8
Narcissistic Personalities
The term “narcissistic” refers to people whose personalities are organized around maintaining their self-esteem by getting affirmation from outside themselves. All of us have vulnerabilities in our sense of who we are and how valuable we feel, and we try to run our lives so that we can feel good about ourselves. Our pride is enhanced by approval and injured by disapproval from significant others. In some of us, concerns with “narcissistic supplies,” or supports to self-esteem, eclipse other issues to such an extent that we may be considered excessively self-preoccupied. Terms like “narcissistic personality” and “pathological narcissism” apply to this disproportionate degree of self-concern, not to ordinary responsiveness to approval and sensitivity to criticism.
Narcissism, normal as well as pathological, is a topic to which Freud (1914a) gave recurrent attention. He borrowed the term from the Greek myth of Narcissus, the youth who fell in love with his reflection in a pool of water and eventually died of a kind of longing that his image could never satisfy. Yet Freud had little to say about therapy for those in whom narcissistic concerns are central. Alfred Adler (e.g., 1927) and Otto Rank (e.g., 1929) both wrote on topics we would now include under narcissism, but their respective estrangements from Freud made their work unfamiliar to many therapists. Since the early psychoanalytic era, it has been noted that some people have problems with self-esteem that are hard to construe solely in terms of drives and unconscious conflicts, and are correspondingly hard to treat by reference to conflict-based models of therapy. A deficit model seems to fit their experience better: There is something missing from their inner lives.
Preoccupied with how they appear to others, narcissistically organized people may privately feel fraudulent and loveless. Ways of helping them to develop self-acceptance and to deepen their relationships awaited the expansion of dynamic psychology into areas that Freud had only begun to touch. Attention to concepts like basic security and identity (Erikson, 1950, 1968; Sullivan, 1953); the self as opposed to the more functionalist concept of the ego (Jacobson, 1964; Winnicott, 1960b); self-esteem regulation (A. Reich, 1960); attachment and separation (Bowlby, 1969, 1973; Spitz, 1965); developmental arrest and deficit (Kohut, 1971; Stolorow & Lachmann, 1978); shame (H. B. Lewis, 1971; Lynd, 1958; Morrison, 1989); and affect regulation, trauma, and attachment (Banai, Mikulincer, & Shaver, 2005; Schore, 2002) contributed to our understanding of narcissism.
As new theoretical areas were explored in the post-Freudian years, old areas were reworked, leading to improvements in treating narcissistic problems. Much ferment followed challenges by object relations theorists (Balint, 1960; Fairbairn, 1954; Horney, 1939) to Freud’s concept of “primary narcissism,” the assumption that the infant cathects (invests emotionally in) self before others. Thinkers who stressed primary relatedness understood narcissistic pathology not as fixation on normal infantile grandiosity but as compensatory for early disappointments in relationship. Around the same time, notions like containment (Bion, 1967), the holding environment (Modell, 1976; Winnicott, 1960b), and mirroring (Kohut, 1968; Winnicott, 1967) were redefining theories of therapy. These ideas were more applicable than earlier models of psychopathology and treatment to people for whom the continuity of a sense of self, and the feelings of reasonable worth attached to it, are fundamentally problematic.
It is also likely that when Freud was writing, narcissistic problems of the kind that are epidemic today were less common. Psychoanalytically influenced social theorists (e.g., Cushman, 1995; Fromm, 1947; Hendin, 1975; Lasch, 1978, 1984; Layton, 2004; Slater, 1970) have argued that the vicissitudes of contemporary life reinforce narcissistic concerns. The world changes rapidly; we move frequently; mass communications exploit our insecurities and pander to our vanity and greed; secularization dilutes the internal norms that religious traditions once provided. In mass societies and in times of rapid change, the immediate impression one makes may be more compelling than one’s integrity and sincerity, qualities that are prized in smaller, more stable communities where people know each other well enough to make judgments based on someone’s history and reputation. In the United States, a climate of narcissistic absorption may not be a particularly recent phenomenon. In 1831, Alexis de Tocqueville (2002) noted that a society that touts equality of opportunity leaves citizens concerned with how to demonstrate their claim to special worth. Without a class system to provide visible levels of status, they try to accumulate observable evidence of their superiority, as inferiority would be equated with personal failure.
Many of Freud’s patients suffered from too much internal commentary about their goodness or badness, a condition he came to depict as reflecting a “harsh superego.” Contemporary clients, in contrast, often feel subjectively empty rather than full of critical internalizations; they worry that they “don’t fit in” rather than that they are betraying their principles, and they may ruminate about observable assets such as beauty, fame, wealth, or the appearance of political correctness rather than more private aspects of their identity and integrity. Image replaces substance, and what Jung (1945) called the persona (the self one shows to the world) becomes more vivid and dependable than one’s actual person.
Ernest Jones (1913) may have been the first analytic writer to describe the more overtly grandiose narcissistic person. He depicted a man characterized by exhibitionism, aloofness, emotional inaccessibility, fantasies of omnipotence, overvaluation of his creativity, and a tendency to be judgmental. He portrayed such individuals as on a continuum from psychotic to normal, commenting that “when such men become insane they are apt to express openly the delusion that they actually are God, and instances of the kind are to be met within every asylum” (p. 245). W. Reich (1933) devoted a section of Character Analysis to the “phallic–narcissistic character,” represented as “self-assured ... arrogant ... energetic, often impressive in his bearing ... [who] will usually anticipate any impending attack with an attack of his own” (pp. 217–218). This familiar type appears in its essentials in the DSM-IV criteria for narcissistic personality disorder.
