Episode 185: Narcissism with Jonathan Shedler, PhD
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Article Authors: Nha Nguyen, Catalina Baas, Jorge Salazar, Jonathan Shedler, PhD, David Puder, MD
In this episode of the podcast, we are joined by Dr. Jonathan Shedler to discuss narcissistic personality disorder. Dr. Shedler is a psychologist, consultant, clinical educator, researcher, and author with over 100 scholarly publications. His article, “The Efficacy of Psychodynamic Psychotherapy,” has garnered worldwide recognition for establishing evidence-based support of psychodynamic psychotherapy.
Narcissism In Pop Culture
It is common in social media and pop culture to blame all manner of bad conduct on “the narcissist.'' Abusive parent? Narcissist. Overbearing boss? Narcissist. Cheating boyfriend? Narcissist. But clinicians with expertise in narcissistic personality understand that narcissism is a complex, many-headed Hydra. There is no such thing as “the narcissist” because narcissism is not one thing but many things. In fact, most descriptions of “the narcissist” on social media mistakenly conflate narcissism with borderline personality and psychopathy. Let’s unpack these things.
In the psychodynamic tradition from which the term “narcissism” arose, narcissistic personality styles exist at different levels on a continuum of health-pathology: at a healthier, neurotic level of personality organization, at a more disturbed borderline level of personality organization, and at a still more disturbed psychotic level. These distinctions are lost in pop culture descriptions that portray all narcissistic people as arrogant, self-inflated, and exploitive, when that is not at all the case.
If we go deeper behind an overt narcissist’s facade of superiority, there is considerable pain. For example, individuals with narcissistic personality are likely to struggle with feelings of emptiness, meaninglessness, and inadequacy, berate themselves for failing to live up to impossible self-imposed standards, and suffer from their inability to develop and keep meaningful relationships. But in social media and pop culture usage, the term “narcissistic” is often used as little more than an epithet to vilify.
Narcissistic Personality
Narcissistic personality is characterized by the coexistence of contradictory feelings of superiority and grandiosity and feelings of vulnerability, emptiness, and inadequacy. In overt narcissism, we tend to see only one side of this inner conflict: the self-importance, grandiosity, and entitlement. But internally, the person is torn between feelings of superiority and painful feelings of emptiness and unworthiness. The overt grandiosity defends against and masks the underlying feelings of emptiness, inadequacy, and inferiority. The person works continually to shore up their fragile sense of self and makes use of others to support this effort. They need others as an audience, to witness and affirm their importance, and this need can override the awareness that those recruited as their audience are also human beings with their own emotions, needs, vulnerabilities, and experiences. This interferes with developing the kind of mutual, genuine relationships that give life a sense of meaning and purpose, that could counteract the inner sense of emptiness and deficiency. The result is that a person with a narcissistic personality dynamics can be surrounded by admirers, but starve emotionally in a sea of plenty.
There are two main manifestations of narcissistic personality: grandiose (or overt) narcissism and vulnerable (or covert) narcissism. People with grandiose or overt narcissism present as self-important, entitled, and superior. Their narcissistic defenses are generally effective in keeping their feelings of inadequacy at bay, at least most of the time. Underneath the overt self-importance, however, lie deep feelings of fragility and inadequacy.
In vulnerable or covert narcissism, in contrast, the narcissistic defenses against inadequacy fail. Rather than experiencing themselves as superior, people with covert narcissism experience themselves, and come across to others, as deflated, self-critical, and beaten down by life. Although they often present symptoms of depression in clinical practice, they generally derive little benefit from treatments that specifically target these depressive symptoms. Beneath their suffering and self-criticism, clinicians often find that their inner life is dominated by fantasies of importance, success, and glory. They are the main characters in their internal narratives --unappreciated, unrecognized, and denied their rightful place in the world. At different times, the same individual may present as either a grandiose or vulnerable narcissist, depending on how well their defenses are functioning at that point in time and how well the external world is cooperating with those defenses. Both manifestations of narcissism lead to difficulties in developing and maintaining meaningful and lasting interpersonal connections. Ultimately, the person’s life feels painfully empty.
The expressions of grandiose and vulnerable narcissism reflects the operation of psychological defenses. Kampe et al., in their 2021 study, found that both types of narcissism are associated with neurotic and maladaptive defenses such as reaction formation, acting out, splitting, and passive-aggression. However, unlike the vulnerable type, the grandiose type was also significantly associated with some defense mechanisms they deemed adaptive, including rationalization, anticipation, and dissociation (Kampe et al., 2021). These defenses help protect against painful emotions and are associated with a more positive mental state, at least on the surface. This may help explain why vulnerable narcissism is more often associated with observable psychological distress.
