Narcissistic Personality Disorder Treatment Modalities and Therapies
Frequently Asked Question # 77
Narcissists attend therapy only as a last resort and only in order to restore their access to narcissistic supply.
Narcissists hold the therapist in contempt and seek to establish their grandiose superiority and entitlement by playing mind games and by undermining the therapeutic alliance.
By: Dr. Sam Vaknin
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Is Narcissistic Personality Disorder (NPD) more amenable to Cognitive-Behavioural therapies or to Psychodynamic/Psychoanalytic ones?
Narcissism pervades the entire personality. It is all-pervasive. Being a narcissist is akin to being an alcoholic but much more so. Alcoholism is an impulsive behaviour. Narcissists exhibit dozens of similarly reckless behaviours, some of them uncontrollable (like their rage, the outcome of their wounded grandiosity). Narcissism is not a vocation. Narcissism resembles depression or other disorders and cannot be changed at will.
Adult pathological narcissism is no more "curable" than the entirety of one's personality is disposable. The patient 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.
Replaces problem behaviors with constructive ones via conditioning and reinforcement
Changes negative automatic thoughts and schemas that lead to attributional and other biases as well as errors in order to alter problematic behaviors and dysfunctional feelings and behaviors.
Third wave of behavior therapy:
Primacy of therapeutic relationship, learning principles, analyze triggers and environmental cues, explore schemas and emotions, utilize modelling, homework, and imagery.
Dialectical Behavior Therapy (DBT)
Developed by Linehan in 1993 to treat BPD, but used with other personality disorders and disorders of mood, anxiety, eating, and substance abuse. It is deployed mainly with female patients in inpatient or residential settings.
Emphasizes emotional and affect regulation rather than cognitions.
Concerned with how were schemas formed via dialectic conflicts: seeks to connect affect and need to cognitive inference processes and belief systems so as to be reinterpreted with greater self-awareness
Identifies fixation or perseveration causes by early developmental deprivation and protective attentional constriction
Examines effects of negative reinforcement through emotional avoidance or inadequate coping skills rewarded through the partial reinforcement effect
Involves individual therapy, group skills training, phone contact, and therapist consultation. Focuses on using validation and problem solving to counter severe behavioral dyscontrol, issues of quiet desperation, problems of living, and reducing incompleteness.
Cognitive Behavior Analysis System of Psychotherapy (CBASP)
Developed by McCullough and adapted by Sperry. Not used with BPD.
Clients learn to analyze life situations and manage daily stressors. They evaluate which thoughts and behaviors prevent desired outcomes.
Elicitation and remediation: questions about the situation, the client's role and functioning in it, and the desired outcome lead to a revision of counterproductive behaviors and cognitions.
Replaces emotional reasoning with consequential one.
Mindfulness-based Cognitive Therapy (MBCT)
Developed by Teasdale.
Fosters aware focus on thoughts, feelings, and experiences in the present with an attitude of acceptance and without analysis or judgment.
Developed by Sperry
Pattern: predictable, consistent, self-perpetuating style of thinking, feeling, acting, coping, and self-defense. Can be adaptive (competent) or maladaptive (inflexible, ineffective, inappropriate, cause symptoms, impair functioning and satisfaction).
Therapy consists of replacing hurtful maladaptive patterns (situational interpretations and behaviors) with helpful adaptive ones.
Developed by Young
Changes maladaptive schemas: 18 enduring and self-defeating ways of regarding oneself and others, arranged in 5 domains. Schemas are perpetuated through coping styles: schema maintenance, avoidance, and compensation.
Schemas can be reconstructed, modified, interpreted, or camouflaged.
TABLE 1.2 Maladaptive Schemas and Schema Domains
Disconnection and Rejection
• Abandonment/Instability: The belief that significant others will not or cannot
provide reliable and stable support.
• Mistrust/Abuse: The belief that others will abuse, humiliate, cheat, lie,
manipulate, or take advantage.
• Emotional Deprivation: The belief that one’s desire for emotional support will
not be met by others.
• Defectiveness/Shame: The belief that one is defective, bad, unwanted, or inferior
in important respects.
• Social Isolation/Alienation: The belief that one is alienated, different from
others, or not part of any group.
