickster is
an example of another truth about mentalizing. We can be “too good” at aspects of
mentalizing and exploit that talent for our own ends, while being unable to use other
aspects effectively for constructive social relationships.
Where does the information come from that allows us to imagine what is going on
in our own and others’ minds? Mostly it is based on external observation: the body
suggests what is beneath, tone of voice speaks louder than words as someone says they
are “fine” when it is obvious they are not. Our assumptions about someone else are
commonly accompanied by a question about the mind beyond (“You seem tense. Are
you OK?”; “What are you looking at me like that for? Don’t you believe me?”) to con-
firm or disconfirm our working hypothesis. This is named the internal/external po-
larity of mentalizing (see Chapter 13). When the poles are in balance and being used
appropriately, interactions take on a reciprocity of “serve and return.” It is only when
the ball hits the net do we stop for a moment and check out a potential misconception,
before continuing.

The healthy development of mentalization

The overall aim of focusing on mentalizing in treatment is to increase patients’ ef-
fective deployment of mentalizing in social interactions, allowing them to establish
themselves effectively and constructively in their social world. To kick-start this pro-
cess, we structure treatment in such a way that mentalizing is encouraged, and mental
states become something of interest for patients (see Chapters 4 & 5). As treatment
advances, patients gradually progress along what might be understood as a “devel-
opmental trajectory” of mentalizing, which parallels the healthy development of
mentalization throughout the lifespan: from I-mode, to me-mode, to personalized
me-mode, and ultimately to we-mode. We offer these conjectures as a potentially
useful heuristic, rather than any definitive statement. In everyday experience, these
modes often blur together quite seamlessly, shifting continuously in a manner that is
dynamic, non-linear, and always sensitive to interpersonal context.
I-mode: Focus on internal states in self
A young child develops a sense of their own mind, and later other people’s, through
early experiences of caregivers accurately recognizing, mirroring, and responding
to the child’s emotions. These interpretations or responses to the child help them to
build a sense of who they are, and to acquire a sense of personal agency. I have active
presence in the world. My experiences matter, are of interest to those around me, and
can make things happen. These reflections allow the child to build a set of represen-
tations of internal states often called “secondary representations.” As people around
us decipher and delineate who we are, we attain a coherent sense of self, or “self-
representation.” Selfhood, rather than being all about individuality, is an intrinsically
social phenomenon.
The sense of an “I” ideally grows into a robust and coherent representation, arising
from the accumulated integration and synthesis of sensory information pertaining to
the person. Under optimal combinations of nature and nurture, this process gener-
ates an embodied sense of personhood, with continuous and stable contact with the
surrounding world. Individuals who have not had the benefit of such secondary rep-
resentations may develop a less coherent self-representation, building a “not-I” that
feels foreign and alien (see Chapter 2). This may include people who have been ex-
posed to responsive care but, for a complex range of possible reasons, have not been
able to benefit from it.
We gradually become more or less confident about our own thoughts and ex-
periences. This level of confidence about our self-states forms the basis of all other
aspects of mentalizing. Confidence in personal mental states refers to our subjective
beliefs about the validity of our thoughts and judgments, irrespective of objective ac-
curacy measures. This is my inner experience. This is as I am and what I think. But
mentalizing of self is dynamic, so we update or change our assessment, either because

our interpretation of ourselves seems incorrect or unproductive, or because feed-

back from social interaction suggests modification. Rejection, acceptance, productive
interaction with others—all create change in our self-experience. “Having talked to
you, I feel rather differently about it now.” Being impervious to such influence leads
to isolation and loneliness. Dissonance between how we see ourselves and how others
see us is a threat and cannot be tolerated.
Patients with PN often feel too sure about their self-states, expecting others to see
them as they see themselves. They may fail to engage in learning about their own
states through the mind of others. Their mind becomes focused on self, and there
is little time for assessing others’ mental states. I-mode becomes dominant, with no
room for me-mode. The “I” is asserted, and the person becomes overconfident in
themselves and their inner experience. In the case of vulnerable PN, patients may lack
confidence in reading states of mind altogether, relying extensively on other people to
determine their own thoughts and feelings. Without confidence in their own mental
states, or in their ability to read others, patients remain vulnerable and dependent on
other people.
At a more moderate level, there can be benefits to this sort of humility. When
people mentalize adaptively at lower levels of certainty, they seek more information
from others or conform to a consensus view, thus contributing to a form of “collective
mentalizing” in relationships. In this way, the person fits in and becomes a team
player, rather than a self-centered loner.
Me-mode: Reading others’ mental states
While accuracy is obviously important when considering others’ mental states, ex-
cessive confidence in our interpretations is also an important driver of difficulties.
For example, high confidence may be paired with significant inaccuracy and in-
sensitivity. Those with high confidence are likely to overestimate their own ability to
mentalize, while also underestimating others’ ability to recognize mental states ac-
curately. Individuals with high confidence may be projecting their own minds, rather
than seeing the mind of the other person as an independent and differentiated entity.
Continuing to interact with the other person as having an identical mind alienates
the other, who feels increasingly misunderstood. A responsive feedback loop should
change our understanding of someone else when mismatches occur, but all of us can
ignore signals that contradict our original assumptions.
In everyday interactions, recognizing and respecting someone’s current social role
helps to see things from their perspective. But reading others’ mental states at a more
complex level requires an understanding of their history and current context. If we are
to understand someone else and compare their experience with ours, an effort has to
be made to set aside our own mind. This shift from our perspective to someone else’s
perspective (while still maintaining our own) is sometimes thought of as a flexible
move from I-mode to me-mode mentalizing.

