(audio version of blog)
Introduction
The word 'narcissist' has been in the cultural consciousness for some time. I hear it with patients, among friends and colleagues. Perhaps, in the wake of recent high profile politicians, society's awareness of narcissistic behaviour is higher than ever. Type narcissist into a search engine, and you'll find the internet is full of articles like, Nine tell-tale signs you're dating a narcissist or How to piss off a narcissist: 12 things that make the narcissist really angry. In the therapy room, people use the word to describe (usually male) parents or partners who lack empathy and care for their loved ones. It's also used as a slur. Hearing someone say they're 'such a narcissist' now feels commonplace. It has become a term to describe a person whose character traits or behaviour pushes our buttons or is triggering. Within all of this, I often believe something is overlooked - the recognition that narcissism is a disorder, Narcissistic Personality Disorder (NPD).
Psychological prejudice
A personality disorder is typically a moderate to severe mental health illness that can make everyday life extremely challenging. However, someone living with a narcissistic personality disorder rarely gets the same empathy or space to explore these challenges as people with other disorders, such as BoarderLine Personality Disorder (BPD). Society can find it difficult to empathise with people who don't fit into our expectations of someone who is mentally unwell, particularly if that someone has a negative impact on our wellbeing. Anecdotally, I've spoken to trainee psychotherapists who have gone to their university clinical supervisors expressing concerns about working with a narcissistic personality disorder to be told, "don't worry, narcissists don't go to therapy, and if they do, they want to humiliate the therapist, then leave the therapy."
This anecdote is not an isolated incident. A difficult attitude toward NPD is well documented in the psychological world. Freud distinguished various forms of narcissism as untreatable. He felt that a person suffering from certain types of NPD would be too self-absorbed and preoccupied with themselves to develop Transference onto the therapist and engage meaningfully in therapy. Others, he supposed, were treatable only when met with confrontation, directly analysing and pointing out the patient's defences, self-centredness, or arrogance (Mitchell, 2016.) To me, this feels unethical and lacks psychological merit. Saying to a client they are untreatable can have severe psychological consequences, as can calling their behaviour self-centred or arrogant.
Sometimes, attempting to break through a narcissistic patient's grandiosity, analysts would "adopt a joking, ironic stance that was supposed to kindle the patient's humour, but often slid into sarcasm, ridicule, even mockery" (Kligerman, 1985).
Types of Narcissism
The internet is full of articles listing different types of narcissism. Some say there are three types of narcissists. Some say five, while others say seven. I suspect this is because a person can have some narcissistic personality traits without having a diagnosis or meeting the diagnostic threshold for one. This leaves much room for interpretation and pop-psychology. The DSM-5 gives us remarkably little information about NPD. Nevertheless, it views narcissism on a spectrum. People with NPD will experience different symptoms at different severities.
Important sidebar: just because a person exhibits narcissistic behaviours does not mean that they have a clinical personality disorder.
Personally, there are two categories of narcissists I find helpful to consider. Grandiose and Vulnerable.
1) Grandiose: Grandiose can be ‘adaptive’; typically social, able and motivated. Often unable to tolerate negativity or lack of control. Grandiose can also be ‘maladaptive,’ less able to be sociable or likeable. Their actions can be interpreted as manipulative or self-servicing with little regard for others.
2) Vulnerable: A Vulnerable narcissist typically appears insecure. They can still be high achievers but wear their low self-esteem close to the surface and even use it to get what they want, positioning themselves as a victim. This can be particularly difficult in family dynamics.
What is it like to live with NPD?
Living with NPD (or even a few of the symptoms) can be extremely difficult. Even people who exhibit Grandiose symptoms can live with depression and anxiety. Some narcissists can be very aware of how difficult it is to connect to people and the world around them, feeling overwhelmed and lonely. Vulnerable narcissists who appear to be constantly insecure and victimised can genuinely feel like that, in a constant state of low self-esteem and self-worth. It is a disorder that can leave a person feeling like nothing and no one in the world could meet their emotional needs.
Dr Royce Lee, Associate Prof. of Psychiatry and Behavioural Neuroscience at the University of Chicago Medicine published a fascinating study that identified not just behavioural, but biological differences in people with NPD. It included a drawing together of evidence that people living with NPD also tend to have hypersensitivity and issues with shame: Study summary HERE
Post Freud and the treatment of narcissism
Heinz Kohut (3 May 1913 – 8 October 1981) was an Austrian-born American psychoanalyst. He admired traditional Freudian psychoanalysis and was Secretary, then President-elect of the Journal of the American Psychoanalytic Association in the '60s. However, he began to believe that Freud's theories on narcissism encouraged therapists to think too rigidly about patients, predetermining meaning in narcissistic behaviour. Instead, Kohut approached a narcissistic patient with what he called empathic immersion. Kohut ventured to put himself in each patient's shoes, experiencing them as unique. This way, he felt he would perceive meaning and significance in narcissistic behaviours he could not see by using traditional psychoanalysis. Kohut stressed the importance of empathy in therapeutic practice, not just to make the patient feel accepted but as a way of understanding their behaviours in new ways - breaking from traditional psychoanalysis of the time.
In defence of Narcissism
Ultimately, someone with this disorder, or exhibiting symptoms, can carry around vast amounts of pain and insecurities. The cycle of complex narcissistic behaviour can create a sense of isolation and disconnection - it can be lonely and painful. Society's attitude to narcissism can compound this disconnection. It could be said this societal attitude mirrors Freud, either dismissing or attacking narcissism with little hope of finding resolve or psychological development. This of course can be easy to do, narcissistic behaviours can test our patience, particularly during public holidays, at work, or at family events. There is no one way to deal with someone who challenges you like this, but perhaps Kohut’s empathic immersion can offer us some guidance. He may have told us to be empathetic: Listen, try to understand and remember that there is a reason for all human behaviour - narcissistic behaviour is no exception. Tapping into our empathy can help us manage narcissistic behaviour and provide insight into a person's motives, personal struggles, and point of view. I would also add stay safe*: Decide what your emotional boundaries are, how much time and energy you have to give and how to claim your own space to recover and recharge. Lastly, I’d say seek your own support: Consider what will support you outside of your relationship with the narcissistic person. This can be hobbies, reading, exercise or psychotherapy.
*A narcissistic person is not automatically unsafe, either emotionally or physically. However, if you feel unsafe with someone or they have harmed you before, consider accessing professional help immediately. HERE is a list of mental health helplines and organisations that may help you find support.
Further reading: The Narcissist Test by Craig Malkin
Craig Malkin works a lot with relationships, attraction and narcissism and has some good & accessible videos and blogs on his website www.drcraigmalkin.com
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