| Narcissism constitutes the entire personality. It is | | | | 1995), says (p. 309): |
| all-pervasive. Being a narcissist is akin to being an | | | | "(People with personality disorders) ... cause |
| alcoholic but much more so. Alcoholism is an impulsive | | | | resentment and possibly even alienation and burnout in |
| behaviour. Narcissists exhibit dozens of similarly | | | | the healthcare professionals who treat them ... (p. 318) |
| reckless behaviours, some of them uncontrollable (like | | | | Long-term psychoanalytic psychotherapy and |
| their rage, the outcome of their wounded grandiosity). | | | | psychoanalysis have been attempted with (narcissists), |
| Narcissism is not a vocation. Narcissism resembles | | | | although their use has been controversial." |
| depression or other disorders and cannot be changed | | | | The reason narcissism is under-reported and healing |
| at will. | | | | over-stated is that therapists are being fooled by |
| Adult pathological narcissism is no more "curable" than | | | | smart narcissists. Most narcissists are expert |
| the entirety of one's personality is disposable. The | | | | manipulators and they learn how to deceive their |
| patient is a narcissist. Narcissism is more akin to the | | | | therapists. |
| colour of one's skin rather than to one's choice of | | | | Here are some hard facts: |
| subjects at the university. | | | | There are gradations and shades of narcissism. The |
| Moreover, the Narcissistic Personality Disorder (NPD) is | | | | difference between two narcissists can be great. The |
| frequently diagnosed with other, even more intractable | | | | existence of grandiosity and empathy or lack thereof |
| personality disorders, mental illnesses, and substance | | | | are not minor variations. They are serious predictors of |
| abuse. | | | | future dynamics. The prognosis is much better if they |
| Cognitive-Behavioral Therapies (CBTs) | | | | do exist. |
| The CBTs believe that insight - even if merely verbal | | | | There are cases of spontaneous healing and of |
| and intellectual - is sufficient to induce an emotional | | | | "short-term NPD" [see Gunderson's and Roningstam |
| outcome. If properly manipulated, verbal cues, insights, | | | | work, 1996]. |
| analyses of standard sentences we keep saying to | | | | The prognosis for a classical NPD case (grandiosity, |
| ourselves ("I am ugly", "I am afraid no one would like to | | | | lack of empathy and all) is decidedly not good as far |
| be with me"), inner dialogues and narratives, and | | | | as long-term, lasting, and complete healing. Moreover, |
| repeated behavioural patterns (learned behaviours) | | | | narcissists are intensely disliked by therapists. |
| coupled with positive (and, rarely, negative) | | | | BUT... |
| reinforcements - are sufficient to induce a cumulative | | | | Side effects, co-morbid disorders (such as |
| emotional effect tantamount to healing. | | | | Obsessive-Compulsive behaviors) and some aspects |
| Psychodynamic theories do not believe that cognition | | | | of NPD (the dysphorias, the paranoiac dimensions, the |
| can influence emotion. They believe that much deeper | | | | outcomes of the sense of entitlement, the pathological |
| strata have to be accessed and studied by both | | | | lying) can be modified (using talk therapy and, |
| patient and therapist. The very exposure of these | | | | depending on the problem, medication). these are not |
| strata is considered sufficient to induce a dynamic of | | | | short-term or complete solutions - but some of them |
| healing. The therapist's role is either to interpret the | | | | do have long-term effects. |
| material revealed to the patient (psychoanalysis) by | | | | The DSM is a billing and administration oriented |
| allowing the patient to transfer past experience and | | | | diagnostic tool. It is intended to "tidy" up the |
| superimpose it on the therapist - or to actively engage | | | | psychiatrist's desk. The Personality Disorders are ill |
| in providing a safe emotional and holding environment | | | | demarcated. The differential diagnoses are vaguely |
| conducive to changes in the patient. | | | | defined. There are some cultural biases and |
| The sad fact is that no known therapy is effective | | | | judgements [see the diagnostic criteria of the |
| with narcissism ITSELF - though a few therapies are | | | | Schizotypal PD]. The result is sizeable confusion and |
| reasonably successful as far as coping with some of | | | | multiple diagnoses ("co-morbidity"). NPD was introduced |
| its effects goes (behavioural modification). | | | | to the DSM in 1980 [DSM-III]. There isn't enough |
| Dynamic Psychotherapy | | | | research to substantiate any view or hypothesis about |
| Or Psychodynamic Therapy, Psychoanalytic | | | | NPD. Future DSM editions may abolish it altogether |
| Psychotherapy | | | | within the framework of a cluster or a single |
| As opposed to common opinion it is NOT | | | | "personality disorder" category. As it is, the difference |
| psychoanalysis. It is an intensive psychotherapy | | | | between HPD, BPD, AsPD, and NPD is, to my mind, |
| BASED on psychoanalytic theory WITHOUT the (very | | | | rather blurred. When we ask: "Can NPD be healed?" |