“Me” refers to the self-as-object—the self as defined by others’ depictions. Or ra-

ther, these depictions are seen and felt but experienced as if they were the self—the “I”
as described by William James (1890). By definition, the “me” is context dependent.
It is, after all, a function of the immediate social environment that is ever-changing,
making self-experiences originating from within the “me” inherently precarious. In
the right context, me-mode is comfortable and self-affirming. However, when the
environment changes, me-mode may become unstable, and reliance on I-mode ex-
perience is necessary to maintain mental safety. Like other approaches, MBT distin-
guishes the “me” from the “I” discussed earlier (Drozek, 2015). Of course, a dominant
“me” (a context-dependent self-experience) can obscure and eclipse “I” experiences.
In circumstances that compromise the integration of the “I” (e.g., genetic vulner-
ability, adversity, deprivation), the “me” becomes the primary determinant of self-
experience, leaving the individual potentially encountering the emptiness of their
existence if others ignore them.
In the treatment of PN, this distinction between “I” and “me” is essential to bear in
mind. As clinicians, we need to assess the extent of the dominance of I-mode func-
tioning, as well as its relationship with me-mode functioning. Patients with PN may
rely exclusively on I-mode mentalizing processes, as me-mode is too variable and
creates dangers. Alternatively, thin-skinned patients with PN may rely excessively on
me-mode and personalized me-mode mentalizing (see below), requiring admiration
from others and constant mental support. I-mode function is rudimentary and fails to
create a continuous sense of self.
Furthermore, sudden changes in risk may not be preceded by the obvious warning
signs which are typically found in patients with BPD, who often become increas-
ingly emotionally dysregulated and demanding as their “I” fragments. In PN, the “I”
can go from “one-hundred to zero” with shocking immediacy, based on perceived
changes in interpersonal context. What may appear to be a small slight to an outside
observer becomes an existential insult to patients with PN (see Chapter 2). Predicting
risk becomes almost impossible. The incongruity in representations of the socially de-
pendent “me” is so stark that the I-mode collapses.
Personalized me-mode: Reading others’ mental states

about self
How do others see me, and am I differentiating this from how I see myself? This can be
called personalized me-mode. This mode refers not simply to our ability to apprehend
other people’s minds and their complex workings (i.e., as indicated in the aforemen-
tioned me-mode), but also to the capacity to recognize others’ mental states about our-
selves: how other people experience us, as well as how they think and feel about us. Too
often individuals cloak how others see them with their own self-experience. This can
work to enhance self-esteem as much as to undermine it. Overinflated self-image and
excess self-confidence are applied to how a person thinks other people see them, and so

the person feels good about themselves irrespective of how other people view them in
reality. Conversely, negative self-experience (e.g., the shame or self-loathing in avoidant
PD, and sometimes ASPD) can infiltrate experience of all interactions with others.
Since the person’s own sense of shame leads them to believe that others are judging
them negatively, the person naturally retreats from relationships as much as possible.
In MBT, we develop an image of patients’ patterns of attachment-seeking and
avoidance in relationships. We do this by exploring examples of when patients’ per-
sonal expectations are met, and when they are not met (see Chapter 3). This may ex-
pose the chinks and vulnerabilities in the armor of narcissistic function, and patients
can then decide if the fault lines need repair. Recognizing one’s own weakness is not
easy for anyone. The vulnerabilities are best characterized as exceptional sensitivities,
so that the exposure does not undermine self-esteem. Patients with vulnerable PN
may engage better when other people empathically validate them, rather than dir-
ectly challenging them. In contrast, empathic validation with grandiose PN will have
little effect because patients are impervious to others, having created a bubble of self-
importance that isolates them. Patients in that state experience little need for others’
affective understanding of their mental states. Instead, they often over-recruit their
cognitive processing systems to buttress their sense of self-esteem, independent of
their immediate social context.
We-mode: Co-mentalizing and epistemic trust
As human beings, we are tuned into each other. We need to share our inner states
and let others know our underlying beliefs, goals, thoughts, and feelings. In so doing,
we build a shared mind and generate common goals, from infancy to adulthood
through attachment processes that underpin the evolution of mentalization. Sharing
mentalizing with others leads to more confidence about our own mentalizing. When
we take into account the inferred inner states of others, a shared reality is achieved,
building social bonds. Taking the perspective of others whom we respect, and
adjusting the communication between people toward a mutual understanding or
“shared reality,” maintains friendships and triggers cohesion in relationships.
When this co-mentalizing is achieved, a particular subjective experience of social
cognition is generated, referred to as “we-mode.” The we-mode—also described as
relational mentalizing in MBT (see Chapter 12)—is an interpersonal experience of
being attuned to someone else, where intentional states are shared with a common
purpose (Gallotti & Frith, 2013; Higgins, 2021). The we-mode generates trust, which
in turn opens up the pathway for learning from the trusted source. You make me feel
like a person with my own struggle. So I listen to you. The aim of restoring mentalizing
in MBT, or any other treatment modality, is then in the service of reopening the pos-
sibility of experiencing we-mode, initially with the clinician and ultimately with other
people in patients’ lives outside the treatment situation. The experience of epistemic
match gives rise to an ability to learn from social interaction. There is an inherently

