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Narcissistic Personality Disorder Treatment Modalities and Therapies

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Quesiton:

Is the Narcissistic Personality Disorder (NPD) more amenable to Cognitive-Behavioural therapies or to Psychodynamic/Psychoanalytic ones?

Answer:

Narcissism pervades 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 postulate that insight - even if merely verbal and intellectual - is sufficient to induce an emotional outcome. Verbal cues, analyses of mantras we keep repeating ("I am ugly", "I am afraid no one would like to be with me"), the itemizing of our inner dialogues and narratives and of our repeated behavioural patterns (learned behaviours) coupled with positive (and, rarely, negative) reinforcements - are used to induce a cumulative emotional effect tantamount to healing.

Psychodynamic theories reject the notion that cognition can influence emotion. Healing requires access to and the study of much deeper strata by both patient and therapist. The very exposure of these strata to the therapeutic 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 provide 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

This 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 in these therapies - only that it is not a pillar of the technique. Dynamic therapies are usually applied to patients not considered "suitable" for psychoanalysis (such as those suffering from 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.

Psychodynamic therapies are open-ended. At the commencement of the therapy, the therapist (analyst) makes an agreement (a "pact" or "alliance") with the analysand (patient or client). The pact says that the patient undertakes to explore his problems for as long as may be needed. 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 or 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 (instinctual, related to drives) pressures. Supportive therapies seek to increase the patient's ability to REPRESS conflicts (rather than bring them to the surface of consciousness).

When the patient's painful conflicts are suppressed, the attendant dysphorias and symptoms vanish or are ameliorated. 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).