Understanding Narcissistic Personality Disorder Through the Lens of Self-Psychology by Allen Shamon
Understanding Narcissistic Personality Disorder Through the Lens of Self-Psychology
When it is determined that a client meets diagnostic criteria for narcissistic personality disorder in a therapeutic session, the clinician who assists the client may feel unsure about what psychoanalytic theory best explains why the diagnosis has occurred and how to potentially mitigate negative health outcomes. Evaluating narcissistic personality disorder from the theoretical perspective of Heinz Kohut’s self-psychology model provides a framework in better understanding how a client may have arrived at their diagnosis, and how it is affecting their overall biopsychosocial well-being. Understanding the role that self-psychology theory has on narcissistic personality disorder in terms of how health and mental health integrate, how neurobiology plays a role, the persons diversity factors that are involved, and what type of treatment would be most adequate is of the upmost importance in understanding how the personality disorder and psychoanalytic theory affect and intertwine with one another.
Health/Mental Health Theory
Although discussion of research is ongoing about what accurately forms a persons character throughout their life, researchers believe that certain biological factors, developmental, and environmental conditions all contribute to character formation both in the normative and pathological evolution of a person (Hertz & Hertz, 2016). In understanding how a person’s character develops tendencies that lead to a diagnosis of narcissistic personality disorder, one must begin to evaluate how narcissistic personality disorder is formed. According to Kohut’s self-psychology model (McLean, 2007), narcissistic psychopathology is a result of a parental lack of empathy during childhood development that consequently leads an individual to develop lower self-esteem. Kohut also believes that a narcissistic adult fluctuates between an unreasonable overestimation of the self and an irrational feeling of inferiority which leads the person to rely on others to regulate their self-esteem and ultimately give them some sense of value. Some of the central features that comprise narcissistic personality disorder are a sense of imposingness, a need for admiration by others, and a lack of empathy. Many patients with narcissistic personality disorder accomplish high achievements, however, behind the features that comprise narcissistic personality disorder are feelings of inadequacy and a constant desire for further admiration (McLean, 2007).
Our society regularly pitches around the word narcissism often to describe someone who seems excessively vain or full of themselves. But in psychological terms, narcissism doesn’t mean self-love but instead is more accurate to say that people with narcissistic personality disorder are in love with an idealized, grandiose image of themselves in the eyes of those around them. Being so in love with this inflated self-image allows them to avoid and repress deep feelings of insecurity. According to (Morey & Stagner, 2012), some therapeutic patient cases of narcissistic personality disorder may report a very fractious relationship with their parents throughout their childhood. Patients with narcissistic personality disorder may claim that they were a constant disappointment and never good enough for their parents despite their accomplishments, thus building resentment. The two types of narcissistic personality disorder comprise a preoccupied and avoidant style relative to under and overregulated personalities in which the behavioral patterns of their dissociation reflect their reactions towards either hyper or hypoarousal (Hill, 2015). Patients with both types of narcissistic personality disorders may assert that one or both of their parents were judgmental, distant, emotionally volatile, inconsistent, and overall perpetually disappointed that their child did not meet their standard of expectations.
In approaching the narcissistic patient from the point of view of Kohut’s self-psychology theory, the clinician should attempt to acknowledge with the patient that the parental lack of empathy during their childhood development led to the them being unable to adequately regulate their self-esteem. "What distinguishes self-psychology (and the reason it is called self-psychology) is its focus on understanding that the self has a separate line of development that should ideally lead to a creative, loving, and, especially, cohesive whole. The emphasis is on the person’s subjective sense of cohesion and well-being rather than on the supposedly objective functioning of various aspects or parts of the self, such as the id, ego, and superego.” (Flanagan, 2016, pp. 167). Self-psychologists attempt to try and understand the experience of self from the inside out, rather than from the outside in when working with a patient that is diagnosed with narcissistic personality disorder. Kohut suggests that in order for a therapist to fully comprehend their narcissistic patient, the therapist must assume an empathic-introspective observational stance and that by doing so, the therapist can understand the multifaceted, inner world of the patient and the patient’s inner personal experience (McLean, 2007). Self-psychology theorizes a debilitated or deficient self as the fundamental principle behind narcissistic personality disorder, instead of viewing the disorder according to other psychoanalytic models and theories that are driven by conflict. Knowledge of the psychology behind what creates one’s deficient personality characteristics that comprise narcissistic personality disorder can be summarized by a result from an insufficient environment the person was subjected to in their development as a child which formed their adult character (Cara, 2009).
