NARCISSISTIC_PERSONALITY

From my book "Malignant self Love - Narcissism Revisited"

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Treatment Modalities and Therapies

Frequently Asked Question # 77

Narcissism constitutes the entire personality. It is all-pervasive. Being a narcissist is akin to being an alcoholic but much more so. Alcoholism is an impulsive behaviour. Narcissists exhibit dozens of similarly reckless behaviours, some of them uncontrollable (like their rage, the outcome of their wounded grandiosity). Narcissism is not a vocation. Narcissism resembles depression or other disorders and cannot be changed at will.

Adult pathological narcissism is no more "curable" than the entirety of one's personality is disposable. The patient is a narcissist. Narcissism is more akin to the colour of one's skin rather than to one's choice of subjects at the university.

Moreover, the Narcissistic Personality Disorder (NPD) is frequently diagnosed with other, even more intractable personality disorders, mental illnesses, and substance abuse.

Cognitive-Behavioral Therapies (CBTs)

The CBTs believe that insight �?even if merely verbal and intellectual �?is sufficient to induce an emotional outcome. If properly manipulated, verbal cues, insights, analyses of standard sentences we keep saying to ourselves ("I am ugly", "I am afraid no one would like to be with me"), inner dialogues and narratives, and repeated behavioural patterns (learned behaviours) coupled with positive (and, rarely, negative) reinforcements �?are sufficient to induce a cumulative emotional effect tantamount to healing.

Psychodynamic theories do not believe that cognition can influence emotion. They believe that much deeper strata have to be accessed and studied by both patient and therapist. The very exposure of these strata is considered sufficient to induce a dynamic of healing. The therapist's role is either to interpret the material revealed to the patient (psychoanalysis) by allowing the patient to transfer past experience and superimpose it on the therapist �?or to actively engage in providing a safe emotional and holding environment conducive to changes in the patient.

The sad fact is that no known therapy is effective with narcissism ITSELF �?though a few therapies are reasonably successful as far as coping with some of its effects goes (behavioural modification).

Dynamic Psychotherapy
Or Psychodynamic Therapy, Psychoanalytic Psychotherapy

As opposed to common opinion it is NOT psychoanalysis. It is an intensive psychotherapy BASED on psychoanalytic theory WITHOUT the (very important) element of free association. This is not to say that free association is not used �?only that it is not a pillar of the technique in dynamic therapies. Dynamic therapies are usually applied to patients not considered "suitable" for psychoanalysis (such as Personality Disorders, except the Avoidant PD).

Typically, different modes of interpretation are employed and other techniques borrowed from other treatments modalities. But the material interpreted is not necessarily the result of free association or dreams and the psychotherapist is a lot more active than the psychoanalyst.

These treatments are open-ended. At the commencement of the therapy the therapist (analyst) makes an agreement (a "pact") with the analysand (patient or client). The pact says that the patient undertakes to explore his problems no matter how long it takes (and how expensive it becomes). This is supposed to make the therapeutic environment much more relaxed because the patient knows that the analyst is at his/her disposal no matter how many meetings would be required in order to broach painful subject matter.

Sometimes, these therapies are divided to expressive versus supportive, but I regard this division as misleading.

Expressive means uncovering (=making conscious) the patient's conflicts and studying his/her defences and resistances. The analyst interprets the conflict in view of the new knowledge gained and guides the therapy towards a resolution of the conflict. The conflict, in other words, is "interpreted away" through insight and the change in the patient motivated by his/her insights.

The supportive therapies seek to strengthen the Ego. Their premise is that a strong Ego can cope better (and later on, alone) with external (situational) or internal (instincts, drives) pressures. Supportive therapies seek to increase the patient's ability to REPRESS conflicts (rather than bring them to the surface of consciousness). As a painful conflict is suppressed �?so are all manner of dysphorias and symptoms. This is somewhat reminiscent of behaviourism (the main aim is to change behaviour and to relieve symptoms). It usually makes no use of insight or interpretation (though there are exceptions).

Group Therapies

Narcissists are notoriously unsuitable for collaborative efforts of any kind, let alone group therapy. They immediately size up others as potential Sources of Narcissistic Supply �?or potential competitors. They idealise the first (suppliers) and devalue the latter (competitors). This, obviously, is not very conducive to group therapy.