Impaired Autonomy and Performance
• Dependence/Incompetence: The belief that one is unable to competently meet
everyday responsibilities without considerable help from others.
• Vulnerability to Harm or Illness: The exaggerated fear that imminent
catastrophe will strike at any time and that one will be unable to prevent it.
• Enmeshment/Undeveloped Self: The belief that one must be emotionally close
with others at the expense of full individuation or normal social development.
• Failure: The belief that one will inevitably fail or is fundamentally inadequate in
achieving one’s goals.
• Entitlement/Grandiosity: The belief that one is superior to others and not bound
by the rules and norms that govern normal social interaction.
• Insufficient Self-Control/Self-Discipline: The belief that one is incapable of
self-control and frustration tolerance.
• Subjugation: The belief that one’s desires, needs, and feelings must be suppressed
in order to meet the needs of others and avoid retaliation or criticism.
• Self-Sacrifice: The belief that one must meet the needs of others at the expense of
one’s own gratification.
• Approval-Seeking/Recognition-Seeking: The belief that one must constantly
seek to belong and be accepted at the expense of developing a true sense of self.
Overvigilance and Inhibition
• Negativity/Pessimism: A pervasive, lifelong focus on the negative aspects of life
while minimizing the positive and optimistic aspects.
• Emotional inhibition: The excessive inhibition of spontaneous action, feeling, or
communication—usually to avoid disapproval by others, feelings of shame, or losing
control of one’s impulses.
• Unrelenting Standards/Hypercriticalness: The belief that striving to meet
unrealistically high standards of performance is essential to be accepted and to avoid
• Punitiveness. The belief that others should be harshly punished for making errors.
Developed by Kernberg
Infants form internal representations of self-others (objects) connected via affect. A personality disorder occurs when positive and negative representations fail to integrate later in life. Such splitting affects all relationships, including the therapeutic one.
Transference to the therapist exposes the faulty relationship template and allows for its empathic correction. Identity integration is accomplished as the patient experiences negative emotions in a safe environment.
Developed by Bateman and Fonagy.
Experience secure attachment and enhancing impulse control by empathically and insightfully reflecting on and correctly labelling one’s state of mind, especially one’s powerful emotions, and cognitive errors. This leads to improves relational skills.
Developed mainly by Blocher, Citright, and Sperry
Regards problems in personal growth and needs satisfaction on a dimensional continuum from disordered to adequate to optimal.
Developed by Vaknin
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Developed by Sam Vaknin, Cold Therapy is based on two premises: (1) That narcissistic disorders are actually forms of complex post-traumatic conditions; and (2) That narcissists are the outcomes of arrested development and attachment dysfunctions. Consequently, Cold Therapy borrows techniques from child psychology and from treatment modalities used to deal with PTSD.
Cold Therapy consists of the re-traumatization of the narcissistic client in a hostile, non-holding environment which resembles the ambience of the original trauma. The adult patient successfully tackles this second round of hurt and thus resolves early childhood conflicts and achieves closure rendering his now maladaptive narcissistic defenses redundant, unnecessary, and obsolete.
Cold Therapy makes use of proprietary techniques such as erasure (suppressing the client’s speech and free expression and gaining clinical information and insights from his reactions to being so stifled). Other techniques include: grandiosity reframing, guided imagery, negative iteration, other-scoring, happiness map, mirroring, escalation, role play, assimilative confabulation, hypervigilant referencing, and re-parenting. It is proving to be an effective treatment for major depressive episodes (see this article about the link between pathological narcissism and depression and this article about depression and regulatory narcissistic supply in narcissism).
Cold Therapy is also a philosophical (really, metaphysical)
I suggest that the client should regard his or her life as a movie. The main goal in life, the core task, and the engine of meaning is to direct the film so as to render it an accomplished hit, a work of art and a masterpiece of narrative.
At every inflection point and faced with any critical decision, the client should truthfully answer the question: would I have paid money to watch this yarn I am weaving, the flick that is my life? If the answer is NO, a transformative change of course is called for.
Directing the film should be the client's overriding priority. Every other thing should be subservient and secondary to it, everyone in the client's life should feature in it.
