How can Narcissism be understood and worked with in a clinical capacity? A meta-analysis of three clinical case studies by Mitchell Kirkham Cooper

The International Journal of Psychoanalysis, celebrating its centenary in 2020, publishes 6 issues per year. If you consider that, in its 100 year history, it could have produced as many as 600 issues, it puts into perspective that a quick search of its archives yields over 1000 articles on or about narcissism. Such is the hold that narcissism has on the collective psyche of the pscyhoanalytic community that one of its most well-respected journals averages over 1.5 articles per issue on the subject.

One of the most salient features of this discourse is how varied and often contradictory it can be. Since Freud’s foundational paper ‘On Narcissism’ in 1914, the thorny and labyrinthine discourse on narcissism as a clinical issue has led Stollerow to label it a “conceptual mulberry bush” (Stollerow, 1975). The historical difficulty of defining narcissism seems to lie in the fact that it can be understood in a number of ways. Britton highlights three different uses:

“Narcissism is used in the literature to describe a phenomenon found in various clinical states; secondly it is used to refer to a force in the personality opposed to object relations and thirdly it is used to designate a group of personality disorders.” (Britton, 2004, p.478).

To compound this confusion, Britton explains that “clinical narcissism” is capable of motivating completely contradictory states “in both a positive and a negative form: positive when it is manifest as self-admiration, and negative when it manifests itself in self-denigration” (2004, p. 481). However, in all of its divergent manifestations and understandings, there seems to be one common thread; that narcissism frustrates a psychoanalytical approach to clinical treatment. Britton notes: “sufferers… cannot, at least initially, function in analysis in an ordinary way because they cannot form an ordinary transference relationship” (2004, p.478). The narcissistic inability to accept or interact with external objects is what Abraham terms “transference resistance in pathological narcissism” (Abraham, 1919). Although the literature on this subject is exhaustive, and any attempt to develop a definitive answer to the problems of narcissism is the work of a much longer much more involved study, this essay will attempt to distil and clarify a foundational understanding of narcissism which, similar to Descartes meditations, seeks “build anew from the foundation” (Descartes, 1998). If we are able to distil a common truth about clinical narcissism and test this against a meta-analysis of a couple of clinical case studies, we might be able to provide a clearer understanding of why narcissism is difficult to work with clinically, and how to ” approach the treatment of narcissistic patients psychodynamically that mitigates both the patients’ “transference resistance”, and the complexity of the cacophony of different voices and viewpoints that can be found in the literature.

Derived from the myth of Narcissus, a lay understanding of narcissism equates it with a form of self-love. Freud initially used the term narcissism to denote a perverse “auto-eroticism” and later an investment of libido in the ego (Freud, 1914). However, these understandings are inadequate in explaining the diverse constellation of narcissistic disorders that can result in both self-destructive and self-admiring behaviours. In his essay ‘Working towards a functional definition of narcissism’ (1975), Stollerow makes a key distinction between “the self” and “the selfrepresentation”. He suggests that, rather than “the libidinal cathexis of the self” (p.197), “narcissism is the libidinal cathexis of the self-representation” (p.199): “[it] refers not to the love of oneself, but to the love of one’s mirror image” (Stollerow, 1975, p.199). According to Lacan, the “the mirror stage”, through which we first identify a unified idea of our “self”, is an innate part of the development of human consciousness. It is:

“the dialectic that will henceforth link the I to socially elaborated situations. It is this moment that decisively tips the whole of human knowledge into mediatization through the desire of the other… the term primary narcissism… throws light on the dynamic opposition between this libido and the sexual libido… in order to explain the evident connection between the narcissistic libido and the alienating function of the I, the aggressivity it releases in any relation to the other.” (Lacan, 1949, p.6)

Lacan refers to the mechanism through which we first identify a unified idea of “self” at the mirror stage as “primary narcissism”. However he points to its “alienating function”, namely “the aggressivity it releases in any relation to the other” (1949, p.6). According to Lacan, this “aggressivity” represents “the correlative tendency of a mode of identification that we call narcissistic, and which determines the formal structure of man’s ego and of the register of entities characteristic of his world” (1948, p.18). He is suggesting that narcissism is a force that carves out a unified “self-representation” from a selective fusion of the external and internal reality. Moreover, this mechanism defines the self into the illusion of a unified whole by brutally annexing and assimilating that which is deemed part of the ‘I’, and by aggressively rejecting that which is ” deemed to be “other”. Despite being a fundamental mechanism of human consciousness, Lacan argues that the mirror stage creates a self-representation that is only ever an approximation:

