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.
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.
self-psychology, narcissistic personality disorder, temporary indwelling, self object, empathy, psychoanalytic psychotherapy, mirroring transference, idealizing transference, transmuting internalizationKey Words:Kohut,
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. 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. This disorder tends to be more predominant in male subjects with 50 to 75 percent of NPD cases being male.
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.
There are many theories about the causes of NPD. Often certain childhood developmental and parental factors have been implicated. An example of a developmental factor includes a postulated innate oversensitive temperament in the child; parental factors include excessive admiration by parents, lack of realistic feedback from parents during development, unreliable parental caregiving, and/or emotional abuse during childhood.
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.
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).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. 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. 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)