| important) element of free association. This is not to | | | | we need to realise that we don't know for sure what |
| say that free association is not used - only that it is not | | | | is NPD and what constitutes long-term healing in the |
| a pillar of the technique in dynamic therapies. Dynamic | | | | case of an NPD. There are those who seriously claim |
| therapies are usually applied to patients not considered | | | | that NPD is a cultural disease with a societal |
| "suitable" for psychoanalysis (such as Personality | | | | determinant. |
| Disorders, except the Avoidant PD). | | | | Narcissists in Therapy |
| Typically, different modes of interpretation are | | | | In therapy, the general idea is to create the conditions |
| employed and other techniques borrowed from other | | | | for the True Self to resume its growth: safety, |
| treatments modalities. But the material interpreted is | | | | predictability, justice, love and acceptance - a mirroring |
| not necessarily the result of free association or | | | | and holding environment. Therapy is supposed to |
| dreams and the psychotherapist is a lot more active | | | | provide these conditions of nurturance and the |
| than the psychoanalyst. | | | | guidance necessary to achieve these goals (through |
| These treatments are open-ended. At the | | | | transference, cognitive re-labelling or other methods). |
| commencement of the therapy the therapist (analyst) | | | | The narcissist must learn that his past experiences are |
| makes an agreement (a "pact") with the analysand | | | | not laws of nature, that not all adults are abusive, that |
| (patient or client). The pact says that the patient | | | | relationships can be nurturing and supportive. |
| undertakes to explore his problems no matter how | | | | Most therapists try to co-opt the narcissist's inflated |
| long it takes (and how expensive it becomes). This is | | | | ego (False Self) and defences. They compliment the |
| supposed to make the therapeutic environment much | | | | narcissist, challenging him to prove his omnipotence by |
| more relaxed because the patient knows that the | | | | overcoming his disorder. They appeal to his quest for |
| analyst is at his/her disposal no matter how many | | | | perfection, brilliance, and eternal love - and his paranoid |
| meetings would be required in order to broach painful | | | | tendencies - in an attempt to get rid of |
| subject matter. | | | | counterproductive, self-defeating, and dysfunctional |
| Sometimes, these therapies are divided to expressive | | | | behaviour patterns. |
| versus supportive, but I regard this division as | | | | By stroking the narcissist's grandiosity, they hope to |
| misleading. | | | | modify or counter cognitive deficits, thinking errors, and |
| Expressive means uncovering (=making conscious) the | | | | the narcissist's victim-stance. They contract with the |
| patient's conflicts and studying his/her defences and | | | | narcissist to alter his conduct. Some even go to the |
| resistances. The analyst interprets the conflict in view | | | | extent of medicalizing the disorder, attributing it to a |
| of the new knowledge gained and guides the therapy | | | | hereditary or biochemical origin and thus "absolving" the |
| towards a resolution of the conflict. The conflict, in | | | | narcissist from guilt and responsibility and freeing his |
| other words, is "interpreted away" through insight and | | | | mental resources to concentrate on the therapy. |
| the change in the patient motivated by his/her insights. | | | | Confronting the narcissist head on and engaging in |
| The supportive therapies seek to strengthen the Ego. | | | | power politics ("I am cleverer", "My will should prevail", |
| Their premise is that a strong Ego can cope better | | | | and so on) is decidedly unhelpful and could lead to |
| (and later on, alone) with external (situational) or internal | | | | rage attacks and a deepening of the narcissist's |
| (instincts, drives) pressures. Supportive therapies seek | | | | persecutory delusions, bred by his humiliation in the |
| to increase the patient's ability to REPRESS conflicts | | | | therapeutic setting. |
| (rather than bring them to the surface of | | | | Successes have been reported by applying 12-step |
| consciousness). As a painful conflict is suppressed - so | | | | techniques (as modified for patients suffering from the |
| are all manner of dysphorias and symptoms. This is | | | | Antisocial Personality Disorder), and with treatment |
| somewhat reminiscent of behaviourism (the main aim | | | | modalities as diverse as NLP (Neurolinguistic |
| is to change behaviour and to relieve symptoms). It | | | | Programming), Schema Therapy, and EMDR (Eye |
| usually makes no use of insight or interpretation | | | | Movement Desensitization). |
| (though there are exceptions). | | | | But, whatever the type of talk therapy, the narcissist |
| Group Therapies | | | | devalues the therapist. His internal dialogue is: "I know |
| Narcissists are notoriously unsuitable for collaborative | | | | best, I know it all, the therapist is less intelligent than I, I |
