Monday, January 2, 2012

Treatment Modalities and Therapies

Treatment Modalities and Therapies
by: Sam Vaknin

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.
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.

About The Author

Sam Vaknin is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East. He is a columnist for Central Europe Review, PopMatters, and eBookWeb , a United Press International (UPI) Senior Business Correspondent, and the editor of mental health and Central East Europe categories in The Open Directory Bellaonline, and Suite101 .

Until recently, he served as the Economic Advisor to the Government of Macedonia.

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