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Treatment Modalities and Therapies

 by: Sam Vaknin

Narcissism constitutes 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.

Moreover, the Narcissistic Personality Disorder (NPD) is frequently diagnosed with other, even more intractable personality disorders, mental illnesses, and substance abuse.

Cognitive-Behavioral Therapies (CBTs)

The CBTs 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 as far as coping with some of its effects goes (behavioural modification).

Dynamic Psychotherapy

Or Psychodynamic Therapy, Psychoanalytic Psychotherapy

As opposed to 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 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.

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).

Group Therapies

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 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 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 ameliorates or even vanquishes some antisocial behaviors.

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 they learn how to deceive their therapists.

Here are some hard facts:

There are gradations and shades of narcissism. The difference between two narcissists can be great. The existence of grandiosity and empathy or lack thereof are not

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