| efforts of any kind, let alone group therapy. They | | | | can't afford the top level therapists who are the only |
| immediately size up others as potential Sources of | | | | ones qualified to treat me (as my equals, needless to |
| Narcissistic Supply - or potential competitors. They | | | | say), I am actually a therapist myself..." |
| idealise the first (suppliers) and devalue the latter | | | | A litany of self-delusion and fantastic grandiosity (really, |
| (competitors). This, obviously, is not very conducive to | | | | defences and resistances): "He (my therapist) should |
| group therapy. | | | | be my colleague, in certain respects it is he who should |
| Moreover, the dynamic of the group is bound to reflect | | | | accept my professional authority, why won't he be my |
| the interactions of its members. Narcissists are | | | | friend, after all I can use the lingo (psycho-babble) even |
| individualists. They regard coalitions with disdain and | | | | better than he does? It's us (him and me) against a |
| contempt. The need to resort to team work, to adhere | | | | hostile and ignorant world (follies-a-deux)..." |
| to group rules, to succumb to a moderator, and to | | | | Then there is: "Just who does he think he is, asking me |
| honour and respect the other members as equals - is | | | | all these questions? What are his professional |
| perceived by them to be humiliating and degrading (a | | | | credentials? I am a success and he is a nobody |
| contemptible weakness). Thus, a group containing one | | | | therapist in a dingy office, he is trying to negate my |
| or more narcissists is likely to fluctuate between | | | | uniqueness, he is an authority figure, I hate him, I will |
| short-term, very small size, coalitions (based on | | | | show him, I will humiliate him, prove him ignorant, have |
| "superiority" and contempt) and outbreaks (acting outs) | | | | his licence revoked (transference). Actually, he is |
| of rage and coercion. | | | | pitiable, a zero, a failure..." |
| Can Narcissism be Cured? | | | | And this is only in the first three sessions of the |
| Adult narcissists can rarely be "cured", though some | | | | therapy. This abusive internal dialogue becomes more |
| scholars think otherwise. Still, the earlier the therapeutic | | | | vituperative and pejorative as therapy progresses. |
| intervention, the better the prognosis. A correct | | | | Narcissists generally are averse to receiving |
| diagnosis and a proper mix of treatment modalities in | | | | medication. Resorting to medicines is an implied |
| early adolescence guarantees success without | | | | admission that something is wrong. Narcissists are |
| relapse in anywhere between one third and one half | | | | control freaks. Additionally, many of them believe that |
| the cases. Additionally, ageing ameliorates or even | | | | medication is the "great equaliser" - it will make them |
| vanquishes some antisocial behaviors. | | | | lose their uniqueness, superiority and so on. That is |
| In their seminal tome, "Personality Disorders in Modern | | | | unless they can convincingly present the act of taking |
| Life" (New York, John Wiley & Sons, 2000), | | | | their medicines as "heroism", a part of a daring |
| Theodore Millon and Roger Davis write (p. 308): | | | | enterprise of self-exploration, a distinguishing feature |
| "Most narcissists strongly resist psychotherapy. For | | | | and so on. |
| those who choose to remain in therapy, there are | | | | They often claim that the medicine affects them |
| several pitfalls that are difficult to avoid ... Interpretation | | | | differently than it does other people, or that they have |
| and even general assessment are often difficult to | | | | discovered a new, exciting way of using it, or that they |
| accomplish..." | | | | are part of someone's (usually themselves) learning |
| The third edition of the "Oxford Textbook of | | | | curve ("part of a new approach to dosage", "part of a |
| Psychiatry" (Oxford, Oxford University Press, reprinted | | | | new cocktail which holds great promise"). Narcissists |
| 2000), cautions (p. 128): | | | | must dramatise their lives to feel worthy and special. |
| "... (P)eople cannot change their natures, but can only | | | | Aut nihil aut unique - either be special or don't be at all. |
| change their situations. There has been some progress | | | | Narcissists are drama queens. |
| in finding ways of effecting small changes in disorders | | | | Very much like in the physical world, change is brought |
| of personality, but management still consists largely of | | | | about only through incredible powers of torsion and |
| helping the person to find a way of life that conflicts | | | | breakage. Only when the narcissist's elasticity gives |
| less with his character ... Whatever treatment is used, | | | | way, only when he is wounded by his own |
| aims should be modest and considerable time should | | | | intransigence - only then is there hope. |
| be allowed to achieve them." | | | | It takes nothing less than a real crisis. Ennui is not |
| The fourth edition of the authoritative "Review of | | | | enough. |
| General Psychiatry" (London, Prentice-Hall International, | | | | |