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Peter Salerno, Psy.D. - Guest
Peter Salerno, Psy.D. is a Doctor of Psychology, retired licensed psychotherapist, and nationally recognized expert on personality disorders and pathological relationships. Over the course of his career, he has specialized in personality disorders, family trauma, complex trauma, and pathological abuse. He was trained and qualified to administer the Hare Psychopathy Checklist–Revised (PCL-R), the gold standard for identifying psychopathy in clinical and forensic settings. He was also a featured expert in the docuseries Ted Bundy: Dialogue with the Devil, streaming on Hulu and Disney+. His work has always been driven by a passion for understanding the human mind and helping people make sense of some of its most challenging and misunderstood conditions. Today, he uses that expertise to help people around the world understand painful, confusing, and often manipulative relationship dynamics. While he no longer practices traditional therapy, he offers remote consultations focused on clarity, insight, and practical decision-making—not treatment. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible. Today, I'll be speaking with Peter Salerno, who is a doctor of psychology and retired licensed psychotherapist and nationally recognized expert on personality disorders and pathological relationships.
Keith Sutton, Psy.D. (02:30):
Over the course of his career, he has specialized in personality disorders, family trauma, complex trauma, and pathological abuse. He was trained and qualified to administer the Hare Psychopathy Checklist, the revised gold standard for identifying psychopathy in clinical and forensic settings. He was also a featured expert in the docuseries Ted Bundy: Dialogue with the Devil, streaming on Hulu and Disney Plus. His work has always been driven by a passion for understanding the human mind and helping people make sense of some of its most challenging and misunderstood conditions. Today, he uses that expertise to help people around the world understand painful, confusing, and often manipulative relationship dynamics. While he no longer practices traditional therapy, he offers remote consultations focused on clarity, insight, and practical decision-making, not treatment. Let's listen to the interview.
Keith Sutton, Psy.D. (03:22):
Well, hi, Peter. Welcome. Thanks for joining.
Peter Salerno, Psy.D. (03:25):
Thank you for having me. I appreciate you having me on your show.
Keith Sutton, Psy.D. (03:29):
Yeah, definitely. So, I saw your information. I think you posted on one of the listservs I'm on—about a workshop or a group that you're doing. And I looked and saw a little more, and you've got a book that you've done on cognitive dissonance and trauma, particularly for folks who have been in relationships with partners with personality disorders, narcissism, and so on. And so I got really interested. I really think your book looks really interesting, so I reached out to see if you'd be available to do a podcast. I'd love to hear about your work and about this area that you're working in.
First, I always like to find out about how people got to doing what they're doing—the evolution of their thinking. So yeah, how'd you get into this work?
Peter Salerno, Psy.D. (04:14):
Yeah, so, well, I actually—when I was in grad school, I was actually pursuing a literature degree. And then I kind of pivoted and switched to psychology. I always thought I was going to be teaching, because that's kind of what I was planning on doing with my liberal arts education.
Then, the program that I was in—the master’s program—was a predoctoral program. Basically, they make you do a practicum and counseling, even if you're not planning on pursuing licensure. So I kind of got thrown into doing some practicum work. And it turned out that I ended up deciding I wanted to pursue licensure as a psychotherapist, and then I ended up pursuing a doctorate following that.
So I would say for the last 12—almost 15—years, between 12 and 15 years, I've been working in clinical practice in some capacity.
Peter Salerno, Psy.D. (05:16):
When I initially started, I wasn't planning on specializing in personality disorders and pathology. But what ended up happening was I found myself attending trainings for some continuing education—one, because I wanted to understand personality disorders, and another reason was because I actually ended up getting involved in a personal situation.
I was having difficulty navigating my way out of it, because the perspective I was taking was what I was taught in degree programs, which is that people who misbehave or mistreat others likely have been mistreating themselves and might be reenacting their trauma. And so that was something that actually kept me stuck for a little bit—you know, that kind of lens.
So I started investigating some alternative perspectives in my continuing education and discovered the work of Dr. George Simon, Dr. Robert Hare, and others who were dealing more with character pathology or the severe personality pathology that was wreaking havoc in people's lives—unapologetically.
And so I started really dedicating my education to figuring out: is there ever room to understand that maybe some of this abuse has intentionality behind it, rather than just being reenactments or the whole “hurt people hurt people” idea?
It kind of led me down this path of exploring research from a multidisciplinary perspective. I got really involved in behavioral genetics, neuroscience, and just looking outside of classical psychological theory, and integrating that into my clinical practice. I ended up taking trainings to become a personality disorder treatment provider and specialist.
Peter Salerno, Psy.D. (07:27):
Oh, great. And that just ended up becoming my trajectory, even with my writing. I published a book about narcissism and some of the myths that have been perpetuated about it, and some of the new research that offers counterarguments to some of the persistent myths popular in the media. That also turned into me writing the self-help book you referenced--Traumatic Cognitive Dissonance—which helps people come to terms with identifying how likely it is that some of these individuals will change without the right interventions. And also, is there room for this
Keith Sutton, Psy.D. (08:20):
Okay.
Peter Salerno, Psy.D. (08:21):
But that's basically my background.
Keith Sutton, Psy.D. (08:25):
Sure. Definitely. Well, I'd love to understand more. I mean, it is such a broad topic, also—personality disorders. I actually came from more of a postmodern approach, in narrative therapy, at the beginning of my graduate school experience, which didn’t necessarily put a lot of weight on personality disorders and pathology.
But definitely, there’s— I know clients I’ve worked with, or people I’ve known, who definitely fit into those profiles. I’d love to hear your thoughts on personality disorders and what’s important for a therapist to know. Because I think in my own training, in our area here, there’s a lot of psychoanalytic and psychodynamic focus.
I actually had another student at the practicum site I was working at who thought everybody had borderline personality disorder from her perspective. And so oftentimes, people are jumping to, “Oh, that one's narcissistic, that one's borderline,” and so on. So yeah, I’d love to hear your thoughts on the diagnosis, the utility of it, and potential pathology.
Peter Salerno, Psy.D. (09:42):
Yeah. So actually, my master’s program was a predoctoral program. We did psych testing, psych assessment, and some research methodology courses, but it was predominantly a psychodynamic program. Following that, I pursued a two-year certification in psychoanalytic psychotherapy, so I’m very well versed in that and have an affection for that background and perspective.
But what I noticed is there’s a certain population of clients I’ve encountered in private practice and other clinical settings who weren’t really responding to that type of intervention or philosophy—it even seemed to make some people worse. It was fascinating to me. I was very reluctant, because I didn’t come from programs that pathologized anybody. My training was very person-centered, unconditional positive regard, humanistic in a sense. I have a lot of respect for that perspective. What really started to shift my thinking was encountering a non-collaborative population of clients. No matter how much you try to intervene in ways that typically work with collaborative clients, there’s something about certain people—they seem hell-bent on refusing to collaborate and even creating more problems while rejecting your help. Freud talked about neurosis in a way, but this went beyond that. I started attending trainings that acknowledged potential biological underpinnings, rather than seeing everyone as a blank slate or someone who responds the same way to interventions. I almost felt like I was betraying my own training and education by considering other perspectives—that maybe some people have proclivities or inclinations to be manipulative and are doing it intentionally because it works for them, rather than it being purely a reaction or defense. I don’t like to overgeneralize or pathologize universally, but I started understanding narcissism and Cluster B pathology differently. From the psychoanalytic perspective, we know about borderline organization and narcissistic personality structure. Their etiology is a bit different from the DSM categorical criteria. I started considering that personality disorders might be better understood by incorporating biological underpinnings, maybe even heritable components, rather than assuming it’s 100% environmental.
Keith Sutton, Psy.D. (14:02):
Okay. Tell me about that—the genetic or trait pieces that are playing a role here.
Peter Salerno, Psy.D. (14:10):
Yeah. There’s the dimensional or alternative model of personality disorders in Section III of the DSM. It tries to bridge the gap from a black-or-white, all-or-nothing perspective—you either have the disorder or you don’t. That model offers a perspective that these disorders may operate on a continuum or spectrum of severity. Someone might meet criteria for narcissistic personality disorder to a moderate degree—the impairment is moderate versus severe. The genetic component relates to whether traits like grandiosity, lack of empathy, or attention-seeking are heritable versus learned—or possibly a combination of both. I dove deep into meta-analyses of twin and adoption studies.