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Hide-bearers resting by the Roadside 230
Bétsiléo Tombs 230
Memorial Stone 234
Types of Carved Ornamentation in Houses 236
” ” ” 238
Group of Tanàla Girls in Full Dress 242
Tanàla Girls singing and clapping Hands 242
Tanàla Spearmen 248
Coiffures 250
A Forest River 252
Tree Ferns 260
Traveller’s Trees 260
A Malagasy Orchid 272
Malagasy Men dancing 274
Woman of the Antànkàrana Tribe 278
Woman of the Antanòsy Tribe 278
The Fòsa 302
Malagasy Oxen 302
MAPS
Physical Sketch Map of Madagascar 16
Ethnographical Sketch Maps of Madagascar 17
General Map of Madagascar 314
PHYSICAL SKETCH-MAP OF MADAGASCAR
showing lines of Forest, and limits of high land of Interior exceeding
2500 feet above Sea-level
ETHNOGRAPHICAL SKETCH-MAP OF MADAGASCAR
A NATURALIST IN
MADAGASCAR
CHAPTER I
INTRODUCTORY
T
HE great African island of Madagascar has become well known
to Europeans during the last half-century, and especially since
the year 1895, when it was made a colony of France. During
that fifty years many books—the majority of these in the French
language—have been written about the island and its people; what
was formerly an almost unknown country has been traversed by
Europeans in all directions; its physical geography is now clearly
understood; since the French occupation it has been scientifically
surveyed, and a considerable part of the interior has been laid down
with almost as much detail as an English ordnance map. But
although very much information has been collected with regard to
the country, the people, the geology, and the animal and vegetable
productions of Madagascar, there has hitherto been no attempt, at
least in the English language, to collect these many scattered
notices of the Malagasy fauna and flora, and to present them to the
public in a readable form.
In several volumes of a monumental work that has been in
progress for many years past, written and edited by M. Alfred
Grandidier,[1] the natural history and the botany of the island are
being exhaustively described in scientific fashion; but these great
quartos are in the French language, while their costly character
renders them unknown books to the general reader. It is the object of
the following pages to describe, in as familiar and popular a fashion
as may be, many of the most interesting facts connected with the
exceptional animal life of Madagascar, and with its forestal and other
vegetable productions. During nearly fifty years’ connection with this
country the writer has travelled over it in many directions, and while
his chief time and energies have of course been given to missionary
effort, he has always taken a deep interest in the living creatures
which inhabit the island, as well as in its luxuriant flora, and has
always been collecting information about them. The facts thus
obtained are embodied in the following pages.
It is probably well known to most readers of this ROADS AND
book that a railway now connects Tamatave, the chief TRAVELLING
port of the east coast, with Antanànarìvo, the capital, which is about
a third of the way across the island. So that the journey from the
coast to the interior, which, up to the year 1899, used to take from
eight to ten days, can now be accomplished in one day. Besides this,
good roads now traverse the country in several directions, so that
wheeled vehicles can be used; and on some of these a service of
motor cars keeps up regular communication with many of the chief
towns and the capital.
But we shall not, in these pages, have much to do with these
modern innovations, for a railway in Madagascar is very much like a
railway in Europe. Our journeys will mostly be taken by the old-
fashioned native conveyance, the filanjàna or light palanquin, carried
by four stout and trusty native bearers. We shall thus not be whirled
through the most interesting portion of our route, catching only a
momentary glimpse of many a beautiful scene. We can get down
and walk, whenever we like, to observe bird or beast or insect, to
gather flower or fern or lichen or moss, or to take a rock specimen,
things utterly impracticable either by railway or motor car, and not
very easy to do in any wheeled conveyance. Our object will be, not
to get through the journey as fast as possible, but to observe all that
is worth notice during the journey. We shall therefore, in this style of
travel, not stay in modern hotels, but in native houses,
notwithstanding their drawbacks and discomforts; and thus we shall
see the Malagasy as they are, and as their ancestors have been for
generations gone by, almost untouched by European influence, and
so be able to observe their manners and customs, and learn
something of their ideas, their superstitions, their folk-lore, and the
many other ways in which they differ from ourselves.
Let us, however, first try to get a clear notion about EXTENT OF THE
this great island, and to realise how large a country it ISLAND
is. Take a fair-sized map of Madagascar, and we see that it rises like
some huge sea-monster from the waters of the Indian Ocean; or, to
use another comparison, how its outline is very like the sole—the
left-hand one—of a human foot. As we usually look at the island in
connection with a map of Africa, it appears as a mere appendage to
the great “Dark Continent”; and it is difficult to believe that it is really
a thousand miles long, and more than three hundred miles broad,
with an area of two hundred and thirty thousand square miles, thus
exceeding that of France, Belgium and Holland all put together.[2]
Before the year 1871 all maps of Madagascar, as regards its interior,
were pure guesswork. A great backbone of mountains was shown,
with branches on either side, like a huge centipede. But it is now
clear that, instead of these fancy pictures, there is an extensive
elevated region occupying about two-thirds of the island to the east
and north, leaving a wide stretch of low country to the west and
south; and as the watershed is much nearer the east than the west
of the island, almost all the chief rivers flow, not into the Indian
Ocean, but into the Mozambique Channel. When we add that a belt
of dense forest runs all along the east side of Madagascar, and is
continued, with many breaks, along the western side, and that
scores of extinct volcanoes are found in several districts of the
interior, we shall have said all that is necessary at present as to the
physical geography. Many more details of this, as well as of the
geology, will come under our notice as we travel through the country
in various directions.
[1] Histoire Physique, Naturelle et Politique de Madagascar,
