The Narcissist in Therapy

Interview granted to The New Therapist
By Sam Vaknin
Author of “Malignant Self Love – Narcissism Revisited”

Q. Have you ever been in psychotherapy? If so, was it with a view to managing your narcissism? If not would you consider psychotherapy to be potentially useful to yourself or not?

A. I have attended therapy twice. Once in an attempt to pre-empt the breakdown of the first romantic affair I have had and the second time, I was compelled to by a court order. The first time around, I was not even aware that I had a personality disorder, let alone that I should manage it. The second time around – in the throes of a total meltdown of my world – I finally grasped that something was seriously amiss and was, indeed, in quest for a cure. Alas, psychotherapy proved utterly useless. In my case, it failed to even modify the more egregious forms of misconduct and ill-adaptation. This has to do with the fact that my pathology involves heavy emotional investment (cathexis) in a grandiose, inflated, omnipotent, omniscient, and brilliant False Self. I perceived therapy to be a direct and assaultive challenge to this entrenched self-image.

Q. If forced to choose a therapeutic modality, what would you consider the most potentially valuable for yourself and why?

A. I would opt for CBT (a cognitive-behavioural therapy). It strikes me as cerebral, analytic, and “intellectual”: precisely the traits I admire and which form the dimensions of my self-imputed identity. I feel less threatened when I can avoid directly confronting my emotions. Additionally, CBTs propagate, however subversively and inadvertently, a mechanistic (almost behavioural) view of the psyche. I like it. I often compare myself to a machine or a robot. Positive reinforcements, verbal cues, the emphasis on cognition, inner tapes and narratives (the equivalent of programming) all strike a cord within me.

Q. Pathologically narcissistic clients, it would seem, often end up being forced into therapy more by a difficult context in which they find themselves (a narcissistic wound, the end of a relationship, court-mandated clients, etc.) than as  a result of their soul-searching or awareness that their narcissistic pathology is something that would warrant further understanding. Research also suggests that they are prone to early termination of psychotherapeutic treatments because of the narcissistic wounds they suffer when the therapist will not serve solely as a source of narcissistic supply, but attempts to get beneath this constant need for affirmation. In short, pathological narcissists appear to be difficult to get into therapy and, often, very difficult to keep in therapy. In light of the above, and with reference to the understanding you have of what is of value  to you in preventing your own narcissistic impulses from causing you longer-term difficulties, can you look at a few ideas that you might recommend to therapists who wish to be of as much value as possible to their pathologically narcissistic clients? You have suggested that pathological narcissism cannot be cured. I suspect many therapists might agree in large part with that idea on the basis of their disappointing results with narcissistic clients.  But, as you suggest, therapists might be able to help manage their expressions of narcissism to help moderate the damaging effects of too rampant a narcissistic engagement with other parts of their world. What, if any, are the therapeutic techniques/approaches/ ideas that you think might be most effective in this more humble goal of managing narcissistic pathology.

A. I see most of the problems with the therapist, not with his or her narcissistic client. Therapists must learn to moderate their expectations and control their own narcissistic defences and impulses. Here are a few tips: (1) it is not possible to establish a therapeutic alliance with the narcissist. Equally impossible is to set the agenda. The therapist must learn to let the narcissist win the inevitable power plays and mind games early on, so as to get them out of the way; (2) the therapist should not let the narcissist corrupt him or the therapeutic settings. Narcissists often offer rewards or “bribes” in return for acquiescence and obsequiousness; (3) the aims of the therapy should be modest and infinitesimally incremental. Progress should be marked and attributed to the narcissist, not to the therapist; (4) the therapy should emphasize adaptive behaviour modification, not reinterpretation, reframing, or “healing”. The therapist should let the narcissist identify areas of dysfunction and discomfort zones and, thus, to direct the therapy towards these sore points; (5) The therapist should never take sides (e.g., sympathize with the narcissist’s long-suffering wife), should never challenge the narcissist’s delusions, grandiose fantasies, and False Self, and should never used the reality test as a measure of the narcissist’s accomplishments in therapy. Narcissism is, by definition, a variant of fantastic realism. It is useful to regard the narcissist as an artist, an auteur: his life is his masterpiece. Narcissism is not merely a mental health disorder: it is also an organizing principle and an exegetic framework; Finally (6) Wherever and whenever not detrimental to therapeutic goals, the therapist should provide the narcissist with narcissistic supply in the form of affirmation, acceptance, deserved accolades, sympathy, and appreciation (but not adulation!)

