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Narcissism and Its Discontents

Diagnostic Dilemmas and Treatment Strategies With Narcissistic Patients


Journal of Psychiatric Practice®: May 2019 - Volume 25 - Issue 3 - p 239–240
doi: 10.1097/PRA.0000000000000379
Book Reviews

Elsa Ronningstam, PhD, Department of Psychiatry, Harvard Medical School, Belmont, MA

Marcia L. Verduin, MD, Book Editor


We are facing an era in our society with increased attention to narcissism and its different implications. By now a broad concept related to both cultural and sociopolitical as well as personality and psychopathological contexts, narcissism has gradually reached specificity as well as being the subject of significant controversy. Within our field of mental health, narcissism and its disordered conditions, including narcissistic personality disorder, are facing increasing attention, which unfortunately has led to negative connotations, misconceptions, and clinicians’ avoidance of both diagnosing and treating patients with these conditions. Consequently, patients struggling with narcissistic personality disorder tend to shun such a diagnosis and even reject hints of being perceived as “narcissistic.” On the other hand, many clinical and empirical contributions over the past 20 to 25 years have offered important facts and perspectives on the nature of pathologic narcissism, which have been informative for implementing improved strategies for diagnosis and treatment. Nevertheless, the controversy and contrasting views on narcissism and narcissistic personality pathology call for more solid and clarifying guidelines for clinicians. There is an urgent need for strategies to help identify and treat these patients who, underneath a more or less strikingly superior and provocative facade, can struggle with internal fluctuations, insecurity, fear, despair, shame, and trauma.

Glen Gabbard’s and Holly Crips’s most timely and informative book Narcissism and Its Discontents, focusing on diagnostic dilemmas and treatment strategies with narcissistic patients, serves to fill this gap. It is an exceptionally thoughtful integration of multiple clinical perspectives on narcissism with attention to recent empirical and clinical contributions. The authors direct the readers’ attention away from these patients’ strikingly provocative appearance and interactive behavior, guiding readers toward an understanding of the fluctuations in narcissistic individuals self-regulation and self-esteem. Attending to and recognizing each individual’s internal struggle and subjective experiences related to disordered narcissism are indeed essential for clinicians to be able to reach and treat patients with narcissistic pathology.

This book is most helpful and timely as it highlights the tension between our efforts to find the optimal strategy to treat pathologic narcissism and more persistent narcissistic character disorder, and the inevitable emerging challenges in the alliance between therapist and patient. It questions the ambition and rationalization of implementing a principal strategy that guarantees “change” and “cure” in narcissistic behavior, and points to the necessity of integrating therapeutic interventions in the context of exploration and the gradually unfolding understanding of the individual narcissistic patient. The authors repeatedly point to the importance of adjusting the treatment to the patient, to meet the patient and to balance interventions. The descriptions of narcissistic patterns, facets, and characteristics in nonjudgmental, informative terms help to explain the often complex interactions and contradictions between patients’ subjective experiences and feelings and their ways of relating to others in different contexts, including the therapeutic relationship. In particular, the authors attend to the dilemma most psychotherapists struggle with of coming to premature or hasty conclusions, providing comments or interpretations that can readily make the patients feel misunderstood, blamed, or criticized, and stirring up disagreements and alliance ruptures.

The authors also stress the necessity of flexibility and openness in approaching patients with narcissistic pathology, especially given the range and diversity of individual narcissistic functioning. They pay attention to the meaning behind patients’ provocative behavior or resistance and how this can inform the clinician about the patient’s actual internal functioning and experiences. They convey a remarkable and most important respect and curiosity, and they emphasize the significance of finding a proactive approach to balance patients’ demands and their objections to involvement with treatment frame and technique. This is helpful guidance for clinicians and psychotherapists as it incorporates the many dimensions of pathologic narcissism—from vulnerable to grandiose, from high competency to low functioning, with more or less severe comorbidity, from overtly evident/manifest to covertly indiscernible, and from oblivious to hypervigilant. The authors also pay attention to patients’ competence as a resource, a foundation for affiliation and functioning in life to be incorporated in treatment independently of its fragility, or its association with enhancement and grandiosity.

In a chapter devoted to treatment strategies, the authors specifically address numerous dilemmas, challenges, and impasses that can unfold in the treatment of patients with narcissistic pathology. The common denominator in their guidelines is to attend both to the therapists’ difficult experiences as well as to the patients’ intentions from a subjective narcissistic perspective. Their respectful and nonjudgmental approach in outlining each problem, including entitlement and demands, envy, shame, contempt, rage, and suicidality, provides remarkable grounding and practical approaches that can help therapists find their way through times of agonizing countertransference. Perceiving and utilizing countertransference as an informative source of guidance to attend to patients’ ability and motivation and to put aside “power struggles” is remarkably helpful. Reading this book can also help clinicians and therapists accept and tolerate that there is not and cannot be a single superior or effective approach to treatment of disordered narcissism, but that alliance building and choice of treatment approaches have to be a gradual process adjusted to the individual patient’s motivation and functioning, as well as to basic treatment frames and strategies.

In sum, this is a very timely and helpful contribution for clinicians and psychotherapists independent of the stage of their careers. It is also a most instructive and needed educational guide on the range of narcissistic pathology and its treatment.

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