In one major study conducted by Kohut, he observed that when he was treating a group of patients who were not helped by other psychoanalytical methods that resolve drive and conflict, he began to suggest that the patients of the group struggled with dilemmas related to narcissism. Kohut found that the members of the group tended to portray a sense of not needing anyone but also presented themselves at the same time as very fragile and easily prone to shame. Due to the observations Kohut found, he began to rethink the idea of what constitutes a healthy self. "At first, Kohut believed that his new insights applied only to certain patients, those who suffered from narcissistic character problems. He still saw the validity of drive, ego, and object relations theories for problems of a neurotic nature. However, by the end of his life he believed that all psychopathology was based on flaws in the self and that ‘all these flaws in the self are due to disturbances of self-object relationships in childhood" (Flanagan, 2016, pp. 167). Gaining a better understanding of how narcissism develops within a person allowed Kohut to study a therapeutic trait that changes the course of a narcissistic patients relationship with their clinician and their overall positive gain from therapy: empathy.
Empathy, as a clinician behavior tool, became an important part of Kohut’s work, as he came to feel that overly stiff adherence to Sigmund Freud’s ideas often encouraged clinicians to impose their own beliefs on the client they were treating, when understanding the distinctive perspective of those in treatment on the concerns they sought help with was more likely to produce better treatment results. Self-psychology places an extraordinary value on empathy, or the ability of the counselor to understand the experience from the viewpoint of the client in treatment (GoodTherapy, 2016). Kohut suggests that the role of transference between the therapeutic relationship of client and clinician is of extreme importance. In the psychoanalytic theory of self-psychology, transference can be presented in the form of mirroring, idealizing, and a twinship/alter ego presentation on behalf of the patient. A person with narcissistic personality disorder may use mirroring throughout the therapeutic sessions to determine and reflect back a sense of self-worth and value as they measure the responses of the clinician to see positive traits within themselves. Mirroring is often considered one of the main forms of a transference response by patients who present symptoms related to narcissistic personality disorder.
With idealizing, narcissistic clients who reflect unmet self-object needs may need their clinicians to make them feel calm and comfortable while in session. Idealizing by narcissistic patients can present in a way where the patient believes that they only deserve the best responses by their clinician to keep them in a good state of mind at all times in therapeutic sessions. Kohut also explains that the twinship/alter ego displayed by narcissistic patients suggests that patients will feel a sense of likeness with others and may even mimic behaviors. Grasping the way transference is presented by patients who signify narcissistic personality disorder is fundamental in comprehending why the empathy aspect of the self-psychology psychoanalytical theory is so important. Expressing empathy can ground narcissistic patients in therapeutic sessions as they may feel that they are being heard, their point of view concerns are understood, and that they are getting the exemplary counseling services that are sufficiently meeting their needs.
Kohut’s self-psychology theory has charted a path that provides more comprehension and clarity in understanding narcissistic personality disorder and narcissism on its own, allowing some narcissism to be seen as a natural part of development. Some critics of self-psychology theory argue that the theory is no more than supportive therapy and say that it is unlikely to create lasting change in narcissistic patients seeking treatment, while others state that the theory does not adequately address all factors of the psyche, such as drives and the unconscious, which may also have an impact on a person’s development (GoodTherapy, 2016). Numerous studies counter critics remarks as they have shown the positive outcomes and effectiveness of the self-psychology analytical perspective with a strong emphasis on empathy. Through Kohut’s extensive research regarding the application of self-psychology theory on narcissism and narcissistic personality disorder, he demonstrates that the ability to understand a person’s concerns through their point of view may move treatment forward at a greater trajectory.
