Narcissism: Psychological Theories and Therapeutic Interventions in t

he
Narcissistic Disorders
Narcissism: Psychological Theories and Therapeutic Interventions in the
Narcissistic Disorders
Introduction
Understanding the Narcissistic Phenomenon
The so called "narcissistic personality disorder" is a complex and often
misunderstood disorder.

The cardinal feature of the narcissistic personality
is the grandiose sense of self importance, but paradoxically underneath this
grandiosity the narcissist suffers from a chronically fragile low self esteem.The grandiosity of the narcissist, however, is often so pervasive that we tend
to dehumanize him or her. The narcissist conjures in us images of the
mythological character Narcissus who could only love himself, rebuffing anyone
who attempted to touch him. Nevertheless, it is the underlying sense of
inferiority which is the real problem of the narcissist, the grandiosity is
just a facade used to cover the deep feelings of inadequacy.

The Makeup of the Narcissistic Personality
The narcissist's grandiose behavior is designed to reaffirm his or her
sense of adequacy. Since the narcissist is incapable of asserting his or her
own sense of adequacy, the narcissist seeks to be admired by others. However,
the narcissist"s extremely fragile sense of self worth does not allow him or
her to risk any criticism. Therefore, meaningful emotional interactions with
others are avoided. By simultaneously seeking the admiration of others and
keeping them at a distance the narcissist is usually able to maintain the
illusion of grandiosity no matter how people respond. Thus, when people praise
the narcissist his or her grandiosity will increase, but when criticized the
grandiosity will usually remain unaffected because the narcissist will devalue
the criticizing person.

Akhtar (1989) as cited in Carson & Butcher, 1992; P. 271 discusses six
areas of pathological functioning which characterize the narcissist. In
particular, four of these narcissistic character traits best illustrate the
pattern discussed above. " (1) a narcissistic individual has a basic sense of
inferiority, which underlies a preoccupation with fantasies of outstanding
achievement; (2) a narcissistic individual is unable to trust and rely on
others and thus develops numerous, shallow relationships to extract tributes
from others; (3) a narcissistic individual has a shifting morality-always
ready to shift values to gain favor; and (4) a narcissistic person is unable to
remain in love, showing an impaired capacity for a committed relationship".

The Therapeutic Essence of Treating Narcissism
The narcissist who enters therapy does not think that there is something
wrong with him or her. Typically, the narcissist seeks therapy because he or
she is unable to maintain the grandiosity which protects him or her from the
feelings of despair. The narcissist views his or her situation arising not as
a result of a personal maladjustment; rather it is some factor in the
environment which is beyond the narcissist"s control which has caused his or
her present situation. Therefore, the narcissist expects the therapist not to
"cure" him or her from a problem which he or she does not perceive to exist,
rather the narcissist expects the therapist to restore the protective feeling of
grandiosity.

It is therefore essential for the therapist to be alert to the
narcissists attempts to steer therapy towards healing the injured grandiose
part, rather than exploring the underlying feelings of inferiority and despair.
Differential Psychological Views of Narcissism
The use of the term narcissism in relation to psychological phenomena was
first made by Ellis in 1898. Ellis described a special state of auto-erotism
as Narcissus like, in which the sexual feelings become absorbed in self
admiration (Goldberg, 1980). The term was later incorporated into Freud"s
psychoanalytic theory in 1914 in his essay "On Narcissism". Freud
conceptualized narcissism as a as a sexual perversion involving a pathological
sexual love to one"s own body (Sandler ; Person, 1991).

Henceforth, several
psychological theories have attempted to explain and treat the narcissistic
phenomenon. Specifically, the most comprehensive psychological theories have
been advanced by the psychodynamic perspective and to a lesser extent the
Jungian (analytical) perspective. Essentially, both theories cite
developmental problems in childhood as leading to the development of the
narcissistic disorder. The existential school has also attempted to deal with
the narcissistic problem, although the available literature is much smaller.

Existentialists postulate that society as a whole can be the crucial factor in
the development of narcissism. The final perspective to be discussed is the
humanistic approach which although lacking a specific theory on narcissism, can
nevertheless be applied to the narcissistic disorder. In many ways the
humanistic approach to narcissism echoes the sentiments of the psychodynamic
approach. The Psychodynamic Perspective of Narcissism
The psychodynamic model of narcissism is dominated by two overlapping
schools of thought, the self psychology school and the object relations school.The self psychology school, represented by Kohut, posits that narcissism is a
component of everyone"s psyche.