As psychoanalytic observations of personality continued, it became clear that the overtly grandiose personality was only one form of a “disorder of the self” (Kohut & Wolf, 1978). Current analytic conceptualization recognizes many different external manifestations of a core difficulty with identity and self-esteem. Bursten (1973b) suggested a typology of narcissistic personalities that includes craving, paranoid, manipulative, and phallic narcissistic subvarieties. Many have noted that in every vain, grandiose narcissist hides a self-conscious, shame-faced child, and in every depressed and self-critical narcissist lurks a grandiose vision of what that person should or could be (Meissner, 1979; A. Miller, 1975; Morrison, 1983). Repeatedly, the clinical literature has distinguished between two versions of narcissism, variously dubbed the “oblivious” versus the “hypervigilent” type (Gabbard, 1989), the overt versus the covert or “shy” type (Akhtar, 2000); the exhibitionistic versus the “closet” type (Masterson, 1993), and (my personal favorite) the “thick-skinned” versus the “thin-skinned” type (Rosenfeld, 1987). Pharis (2004) has described a “virtuous narcissist,” often an inspiring political figure, who accomplishes great things but quietly lets an associate take blame for any mistakes.
What narcissistic people of all appearances have in common is an inner sense of, and/or terror of, insufficiency, shame, weakness, and inferiority (Cooper, 1984). Their compensatory behaviors might diverge greatly yet still reveal similar preoccupations. Hence, individuals as different as Janis Joplin and Socrates’s problematic student Alcibiades might be reasonably viewed as narcissistically organized.
DRIVE, AFFECT, AND TEMPERAMENT IN NARCISSISM
I am not aware of research on the topic of constitutional and temperamental contributions to narcissistic personality organization in adulthood. Unlike antisocial people, who pose obvious and costly problems to society and therefore prompt funding for scientific investigation into psychopathy, narcissistic individuals are quite diverse, often subtle in their pathology, and not so patently damaging. Successful narcissistic people (monetarily, socially, politically, militarily, or however their success is manifested) may be admired and emulated. The internal costs of narcissistic hunger for recognition are rarely visible to onlookers, and injuries done to others in the pursuit of narcissistically driven projects may be rationalized as trivial or necessary side effects of competence (“You can’t make an omelet without breaking eggs”). Also, recognition of more subtle kinds of narcissism as treatable character problems is an achievement of only the past few decades.
Although Shedler and Westen’s work (e.g., 2010) establishes that therapists are quite reliable in identifying narcissistic dynamics, most of our ideas about etiology are still untested, clinically generated hypotheses. One of these is that people at risk for developing a narcissistic character structure may be constitutionally more sensitive than others to unverbalized emotional messages. Specifically, narcissism has been associated with the kind of infant who seems preternaturally attuned to the unstated affects, attitudes, and expectations of others. Alice Miller (1975) suggested, for example, that many families contain one child whose natural intuitive talents are unconsciously exploited by his or her caregivers for the maintenance of their self-esteem and that this child grows up confused about whose life he or she is supposed to lead. Miller believed that such gifted children are more likely than untalented youngsters to be treated as “narcissistic extensions” of their caregivers and are hence more apt to become narcissistic adults.
On a different note, in discussing entitled, grandiose narcissistic clients, Kernberg (1970) has suggested that they may have either an innately strong aggressive drive or a constitutionally determined lack of tolerance for anxiety about aggressive impulses. Such dispositions would partially explain the lengths to which narcissistic people may go to avoid acknowledging their own drives and appetites: They may be scared of their power. Beyond these speculations, we know little about temperamental propensities that may contribute to a narcissistic character structure.
As for the main emotions associated with narcissistic personality organization, shame and envy are recurrently stressed in the clinical literature (e.g., Steiner, 2006). Feelings of shame and fears of being shamed pervade the subjective experience of narcissistic people. The early analysts underestimated the power of this emotional state, often mistaking it for guilt and making guilt-oriented interpretations that narcissistic patients found unempathic. Guilt is the conviction that one is sinful or has committed wrongdoings; it is easily conceptualized in terms of an internal critical parent or the superego. Shame is the sense of being seen as bad or wrong; the audience here is outside the self. Guilt carries with it a sense of an active potential for evil, whereas shame has connotations of helplessness, ugliness, and impotence.
The narcissistic person’s vulnerability to envy is a related phenomenon, one that Melanie Klein’s work illuminates (Segal, 1997). If I have an internal conviction that I am lacking in some way and that my inadequacies are at constant risk of exposure, I will be envious toward those who seem content or who have assets that I believe would make up for what I lack. Envy may also be the root of the much-noted judgmental quality of narcissistically organized persons, toward themselves and toward others. If I feel deficient and I perceive you as having it all, I may try to destroy what you have by deploring, scorning, or ridiculing it.
DEFENSIVE AND ADAPTIVE PROCESSES IN NARCISSISM
Narcissistically structured people may use a whole range of defenses, but the ones they depend on most fundamentally are idealization and devaluation. These processes are complementary, in that when the self is idealized, others are devalued, and vice versa. Kohut (1971) originally used the term “grandiose self” to capture the sense of self-aggrandizement and superiority that characterizes one polarity of the inner world of narcissistic people. This grandiosity may be felt internally, or it may be projected. There is a constant “ranking” process that narcissistic people use to address any issue that faces them: Who is the “best” doctor? What is the “finest” preschool? Where is the “most rigorous” training? Realistic advantages and disadvantages may be completely overridden by concerns about comparative prestige.