Health and Mental Health Integration
Narcissistic personality disorder in mild and severe cases can have many secondary negative effects on the biological, psychological, and social aspects of a persons life. Understanding how and why the secondary issues of narcissistic personality disorder may occur and how they have an effect on health and mental health can help patients understand and address their core issue of the disorder earlier in treatment. According to the (Mayo foundation, 2017), some of the secondary psychological complications that may arise as a result of narcissistic personality disorder can present as high generalized or social anxiety, depression, or even suicidal thoughts or behaviors. Narcissistic patients who are especially vulnerable to criticism from themselves or others have a higher risk of having depression or anxiety, as 15% of people with narcissistic personality disorder are also diagnosed with depression, 13.5% have anxiety and approximately 17% have some other form of mood disorder (Hull & Pinkering, 2021). Due to the different forms of mental health disorders that can arise out of narcissistic personality disorder, patients who suffer from the negative outcomes may tend to enact harmful tendencies that affect their biological health such as drug and alcohol abuse related problems. According to (Hull & Pinkering, 2021), data suggests that about 14% of people with narcissistic personality disorder have alcohol use disorder, while roughly 24% abuse other types of drugs. While there may be many negative effects on the biological and psychological health of narcissistic patients, the social aspect of their lives is usually what is most reported as being adversely impacted. Due to their neglected childhood upbringing, many narcissistic patients develop character tendencies that have a harsh impact on their social functioning and their overall ability to maintain a healthy social network of friends, family, coworkers, and other loved ones. Narcissistic patients can report continuous relationship difficulties, problems at work or school, constant issues with coworkers or members of the public, and feeling as they deserve the best treatment at all times and anything else is completely unacceptable. Patients with narcissistic tendencies tend to judge others in their social network as either perfect or flawed, and based on this aspect, they not only are unable to accept themselves but may continuously lose relationships they actually wish to keep, thus having a negative overall impact on their mental health and overall psychical health.
The after effects that a patient with narcissistic personality disorder has can be devastating on the health of their relationships. Throughout their relationships, according to (Watson et al., 1992), narcissistic people can be presented as going through three types of phases. The idealizing phase of a relationship with a narcissistic person presents as the person being charming in the beginning stages of the relationship due to their idea of romanticized fantasies of a perfect relationship. The waning phase comprises the narcissistic person beginning to point out flawed qualities in people and may make frequent comments about unnecessary improvement. Throughout the phases, narcissistic people can replay the same events over and over with people they actually do care for and end up losing that person due to their own insecurities. Due to the phases narcissistic people tend to go through in their relationships, maintaining healthy relationships is virtually impossible, thus having an effect on their mental and physical health.
People with narcissistic personality disorder or narcissistic tendencies may also experience impaired gut health due to the secondary diagnosis they incur as a result of their disorder. Narcissistic people can feel many different emotions rather quickly about a situation or person, and in doing so, the activity of their brain circuits affects their mind-gut correlation and other organs as well, producing an aligned response to ever emotion they feel. According to (Mayer, 2016), the brain is tied to the gut and because of this, every time a person feels overwhelmed, stressed, neglected, or has a bad experience, they can feel as if their stomach is tied up in knots because the emotion-generating circuits of the brain that were activated. If a narcissistic person decides to seek medical attention from their physician due to gut related issues, and their results do not reveal something such as gut inflammation or a tumor, they may not be properly helped leading the narcissistic person to potentially further their narcissistic characteristics about what type of care they are receiving. About 15% of the United States population suffers from a range of severe gut reactions, and data shows that most patients suffering from abnormal gut reactions have no idea that the cause of their gut related issues are a result of their emotional states (Mayer, 2016). With empathy in understanding their narcissistic clients point of view from the self-psychology psychoanalytical theory, a healthy therapeutic alliance can help alleviate some of the secondary mental effects of their disorder, thus potentially having a positive effect on any biological and gut related issues as well.