Yet, the client should navigate this leitmotif and channel his or her creativity without a script, as an exercise in extemporizing. The twists and turns of the plot should come as a surprise first and foremost to the client itself.
Mindfulness in Various Therapies
Modern treatment modalities (psychotherapies) emphasize the
present over the past and future (mindfulness).
There is a clinical diagnosis for the kind of people who are focuses on the moment, care little about the past and others in it, and cannot foresee or take into reckoning the consequences of their actions in the future: psychopaths.
Mindfulness fosters entitlement, grandiosity, dysempathy, and recklessness.
Cognitive-Behavioral Therapies (CBTs)
The CBTs postulate that insight – even if merely verbal and intellectual – is sufficient to induce an emotional outcome. Verbal cues, analyses of mantras we keep repeating ("I am ugly", "I am afraid no one would like to be with me"), the itemizing of our inner dialogues and narratives and of our repeated behavioural patterns (learned behaviours) coupled with positive (and, rarely, negative) reinforcements – are used to induce a cumulative emotional effect tantamount to healing.
Cognitive reframing is not a technique in any treatment
modality. It refers to a mental process of shifting thinking: the inner
conversion of positive thoughts regarding oneself, one's life, and others into
negative cognitions - or vice versa. Cognitive reframing can be induced in
therapy or by the shifting circumstances of one's life as well as by new
Reframing is a shift from one narrative of one's life and of others' place and roles in one's life into another narrative with an explanatory power: an organizing principle which imbues one's personal history with meaning and direction.
The technique used in various psychotherapies is known as cognitive restructuring of cognitive distortions ("automatic negative thoughts" or ANTs). Cognitive restructuring is the main technique used in CBT (Cognitive Behavioral Therapy). Some elements of cognitive restructuring (like guided imagery) are incorporated in Cold Therapy as well (scroll down for more on Cold Therapy).
Psychodynamic theories reject the notion that cognition can influence emotion. Healing requires access to and the study of much deeper strata by both patient and therapist. The very exposure of these strata to the therapeutic 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 provide 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 as far as coping with some of its effects goes (behavioural modification).
Dynamic Psychotherapy, or Psychodynamic Therapy, Psychoanalytic Psychotherapy
This 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 in these therapies – only that it is not a pillar of the technique. Dynamic therapies are usually applied to patients not considered "suitable" for psychoanalysis (such as those suffering from personality disorders, except the Avoidant PD).
Typically, 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.
Psychodynamic therapies are open-ended. At the commencement of the therapy, the therapist (analyst) makes an agreement (a "pact" or "alliance") with the analysand (patient or client). The pact says that the patient undertakes to explore his problems for as long as may be needed. 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 or 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 (instinctual, related to drives) pressures. Supportive therapies seek to increase the patient's ability to REPRESS conflicts (rather than bring them to the surface of consciousness).
When the patient's painful conflicts are suppressed, the attendant dysphorias and symptoms vanish or are ameliorated. 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 collaborative efforts of any kind, let alone group therapy. They immediately size up others as potential Sources of Narcissistic Supply – or as potential competitors. They idealise 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 interactions of its members. Narcissists are individualists. They regard coalitions with disdain and contempt. The need to resort to team work, to adhere to group rules, to succumb to a moderator, and to honour and respect the other members as equals is perceived by them to be humiliating and degrading (a contemptible weakness). Thus, a group containing one or more narcissists is likely to fluctuate between short-term, very small size, coalitions (based on "superiority" and contempt) and narcissistic outbreaks (acting outs) of rage and coercion.
Can Narcissism be Cured?
Adult narcissists can rarely be "cured", though some scholars think otherwise. Still, the earlier the therapeutic intervention, the better the prognosis. A correct diagnosis and a proper mix of treatment modalities in early adolescence guarantees success without relapse in anywhere between one third and one half the cases. Additionally, ageing moderates or even vanquishes some antisocial behaviours.
This article appears in my book, "Malignant Self-love: Narcissism Revisited"
Click HERE to buy electronic books (e-books) and video lectures (DVDs) about narcissists, psychopaths, and abuse in relationships
In their seminal tome, "Personality Disorders in Modern Life" (New York, John Wiley & Sons, 2000), Theodore Millon and Roger Davis write (p. 308):
"Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid ... Interpretation and even general assessment are often difficult to accomplish..."