For example, a woman I know was determined that her son would go to the “best” college. She took him to see several exclusive schools, pulled strings where she had any, and even wrote thank-you notes to deans of admission with whom he had interviewed. By mid-April, he had been accepted by several excellent colleges and universities, and he was on the waiting list at Yale. Her response was a sense of devastation that he had been rejected by Harvard. The young man elected to attend Princeton. Throughout his freshman year, his mother badgered Harvard to take him as a transfer student. Although he thrived at Princeton, when Harvard finally capitulated to his mother’s relentless entreaties, there was no question about his destination.
The subordination of other concerns to issues of general valuation and devaluation is of note here. This mother knew that professors in her son’s chosen field considered Harvard inferior to Princeton in that area; she also knew that Harvard undergraduates tend to receive less attention than those at Princeton; and she was aware that her son would suffer socially at Harvard for missing his freshman year there. Nevertheless, she persisted. Although she did not have a diagnosable narcissistic personality disorder, this woman used her son as a narcissistic extension in this instance because she had a defensive belief system that included the conviction that her own life would have been dramatically transformed had she gone to Radcliffe, the “sister” school to Harvard and the “best” school for women at the time she was applying to college.
In an instance where a parent’s valuation and devaluation were characterological, a patient of mine, a college student with artistic and literary sensibilities, was told by his grandiose father that he would support his becoming a doctor (preferably) or a lawyer (if he proved untalented in the natural sciences), but nothing else. Medicine and law would bring in money and command respect; any other career would reflect badly on the family. Because this young man had been treated like a narcissistic extension his whole life, he saw nothing unusual in his father’s position, which is culturally quite aberrant in the United States.
A related defensive position in which narcissistically motivated people are trapped concerns perfectionism. They hold themselves up to unrealistic ideals and either convince themselves that they have attained them (the grandiose outcome) or respond to their falling short by feeling inherently flawed rather than forgivably human (the depressive outcome). In therapy, they may have the ego-syntonic expectation that the point of undergoing treatment is to perfect the self rather than to understand it and to find more effective ways of handling its needs. The demand for perfection is expressed in chronic criticism of self or others (depending on whether or not the devalued self is projected) and in an inability to find joy amid the ambiguities of human existence.
Sometimes narcissistic people handle their self-esteem problem by regarding someone else—a lover, a mentor, a hero—as perfect and then feeling inflated by identification with that person (“I am an appendage of So-and-so, who can do no wrong”). Some have lifelong patterns of idealizing someone and then sweeping that idol off the pedestal when an imperfection appears. Perfectionistic solutions to narcissistic dilemmas are inherently self-defeating: One creates exaggerated ideals to compensate for defects in the sense of self that are felt as so contemptible that nothing short of perfection will make up for them, and yet, since no one is perfect, the strategy is doomed, and the depreciated self emerges again.
RELATIONAL PATTERNS IN NARCISSISM
From this description of some of their dynamics, the reader has probably already concluded that relationships between narcissistic people and others are overly burdened with the self-esteem issues of the narcissistic party. Although it is rare for someone with a narcissistic personality disorder to come to therapy with the explicit agenda of becoming a better friend or family member or lover, it is not uncommon for clients with this problem, especially in midlife or later, to be aware that something is wrong in their interactions with others. One problem in helping them is conveying to them what it would be like to accept a person nonjudgmentally and nonexploitively, to love others as they are, without idealizing, and to express genuine feelings without shame. Narcissistic people may have no concept of such possibilities; the therapist’s acceptance of them can become the prototype for their emotional understanding of intimacy.
Self psychologists have coined the term “selfobjects” for the people in our lives who support our self-esteem by their affirmation, admiration, and approval (see Basch, 1994). The term reflects the fact that individuals in that role function as objects outside the self and also as part of one’s self-definition. By helping to modulate self-esteem, they augment what most of us also do internally. We all have selfobjects, and we need them. If we lose them we feel diminished, as if some vital piece of us has died. Yet reality and morality require that others be more than selfobjects, that we recognize them (Benjamin, 1988) in terms of who they are and what they need, not just in terms of what they do for us.
The narcissistic person needs selfobjects so greatly that other aspects of relationship pale, and may even be unimaginable, as they were to my client whose father would not support his being anything but a doctor or lawyer. Thus, the most grievous cost of a narcissistic orientation is a stunted capacity to love. Despite the importance of other people to the equilibrium of a narcissistic person, his or her consuming need for reassurance about self-worth leaves no energy for others except in their function as selfobjects and narcissistic extensions. Hence, narcissistic people send confusing messages to their friends and families: Their need for others is deep, but their love for them is shallow. Symington (1993) believes that the ultimate cause of this deficit is a child’s having repudiated, for whatever reason, the original emotional “lifegiver,” with the long-term consequence of internal deadness and incapacity to find one’s vitality.