publiée par Alfred Grandidier, Paris, à l’Imprimerie Nationale; in
fifty-two volumes, quarto.
[2] I have often been astonished and amused by the notions some
English people have about Madagascar. One gentleman asked
me if it was not somewhere in Russia!—and a very intelligent lady
once said to me: “I suppose it is about as large as the Isle of
Wight!”
CHAPTER II
TA M ATAV E A N D F I R S T I M P R E S S I O N S O F T H E C O U N T R Y
I
T was on a bright morning in September, 1863, that I first came in
sight of Madagascar. In those days there was no service of
steamers, either of the “Castle” or the “Messageries Maritimes”
lines, touching at any Madagascar port, and the passage from
Mauritius had to be made in what were termed “bullockers.” These
vessels were small brigs or schooners which had been condemned
for ordinary traffic, but were still considered good enough to convey
from two to three hundred oxen from Tamatave to Port Louis or
Réunion. It need hardly be said that the accommodation on board
these ships was of the roughest, and the food was of the least
appetising kind. A diet of cabbage, beans and pumpkin led one of
my friends to describe the menu of the bullocker as “the green, the
brown, and the yellow.” Happily, the voyage to Madagascar was
usually not very long, and in my case we had a quick and pleasant
passage of three days only; but I hardly hoped that daylight on
Wednesday morning would reveal the country on which my thoughts
had been centred for several weeks past; so it was with a strange
feeling of excitement that soon after daybreak I heard the captain
calling to me down the hatchway: “We are in sight of land!” Not many
minutes elapsed before I was on deck and looking with eager eyes
upon the island in which eventually most of my life was to be spent.
We were about five miles from the shore, running under easy sail to
the northward, until the breeze from the sea should set in and enable
us to enter the harbour of Tamatave.
There was no very striking feature in the scene—no TAMATAVE AND
towering volcanic peaks, as at Mauritius and Aden, yet FIRST
IMPRESSIONS
it was not without beauty. A long line of blue
mountains in the distance, covered with clouds; a comparatively
level plain extending from the hills to the sea, green and fertile with
cotton and sugar and rice plantations; while the shore was fringed
with the tall trunks and feathery crowns of the cocoanut-palms which
rose among the low houses of the village of Tamatave. These,
together with the coral reefs forming the harbour, over which the
great waves thundered and foamed—all formed a picture thoroughly
tropical, reminding me of views of islands in the South Pacific.
The harbour of Tamatave is protected by a coral reef, which has
openings to the sea both north and south, the latter being the
principal entrance; it is somewhat difficult of access, and the ribs and
framework of wrecked vessels are (or perhaps rather were) very
frequently seen on the reef. The captain had told me that sometimes
many hours and even days were spent in attempting to enter, and
that it would probably be noon before we should anchor. I therefore
went below to prepare for landing, but in less than an hour was
startled to hear by the thunder of the waves on the reef and the
shouts of the seamen reducing sail that we were already entering the
harbour. The wind had proved unexpectedly favourable, and in a few
more minutes the cable was rattling through the hawsehole, the
anchor was dropped, and we swung round at our moorings.
There were several vessels in the harbour. Close to us was H.M.’s
steamer Gorgon, and, farther away, two or three French men-of-war,
among them the Hermione frigate, bearing the flag of Commodore
Dupré, their naval commandant in the Indian Ocean, as well as
plenipotentiary for the French Government in the disputes then
pending concerning the Lambert Treaty. I was relieved to find that
everything seemed peaceful and quiet at Tamatave, and that the
long white flag bearing the name of Queen Ràsohèrina, in scarlet
letters, still floated from the fort at the southern end of the town. I had
been told at Port Louis that things were very unsettled in
Madagascar, and that I should probably find Tamatave being
bombarded by the French; but it is unnecessary to refer further to
what is now ancient history, or to touch upon political matters, which
lie quite outside the main purpose of this book.
Tamatave, as a village, has not a very inviting appearance from
the sea, and man’s handiwork had certainly not added much to the
beauty of the landscape. Had it not been for the luxuriant vegetation
of the pandanus, palms, and other tropical productions, nothing
could have been less interesting than the native town, which
possessed at that time few European residences and no buildings
erected for religious worship.[3] Canoes, formed out of the trunk of a
single tree, soon came off to our ship, but I was glad to dispense
with the services of these unsafe-looking craft, and to accept a seat
in the captain’s boat. Half-an-hour after anchoring we were rowing
towards the beach, and in a few minutes I leaped upon the sand,
with a thankful heart that I had been permitted to tread the shores of
Madagascar.
Proceeding up the main street—a sandy road bordered by
enclosures containing the stores of a few European traders—we
came to the house of the British Vice-Consul. Here I found Mr
Samuel Procter, who was subsequently the head for many years of
one of the chief trading houses in the island, and also Mr F. Plant, a
gentleman employed by the authorities of the British Museum to
collect specimens of natural history in the then almost unknown
country. From them I learned that a missionary party which had
preceded me from Mauritius had left only two days previously for the
capital, and that Mr Plant had kindly undertaken to accompany me
on the journey for the greater part of the distance to Antanànarìvo. At
first we thought of setting off on that same evening, so as to overtake
our friends, but finding that this would involve much fatigue, we
finally decided to wait for two or three days and take more time to
prepare for the novel experiences of a Madagascar journey. In a little
while I was domiciled at Mr Procter’s store, where I was hospitably
entertained during my stay in Tamatave.
The afternoon of my first day on shore was occupied in seeing
after the landing of my baggage. This was no easy or pleasant task;
the long rolling swell from the ocean made the transfer of large
wooden cases from the vessel to the canoes a matter requiring
