The Myth of Mental Illness

"You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird? So let's look at the bird and see what it's doing - that's what counts. I learned very early the difference between knowing the name of something and knowing something."

Richard Feynman, Physicist and 1965 Nobel Prize laureate (1918-1988)

"You have all I dare say heard of the animal spirits and how they are transfused from father to son etcetera etcetera - well you may take my word that nine parts in ten of a man's sense or his nonsense, his successes and miscarriages in this world depend on their motions and activities, and the different tracks and trains you put them into, so that when they are once set a-going, whether right or wrong, away they go cluttering like hey-go-mad."

Lawrence Sterne (1713-1758), "The Life and Opinions of Tristram Shandy, Gentleman" (1759)

I. Overview

Someone is considered mentally "ill" if:

His conduct rigidly and consistently deviates from the typical, average behaviour of all other people in his culture and society that fit his profile (whether this conventional behaviour is moral or rational is immaterial), or

His judgment and grasp of objective, physical reality is impaired, and

His conduct is not a matter of choice but is innate and irresistible, and

His behavior causes him or others discomfort, and is

Dysfunctional, self-defeating, and self-destructive even by his own yardsticks.

Descriptive criteria aside, what is the essence of mental disorders? Are they merely physiological disorders of the brain, or, more precisely of its chemistry? If so, can they be cured by restoring the balance of substances and secretions in that mysterious organ? And, once equilibrium is reinstated - is the illness "gone" or is it still lurking there, "under wraps", waiting to erupt? Are psychiatric problems inherited, rooted in faulty genes (though amplified by environmental factors) - or brought on by abusive or wrong nurturance?

These questions are the domain of the "medical" school of mental health.

Others cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium - the soul. Theirs is a holistic approach, taking in the patient in his or her entirety, as well as his milieu.

The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviours and manifestations of "healthy" individuals, or as dysfunctions. The "sick" individual - ill at ease with himself (ego-dystonic) or making others unhappy (deviant) - is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference.

In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter - but, to a counter intuitively large degree, a faulty methodology.

As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities.

This form of "reverse engineering" of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method. The theory must be all-inclusive (anamnetic), consistent, falsifiable, logically compatible, monovalent, and parsimonious. Psychological "theories" - even the "medical" ones (the role of serotonin and dopamine in mood disorders, for instance) - are usually none of these things.

The outcome is a bewildering array of ever-shifting mental health "diagnoses" expressly centred around Western civilisation and its standards (example: the ethical objection to suicide). Neurosis, a historically fundamental "condition" vanished after 1980. Homosexuality, according to the American Psychiatric Association, was a pathology prior to 1973. Seven years later, narcissism was declared a "personality disorder", almost seven decades after it was first described by Freud.

II. Personality Disorders

Indeed, personality disorders are an excellent example of the kaleidoscopic landscape of "objective" psychiatry.

The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952, in the first edition of the DSM.

The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.

The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.

The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).

The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders.

A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.

Numerous personality disorders are "not otherwise specified" - a catchall, basket "category".

Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

"An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another" (p.689)

The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research. But their omission from official discourse hitherto is both startling and telling:

The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;

The genetic and biological underpinnings of personality disorder(s);

The development of personality psychopathology during childhood and its emergence in adolescence;

The interactions between physical health and disease and personality disorders;

The effectiveness of various treatments - talk therapies as well as psychopharmacology.

III. The Biochemistry and Genetics of Mental Health

Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain - or are ameliorated with medication. Yet the two facts are not ineludibly facets of the same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by the processes or substances affected by the drug administered. Causation is only one of many possible connections and chains of events.

To designate a pattern of behaviour as a mental health disorder is a value judgment, or at best a statistical observation. Such designation is effected regardless of the facts of brain science. Moreover, correlation is not causation. Deviant brain or body biochemistry (once called "polluted animal spirits") do exist - but are they truly the roots of mental perversion? Nor is it clear which triggers what: do the aberrant neurochemistry or biochemistry cause mental illness - or the other way around?

That psychoactive medication alters behaviour and mood is indisputable. So do illicit and legal drugs, certain foods, and all interpersonal interactions. That the changes brought about by prescription are desirable - is debatable and involves tautological thinking. If a certain pattern of behaviour is described as (socially) "dysfunctional" or (psychologically) "sick" - clearly, every change would be welcomed as "healing" and every agent of transformation would be called a "cure".