Some theorize that people get this way by having been used as narcissistic appendages themselves. Narcissistic clients may have been vitally important to parents or other caregivers, not because of who they really were but because of the function they fulfilled. The confusing message that one is highly valued, but only for a particular role that one plays, makes children worry that if their real feelings, especially hostile or selfish ones, are visible, rejection or humiliation will follow. It fosters the development of what Winnicott (1960a) called the “false self,” the presentation of what one has learned is acceptable. A crucial difference between the etiologies of psychopathy and narcissism may be that whereas antisocial psychology derives from overt abuse and neglect, narcissistic psychology springs from a particular kind of attention or even doting, in which support is given on the implicit condition that the child cooperate with a parent’s narcissistic agenda.
I assume that most parents regard their children with a combination of narcissistic needs and true empathy. In moderation, children enjoy being treated as narcissistic extensions. Making parents feel proud, as if they also have been admired when their son or daughter gets recognition, is one of the sweeter pleasures of childhood. As usual, the issue is one of degree and balance: Does the child also get attention unrelated to whether the parent’s aims are furthered? A markedly non-narcissistic attitude toward offspring informs the remarks of a now-deceased friend of mine who reared 12 children during the 1930s, all of whom have turned out well despite borderline poverty and some painful losses:
“Every time I’d get pregnant, I’d cry. I’d wonder where the money would come from, how I was going to nurse this child and take care of everything else. But around the fourth month I’d begin to feel life, and I’d get all excited, thinking, ‘I can’t wait till you come out and I find out who you are!’ ”
I quote this to contrast her sentiments with those of a prospective parent who “knows” who the child is going to be: Someone to be molded by the parent into a person who realizes all the parent’s failed ambitions and brings reflected glory to the family.
A related aspect of the upbringing of people who become narcissistic is a family atmosphere of constant evaluation. If I have an agenda for a child that is vital to my own self-esteem, then every time that child disappoints me, I will be implicitly or explicitly critical. I doubt that anyone has ever brought up a child without criticism, but the background message that one is not good enough in some vague way is quite different from specific feedback on behaviors that offend. An evaluative atmosphere of perpetual praise and applause, which one finds in some families with narcissistic children, is equally damaging to the development of realistic self-esteem. The child is always aware of being judged, even if the verdict is positive. He or she knows on some level that there is a false quality to the attitude of constant admiration, and despite the conscious sense of entitlement that may issue from such a background, it creates a nagging worry that one is a bit of a fraud, undeserving of this adulation that seems tangential to who one really is. Fernando (1998) has argued that overindulgence of this kind is the primary etiology of pathological narcissism. Fiscalini (1993), noting different versions of narcissistic orientation, identified the shamed child, the spoiled child, and the special child as precursors of pathological narcissism in adulthood.
Thus we see again how certain character structures can be “inherited,” though parents do not have to have narcissistic personalities themselves to rear a son or daughter who is disturbed narcissistically. Parents may have narcissistic needs toward a particular child (as in the case of the woman whose son had to go to Harvard) that set the stage for that child’s not being able to discriminate between genuine feelings and efforts to please or impress others. What is a nonissue to one parent is a central one to another. We all want for our children the things we lacked, a harmless desire as long as we spare them any pressure to live their lives for our sakes.
Martha Wolfenstein gave us an interesting glimpse of narcissistic processes in a 1951 article “The Emergence of Fun Morality,” depicting how liberal intellectual New Yorkers in the postwar era, having grown up during hard times, gave their children the message that they should feel bad about themselves if they were not having fun. People whose options were drastically curtailed by some disaster such as war or persecution are apt to send signals that their children should live the life they never had. Frequently, the children of traumatized parents grow up with some identity confusion and feelings of vague shame and emptiness (see Bergmann, 1985; Fogelman, 1988; Fogelman & Savran, 1979). The communication that “unlike me, you can have it all” is particularly destructive, in that no one can have it all; every generation will face its own constraints. For self-esteem to be contingent on such an unrealistic goal is a crippling inheritance.
THE NARCISSISTIC SELF
I have already alluded to many of the self-experiences of people who are diagnosably narcissistic. They include a sense of vague falseness, shame, envy, emptiness or incompleteness, ugliness, and inferiority, or their compensatory counterparts: self-righteousness, pride, contempt, defensive self-sufficiency, vanity, and superiority. Kernberg (1975) describes such polarities as opposite ego states, grandiose (all-good) versus depleted (all-bad) definitions of self, which are the only options narcissistic persons have for organizing their inner experience. The sense of being “good enough” is not one of their internal categories.
Narcissistically structured people are aware at some level of their psychological fragility. They are afraid of falling apart, of precipitously losing their self-esteem or self-coherence (e.g., when criticized), and abruptly feeling like nobody rather than somebody (Goldberg, 1990b). They sense that their identity is too tenuous to hold together and weather some strain. Their fear of the fragmentation of their inner self is often displaced into a preoccupation with their physical health; thus, they are vulnerable to hypochondriacal preoccupations and morbid fears of death.
One subtle outcome of the perfectionism of narcissistic people is the avoidance of feelings and actions that express awareness of either personal fallibility or realistic dependence on others. In particular, remorse and gratitude are attitudes that narcissistic people tend to deny (McWilliams & Lependorf, 1990). Remorse about some personal error or injury includes an admission of defect, and gratitude for someone’s help acknowledges one’s need. Because narcissistic individuals try to build a sense of self on the illusion of not having failings and not being in need, they fear that the admission of guilt or dependency exposes something unacceptably shameful. Sincere apologies and heartfelt thanks, the behavioral expressions of remorse and gratitude, may thus be avoided or compromised in narcissistic people, to the great impoverishment of their relationships with others.
