Duquesne University Pittsburgh, February 2, 2020
Nancy McWilliams, PhD Rutgers Graduate School of Applied & Professional Psychology Mass culture and globalization Mobility and change Extension of adolescence Increased insecurity about one’s role Celebrity culture and illusions of perfection Increased global insecurity and wishes for perfect security from an idealized parent ◦ Realistic and reliable self-esteem
◦ Realistic ambition
◦ Ordinary needs for validation
◦ Relationship to developmental life stages Jones, E. (1913). The God complex: The belief that one is God, and the resulting character traits. In Essays in applied psycho-analysis (vol. 2, pp. 244-265). London: Hogarth Press. Adler, A. (1927). Understanding human nature. Garden City, NY: Garden City Publishing. Freud, S. (1914). On narcissism: An introduction. Standard Edition, 14, 67-102. Reich, W. (1933). Character analysis. New York: Farrar, Straus, & Giroux. Rosenfeld, 1987: “thick-skinned” / “thin-skinned” Gabbard, 1989: “oblivious” / “hypervigilent” types Masterson, 1993: “exhibitionistic” / “closet” types McWilliams, 1994: “arrogant” / “depressed-depleted” Akhtar, 2000: “overt” / “covert or shy” types
Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the therapeutic process. Washington, DC: American Psychological Association. Russ, E., Bradley, R., Shedler, J., & Westen, D. (2008). Refining the construct of narcissistic personality disorder: Diagnostic criteria. American Journal of Psychiatry, 165, 1473-1481. Developmentally normal narcissistic concerns; Narcissistic tendencies, especially under specific stresses; Narcissistic personality disorder; Malignant narcissism; Psychopathy (antisocial personality disorder).
Kernberg, O. (2014). An overview of the treatment of severe narcissistic pathology. International Journal of Psychoanalysis, 95(5), 865-888. Kernberg, O. F. (1975). Borderline states and pathological narcissism. New York: Jason Aronson. Kernberg, O. F. (1976). Object relations theory and clinical psychoanalysis. New York: Jason Aronson. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Kohut, H. (1977). The restoration of the self. New York: International Universities press. Kohut, H. (1984). How does analysis cure? (A. Goldberg, Ed., with P. Stepansky). Chicago: University of Chicago Press. Carl Rogers: Rogers, C. R. (1951) Client-centered therapy: Its current practice, implications, and theory. Boston: Houghton Mifflin. Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin. D. W. Winnicott: Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York: International Universities Press. Miller, A. (1984). Prisoners of childhood: The drama of the gifted child and the search for the true self. New York: Basic Books. Mucci, C. (2019). Borderline bodies: Affect regulation therapy for personality disorders. New York, NY: Norton.
Clinical observations about the person’s having been used as a narcissistic extension:
◦ The caregiver needs the child for mirroring rather than vice versa. ◦ Never-satisfied and inflated versions of child care. ◦ Parents continuing to deal with their own adolescent issues. Morrison, A. P. (Ed.) (1986). Essential papers on narcissism. New York: New York University Press.
Masterson, J. F., & Klein, R. (Eds.) (1995). Disorders of the self: New Therapeutic Horizons. The Masterson Approach. Part III: Perspectives on treating the narcissistic disorder of the self (pp. 281-335). Lynd, H. M. (1958). On shame and the search for identity. New York: Harcourt, Brace & World. Lewis, H. B. (1971). Shame and guilt in neurosis. New York: International Universities Press. Wurmser, L. (1981). The mask of shame. Baltimore, MD: Johns Hopkins University Press. Nathanson, D. (Ed.) (1987). The many faces of shame. New York: Guilford. Morrison, A. P. (1989). Shame: The underside of narcissism. Hillsdale, NJ: Analytic Press. Lewis, M. (1995). Shame: The exposed self. New York: The Free Press. Kelly, V. C., Jr., & Lamia, M. (2018). The upside of shame: Therapeutic interventions using the positive aspects of a “negative” emotion. New York: Norton. Deborah Thomas, doctoral thesis and forthcoming book. Bursten, B. (1973). Some narcissistic personality types. International Journal of Psycho-Analysis, 54, 287-300. McWilliams, N., & Lependorf, S. (1990). Narcissistic pathology of everyday life: The denial of remorse and gratitude. Journal of Contemporary Psychoanalysis, 26, 430-451. Inability to make one’s needs explicit; Inability to express genuine appreciation; Inability to express genuine remorse; Confusion between love and idealization, leading to constant criticism of others once the idealization fades. Terror of death and preoccupation with bodily integrity; Blaming when up against a “no,” no matter how reasonable the limit; Difficulty in treating narcissistic dynamics in people who have not run into limits (of health, beauty, competence, power): narcissism and psychopathy as the only two personality styles that become more treatable the older one is. Inability to mourn, including resistance to feeling separation and tolerating normal termination in psychotherapy. Drive theory: When all one’s energy goes into keeping oneself together, there is nothing left for others. Object relations: The diminished self, becoming a false self, seeks perfect merger with a perfect object which cannot be relinquished to a good-enough reality. Ego psychology: Defenses of primitive idealization and devaluation prevent appreciation of others as they really are. Self psychology: If challenges to normal self-esteem development are too great, the project of maintaining self- esteem overrides care for others. Attachment theory: An insecure attachment style negates the possibility of “mentalizing” other minds. Relational psychoanalysis: Lack of recognition creates inability to see others as subjects. Affect theory: Deep shame and humiliation prevent authentic engagement with others. Freud was wrong in believing that narcissistic people do not form transferences in therapy.