It is also important to address the spiritual aspect of the narcissistic client as some clinicians overlook it when considering heavily the overall biological, psychological, and social focus of their client. Research suggests that mechanisms of spiritual involvement may improve the social integration that promotes healthy behaviors and provides social support, optimism, and purpose (VanderWeele et al., 2015). If a client with narcissistic personality disorder is open to talking about their religion or spiritual health, it may be beneficial for the client to reengage with some empathetic community support that can turn around some of their automatic negative cognitions.
According to the Health Belief Model (HBM), people are likely to engage in a health behavior that promotes change to a negative health outcome if they believe that: they are susceptible to a condition, the condition could have severe consequences, a course of action in reducing the negative impact is available, there are benefits to taking action, and their perceived barriers are outweighed by the benefits (Skinner et al., 2015). The HBM promotes the need for adequate action on behalf of the clinician working with a narcissistic person in getting the client to view that their negative behaviors are causing other significant negative outcomes in their biological, psychological, and social health. If the clinician provides empathy and builds a healthy therapeutic alliance with their narcissistic client, they may be able to get their client to see that they have an issue and which can potentially lead to further action that promotes a change in behavior.
Neurobiology
Narcissistic personality disorder can be represented as a long-term pattern of behavior a person presents as extreme exaggerated feelings of self-importance, an excessive need for others admiration, and a lackluster understanding of others’ feelings. The body of evidence that is available on the neurobiology of narcissistic personality disorder suggests that abnormalities in certain brain areas, such as the insular cortex are associated with features of the disorder, especially a lack of empathy for others (George & Short, 2018). The research further suggests that narcissistic personality disorder severely impairs a healthy form of emotional regulation and irregularities in communication with others. The abnormalities point to being associated primarily within the insular cortex and also in the frontal lobes of the brain (George & Short, 2018).
In applying the polyvagal theory to a patient with narcissistic personality disorder, a clinician may begin to better understand some of the neurobiology components involved in a narcissistic persons actions. The polyvagal theory is summarized as how people can assess stress or danger based on cues in their environment and how their sympathetic or activation systems react. The ventral vegal which can be described as the social engagement system is engaged and a person may flight or fight in a stressful situation. The three principles that comprise the polyvagal theory are: hierarchy, neuroception, and co-regulation (Dana, 2018). Hierarchy describes how the autonomic nervous system counters the sensations in the body and signals from the environment and the three areas that comprise hierarchy are the dorsal vagus, the sympathetic nervous system, and the ventral vagus. Neuroception describes the ways a person’s autonomic nervous system responds to cues of security, vulnerability, and life risks from within the body, in the world, and from influences of others. Co-regulation in the polyvagal theory identifies a need that must be met to sustain life, and through mutual regulation of the autonomic conditions so that the person can feel safe to move into connection and generate trustful relationships (Dana, 2018). Studies of explicit and implicit self-worth, self-esteem, and the conscious vs autonomic/unconscious evaluation of self in narcissistic personality disorder patients incline to support the notion that autonomic neurological functioning can sternly rupture a narcissistic individual’s regulatory pattern, including both enhancing and avoiding protective strategies, leading to a loss of functioning and an even more severe narcissistic pathology (Ronningstam, 2017).
Diversity
While it is believed by researches that levels of narcissism fall on a spectrum and can affect anyone based upon their childhood upbringings, some statistics show a higher prevalence that correlate with certain populations. Approximately 0.5% of the United States population or 1 out of 200 people has narcissistic personality disorder (Hull & Pinkering, 2021). What is interesting about the population that comprises narcissistic personality disorder is the difference in prevalence based upon gender. According to data found by (Hull & Pinkering, 2021), the approximately 0.5% of people diagnosed are comprised as being 75% men, displaying a huge gender gap between the diagnosing of narcissistic personality disorder between men and women. While there is a significant gender difference in the diagnosis of narcissistic personality disorder, research suggests that the disorder is not more common in any certain ethnicity (Hull & Pinkering, 2021).