The same applies to the alleged heredity of mental illness. Single genes or gene complexes are frequently "associated" with mental health diagnoses, personality traits, or behaviour patterns. But too little is known to establish irrefutable sequences of causes-and-effects. Even less is proven about the interaction of nature and nurture, genotype and phenotype, the plasticity of the brain and the psychological impact of trauma, abuse, upbringing, role models, peers, and other environmental elements.

Nor is the distinction between psychotropic substances and talk therapy that clear-cut. Words and the interaction with the therapist also affect the brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines - as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) - treat symptoms, not the underlying processes that yield them.

IV. The Variance of Mental Disease

If mental illnesses are bodily and empirical, they should be invariant both temporally and spatially, across cultures and societies. This, to some degree, is, indeed, the case. Psychological diseases are not context dependent - but the pathologizing of certain behaviours is. Suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, even psychosis are considered sick by some cultures - and utterly normative or advantageous in others.

This was to be expected. The human mind and its dysfunctions are alike around the world. But values differ from time to time and from one place to another. Hence, disagreements about the propriety and desirability of human actions and inaction are bound to arise in a symptom-based diagnostic system.

As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms - i.e., mostly on observed or reported behaviours - they remain vulnerable to such discord and devoid of much-sought universality and rigor.

V. Mental Disorders and the Social Order

The mentally sick receive the same treatment as carriers of AIDS or SARS or the Ebola virus or smallpox. They are sometimes quarantined against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy. This is done in the name of the greater good, largely as a preventive policy.

Conspiracy theories notwithstanding, it is impossible to ignore the enormous interests vested in psychiatry and psychopharmacology. The multibillion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departments, and law enforcement agencies rely, for their continued and exponential growth, on the propagation of the concept of "mental illness" and its corollaries: treatment and research.

VI. Mental Ailment as a Useful Metaphor

Abstract concepts form the core of all branches of human knowledge. No one has ever seen a quark, or untangled a chemical bond, or surfed an electromagnetic wave, or visited the unconscious. These are useful metaphors, theoretical entities with explanatory or descriptive power.

"Mental health disorders" are no different. They are shorthand for capturing the unsettling quiddity of "the Other". Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed. Relegating both the dangerous and the idiosyncratic to the collective fringes is a vital technique of social engineering.

The aim is progress through social cohesion and the regulation of innovation and creative destruction. Psychiatry, therefore, is reifies society's preference of evolution to revolution, or, worse still, to mayhem. As is often the case with human endeavour, it is a noble cause, unscrupulously and dogmatically pursued.


By Sam Vaknin

Powered by Qumana

Eating Disorders and the Narcissist

Patients suffering from eating disorders binge on food and sometimes are both anorectic and bulimic. This is an impulsive behaviour as defined by the DSM (particularly in the case of BPD and to a lesser extent of Cluster B disorders in general). Some patients develop these disorders as a way to self-mutilate. It is a convergence of two pathological behaviours: self-mutilation and an impulsive (rather, compulsive or ritualistic) behaviour.

The key to improving the mental state of patients with dual diagnosis (a personality disorder plus an eating disorder) lies in concentrating upon their eating and sleeping disorders.

By controlling their eating disorders, patients assert control over their lives. This is bound to reduce their depression (even eliminate it altogether as a constant feature of their mental life). This is likely to ameliorate other facets of their personality disorders. Here is the chain: controlling one's eating disorders controlling one's life enhanced sense of self-worth, self-confidence, self-esteem a challenge, an interest, an enemy to subjugate a feeling of strength socialising feeling better.

When a patient has a personality disorder and an eating disorder, the therapist should concentrate on the eating disorder. Personality disorders are intricate and intractable. They are rarely curable (though certain aspects, like OCD, or depression can be ameliorated with medication). Their treatment calls for the enormous, persistent and continuous investment of resources of every kind by everyone involved. From the patient's point of view, the treatment of her personality disorder is not an efficient allocation of scarce mental resources. Also personality disorders are not the real threat. If a patient with a personality disorder is cured of it but her eating disorders are aggravated, she might die (though mentally healthy)?

An eating disorder is both a signal of distress ("I wish to die, I feel so bad, somebody help me") and a message: "I think I lost control. I am very afraid of losing control. I will control my food intake and discharge. This way I control at least ONE aspect of my life."

This is where we can and should begin to help the patient. Help him to regain control. The family or other supporting figures must think what they can do to make the patient feel that he is in control, that he manages things his own way, that he is contributing, has his own schedules, his own agenda, matter.

Eating disorders indicate the strong combined activity of an underlying sense of lack of personal autonomy and an underlying sense of lack of self-control. The patient feels inordinately, paralysingly helpless and ineffective. His eating disorders are an effort to exert and reassert mastery over his own life. At this stage, he is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions (for instance, regarding body image - somatoform disorders) only increase his feeling of personal ineffectiveness and his need to exercise even more self-control (on his diet, the only thing left).