We are all born as narcissists and gradually
our infantile narcissism matures into a healthy adult narcissism. A
narcissistic disorder results when this process is somehow disrupted. By
contrast the object relations school, represented by Kernberg, argues that
narcissism does not result from the arrest of the normal maturation of infantile
narcissism, rather a narcissism represents a fixation in one of the
developmental periods of childhood. Specifically, the narcissist is fixated at
a developmental stage in which the differentiation between the self and others
is blurred.

Kohut"s Theory of Narcissism
Kohut believes that narcissism is a normal developmental milestone, and the
healthy person learns to transform his or her infantile narcissism into adult
narcissism. This transformation takes place through the process which Kohut
terms transmuting internalizations. As the infant is transformed into an adult
he or she will invariably encounter various challenges resulting in some
frustration. If this frustration exceeds the coping abilities of the person
only slightly the person experiences optimal frustration. Optimal frustration
leads the person to develop a strong internal structure (i.

e., a strong sense
of the self) which is used to compensate for the lack of external structure
(i.e., support from others).

In the narcissist the process of transmuting
internalizations is arrested because the person experiences a level of
frustration which exceeds optimal frustration. The narcissist thus remains
stuck at the infantile level, displaying many of the characteristics of the
omnipotent and invulnerable child (Kohut, 1977).
Kernberg's Theory of Narcissism
Kernberg's views on narcissism are based on Mahler's theory of the
separation-individuation process in infancy and early childhood. Mahler's
model discusses how the developing child gains a stable self concept by
successfully mastering the two forerunner phases (normal autism and normal
symbiosis) and the four subphases (differentiation, practicing, rapprochement,
and consolidation) of separation-individuation.

Kernberg argues that the
narcissist is unable to successfully master the rapprochement subphase and is
thus fixated at this level. It is essential, however, to understand the
dynamics of the practicing subphase before proceeding to tackle the
narcissist"s fixation at the rapprochement subphase.
The practicing subphase (age 10 to 14 months) marks the developmental stage
at which the child learns to walk. The ability to walk gives the child a whole
new perspective of the world around him. This new ability endows the child
with a sense of grandiosity and omnipotence which closely resemble the
narcissist"s behavior.

However, reality soon catches up with the child as the
child enters the rapprochement subphase (age 14 to 24 months). At this stage
the child discovers that he or she is not omnipotent, that there are limits to
what he or she can do. According to Kernberg if the child is severely
frustrated at this stage he or she can adapt by re-fusing or returning to the
practicing subphase, which affords him the security of grandiosity and
omnipotence (Kernberg, 1976).
The Preferred Psychodynamic model
The Psychodynamic literature in general tends to lean towards the object
relations school because of the emphasis it places on a comprehensive
developmental explanation (i.e. the use of Mahler"s individuation-separation
model).

Nevertheless, the theory of Kohut has left a deep impression on
Psychodynamic thinking as is evident by the utilization of many of his concepts
in the literature (i.e. Johnson, 1987; Manfield, 1992; and Masterson, 1981).Therefore in the remainder of the Psychodynamic section a similar approach will
be taken, by emphasizing object relations concepts with the utilization of the
occasional Kohutian idea.
The Emergence of the Narcissistic Personality
According to Kernberg and the object relations school the crisis of the
rapprochement subphase is critical to the development of the narcissistic
personality. The individual who is unable to successfully master the
challenges of this stage will sustain a narcissistic injury.

In essence the
narcissistic injury will occur whenever the environment (in particular
significant others) needs the individual to be something which he or she is not.The narcissistically injured individual is thus told "Don"t be who you are, be
who I need you to be. Who you are disappoints me, threatens me angers me,
overstimulates me. Be what I want and I will love you" (Johnson, 1987; P. 39).

The narcissistic injury devastates the individual"s emerging self. Unable
to be what he or she truly is the narcissistically injured person adapts by
splitting his personality into what Kohut terms the nuclear (real) self and the
false self. The real self becomes fragmented and repressed, whereas the false
self takes over the individual. The narcissist thus learns to reject himself
or herself by hiding what has been rejected by others.

Subsequently, the
narcissist will attempt to compensate for his or her "deficiencies" by trying
to impress others through his or her grandiosity. The narcissist essentially
decides that "There is something wrong with me as I am. Therefore, I must be
special" (Johnson, 1987; P. 53).

The Narcissist"s View of Others
Just as the individual becomes narcissistic because that is what the
environment "needed" him or her to be, so does the narcissist view others not
as they are, but as what he or she needs them to be. Others are thus perceived
to exist only in relation to the narcissist's needs. The term object relations
thus takes on a special meaning with the narcissist. "We are objects to him,
and to the extent that we are narcissistic, others are objects to us.