Keith Sutton, Psy.D. (15:23):
I was going to ask—are there twin studies?
Peter Salerno, Psy.D. (15:25):
Yes. About ten years ago, there was a landmark meta-analysis covering fifty years of twin and adoption research. It compiled thousands of studies, with millions of twin pairs. The findings were interesting: even identical twins raised apart—a natural experiment for genetics—showed that at least 50% of differences in psychological traits across the board seem more heritable than environmentally determined. It doesn’t mean we discard old theories about the environment, but 50% heritability is significant.
Keith Sutton, Psy.D. (16:32):
That's--
Peter Salerno, Psy.D. (16:33):
Why? So we might want to consider the possibility that some people are born with vulnerabilities to developing these disorders, rather than it being solely parenting or environment.
Keith Sutton, Psy.D. (16:45):
Now, are you saying 50% of all identical twins raised separately show this in their general traits, or specifically in personality disorder traits?
Peter Salerno, Psy.D. (16:58):
Great question. Actually, the personality disorder traits are even higher than 50%. Concordance rates for narcissism, for example, reach as high as 79% in some studies.
So, pathological personality traits are more heritable, whereas psychological traits in general—whether mental health, cognitive ability, or other domains—tend to be around 50%. Differences in people are roughly 50% attributed to DNA versus environment or shared environment.
I think this is something that can give people pause and can be controversial. Many might hear it and think it’s overblown or exaggerated, but it highlights that we need to consider risk factors beyond just upbringing or adversity.
Keith Sutton, Psy.D. (18:10):
And have there been studies looking at childhood characteristics for the development of these traits, in the absence of trauma or adversity?
Peter Salerno, Psy.D. (18:24):
Yeah.
Keith Sutton, Psy.D. (18:25):
Yeah. So--
Peter Salerno, Psy.D. (18:26):
There have been studies identifying what are known as callous-unemotional traits. Some studies show these traits can be identifiable as early as age two. Of course, the right environment can buffer or balance these traits. If these traits are identified early, interventions can reduce the likelihood of them amplifying.
People often resist the idea that children could exhibit callous-unemotional traits because they want to view children as inherently pro-social and resilient if given the right support. I don’t see this as controversial or a doom sentence—it’s just variation in traits. Early identification of problematic traits gives children a better chance of overcoming associated obstacles.
Keith Sutton, Psy.D. (19:48):
Sure. Early intervention, basically.
Peter Salerno, Psy.D. (19:50):
Yeah. Exactly.
Keith Sutton, Psy.D. (19:53):
Could you talk a little about your work on narcissism and how you conceptualize it? I know there are different typologies or degrees of narcissism.
Peter Salerno, Psy.D. (20:14):
Yeah. I think it’s important to define narcissism. Traditionally, we have different definitions. Freud talked about primary narcissism, which is a normal stage in development where self-regard outweighs altruism or consideration for others. That’s inherent in all of us and generally outgrown as the brain and relational capacities develop, allowing us to consider others’ needs and see people as equals. Secondary narcissism is more pathological—it’s persistent and not naturally outgrown. Much of my research and writing, especially in my book on narcissism, aims to expose people to the reality that many enter therapy assuming everyone in a system—the spouse, child, parent, or family—is collaborating to improve the system or relationship. What’s often disconcerting is that professionals sometimes take this assumption for granted, not accounting for members who may not be collaborative or who are engaging in manipulative patterns.
Peter Salerno, Psy.D. (22:07):
And so the backlash of that has been that a lot of people who are being abused by individuals who are not collaborating at home have felt invalidated in professional settings. They’re often told, “Well, this dynamic has been co-created,” and that the person who is abusing them—if we’re going to call it that—is really just compensating for their own shortcomings, inferiority, or acting out. There was a population of people who felt really dismissed and invalidated because the way they were being abused seemed intentional. That’s the perspective I wanted to expose related to narcissism: some people genuinely benefit from exploiting others, and it’s not necessarily unconscious.
Peter Salerno, Psy.D. (23:12):
They’re actually doing it deliberately. This is very controversial, because we often hear narcissism described as a self-esteem issue or a shame-based disorder. But research shows that for some people, it’s not that they can’t stop these behaviors—it’s that they don’t want to, because it benefits them and they don’t experience guilt or remorse in a way that motivates change. It’s a bleak reality in some cases.
Keith Sutton, Psy.D. (23:55):
But there’s conscious awareness of the malicious behavior.
Peter Salerno, Psy.D. (24:02):
Yeah.
Peter Salerno, Psy.D. (24:04):
To be honest, working with this population, many admit it in moments of rare clarity.
Keith Sutton, Psy.D. (24:13):
Yeah.
Peter Salerno, Psy.D. (24:13):
They’ll say, “Why would I give this up? It gives me power and advantage.” So for them, there has to be significant motivation to stop, because it’s working for them and they don’t feel bad about it. There’s not enough shame in some of these cases.
Keith Sutton, Psy.D. (24:37):
Mm.
Peter Salerno, Psy.D. (24:39):
Yeah.
Keith Sutton, Psy.D. (24:40):
So it’s almost like an antisocial personality aspect.
Peter Salerno, Psy.D. (24:44):
I would say so, but narcissism exists on a continuum. Some narcissists don’t engage in antisocial acts, but they share traits like callousness and lack of empathy that go far beyond the benign narcissism often attributed to childhood overvaluation or neglect. Some may reach a malignant category but still don’t meet full antisocial criteria because they avoid those behaviors.
Keith Sutton, Psy.D. (25:34):
There’s some line—they’re willing to engage in harmful behaviors, but not fully cross into antisocial territory.
Peter Salerno, Psy.D. (25:46):
Exactly. It’s fascinating. I’d like professionals to consider that there’s more to learn about these disorders. We shouldn’t assume we already know everything. Classical theories remain invaluable, but they may not be the whole story.
Keith Sutton, Psy.D. (26:30):
Sure. It sounds like in the past, too much benefit of the doubt was given—assuming “hurt people, hurt people”—and that sometimes hurt people stayed in unhealthy relationships longer than they should have. People might rationalize or minimize abusive behavior because they understand the other person’s trauma, but that can prevent them from protecting themselves.
Peter Salerno, Psy.D. (27:30):
Exactly. If people believe all abuse is a reaction to trauma—meaning the abuser is a trauma survivor themselves—they may hold hope that the person can change if they heal. But some people aren’t collaborating in treatment, even if they have adversity and personality pathology. They’re content with how life is and have no interest in improving their character or reducing harmful behaviors.
Peter Salerno, Psy.D. (28:38):
Which is, I mean, you know, it's sad to think that way. But I also think that it can be a detriment to certain clients if there's not some psychoeducational component that helps them consider that if this has been going on for 20 years, and the person doesn’t seem like they think they have a problem, then the likelihood of it changing at this point is low. Maybe there is room to consider that the relationship might not be worth saving.
Keith Sutton, Psy.D. (29:15):
Yeah. It might even be unknowingly enabling it, because rather than having the negative consequence of the person leaving the relationship, staying in it sometimes decreases the negative consequences of the behaviors.
Peter Salerno, Psy.D. (29:31):
Right.
Keith Sutton, Psy.D. (29:35):
And how about the recovery and the work that you do with partners who have been in a relationship such as this?
Peter Salerno, Psy.D. (29:43):
Yeah. One of the biggest components, which is really hard for people to wrap their minds around, is accepting the reality that maybe some of this abuse was beneficial to the abuser. There’s a kind of paradigm shift that needs to take place from a psychoeducational perspective, where people begin evaluating this enduring pattern of behavior and consider that maybe there was some benefit to it, rather than it being completely reactive and unconscious. Maybe it was deliberate in some way because it was working for that person. That’s one of the hardest things for people to understand. But I think even entertaining that possibility helps resolve the cognitive dissonance. Because the cognitive dissonance I’m talking about is when someone has experienced truth manipulation or reality distortion—what we now commonly call gaslighting—to the point where they don’t know what was real anymore and what was not. To resolve that, it can help to consider that maybe the other person benefited from keeping them ambivalent or uncertain—keeping them in that state of ambiguity. So the recovery process involves asking: am I willing to come to terms with the possibility that I may have been intentionally manipulated by someone who claimed to love me, and that they may never have intended to change? That’s a major component. Then, other evidence-based trauma interventions can follow from there.