The patient does not trust himself in the slightest. He is his worst enemy, a mortal enemy, and he knows it. Therefore, any efforts to collaborate with HIM against his disorder - are perceived as collaboration with his worst enemy against his only mode of controlling his life to some extent.

The patient views the world in terms of black and white, of absolutes. So, he cannot let go even to a very small degree. He is HORRIFIED - constantly. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of loss of control). All this leads to a chronic absence of self-esteem. These patients like their disorder. Their eating disorder is their only achievement. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through shame and disgust directed at their bodies).

There is a chance to cure the patient of his eating disorders (though the dual diagnosis of eating disorder and personality disorder has a poor prognosis). This - and ONLY this - must be done at the first stage. The patient's family should consider therapy AND support groups (Overeaters Anonymous). Recovery prognosis is good after 2 years of treatment and support. The family must be heavily involved in the therapeutic process. Family dynamics usually contribute to the development of such disorders.

Medication, cognitive or behavioural therapy, psychodynamic therapy and family therapy ought to do it.

The change in the patient IF the treatment of his eating disorders is successful is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and gets a life. His personality disorder might make it difficult for him - but, in isolation, without the exacerbating circumstances of his other disorders, he finds it much easier to cope with.

Patients with eating disorders may be in mortal danger. Their behaviour is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. Our goal is to buy them time. The older they get, the more experienced they become, the more their body chemistry changes with age - the better their prognosis.


By Sam Vaknin

No Picnic In Sight

Upon being diagnosed with Obsessive-Compulsive Disorder, I saw the reality behind the greatest myth of mental illness, the myth that The Victim Is Unaware of His or Her Own Condition. A childhood flooded with media depictions of the mentally ill had lead me to believe that the afflicted had somehow been robbed of their objectivity, thrown into a dark hall-of-mirrors beyond the realm of rational perspective.

Nonsense. My rational mind remained intact, albeit uncomfortably so. From the lighter corner of my mind, I watched darkness flow in. Obsessive images of violence and amorality. Urges, or rather, "pseudo-urges" to do things I didn't want to. Yin (the rational mind) duking it out with yang (the imbalanced, irrational mind) on a daily basis. The word "Hell" was used often when describing this state.

I'm certain that the suffering of many leads to punctured objectivity and the loss of rational self-awareness. Fortunately, I remained aware. No matter how awful I felt, I could at least articulate what was going on. The power of descriptive articulation should not be underestimated. It keeps the disorder in context as a disorder, preserving a firm boundary between the right mind and the ill mind. For me, imagining such a boundary was a vital survival tool. I focused on finding a day when Yin overran Yang, so to speak.

The afflicted mind has difficulty inspiring itself to seek assistance. What a complex entity the mind is; even in sickness, it has only itself to rely upon. Unlike somebody with a broken leg, a person with an anxiety disorder cannot lean on his or her other mind. Overcoming mental duress is like trying to kiss your own lips. Quite tricky, but possible with enough imagination.

Imagination and resourcefulness, that's what it comes down to. These strange ailments go just as they came. I knew that elements of my mind were strong; the challenge was getting these elements to positively influence the weaker ones. This required many analysts, many appointments, many schools of healing. Psychology, psychiatry, homeopathy, reflexology, reiki, energy healing-- these were all thrown in the pot to little avail. Finally and unexpectedly, acupuncture provided balance. I've improved significantly. I thank acupuncture and I thank my supportive family, but, most importantly, I thank counter-mythology: even when afflicted, the human mind sees itself. And in itself, it sees solutions.


Eric Shapiro

Narcissism, Substance Abuse, and Reckless Behaviours

Pathological narcissism is an addiction to Narcissistic Supply, the narcissist's drug of choice. It is, therefore, not surprising that other addictive and reckless behaviours - workaholism, alcoholism, drug abuse, pathological gambling, compulsory shopping, or reckless driving - piggyback on this primary dependence.

The narcissist - like other types of addicts - derives pleasure from these exploits. But they also sustain and enhance his grandiose fantasies as "unique", "superior", "entitled", and "chosen". They place him above the laws and pressures of the mundane and away from the humiliating and sobering demands of reality. They render him the centre of attention - but also place him in "splendid isolation" from the madding and inferior crowd.

