Today, I am discussing narcissistic personality with Dr. Frank Yeomans, a world leader in the psychotherapy of personality disorders.

Published On: 03/11/2024

Duration: 31 minutes, 17 seconds

Transcript: 

MARK RUFFALO: Before we begin, we have some exciting news to share with you, you can now earn CME credit by listening to this episode and all future episodes on this channel. To access the CME post-test for this episode and upcoming episodes, please follow the podcast CME subscription link provided in the show notes. Welcome to The Carlat Psychotherapy Report. I am joined today by Frank Yeomans, MD, PhD, who is on the faculty at Cornell in New York City and is a world leader in the psychotherapy of personality disorders. And we're going to be discussing narcissistic personality today on the podcast. Dr. Yeomans, welcome, and thank you so much for joining us. Would you mind sharing a little bit about yourself, your training, your background, and your expertise in this area? 

FRANK YEOMANS: Well, I can provide a little bit of that. That's not the most interesting part of the interview, but I went into psychiatry because of my interest in the human experience. At the time I did my residency in psychiatry, it was just the beginning of the kind of impact of psychopharmacology, which in my opinion, has taken over psychiatry a little bit excessively. My challenge at that point was to continue to want to understand the whole person when the field was beginning to focus more on symptoms. How do we cure the symptoms of anxiety? How do we cure the symptoms of depression? And that's certainly a very valid and important work, but in my experience, often these symptoms are embedded in the whole personal experience. That's what led me to focus on personality disorders because it takes the whole person into account, and it's kind of more complex but also more interesting and more challenging than isolating a symptom and treating it. Initially, the group I've been working with for 40 years that's the group of Dr. Otto Kernberg, focused on borderline personality disorder, which is a major clinical challenge and a very serious problem. But over the years, we began to notice that as we got more skilled, we felt that in treating people with borderline personality disorders, we didn't do quite as good a job with patients who suffered from narcissistic personality disorder. So, about ten years ago, we decided to think very specifically about that disorder and study our cases of narcissistic personality disorder. Two years ago, we came out with a book that summarizes our thinking on that; I'll finish by saying that in the words I've just spoken, it sounds like borderline personality disorder and narcissistic personality disorder are two distinct phenomena. They overlap quite a bit and have many of the same core issues. 

MARK RUFFALO: Yes, and I'd certainly like to maybe get into that at some point in the interview. So, to begin, my first question is, would you mind telling us a little bit about how you conceive of narcissistic personality disorder and how it differs from what psychodynamic theorists describe as healthy narcissism? 

FRANK YEOMANS: Well, first of all, healthy narcissism is an interesting term, and it is evidence that the meaning of words changes always over time. Because the whole concept of narcissism comes from the Greek myth of Narcissus, which was a pathological self-love, so if the term comes from Narcissus, the Greek mythological figure, there really isn't a form of healthy narcissism because the whole point of Narcissus himself was that he couldn't love anyone but himself. So, if that's the historical meaning of narcissism, healthy narcissism is a little odd, but we still use the term. It has basically to do with the capacity to love and appreciate oneself in a realistic way, to have good feelings about oneself, to judge oneself, to evaluate oneself in accordance with true things, the real potential one has as a person and the circumstances in which a person lives and functions. So healthy narcissism is feeling good about oneself because one has achieved a satisfactory position in the world that's in sync with one's capacities and the realities of society and the social circumstances you're in; this is in contrast to somebody who cannot appreciate themselves. 

