Series Editor: Paulette M. Gillig, MD, PhD
Drs. McLean and Gillig are from the Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.
Editor Note:All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.
Abstract
Kohut’s self psychology model, narcissistic psychopathology is a result of parental lack of empathy during development. Consequently, the individual does not develop full capacity to regulate self esteem. The narcissistic adult, according to Kohut’s concepts, vacillates between an irrational overestimation of the self and irrational feelings of inferiority, and relies on others to regulate his self esteem and give him a sense of value. In treatment, Kohut recommends helping the patient develop these missing functions. Kohut proposes that the therapist should empathically experience the world from the patient’s point of view (temporary indwelling) so that the patient feels understood. Interpretations are used when they can help the patient understand his sometimes intense feelings about any empathic failure on the part of the therapist, and understand why he (the patient) needs to restore solidity and comfort after being injured by any failed empathic (self object) ties. As insight develops, the patient begins to understand why he might experience these apparently small empathic failures so deeply.
In this article, therapy with a narcissistic patient is approached from the point of view of Kohut’s self psychology theory, and the successes and problems that were encountered with this approach are described and discussed.
Key Words:Kohut, self-psychology, narcissistic personality disorder, temporary indwelling, self object, empathy, psychoanalytic psychotherapy, mirroring transference, idealizing transference, transmuting internalization
Introduction
Narcissistic personality disorder (NPD) is one of the least diagnosed of the personality disorders. However, it is estimated that the disorder, or narcissistic traits, are present in a large number of patients presenting to a psychiatrist’s office with complaints of depression or other mood symptoms.
Approximately 18 percent of males and six percent of females have narcissistic traits.[1] The prevalence of the full-blown NPD in the clinical population ranges from 2 to 16 percent and exists in the general population at a rate of less than one percent.[2] This disorder tends to be more predominant in male subjects with 50 to 75 percent of NPD cases being male.[2]
The main characteristics of NPD are grandiosity, need for admiration, and lack of empathy (Table 1). These characteristic behavior patterns can affect a patient’s interpersonal relationships and life in a profoundly negative manner. Often these patients will outwardly behave with a sense of entitlement and superiority, be dismissive of others, and often display disdainful or patronizing attitudes. However, behind these attitudes, and central to this personality disorder, are low self esteem and feelings of inadequacy. Although many patients accomplish high achievements, eventually the characteristics of this disorder interfere with both the patient’s occupation and his or her personal relationships. This is because the patient often is unable to recover from criticism or rejection and also because he or she has behaved in an unempathic manner with overall disregard for others.
Heinz Kohut proposes that in order to understand the narcissistic patient, the therapist must assume an empathic-introspective observational stance. By doing so, the therapist can understand the complex, inner world of the patient and the patient’s inner subjective experience. The patient can then communicate freely, and the analyst becomes privy to what is being repressed or warded off by the patient. Self psychology, like object-relations theory, emerged out of an effort to treat patients who were not responding to ego psychology therapies constructed around the analysis of psychological defenses.[4]
Heinz Kohut asserts that adult narcissistic psychopathology is a result of parental lack of empathy during development. By failing to provide appropriate empathic feedback during critical times in a child’s development, the child does not develop the ability to regulate self esteem, and so the adult vacillates between an irrational overestimation of the self and feelings of inferiority.
Figures 1 and 2).[4]
Furthermore, the adult relies on others to regulate his self esteem and give him a sense of value, essentially looking for empathic feedback not received during development. Kohut believes that under normal circumstances, the developing infant has two important psychological constructs: the grandiose-exhibitionistic self (normally evolving into self-assertive ambitions) and the idealized parental imago (normally evolving into internalized values and ideals). Pathology in the first area results in fixation on grandiosity, and pathology in the latter area results in deficits, where the psychopathology is rooted in fixations on archaic idealizations (In Kohut’s self psychology model, the dyad occurring between a child and his parents is a continually evolving process (via the formation of self objects). In Kohut’s theory, a self object consists of the developing child plus each of those people who give the child the abilities to maintain self structure and firmness and a sense of cohesion and steadiness.[5] They are self objects because, according to Kohut, the infant is unaware that they are not part of his- or herself and that they are providing functions the infant will later learn to do on his or her own as these functions are incorporated into his or her psychic structure. In Kohut’s model, when certain self object needs are not met empathically, a developmental arrest occurs and pathologic narcissism can occur. Kohut describes three reasons for this relative lack of parental empathy to occur: 1) A poor fit between the child and parents in regards to the disposition of both; 2) the parent(s) is unable to react to and nurture the child, which can often be secondary to physical or mental limitations; and/or 3) the child has unusually great self object needs.[6] Whatever the reason, the earlier and more pervasive the failures occur, the more severe the developmental arrest and the degree of narcissistic pathology in the adult.