Such compulsory and wild pursuits provide a psychological exoskeleton. They are a substitute to quotidian existence. They afford the narcissist with an agenda, with timetables, goals, and faux achievements. The narcissist - the adrenaline junkie - feels that he is in control, alert, excited, and vital. He does not regard his condition as dependence. The narcissist firmly believes that he is in charge of his addiction, that he can quit at will and on short notice.

The narcissist denies his cravings for fear of "losing face" and subverting the flawless, perfect, immaculate, and omnipotent image he projects. When caught red handed, the narcissist underestimates, rationalises, or intellectualises his addictive and reckless behaviours - converting them into an integral part of his grandiose and fantastic False Self.

Thus, a drug abusing narcissist may claim to be conducting first hand research for the benefit of humanity - or that his substance abuse results in enhanced creativity and productivity. The dependence of some narcissists becomes a way of life: busy corporate executives, race car drivers, or professional gamblers come to mind.

The narcissist's addictive behaviours take his mind off his inherent limitations, inevitable failures, painful and much-feared rejections, and the Grandiosity Gap - the abyss between the image he projects (the False Self) and the injurious truth. They relieve his anxiety and resolve the tension between his unrealistic expectations and inflated self-image - and his incommensurate achievements, position, status, recognition, intelligence, wealth, and physique.

Thus, there is no point in treating the dependence and recklessness of the narcissist without first treating the underlying personality disorder. The narcissist's addictions serve deeply ingrained emotional needs. They intermesh seamlessly with the pathological structure of his disorganised personality, with his character faults, and primitive defence mechanisms.

Techniques such as "12 steps" may prove more efficacious in treating the narcissist's grandiosity, rigidity, sense of entitlement, exploitativeness, and lack of empathy. This is because - as opposed to traditional treatment modalities - the emphasis is on tackling the narcissist's psychological makeup, rather than on behaviour modification.

The narcissist's overwhelming need to feel omnipotent and superior can be co-opted in the therapeutic process. Overcoming an addictive behaviour can be - truthfully - presented by the therapist as a rare and impressive feat, worthy of the narcissist's unique mettle.

Narcissists fall for these transparent pitches surprisingly often. But this approach can backfire. Should the narcissist relapse - an almost certain occurrence - he will feel ashamed to admit his fallibility, need for emotional sustenance, and impotence. He is likely to avoid treatment altogether and convince himself that now, having succeeded once to get rid of his addiction, he is self-sufficient and omniscient.

First published in my
"Narcissistic Personality Disorder"
Topic Page on Suite 101


By Sam Vaknin

The Cyber Narcissist

To the narcissist, the Internet is an alluring and irresistible combination of playground and hunting grounds, the gathering place of numerous potential Sources of Narcissistic Supply, a world where false identities are the norm and mind games the bon ton. And it is beyond the reach of the law, the pale of social norms, the strictures of civilized conduct.

The somatic finds cyber-sex and cyber-relationships aplenty. The cerebral claims false accomplishments, fake skills, erudition and talents. Both, if minimally communicative, end up at the instantly gratifying epicenter of a cult of fans, followers, stalkers, erotomaniacs, denigrators, and plain nuts. The constant attention and attendant quasi-celebrity feed and sustain their grandiose fantasies and inflated self-image.

The Internet is an extension of the real-life Narcissistic Pathological Space but without its risks, injuries, and disappointments. In the virtual universe of the Web, the narcissist vanishes and reappears with ease, often adopting a myriad aliases and nicknames. He (or she) can thus fend off criticism, abuse, disagreement, and disapproval effectively and in real time - and, simultaneously, preserve the precarious balance of his infantile personality. Narcissists are, therefore, prone to Internet addiction.

The positive characteristics of the Net are largely lost on the narcissist. He is not keen on expanding his horizons, fostering true relationships, or getting in real contact with other people. The narcissist is forever the provincial because he filters everything through the narrow lens of his addiction. He measures others - and idealizes or devalues them - according to one criterion only: how useful they might be as Sources of Narcissistic Supply.

The Internet is an egalitarian medium where people are judged by the consistency and quality of their contributions rather than by the content or bombast of their claims. But the narcissist is driven to distracting discomfiture by a lack of clear and commonly accepted hierarchy (with himself at the pinnacle). He fervently and aggressively tries to impose the "natural order" - either by monopolizing the interaction or, if that fails, by becoming a major disruptive influence.

But the Internet may also be the closest many narcissists get to psychodynamic therapy. Because it is still largely text-based, the Web is populated by disembodied entities. By interacting with these intermittent, unpredictable, ultimately unknowable, ephemeral, and ethereal voices - the narcissist is compelled to project unto them his own experiences, fears, hopes, and prejudices.