Keith Sutton, Psy.D. (31:48):
Yeah. And so the idea that it was intentional and conscious—because oftentimes it is intentional in the sense that it makes sense to the person doing it. They may feel justified, or think the behavior is okay, or that the other person deserved it.
But that’s different from someone knowing it’s not okay and choosing to manipulate anyway for their own benefit.
Peter Salerno, Psy.D. (32:30):
Yeah. I make a distinction between pathological and non-pathological abuse. Non-pathological abuse can involve people who have learned these behaviors and aren’t fully aware of them. They don’t necessarily endorse them—they may feel guilt or have ego dystonia, where they recognize, “I’m doing this, but I don’t like it,” and they have a genuine desire to change. Versus someone who views the world through a lens of entitlement—where relationships are “you or me,” a dog-eat-dog dynamic. We see this in some personality disorder criteria. They feel entitled to exploit and aim for advantage rather than mutuality. It becomes almost like a predator-prey dynamic, where the goal is not equality or reciprocity, but maintaining control or advantage. So I think it’s important to educate people that even if this behavior is influenced by conditioning or wiring, it’s still not okay. If someone continues to view it only as “this person is wounded and reacting,” they may stay in a situation much longer than they should—one that is unlikely to change.
Keith Sutton, Psy.D. (34:30):
How do you tease that out, I guess, as the partner in that situation? Because I guess, you know, it makes me think of the question of like, you know, yeah, people grapple with, like, is there, are there evil people versus somebody that is doing these things and for some reason it makes sense in their mind. Usually most people aren't the villain in their own story, right? In some situations, like I'm thinking of the Gottman research on couples domestic violence where there's the, what they call the cobras, the people whose heart rate goes down before they get aggressive with their partner versus the pit bull, which is more reactive. Yeah, just even thinking about somebody that is literally exploiting other people, like, you know, these kinds of things do exist. And there's a way that people, I guess, make sense of that or justify that or deal with their own cognitive dissonance around that. But yeah, most people would hope that the nature of people is good and that they're well-meaning and reciprocity and equality or so on. But unfortunately, there are people where that is not the rule or not the basis they're operating under.
Peter Salerno, Psy.D. (35:48):
I think the best way to tease it out is to consider the collaborative capacity. So what I mean by that is if people, you know, the Gottman method is a great example because Gottman presumes collaboration. Like two people are here to solve and they don't like the defensiveness and the criticism and the stonewalling and the things that are taking place on a regular basis that erode the likelihood of the relationship's success.
And so if those two people can problem solve together, I mean, that's a very successful method. However, I think it does assume collaboration. So that's one way to tease it out. If you're going to go to couples therapy and you're going to have a trained therapist or an EFT-trained therapist, those are very effective methods, but it does require collaboration on both parties.
So if those types of methods consistently fail, I don't think it's the method that's failing. I think it's the lack of collaboration that's interfering with the success of the method. So that's definitely one way to tease it out if you're dealing with someone who just isn't going to problem solve with you. Because those methods are very effective. Two people go to couples therapy and they have a Gottman-trained therapist—I'm not going to say it's easy—but if they really both want it to work and they can, and that insight orientation and then practicing the techniques, I mean, it can work. Unless somebody doesn't have any intention of following through with that problem solving.
Keith Sutton, Psy.D. (37:28):
Yeah. Yeah.
Peter Salerno, Psy.D. (37:29):
So that's definitely one way to tease it out—if things just aren't getting better and possibly even getting worse after the evidence-based methods don't prove to have affected the relationship in a positive way.
Keith Sutton, Psy.D. (37:42):
Yeah. Well, I think too, like at least I—so I'm trained in emotionally focused couples therapy. And because it's so process-oriented, oftentimes you can kind of dig into the process of what the person consciously or unconsciously is trying to have an effect on the other. I sometimes conceptualize narcissism too as when somebody basically wishes they could just kind of open up the other person's brain, just push all the buttons and get them to do exactly what they want. There's not that conceptualization of this as another person with their own needs and beliefs. It's almost like a total lack of boundaries or even seeing the other person, and getting frustrated when they're not doing the exact thing that they're wanting them to do because they are coming from this place of—I don't know a better word for it—but righteousness, where the way they're thinking about things and their reality is the correct reality.
Peter Salerno, Psy.D. (38:39):
Yeah. I actually love that because that's really what they're looking to do. It's like as long as the other holds up a mirror and reflects back to me exactly what I want and lets me basically push all those buttons, open up their brain, we're happy as clams. Things are great. As soon as I'm confronted because I did something that they didn't like, that's where that blame externalization comes into play. And all of a sudden, I think a lot of people think that the narcissist at that point feels very ashamed of themselves, but oftentimes it's just a rage. They get enraged that they didn't get their way.
Keith Sutton, Psy.D. (39:23):
Yeah. I guess the question is, I mean, is there shame there that's just so buried? Or, going back to EFT, there's primary and secondary emotions— is that shame there that they're just so far removed from, that they're reacting to because someone else is suggesting that they did something wrong or bad or not good? And then ultimately feeling almost attacked and attacking back, but so far removed from that that they just—I don't know.
Peter Salerno, Psy.D. (39:59):
Yeah. I don't know either because I kind of have a problem with this idea. I mean, I think we all know what it's like to feel ashamed. Shame is a universal experience. It's not exclusive to narcissism or any particular disorder or pathology. It's part of the human condition. So there certainly are narcissists who exist who don't experience shame. Well, let me correct that—they feel shame, but it's not because they're narcissistic. And they're not narcissistic because they feel shame. So there's been some research on narcissism recently within the last five years that talks about shame and self-esteem being so weakly related to narcissism. Because if they're coexisting, it's not because they're necessarily related—it’s just that shame is a universal human experience. It's not that narcissists are narcissistic because of shame. There are a lot of people who disagree with that and say there’s a profound unconscious shame fueling this grandiosity. I personally have a problem with that because the people that I've worked with who have real shame—even shame they're not fully aware of—know what it feels like, and they avoid the things that have made them feel ashamed rather than doing them to other people. But this is an argument that we could have with a bunch of different theorists.
Keith Sutton, Psy.D. (41:39):
When I think about it too, sometimes there's shame—and I do a lot of work with couples—but then the defenses are so strong. Sometimes I think about it like the emotional experience is almost the defense against shame. Like somebody says, “You did something…” I just had this today actually. That partner was, “Hey, you fell asleep while we were watching the movie and it really bugged me.” And then the reaction was just so intense. Because it's like, “Well, I gotta sleep,” rather than, “Oh gosh, I'm sorry, that must have been frustrating. I know the movie was important to you.” It's almost like this reaction—feeling like the other person is trying to make them feel bad or shame them because they did something incorrectly. So they have to react aggressively to show they didn’t do anything wrong. And oftentimes, with that black-and-white thinking, it's either I'm bad or they're bad. So I'm going to fight to prove that I'm not bad. They're trying to make me feel bad, but I'm going to go up in arms against that and fight tooth and nail.
Peter Salerno, Psy.D. (42:46):
And I would agree wholeheartedly that that injury is so intolerable for that person. In that moment, I can't be that bad, because what would happen if you actually really believed I'm that bad? And there's that reaction. But I wouldn't say that that's exclusive to narcissism.
Keith Sutton, Psy.D. (43:04):
No, no, definitely not at all. Yeah. Most people, I think, have that.
Peter Salerno, Psy.D. (43:07):
But I think most people have that impression that that is a narcissistic injury only and only narcissists do that. I think we all can do that from time to time.