Q. How would you recommend therapists respond most valuably for narcissistic clients when their clients attempt repeatedly to devalue the therapist?

A. The narcissist constantly tests authority figures such as the therapist: are they for real? Are they faking their knowledge, emotions, judgements, opinions, values? Are they reliable: can the narcissist trust their promises and threats? How far will they go? Will they truly punish the narcissist? Are they intelligent as their academic credentials imply? How do they stand in comparison and in relation to the narcissist? This puerile power politics is a part and parcel of the constant, far-reaching, and all-pervasive mind game that the narcissist plays with all his nearest (and dearest). He understands interpersonal interactions in terms of matrices of influence and superiority-inferiority, not as collaborative modes. It is, therefore, very counterproductive to engage in one-upmanship with the narcissist. The therapist should avoid this minefield by conceding defeat immediately when the issue rises. Such “surrender” may “awaken” the narcissist and render him aware of his own pettiness and infantile behaviour. The therapy can then move on to more fertile grounds.

Q. As I read through the tomes you have penned on the subject of narcissism, at least three thoughts occur rather forcefully to me:

1. Your knowledge of the body of professional knowledge on, and insights into, the dynamics of narcissism are so impressive that I feel naturally and ungrudgingly inclined to provide the affirmation you indicate have driven you to become so competent in this field. That is often the case with narcissists in therapy: They are instantly impressive on first meeting but eventually turn out to be insatiably desirous of so much of this mirroring that they overwhelm the therapist. Freud suggested that insight is necessary and sufficient for the cure in therapy.

2. To what extent does your insight on your narcissism moderate or “cure” or help you to manage your pathological expression of it? To what extent do you believe that insight is sufficient for the “cure” in your case?

3. Do you really wish to moderate your narcissistic tendencies or do you feel that they serve you reasonably well in the general cut and thrust of life?

A. Thank you for (1). Yes, the narcissist’s need for narcissistic supply (the mirroring of his perfect, brilliant, omniscient, and omnipotent False Self) is insatiable and overwhelming. He perceives everyone around him – his therapist included and especially – as potential or actual sources of narcissistic supply. It is a delicate balancing act: not giving the narcissist his “due” is likely to alienate and enrage him (he has a strong sense of entitlement, often incommensurate with his real-life achievements), give him too much supply and he clings and extorts. Either way, the therapy is doomed.

Regarding (2): Cognitive understanding of the disorder does not constitute a transforming INSIGHT. In other words, it has no emotional correlate. I did not INTERNALIZE what I have leaned and what I know and understand about my disorder. This new gained knowledge did not become a motivating part of me. It remains an inert and indifferent piece of “wisdom”, with minor influence on my psyche. When I first found out about the Narcissistic Personality Disorder (NPD), I really believed that I could change. I fervently wanted to. This was especially true since my whole world was in shambles. Time in prison, a divorce, a bankruptcy, a death of a major source of narcissistic supply are all transforming life crises. I admitted to my problem only having been abandoned, having been rendered destitute, and devastated. I felt that I don’t want any more of this. I wanted to change. And there often were signs that I am changing. And then it faded. I reverted to old form. The “progress” I had made was ephemeral: it evaporated virtually overnight. Many narcissists report the same process of progression followed by recidivist remission and many therapists refuse to treat narcissists because of the Sisyphean frustration involved. I never said that narcissists cannot CHANGE – only that they cannot HEAL. There is a huge difference between behavior modification and a permanent alteration of the psychodynamic landscape. Narcissistic behavior CAN be modified using a cocktail of talk therapy, conditioning, and medication. I have yet to encounter a healed narcissist, though. The emphasis in therapy should thus be placed on accommodating the needs of those closest to the narcissist: spouse, children, colleagues, friends, not on “treating” the narcissist. When the narcissist’s abrasiveness, rage, mood swings, reckless and impulsive behaviors are modified, those around him benefit most. The narcissist’s therapy should devolve into a form of social engineering.