To give a little example, I've had highly successful people in my office saying I wish I could go through the day humming a tune like that cab driver in the cab I just got out of. So, of course, who knows what's the real internal experience of the cab driver? But the point of the patient's comment is that man seems to have a simple life and appreciates himself. I have this high-achieving life, and I feel awful about myself. So healthy self-esteem is appreciating oneself in a realistic way that is in accord with one's abilities and one's situation in life; in contrast, pathological narcissism, since you asked, in my mind, is mostly a defense; this is an increasingly common understanding of it, but it goes against the more traditional DSM definition. The DSM definition, DSM has a lot of good things about it, but it has limitations. The traditional DSM definition is about arrogance, grandiosity, and excessive pride, exploitation of others. Now, I don't disagree with those as characterizing many people who have narcissistic pathology, but what seems to be the case, and I'm, there's a little caveat here because it might not be the case with people who don't seek treatment, but still even observing narcissistic individuals from afar, it often seems to be the case. Anyway, what is the case? What seems to be the case is that all of the arrogance, pride, and boastfulness is a defense against a horrible sense of inferiority that's at the core of the person's sense of self. They don't feel like they're worth anything. It's even worse in my clinical experience than feeling inferior. You feel like you're nothing, you feel like you barely exist. So you have to compensate for that by this show of importance arrogance, and superiority.

MARK RUFFALO: So, in your mind, is it fair to say that your view is that pathological narcissism does not exist on the same spectrum, if you will, as what we might describe as healthy narcissism, that we're dealing with a discrete entity that is categorically different from healthy narcissism?

FRANK YEOMANS: Yeah. I'm smiling because it's an important debate you're putting your finger on. When we were writing the book I mentioned, we spent quite a good deal of time deciding on whether the title would be Treating Narcissistic Personality Disorder. That's the first choice, but we went with the second choice, which is treating Narcissistic Pathology. Narcissistic Personality Disorder is an entity that, as we see it, has a clear, not totally clear, but clearer definition, whereas narcissistic pathology has a spectrum with all different levels of severity and problems. So, if we're talking about narcissistic personality disorder, I see that it's a reasonably well-defined entity but the trend in all personality disorders these days is to see them dimensionally, the spectrum rather than categorically. 

MARK RUFFALO: Yes. I would certainly love to continue this discussion, but in the interest of time, I'd like to jump to some other questions. So, you know, a common belief amongst the general public, and I think even some psychotherapists, is that narcissistic personality disorder is a largely untreatable condition. What is your take on this, and what does the research tell us in this regard? 

FRANK YEOMANS: Well, first of all, unfortunately, there is, to my knowledge, no good research on the treatment of narcissistic personality disorder. There's a lot of research on the treatment of borderline personality disorder. I don't know of any randomized controlled trials of narcissistic personality disorder. Of course, when one looks at studies, there's a whole range of the methodology of studies. So, there are a lot of case reports that can be considered research, but again, I don't know of a randomized controlled trial; but the notion that people with, let's call it NPD for time's sake, are not treatable is a pretty strongly held opinion. When I was a resident in psychiatry, some of my highly esteemed and very skilled professors communicated that. So we're fighting an uphill battle. Our experience as a group is that people with NPD can respond successfully to treatment, but it's a real long haul and a difficult treatment to engage in. The first problem is the patient needs to be motivated for treatment, and there's two problems there. One is the nature of the narcissistic defensive system often leaves people seeing the problem outside they always are projecting onto others, and it's this one that's frustrating my career. It's not the way I behave, and so on. So, a lot of people with NPD don't acknowledge a problem within themselves, and the related issue is how painful it is if they do begin to see a problem in themselves. It can be devastating, and that's part of the work to help the person go through getting in touch with what they're defending against that awful negative sense of self.

MARK RUFFALO: It takes us to my next question, which is, can you describe briefly the different stages of psychotherapy with the patient with NPD and how you typically proceed throughout what I imagine is a year-long process? 

FRANK YEOMANS: Yes. I'll tell you what we do in the type of therapy that I practice and that we wrote about in our book. It's called transference-focused psychotherapy, a form of psychoanalytic psychotherapy based on the subset of psychoanalytic theory, referred to as object relations theory; since you asked about the trajectory of treatment, we start with a very careful assessment because one of the very important things for clinicians to know is that NPD can exist underneath other clinical presentations. In particular, I've seen many cases of treatment-refractory or treatment-resistant depression. People are depressed, all of the classical treatments for depression fail, and you have to wonder, is there a narcissistic personality structure underlying that? I'll get to the concept of structure in a minute.