Keith Sutton, Psy.D. (43:14):
No, definitely. Well, and I think that, you know, I guess the way that I've conceptualized it too, sometimes the narcissist is just so far removed from that shame, or even the possibility they could have done something wrong versus whether the person is not, they might feel shame and they might get defensive or something. But exactly like you're saying, sometimes I'll say, like, when you think of that person that your partner's describing, what do you think of that person? Like, oh, that person's a jerk. Who would want to be in a relationship with that person? Exactly. So of course they're naturally motivated to then try to point out how they're not that person. But it's almost like, I think sometimes when somebody's along that spectrum of narcissism, it's like they're not even going to entertain that they could possibly be that. They're not going to go there to even have the thought experiment. It is just like, no, just not even.
Peter Salerno, Psy.D. (44:01):
Yeah, because what a lot of people, I think, it's important for people to realize about, I don't want to say all, but many narcissists, is narcissism can often be passive in its presentation. As opposed to an antisocial who's very active in their exploitation, narcissists can often think, I already know I'm right. I don't have to prove it to you. It's your job to accept that I'm right. So sometimes they don't even react at all to that type of thing. If you're trying to shame them, they're going to be indifferent to it. Like, you just don't know what you're talking about. Versus having this overt reaction. In other cases, though, narcissists can certainly, if they feel like you can somehow tarnish the impression management they work so hard to maintain, they can get enraged and have a more overt reaction. But a lot of times people desire a reaction from them, and they just don't give it because they're so disinterested in you.
Keith Sutton, Psy.D. (45:08):
Their needs are dismissive.
Peter Salerno, Psy.D. (45:10):
Yeah.
Keith Sutton, Psy.D. (45:11):
Yeah. And I was reading a little bit on some of the descriptions on Amazon about helping people that maybe are in an invalidating environment, right? That the person is in the relationship and questioning their own perceptions or their own sense of reality, and helping them kind of recover from that. Is that a piece of the work?
Peter Salerno, Psy.D. (46:36):
What do I believe about other people? What do I believe about this relationship? And so there's a lot of self-doubt and confusion and disorientation that takes place with people who've—I kind of like to describe it like their mind has been scrambled. What they really held onto as their truth and their reality has been completely scrambled. And so part of the recovery process is rebuilding this core belief system of who I am, what I believe about myself, what's true about me. I've worked with a lot of survivors who feel like they were the bad person, or that maybe they never really knew who they were. They've been convinced by somebody that they're a terrible person, and it takes a while for those positive attributes and characteristics to get back online, so to speak, for a lot of these victims and survivors.
Keith Sutton, Psy.D. (47:34):
Yeah, definitely. Yeah. I don't know if there's been any research or anything on that about if there are qualities of a person that sometimes get stuck in these relationships. Because I imagine, you know, I'm thinking of some of my complex PTSD clients—they don't have a very strong sense of self, and their sense of self is very much affected by others, whether they're happy with them or unhappy with them. And so there's not that kind of internal measuring stick of like, I know what's right and what's wrong. I imagine somebody in that situation getting together with somebody that's a narcissist in this way would have a really hard time kind of knowing up from down.
Peter Salerno, Psy.D. (48:22):
Absolutely. Yeah. And so sometimes it's a restoration of those core beliefs, and sometimes it's like an installation because they've never—I mean, maybe they had complex trauma from childhood and then they got involved with a narcissist or somebody where their entire life has been a parent or caregiver who completely invalidated and abused them, and then a spouse who's done the same thing. It's like they've really never had an experience of what quote unquote normal or non-dramatic relationships can feel like, so they have to design a core belief system from the ground up, like what's really true about me. Which is a very difficult thing for some people, but I think it's hopeful too, because I don't think it's ever too late to establish that.
Keith Sutton, Psy.D. (49:13):
Yeah, definitely. So yeah, what is your big takeaway, or what are you kind of hoping that people— I mean, it sounds like there's one, the controversial idea around that there might actually be some genetic credibility related to some traits that potentially later turn into narcissism or other personality disorders, and this other piece that there is intentionality at times. Not just benign reactivity to the situation the person had growing up, but sometimes that there—because oftentimes there's a benefit to the behavior in general—but then whether there's a benefit to taking advantage of somebody else for your own purpose. It sounds like that's kind of the piece that maybe you feel is neglected or missed or dismissed in the community and in the therapy world.
Peter Salerno, Psy.D. (50:23):
I think the takeaway would be that I would like victims of abuse to at least be heard. That maybe this is a pattern. And again, with therapy, it's kind of tricky, right? Because we're supposed to be treating the person in the room, not the person they're talking about. So there is a challenge there. But I think people who are too quick to say, well, this may be your insecure attachment or your codependency or whatever else that's contributing to this dynamic—fix that, and then the relationship will improve—it would be important for therapists in particular to consider the possibility that maybe no matter how much somebody fixes their side of the fence and cleans up their room, this abuse is inevitable.
Peter Salerno, Psy.D. (51:13):
There's inevitable harm in some relationships, and that needs to be validated for some of these survivors. A lot of the people who come my way have had five therapists, and it's not that the therapists were bad therapists, it's just that they didn't consider the possibility that this person might have been just a victim of abuse. They keep trying to redirect it back to that person—well, you have these tendencies or this attachment style or whatever—and let's focus on you. People can feel very invalidated and hopeless when they've been intentionally abused. So it's not to condemn or dismiss anyone's competence. It's more like this is an area of education I think we could all benefit from looking into.
Keith Sutton, Psy.D. (52:04):
Yeah. No, I think that's a good point because sometimes it can go to either extreme. Sometimes the individual therapist can go too far away from systemic thinking and say, don’t believe what they said, you need to be assertive, and not really see what's playing out in the dynamic between the two, or even attribute malicious intent. But on the other end, going too far the other way of putting it into context—I was working with somebody around this, and we actually brought the partner in. The partner basically admitted, like, oh yeah, I've got just so much.
Keith Sutton, Psy.D. (52:52):
He could admit it, but was acting out of shame. He was doing the wrong thing and felt bad about it, but was still reacting and getting upset. She would get upset with him, and then he would get upset that she was upset, and so on. There was actually some consciousness to it. Again, he wasn't trying to be manipulative or abusive, but he was making it her fault, which I was missing until I brought him in. Then I was like, oh, okay. She was able to resolve and move on from the relationship fairly quickly after getting that validation, like okay, this is what's going on. He wanted to try and work on it, but struggled with it to the point where she decided, I'm going to move on and not put time and effort into helping this person grow in this way.
Peter Salerno, Psy.D. (53:47):
I think, real quick, the people that I'm really talking about where there's intentionality is sometimes they'll come to a couple sessions, and I've been amazed at this. I don't know if you've ever had this experience, but I've felt like the feedback from the session was that both of them felt it was very productive and very helpful. Then when they left, the relationship got exponentially worse. And the person who was the antagonist basically said that session was a bunch of bs, that guy doesn't know what he's talking about, he sided with you. It's like they paint this picture that there was this conjoined effort on the part of the professional, me in this case, and the couple, where they felt like they were making progress, but then they go home and have a completely different narrative.
Keith Sutton, Psy.D. (54:39):
Yeah. Yeah.
Peter Salerno, Psy.D. (54:40):
And, you know, I guess we could analyze that as potentially self-sabotage or a secondary gain that's unconscious, but there are times where there's just no accountability whatsoever in some of these individuals.
Keith Sutton, Psy.D. (54:58):
No, I'm thinking of another couple I worked with where she would avoid talking. After the session, she didn't discuss it with me because of the way he would just talk at her, like he could push buttons and make her think a certain way. It took a while for her, partway through therapy, to see that this was not going to change. They were in their sixties, and she eventually realized, okay, this isn't going to change. But seeing that pattern in the session highlighted his inability to take responsibility or even see what he was contributing to the dynamic.
Keith Sutton, Psy.D. (55:41):
It's a tough area. It's great that you're doing this work. It’s challenging because sometimes therapists might go too far, having no compassion or understanding for the person with the difficulty, but then there’s the other extreme—too much understanding or compassion—which could be enabling and not really addressing that it’s not a good situation. Unfortunately, there are really hurtful people who are malicious and knowingly do things beyond just their own character pathology.
Peter Salerno, Psy.D. (56:23):
Right. I think dichotomizing it is never a good idea because there are a lot of nuances. We don’t want to swing the pendulum too far.