Moreover, the dynamic of the group is bound to reflect the interactions of its members. Narcissists are individualists. They regard coalitions with disdain and contempt. The need to resort to team work, to adhere to group rules, to succumb to a moderator, and to honour and respect the other members as equals - is perceived by them to be humiliating and degrading (a contemptible weakness). Thus, a group containing one or more narcissists is likely to fluctuate between short-term, very small size, coalitions (based on "superiority" and contempt) and outbreaks (acting outs) of rage and coercion.

Can Narcissism be Cured?

Adult narcissists can rarely be "cured", though some scholars think otherwise. Still, the earlier the therapeutic intervention, the better the prognosis. A correct diagnosis and a proper mix of treatment modalities in early adolescence guarantees success without relapse in anywhere between one third and one half the cases. Additionally, ageing ameliorates or even vanquishes some antisocial behaviors.

In their seminal tome, "Personality Disorders in Modern Life" (New York, John Wiley & Sons, 2000), Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid ... Interpretation and even general assessment are often difficult to accomplish..."

The third edition of the "Oxford Textbook of Psychiatry" (Oxford, Oxford University Press, reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only change their situations. There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character ... Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve them."

The fourth edition of the authoritative "Review of General Psychiatry" (London, Prentice-Hall International, 1995), says (p. 309):

"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."

The reason narcissism is under-reported and healing over-stated is that therapists are being fooled by smart narcissists. Most narcissists are expert manipulators and they learn how to deceive their therapists.

Here are some hard facts:

There are gradations and shades of narcissism. The difference between two narcissists can be great. The existence of grandiosity and empathy or lack thereof are not minor variations. They are serious predictors of future dynamics. The prognosis is much better if they do exist.

There are cases of spontaneous healing and of "short-term NPD" [see Gunderson's and Roningstam work, 1996].

The prognosis for a classical NPD case (grandiosity, lack of empathy and all) is decidedly not good as far as long-term, lasting, and complete healing. Moreover, narcissists are intensely disliked by therapists.

BUT�?/SPAN>

Side effects, co-morbid disorders (such as Obsessive-Compulsive behaviors) and some aspects of NPD (the dysphorias, the paranoiac dimensions, the outcomes of the sense of entitlement, the pathological lying) can be modified (using talk therapy and, depending on the problem, medication). these are not short-term or complete solutions �?but some of them do have long-term effects.

The DSM is a billing and administration oriented diagnostic tool. It is intended to "tidy" up the psychiatrist's desk. The Personality Disorders are ill demarcated. The differential diagnoses are vaguely defined. There are some cultural biases and judgements [see the diagnostic criteria of the Schizotypal PD]. The result is sizeable confusion and multiple diagnoses ("co-morbidity"). NPD was introduced to the DSM in 1980 [DSM-III]. There isn't enough research to substantiate any view or hypothesis about NPD. Future DSM editions may abolish it altogether within the framework of a cluster or a single "personality disorder" category. As it is, the difference between HPD, BPD, AsPD, and NPD is, to my mind, rather blurred. When we ask: "Can NPD be healed?" we need to realise that we don't know for sure what is NPD and what constitutes long-term healing in the case of an NPD. There are those who seriously claim that NPD is a cultural disease with a societal determinant.

Narcissists in Therapy

In therapy, the general idea is to create the conditions for the True Self to resume its growth: safety, predictability, justice, love and acceptance - a mirroring and holding environment. Therapy is supposed to provide these conditions of nurturance and the guidance necessary to achieve these goals (through transference, cognitive re-labelling or other methods). The narcissist must learn that his past experiences are not laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive.

Most therapists try to co-opt the narcissist's inflated ego (False Self) and defences. They compliment the narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.

By stroking the narcissist's grandiosity, they hope to modify or counter cognitive deficits, thinking errors, and the narcissist's victim-stance. They contract with the narcissist to alter his conduct. Some even go to the extent of medicalizing the disorder, attributing it to a hereditary or biochemical origin and thus "absolving" the narcissist from guilt and responsibility and freeing his mental resources to concentrate on the therapy.