So, you do a very careful assessment if you have found that the most likely diagnosis is NPD. You have to, in our mind, have a layman's kind of discussion of your diagnostic impression. You don't say, I think you're a narcissist, that could be a little harsh and could be a narcissistic injury, but we try to explain that even though you've been treated for depression or whatever for a long time, we think the problem is more along the lines of what we call a personality disorder, which is a term that many people bristle against, but it's nothing to be ashamed of. It has to do with your core automatic, instinctive sense of who you are, who you are in the world, and how others are about you. And we want to examine all that in the course of the therapy. So then we set up the frame of the treatment.

We have to have clear parameters of treatment, because it becomes a very vague and sometimes unfocused and unending process to say, oh, we'll sit together and understand things about you, and that will lead to change. No, we have to have clear parameters, we have to have clear goals, better functioning at work, and better functioning in relationships, and then once the frame is in place, it is a psychoanalytically based treatment. So, it's up to the patient to begin the free association process, with which there is inevitably difficulty because if you're a narcissistic person, you're really afraid to spontaneously say what comes to your mind because something might slip out that doesn't fit with the image you want to give. Almost universally, there's also a devaluing of the therapist.

I thought you were supposed to be good. I've been meeting with you for three weeks now, and you don't have anything to offer that I haven't had before, and that was all worthless. So, we have to get to one of the things you anticipated we would get to, which is countertransference. Studies have shown that the two most typical countertransferences are either to retaliate and kind of argue or fight back when you're devalued or to disengage, to be in session bodily, but kind of to check out mentally, which is a terrible abandonment of the patient because the patient senses if you sort of stop being present with them. So, the first thing we teach our therapists is to tolerate being devalued you're going to go through weeks and probably months of being told you're no good, and what's the point of all this? And can't you do anything useful? And you have to absorb that, you have to contain that, and you have to, what we call hold the projection because the patient is essentially seeing in you the part of themselves that is too unpleasant, scary, or uncomfortable to be in touch with.

So we do what we call therapist-centered work rather than say I could give you an example if you like a slightly elaborated clinical example and say, I think you have to make yourself sound so special because underneath, it does seem that maybe you don't feel so good about yourself and you have strong doubts about yourself. Yeah, that would be a reasonable interpretation, but usually, it doesn't go anywhere. So, we empathize with the patient's frustration and disappointment with us. And we get the patient, we at least hope to, we get the patient to begin to be familiar with what we call the devalued object, the person who is defective, flawed, imperfect, and in holding that projection and yet continuing to function and do our work as best we can, it's kind of a revelation to the patient because in the mind of the narcissistic person, either you're perfect or you're nothing at all.

So, we hold on to the devalued object. We let ourselves be devalued, and gradually, as this work progresses, that's how we establish an alliance, and the patient begins, I'm hesitating in what I'm going to say next because I don't want to give the impression it's simply a corrective emotional experience, but if we can contain and not act out our countertransferences, the patient begins to perceive a genuine interest on our part in them, a curiosity and a wish to help them, unshakable no matter how much they attack us and devalue us and criticize us. That becomes an object of curiosity for them and a kind of a new experience because the person has in their own mind a template of what a relationship with another person is and that template is anytime two people interact, one's got to be superior, and one's got to be inferior. One's on top, one's on the bottom. So, they expect you to react by trying to impose your superiority. And when you respond with this neutrality, this acceptance of the projection, they begin to get curious about it. So, what you have to do is interpret what we call the negative transference, the view of the therapist as either incompetent or stupid or even worse, malicious and harmful in some way, and then once the negative transference has been understood to some degree, it frees the patient up to experience our genuine interest in them and becomes a kind of a bridge out of their isolation in their grandiose defensive system into a more genuine connectedness with people in the world, which is what they've been missing.

MARK RUFFALO: Yes, and generally speaking, in your clinical experience, how long does this work take? 

FRANK YEOMANS: Yeah, I hate to say it because there are so many critics of psychodynamic work who say it takes forever, but I couldn't imagine success in less than three years, and sometimes it's more four or five, six.