By definition, the assessment of narcissistic personality organization conveys that the client needs external affirmation in order to feel internal validity. Theorists diverge rather strikingly in whether they stress the grandiose or the depleted aspects of narcissistic self-experience, a difference of emphasis central to the disagreement between Kernberg and Kohut on how to understand and treat narcissistic characters, about which I say more later. Disputes on this question go back at least as far as differences of opinion between Freud (1914b), who stressed the individual’s primary love of self, and Alfred Adler (1927), who emphasized how narcissistic defenses compensate for feelings of inferiority. Which came first in the evolution of pathological narcissism, the grandiose self-state or the depleted, shamed one, may be the psychoanalytic equivalent of a chicken–egg riddle. From a phenomenological standpoint, these contrasting ego states are intimately connected, much as depression and mania are opposite sides of the same psychological coin.
TRANSFERENCE AND COUNTERTRANSFERENCE
WITH NARCISSISTIC PATIENTS
The transference environment with narcissistic clients feels qualitatively different from what one feels with clients who lack pathological narcissism. Even the highest-functioning, most cooperative person with a narcissistic character may contribute to an ambiance in the therapeutic relationship that contrasts sharply with the atmosphere that emerges between the therapist and other clients. Typically, the therapist first notices the patient’s lack of interest in exploring the therapeutic relationship. The early psychoanalysts noted this and concluded that narcissistic patients did not have transferences because all their libidinal energy was directed toward the self; this was another basis for doubting that they were treatable. Contemporary analytic theory acknowledges that narcissistic clients do have transference reactions but of a different sort from those of other patients.
Inquiries into how the client is feeling toward the clinician may be received as distracting, annoying, or irrelevant to the client’s concerns. It is not unusual for narcissistic patients to conclude that the therapist is asking about their experience of the therapeutic relationship out of conceit or a need for reassurance. (Such silent hypotheses may be projections, of course, even if true, but they tend to be unverbalized, and they can rarely be usefully addressed, at least early in treatment.) This does not mean that narcissistic patients lack strong reactions to the therapist. They may devalue or idealize intensely. Yet they are curiously uninterested in the meaning of those reactions and are genuinely confused about why the clinician is asking about them. Their transferences may be so ego syntonic as to be inaccessible to exploration. A narcissistic patient may believe he or she is devaluing the therapist because the therapist is objectively second-rate or idealizing the therapist because the therapist is objectively wonderful. Efforts to make such reactions ego alien will usually fail, at least initially: The devalued practitioner who comments on the patient’s critical attitude will be perceived as defensive, and the idealized one who comments on the patient’s overvaluation will be further idealized as someone whose perfection includes an admirable humility.
Beginning therapists get a lot more devaluing transferences than idealizing ones. It may be some consolation for the misery one endures at being the object of subtle and relentless disparagement that being the recipient of a narcissistic idealizing transference is not much better. In both circumstances one may feel that one’s realistic existence as a human being with some emotional intelligence, who is sincerely trying to help, has been extinguished. In fact, this countertransference sense of having been obliterated, of having been made invisible as a real person, is diagnostic of a probable narcissistic dynamic.
Related to these phenomena are countertransferences that include boredom, irritability, sleepiness, and a vague sense that nothing is happening in the treatment. A typical comment about a narcissistic client from a therapist in supervision: “She comes in every week, gives me the news of the week in review, critiques my clothing, dismisses all my interventions, and leaves. Why does she keep coming back? What is she getting out of this?” A strange sense that one does not quite exist in the room is common. Extreme drowsiness is perhaps the most unpleasant of the countertransference reactions to narcissistic patients; every time I experience this, I find myself generating biological explanations (“I didn’t get enough sleep last night”; “I just ate a big lunch”; “I must be coming down with a cold”), and then once that patient is out the door and another one is inside, I am wide awake and interested. Occasionally one’s countertransference to an idealizing person is a sense of grandiose expansion, of joining the patient in a mutual admiration society. But unless the therapist is also characterologically narcissistic, such reactions are both unconvincing and short-lived.
The psychoanalytic explanation for these phenomena relates to the special kind of transference characteristic of narcissistic people. Rather than projecting a discrete internal object such as a parent onto the therapist, they externalize an aspect of their self. Specifically, instead of feeling that the therapist is like mother or father (although sometimes one can see aspects of such transferences), the client projects either the grandiose or the devalued part of the self. The therapist thus becomes a container for the internal process of self-esteem maintenance. He or she is a selfobject, not a fully separate person who feels to the patient like a previously known, well-delineated figure from the past.
To be used for a self-esteem maintaining function rather than perceived as a separate person is disconcerting, even unnerving. The dehumanizing effect of the narcissistic person’s attitude accounts for some of the negative countertransference reactions therapists have described in connection with treating such clients. Yet most therapists also report that they can tolerate, control, and derive empathy from such internal reactions once they understand them as comprehensible and expectable features of working with narcissistic patients. The disposition to feel flawed as a therapist is a virtually inevitable mirror of the patient’s core worries about self-worth; it is relieving to substitute a revised clinical formulation for ruminations about what one is doing wrong.