He
doesn't really see and hear and feel who we are and, to the extent that we are
narcissistic, we do not really see and hear and feel the true presence of others.They, we, are objects, I am not real. You are not real. You are an object to
me. I am an object to you" (Johnson, 1987; P.

48). It is apparent than that
the narcissist maintains the infantile illusion of being merged to the object.At a psychological level he or she experiences difficulties in differentiating
the self from others. It is the extent of this inability to distinguish
personal boundaries which determines the severity of the narcissistic disorder
(Johnson, 1987).
Levels of Narcissism
The most extreme form of narcissism involves the perception that no
separation exists between the self and the object.

The object is viewed as an
extension of the self, in the sense that the narcissist considers others to be
a merged part of him or her. Usually, the objects which the narcissist chooses
to merge with represent that aspect of the narcissist"s personality about which
feelings of inferiority are perceived. For instance if a narcissist feels
unattractive he or she will seek to merge with someone who is perceived by the
narcissist to be attractive. At a slightly higher level exists the narcissist
who acknowledges the separateness of the object, however, the narcissist views
the object as similar to himself or herself in the sense that they share a
similar psychological makeup. In effect the narcissist perceives the object as
"just like me". The most evolved narcissistic personality perceives the object
to be both separate and psychologically different, but is unable to appreciate
the object as a unique and separate person.

The object is thus perceived as
useful only to the extent of its ability to aggrandize the false self (Manfield,
1992).
Types of narcissism
Pending the perceived needs of the environment a narcissist can develop in
one of two directions. The individual whose environment supports his or her
grandiosity, and demands that he or she be more than possible will develop to
be an exhibitionistic narcissist. Such an individual is told "you are
superior to others", but at the same time his or her personal feelings are
ignored. Thus, to restore his or her feelings of adequacy the growing
individual will attempt to coerce the environment into supporting his or her
grandiose claims of superiority and perfection.

On the other hand, if the
environment feels threatened by the individual"s grandiosity it will attempt to
suppress the individual from expressing this grandiosity. Such an individual
learns to keep the grandiosity hidden from others, and will develop to be a
closet narcissist. The closet narcissist will thus only reveal his or her
feelings of grandiosity when he or she is convinced that such revelations will
be safe (Manfield, 1992)
Narcissistic Defense Mechanisms
Narcissistic defenses are present to some degree in all people, but are
especially pervasive in narcissists. These defenses are used to protect the
narcissist from experiencing the feelings of the narcissistic injury.

The most
pervasive defense mechanism is the grandiose defense. Its function is to
restore the narcissist"s inflated perception of himself or herself. Typically
the defense is utilized when someone punctures the narcissist"s grandiosity by
saying something which interferes with the narcissist's inflated view of
himself or herself. The narcissist will then experience a narcissistic injury
similar to that experienced in childhood and will respond by expanding his or
her grandiosity, thus restoring his or her wounded self concept. Devaluation is
another common defense which is used in similar situations.

When injured or
disappointed the narcissist can respond by devaluing the "offending" person.Devaluation thus restores the wounded ego by providing the narcissist with a
feeling of superiority over the offender. There are two other defense
mechanisms which the narcissist uses. The self-sufficiency defense is used to
keep the narcissist emotionally isolated from others. By keeping himself or
herself emotionally isolated the narcissist"s grandiosity can continue to exist
unchallenged. Finally, the manic defense is utilized when feelings of
worthlessness begin to surface.

To avoid experiencing these feelings the
narcissist will attempt to occupy himself or herself with various activities,
so that he or she has no time left to feel the feelings (Manfield, 1992).
Psychodynamic Treatment of the Narcissist
The central theme in the Psychodynamic treatment of the narcissist revolves
around the transference relationship which emerges during treatment. In order
for the transference relationship to develop the therapist must be emphatic in
understanding the patient"s narcissistic needs. By echoing the narcissist the
therapist remains "silent" and "invisible" to the narcissist. In essence the
therapist becomes a mirror to the narcissist to the extent that the narcissist
derives narcissistic pleasure from confronting his or her "alter ego".Grunberger"s views are particularly helpful in clarifying this idea.

According
to him "The patient should enjoy complete narcissistic freedom in the sense that
he should always be the only active party. The analyst has no real existence
of his own in relation to the analysand. He doesn"t have to be either good or
bad-he doesn"t even have to be Analysis is thus not a dialogue at all; at
best it is a monologue for two voices, one speaking and the other echoing,
repeating, clarifying, interpreting correctly-a faithful and untarnished
mirror" (Grunberger, 1979; P. 49).