Keith Sutton, Psy.D. (56:33):
Yeah. Definitely. Well, thank you so much for taking the time today. I really appreciate it. Great topic and great to think about. I appreciate all the work you’re doing.
Peter Salerno, Psy.D. (56:44):
Thank you. I'm glad you reached out. I appreciate you having me on.
Keith Sutton, Psy.D. (56:47):
Yeah. Take care. You too. Bye.
Peter Salerno, Psy.D. (56:50):
Bye.
Keith Sutton, Psy.D. (56:51):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible. Today, I'll be speaking with Peter Salerno, who is a doctor of psychology and retired licensed psychotherapist and nationally recognized expert on personality disorders and pathological relationships.
Keith Sutton, Psy.D. (02:30):
Over the course of his career, he has specialized in personality disorders, family trauma, complex trauma, and pathological abuse. He was trained and qualified to administer the Hare Psychopathy Checklist, the revised gold standard for identifying psychopathy in clinical and forensic settings. He was also a featured expert in the docuseries Ted Bundy: Dialogue with the Devil, streaming on Hulu and Disney Plus. His work has always been driven by a passion for understanding the human mind and helping people make sense of some of its most challenging and misunderstood conditions. Today, he uses that expertise to help people around the world understand painful, confusing, and often manipulative relationship dynamics. While he no longer practices traditional therapy, he offers remote consultations focused on clarity, insight, and practical decision-making, not treatment. Let's listen to the interview.
Keith Sutton, Psy.D. (03:22):
Well, hi, Peter. Welcome. Thanks for joining.
Peter Salerno, Psy.D. (03:25):
Thank you for having me. I appreciate you having me on your show.
Keith Sutton, Psy.D. (03:29):
Yeah, definitely. So, I saw your information. I think you posted on one of the listservs I'm on—about a workshop or a group that you're doing. And I looked and saw a little more, and you've got a book that you've done on cognitive dissonance and trauma, particularly for folks who have been in relationships with partners with personality disorders, narcissism, and so on. And so I got really interested. I really think your book looks really interesting, so I reached out to see if you'd be available to do a podcast. I'd love to hear about your work and about this area that you're working in.
First, I always like to find out about how people got to doing what they're doing—the evolution of their thinking. So yeah, how'd you get into this work?
Peter Salerno, Psy.D. (04:14):
Yeah, so, well, I actually—when I was in grad school, I was actually pursuing a literature degree. And then I kind of pivoted and switched to psychology. I always thought I was going to be teaching, because that's kind of what I was planning on doing with my liberal arts education.
Then, the program that I was in—the master’s program—was a predoctoral program. Basically, they make you do a practicum and counseling, even if you're not planning on pursuing licensure. So I kind of got thrown into doing some practicum work. And it turned out that I ended up deciding I wanted to pursue licensure as a psychotherapist, and then I ended up pursuing a doctorate following that.
So I would say for the last 12—almost 15—years, between 12 and 15 years, I've been working in clinical practice in some capacity.
Peter Salerno, Psy.D. (05:16):
When I initially started, I wasn't planning on specializing in personality disorders and pathology. But what ended up happening was I found myself attending trainings for some continuing education—one, because I wanted to understand personality disorders, and another reason was because I actually ended up getting involved in a personal situation.
I was having difficulty navigating my way out of it, because the perspective I was taking was what I was taught in degree programs, which is that people who misbehave or mistreat others likely have been mistreating themselves and might be reenacting their trauma. And so that was something that actually kept me stuck for a little bit—you know, that kind of lens.
So I started investigating some alternative perspectives in my continuing education and discovered the work of Dr. George Simon, Dr. Robert Hare, and others who were dealing more with character pathology or the severe personality pathology that was wreaking havoc in people's lives—unapologetically.
And so I started really dedicating my education to figuring out: is there ever room to understand that maybe some of this abuse has intentionality behind it, rather than just being reenactments or the whole “hurt people hurt people” idea?
It kind of led me down this path of exploring research from a multidisciplinary perspective. I got really involved in behavioral genetics, neuroscience, and just looking outside of classical psychological theory, and integrating that into my clinical practice. I ended up taking trainings to become a personality disorder treatment provider and specialist.
Peter Salerno, Psy.D. (07:27):
Oh, great. And that just ended up becoming my trajectory, even with my writing. I published a book about narcissism and some of the myths that have been perpetuated about it, and some of the new research that offers counterarguments to some of the persistent myths popular in the media. That also turned into me writing the self-help book you referenced--Traumatic Cognitive Dissonance—which helps people come to terms with identifying how likely it is that some of these individuals will change without the right interventions. And also, is there room for this
Keith Sutton, Psy.D. (08:20):
Okay.
Peter Salerno, Psy.D. (08:21):
But that's basically my background.
Keith Sutton, Psy.D. (08:25):
Sure. Definitely. Well, I'd love to understand more. I mean, it is such a broad topic, also—personality disorders. I actually came from more of a postmodern approach, in narrative therapy, at the beginning of my graduate school experience, which didn’t necessarily put a lot of weight on personality disorders and pathology.
But definitely, there’s— I know clients I’ve worked with, or people I’ve known, who definitely fit into those profiles. I’d love to hear your thoughts on personality disorders and what’s important for a therapist to know. Because I think in my own training, in our area here, there’s a lot of psychoanalytic and psychodynamic focus.
I actually had another student at the practicum site I was working at who thought everybody had borderline personality disorder from her perspective. And so oftentimes, people are jumping to, “Oh, that one's narcissistic, that one's borderline,” and so on. So yeah, I’d love to hear your thoughts on the diagnosis, the utility of it, and potential pathology.
Peter Salerno, Psy.D. (09:42):
Yeah. So actually, my master’s program was a predoctoral program. We did psych testing, psych assessment, and some research methodology courses, but it was predominantly a psychodynamic program. Following that, I pursued a two-year certification in psychoanalytic psychotherapy, so I’m very well versed in that and have an affection for that background and perspective.
But what I noticed is there’s a certain population of clients I’ve encountered in private practice and other clinical settings who weren’t really responding to that type of intervention or philosophy—it even seemed to make some people worse. It was fascinating to me. I was very reluctant, because I didn’t come from programs that pathologized anybody. My training was very person-centered, unconditional positive regard, humanistic in a sense. I have a lot of respect for that perspective. What really started to shift my thinking was encountering a non-collaborative population of clients. No matter how much you try to intervene in ways that typically work with collaborative clients, there’s something about certain people—they seem hell-bent on refusing to collaborate and even creating more problems while rejecting your help. Freud talked about neurosis in a way, but this went beyond that. I started attending trainings that acknowledged potential biological underpinnings, rather than seeing everyone as a blank slate or someone who responds the same way to interventions. I almost felt like I was betraying my own training and education by considering other perspectives—that maybe some people have proclivities or inclinations to be manipulative and are doing it intentionally because it works for them, rather than it being purely a reaction or defense. I don’t like to overgeneralize or pathologize universally, but I started understanding narcissism and Cluster B pathology differently. From the psychoanalytic perspective, we know about borderline organization and narcissistic personality structure. Their etiology is a bit different from the DSM categorical criteria. I started considering that personality disorders might be better understood by incorporating biological underpinnings, maybe even heritable components, rather than assuming it’s 100% environmental.
Keith Sutton, Psy.D. (14:02):
Okay. Tell me about that—the genetic or trait pieces that are playing a role here.
Peter Salerno, Psy.D. (14:10):
Yeah. There’s the dimensional or alternative model of personality disorders in Section III of the DSM. It tries to bridge the gap from a black-or-white, all-or-nothing perspective—you either have the disorder or you don’t. That model offers a perspective that these disorders may operate on a continuum or spectrum of severity. Someone might meet criteria for narcissistic personality disorder to a moderate degree—the impairment is moderate versus severe. The genetic component relates to whether traits like grandiosity, lack of empathy, or attention-seeking are heritable versus learned—or possibly a combination of both. I dove deep into meta-analyses of twin and adoption studies.
Keith Sutton, Psy.D. (15:23):
I was going to ask—are there twin studies?