Heinz Kohut and other analysts influenced by the self psychology movement (e.g., Bach, 1985; Buirski & Haglund, 2001; Rowe & MacIsaac, 1989; Stolorow, Brandchaft, & Atwood, 1987; E. S. Wolf, 1988) have described several subtypes of selfobject transferences that may appear in narcissistic patients, including mirroring, twinship, and alter-ego patterns, and many scholars have found parallels between these concepts and contemporary infant research (Basch, 1994). Although I cannot do justice to the complexity of such ideas here, readers who find that the description of narcissistic personality fits a patient they have previously been construing some other way may find it helpful to explore the language of self psychologists for conceptualizing their clients’ experience.
THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF NARCISSISM
A therapist who is able to help a narcissistic person to find self-acceptance without either inflating the self or disparaging others has done a truly good deed, and a difficult one. A primary requisite for treating narcissistic pathology is patience: No one with a track record for influencing the psychology of narcissistic patients has done it very fast. Although modification of any kind of character structure is a long-term undertaking, the requirement of patience may be more keenly felt with narcissistic clients than with those of other character types because of one’s having to endure countertransference reactions of boredom and demoralization.
Because there are competing theories of etiology and therapy, it is hard to summarize psychodynamic wisdom about treating narcissistic patients. Most arguments are variants on a complex disagreement between Kohut and Kernberg that appeared in the 1970s and 1980s. The gist of their respective positions was that Kohut (1971, 1977, 1984) saw pathological narcissism developmentally (the patient’s maturation was going along normally and ran into some difficulties in the resolution of normal needs to idealize and deidealize), while Kernberg (1975, 1976, 1984) viewed it structurally (something went askew very early, leaving the person with entrenched primitive defenses that differ in kind rather than in degree from normality: “Pathological narcissism reflects libidinal investment not in a normal integrated self-structure but in a pathological self-structure [1982, p. 913]). Kohut’s conception of a narcissistic person can be imaged as a plant whose growth was stunted by too little water and sun at critical points; Kernberg’s narcissist can be viewed as a plant that has mutated into a hybrid.
A consequence of their differing theories is that some approaches to narcissism stress the need to give the plant plenty of water and sun so that it will finally thrive, and others propose that it must be pruned of its aberrant parts so that it can become what it should have been. Those more responsive to Kohut’s formulation (e.g., 1971, 1977) recommend benign acceptance of idealization or devaluation and unwavering empathy for the patient’s experience. Kernberg (e.g., 1975, 1976) advocates the tactful but insistent confrontation of grandiosity, whether owned or projected, and the systematic interpretation of defenses against envy and greed. Self psychologically oriented therapists try to remain inside the patient’s subjective experience, whereas analysts influenced by ego psychology and object relations theory oscillate between internal and external positions (see Gardner, 1991).
Most analysts I know have patients for whom Kohut’s formulations, both etiological and therapeutic, seem to fit and others for whom Kernberg’s seem apt. Kernberg has suggested that Kohut’s approach might be considered a subtype of supportive therapy, and hence appropriate for narcissistic patients in the borderline-to-psychotic range (even though Kohut’s clinical work, unlike Kernberg’s, was mostly with high-functioning patients). This idea is implicitly endorsed by many of my colleagues, who say they find Kohut’s recommendations applicable to their more disturbed and depressed–depleted narcissistic clients. Because the jury is still out on the dispute, and because readers can consult the original sources for recommendations about overall approach, I offer some general suggestions on the treatment of narcissism that exist outside this controversy.
I have already mentioned patience. Implicit in that attitude is an acceptance of human imperfections that make therapeutic progress a tedious and taxing business. The matter-of-fact assumption that we are all imperfect and resistant to change contrasts sharply with what the narcissistic person has internalized. Such an attitude is humane and realistic rather than critical and omnipotent. Some therapeutic mileage is already inherent in such a position. Although humility is important to all clinical work, it is particularly critical when one works with narcissistic patients that therapists embody a nonjudgmental, realistic attitude toward their own frailties.
One of Kohut’s greatest contributions to practice (Kohut, 1984) was his attention to the consequences of the therapist’s acknowledgment of errors, especially of lapses in empathy. According to the ego psychologists who preceded him (e.g., Greenson, 1967), a therapist’s mistake need not impel any activity other than private reflection; the patient is simply encouraged, as always, to associate to what happened and to report any reactions. Even Carl Rogers (1951), who had advocated a style almost identical to Kohut’s later recommendations (Stolorow, 1976), seems not to have assumed, as Kohut did, that well-meaning therapists would inevitably inflict narcissistic injuries on clients. Thus, client-centered therapy did not address whether to acknowledge such errors—though I read Rogers’s principle of authenticity as implying that they should. Self psychologists have called our attention to how devastated a narcissistic person can be by a professional’s failure of empathy, and how the only way to repair such an injury is by expressing regret. An apology both confirms the client’s perception of mistreatment (thereby validating his or her real feelings rather than furthering the insincere compliance with which narcissistic people are used to operating) and sets an example of maintaining self-esteem while admitting to shortcomings.