One diversity factor that is extremely concerning is the data that strongly correlates narcissism and homosexuality. In one research study, the data collected compared self-esteem and two measures of narcissism among 90 homosexual and 109 heterosexual male students, who completed a demographic survey, which addressed both grandiose and vulnerable subtypes of narcissism. The results of the study indicated that the homosexual students score considerably higher in both measures of narcissism and poorer on the self-esteem measure, compared to their heterosexual equivalents (Rubinstein, 2010). The discussion behind the study can be linked to the lack of acceptance in childhood development due to a parental lack of approval. The parental lack of accepting and/or approving of their gay son could form adult narcissistic characteristics, (such as a need for admiration from others, approval, etc.), at a much higher prevalence in adult gay men. The research and data points suggests that men, and specifically, gay men are being diagnosed or have a chance of being diagnosed at higher rates of narcissistic personality disorder.
Treatment
While there are no current medications specifically used to treat narcissistic personality disorder, treatment is usually positioned around talk therapy between a clinician and patient, and is also called psychotherapy. Through talk therapy treatment, patients analyzed with narcissistic personality disorder may be able to better relate to others so that their relationships are more cherished, pleasurable, fulfilling, and they may also begin to understand that sources of their sentiments and what drives them to despise others or perhaps even themselves. As discussed earlier with the health belief model: promoting the need for sufficient realization on behalf of the client to view that their negative behaviors are causing other significant negative outcomes in their biological, psychological, and social health is of the highest importance in the therapeutic tasks of the clinician.
Due to the research findings by Kohut and the self-psychology theory, he began to rethink the idea of how to approach the therapeutic alliance between a clinician and patient. Kohut witnessed through his own research that the rationality of drive and ego within his narcissistic clients were problems of a neurotic nature. Acquirement of a better grasp of how narcissism develops within a person allowed Kohut to study a therapeutic mannerism that changed the sequence of a narcissistic patients behavior over a period of time.
Kohut suggests that empathy towards the clients most inner points of view is essential in talk therapy. Empathy became such an important aspect of the self-psychology analytical theory as it encouraged therapists to execute the self-realization of the client they were treating. Self-psychology places a particular importance on empathy, and the ability of the therapist to understand the experience from the viewpoint of the client in treatment. Through an emphasis on empathy in talk therapy, clients may being to increase the ability to understand an regulate their feelings, thus learning how to maintain healthy relationships within their social network. Clients who are treated in talk therapy with the self-psychology model may also begin to realize their own desire for unattainable goals and gain an acceptance of what is attainable and what they sincerely want to accomplish for themselves.
In other studies, some researchers place a heavy emphasis on approaching talk therapy with a narcissistic personality disorder patient from an interpretive psychoanalytic stance at the very beginning of treatment. The four principles that can formulate the interpretive psychoanalytic stance are: interpretation, transference analysis, technical neutrality, and a countertransference analysis (Kernberg, 2014). Kohut also mentions the importance of transference in the aspect of the self-psychology analytical theory. Understanding how and why the narcissistic patient may be interpreting and feeling a certain way is important to the continuation of treatment. Of the interpretive psychoanalytic stance, the particular approach facilitates mentalization, and constitutes an important aspect of the technical approach at severe levels of regression (Kernberg, 2014). It is suggested that narcissists are actually capable of empathy at times but most of the time are not able to fully consider another person’s perspective and view of things. In order to engage narcissists in talk therapy to change their behavior towards others in their social network, the clinician working with the patient must show them empathy, and therefore, help the patient see other people’s point of view rather than just focusing solely on themselves.
Conclusion
Overall, when it is determined that a client meets diagnostic criteria for narcissistic personality disorder, a clinician may want to consider applying Kohut’s self-psychology framework as a psychoanalytical treatment method for best potential outcomes. Understanding how narcissistic personality disorder has an impact on health and mental health integration is important in adequately addressing all aspects of a patients biopsychosocial-spiritual wellness. Comprehending what neurobiology aspects may be activated and what diversity statistics are most prevalent can give a clinician a better perspective on certain reactions and their particular client in therapy. Applying empathy and an interpretive psychoanalytic stance regarding the importance of transference in therapy are extremely important to the continuation of therapeutic treatment and the overall success of the narcissistic patient in reducing their negative outcomes.