Confronting the narcissist head on and engaging in power politics ("I am cleverer", "My will should prevail", and so on) is decidedly unhelpful and could lead to rage attacks and a deepening of the narcissist's persecutory delusions, bred by his humiliation in the therapeutic setting.

Successes have been reported by applying 12-step techniques (as modified for patients suffering from the Antisocial Personality Disorder), and with treatment modalities as diverse as NLP (Neurolinguistic Programming) and EMDR (Eye Movement Desensitization).

But, whatever the type of talk therapy, the narcissist devalues the therapist. His internal dialogue is: "I know best, I know it all, the therapist is less intelligent than I, I can't afford the top level therapists who are the only ones qualified to treat me (as my equals, needless to say), I am actually a therapist myself�?

A litany of self-delusion and fantastic grandiosity (really, defences and resistances): "He (my therapist) should be my colleague, in certain respects it is he who should accept my professional authority, why won't he be my friend, after all I can use the lingo (psycho-babble) even better than he does? It's us (him and me) against a hostile and ignorant world (follies-a-deux)�?

Then there is: "Just who does he think he is, asking me all these questions? What are his professional credentials? I am a success and he is a nobody therapist in a dingy office, he is trying to negate my uniqueness, he is an authority figure, I hate him, I will show him, I will humiliate him, prove him ignorant, have his licence revoked (transference). Actually, he is pitiable, a zero, a failure�?

And this is only in the first three sessions of the therapy. This abusive internal dialogue becomes more vituperative and pejorative as therapy progresses.

Narcissists generally are averse to receiving medication. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks. Additionally, many of them believe that medication is the "great equaliser" �?it will make them lose their uniqueness, superiority and so on. That is unless they can convincingly present the act of taking their medicines as "heroism", a part of a daring enterprise of self-exploration, a distinguishing feature and so on.

They often claim that the medicine affects them differently than it does other people, or that they have discovered a new, exciting way of using it, or that they are part of someone's (usually themselves) learning curve ("part of a new approach to dosage", "part of a new cocktail which holds great promise"). Narcissists must dramatise their lives to feel worthy and special. Aut nihil aut unique �?either be special or don't be at all. Narcissists are drama queens.

Very much like in the physical world, change is brought about only through incredible powers of torsion and breakage. Only when the narcissist's elasticity gives way, only when he is wounded by his own intransigence �?only then is there hope.

It takes nothing less than a real crisis. Ennui is not enough.

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Narcissists, Paranoiacs and Psychotherapists

Frequently Asked Questions # 26-27

By: Dr. Sam Vaknin

The narcissist's paranoidal delusions extend to the therapeutic sessions.

One of the most important presenting symptoms of a narcissist is his (or her) insistence that he (or she) is equal to the psychotherapist in knowledge, in experience, in social status. The narcissist in the therapeutic session spices his speech with psychiatric lingo and professional terms. He distances himself from his painful emotions by generalising them, analysing them to small verbal pieces, slicing life and hurt and neatly tacking the results under what he thinks are "professional insights". In effect, he is telling the psychotherapist: there is nothing much that you can teach me, I am as intelligent as you, you are not superior to me, actually, we should both collaborate as equals in this unfortunate state of things in which we, inadvertently, find ourselves involved.

Finally, the partner gathers enough courage to confront the narcissist with the facts about the narcissist's self (as seen from the partner's vantage point). The threshold of tolerance is crossed, the measure of suffering exceeded. The partner does not expect to induce changes in the narcissist (though she is most likely to insist otherwise). The partner's motivation is much baser: to exact revenge for a period of mental slavery, subservience, subjugation, subordination, exploitation, humiliation and objectification. The aim is to anger the narcissist, and, thus, to make him vulnerable, inferior for a minute. It is a mini-rebellion (which does not last long), sometimes possessed of sadistic elements.

