Is NPD more amenable to Cognitive-Behavioural therapies or to Psychodynamic / Psychoanalytic ones?
Narcissism is the WHOLE personality. It is ALL-pervasive. Being a narcissist is akin to being an alcoholic but MUCH more so.
Alcoholism is impulsive behaviour. Narcissists have this plus hundreds of other attributes (problems). Narcissists exhibit dozens of behaviours, some of them uncontrollable (like their rage or behaviours, which are the outcomes of their grandiosity). Narcissism is not a vocation. Narcissism can be compared to depression or to other disorders, but not to traits or attributes that we can change at will.
Narcissism is no more “curable” than the entirety of one’s personality is disposable. One IS a narcissist. Narcissism is more akin to the colour of one’s skin rather than to one’s choice of subjects at the university.
This is the seemingly eternal debate between the cognitive-behavioural theories of therapy and the psychodynamic ones.
To grossly oversimplify:
The CBTs (cognitive behavioural therapies) believe that insight – even if merely verbal and intellectual – is sufficient to induce an emotional outcome. If properly manipulated, verbal cues, insights, analyses of standard sentences we keep saying to ourselves (“I am ugly”, “I am afraid no one would like to be with me”), inner dialogues and narratives, and repeated behavioural patterns (learned behaviours) coupled with positive (and, rarely, negative) reinforcements – are sufficient to induce a cumulative emotional effect tantamount to healing.
Psychodynamic theories do not believe that cognition can influence emotion. They believe that much deeper strata have to be accessed and studied by both patient and therapist. The very exposure of these strata is considered sufficient to induce a dynamic of healing. The therapist’s role is either to interpret the material revealed to the patient (psychoanalysis) by allowing the patient to transfer past experience and superimpose it on the therapist – or to actively engage in providing a safe emotional and holding environment conducive to changes in the patient.
The sad fact is that no known therapy is effective with narcissism ITSELF – though a few therapies are reasonably successful with coping with its effects (behavioural modification).
Or Psychodynamic Therapy, Psychoanalytic Psychotherapy
As opposed to (wrong) common opinion it is NOT psychoanalysis. It is an intensive psychotherapy BASED on psychoanalytic theory WITHOUT the (very important) element of free association. This is not to say that free association is not used – only that it is not a pillar of the technique in dynamic therapies. Dynamic therapies are usually applied to patients not considered “suitable” for psychoanalysis (such as PDs, except Avoidant PD). Usually, different modes of interpretation are employed and other techniques borrowed from other treatments modalities. But the material interpreted is not necessarily the result of free association or dreams and the psychotherapist is a lot more active than the psychoanalyst.
These treatments are open-ended. At the commencement of the therapy the therapist (analyst) makes an agreement (a “pact”) with the analysand (patient or client). The pact says that the patient undertakes to explore his problems no matter how long it takes (and how expensive it becomes). This is supposed to make the therapeutic environment much more relaxed because the patient knows that the analyst is at his/her disposal no matter how many meetings would be required in order to broach painful subject matter.
Sometimes, these therapies are divided to expressive versus supportive, but I regard this division as misleading.
Expressive means uncovering (=making conscious) the patient’s conflicts and studying his/her defences and resistances. The analyst interprets the conflict in view of the new knowledge gained and guides the therapy towards a resolution of the conflict. The conflict, in other words, is “interpreted away” through insight and the change in the patient motivated by his/her insights.
The Supportive therapies seek to strengthen the Ego. Their premise is that a strong Ego can cope better (and later on, alone) with external (situational) or internal (instincts, drives) pressures. Supportive therapies seek to increase the patient’s ability to REPRESS conflicts (rather than bring them to the surface of consciousness). As a painful conflict is suppressed – so are all manner of dysphorias and symptoms. This is somewhat reminiscent of behaviourism (the main aim is to change behaviour and to relieve symptoms). It usually makes no use of insight or interpretation (though there are exceptions).
Narcissists are notoriously unsuitable for group activities of ANY kind, let alone group therapy. They immediately size up others as potential sources of narcissistic supply – or potential competitors for such. They idealize the first (suppliers) and devalue the latter (competitors). This, obviously, is not very conducive to group therapy.
Moreover, the dynamic of the group is bound to reflect the combined dynamics of its members. Narcissists are individualists. They regard coalitions with disdain and contempt. The need to resort to coalitions is perceived by them to be humiliating and degrading (a contemptible weakness). Thus, the group is likely to fluctuate between short term, very small size, coalitions (based on “superiority” and contempt) and outbreaks (acting outs) of rage and coercion.