References
Cara, E. (2009). Neutralizing the narcissistic style: Occupational Therapy In Health Care, 8(2- 3), 135–156. https://doi.org/10.1080/j003v08n02_07
Cozolino, L. (2017). The self in exile: Narcissism and pathological caretaking. In The neuroscience of psychotherapy (3rd ed., pp .342-358). New York, NY: W.W. Norton.
Dana, D. (2018). Befriending the nervous system. In The polyvagal theory in therapy. Engaging the rhythm of regulation (pp. 3-15). New York, NY: W.W.Norton.
Flanagan, L. M. (2016). The theory of self psychology. In J. Berzoff, L.M. Flanagan, & P. Hertz
(Eds.), Inside out and outside in (4th ed., pp. 166-195). Lanham, MD: Rowman & Littlefield.
George, F. R., & Short, D. (2018, February 28). The cognitive neuroscience of narcissism. Journal of Brain, Behaviour and Cognitive Sciences. https://www.imedpub.com/articles/the-cognitive-neuroscience-of- narcissism.php?aid=22149.
GoodTherapy. (2016, September 22). Self psychology. GoodTherapy. https://www.goodtherapy.org/learn-about-therapy/types/self-psychology.
Hertz, P. & Hertz, M. (2016). Personality disorders with a special emphasis on borderline and narcissistic syndromes. In J. Berzoff, L.M. Flanagan, & P. Hertz (Eds.), Inside out and outside in (4th ed., pp. 363-411). Lanham, MD: Rowman & Littlefield.
Hill, D. (2015). Personality disorders. In Affect regulation theory: A clinical model. New York, NY: W.W.Norton. 168-182)
Hull, M., & Pinkering, N. (2021, April 16). Narcissistic personality disorder statistics. The Recovery Village Drug and Alcohol Rehab. https://www.therecoveryvillage.com/mental- health/narcissistic-personality-disorder/npd-statistics/.
Kernberg, O. F. (2014). An overview of the treatment of severe narcissistic pathology. The International Journal of Psychoanalysis, 95(5), 865–888. https://doi.org/10.1111/1745- 8315.12204
Mayer, E. (2016). How the mind communicates with the gut. In The mind-gut connection (pp.29-50). New York, NY: Harper Collins.
Mayo Foundation for Medical Education and Research. (2017, November 18). Narcissistic personality disorder. Mayo Clinic. https://www.mayoclinic.org/diseases- conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662.
McLean, J. (2007). Psychoanalysis and psychotherapy. Psychotherapy After Kohut, 212–230. https://doi.org/10.4324/9780203778685-20
Morey, L. C., & Stagner, B. H. (2012). Narcissistic pathology as core personality dysfunction: Comparing the dsm-iv and the dsm-5 proposal for narcissistic personality disorder. Journal of Clinical Psychology, 68(8), 908–921. https://doi.org/10.1002/jclp.21895
Ronningstam, E. (2017). Intersect between self-esteem and emotion regulation in narcissistic personality disorder - implications for alliance building and treatment. Borderline Personality Disorder and Emotion Dysregulation, 4(1). https://doi.org/10.1186/s40479- 017-0054-8
Rubinstein, G. (2010). Narcissism and self-esteem among homosexual and heterosexual male students. Journal of Sex & Marital Therapy, 36(1), 24–34. https://doi.org/10.1080/00926230903375594
Skinner, C.S., Tiro, J., & Champion, V. (2015). The health belief model. In K. Glanz., B. Rimer., & K. Viswanath (Eds.), Health behavior: Theory (pp. 76-94). San Francisco, CA: Jossey- Bass.
VanderWeele, T., Balboni, T., & Koh, H. (2017). Health and spirituality. Journal of the American Medical Association. Advance online publication. Retrieved from http://jamanetwork.com
Watson, P. J., Little, T., Sawrie, S. M., & Biderman, M. D. (1992). Measures of the narcissistic personality: Complexity of relationships with self-esteem and empathy. Journal of Personality Disorders, 6(4), 434–449. https://doi.org/10.1521/pedi.1992.6.4.434