Transference (and counter-transference) are quite common on the Net and the narcissist's defence mechanisms - notably projection and projective identification - are frequently aroused. The therapeutic process is set in motion by the - unbridled, uncensored, and brutally honest - reactions to the narcissist's repertory of antics, pretensions, delusions, and fantasies.

The narcissist - ever the intimidating bully - is not accustomed to such resistance. Initially, it may heighten and sharpen his paranoia and lead him to compensate by extending and deepening his grandiosity. Some narcissists withdraw altogether, reverting to the schizoid posture. Others become openly antisocial and seek to subvert, sabotage, and destroy the online sources of their frustration. A few retreat and confine themselves to the company of adoring sycophants and unquestioning groupies.

But a long exposure to the culture of the Net - irreverent, skeptical, and populist - usually exerts a beneficial effect even on the staunchest and most rigid narcissist. Far less convinced of his own superiority and infallibility, the online narcissist mellows and begins - hesitantly - to listen to others and to collaborate with them.

First published in my
"Narcissistic Personality Disorder"
Topic Page on Suite 101


By Sam Vaknin

Treatment Modalities and Therapies

Narcissism constitutes the entire personality. It is all-pervasive. Being a narcissist is akin to being an alcoholic but much more so. Alcoholism is an impulsive behaviour. Narcissists exhibit dozens of similarly reckless behaviours, some of them uncontrollable (like their rage, the outcome of their wounded grandiosity). Narcissism is not a vocation. Narcissism resembles depression or other disorders and cannot be changed at will.

Adult pathological narcissism is no more "curable" than the entirety of one's personality is disposable. The patient is a narcissist. Narcissism is more akin to the colour of one's skin rather than to one's choice of subjects at the university.

Moreover, the Narcissistic Personality Disorder (NPD) is frequently diagnosed with other, even more intractable personality disorders, mental illnesses, and substance abuse.

Cognitive-Behavioral Therapies (CBTs)

The CBTs believe that insight - even if merely verbal and intellectual - is sufficient to induce an emotional outcome. If properly manipulated, verbal cues, insights, analyses of standard sentences we keep saying to ourselves ("I am ugly", "I am afraid no one would like to be with me"), inner dialogues and narratives, and repeated behavioural patterns (learned behaviours) coupled with positive (and, rarely, negative) reinforcements - are sufficient to induce a cumulative emotional effect tantamount to healing.

Psychodynamic theories do not believe that cognition can influence emotion. They believe that much deeper strata have to be accessed and studied by both patient and therapist. The very exposure of these strata is considered sufficient to induce a dynamic of healing. The therapist's role is either to interpret the material revealed to the patient (psychoanalysis) by allowing the patient to transfer past experience and superimpose it on the therapist - or to actively engage in providing a safe emotional and holding environment conducive to changes in the patient.

The sad fact is that no known therapy is effective with narcissism ITSELF - though a few therapies are reasonably successful as far as coping with some of its effects goes (behavioural modification).

Dynamic Psychotherapy

Or Psychodynamic Therapy, Psychoanalytic Psychotherapy

As opposed to common opinion it is NOT psychoanalysis. It is an intensive psychotherapy BASED on psychoanalytic theory WITHOUT the (very important) element of free association. This is not to say that free association is not used - only that it is not a pillar of the technique in dynamic therapies. Dynamic therapies are usually applied to patients not considered "suitable" for psychoanalysis (such as Personality Disorders, except the Avoidant PD).

Typically, different modes of interpretation are employed and other techniques borrowed from other treatments modalities. But the material interpreted is not necessarily the result of free association or dreams and the psychotherapist is a lot more active than the psychoanalyst.

These treatments are open-ended. At the commencement of the therapy the therapist (analyst) makes an agreement (a "pact") with the analysand (patient or client). The pact says that the patient undertakes to explore his problems no matter how long it takes (and how expensive it becomes). This is supposed to make the therapeutic environment much more relaxed because the patient knows that the analyst is at his/her disposal no matter how many meetings would be required in order to broach painful subject matter.

Sometimes, these therapies are divided to expressive versus supportive, but I regard this division as misleading.

Expressive means uncovering (=making conscious) the patient's conflicts and studying his/her defences and resistances. The analyst interprets the conflict in view of the new knowledge gained and guides the therapy towards a resolution of the conflict. The conflict, in other words, is "interpreted away" through insight and the change in the patient motivated by his/her insights.