Peter Salerno, Psy.D. (15:25):
Yes. About ten years ago, there was a landmark meta-analysis covering fifty years of twin and adoption research. It compiled thousands of studies, with millions of twin pairs. The findings were interesting: even identical twins raised apart—a natural experiment for genetics—showed that at least 50% of differences in psychological traits across the board seem more heritable than environmentally determined. It doesn’t mean we discard old theories about the environment, but 50% heritability is significant.
Keith Sutton, Psy.D. (16:32):
That's--
Peter Salerno, Psy.D. (16:33):
Why? So we might want to consider the possibility that some people are born with vulnerabilities to developing these disorders, rather than it being solely parenting or environment.
Keith Sutton, Psy.D. (16:45):
Now, are you saying 50% of all identical twins raised separately show this in their general traits, or specifically in personality disorder traits?
Peter Salerno, Psy.D. (16:58):
Great question. Actually, the personality disorder traits are even higher than 50%. Concordance rates for narcissism, for example, reach as high as 79% in some studies.
So, pathological personality traits are more heritable, whereas psychological traits in general—whether mental health, cognitive ability, or other domains—tend to be around 50%. Differences in people are roughly 50% attributed to DNA versus environment or shared environment.
I think this is something that can give people pause and can be controversial. Many might hear it and think it’s overblown or exaggerated, but it highlights that we need to consider risk factors beyond just upbringing or adversity.
Keith Sutton, Psy.D. (18:10):
And have there been studies looking at childhood characteristics for the development of these traits, in the absence of trauma or adversity?
Peter Salerno, Psy.D. (18:24):
Yeah.
Keith Sutton, Psy.D. (18:25):
Yeah. So--
Peter Salerno, Psy.D. (18:26):
There have been studies identifying what are known as callous-unemotional traits. Some studies show these traits can be identifiable as early as age two. Of course, the right environment can buffer or balance these traits. If these traits are identified early, interventions can reduce the likelihood of them amplifying.
People often resist the idea that children could exhibit callous-unemotional traits because they want to view children as inherently pro-social and resilient if given the right support. I don’t see this as controversial or a doom sentence—it’s just variation in traits. Early identification of problematic traits gives children a better chance of overcoming associated obstacles.
Keith Sutton, Psy.D. (19:48):
Sure. Early intervention, basically.
Peter Salerno, Psy.D. (19:50):
Yeah. Exactly.
Keith Sutton, Psy.D. (19:53):
Could you talk a little about your work on narcissism and how you conceptualize it? I know there are different typologies or degrees of narcissism.
Peter Salerno, Psy.D. (20:14):
Yeah. I think it’s important to define narcissism. Traditionally, we have different definitions. Freud talked about primary narcissism, which is a normal stage in development where self-regard outweighs altruism or consideration for others. That’s inherent in all of us and generally outgrown as the brain and relational capacities develop, allowing us to consider others’ needs and see people as equals. Secondary narcissism is more pathological—it’s persistent and not naturally outgrown. Much of my research and writing, especially in my book on narcissism, aims to expose people to the reality that many enter therapy assuming everyone in a system—the spouse, child, parent, or family—is collaborating to improve the system or relationship. What’s often disconcerting is that professionals sometimes take this assumption for granted, not accounting for members who may not be collaborative or who are engaging in manipulative patterns.
Peter Salerno, Psy.D. (22:07):
And so the backlash of that has been that a lot of people who are being abused by individuals who are not collaborating at home have felt invalidated in professional settings. They’re often told, “Well, this dynamic has been co-created,” and that the person who is abusing them—if we’re going to call it that—is really just compensating for their own shortcomings, inferiority, or acting out. There was a population of people who felt really dismissed and invalidated because the way they were being abused seemed intentional. That’s the perspective I wanted to expose related to narcissism: some people genuinely benefit from exploiting others, and it’s not necessarily unconscious.
Peter Salerno, Psy.D. (23:12):
They’re actually doing it deliberately. This is very controversial, because we often hear narcissism described as a self-esteem issue or a shame-based disorder. But research shows that for some people, it’s not that they can’t stop these behaviors—it’s that they don’t want to, because it benefits them and they don’t experience guilt or remorse in a way that motivates change. It’s a bleak reality in some cases.
Keith Sutton, Psy.D. (23:55):
But there’s conscious awareness of the malicious behavior.
Peter Salerno, Psy.D. (24:02):
Yeah.
Peter Salerno, Psy.D. (24:04):
To be honest, working with this population, many admit it in moments of rare clarity.
Keith Sutton, Psy.D. (24:13):
Yeah.
Peter Salerno, Psy.D. (24:13):
They’ll say, “Why would I give this up? It gives me power and advantage.” So for them, there has to be significant motivation to stop, because it’s working for them and they don’t feel bad about it. There’s not enough shame in some of these cases.
Keith Sutton, Psy.D. (24:37):
Mm.
Peter Salerno, Psy.D. (24:39):
Yeah.
Keith Sutton, Psy.D. (24:40):
So it’s almost like an antisocial personality aspect.
Peter Salerno, Psy.D. (24:44):
I would say so, but narcissism exists on a continuum. Some narcissists don’t engage in antisocial acts, but they share traits like callousness and lack of empathy that go far beyond the benign narcissism often attributed to childhood overvaluation or neglect. Some may reach a malignant category but still don’t meet full antisocial criteria because they avoid those behaviors.
Keith Sutton, Psy.D. (25:34):
There’s some line—they’re willing to engage in harmful behaviors, but not fully cross into antisocial territory.
Peter Salerno, Psy.D. (25:46):
Exactly. It’s fascinating. I’d like professionals to consider that there’s more to learn about these disorders. We shouldn’t assume we already know everything. Classical theories remain invaluable, but they may not be the whole story.
Keith Sutton, Psy.D. (26:30):
Sure. It sounds like in the past, too much benefit of the doubt was given—assuming “hurt people, hurt people”—and that sometimes hurt people stayed in unhealthy relationships longer than they should have. People might rationalize or minimize abusive behavior because they understand the other person’s trauma, but that can prevent them from protecting themselves.
Peter Salerno, Psy.D. (27:30):
Exactly. If people believe all abuse is a reaction to trauma—meaning the abuser is a trauma survivor themselves—they may hold hope that the person can change if they heal. But some people aren’t collaborating in treatment, even if they have adversity and personality pathology. They’re content with how life is and have no interest in improving their character or reducing harmful behaviors.
Peter Salerno, Psy.D. (28:38):
Which is, I mean, you know, it's sad to think that way. But I also think that it can be a detriment to certain clients if there's not some psychoeducational component that helps them consider that if this has been going on for 20 years, and the person doesn’t seem like they think they have a problem, then the likelihood of it changing at this point is low. Maybe there is room to consider that the relationship might not be worth saving.
Keith Sutton, Psy.D. (29:15):
Yeah. It might even be unknowingly enabling it, because rather than having the negative consequence of the person leaving the relationship, staying in it sometimes decreases the negative consequences of the behaviors.
Peter Salerno, Psy.D. (29:31):
Right.
Keith Sutton, Psy.D. (29:35):
And how about the recovery and the work that you do with partners who have been in a relationship such as this?
Peter Salerno, Psy.D. (29:43):
Yeah. One of the biggest components, which is really hard for people to wrap their minds around, is accepting the reality that maybe some of this abuse was beneficial to the abuser. There’s a kind of paradigm shift that needs to take place from a psychoeducational perspective, where people begin evaluating this enduring pattern of behavior and consider that maybe there was some benefit to it, rather than it being completely reactive and unconscious. Maybe it was deliberate in some way because it was working for that person. That’s one of the hardest things for people to understand. But I think even entertaining that possibility helps resolve the cognitive dissonance. Because the cognitive dissonance I’m talking about is when someone has experienced truth manipulation or reality distortion—what we now commonly call gaslighting—to the point where they don’t know what was real anymore and what was not. To resolve that, it can help to consider that maybe the other person benefited from keeping them ambivalent or uncertain—keeping them in that state of ambiguity. So the recovery process involves asking: am I willing to come to terms with the possibility that I may have been intentionally manipulated by someone who claimed to love me, and that they may never have intended to change? That’s a major component. Then, other evidence-based trauma interventions can follow from there.