Living with a narcissist is a harrowing experience. It can tilt one's mind toward abnormal reactions (really normal reactions to an abnormal situation). The capriciousness, volatility, arbitrariness and vicissitudinal character of the narcissist's behaviour can facilitate the formation of paranoid reactions. The less predictable the world, the more ominous and precarious it is and the more paranoid the pattern of reactions to it. Sometimes �?through the mechanism of narcissistic mirroring �?the partner adopts a way of reacting to a prolonged period of emotional deprivation and stress by emulating the narcissist himself. The latter is then likely to reproach the partner by saying: "You became I and I became you!!! I do not know you anymore!"

The narcissist has a way of getting under his partners' skin. They cannot escape him because he is part of their lives and part of their selves, as internalised as any parent is. Even after a long sought separation, the partners still care for the narcissist greatly �?enough to be mulling over the expired relationship endlessly. It is this that the partner should clarify to herself: she may be able to exit the narcissist's life �?but will he ever exit hers?

A narcissist's partner wrote to me these heartbreaking words:

"I have made him sound like a monster, and in many ways he really is. At the same time, I have always seen a vulnerability in him, the small terrified hungry child (almost split-off from the rest of him) and I suppose this is why I tried so hard with him. I knew, almost intuitively, that while his (False) Ego was constantly swelling, his heart (True Ego) was starving�?/SPAN>

I tried as hard as I could, in as many ways as I could, to feed the real person inside (and I believed there was a fragment of that person still alive, represented by the child). In a way, I think the violence of his reactions near the end was due to my coming so close, in arousing those ordinary needs. When he realised he has become dependent on me, and that I knew it, I think he just couldn't take it. He could not finally take the chance of trusting me.

It was an orgy of destruction. I keep thinking I could have handled it better, could and should have done things differently. Maybe it wouldn't have made any difference, but I will say that there was a real person in there somewhere, and a quite delightful one.

But as you pointed out, the narcissist would always prefer his invented self to the true one. I could not make him see that his real self was far more interesting and enchanting than his grotesque inflated grandiose superman construct. I think it is a tragic loss of a truly interesting and talented human being."

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Reconditioning the Narcissist

Frequently Asked Question # 63

By: Dr. Sam Vaknin

Question:

In your writing, you seem to be very sceptical that the individual with a Narcissistic Personality Disorder can be treated successfully. Is that your position?

Answer:

No, it is the position of clinical psychologists (which I am NOT) who wrote about the subject. NPD has been recognised as a distinct mental disorder a little more than two decades ago. There is no one who can honestly claim expertise or even in-depth understanding of this complex condition. My writings are limited to its phenomenology. I deal very briefly (and unconvincingly) with its aetiology (and I follow in this the object-relations school of psychodynamics for want of a better "explanation"). So, no one knows whether therapy works. What IS known is that therapists find narcissists repulsive, overbearing and unnerving. It is also known that narcissists try to co-opt, idolize, or humiliate the therapist.

To a narcissist, I would recommend a functional approach, perhaps along the following lines:

Know and accept thyself. This is what you are. You are highly intelligent. You are very inquisitive. You are a narcissist. These are facts. Narcissism is an adaptive mechanism. It is dysfunctional �?but it saved you from a LOT MORE dysfunction or even non-function. Make a list: what does it mean to be a narcissist in your specific case? What are your typical behaviour patterns? Which types of behaviour are counterproductive, irritating, self-defeating or self-destructive? Which are productive, constructive and should be enhanced DESPITE their pathological origin?

Decide to suppress the first and to promote the latter. Construct lists of self-punishments, negative feedback and negative reinforcements. Impose them upon yourself when you exhibit one of the behaviours in the first list. Make a list of prizes, little indulgences, positive feedbacks and positive reinforcements. Use them to reward yourself when you display a behaviour of the second kind.

Keep doing this with the express intent of conditioning yourself. Be objective, predictable and just in the administration of both punishments and awards, positive reinforcements and feedback and negative ones. Learn to trust your "inner court". Constrain the sadistic, immature and ideal parts of your personality (known as Superego in psychoanalytic parlance) by the application of a uniform codex, a set of immutable and invariably applied rules.

Once sufficiently conditioned, monitor yourself incessantly. Narcissism is sneaky and it possesses all your resources because it is you. Your disorder is intelligent because you are. Beware and never lose control. With time this onerous regime will become a second habit and supplant the narcissistic (pathological) superstructure.