The supportive therapies seek to strengthen the Ego. Their premise is that a strong Ego can cope better (and later on, alone) with external (situational) or internal (instincts, drives) pressures. Supportive therapies seek to increase the patient's ability to REPRESS conflicts (rather than bring them to the surface of consciousness). As a painful conflict is suppressed - so are all manner of dysphorias and symptoms. This is somewhat reminiscent of behaviourism (the main aim is to change behaviour and to relieve symptoms). It usually makes no use of insight or interpretation (though there are exceptions).

Group Therapies

Narcissists are notoriously unsuitable for collaborative efforts of any kind, let alone group therapy. They immediately size up others as potential Sources of Narcissistic Supply - or potential competitors. They idealise the first (suppliers) and devalue the latter (competitors). This, obviously, is not very conducive to group therapy.

Moreover, the dynamic of the group is bound to reflect the interactions of its members. Narcissists are individualists. They regard coalitions with disdain and contempt. The need to resort to team work, to adhere to group rules, to succumb to a moderator, and to honour and respect the other members as equals - is perceived by them to be humiliating and degrading (a contemptible weakness). Thus, a group containing one or more narcissists is likely to fluctuate between short-term, very small size, coalitions (based on "superiority" and contempt) and outbreaks (acting outs) of rage and coercion.

Can Narcissism be Cured?

Adult narcissists can rarely be "cured", though some scholars think otherwise. Still, the earlier the therapeutic intervention, the better the prognosis. A correct diagnosis and a proper mix of treatment modalities in early adolescence guarantees success without relapse in anywhere between one third and one half the cases. Additionally, ageing ameliorates or even vanquishes some antisocial behaviors.

In their seminal tome, "Personality Disorders in Modern Life" (New York, John Wiley & Sons, 2000), Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid ... Interpretation and even general assessment are often difficult to accomplish..."

The third edition of the "Oxford Textbook of Psychiatry" (Oxford, Oxford University Press, reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only change their situations. There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character ... Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve them."

The fourth edition of the authoritative "Review of General Psychiatry" (London, Prentice-Hall International, 1995), says (p. 309):

"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."

The reason narcissism is under-reported and healing over-stated is that therapists are being fooled by smart narcissists. Most narcissists are expert manipulators and they learn how to deceive their therapists.

Here are some hard facts:

There are gradations and shades of narcissism. The difference between two narcissists can be great. The existence of grandiosity and empathy or lack thereof are not minor variations. They are serious predictors of future dynamics. The prognosis is much better if they do exist.

There are cases of spontaneous healing and of "short-term NPD" [see Gunderson's and Roningstam work, 1996].

The prognosis for a classical NPD case (grandiosity, lack of empathy and all) is decidedly not good as far as long-term, lasting, and complete healing. Moreover, narcissists are intensely disliked by therapists.

BUT?

Side effects, co-morbid disorders (such as Obsessive-Compulsive behaviors) and some aspects of NPD (the dysphorias, the paranoiac dimensions, the outcomes of the sense of entitlement, the pathological lying) can be modified (using talk therapy and, depending on the problem, medication). these are not short-term or complete solutions - but some of them do have long-term effects.

The DSM is a billing and administration oriented diagnostic tool. It is intended to "tidy" up the psychiatrist's desk. The Personality Disorders are ill demarcated. The differential diagnoses are vaguely defined. There are some cultural biases and judgements [see the diagnostic criteria of the Schizotypal PD]. The result is sizeable confusion and multiple diagnoses ("co-morbidity"). NPD was introduced to the DSM in 1980 [DSM-III]. There isn't enough research to substantiate any view or hypothesis about NPD. Future DSM editions may abolish it altogether within the framework of a cluster or a single "personality disorder" category. As it is, the difference between HPD, BPD, AsPD, and NPD is, to my mind, rather blurred. When we ask: "Can NPD be healed?" we need to realise that we don't know for sure what is NPD and what constitutes long-term healing in the case of an NPD. There are those who seriously claim that NPD is a cultural disease with a societal determinant.

Narcissists in Therapy

In therapy, the general idea is to create the conditions for the True Self to resume its growth: safety, predictability, justice, love and acceptance - a mirroring and holding environment. Therapy is supposed to provide these conditions of nurturance and the guidance necessary to achieve these goals (through transference, cognitive re-labelling or other methods). The narcissist must learn that his past experiences are not laws of nature, that not all adults are abusive, that relationships can be nurturing and supportive.

Most therapists try to co-opt the narcissist's inflated ego (False Self) and defences. They compliment the narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.