MARK RUFFALO:  And in transference-focused psychotherapy for NPD, you see the patient once a week or twice a week?

FRANK YEOMANS: Ideally, twice a week. Now, in this day and age, most patients somehow think therapy is a once-a-week endeavor. I'm not sure why that seems so widespread. It's not just by a whim that we think twice a week is better. When you establish this kind of therapy, it's a pretty intense emotional experience. So, two contacts a week help the attachment develop much more effectively than once a week, and I want to say something to any listeners who might be young therapists. When I was a young therapist, I thought, oh, therapy is great, it's all about achieving important understandings and exchanging interesting ideas before any of that. It's an intense emotional experience. So the twice-a-week format allows for an attachment to develop, but any attachment from a narcissistic personality disorder patient, or a borderline one for that matter, is a complicated attachment, it's an insecure attachment. So, you have to get into the relationship as a lived experience and then begin to work on how it provokes anxiety in the patient because it's an uncomfortable experience and one where trust is not there to begin with.

MARK RUFFALO: Yes, I see. I interviewed Jonathan Shedler for this podcast a few weeks ago and one thing that he has talked about on social media and elsewhere is how the concept of narcissistic personality disorder has sort of, in a sense, been corrupted by the now common use of the label in the general public, and they'll say things, and I'm sort of in agreement with them that, everyone is now a narcissist to their ex-partner. How do we, as professionals, combat this misunderstanding of what is, in actuality, a quite severe and relatively rare psychiatric disorder? 

FRANK YEOMANS: Well, let me start with the relatively rare. I'm not sure it's relatively rare. Prevalence studies have found anywhere from one to seven percent of the population having narcissistic pathology. The studies have that widespread because it's difficult to accurately assess narcissism in the population, most simply because people who are narcissistic don't like to answer questions in a way that puts them in a bad light. But anyway, if you consider that it could be up to seven percent of the population, it's not that unusual. Interestingly, the demographic studies show a little bit of a higher prevalence in men than in women. But anyway, to get back to your question, I think Jonathan Shedler is a wonderful guy. I always enjoy talking to him, dialoguing with him, always learning something. Yeah, I think there's been a trivialization of the term, and we have to remind ourselves that it's a serious pathology. It causes huge damage in people's lives, in the lives of the people with whom narcissistic persons interact and it can cause major damage to society because there's a whole area of study that talks about narcissistic leaders who get positions of power and then the narcissism becomes has an influence on what they do with the group that has begun. 

I mean, the worst example I can think of is Jim Jones. The, if you remember, the Jonesville disaster. He was a charismatic, narcissistic figure who got all these people to worship him, and it was all based on nothing. It's kind of like I was saying the narcissism of the individual is based on nothing. So, in the end, when reality came crashing in, he got them all to kill themselves. So, it's a very serious form of pathology. I'm extrapolating a little bit, and we shouldn't mix it up with somebody who's a little sort of stuck up or a little grandiose. I mean there might be a little narcissism in all of us. This person, speaking for myself, I like to sing, but I'm sure my appreciation of my singing talent is a little exaggerated and probably has a little narcissistic flavor to it. But that is an exaggeration of one or another of one's qualities. It's not the same.

And let me get to that core structure. The real narcissist, as I said, inside of him or herself feels like nothing. So, they construct a narrative that defines them, but it can't hold up in reality. If I could give you a simple example, a patient was referred by her father, and she was years out of college, doing nothing with her life, he was concerned that she wasn't building a life for herself, and in the initial assessment, I said, well, as tactfully as I could, you haven't seemed to have got into any serious involvement since graduating a few years ago. And most people think about a career, some way to invest their energies. I said I wonder if you have thoughts along those lines. And she responded in a sharp kind of contemptuous way she said, of course, of course, I've thought about that, but it's time for me to have a career. I'll go to Hollywood and be the head of a major movie studio. 