considerable dexterity. More than once I expected to be swamped,
and that through the rolling of the ship the packages would be
deposited at the bottom of the harbour. It was therefore with great
satisfaction that I saw all my property landed safely on the beach.
Although Tamatave has always been the chief port THE BULLOCKER
on the east coast of Madagascar, there were, for many
years after my arrival there, no facilities for landing or shipping
goods. The bullocks, which formed the staple export, were swum off
to the ships, tied by their horns to the sides of large canoes, and
then slung on board by tackles from the yard-arm. From the shouting
and cries of the native drovers, the struggles of the oxen, and their
starting back from the water, it was often a very exciting scene. A
number of these bullockers were always passing between the
eastern ports of Madagascar and the islands of Mauritius and
Réunion, and kept the markets of these places supplied with beef at
moderate rates. The vessels generally ceased running for about four
months in the early part of the year, when hurricanes are prevalent in
the Indian Ocean; and it may easily be supposed that the passenger
accommodation on board these ships was not of the first order.
However, compared with the discomforts and, often, the danger and
long delays endured by some, I had not much to complain of in my
first voyage to Madagascar. It had, at least, the negative merit of not
lasting long, and I had not then the presence of nearly three hundred
oxen as fellow-passengers for about a fortnight, as on my voyage
homewards, when I had also a severe attack of malarial fever.
The native houses of Tamatave, like those of the other coast
villages, were of very slight construction, being formed of a
framework of wood and bamboo, filled in with leaves of the
pandanus and the traveller’s tree. In a few of these some attempts at
neatness were observable, the walls being lined with coarse cloth
made of the fibre of rofìa-palm leaves, and the floor covered with
well-made mats of papyrus. But the general aspect of the native
quarter of the town was filthy and repulsive; heaps of putrefying
refuse exhaled odours which warned one to get away as soon as
possible. In almost every other house a large rum-barrel, ready
tapped, showed what an unrestricted trade was doing to demoralise
the people.
I could not help noticing the strange articles of food exposed for
sale in the little market of the Bétsimisàraka quarter. Great heaps of
brown locusts seemed anything but inviting, nor were the numbers of
minute fresh-water shrimps much more tempting in appearance.
With these, however, were plentiful supplies of manioc root, rice of
several kinds, potatoes and many other vegetables, the brilliant
scarlet pods of different spices, and many varieties of fruit—pine-
apples, bananas, melons, peaches, citrons and oranges. Beef was
cheap as well as good, and there was a lean kind of mutton, but it
was much like goat-flesh. Great quantities of poultry are reared in
the interior and are brought down to the coast for sale to the ships
trading at the ports.
The houses of the Malagasy officials and the NATIVE HOUSES
principal foreign traders were substantially built of
wooden framework, with walls and floors of planking and thatched
with the large leaves of the traveller’s tree. No stone can be procured
near Tamatave, nor can bricks be made there, as the soil is almost
entirely sand; the town itself is indeed built on a peninsula, a sand-
bank thrown up by the sea, under the shelter of the coral reefs which
form the harbour. The house where I was staying consisted of a
single long room, with the roof open to the ridge; a small sleeping
apartment was formed at one corner by a partition of rofìa cloth.
There was no window, but light and air were admitted by large doors,
which were always open during the day. A few folds of Manchester
cottons, to serve as mattress, and a roll of the same for a pillow, laid
on Mr Procter’s counter, formed a luxurious bed after the discomforts
of a bullock vessel. All around us, in the native houses, singing and
rude music, with drumming and clapping of hands, were kept up far
into the night; and these sounds, as well as the regular beating of the
waves all round the harbour, and the excitement of the new and
strange scenes of the past day, kept me from sleep until the small
hours of the morning.
The following day I went to make a visit to the Governor of
Tamatave, as a new arrival in the country. My host accompanied me,
as I was of course quite unable to talk Malagasy. As this was a visit
of ceremony, it was not considered proper to walk, so we went by the
usual conveyance of the country, the filanjàna. This word means
anything by which articles or persons are carried on the shoulder,
and is usually translated “palanquin,” but the filanjàna is a very
different thing from the little portable room which is used in India. In
our case it was a large easy-chair, attached to two poles, and carried
by four stout men, or màromìta, as they are called. They carried us
at a quick trot; but this novel experience struck me—I can hardly now
understand why—as irresistibly ludicrous, and I could not restrain my
laughter at the comical figure—as it then seemed to me—that we
presented, especially when I thought of the sensation we should
make in the streets of an English town.
The motion was not unpleasant, as the men keep step together.
Every few minutes they change the poles from one shoulder to the
other, lifting them over their heads without any slackening of speed.
A few minutes brought us to the fort, at the southern THE GOVERNOR
end of the town; this was a circular structure of stone,
with walls about twenty feet high, which were pierced with openings
for about a dozen cannon. We had to wait for a few minutes until the
Governor was informed of our arrival, and thus had time to think of
the scene this fort presented not twenty years before that time, when
the heads of many English and French sailors were fixed on poles
around the fort. These ghastly objects were relics of those who were
killed in an attack made upon Tamatave in 1845, by a combined
English and French force, to redress some grievances of the foreign
traders. But we need not be too hard on the Malagasy when we
remember that, not a hundred years before that time, we in England
followed the same delectable custom, and adorned Temple Bar and
other places with the heads of traitors.
Presently we were informed that the Governor was ready to
receive us. Passing through the low covered way cut through the
wall, we came into the open interior space of the fort. The