You might have noticed that all the above can be amply summed by suggesting to you to become your own parent. This is what parents do and the process is called "education" or "socialisation". If your path to the adoption of this course is a particular therapy �?go ahead. As a metaphor, a narrative, no therapeutic approach is better or worse than any other.

The heart of the beast is the inability of the narcissist to distinguish true from false, posing from being, Narcissistic Supply from genuine relationships and compulsive drives from true interests and avocations in his life. Narcissism is about deceit. It blurs the distinction between authentic actions, true motives, real desires, original emotions �?and the malignant forms that are the attributes of narcissism. Narcissists are no longer capable of knowing themselves. Terrified by their internal apparitions, paralysed by their inauthenticity, suppressed by the weight of their repressed emotions �?they occupy a hall of mirrors. Munch-like, their elongated figures stare at them, on the verge of THE scream, yet somehow, without sound. Their curious, vibrant, optimistic True Self is dead. How can a False Self be anything but false? How can anyone on a permanent diet of reflections ever see true objects? How can the narcissist �?whose essence is the devouring of meaningful others and their transformation into meaningless and other �?ever love?

The answer is: discipline, decisiveness, clear targets, conditioning, justice. The narcissist is the product of unjust, capricious and cruel treatment. He is the finished product of a production line of self-recrimination, guilt and fear. He needs to take the antidote to counter the narcissistic poison. Unfortunately, there is no drug I know of which can ameliorate pathological narcissism. Confronting one's parents and childhood is a good idea if the narcissist feels that he is ready for it. Can he take it? Can he cope with new truths, however painful? The narcissist must be careful. This is playing with fire. But if he feels confident that there is nothing that can be revealed to him in such a confrontation that he cannot withstand or does not already know �?it is a good and wise move in the right direction. My advice to the narcissist would then be: just dedicate a lot of time to rehearsing it and define well what is it exactly that you want to ask. Do not turn this into a monodrama, group dynamics or trial. Ask so that you shall be answered. Don't try to prove anything, to vindicate, to take revenge, to win, to exculpate. Talk as you would with yourself. Do not try to sound professional, mature, intelligent, knowledgeable and distanced. There is no "problem to solve" �?just a condition to adjust yourself to. Think about it as diabetes.

At the risk of sounding heartless, I will make three concluding comments:

The narcissist should take life in general and himself, in particular, much less seriously. Being immersed in one's self and in one's condition is never the right recipe to functionality, let alone happiness. The world is a comic, absurd place. It is indeed a theatre to be enjoyed. It is full of colours and smells and sounds to be treasured and cherished. It is varied and it accommodates and tolerates everyone and everything, even narcissists.

The narcissist should regard his condition as an asset. I am a narcissist, so I write about it. My advice to the narcissist would be: ask yourself what can you do with it? In Chinese the ideogram for "crisis" and "opportunity" is one and the same. Why don't you transform the curse in your life �?into a blessing in other people's lives? Why don't you tell them your story, warn them, teach them how to avoid the same pitfalls, how to cope with the damage? Why don't you do all this in a more institutionalised manner? For instance, you can start a discussion group on the internet. You can establish "narcissists anonymous" in some community shelter. You can open a correspondence network, a help centre for men in your condition, for women abused by narcissists �?the possibilities are endless. And it will instil in you a regained sense of self-worth, a purpose, self-confidence and reassurance. It is only by helping others that we help ourselves. This is, of course, a suggestion �?not a prescription. But it demonstrates the ways in which you can derive power from adversity.

It is easy for the narcissist to think about Pathological Narcissism as the source of all that is evil and wrong in his life. Narcissism is a catchall phrase, a conceptual scapegoat, an evil seed. It conveniently encapsulates the predicament of the narcissist. It introduces logic and causal relations into his baffled, tumultuous world. But this is a trap. The human psyche is too complex to be captured by a single, all-encompassing explanation, however convincing. The road to self-help and self-betterment passes through numerous junctions and stations. Narcissism is the first and the foremost. But there are many other elements in the complex dynamics that is the soul of the narcissist. The narcissist should take responsibility for his life and not relegate it to some hitherto rather obscure psychodynamic concept. This is the first and most important step to healing.