What Kohut called “self-object transferences” can be understood as the patient’s treating the therapist as a source of self-esteem regulation, much as the parents may have used the patient as a narcissistic extension. Boredom Sleepiness Feelings of invisibility Irritability Defensiveness Empty grandiosity The narcissistic person experiences any difference of opinion or recommendations to solve problems as disabling criticism. If we try to be a constantly approving witness to the narcissistic person’s life, nothing changes, and bad habits are supported. But if we try, however empathically, to call attention to something that might be changed, the narcissistic person fragments into a depressive state or defends against it by attacking, blaming, and devaluing. Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press. Bach, S. (1993). Narcissistic states and the therapeutic process. Northvale, NJ: Jason Aronson. Riordan, R. W. (2012). The management of narcissistic vulnerability: Three cases guided by Stephen Mitchell’s integrated treatment model. Pragmatic Case Studies in Psychotherapy, 8(3), Article 1, 150-203. Available: http://pcsp.libraries.rutgers.edu. http://dx.doi.org/10.14713/pcsp.v8i3.1771. Mucci, C. (2019). Borderline bodies: Affect regulation therapy for personality disorders. New York, NY: Norton. Gabbard, G. O., & Crisp, H. (2019). Narcissism and its discontents: Diagnostic dilemmas and treatment strategies with narcissistic patients. Washington, DC: American Psychiatric Association. Remembering that this is the best way this person knows how to relate to another; Focusing on whether the patient has made his or her needs explicit; Focusing on thanking and apologizing; Thanking and apologizing from the therapist: exemplifying that one can maintain self-esteem without having to be needless and flawless; Embedding all intervention in respect for realistic positives in the person; Expressing humor in the face of devaluation. Encouraging normal mourning. Educating Coaching Finding other sources of personal support Mourning what is not possible [email protected]
27 psychiatrists and mental health experts assess a president. New York: St. Martin’s Press. The DSM description of Antisocial Personality Disorder was taken from the work of Lee Robins, a sociologist who tried to describe psychopathic individuals in terms of externally observable qualities.
Therapists have contrastingly been struck with the internal dynamics that constitute a psychopathic mental set. Henderson, D. K. (1939). Psychopathic states. New York: Norton.
Cleckley, H. (1941). The mask of sanity: An attempt to clarify some issues about the so-called psychopathic personality. St. Louis, MO: Mosby.
Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and treatment. Northvale, NJ: Jason Aronson.
Hare, R. D. (1999). Without conscience: The disturbing world of the psychopaths among us. New York: Guilford. 1. Inability to sustain consistent work behavior; 2. Inability to function as a responsible parent; 3. Failure to accept social norms; 4. Inability to maintain enduring attachment to a sexual partner; 5. Irritability and aggressiveness; 6. Failure to honor financial obligations; 7. Failure to plan ahead (impulsivity); 8. Disregard for the truth (repeated lying); 9. Recklessness (e.g., speeding, driving drunk). The DSM Antisocial Personality Disorder section was originally normed on prison inmates, who cannot all be assumed to be psychopathic. Other sources of criminal behavior include addiction, poverty, socialization to psychopathic norms, and loyalty to fellow criminals and the conventions of law-breaking subcultures.
As a result, it overdiagnoses psychopathy in poor, minority, and traumatized populations and underdiagnoses it in individuals of higher socioeconomic status. Lack of remorse (in response to complaints from clinicians, for whom this was the pathognomonic symptom of a psychopathic orientation) 1. Manipulativeness 2. Callousness 3. Deceitfulness 4. Hostility 5. Risk-taking 6. Impulsivity (actually, this is not distinctively characteristic of psychopathy) 7. Irresponsibility Profound attachment disorder Profound superego pathology (lacunae) Omnipotent control as the organizing defense Orientation toward power above all else Treatment of others as objects to manipulate rather than subjects to respect Self-esteem based on “getting over” on others Restricted range of affects, with rage and envy predominating High threshold for stimulation Lack of capacity for remorse People in general will act psychopathically if they are in situations in which authorities seem to be arbitrary, ruthless, capricious, or negligent.
For example, a majority of doctors will lie to insurance companies on behalf of their patients’ well-being. Some people with significant psychopathy, especially those with histories of violence, are untreatable. Like narcissistic dynamics, treatment has a better prognosis the older the patient is. Relationship must be based on respect for power rather than conventional empathy. Therapist must be brutally honest. Therapist must have very clear boundaries and enforce them relentlessly. Therapist must emphasize the cost to the patient of psychopathic behavior. Bursten, B. (1973). The manipulator: A psychoanalytic view. New Haven, CT: Yale University Press. Kernberg, O. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Meloy, J. R. (1988). The psychopathic mind: Origins, dynamics, and treatment. Northvale, NJ: Jason Aronson. Meloy, J. R. (2001). The mark of Cain: Psychoanalytic insight and the psychopath. Psychiatric Annals, 27, 630- 633. Babiak, P., & Hare, R. D. (2007). Snakes in suits: When psychopaths go to work. New York: Harper Paperback. Stone, M. (2009). The anatomy of evil. New York: Prometheus Books. [email protected]