Governor’s house, a long low wooden structure, was opposite to us;
while, on the right, he was seated under the shade of a large tree,
with a number of his officers and attendants squatting around him.
They were mostly dressed in a mixture of European and native
costume—viz. a shirt and trousers, over which were thrown the folds
of the native làmba, an oblong piece of calico or print, wrapped
round the body, with one end thrown over the left shoulder. Neat
straw hats of native manufacture completed their costume. The
Governor, whose name was Andrìamandròso, was dressed in
English fashion, with black silk “top hat” and worked-wool slippers.
He had a very European-looking face, dark olive complexion, and
was an andrìana—that is, one of a clan or tribe of the native nobility.
He did not speak English, but through Mr Procter we exchanged a
few compliments and inquiries. I assured him of the interest the
people of England took in Madagascar, and their wish to see the
country advancing. Presently wine was brought, and after drinking to
the Governor’s health we took our leave. The Hova government
maintained, until the French conquest, a garrison of from two to
three hundred men at Tamatave. These troops had their quarters
close to the fort, in a number of houses placed in rows and enclosed
in a large square or ròva, formed of strong wooden palisades, with
gateways.
The following day was occupied in making A ROUGH AND
preparations for the journey, purchasing a few of the READY CANTEEN
most necessary articles of crockery, etc., and unpacking my canteen.
This latter was a handsome teak box, and fitted up most neatly with
plates, dishes, knives and forks, etc. But Mr Plant said that both the
box and most of its contents were far too good to be exposed to the
rough usage they would undergo on the journey; so I took out some
of the things and repacked the box in its wooden case. Subsequent
experience showed the wisdom of this advice, and that it was a
mistake to use too expensive articles for such travelling as that in
Madagascar, or to have to spend much time in getting out and
putting in again everything in its proper corner. Upon reaching the
halting-place after a fatiguing journey of several hours, it is a great
convenience to get at one’s belongings with the least possible
amount of exertion; and when starting before sunrise in the
mornings, it is not less pleasant to be able to dispense with an
elaborate fitting of things into a canteen. By my friend’s advice, I
therefore bought a three-legged iron pot for cooking fowls, some
common plates, and a tin coffee-pot, which also served as a teapot
when divested of its percolator. These things were stowed away in a
mat bag, which proved the most convenient form of canteen possible
for such a journey The contents were quickly put in, and as readily
got out when wanted; and, thus provided, we felt prepared to explore
Madagascar from north to south, quite independent of inns and
innkeepers, chambermaids and waiters, had such members of
society existed in this primitive country.
[3] It is perhaps hardly necessary to say that for some years past
Tamatave has been a very different place from what is described
above. Many handsome buildings—offices, banks, shops, hotels
and government offices—have been erected; the town is lighted
at night by electricity; piers have been constructed; and in the
suburbs shady walks and roads are bordered by comfortable villa
residences and their luxuriant gardens.
CHAPTER III
F R O M C O A S T T O C A P I TA L : A L O N G T H E S E A S H O R E
T
RAVELLING in Madagascar fifty years ago, and indeed for
many years after that date, differed considerably from what we
have any experience of in Europe. It was not until the year
1901 that a railway was commenced from the east coast to the
interior, and it is only a few months ago that direct communication by
rail has been completed between Tamatave and Antanànarìvo. But
until the French occupation, in 1895, a road, in our sense of the
word, did not exist in the island; and all kinds of merchandise
brought from the coast to the interior, or taken between other places,
were carried for great distances on men’s shoulders. There were but
three modes of conveyance—viz. one’s own legs, the làkana or
canoe, and the filanjàna or palanquin. We intended to make use of
all these means of getting over the ground (and water); but by far the
greater part of the journey of two hundred and twenty miles would be
performed in the filanjàna, carried on the sinewy shoulders of our
bearers or màromìta. This was the conveyance of the country (and it
is still used a good deal); for during the first thirty years and more of
my residence in Madagascar there was not a single wheeled vehicle
of any kind to be seen in the interior, nor did even a wheelbarrow
come under my observation during that time.
This want of our European means of conveyance arose from the
fact that no wheeled vehicles could have been used owing to the
condition of the tracks then leading from one part of the country to
another. The lightest carriage or the strongest waggon would have
been equally impracticable in parts of the forest where the path was
almost lost in the dense undergrowth, and where the trees barely left
room for a palanquin to pass. Nor could any team take a vehicle up
and down some of the tremendous gorges, by tracks which
sometimes wind like a corkscrew amidst rocks and twisted roots of
trees, sometimes climb broad surfaces of slippery basalt, where a
false step would send bearers and palanquin together into steep
ravines far below, and again are lost in sloughs of adhesive clay, in
which the bearers at times sink to the waist, and when the traveller
has to leap from the back of one man to another to reach firm
standing-ground. Shaky bridges of primitive construction, often
consisting of but a single tree trunk, were frequently the only means
of crossing the streams; while more often they had to be forded, one
of the men going cautiously in advance to test the depth of the water.
It occasionally happened that this pioneer suddenly disappeared,
affording us and his companions a good deal of merriment at his
expense. At times I have had to cross rivers when the water came
up to the necks of the bearers, the shorter men having to jump up to
get breath, while they had to hold the palanquin high up at arm’s-
length to keep me out of the water.
It was often asked: Why do not the native GENERAL
government improve the roads? The neglect to do so FOREST AND
GENERAL FEVER
was intentional on their part, for it was evident to