Case Presentation (Composite Case)
Michael was a 38-year-old man who presented with complaints that he lacked the ability to develop and maintain friendships. He spent most of his adult life employed as a police officer but had made few friendships with his coworkers. He attributed this to their jealously of his intelligence and overall better skill, but also felt that it was also due to his inability to make small talk with people. He desired therapy because in one month he would be switching careers from law enforcement to fire fighting. He said that he wanted a quick fix in order to have an easier time making friends with his new coworkers. Furthermore, he said he was depressed, with low energy, poor focus and concentration, early morning awakening, decreased interest and motivation, and feelings of guilt and shame. Most of the stressors in his life were due to the fact that he did not have many friends or family in his life. In fact, he hoped that by learning to make friends he would also be able to form relationships with his children, with whom he had not had much contact in at least a year.
Michael was born an only child. His parents divorced while his mother was pregnant with him, and after his birth, his mother was left to raise him without the help or support of his father (His father left town never to be heard from again except on a few occasions in Michael’s life). Consequently, Michael’s mother worked two jobs in order to financially support herself and her son. This left Michael to be raised by various relatives in many different homes, as his mother would ask relatives if they could temporarily adopt Michael for short periods of time.
Consequently, he lived in 11 different homes, many in different states, and attended nine different schools from kindergarten through high school. During his last years of high school, he lived with his mother and her boyfriend and was verbally abused by both. After high school graduation, he left his mother’s home and married soon after. He and his wife had two children. They divorced after six years of marriage because “I just didn’t love her anymore. She wasn’t doing anything for me.” He remarried approximately three years later and had two more children. This marriage lasted nine years. Michael reports that his second wife “became too demanding and needy,” which he had difficulty tolerating.
Michael’s children were all living in his current town, yet he did not have a close relationship with any of them. Michael named this as one of his sources of sadness and stated that more recently, as he was aging, he was starting to feel that they should want a closer relationship with him. He was able to admit that he was not a good father to them and was “emotionally not there.” Despite wanting a closer relationship with them, he felt that he had gone out of his way to communicate with them by e-mailing each of them and stating that he was not to blame for being a poor father since he was only parenting the best way he knew how. To do more, he stated, would “be letting them walk all over me.” He felt there was nothing more he could do and that they should voluntarily come to him.
Self Psychology
By describing the quest for a narcissistic individual to fulfill unmet self object needs, Kohut describes a certain aspect of narcissism inherent in all of us. Kohut describes the self as “the center of the psychological universe” and believes we spend our entire lives trying to build and maintain our self esteem through the use of self objects.[7] However, in contrast to other theorists, Kohut does not believe this type of narcissism to be pathologic and argues for continuity between normal infantile narcissism and pathologic narcissism. Kohut argues that pathologic narcissism occurs only with early self object failures. When these failures occur, these patients search for gratification of missing childhood self object needs in their adult lives. They also are fearful of encountering, or repeating, earlier past failures. Therefore, they may present with an attitude of superiority or haughtiness, reflecting anxiety they feel over encountering further self object failures.[7] This fear may also manifest itself in relationships.
Patients with NPD may have a history of many failed relationships secondary to disappointment that the relationship is not giving them the longed-for childhood gratification and their missing self object needs.7 In the case presented in this article, Michael’s perceptions of his current interpersonal relationships reflect this need for gratification, fearfulness, disguised as haughtiness, of encountering earlier past failures, and disappointment in current relationships causing him to abandon them.
Case Presentation, Continued
Michael’s concerns over his children were soon placed on a backburner when his new career began. Instead of mentioning his children, every session focused on peer relationships with his coworkers and how he was feeling left out. He complained that he was never included in card games played during down times at the firehouse and that no one seemed to like him. He could not understand why this was happening to him again as it did with the police force. He said that he was “…someone they should all like. I mean, I’m cooler than most of them.” He also struggled with learning that he was not the most skilled among his peers. During his training, all of his evaluations from his supervisors indicated that his physical fitness and knowledge of firefighting were average. They also indicated that he needed to listen better to suggestions provided by his more experienced peers. One supervisor said that it would serve Michael well to learn to better accept criticism.