By stroking the narcissist's grandiosity, they hope to modify or counter cognitive deficits, thinking errors, and the narcissist's victim-stance. They contract with the narcissist to alter his conduct. Some even go to the extent of medicalizing the disorder, attributing it to a hereditary or biochemical origin and thus "absolving" the narcissist from guilt and responsibility and freeing his mental resources to concentrate on the therapy.

Confronting the narcissist head on and engaging in power politics ("I am cleverer", "My will should prevail", and so on) is decidedly unhelpful and could lead to rage attacks and a deepening of the narcissist's persecutory delusions, bred by his humiliation in the therapeutic setting.

Successes have been reported by applying 12-step techniques (as modified for patients suffering from the Antisocial Personality Disorder), and with treatment modalities as diverse as NLP (Neurolinguistic Programming), Schema Therapy, and EMDR (Eye Movement Desensitization).

But, whatever the type of talk therapy, the narcissist devalues the therapist. His internal dialogue is: "I know best, I know it all, the therapist is less intelligent than I, I can't afford the top level therapists who are the only ones qualified to treat me (as my equals, needless to say), I am actually a therapist myself?"

A litany of self-delusion and fantastic grandiosity (really, defences and resistances): "He (my therapist) should be my colleague, in certain respects it is he who should accept my professional authority, why won't he be my friend, after all I can use the lingo (psycho-babble) even better than he does? It's us (him and me) against a hostile and ignorant world (follies-a-deux)?"

Then there is: "Just who does he think he is, asking me all these questions? What are his professional credentials? I am a success and he is a nobody therapist in a dingy office, he is trying to negate my uniqueness, he is an authority figure, I hate him, I will show him, I will humiliate him, prove him ignorant, have his licence revoked (transference). Actually, he is pitiable, a zero, a failure?"

And this is only in the first three sessions of the therapy. This abusive internal dialogue becomes more vituperative and pejorative as therapy progresses.

Narcissists generally are averse to receiving medication. Resorting to medicines is an implied admission that something is wrong. Narcissists are control freaks. Additionally, many of them believe that medication is the "great equaliser" - it will make them lose their uniqueness, superiority and so on. That is unless they can convincingly present the act of taking their medicines as "heroism", a part of a daring enterprise of self-exploration, a distinguishing feature and so on.

They often claim that the medicine affects them differently than it does other people, or that they have discovered a new, exciting way of using it, or that they are part of someone's (usually themselves) learning curve ("part of a new approach to dosage", "part of a new cocktail which holds great promise"). Narcissists must dramatise their lives to feel worthy and special. Aut nihil aut unique - either be special or don't be at all. Narcissists are drama queens.

Very much like in the physical world, change is brought about only through incredible powers of torsion and breakage. Only when the narcissist's elasticity gives way, only when he is wounded by his own intransigence - only then is there hope.

It takes nothing less than a real crisis. Ennui is not enough.


By Sam Vaknin

Traumas as Social Interactions

("He" in this text - to mean "He" or "She")

We react to serious mishaps, life altering setbacks, disasters, abuse, and death by going through the phases of grieving. Traumas are the complex outcomes of psychodynamic and biochemical processes. But the particulars of traumas depend heavily on the interaction between the victim and his social milieu.

It would seem that while the victim progresses from denial to helplessness, rage, depression and thence to acceptance of the traumatizing events - society demonstrates a diametrically opposed progression. This incompatibility, this mismatch of psychological phases is what leads to the formation and crystallization of trauma.

PHASE I

Victim phase I - DENIAL

The magnitude of such unfortunate events is often so overwhelming, their nature so alien, and their message so menacing - that denial sets in as a defence mechanism aimed at self preservation. The victim denies that the event occurred, that he or she is being abused, that a loved one passed away.

Society phase I - ACCEPTANCE, MOVING ON

The victim's nearest ("Society") - his colleagues, his employees, his clients, even his spouse, children, and friends - rarely experience the events with the same shattering intensity. They are likely to accept the bad news and move on. Even at their most considerate and empathic, they are likely to lose patience with the victim's state of mind. They tend to ignore the victim, or chastise him, to mock, or to deride his feelings or behaviour, to collude to repress the painful memories, or to trivialize them.

Summary Phase I

The mismatch between the victim's reactive patterns and emotional needs and society's matter-of-fact attitude hinders growth and healing. The victim requires society's help in avoiding a head-on confrontation with a reality he cannot digest. Instead, society serves as a constant and mentally destabilizing reminder of the root of the victim's unbearable agony (the Job syndrome).