The Mirror Transference
Once the therapeutic relationship is established two transference like
phenomena, the mirror transference and the idealizing transference,
collectively known as selfobject transference emerge. The mirror transference
will occur when the therapist provides a strong sense of validation to the
narcissist. Recall that the narcissistically injured child failed to receive
validation for what he or she was. The child thus concluded that there is
something wrong with his or her feelings, resulting in a severe damage to the
child"s self-esteem.

By reflecting back to the narcissist his or her
accomplishments and grandeur the narcissist's self esteem and internal cohesion
are maintained (Manfield, 1992).
There are three types of the mirror transference phenomenon, each
corresponding to a different level of narcissism (as discussed previously). The
merger transference will occur in those narcissists who are unable to
distinguish between the object and the self. Such narcissists will perceive
the therapist to be a virtual extension of themselves. The narcissist will
expect the therapist to be perfectly resonant to him or her, as if the
therapist is an actual part of him or her. If the therapist should even
slightly vary from the narcissist's needs or opinions, the narcissist will
experience a painful breach in the cohesive selfobject function provided by the
therapist.

Such patients will then likely feel betrayed by the therapist and
will respond by withdrawing themselves from the therapist (Manfield, 1992).
In the second type of mirror transference, the twinship or alter-ego
transference, the narcissist perceives the therapist to be psychologically
similar to himself or herself. Conceptually the narcissist perceives the
therapist and himself or herself to be twins, separate but alike. In the
twinship transference for the selfobject cohesion to be maintained, it is
necessary for the narcissist to view the therapist as "just like me" (Manfield,
1992).

The third type of mirror transference is again termed the mirror
transference. In this instance the narcissist is only interested in the
therapist to the extent that the therapist can reflect his or her grandiosity.In this transference relationship the function of the therapist is to bolster
the narcissist"s insecure self (Manfield, 1992).
The Idealizing Transference
The second selfobject transference, the idealizing transference, involves
the borrowing of strength from the object (the therapist) to maintain an
internal sense of cohesion. By idealizing the therapist to whom the narcissist
feels connected, the narcissist by association also uplifts himself or herself.

It is helpful to conceptualize the "idealizing" narcissist as an infant who
draws strength from the omnipotence of the caregiver. Thus, in the idealizing
transference the therapist symbolizes omnipotence and this in turn makes the
narcissist feel secure. The idealization of the object can become so important
to the narcissist that in many cases he or she will choose to fault himself or
herself, rather than blame the therapist (Manfield, 1992).
The idealizing transference is a more mature form of transference than the
mirror transference because idealization requires a certain amount of internal
structure (i.e., separateness from the therapist).

Oftentimes, the narcissist
will first develop a mirror transference, and only when his or her internal
structure is sufficiently strong will the idealizing transference develop
(Manfield, 1992).
Utilizing the Transference Relationship in Therapy
The self object transference relationships provide a stabilizing effect for
the narcissist. The supportive therapist thus allows the narcissist to heal
his or her current low self esteem and reinstate the damaged grandiosity.However, healing the current narcissistic injury does not address the
underlying initial injury and in particular the issue of the false self.

To
address these issues the therapist must skillfully take advantage of the
situations when the narcissist becomes uncharacteristically emotional; that is
when the narcissist feels injured. It thus becomes crucial that within the
context of the transference relationship, the therapist shift the narcissist"s
focus towards his or her inner feelings (Manfield, 1992).
The prevailing opinion amongst Psychodynamic theorists is that the best way
to address the narcissist"s present experience, is to utilize a hands-off type
of approach. This can be accomplished by letting the narcissist "take control"
of the sessions, processing the narcissist"s injuries as they inevitably occur
during the course of treatment. When a mirror transference develops injuries
will occur when the therapist improperly understands and/or reflects the
narcissist"s experiences.

Similarly, when an idealizing transference is formed
injuries will take the form of some disappointment with the therapist which
then interferes with the narcissist"s idealization of the therapist. In either
case, the narcissist is trying to cover up the injury so that the therapist will
not notice it. It remains up to the therapist to recognize the particular
defense mechanisms that the narcissist will use to defend against the pain of
the injury, and work backwards from there to discover the cause of the injury
(Manfield, 1992).
Once the cause of the injury is discovered the therapist must carefully
explore the issue with the narcissist, such that the patient does not feel
threatened. The following case provides a good example of the patience and
skill that the therapist must possess in dealing with a narcissistic patient.

"a female patient in her mid-thirties came into a session feeling elated about
having gotten a new job. All she could talk about is how perfect this job was;
there was no hint of introspection or of any dysphoric affect. The therapist
could find no opening and made no intervention the entire session except to
acknowledge the patient"s obvious excitement about her new job. Then, as the
patient was leaving, the therapist noticed that she had left her eyeglasses on
the table. He said, "you forgot your glasses," to which she responded with an
expression of surprise and embarrassment saying, "Oh, how clumsy of me.