So, I mean, this is so far from reality. It's almost comic, and it's so far from reality. It's almost psychotic. It was the self-narrative that kept her from despair. Now you can see that if somebody develops that kind of self-narrative that doesn't correspond to reality, they can't get close to other people. Because if she were having coffee with a potential friend, the friend might say, oh, are you taking film studies? Are you interning on a production? And then my patient would say, oh, what a stupid person. She doesn't understand. The real narcissist has a precarious hold on reality, and their grandiosity can be shattered by a sudden event and then they fall into despair. That, by the way, brings us back to treatment.

In the middle of treatment with somebody with NPD, and this brings us back to the similarity between NPD and BPD when you do what we call dismantling or taking apart the grandiose self or the grandiose narrative, the person gets in touch with their doubts about themselves, their fears, and particularly their fear of dependency, because it's very frightening to depend on someone when you don't think anybody is going to respond positively to your dependency wishes. So, the middle phase of therapy is hard; patients should say, I feel worse than when I started it. What's wrong, doctor? You're making me feel worse. And our response is, I understand how awful this feels right now, but I think what you're feeling now has always been there. You've protected yourself from feeling it, but it is only by feeling it and working on this that we can get you truly better.

MARK RUFFALO: So, the dismantling is a part of the psychotherapeutic work, and I've always wondered, the narcissistic patient, the untreated narcissistic patient, do those insecurities, that deep-rooted sense of inferiority in the world, does it sometimes break through the, the grandiosity, and does the person at times feel those deeper rooted ideas about the self? 

FRANK YEOMANS: That's where the spectrum comes in. There are some- we talk about thick-skinned narcissists and thin-skinned narcissists- and the thick-skinned ones seem to hold on to their defenses come hell or high water, and they manage not to fall into moments of doubt and insecurity. But the thin-skinned narcissist can very quickly go into some terrible anxiety. The thin-skinned narcissist, they go to a party, and they don't know anybody, and nobody's talking to them, and they run for cover. Now, the other thing that can have an impact is the aging process; narcissistic people have enough time, success will come. My goals will be achieved, this will be acknowledged. When you get into your forties and fifties a lot of these people begin to see that isn't going to happen, and that might be when they come for treatment, when it's so hard to sustain the grandiose narrative. 

MARK RUFFALO: I think we are about out of time for the interview. I really appreciate this; this has been enlightening, Dr. Yeomans. Do you have anything that you'd like to say in closing about NPD or the concept of narcissism that might be helpful for our listeners? 

FRANK YEOMANS: I don't know if it is going to be helpful, but I worry about the state of society because the human experience is so much about rich interactions with others. Everybody's talking these days about a crisis in youth mental health, and I'm sure there are multiple reasons for that. But my concern is the time that people who are developing spend on their screens. Those screens often give you, often, idealized images that don't exist in reality, but they become the standard by which the young person judges and evaluates themselves. And I think there's a terrible problem we are beginning to experience, where people are having a hard time achieving a realistic and satisfactory assessment of themselves because they're bombarded with unrealistic images. 

MARK RUFFALO: The final question, to follow up on that, do you think that the true prevalence of NPD is on the rise?

FRANK YEOMANS: Yes, there are some studies, and here we have to go back to the distinction between NPD and a broader conceptualization of narcissistic pathology. There have been some studies that have taken place over a number of years. I forget at which university in the country, but the psychologists who've carried out this study of college students have seen a small but measurable uptick in narcissistic traits over the years. Don't worry about that; I want to finish by saying that if anybody out there listening has any impact on the education system, I think we should include some basic psychology education in the early years. I mean in public school, we learn about all other kinds of things. Why can't we learn something about how the mind works? And it might help some people adjust a little bit better. 

MARK RUFFALO: I think that's a wonderful suggestion. Thank you so much, Dr. Yeomans, for joining us on The Carlat Psychotherapy Report today. It's been lovely, and I appreciate your time. 

FRANK YEOMANS: Thank you for the opportunity.

MARK RUFFALO: Explore The Carlat Psychotherapy Report for insights into psychotherapy and social work. Get it online with email alerts for news releases. Subscribers enjoy CME credits and full website access, take a moment to check it out! Earn CME credits by listening to our podcasts. Click the link in the description to access them.

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.