PHASE II

Victim phase II - HELPLESSNESS

Denial gradually gives way to a sense of all-pervasive and humiliating helplessness, often accompanied by debilitating fatigue and mental disintegration. These are among the classic symptoms of PTSD (Post Traumatic Stress Disorder). These are the bitter results of the internalization and integration of the harsh realization that there is nothing one can do to alter the outcomes of a natural, or man-made, catastrophe. The horror in confronting one's finiteness, meaninglessness, negligibility, and powerlessness - is overpowering.

Society phase II - DEPRESSION

The more the members of society come to grips with the magnitude of the loss, or evil, or threat represented by the grief inducing events - the sadder they become. Depression is often little more than suppressed or self-directed anger. The anger, in this case, is belatedly induced by an identified or diffuse source of threat, or of evil, or loss. It is a higher level variant of the "fight or flight" reaction, tampered by the rational understanding that the "source" is often too abstract to tackle directly.

Summary Phase II

Thus, when the victim is most in need, terrified by his helplessness and adrift - society is immersed in depression and unable to provide a holding and supporting environment. Growth and healing is again retarded by social interaction. The victim's innate sense of annulment is enhanced by the self-addressed anger (=depression) of those around him.

PHASE III

Both the victim and society react with RAGE to their predicaments. In an effort to narcissistically reassert himself, the victim develops a grandiose sense of anger directed at paranoidally selected, unreal, diffuse, and abstract targets (=frustration sources). By expressing aggression, the victim re-acquires mastery of the world and of himself.

Members of society use rage to re-direct the root cause of their depression (which is, as we said, self directed anger) and to channel it safely. To ensure that this expressed aggression alleviates their depression - real targets must are selected and real punishments meted out. In this respect, "social rage" differs from the victim's. The former is intended to sublimate aggression and channel it in a socially acceptable manner - the latter to reassert narcissistic self-love as an antidote to an all-devouring sense of helplessness.

In other words, society, by itself being in a state of rage, positively enforces the narcissistic rage reactions of the grieving victim. This, in the long run, is counter-productive, inhibits personal growth, and prevents healing. It also erodes the reality test of the victim and encourages self-delusions, paranoidal ideation, and ideas of reference.

PHASE IV

Victim Phase IV - DEPRESSION

As the consequences of narcissistic rage - both social and personal - grow more unacceptable, depression sets in. The victim internalizes his aggressive impulses. Self directed rage is safer but is the cause of great sadness and even suicidal ideation. The victim's depression is a way of conforming to social norms. It is also instrumental in ridding the victim of the unhealthy residues of narcissistic regression. It is when the victim acknowledges the malignancy of his rage (and its anti-social nature) that he adopts a depressive stance.

Society Phase IV - HELPLESSNESS

People around the victim ("society") also emerge from their phase of rage transformed. As they realize the futility of their rage, they feel more and more helpless and devoid of options. They grasp their limitations and the irrelevance of their good intentions. They accept the inevitability of loss and evil and Kafkaesquely agree to live under an ominous cloud of arbitrary judgement, meted out by impersonal powers.

Summary Phase IV

Again, the members of society are unable to help the victim to emerge from a self-destructive phase. His depression is enhanced by their apparent helplessness. Their introversion and inefficacy induce in the victim a feeling of nightmarish isolation and alienation. Healing and growth are once again retarded or even inhibited.

PHASE V

Victim Phase V - ACCEPTANCE AND MOVING ON

Depression - if pathologically protracted and in conjunction with other mental health problems - sometimes leads to suicide. But more often, it allows the victim to process mentally hurtful and potentially harmful material and paves the way to acceptance. Depression is a laboratory of the psyche. Withdrawal from social pressures enables the direct transformation of anger into other emotions, some of them otherwise socially unacceptable. The honest encounter between the victim and his own (possible) death often becomes a cathartic and self-empowering inner dynamic. The victim emerges ready to move on.

Society Phase V - DENIAL

Society, on the other hand, having exhausted its reactive arsenal - resorts to denial. As memories fade and as the victim recovers and abandons his obsessive-compulsive dwelling on his pain - society feels morally justified to forget and forgive. This mood of historical revisionism, of moral leniency, of effusive forgiveness, of re-interpretation, and of a refusal to remember in detail - leads to a repression and denial of the painful events by society.

Summary Phase V

This final mismatch between the victim's emotional needs and society's reactions is less damaging to the victim. He is now more resilient, stronger, more flexible, and more willing to forgive and forget. Society's denial is really a denial of the victim. But, having ridden himself of more primitive narcissistic defences - the victim can do without society's acceptance, approval, or look. Having endured the purgatory of grieving, he has now re-acquired his self, independent of society's acknowledgement.


By Sam Vaknin