Reorienting the Discourse on Narcissism

Narcissistic personality disorder might just be a severe psychiatric illness.

Posted Sep 17, 2018

A few weeks ago, I wrote an article here on the simplification and popular ridicule of the narcissistic concept. The piece was kindly promoted by Psychology Today and quickly became popular. I wish to add some general comments and clarification here.

My main point in broaching the subject of narcissism is that in recent years there has been growing public interest in the topic coupled with a multitude of naive, atheoretical approaches to narcissism centered on the theme of its toxicity in the context of interpersonal relationships. I view this trend as harmful not only to narcissistic patients but also to those affected by narcissists and to the profession of psychotherapy more generally. My call is for mental health professionals to be more careful in their public descriptions of pathological narcissism and its effects.

Below are several common myths perpetuated about narcissism that require careful consideration and repudiation:

Public domain
Narcissus stares at his reflection, painted by the Baroque master Caravaggio, circa 1597-1599.
Source: Public domain

Myth #1: Narcissistic personality disorder is an untreatable condition. Unfortunately, this is a myth that I have heard spread even by mental health professionals. The truth is that psychoanalytic psychotherapy, and in particular transference-focused psychotherapy, can be very effective treatments for pathological narcissism. The myth that personality disorders, in general, are untreatable does sufferers a grave disservice and likely reflects the broader emphasis on pharmacological intervention vs. psychotherapy in recent years. Such a myth prevents people who really need help from seeking or agreeing to it. It also harms those involved with narcissistic persons—family, friends, spouses, and children.

The treatment of narcissistic personality disorder from an analytic perspective involves repeated interpretation of the unconscious processes underlying the disorder, frequently in the context of the transference, i.e., the way the patient comes to relate to the therapist and associated feelings, affects, and behaviors.

Myth #2: Narcissistic personality disorder is a conscious and deliberate choice, not a mental disorder. Narcissistic personality disorder and other personality disorders are generally classified in the psychiatric diagnostic manual (DSM-5) as mental illnesses. Personality disorders can be amongst the most chronic and debilitating conditions treated by psychiatry and psychotherapy, and there is good reason to believe they are grossly underdiagnosed. The claim that individuals consciously choose narcissism ignores the vast contributions by psychoanalysts on this topic and rests on the faulty philosophical assumption that mental disorders are not genuine illnesses. It also conflicts with the fact that narcissistic personality disorder is a problem rooted in the person's unconscious.

Myth #3: Narcissistic persons do not experience any suffering as a result of their condition. They deserve neither care nor empathy. Psychoanalysts see narcissism as representing a defense against deep-rooted insecurities and an unstable sense of self. Usually, this is rooted in problematic object relations in early childhood which result in negativistic and ambivalent feelings about self and other. Thus, at the core of the narcissistic pathology is a deeply wounded, insecure self. The claim that the narcissist experiences no suffering runs counter to the well-established psychodynamic understanding of the condition and certainly deviates from the everyday reality of the narcissist, which is characterized by intense vacillation between feelings of superiority and a deep sense of inferiority in comparison to others.

Experts on narcissistic personality disorder, including Heinz Kohut, M.D., and Otto F. Kernberg, M.D., emphasize the importance of empathic understanding of the narcissistic patient. In fact, the effectiveness of treatment hinges largely on the therapist's ability to empathize with the patient's grandiose self. Readers are directed to the vast writings of Drs. Kernberg and Kohut on this topic.

It is time that mental health professionals who write about narcissism—most unfamiliar with and untrained in analytic treatment—reorient themselves to the psychotherapy of narcissistic personality disorder. Ultimately, it is only in understanding the psychodynamics of the problem that we can lessen the burden of this severe psychiatric disorder.