" This
response presented the therapist with a slight seem in the grandiose armor and
offered the opportunity for him to intervene. He commented, "You are so
excited about the things that are happening to you that this is all you have
been able to think about; in the process you seem to have forgotten a part of
yourself." The patient smiled with a mixture of amusement and recognition. In
this example the patient is defending throughout the session and in a moment of
surprise she is embarrassed and labels herself "clumsy", giving the therapist
the opportunity to interpret the defense (her focus on the excitement of the
external world) and how it takes her away from herself" (Manfield, 1992; PP.

168-169).
The cure of the narcissist than does not come from the selfobject
transference relationships per se. Rather, the selfobject transference
function of the therapist is curative only to the extent that it provides an
external source of support which enables the narcissist to maintain his or her
internal cohesion. For the narcissist to be cured, it is necessary for him or
her to create their own structure (the true self). The healing process is thus
lengthy, and occurs in small increments whenever the structure supplied by the
therapist is inadvertently interrupted.

In this context it is useful to recall
Kohut"s concept of optimal frustration. "If the interruptions to the
therapist"s selfobject function are not so severe as to overwhelm the patient"s
deficient internal structure, they function as optimal frustrations, and lead
to the patient"s development of his own internal structure to make up for the
interrupted selfobject function" (Manfield, 1992; P. 167).
The Jungian (Analytical) Perspective of Narcissism
Analytical psychology views narcissism as a disorder of Self-estrangement,
which arises out of inadequate maternal care. However, prior to tackling
narcissism it is useful to grasp the essence of analytical thought.
The Ego and the Self in Analytical Psychology
It is important to understand that the Self in analytical psychology takes
on a different meaning than in psychodynamic thought (Self is thus capitalized
in analytical writings to distinguish it from the psychodynamic concept of the
self).

In psychodynamic theory the self is always ego oriented, that is the
self is taken to be a content of the ego. By contrast, in analytical
psychology the Self is the totality of the psyche, it is the archetype of
wholeness and the regulating center of personality. Moreover, the Self is also
the image of God in the psyche, and as such it is experienced as a
transpersonal power which transcends the ego. The Self therefore exists before
the ego, and the ego subsequently emerges from the Self (Monte, 1991).

Within the Self we perceive our collective unconscious, which is made up of
primordial images, that have been common to all members of the human race from
the beginning of life. These primordial images are termed archetypes, and play
a significant role in the shaping of the ego. Therefore, "When the ego looks
into the mirror of the Self, what it sees is always "unrealistic" because it
sees its archetypal image which can never be fit into the ego" (Schwartz-Salant,
1982; P. 19).

Narcissism as an Expression of Self-Estrangement
In the case of the narcissist, it is the shattering of the archetypal image
of the mother which leads to the narcissistic manifestation. The primordial
image of the mother symbolizes paradise, to the extent that the environment of
the child is perfectly designed to meet his or her needs. No mother, however,
can realistically fulfill the child"s archetypal expectations. Nevertheless,
so long as the mother reasonably fulfills the child"s needs he or she will
develop "normally". It is only when the mother fails to be a "good enough
mother", that the narcissistic condition will occur (Asper, 1993).

When the mother-child relationship is damaged the child"s ego does not
develop in an optimal way. Rather than form a secure "ego-Self axis" bond, the
child"s ego experiences estrangement from the Self. This Self-estrangement
negatively affects the child"s ego, and thus the narcissist is said to have a
"negativized ego". The negativized ego than proceeds to compensate for the
Self-estrangement by suppressing the personal needs which are inherent in the
Self; thus "the negativized ego of the narcissistically disturbed person is
characterized by strong defense mechanisms and ego rigidity. A person with
this disturbance has distanced himself from the painful emotions of negative
experiences and has become egoistic, egocentric, and narcissistic" (Asper, 1993;
P. 82).

Analytical Treatment of Narcissism
Since the narcissistic condition is a manifestation of Self-estrangement,
the analytical therapist attempts to heal the rupture in the ego-Self axis bond,
which was created by the lack of good enough mothering. To heal this rupture
the therapist must convey to the narcissist through emphatic means that others
do care about him or her; that is the therapist must repair the archetype of
the good mother through a maternally caring approach (Asper, 1993).
A maternal approach involves being attentive to the narcissist"s needs.Just as a mother can intuitively sense her baby's needs so must the therapist
feel and observe what is not verbally e