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Psychologist
is leader in narcissism
research, treatment
(December
2006 Issue)
From Greek mythology to modern psychology, narcissists have come
a long way…and they will be the first to tell you all about it.
Often misunderstood and downright ridiculed by the general public,
narcissists face unique challenges to mental health, both from society's
disregard for this very real illness and from their own inability
to see that there is, in fact, anything wrong. To a narcissist,
believing that he/she deserves to be at the center of the universe
to the exclusion of anyone or anything is just a brutally honest
way of looking at the world.
For years, narcissism was considered untreatable. But during the
past 40 years, mental health professionals have begun to identify
treatment procedures. One of the leaders in the field, Elsa F. Ronningstam,
Ph.D., Harvard Medical School associate professor of psychology
in the Department of Psychiatry, spoke with New England Psychologist's
Catherine Robertson Souter about the condition and the amazing strides
that experts have made in the field. Ronningstam has lectured on
the subject, written many articles and published two books (including
2005's "Identifying and Understanding the Narcissistic Personality").
Q: According to your book jacket, you have spent more than 29
years studying and treating narcissism. What drew you to this field?
A: After I graduated from school in Sweden, I started to see
people whom I found very interesting and fascinating. Although it
was thought that they couldn't relate to anyone else, they gradually
began to relate through treatment.
It is difficult to say what makes a click but I found it extremely
interesting. With those first people, I began to see constructive
results and that opened the idea that they are treatable. As I began
to do my research, it became more interesting.
Q: These early patients had narcissistic tendencies?
A: They had narcissistic disturbance. I didn't recognize it
immediately. At that point, I was a psychologist and then I decided
to pursue my Ph.D. In Sweden, you have a five-year training towards
a masters for psychology and then the Ph.D. is in research. My research
was at McLean Hospital as a fellow.
Q: Tell us about your research.
A: I started with identifying narcissistic personality disorders
and then I did a follow up study in the '90s and developed a diagnostic
instrument together with John Gunderson, M.D., the medical director
of the Center for the Treatment of Borderline Personality Disorder
at McLean, where I am also affiliated. At that time, it was found
that the self-esteem really fluctuated in narcissistic people. They
easily lose self-esteem. They also discovered that narcissists can
change but they may not change in the usual way through treatment.
There can be other factors that contribute to the change like the
experience of corrective life events. They also found that the capacity
for relationships is very important for a positive prognosis. People
who can connect and stay in a relationship and be committed, have
better prognoses.
Another area I studied was suicidality in narcissistic patients.
Narcissistic people can be suicidal or act with suicidal intentions
without being clinically depressed. It is driven by other motives
such as anger or revenge or to save themselves from an impossible
life situation - from being shamed or degraded or facing something
that is disgraceful.
Q: Is narcissism widespread?
A: It is not such a common thing as a full-blown personality
disorder by itself. However, disordered narcissists, people who
have narcissistic tendencies are not an uncommon thing. There is
a new concept that is called trauma associated narcissistic reactions.
People can react with narcissistic traits and behaviors in a stressful
situation like when they lose their job or in situations of divorce
or other very hard life contexts. Suddenly, they will have increased
symptoms. Stress related with trauma can overwhelm the self and
trigger symptoms such as shame, humiliation and rage and extreme
self-esteem fluctuations. That can happen to people with relatively
healthy self-esteem as well as people who have propensity for narcissism.
My way of looking at narcissism is as a continuum. Narcissism is
like a dementia: from healthy narcissism to pathological to narcissistic
personality disorder to psychopathy. It is important to see that
everybody has narcissism, self esteem, self regard, self protection
and a normal sense of entitlement. There are a lot of normal aspects
to narcissism. In stressful situations, anybody's self esteem can
react to the extreme temporarily.
Q: In your research have you identified new ways of treating
the problem?
A: Psychoanalysis and analytic psychotherapy was long considered
the treatment method. But now group therapy is one way of treating
narcissism to make people with the same problem interact and recognize
it in each other. They can understand more about themselves through
others who are not too different.
Another way of treatment is family and couples therapy. Something
I suggested for some narcissistic people is DBT, dialectical behavior
therapy. It teaches skills to handle interpersonal relations and
emotional fluctuations and anger and suicidality.
Q: Can narcissism be cured?
A: There are several things that can contribute to change. One
has to do with maturity and learning through life experiences over
time. People tend to develop more self restraint. They can learn
from experience, our research has proven. If you have a capacity
to mourn or grieve or tolerate depression or regrets, you are more
likely to change. They can also benefit from psychotherapy focusing
on the lying, shame and superiority feelings that often force them
to act in the opposite direction, more superior or more entitled.
It is important to see narcissistic disorder as a dialectical functioning
between very difficult feelings: a strong sense of inferiority and
the opposite, a sense of superiority and unrealistic entitlement.
The purpose of the treatment is to see how these extremes can meet
in the middle.
Q: And many of them won't seek treatment in the first place,
because they don't see anything wrong. Is that a major issue?
A: Right, they only seek treatment if something happens. They
face an ultimatum: come to treatment or they will lose their job
or get divorced. They might have legal problems - something happens
that makes them realize they have to change. That's also why life
experiences are important. That is my next research project. I am
in the beginning of a project focusing on change in narcissistic
patients. I have developed a questionnaire and I am looking for
clinicians who have been treating people with narcissistic personality
disorder or significant narcissistic problems to be able to conceptualize
how narcissistic patients change.
Q: Narcissism gets a very bad rap, possibly worse than any other
mental illness. It is probably more consistently seen as a character
flaw, rather than an illness. Is this unfair and why?
A: I think it's a worthwhile issue for a psychologist to pay
attention to. Developmentally, we know that people who end up with
narcissistic personality disorder have had their share of developmental
experiences. There is documentation on a connection to cold or emotionally
unsatisfying or threatening developmental experiences or parental
relationships. Or they have been over-evaluated as children, assigned
tasks that are beyond their developmental capacities, for instance,
being a replacement for a spouse who left or a mother or sibling
who died.
Narcissistic people have long been considered to be lacking in
empathy. That's something I question. It may be more about the way
they practice empathic functioning. The real exciting thing happening
now is the research on empathy because that has opened up a way
of seeing empathy not just as something you have or don't have but
that there is a broad range of empathic functioning or capacity.
That's also part of my new research. I am looking into what influences
empathic functioning in narcissistic patients.
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