Case Study # 3
By: Dr. Sam Vaknin
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Positive feelings (about oneself or pertaining to one's accomplishments, assets, etc.) are never gained merely through conscious endeavor. They are the outcome of insight. A cognitive component (factual knowledge regarding one's achievements, assets, qualities, skills, etc.) plus an emotional correlate that is heavily dependent on past experience, defense mechanisms, and personality style or structure ("character").
People who consistently feel worthless or unworthy usually overcompensate cognitively for the lack of the aforementioned emotional component.
Such a person doesn't love himself, yet is trying to convince himself that he is loveable. He doesn't trust himself, yet he lectures to himself on how trustworthy he is (replete with supporting evidence from his experiences).
But such cognitive substitutes to emotional self-acceptance won't do.
The root of the problem is the inner dialog between disparaging voices and countervailing "proofs". Such self-doubting is, in principle, a healthy thing. It serves as an integral and critical part of the "checks and balances" that constitute the mature personality.
But, normally, some ground rules are observed and some facts are considered indisputable. When things go awry, however, the consensus breaks. Chaos replaces structure and the regimented update of one's self-image (via introspection) gives way to recursive loops of self-deprecation with diminishing insights.
Normally, in other words, the dialog serves to augment some self-assessments and mildly modify others. When things go wrong, the dialog concerns itself with the very narrative, rather than with its content.
The dysfunctional dialog deals with questions that are far more fundamental (and typically settled early on in life):
"Who am I?"
"What are my traits, my skills, my accomplishments?"
"How reliable, loveable, trustworthy, qualified, truthful am I?"
"How can I separate fact from fiction?"
The answers to these questions consist of both cognitive (empirical) and emotional components. They are mostly derived from our social interactions, from the feedback we get and give. An inner dialog that is still concerned with these qualms indicates a problem with socialization.
It is not one's "psyche" that is delinquent but one's social functioning. One should direct one's efforts to "heal", outwards (to remedy one's interactions with others) not inwards (to heal one's "psyche").
Another important insight is that the disordered dialog is not time-synchronic.
The "normal" internal discourse is between concurrent, equipotent, and same-age "entities" (psychological constructs). Its aim is to negotiate conflicting demands and reach a compromise based on a rigorous test of reality.
The faulty dialog, on the other hand, involves wildly disparate interlocutors. These are in different stages of maturation and possessed of unequal faculties. They are more concerned in monologues than in a dialog. As they are "stuck" in various ages and periods, they do not all relate to the same "host", "person", or "personality". They require time- and energy-consuming constant mediation. It is this depleting process of arbitration and "peacekeeping" that is consciously felt as nagging insecurity or, even, in extremis, self-loathing.
A constant and consistent lack of self-confidence and a fluctuating sense of self-worth are the conscious "translation" of the unconscious threat posed by the precariousness of the disordered personality. It is, in other words, a warning sign.
Thus, the first step is to clearly identify the various segments that, together, however incongruently, constitute the personality. This can be surprisingly easily done by noting down the "stream of consciousness" dialog and assigning "names" or "handles" to the various "voices" in it.
The next step is to "introduce" the voices to each other and form an internal consensus (a "coalition", or an "alliance"). This requires a prolonged period of "negotiations" and mediation, leading to the compromises the underlies such a consensus. The mediator can be a trusted friend, a lover, or a therapist.
The very achievement of such internal "ceasefire" reduces anxiety considerably and remove the "imminent threat". This, in turn, allows the patient to develop a realistic "core" or "kernel", wrapped around the basic understanding reached earlier between the contesting parts of his personality.
The development of such a nucleus of stable self-worth, however, is dependent on two things:
The latter is inextricably bound with the former.
This article appears in my book, "Malignant Self-love: Narcissism Revisited"
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Here is why:
Some of the "voices" in the internal dialog of the patient are bound to be disparaging, injurious, belittling, sadistically critical, destructively skeptical, mocking, and demeaning. The only way to silence these voices or at least "discipline" them and make them conform to a more realistic emerging consensus is by gradually (and sometimes surreptitiously) introducing countervailing "players".
Protracted exposure to the right people, in the framework of mature interactions, negates the pernicious effects of what Freud called a Superego gone awry. It is, in effect, a process of reprogramming and deprogramming.
There are two types of beneficial, altering, social experiences:
The problem with the disordered person is that, usually, his (or her) chances of freely interacting with mature adults (intercourse of the type 2, non-structured kind) are limited to start with and dwindle with time. This is because few potential partners interlocutors, lovers, friends, colleagues, neighbors are willing to invest the time, effort, energy, and resources required to effectively cope with the patient and manage the often-arduous relationship. Disordered patients are typically hard to get along with, demanding, petulant, paranoid, and narcissistic.
Even the most gregarious and outgoing patient finally finds himself isolated, shunned, and misjudged. This only adds to his initial misery and amplifies the wrong kind of voices in the internal dialog.
Hence my recommendation to start with structured activities and in a structured, almost automatic manner. Therapy is only one and at times not the most efficient choice.
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