Keith Sutton, Psy.D. (31:48):
Yeah. And so the idea that it was intentional and conscious—because oftentimes it is intentional in the sense that it makes sense to the person doing it. They may feel justified, or think the behavior is okay, or that the other person deserved it.
But that’s different from someone knowing it’s not okay and choosing to manipulate anyway for their own benefit.
Peter Salerno, Psy.D. (32:30):
Yeah. I make a distinction between pathological and non-pathological abuse. Non-pathological abuse can involve people who have learned these behaviors and aren’t fully aware of them. They don’t necessarily endorse them—they may feel guilt or have ego dystonia, where they recognize, “I’m doing this, but I don’t like it,” and they have a genuine desire to change. Versus someone who views the world through a lens of entitlement—where relationships are “you or me,” a dog-eat-dog dynamic. We see this in some personality disorder criteria. They feel entitled to exploit and aim for advantage rather than mutuality. It becomes almost like a predator-prey dynamic, where the goal is not equality or reciprocity, but maintaining control or advantage. So I think it’s important to educate people that even if this behavior is influenced by conditioning or wiring, it’s still not okay. If someone continues to view it only as “this person is wounded and reacting,” they may stay in a situation much longer than they should—one that is unlikely to change.
Keith Sutton, Psy.D. (34:30):
How do you tease that out, I guess, as the partner in that situation? Because I guess, you know, it makes me think of the question of like, you know, yeah, people grapple with, like, is there, are there evil people versus somebody that is doing these things and for some reason it makes sense in their mind. Usually most people aren't the villain in their own story, right? In some situations, like I'm thinking of the Gottman research on couples domestic violence where there's the, what they call the cobras, the people whose heart rate goes down before they get aggressive with their partner versus the pit bull, which is more reactive. Yeah, just even thinking about somebody that is literally exploiting other people, like, you know, these kinds of things do exist. And there's a way that people, I guess, make sense of that or justify that or deal with their own cognitive dissonance around that. But yeah, most people would hope that the nature of people is good and that they're well-meaning and reciprocity and equality or so on. But unfortunately, there are people where that is not the rule or not the basis they're operating under.
Peter Salerno, Psy.D. (35:48):
I think the best way to tease it out is to consider the collaborative capacity. So what I mean by that is if people, you know, the Gottman method is a great example because Gottman presumes collaboration. Like two people are here to solve and they don't like the defensiveness and the criticism and the stonewalling and the things that are taking place on a regular basis that erode the likelihood of the relationship's success.
And so if those two people can problem solve together, I mean, that's a very successful method. However, I think it does assume collaboration. So that's one way to tease it out. If you're going to go to couples therapy and you're going to have a trained therapist or an EFT-trained therapist, those are very effective methods, but it does require collaboration on both parties.
So if those types of methods consistently fail, I don't think it's the method that's failing. I think it's the lack of collaboration that's interfering with the success of the method. So that's definitely one way to tease it out if you're dealing with someone who just isn't going to problem solve with you. Because those methods are very effective. Two people go to couples therapy and they have a Gottman-trained therapist—I'm not going to say it's easy—but if they really both want it to work and they can, and that insight orientation and then practicing the techniques, I mean, it can work. Unless somebody doesn't have any intention of following through with that problem solving.
Keith Sutton, Psy.D. (37:28):
Yeah. Yeah.
Peter Salerno, Psy.D. (37:29):
So that's definitely one way to tease it out—if things just aren't getting better and possibly even getting worse after the evidence-based methods don't prove to have affected the relationship in a positive way.
Keith Sutton, Psy.D. (37:42):
Yeah. Well, I think too, like at least I—so I'm trained in emotionally focused couples therapy. And because it's so process-oriented, oftentimes you can kind of dig into the process of what the person consciously or unconsciously is trying to have an effect on the other. I sometimes conceptualize narcissism too as when somebody basically wishes they could just kind of open up the other person's brain, just push all the buttons and get them to do exactly what they want. There's not that conceptualization of this as another person with their own needs and beliefs. It's almost like a total lack of boundaries or even seeing the other person, and getting frustrated when they're not doing the exact thing that they're wanting them to do because they are coming from this place of—I don't know a better word for it—but righteousness, where the way they're thinking about things and their reality is the correct reality.
Peter Salerno, Psy.D. (38:39):
Yeah. I actually love that because that's really what they're looking to do. It's like as long as the other holds up a mirror and reflects back to me exactly what I want and lets me basically push all those buttons, open up their brain, we're happy as clams. Things are great. As soon as I'm confronted because I did something that they didn't like, that's where that blame externalization comes into play. And all of a sudden, I think a lot of people think that the narcissist at that point feels very ashamed of themselves, but oftentimes it's just a rage. They get enraged that they didn't get their way.
Keith Sutton, Psy.D. (39:23):
Yeah. I guess the question is, I mean, is there shame there that's just so buried? Or, going back to EFT, there's primary and secondary emotions— is that shame there that they're just so far removed from, that they're reacting to because someone else is suggesting that they did something wrong or bad or not good? And then ultimately feeling almost attacked and attacking back, but so far removed from that that they just—I don't know.
Peter Salerno, Psy.D. (39:59):
Yeah. I don't know either because I kind of have a problem with this idea. I mean, I think we all know what it's like to feel ashamed. Shame is a universal experience. It's not exclusive to narcissism or any particular disorder or pathology. It's part of the human condition. So there certainly are narcissists who exist who don't experience shame. Well, let me correct that—they feel shame, but it's not because they're narcissistic. And they're not narcissistic because they feel shame. So there's been some research on narcissism recently within the last five years that talks about shame and self-esteem being so weakly related to narcissism. Because if they're coexisting, it's not because they're necessarily related—it’s just that shame is a universal human experience. It's not that narcissists are narcissistic because of shame. There are a lot of people who disagree with that and say there’s a profound unconscious shame fueling this grandiosity. I personally have a problem with that because the people that I've worked with who have real shame—even shame they're not fully aware of—know what it feels like, and they avoid the things that have made them feel ashamed rather than doing them to other people. But this is an argument that we could have with a bunch of different theorists.
Keith Sutton, Psy.D. (41:39):
When I think about it too, sometimes there's shame—and I do a lot of work with couples—but then the defenses are so strong. Sometimes I think about it like the emotional experience is almost the defense against shame. Like somebody says, “You did something…” I just had this today actually. That partner was, “Hey, you fell asleep while we were watching the movie and it really bugged me.” And then the reaction was just so intense. Because it's like, “Well, I gotta sleep,” rather than, “Oh gosh, I'm sorry, that must have been frustrating. I know the movie was important to you.” It's almost like this reaction—feeling like the other person is trying to make them feel bad or shame them because they did something incorrectly. So they have to react aggressively to show they didn’t do anything wrong. And oftentimes, with that black-and-white thinking, it's either I'm bad or they're bad. So I'm going to fight to prove that I'm not bad. They're trying to make me feel bad, but I'm going to go up in arms against that and fight tooth and nail.
Peter Salerno, Psy.D. (42:46):
And I would agree wholeheartedly that that injury is so intolerable for that person. In that moment, I can't be that bad, because what would happen if you actually really believed I'm that bad? And there's that reaction. But I wouldn't say that that's exclusive to narcissism.
Keith Sutton, Psy.D. (43:04):
No, no, definitely not at all. Yeah. Most people, I think, have that.
Peter Salerno, Psy.D. (43:07):
But I think most people have that impression that that is a narcissistic injury only and only narcissists do that. I think we all can do that from time to time.
Keith Sutton, Psy.D. (43:14):
No, definitely. Well, and I think that, you know, I guess the way that I've conceptualized it too, sometimes the narcissist is just so far removed from that shame, or even the possibility they could have done something wrong versus whether the person is not, they might feel shame and they might get defensive or something. But exactly like you're saying, sometimes I'll say, like, when you think of that person that your partner's describing, what do you think of that person? Like, oh, that person's a jerk. Who would want to be in a relationship with that person? Exactly. So of course they're naturally motivated to then try to point out how they're not that person. But it's almost like, I think sometimes when somebody's along that spectrum of narcissism, it's like they're not even going to entertain that they could possibly be that. They're not going to go there to even have the thought experiment. It is just like, no, just not even.