Can Narcissism be Cured?
Narcissists can rarely be “cured”. In the early 80’s therapists thought otherwise (Lowen, 1983).
The reason narcissism was under-reported and healing over-stated was that therapists have been fooled by smart narcissists. Most narcissists are expert manipulators and they learned how to deceive the therapists. You can see this very often in prison.
Here are some hard facts:
- There are gradations and shades of narcissism. The difference between two narcissists can be great. The existence or lack of grandiosity and empathy are not minor variations. They are serious predictors of future dynamics. The prognosis is much better if they do exist.
- There are cases of spontaneous healing and of “short term NPD” (see Gunderson’s and Roningstam’s work – 1996).
- The prognosis for a classical NPD case (grandiosity, lack of empathy and all) is decidedly not good IF we are talking about LONG TERM AND COMPLETE HEALING. Moreover, NPDs are intensely disliked by therapists.
- Side effects, associated disorders (such as OCD) and SOME aspects of NPD (certain behaviours, the dysphorias, the paranoiac dimensions, the outcomes of the sense of entitlement, the pathological lying) CAN be modified (using talk therapy and, depending on the problem, medication). We are not talking about SHORT-term solutions – but there are partial solutions and some of them do have long term effects.
- The DSM is billing and administration oriented. It is intended to “tidy” up the psychiatrist’s desk. The PDs are ill demarcated, they tend to intermingle and be cross-referenced. The differential diagnoses are vaguely defined. There are some cultural biases and judgements (see the diagnostic criteria of the Schizotypal PD). The result is sizeable confusion and multiple diagnoses (“co-morbidity”). NPD was introduced in 1980 (DSM III). There isn’t enough research to substantiate any view or hypothesis about NPD. Future DSM editions may abolish it altogether within the framework of a cluster or a single “personality disorder” category. As it is, the difference between HPD, BPD and NPD is, to my mind, rather blurred. So, when we ask: “Can NPD be healed?” we need to realize that we don’t know for sure what is NPD and what constitutes long term healing in the case of an NPD. There are those who seriously claim that NPD is a CULTURAL disease with a massive societal determinant.
Narcissists in Therapy
In therapy, the general idea is to create the conditions for the True Self to resume its growth: safety, predictability, justice, love and acceptance. Therapy is supposed to provide these conditions of nurturance and the guidance necessary to achieve these goals (through transference, cognitive re-labeling or other methods). The Narcissist must learn that his past experiences are NOT laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive.
But the narcissist devalues the therapist. His internal dialogue is:
“I know best, I know it all, the therapist is less intelligent than I, I can’t afford the top level therapists who are the only ones qualified to treat me (as my equals, needless to say), I am actually a therapist myself…”
A litany of self-delusion and fantastic grandeur (really, defences and resistances).
“He (my therapist) should be my colleague, in certain respects HE should accept my professional authority, why won’t he be my friend, after all I can use the lingo (psycho-babble) even better than he can? It’s US (I and he) against the unknowing world (known as follies a deux)…”
Then there is:
“Just who does he think he is, asking me all these questions? What are his professional credentials? I am a success and he is a nobody therapist in a dingy office, he is trying to negate my uniqueness, he is an authority figure, I hate him, I will show him, I will humiliate him, prove him ignorant, have his licence revoked (transference). Actually, he is pitiable, a zero, a failure…”
And this is only in the first three sessions of the therapy. This abusive internal dialogue becomes more vituperative and pejorative as therapy progresses.
Narcissists generally are averse to receiving medication. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks and afraid to lose control. Additionally, many of them believe that medication is the “great equalizer” – it will make them lose their uniqueness, superiority and so on. That is UNLESS they can convincingly present taking the medication as an “act of heroism”, a part of a daring enterprise of self-exploration, a distinguishing feature and so on. They often claim that the medicine affects them differently than it does other people, or that they have discovered a new, exciting way of using it, or that they are part of someone’s (usually themselves) learning curve (“part of a new approach to dosage” “part of a new cocktail which holds great promise”). Narcissists MUST dramatize their lives to feel worthy and special. Aut nihil aut unique – either be special or don’t be at all. Narcissists are drama queens.
Very much like in the physical world, change is brought about only through incredible powers of torsion and breakage. Only when the narcissist’s elasticity gives way, only when he is wounded by his own intransigence – only then is there hope.
It takes nothing less than a real crisis. Ennui is not enough.