everyone who travelled along the route from Tamatave to the capital
that the track might have been very much improved at a
comparatively small expense. The Malagasy shrewdly considered
that the difficulty of the route to the interior would be a formidable
obstacle to an invasion by a European power, and so they
deliberately allowed the path to remain as rugged as it is by nature.
The first Radàma is reported to have said, when told of the military
genius of foreign soldiers, that he had two officers in his service,
“General Hàzo,” and “General Tàzo” (that is, “Forest and Fever”),
whom he would match against any European commander.
Subsequent events so far justified his opinion that the French
invasion of the interior in 1895 did not follow the east forest road, but
the far easier route from the north-west coast. The old road through
the double belt of forests would have presented formidable obstacles
to the passage of disciplined troops, and at many points it might
have been successfully contested by a small body of good
marksmen, well acquainted with the localities.
On the Coast Lagoons
Large dug-out canoes, propelled by paddles on each side, one man to each paddle
It may be gathered from what has been already said PLEASURES AND
DISCOMFORTS
that travelling in Madagascar in the old times had not
a little of adventure and novelty connected with it. Provided the
weather was moderately fine, there was enough of freshness and
often of amusing incident to render the journey not unenjoyable,
especially if travelling in a party; and even to a solitary traveller there
is such a variety of scenery, and so many and beautiful forms of
vegetation, to arrest the attention, that it was by no means
monotonous. Of course there must be a capacity for “roughing it,”
and for turning the very discomforts into sources of amusement. We
must not be too much disturbed at a superabundance of fleas or
mosquitoes in the houses, nor be frightened out of sleep by the
scampering of rats around and occasionally even upon us. It
sometimes happens, too, that a centipede or a scorpion has to be
dislodged from under the mats upon which we are about to lay our
mattresses, but, after all, a moderate amount of caution will prevent
us taking much harm.
It must be confessed, however, that if the weather prove
unfavourable the discomforts are great, and it requires a resolute
effort to look at the bright side of things. To travel for several hours in
the rain, with the bearers slipping about in the stiff adhesive clay—
now sinking to the knees in a slough in the hollows, and then
painfully toiling up the rugged ascents—with a chance of being
benighted in the middle of the forest, were not enjoyable incidents in
the journey. Added to this, occasionally the bearers of baggage and
bedding and food would be far behind, and sometimes would not
turn up at all, leaving us to go supperless, not to bed, but to do as
well as we could on a dirty mat. But, after all said and done, I can
look back on many journeys with great pleasure; and my wife and I
have even said to each other at the end, “It has been like a
prolonged picnic.” And by travelling at the proper time of the year—
for we never used, if possible, to take long journeys in the rainy
season—and with ordinary care in arranging the different stages,
there was often no more discomfort than that inseparable from the
unavoidable fatigue.
Soon after breakfast on the morning of the 3rd October the yard of
Mr Procter’s house was filled with the bearers waiting to take their
packages, and, as more came than were actually required, there
was a good deal of noise and confusion until all the loads had been
apportioned. Most of my màromìta were strong and active young
men, spare and lithe of limb, and proved to possess great powers of
endurance. The loads they carried were not very heavy, but it was
astonishing to see with what steady patience they bore them hour
after hour under a burning sun, and up and down paths in the forest,
where their progress was often but a scrambling from one foothold to
another. Two men would take a load of between eighty and ninety
pounds, slung on a bamboo, between them; and this was the most
economical way of taking goods, for, on account of the difficulty of
the paths, four men found it more fatiguing to carry in one package a
weight which, divided into two, could easily be borne by two sets of
bearers.
Eight of the strongest and most active young men, MY PALANQUIN
accustomed to work together, were selected to carry
my palanquin, and took it in two sets of four each, carrying
alternately. Most of the articles of my baggage were carried by two
men; but my two large flat wooden cases, containing drawing
boards, paper and instruments, required four men each. All baggage
was carried by the same men throughout the journey, without any
relay or change, except shifting the pole from one shoulder to the
other; but my palanquin, as already said, had a double set. The
personal bearers, therefore, naturally travel quicker than those
carrying the baggage, and we generally arrived at the halting-places
an hour or more before the others came up. The hollow of the
bamboos to which boxes and cases were slung served for carrying
salt, spoons, and various little properties of the bearers, and
sometimes small articles of European make for selling at the capital.
The men were, and still are, very expert in packing and securing
goods committed to their charge. Prints, calicoes and similar
materials were often covered with pandanus leaves and so made
impervious to the wet; and even sugar and salt were carried in the
same way without damage.
As the conveyance of myself and my baggage required more than
thirty men, and Mr Plant took a dozen in addition, it was some time
before everything was arranged, and there was a good deal of
contention as to getting the lightest and most convenient packages
to carry. We had hoped to start early in the forenoon, but it was after
one o’clock when we sent off the last cases and I stepped into my
filanjàna to commence the novel experience of a journey in
Madagascar. We formed quite a large party as we set off from
Tamatave and turned southwards into the open country. The rear
was brought up by a bearer of some intelligence and experience,
who only carried a spear, and was to act as captain over the rest and
look out accommodation for us in the villages, etc. He had also to
see after the whole of the luggage, and take care that everyone had
his proper load and came up to time.
My filanjàna was a different kind of thing from the THE FILANJÀNA
chair in which I had gone to visit the Governor. It was