Levels Of Personality Organization
Based on a theoretical framework developed by psychoanalyst Otto Kernberg, personality styles fall along a continuum of severity with three main levels of organization: neurotic, borderline, and psychotic (Kernberg, 2004).
At the neurotic level of personality organization, there is an intact sense of reality, presence of mature defenses, a coherent sense of self, and the capacity to form meaningful connections with others. Neurotic-level narcissism is a healthier version of narcissism that actually plays a vital role in society. People with neurotic, higher-functioning narcissistic personalities can be visionaries, innovators, and charismatic leaders. We often see them as the tech moguls or CEOs of successful, powerful companies. They are the people with the grand visions and the drive and confidence to make them a reality. Like all people with narcissistic personality styles, they have an inflated self-image, but this exaggerated confidence allows them to take risks, persevere in the face of setbacks, inspire others, and build something of real and lasting value. With healthy narcissism, grandiosity is anchored in reality: in other words, the attention and recognition they crave is linked to actual achievement, not defensive fantasy. Also, their capacity for attachment is largely intact; unlike those at more severe levels of disturbance, they are capable of caring, empathy, and love.
Borderline personality organization is a more severe level of disturbance. Reality testing remains generally intact—that is, the person is not delusional—but immature and highly costly defenses distort perceptions of both self and others and cause substantial impairment in functioning. As a rule, when narcissism is pronounced enough to warrant a DSM diagnosis of narcissistic personality disorder (NPD), the person is functioning at a borderline level of personality organization. The central defenses at this level of organization are splitting (dissociation or compartmentalization of good and bad feelings), projection, and projective identification. The person cannot see themselves or others in shades of gray, recognizing that humans are necessarily a complex mix of good and bad qualities, virtues and shortcomings. Instead, they see people in black-and white categories of good and bad, heroes and villains, saints and unredeemable sinners.
In the case of the borderline-level narcissist, the defense of splitting takes the form of ascribing all good and admirable qualities to themselves and projecting limitations, failures, and bad feelings onto others. Thus, they experience themselves as all-good and all-important while perceiving others as weak, inadequate, and inferior. At this level of personality organization, defensive grandiosity distorts realistic self-perceptions. The person expects recognition and rewards for their unique talents and achievements, irrespective of whether they are real or merely imagined. They expect accolades and preferential treatment, earned or unearned. Kernberg refers to this defensively distorted self-concept as the “pathological grandiose self” (Kernberg, 2007). It is maintained by dissociating and projecting negative aspects of identify onto others. Thus, the self is idealized while others are then devalued. Projective identification takes the defense of projection a step further, by treating others in ways that actually induce or elicit the unwanted feelings that have been projected with such vehemence.
Most social media and pop-culture depictions of narcissistic personality are, in fact, descriptions of a narcissistic personality style at a borderline level of personality organization. For example, “gaslighting”—thought by social media pundits to be a central feature of narcissism—most often results from the borderline-level defense of projective identification, which has the effect of distorting the other person’s experience of self, leading them to doubt and question their own perceptions and judgements. Some clinicians on the receiving end of projective identification have described it as a feeling of having their minds “colonized’ by something alien.
A still more severe and destructive version of narcissism is termed malignant narcissism. Always organized at a borderline level of personality organization, malignant narcissism is narcissism suffused with sadistic aggression. The capacity to attach to and care for others is severely damaged, and interpersonal relationships are dominated by aggression and hate. Others exist merely to be used, exploited, and coldly discarded. Merely feeling important or superior isn’t enough for the malignant narcissist; others must be demeaned, defeated, and vanquished. At this level of functioning, malignant narcissism shades into frank psychopathy. Pop-culture and social media portrayals of “narcissism” often fail to distinguish narcissism, malignant narcissism, borderline personality organization, and outright psychopathy.
At psychotic levels of personality organization, thinking is disordered more globally. Reality testing is compromised and boundaries between inner experience and external reality become blurred. Grandiose fantasies may reach delusion levels, and perceptions of others may likewise be distorted to the point of delusion, leading to serious impairments in social, occupational, and personal functioning.
Origin And Treatment of NPD: Kohut vs. Kernberg
NPD is a complex disorder that has many conflicting ideas about its origin and therapeutic treatment. The most significant arguments surround the theories of Kohut and Kernberg.
Kohut believed that NPD was a result of a developmental deficit; in childhood, narcissistic patients failed to develop a stable identity or capacity to internally regulate their own self-esteem. Consequently, they rely on others for external validation (Russel, 1985). Recognizing this, Kohut advocated for treating narcissism with empathy, understanding, and mirroring. He thought this form of therapy could allow narcissistic patients to resume the developmental trajectory and thrive. In contrast, Kernberg explained narcissism in terms of object relationships theory. He believed narcissism developed as a defense in response to parents who made the child feel inadequate and unloved. He recommended that therapists confront the narcissistic defenses that protect against underlying feelings of inadequacy, with the goal of helping the patient to integrate their split, unintegrated internal representations of self and others.