It is important not to become excessively self-critical when acknowledging one’s inevitable errors. If the patient perceives that the therapist is in an agony of remorse, the message that may be received is that mistakes should be rare and require stern self-censure—a delusion from which the narcissistic person is already suffering. It is better to take one’s cue from Winnicott, who is reputed to have fielded a query about his rules for interpretation with the comment: “I make interpretations for two purposes. One, to show the patient that I am awake. Two, to show the patient that I can be wrong.” Similarly, Arthur Robbins (personal communication, April 1991), a psychoanalyst with expertise in art therapy and other expressive modes of treatment, describes his theory of technique as “Fuck-up therapy: I fuck up, and the patient corrects me.” Contemporary relational writing (e.g., Kieffer, 2007), drawing on research with infants (Beebe & Lachmann, 1994), emphasizes the centrality to all therapy of what Kohut (1984) deemed the inevitable “rupture and repair” process; I think this process is especially central to the treatment of people with characterological narcissism.
Attempts to help a narcissistic patient also require a constant mindfulness of the person’s latent self-state, however overwhelming the manifest one is. Because even the most arrogant, entitled narcissist is subject to excruciating shame in the face of what feels like criticism, therapists must take pains to frame interventions sensitively. True mutuality with narcissistic clients is tenuous because they cannot tolerate circumstances in which their fragile self-esteem is diminished. Their early reputation for being impossible to treat derived partly from analysts’ experience with their abruptly terminating therapies of even several years’ duration when their feelings were hurt.
I have mentioned the power of shame in the experience of the narcissistic person, and the value of the therapist’s discriminating between shame and guilt. People with fragile self-esteem may go to great lengths to avoid acknowledging their role in anything negative. Unlike people who easily feel guilty and who handle their transgressions with efforts at reparation, narcissistically motivated people run from their mistakes and hide from those who would find them out. They may induce in therapists either a disposition to confront them unempathically about their own contributions to their difficulties or a tendency to join them in bemoaning the bad deal they have gotten from others. Neither position is therapeutic, although the second is temporarily palliative to a person who otherwise may suffer chagrin bordering on mortification.
Because of their devastation when their imperfections are visible, narcissistic individuals tend to use obfuscating language that implicitly disowns personal responsibility (“Mistakes were made”). The therapist faces the daunting task of expanding the narcissistic patient’s awareness of, and honesty about, the nature of his or her behavior without stimulating so much shame that the person either leaves treatment or keeps secrets. One way to do this in the context of a client’s complaints and criticisms about others is to ask, “Did you make your needs explicit?” The rationale for this query is that narcissistic people have deep shame about asking for anything; they believe that to admit a need exposes a deficiency in the self. They consequently get into situations where they are miserable because another person does not effortlessly divine their needs and offer what they want without their suffering what they see as the humiliation of asking. They often try to persuade the analyst that their problem is that the people they live with are insensitive. A question about articulating needs may gently expose a narcissistic patient’s belief that it is shameful to need someone and may create opportunities to learn something different about human interdependency.
I noted earlier the difference between selfobject and object transferences. An implication of this difference is that therapists treating narcissistic clients cannot fruitfully investigate their transference reactions as they would those of other people. Questions about who we are to the patient tend to fall flat; interpretations along the lines of “Maybe you’re experiencing me as like your mother right now” may be received as pointless distractions. Therapists need to know that despite the countertransference feeling that one means nothing to the patient, a narcissistic person often actually needs the therapist more than do people without significant self-esteem deficits. It can be stunning to therapists inexperienced with narcissistic patients to learn that the same person who renders them insignificant and impotent during therapy sessions is quoting them admiringly outside the consulting room. Even the arrogant, boastful, seemingly impervious patient betrays a deep dependency on the therapist by his or her vulnerability to feeling crushed when the therapist is insensitive. In working with narcissistic people, practitioners have to become accustomed to absorbing a great deal that they would address with other types of patients.
DIFFERENTIAL DIAGNOSIS
Injuries to self-esteem may lead anyone to behave temporarily like a narcissistic character. Moreover, all types of personality structure have a narcissistic function: They preserve self-esteem via certain defenses. But to qualify as characterologically narcissistic, one must have longstanding, automatic, and situation-independent patterns of subjectivity and behavior. Narcissistic personality organization seems currently overdiagnosed, perhaps especially by psychodynamic clinicians. The concept is often misapplied to people having situation-specific reactions and to psychopathic, depressive, obsessive compulsive, and hysterical personalities.
Narcissistic Personality versus Narcissistic Reactions
I have already suggested one caveat in diagnosing characterological narcissism: Even more than with other psychological conditions to which all human beings are vulnerable, narcissistic concerns are ubiquitous and can easily be situationally incited. Kohut and Wolf (1978) referred to individuals who (like the Chinese graduate student mentioned in the Introduction to this part) confront circumstances that challenge their prior sense of identity and undermine their self-esteem as suffering from a “secondary narcissistic disturbance,” not a narcissistic character disorder. It is an important distinction. Any non-narcissistic person can sound arrogant or devaluing, or empty and idealizing, under conditions that strain his or her identity and confidence.
Medical school and psychotherapy training programs are famous for taking successful, autonomous adults and making them feel like incompetent children. Compensatory behaviors like bragging, opinionated proclamations, hypercritical commentary, or idealization of a mentor are common under such circumstances. Phenomena like these are sometimes referred to in the psychoanalytic literature as comprising a “narcissistic defense” (e.g., Kernberg, 1984). That one is suffering with narcissistic issues does not make one a narcissistic personality. Where situational factors dominate a narcissistic presentation, the interviewer should rely on historical data and the feel of the transference to infer the personality structure underneath the narcissistic injury.