The third edition of the "Oxford Textbook of Psychiatry" (Oxford, Oxford University Press, reprinted 2000), cautions (p. 128):
"... (P)eople cannot change their natures, but can only change their situations. There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character ... Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve them."
The fourth edition of the authoritative "Review of General Psychiatry" (London, Prentice-Hall International, 1995), says (p. 309):
"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."
The reason narcissism is under-reported and healing over-stated is that therapists are being fooled by smart narcissists. Most narcissists are expert manipulators and consummate actors and they learn how to deceive their therapists.
Here are some hard facts:
In therapy, the general idea is to create the conditions for the True Self to resume its growth: safety, predictability, justice, love and acceptance - a mirroring, re-parenting, and holding environment. Therapy is supposed to provide these conditions of nurturance and guidance (through transference, cognitive re-labelling 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.
Most therapists try to co-opt the narcissist's inflated ego (False Self) and defences. They compliment the narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.
By stroking the narcissist's grandiosity, they hope to modify or counter cognitive deficits, thinking errors, and the narcissist's victim-stance. They contract with the narcissist to alter his conduct. Some even go to the extent of medicalizing the disorder, attributing it to a hereditary or biochemical origin and thus "absolving" the narcissist from his responsibility and freeing his mental resources to concentrate on the therapy.
This article appears in my book, "Malignant Self-love: Narcissism Revisited"
Click HERE to buy electronic books (e-books) and video lectures (DVDs) about narcissists, psychopaths, and abuse in relationships
Confronting the narcissist head on and engaging in power politics ("I am cleverer", "My will should prevail", and so on) is decidedly unhelpful and could lead to rage attacks and a deepening of the narcissist's persecutory delusions, bred by his humiliation in the therapeutic setting.
Successes have been reported by applying 12-step techniques (as modified for patients suffering from the Antisocial Personality Disorder), and with treatment modalities as diverse as NLP (Neurolinguistic Programming), Schema Therapy, and EMDR (Eye Movement Desensitization).
But, whatever the type of talk therapy, 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 grandiosity (really, defences and resistances) ensues: "He (my therapist) should be my colleague, in certain respects it is he who 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 does? It's us (him and me) against a hostile and ignorant world (shared psychosis, folie a deux)…"
Then there is this internal dialog: "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 exchange becomes more vituperative and pejorative as therapy progresses.
Agnes Oppenheimer wrote this in the International Dictionary of Psychoanalysis:
“Mirror transference is the remobilization of the grandiose self. Its expression is: "I am perfect and I need you in order to confirm it." When it is very archaic, mirror transference can easily result in feelings of boredom, tension, and impatience in the analyst, whose otherness is not recognized. Counter-transference is thus a sign of it.
The notion, which first appeared in Heinz Kohut's work in "The Psychoanalytic Treatment of Narcissistic Personality Disorders" (1968), was further elaborated in his Analysis of the Self (1971). Mirror transference can take three forms, depending on the degree of regression and the nature of the point of fixation. Fusion transference is the most archaic form and refers to a primary identity relationship in which the Other is completely part of the self. It shows itself when the analyst is taken to be omnipotent and tyrannical and is experienced as an extension of the self. In twinship or alter ego transference, the other is experienced as being like the self. Lastly, in mirror transference properly speaking, the analyst is experienced as a function in service of the patient's needs. If the patient feels recognized, he experiences a sense of well-being linked to the restoration of his narcissism.
Mirror transference can be primary, the reaction to a broken idealizing transference, or secondary to one of these. In The Restoration of the Self (1977), Kohut distinguished it from alter ego transference. Some authors have refused to consider this transference as being a result of the evolution of narcissism; they have seen it as a defense.”
Narcissists generally are averse to being medicated. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks and hate to be "under the influence" of "mind altering" drugs prescribed to them by others.
Additionally, many of them believe that medication is the "great equaliser" – it will make them lose their uniqueness, superiority and so on. That is unless they can convincingly present the act of taking their medicines as "heroism", a daring enterprise of self-exploration, part of a breakthrough clinical trial, 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 dramatise 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.
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