Research On Transference-Focused Psychotherapy With Emphasis On Changing Reflective Function And Attachment
Transference-focused psychotherapy (TFP) is a twice-weekly psychoanalytic psychotherapy most commonly used in the treatment of borderline personality disorder. It utilizes the patient-therapist relationship to help patients with identity consolidation, emotional regulation, and interpersonal functioning (Levy et al., 2019). TFP has shown effectiveness in treating borderline personality disorder, in part, through improvement of attachment style and reflective function.
Reflective function is the ability to understand oneself and other people with respect to the thoughts, feelings, desires, and intentions that drive behaviors. Rather than taking behaviors at face value (for example, a child throwing a tantrum is bad), someone with intact reflective function is able to consider the underlying mental state that might be driving the behavior (the child is tired and grumpy). Reflective function is thought to be critical to proper social functioning, and impairments in this ability have been associated with a poorer state of mental health (Anis, 2020).
Although TFP has primarily been studied for borderline personality disorder, similarities in the underlying pathology (especially attachment style and reflective function) suggest TFP may also be a useful treatment approach for narcissistic personality disorder (Diamond and Hersh, 2020).
Research On Transference-Focused Psychotherapy In BPD
In a randomized-controlled trial conducted by Levy et al., “Changes in attachment organization and reflective function were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD)” (2006). In this study, ninety patients diagnosed with BPD were randomized into three treatment groups: transference-focused psychotherapy, dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. To assess attachment organization, the Adult Attachment Interview and the reflective function coding scales were used. The study found that patients’ narrative coherence and reflective function can increase by participating in one year of intensive transference focused psychotherapy. In addition, the authors found that “patients treated with TFP evidenced significant increases in [reflective function], attachment coherence, and rates of being classified as secure with respect to attachment as compared with the other treatment conditions” (Levy et al., 2006). Overall, the study concluded that TFP is an effective treatment for BPD and is more successful than dialectical behavior therapy and supportive psychotherapy in changing attachment.
A separate publication, which appears to evaluate the same study groups as Levy et al., looked at the effects of TFP, dialectical behavior therapy, and psychodynamic supportive psychotherapy on “suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment” (Clarkin et al., 2007). It was found that TFP and DBT improved suicidality, while TFP and supportive psychotherapy improved both anger and impulsivity. TFP was the only method significantly associated with improvement of irritability and verbal or physical assault.
In a year-long, randomized-controlled trial, 104 female outpatients were treated with either TFP or by a community psychotherapist in order to “compare transference-focused psychotherapy with treatment by experienced community psychotherapists” (Doering et al., 2010). The study found that both treatments significantly improved depression and anxiety; however, TFP improved general psychopathy while treatment with the psychotherapist did not. In general, TFP was shown to be superior to treatment by experienced community psychotherapists in treating BPD and reducing suicidality and psychiatric inpatient admissions.
A 2015 randomized-controlled trial presented by Fischer-Kern et al. used a sample of 104 patients with BPD to evaluate changes in reflective function. Results suggest improvements in reflective function for those treated with TFP within one year of treatment, while the group treated by experienced community therapists showed no improvement.
A 2017 study by Buchheim et al. compared patients undergoing transference focused psychotherapy and patients seeing experienced community psychotherapists (ECP). They aimed to assess changes in attachment representations, focusing on narrative coherence and resolution of unresolved attachment. Coherence refers to the connection, consistency, and logical relationship between different parts of discourse, where thoughts are clearly related and adapted to the context (Main and Goldwyn, 1998). The results showed significant improvements in attachment security and unresolved trauma within the TFP group, but no significant changes within the ECP group. The coherence scale showed significant improvement within both treatment groups, but the improvement was considerably higher in the TFP group. The between-group difference was also significant; the ECP group had a small Cohen's effect size (d=0.18), and the TFP group had a large effect size (d=1.27).
The 2017 study confirmed previous findings that TFP is better at transitioning individuals from insecure to secure attachment. However, it also revealed a new finding that TFP can lead to a change from unresolved to organized attachment, which is significant for patients with a history of severe maltreatment, abuse, and loss. The shift from insecure to secure attachment status suggests an enhancement in “coherence, attachment-related autonomy, and flexible integration” (Buchheim et al., 2017). TFP, with its structured and emotionally intense approach, creates a safe space for patients to reflect on their attachment patterns. It facilitates integration of polarized emotions, as well as improvement of the understanding of oneself and others, to achieve a more coherent mental state with potential for long-lasting benefit (Buchheim et al., 2017).