Narcissistic versus Psychopathic Personality
In the last section of the previous chapter, I mentioned the importance of discriminating between a predominantly psychopathic personality structure and one that is essentially narcissistic. Kohutian efforts at empathic relatedness, at least as they are conventionally put into practice, would be ineffective with psychopathic people because they do not emotionally understand compassionate attitudes; they scorn a sympathetic demeanor as the mark of weakness. The approach advocated by Kernberg (e.g., 1984) centering on the confrontation of the grandiose self, would be more respectfully assimilated by a psychopathically organized person, and is consistent with the recommendations of therapists such as Greenwald (1974), Bursten (e.g., 1973a, 1973b), Groth (e.g., 1979), and Meloy (e.g., 2001), who have specialized in working with psychopathic clients.
Narcissistic versus Depressive Personality
The more depressed kind of narcissistic person can easily be misunderstood as having a depressive personality. The essential difference between the two groups is, to condense a great deal of clinical theory and observation into a simple image, that narcissistically depressed people are subjectively empty, whereas depressive people with introjective psychologies (Blatt, 2004) (those who used to be described as suffering depression of the more “melancholic” or guilty type) are subjectively full—of critical and angry internalizations. The narcissistic depressive feels devoid of a substantial self; the melancholic depressive feels the self is real but irreducibly bad. I comment on these differences and their divergent therapeutic implications more in Chapter 11.
Narcissistic versus Obsessive–Compulsive Personality
It is easy to misconstrue a narcissistic person as obsessive and/or compulsive on the basis of the attention to detail that may be part of the narcissistic quest for perfection. In the early days of psychoanalytic practice, fundamentally narcissistic people were often considered obsessive or compulsive because their presenting symptoms fell into one or both of those categories. They were then treated according to assumptions about the etiology of obsessive–compulsive character that emphasized struggles for control and guilt over anger and fantasied aggression.
Narcissistic patients, who were empty more than angry, did not make much progress in that kind of therapy; they would feel misunderstood and criticized when the therapist seemed to harp on issues that were not central to their subjectivity. Although many people have both narcissistic and more classically obsessive concerns, those whose personalities were predominantly narcissistic tended to get little help from analytic therapy before the 1970s, when theories of the etiology and treatment of pathological narcissism radically extended our capacity to help people with disorders of the self. I know of a number of people treated analytically before that time who still bear grudges against their therapist and against psychoanalysis in general. In popular accounts of psychotherapy experiences one can find what seem to be examples of the effects of this misdiagnosis. I give more details on this distinction and the implications of this diagnostic error in Chapter 13.
Narcissistic versus Hysterical Personality
While the narcissistic versus obsessive–compulsive personality differential is called for somewhat more frequently with men than with women, the need to distinguish between narcissism and hysteria comes up much more commonly with female patients. Because hysterically organized people use narcissistic defenses, they are readily misinterpreted as narcissistic characters. Heterosexual women whose hysterical presentation includes considerable exhibitionistic behavior and a pattern of relating to men in which idealization is quickly followed by devaluation may appear to be basically narcissistic, but their concerns about self are gender specific and fueled by anxiety more than shame. Outside certain highly conflicted areas, they are warm, loving, and far from empty (see Kernberg, 1984).
The import of this differential lies in the contrasting therapeutic requirements for the two groups: Hysterical patients thrive with an attention to object transferences, whereas narcissistic ones require an appreciation of selfobject phenomena. In Chapter 14 I go into more detail on this topic.
SUMMARY
This chapter has described the depleted subjective world of the person with a narcissistically organized character and the compensatory behaviors with which such a person tries to maintain a reliable and valued sense of self. I have emphasized the affects of shame and envy, the defenses of idealization and devaluation, and relational patterns of using and being used to equilibrate one’s self-esteem and to repair damage to it. I discussed the narcissistic person’s propensity for selfobject transferences and noted countertransference reactions in which a sense of unrelatedness prevails. I mentioned some implications for technique that derive from an appreciation of these special aspects of the narcissistic condition, although I acknowledged current controversies in the psychoanalytic understanding of narcissism that make effective approaches with this population a matter of some dispute. Finally, I distinguished narcissistic character organization from narcissistic reactions, from psychopathy, from introjective depressive personality, from obsessive and compulsive character structure, and from hysterical psychology.
SUGGESTIONS FOR FURTHER READING
There has been a voluminous psychoanalytic literature on narcissism since the 1970s, when Kohut published The Analysis of the Self (1971) and Kernberg offered an alternative conception in Borderline Conditions and Pathological Narcissism (1975). Both these books contain so much jargon that they are almost impossible for someone new to psychoanalysis to read. More manageable alternatives include Alice Miller’s Prisoners of Childhood (1975) (known in another edition as The Drama of the Gifted Child), Bach’s Narcissistic States and the Therapeutic Process (1985), and Morrison’s Shame: The Underside of Narcissism (1989). Morrison also edited a collection, available in paperback, titled Essential Papers on Narcissism (1986), which contains major psychoanalytic essays on the topic, most of which are excellent. For a scholarly analysis of the cultural trends behind the “empty self” that is central to narcissistic personality, see Philip Cushman’s Constructing the Self, Constructing America (1995).
Newer works on narcissism tend to be based on the description in DSM-IV, and thus strike me as more superficial, trait based, and one-dimensional than these analytic writings. But the oversimplification and popularization of a concept can have its advantages: There are now many helpful popular books for individuals coping with narcissistic parents, lovers, colleagues, employers, and other difficult people.