Peter Salerno, Psy.D. (44:01):
Yeah, because what a lot of people, I think, it's important for people to realize about, I don't want to say all, but many narcissists, is narcissism can often be passive in its presentation. As opposed to an antisocial who's very active in their exploitation, narcissists can often think, I already know I'm right. I don't have to prove it to you. It's your job to accept that I'm right. So sometimes they don't even react at all to that type of thing. If you're trying to shame them, they're going to be indifferent to it. Like, you just don't know what you're talking about. Versus having this overt reaction. In other cases, though, narcissists can certainly, if they feel like you can somehow tarnish the impression management they work so hard to maintain, they can get enraged and have a more overt reaction. But a lot of times people desire a reaction from them, and they just don't give it because they're so disinterested in you.
Keith Sutton, Psy.D. (45:08):
Their needs are dismissive.
Peter Salerno, Psy.D. (45:10):
Yeah.
Keith Sutton, Psy.D. (45:11):
Yeah. And I was reading a little bit on some of the descriptions on Amazon about helping people that maybe are in an invalidating environment, right? That the person is in the relationship and questioning their own perceptions or their own sense of reality, and helping them kind of recover from that. Is that a piece of the work?
Peter Salerno, Psy.D. (46:36):
What do I believe about other people? What do I believe about this relationship? And so there's a lot of self-doubt and confusion and disorientation that takes place with people who've—I kind of like to describe it like their mind has been scrambled. What they really held onto as their truth and their reality has been completely scrambled. And so part of the recovery process is rebuilding this core belief system of who I am, what I believe about myself, what's true about me. I've worked with a lot of survivors who feel like they were the bad person, or that maybe they never really knew who they were. They've been convinced by somebody that they're a terrible person, and it takes a while for those positive attributes and characteristics to get back online, so to speak, for a lot of these victims and survivors.
Keith Sutton, Psy.D. (47:34):
Yeah, definitely. Yeah. I don't know if there's been any research or anything on that about if there are qualities of a person that sometimes get stuck in these relationships. Because I imagine, you know, I'm thinking of some of my complex PTSD clients—they don't have a very strong sense of self, and their sense of self is very much affected by others, whether they're happy with them or unhappy with them. And so there's not that kind of internal measuring stick of like, I know what's right and what's wrong. I imagine somebody in that situation getting together with somebody that's a narcissist in this way would have a really hard time kind of knowing up from down.
Peter Salerno, Psy.D. (48:22):
Absolutely. Yeah. And so sometimes it's a restoration of those core beliefs, and sometimes it's like an installation because they've never—I mean, maybe they had complex trauma from childhood and then they got involved with a narcissist or somebody where their entire life has been a parent or caregiver who completely invalidated and abused them, and then a spouse who's done the same thing. It's like they've really never had an experience of what quote unquote normal or non-dramatic relationships can feel like, so they have to design a core belief system from the ground up, like what's really true about me. Which is a very difficult thing for some people, but I think it's hopeful too, because I don't think it's ever too late to establish that.
Keith Sutton, Psy.D. (49:13):
Yeah, definitely. So yeah, what is your big takeaway, or what are you kind of hoping that people— I mean, it sounds like there's one, the controversial idea around that there might actually be some genetic credibility related to some traits that potentially later turn into narcissism or other personality disorders, and this other piece that there is intentionality at times. Not just benign reactivity to the situation the person had growing up, but sometimes that there—because oftentimes there's a benefit to the behavior in general—but then whether there's a benefit to taking advantage of somebody else for your own purpose. It sounds like that's kind of the piece that maybe you feel is neglected or missed or dismissed in the community and in the therapy world.
Peter Salerno, Psy.D. (50:23):
I think the takeaway would be that I would like victims of abuse to at least be heard. That maybe this is a pattern. And again, with therapy, it's kind of tricky, right? Because we're supposed to be treating the person in the room, not the person they're talking about. So there is a challenge there. But I think people who are too quick to say, well, this may be your insecure attachment or your codependency or whatever else that's contributing to this dynamic—fix that, and then the relationship will improve—it would be important for therapists in particular to consider the possibility that maybe no matter how much somebody fixes their side of the fence and cleans up their room, this abuse is inevitable.
Peter Salerno, Psy.D. (51:13):
There's inevitable harm in some relationships, and that needs to be validated for some of these survivors. A lot of the people who come my way have had five therapists, and it's not that the therapists were bad therapists, it's just that they didn't consider the possibility that this person might have been just a victim of abuse. They keep trying to redirect it back to that person—well, you have these tendencies or this attachment style or whatever—and let's focus on you. People can feel very invalidated and hopeless when they've been intentionally abused. So it's not to condemn or dismiss anyone's competence. It's more like this is an area of education I think we could all benefit from looking into.
Keith Sutton, Psy.D. (52:04):
Yeah. No, I think that's a good point because sometimes it can go to either extreme. Sometimes the individual therapist can go too far away from systemic thinking and say, don’t believe what they said, you need to be assertive, and not really see what's playing out in the dynamic between the two, or even attribute malicious intent. But on the other end, going too far the other way of putting it into context—I was working with somebody around this, and we actually brought the partner in. The partner basically admitted, like, oh yeah, I've got just so much.
Keith Sutton, Psy.D. (52:52):
He could admit it, but was acting out of shame. He was doing the wrong thing and felt bad about it, but was still reacting and getting upset. She would get upset with him, and then he would get upset that she was upset, and so on. There was actually some consciousness to it. Again, he wasn't trying to be manipulative or abusive, but he was making it her fault, which I was missing until I brought him in. Then I was like, oh, okay. She was able to resolve and move on from the relationship fairly quickly after getting that validation, like okay, this is what's going on. He wanted to try and work on it, but struggled with it to the point where she decided, I'm going to move on and not put time and effort into helping this person grow in this way.
Peter Salerno, Psy.D. (53:47):
I think, real quick, the people that I'm really talking about where there's intentionality is sometimes they'll come to a couple sessions, and I've been amazed at this. I don't know if you've ever had this experience, but I've felt like the feedback from the session was that both of them felt it was very productive and very helpful. Then when they left, the relationship got exponentially worse. And the person who was the antagonist basically said that session was a bunch of bs, that guy doesn't know what he's talking about, he sided with you. It's like they paint this picture that there was this conjoined effort on the part of the professional, me in this case, and the couple, where they felt like they were making progress, but then they go home and have a completely different narrative.
Keith Sutton, Psy.D. (54:39):
Yeah. Yeah.
Peter Salerno, Psy.D. (54:40):
And, you know, I guess we could analyze that as potentially self-sabotage or a secondary gain that's unconscious, but there are times where there's just no accountability whatsoever in some of these individuals.
Keith Sutton, Psy.D. (54:58):
No, I'm thinking of another couple I worked with where she would avoid talking. After the session, she didn't discuss it with me because of the way he would just talk at her, like he could push buttons and make her think a certain way. It took a while for her, partway through therapy, to see that this was not going to change. They were in their sixties, and she eventually realized, okay, this isn't going to change. But seeing that pattern in the session highlighted his inability to take responsibility or even see what he was contributing to the dynamic.
Keith Sutton, Psy.D. (55:41):
It's a tough area. It's great that you're doing this work. It’s challenging because sometimes therapists might go too far, having no compassion or understanding for the person with the difficulty, but then there’s the other extreme—too much understanding or compassion—which could be enabling and not really addressing that it’s not a good situation. Unfortunately, there are really hurtful people who are malicious and knowingly do things beyond just their own character pathology.
Peter Salerno, Psy.D. (56:23):
Right. I think dichotomizing it is never a good idea because there are a lot of nuances. We don’t want to swing the pendulum too far.
Keith Sutton, Psy.D. (56:33):
Yeah. Definitely. Well, thank you so much for taking the time today. I really appreciate it. Great topic and great to think about. I appreciate all the work you’re doing.
Peter Salerno, Psy.D. (56:44):
Thank you. I'm glad you reached out. I appreciate you having me on.
Keith Sutton, Psy.D. (56:47):
Yeah. Take care. You too. Bye.
Peter Salerno, Psy.D. (56:50):
Bye.
Keith Sutton, Psy.D. (56:51):
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