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Adaptive Mentalization-Based Integrative Treatment

Development in Wastewater Treatment Research and

Successful Psychopharmacology: Evidence-Based Treatment

Advanced Oxidation Processes for Effluent Treatment

Development in Wastewater Treatment Research and

Development in Wastewater Treatment Research and

Office-Based Buprenorphine Treatment of Opioid Use

Paleopathology of Children: Identification Pathological

“Mentalization-​Based Treatment for Pathological Narcissism: A Handbook

“Now more than ever, psychotherapy needs a coherent and pragmatic

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“Narcissistic tendencies are on the rise in this modern world of selfies,

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“This is by far the most up-​to-​date and comprehensive practical hand-

“Drozek, Unruh, and Bateman illustrate how deficits in mentalization re-

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It is indeed a heartwarming and substantial privilege to be asked to read and introduce

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ensured by the capacity of the child’s caregivers to provide a reflective environment

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groups. The MBT community’s thinking is remarkably coherent, linking attachment

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The dispositional traits characteristic of pathological narcissism are within the

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in plaster, can be papered over by mentalizing, finding sometimes ingenious solu-

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We want to acknowledge a host of friends, colleagues, and organizations, without

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“step-​by-​step” process of elaborating patients’ emotional experiences, which bol-

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About the Authors  xxv

PART 1 MENTALIZATION AND PATHOLOGICAL NARCISSISM

1. Introduction to Pathological Narcissism and Mentalization-​based

2. A Mentalization-​based Model of Pathological Narcissism  23

PART 2 BEGINNING THE TREATMENT

3. Assessment and Diagnosis of Pathological Narcissism  37

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4. Structure and Aims of MBT for Narcissism  54

PART 3 THE THERAPEUTIC APPROACH

5. Therapeutic Stance and Clinical Principles  85

6. Content-​focused Interventions  107

7. Context-​focused Interventions  142

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8. Process-​focused Interventions: Pretend Mode  180

9. Process-​focused Interventions: Psychic Equivalence Mode  195

“Mentalization-Based Treatment for Pathological Narcissism: A Handbook

“This is by far the most up-to-date and comprehensive practical hand-

“step-by-step” process of elaborating patients’ emotional experiences, which bol-

About the Authors xxv

1. Introduction to Pathological Narcissism and Mentalization-based

2. A Mentalization-based Model of Pathological Narcissism 23

3. Assessment and Diagnosis of Pathological Narcissism 37

4. Structure and Aims of MBT for Narcissism 54

5. Therapeutic Stance and Clinical Principles 85

6. Content-focused Interventions 107

7. Context-focused Interventions 142

8. Process-focused Interventions: Pretend Mode 180

9. Process-focused Interventions: Psychic Equivalence Mode 195

13. Moving Forward in the Treatment 305

Introduction to mentalization-based treatment

I-mode: Focus on internal states in self

Me-mode: Reading others’ mental states

“Me” refers to the self-as-object—the self as defined by others’ depictions. Or ra-

Personalized me-mode: Reading others’ mental states

We-mode: Co-mentalizing and epistemic trust