By Dr. Jason N. Camu
licensed clinical psychologist
The term conjures a variety of different images of self-centered and troubled characters. Curiously, these may also be the patients we love to make important in our minds and in time with colleagues, reliving the therapeutic hour in a verbose parallel process.
Yet a closer examination of the term reveals widespread variation in what the term actually means to clinicians. I have found that for some, especially those that unknowingly identify with the projected feelings and inadequacy of the narcissistic patient (expanded upon later in the prose), the word is an opportunity to disparage the individual, differentiating oneself from this malignant form of self love.
It seems most often, that “narcissistic” unless explained in greater detail by the treating professional, is ambiguous and less than useful. And in fact the term appears to be a simple metaphor for a particular form of counter transference. The reaction I refer to is distaste for this patient’s unregulated self-aggrandizing braggadocio, and egocentric self-centered view of him or herself and the world. Even half a step back with an objective lens reveals this struggling person’s pathetic need for attention, acceptance and approval. Yet when you are the target of projected insignificance and used as a defensive object with whom to see unwanted parts of the self, finding compassion for this patient is more difficult. Complicating matters, the lay-public uses the terms “narcissist” or “narcissistic” to mean a multiplicity of other ambiguous characters, including sociopaths. As I have mentioned in other articles, our responsibility to our patients is to understand more than the layman.
It is the narcissistically damaged patients’ use of defenses that makes them so difficult (perhaps even feared), especially when they are highly intelligent and at times, smarter than the doctor, a fact that may be difficult to accept. Because of their keen awareness of threat, need to sustain their precious image, and sometimes finely tuned interpersonal skills, these patients may be affluent, attractive, articulate, and present other confounding variables to the therapist. These factors are also infuriatingly juxtaposed to the helping professional’s selfless image and prized modesty and humility.
Juvenile-like needs to engage the psychologist in competitions are just the first of so many challenges. Belittling, challenges to competence, aggressive highly personal observations and comments, and a persistent general picking at the therapist may make this fractured person difficult work, i.e., “I [patient] notice you [psychologist] always wear a suit and tie, I remember when I used to have to wear a monkey-suit.”
Narcissistic defenses are generally unattractive with a primitive sometimes almost assaultive quality. Thus,commonly when the narcissistic patient is being described or the term is being used it is the defenses that are being described not the state of the person For example, take the remarkably self-centered individual that demeans. As a very smart, preened, and mega-wealthy patient once said to me, “So you’re a psychologist, I have a number of those on my team, they are like whores to the court, they [psychologists] work great for us [lawyers].” While your reaction can reveal a lot about yourself, this “narcissist” is communicating in the only way he knows how. He must make himself feel bigger and better in a desperate attempt to feel adequate. He must make me as small as possible. Yet in doing so he will succeed in again avoiding his issues with his arsenal of defenses. Only competence will help this patient feel comfortable, safe, and able to use insight to face his greatest weaknesses. With multiple failed relationships he continues to hurt those he loves with immature acting out and cruel and insensitive insults. However, he does love and care for other people. This capacity to take another’s perspective is a fundamental differentiation diagnostic feature that is so important in his treatment. He uses people as objects to inflate the self, but with overwhelming hunger he also craves the very same objects’ respect, love and approval.
Yet like the ill-equipped adolescent, he will not let his image slip in favor of vulnerability. The narcissist acts compulsively and almost instinctively to hurt others. While most of us
may understand why to some degree—he feels small himself—it is the origins of his smallness, and the nature of his strengths that require key diagnostic attention.
I find the narcissistic diagnosis to be remarkably helpful in the broadest sense; it speaks to a category of painful injuries that have damaged this person’s internal self-image. The term in my work refers to an individual with a variety of strengths and abilities but with dire, deeply painful injuries to the self. Said simply, as this patient was in the process of forming his identity he received remarkably damaging and piercing injuries to his self under construction. The developmental process of creating a sense of oneself, that is the biological organism’s interaction with his or her early world and the feedback received, marks the origins of either a healthy internal representation of the self, or a pathological narcissistic formation. Succinctly put, did this person receive adequate praise and recognition along with criticism to create a functional and sufficiently content sense of self? If the biological organism with his or her own unique strengths and weaknesses was met with a poor match in primary caregivers, we may see the genesis of a damaged/inadequate sense of self. I find this concept particularly useful in that it also traverses theoretical orientations while maintaining an essential theme. For example, whether you think in terms of internal representations, schemas, or simply self-image, you can see that the mental image held in memory is fractured, frail and in constant danger of demolition. These deeply stored memories contain interactions with other objects (people), the affect/charge that binds the interaction, and are the basis for identity, but also the seedlings of morality, a conscience, and operation of oneself as an adult.
When the feedback or mirroring from primary caregivers serves to severely damage the blossoming enthusiastic narcissism of the developing child, narcissistic issues may be formed. It is this realization that will ultimately aid the psychologist in finding the elusive compassion for this type of person. With patience, the treating professional will ultimately wade through—perhaps battered and beaten—the onslaught of the patient’s attacks to find the real story, a story rich with deeply hurtful experiences for the patient. Often, although not exclusively the experiences will be easily identified in the form of criticisms and acrid, caustic insults from key developmental figures. As one patient recalled from when he was just a young boy: “I picked a flower, probably just like a weed or something for a neighbor girl. My father said, ‘What are you hiding behind your back there, you little queer?’ He smashed the flower on the ground with his shoe [like a cigarette] and boy did I get a beating.”
Most important are the distinguishing diagnostic characteristics of the narcissistic character. It is here that I find psychoanalytic concepts so helpful. Extending well beyond the limitations of the DSM groupings of symptoms, an excellent diagnostic impression (commonly called ego-assessment) can shape treatment. Unlike the borderline patient who can also attack and criticize, the narcissistic patient has the ability for self-reflection. Under the proper conditions, the narcissistically damaged character can and will look at his or her contribution to life. The borderline patient cannot use introspection, pushing the patient to do so will typically result in disorganization and/or a defensive split, making the therapist the hated agent rather than the bringer of wisdom. It is this distinguishing quality (self-reflection) that makes these patients treatable with insight oriented approaches, not just supportive techniques.
Key assessment considerations include intelligence, strength and forcefulness of drives, focus and attention, affect management and tolerance abilities and skills, ability to articulate feelings, quality of sense of self, and most importantly the ability for introspection. Many patients with insight capabilities may first require tools for affect regulation and management. But he or she may ultimately benefit from more insight oriented forms of treatment because they can acknowledge weaknesses through self-reflection—a process that is based in innate abilities as well as the early internalization of key primary objects that form a conscience and lead to empathy. Carefully using diagnostic labels and terms for oneself, and fully understanding what we mean (for ourselves) by those terms will only strengthen how we implement treatment and help our patients improve. To correspond regarding this or other articles, please contact me, Dr. Jason Camu via email at: firstname.lastname@example.org.