Finally, with respect to your point (3) above:

The narcissist can get better, but rarely does he get well (“heal”). The reason is the narcissist’s enormous life-long, irreplaceable and indispensable emotional investment in his disorder. It serves two critical functions, which together maintain the precariously balanced house of cards called the narcissist’s personality. His disorder endows the narcissist with a sense of uniqueness, of “being special” and it provides him with a rational explanation of his behaviour (an “alibi”). Narcissism is, therefore, a successful adaptive strategy. Thus, paradoxically, the disorder becomes an integral and inseparable part of the narcissist’s inflated self-esteem and vacuous grandiose fantasies.

His False Self (the pivot of his pathological narcissism) is a self-reinforcing mechanism. The narcissist thinks that he is unique BECAUSE he has a False Self. His False Self IS the centre of his “specialness”. Any therapeutic “attack” on the integrity and functioning of the False Self constitutes a threat to the narcissist’s ability to regulate his wildly fluctuating sense of self-worth and an effort to “reduce” him to other people’s mundane and mediocre existence.

The few narcissists that are willing to admit that something is terribly wrong with them, displace their alloplastic defences. Instead of blaming the world, other people, or circumstances beyond their control – they now blame their “disease”. Their disorder become a catch-all, universal explanation for everything that is wrong in their lives and every derided, indefensible and inexcusable behaviour. Their narcissism becomes a “licence to kill”, a liberating force which sets them outside human rules and codes of conduct. Such freedom is so intoxicating and empowering that it is difficult to give up. The narcissist is emotionally attached to only one thing: his disorder. The narcissist loves his disorder, desires it passionately, cultivates it tenderly, is proud of its “achievements” (and in my case, makes a living off it). His emotions are misdirected. Where normal people love others and empathize with them, the narcissist loves his False Self and identifies with it to the exclusion of all else – his True Self included.

Q. If, as you suggest, recidivism is endemic among narcissists and it is a growing problem in the institutions of modern society, do you think there would there be any value in considering more broad-based – even public health-oriented – initiatives that might help to curb the most maladaptive behaviour of pathological narcissists? If so, what would you imagine might be most effective?

A. Governments maintain registries of sex offenders and impose a variety of restrictions on them. Similarly, the authorities should maintain registries of people diagnosed with antisocial, narcissistic, and borderline personality disorders (as well as paranoid-schizophrenics and anyone else whose mental disability may harm society). They should impose limitations on their freedoms. Like sex offenders, albeit owing to different reasons, narcissists and psychopaths are highly recidivistic, lack remorse or empathy, and are predatory. Like sex offenders, they blend well with “normal” people and, like them, they constitute a clear and present danger to their milieu.

The risk of stigmatizing the sick should be offset against concerns of public safety. The risk of driving people away from seeking professional help when they most need it is not great with narcissists and psychopaths: they rarely seek help, or attend therapy. The benefits to society from monitoring these incorrigible misfits and from denying them their “hunting fields” would be immense even in the short-term.

Q. Do you trust the diagnostic systems used to identify pathologically narcissistic people and the medical professionals who use them enough to accurately sort the “bad” narcissists from the “healthy” ones? Is there not a danger of the inherently subjective nature of personality disorder diagnosis prejudicing some people who might fall on the right side of the alleged borderline between pathological and healthy?

A. Narcissists and psychopaths are unlikely to come to the attention of mental health practitioners and be diagnosed unless they have committed some transgression, or have ruined their own lives and the lives of people around them completely. Thus, psychological testing in these cases is likely to be augmented by “anamnetic” case history. More generally, I trust structured interviews and tests such as the MMPI-II to reveal the truth and to be resistant to attempts at manipulation. Don’t forget that narcissists and psychopaths do not feel that they have anything to hide: they are actually proud of their traits and behaviour patterns! They are unlikely to “fake” it for long. Admittedly, pathological narcissism is a spectrum and only the most extreme patients (malignant and psychopathic narcissists), who constitute a clear and present danger to their environment, should be registered and restrained.


One Response

  1. The Narcissist in Therapy…

    I found your entry interesting do I’ve added a Trackback to it on my weblog :)…

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