Research On Transference-Focused Psychotherapy for NPD
A 2017 publication by Stern et al. presented a case example where TFP was used to treat an individual with narcissistic personality disorder. The authors emphasized the importance of “establishing a viable treatment contract, setting the tone and focus of the treatment, and establishing the treatment as an anchor in the patient’s life” early on in the process. They stated that the early stages of therapy can be challenging to work through but, eventually, the patient can be brought to a more exploratory state of mind where they are more receptive to therapeutic reflection and analysis. Eventually, patients become more tolerant of the “negative self-experiences they had projected onto the outside world, while also tolerating more realistic, imperfect representations of self and others” (Stern et al., 2017).
In their 2020 article, Diamond and Hersh describe a treatment model for TFP for narcissistic patients. They cited examples of this method in clinical practice. The first step is contract-setting, which establishes the roles and responsibilities of the patient and therapist. The next stage involves defining and exploring the patient’s dominant object relational dyads. Next, the therapist must identify role-reversal. The narcissistic patient may perceive the therapist as devaluing them and respond by devaluing the therapist through words or actions. As the patient becomes more aware of internally fluctuating between grandiosity and devaluation, they can work toward improvement. Finally, the later stages of TFP involve working through the patient’s narcissistic defenses with the goal of attaining a mature, stable sense of self (Diamond and Hersh, 2020).
Transference And Countertransference In Narcissistic Personality
The therapeutic relationship feels significantly different with narcissistic clients than with clients that are not afflicted with NPD. Therapists frequently observe a resistance in narcissistic patients to reciprocate efforts to delve deeper into their psychological state. For narcissists, transference is expressed in the form of devaluing and idealizing. This transference can be explained psychoanalytically: “Rather than projecting a discrete internal object such as a parent onto the therapist, they externalize an aspect of their self” (McWilliams, 2011). In other words, the narcissistic patient projects their devalued or idealized self onto the therapist.
Both idealization and devaluation serve to shore up the narcissistic patient’s fragile sense of identity. When they devalue the therapist, they feel superior by contrast. The therapist on the receiving end of the devaluation will endure repeated experiences, subtle and not-so-subtle, of disparagement and belittlement. When they idealize the therapist, they feel more special by virtue of their association with the therapist. “The therapist…becomes a container for their internal process of self-esteem maintenance” (McWilliams 2011). The idealized therapist may feel a countertransference “pull” to join with the patient in a mutual admiration society of two, but experienced therapists know that idealization can quickly shift into devaluation, and both reactions are unrealistic and two-dimensional. With both devaluation and idealization, the patient fails to appreciate that therapists, like all people, have their own experiences and feelings, and are complex blends of admirable qualities and personal limitations.
In response to the devaluing transference, therapists often experience countertransference feelings of boredom, disengagement, or anger. These countertransference responses are a window into the kinds of reactions the patient may elicit from others in their life. Therapists often report experiences of feeling invisible to the patient. “A typical comment about a narcissistic client from a therapist supervision: ‘She comes in every week, gives me the news of the week in review, critiques my clothing, dismisses all my interventions, and leaves. Why does she keep coming back? What is she getting out of this?’” (McWilliams 2011). Despite the instinctive reactions of emotional withdrawal or retaliation when faced with devaluation, effective therapists understand that their feelings are information about the patient’s inner world, and learn to use countertransference constructively as a source of information. Therapists who struggle with this are wise to process their own emotional responses in their own psychotherapy or in supervision.
It is helpful for therapists to hold in mind that narcissistic transference, whether expressed through devaluation or idealization, is not a referendum on their own actual positive or negative attributes, but rather serves a psychological function for the patient. The therapeutic task is to understand how and why this is the case, and help the patient come to understand it too.
Applying Countertransference
Treating patients with NPD can be taxing, as the transference can elicit strong negative feelings. As previously mentioned, the natural reaction is to disengage and retort, but it is important to be attentive to the countertransference evoked.
Therapists must be fully aware of the transference and countertransference environment with narcissistic patients. What interactions are present that are drawing out these emotions? Instead of feeding into natural instincts, what can be addressed interpersonally? What does this countertransference reveal about their behavior in the therapy relationship? How does this relate to their reasons for coming to treatment? Through this approach, the therapist can harness countertransference as a tool, sparking introspection in the narcissistic client, thus catalyzing their journey towards self-acceptance and diminishing the propensity to belittle and demean others.
By achieving this, we would simultaneously work towards one of the primary goals of therapy, which is to address the patient's defenses that hinder their ability to perceive the therapist as a complete individual. Once this objective is accomplished, it significantly increases the likelihood of the patient appreciating others as individuals and, as a result, developing the ability to foster healthier relationships.
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