“The mirror stage is a drama whose internal thrust is precipitated from insufficiency to anticipation – and which manufactures, for the subject…the succession of phantasies that extends from a fragmented body-image… to the assumption of the armour of an alienating identity which will mark with its rigid structure the subject’s entire mental development.” (Lacan, 1949, p.5)

The aggressivity of primary narcissism can be understood to alienate and reject elements of both the internal and external world that do not comply with the “rigid structure” of its constructed identity. In the words of Kernberg, “a regressive fusion takes place between a primitive ego ideal and the self” (1970, p.216). Thus the patient introjects an unreachable “ego ideal” and identifies their “self” with it. Consequently, when the reality of the self falls short of this ego ideal, the subject experiences an internal conflict that is expressed in self-denigration or, in extremis, selfdestruction, despite being impelled by the same force that is responsible for the creation of the idea of the self. Britton reduces this concept of narcissism to an elemental idea: “this urge to annihilate otherness” (2004, p.488). I believe this definition of narcissism concisely summarises, not only the urge to annihilate the otherness of external objects (which we use to define the parameters of our self-representation), but also the urge to annihilate the otherness highlighted in our “self” by unfavourable comparisons to this idealised illusion of “self-representation”. With this idea of narcissism in mind we can see how, as a single force, it is capable of inducing two seemingly contradictory constructions in both “self-denigration” and “self-admiration”. Indeed anything that is deemed “other”, even if it a biological part of the patient’s body, is violently rejected, further more things that should be deemed external to the patient can become irretrievably entangled in the patient’s conception of their self. It is through this mechanism of identity creation that you can understand how the acute distress of gender dysphoria could arise, and how an organ of biological sex can be felt as persecutory to a person’s gender identity.

It seems that it is precisely because narcissistic identity-creation relies on an “annihilation of otherness” that narcissism is a difficult issue to address psychodynamically. The psychoanalyst must, by the very nature of the transference, be able to relate symbolically to the patient in different ways. He must therefore be “experienced [by the patient] as both significant and separate” (Britton, 2004, p.478). However, in Britton’s case studies of Prof. D and Patient L contained in his journal article ‘Narcissistic Disorders in Clinical Practice’, we can see how the separateness of the analyst is either rejected completely, or aggressively assimilated into the patients’ phantasies. Britton details how the patient ‘Prof. D’ dismisses the analyst wholesale: “The analytic transference, like her marital relationship, followed the pattern of that with her parents; it was to be preserved by her strictly limiting her expectations of it, and seeking a soul mate elsewhere.” (Britton, 2004, p.487). Whereas, in the case of the patient ‘L’, we see Dr A struggling for autonomy from the patient:

“Dr A could not understand her inability to establish and maintain an analytic setting with this patient… it made her feel as if the analysis was out of her control” (Britton, 2004, p.483). In the latter case, Britton emphasises that “the narcissistic object relations developed by this patient” identify with the analyst in “a twin soul relationship” (Britton, 2004, p.485). In this way the analyst’s separateness is annihilated and she is co-opted into an unconscious collusion with, and the acting-out of the patient’s narrative:

“The plot by the twin souls to kill the malicious old lady could then be seen as an unconscious collusion between patient and analyst to kill off Dr. A’s professional self” (Britton, 2004, p.484)

Stollerow defines a narcissistic object relationship as one “whose function is to maintain the cohesiveness, stability and affective colouring of the self-representation’ (1975, p.201). As an extension of the tendency to annihilate otherness, we see how narcissistic object relations work with a homeostatic principle. They limit any disruption of the patient’s self-representation by either rejecting or engulfing anything that is perceived as other. In both of Britton’s vignettes, we see how the patient’s narrative overrides the process of the therapy and resists the formation of a transference relationship in favour of the patient maintaining their own monologue. Taking Kernberg’s idea that the idealised analyst and narcissistic patient are merely extensions of one another (1975, p.216), it seems that in cases of clinical narcissism, the patient’s relations to external objects – particularly the therapist – are only ever experienced through the distorting prism of their own phantasies.

For this reason, when working clinically with cases of narcissism, we must be acutely aware of acting-out a dominating narcissistic phantasy in the counter-transference. Taylor-Thomas’s case study (2006) provides some indications of how we can work with a narcissistic disorder more effectively in the clinical setting. The patient was brought up in an extremely strict religious household. Thus she introjected the ideal of godliness as a fundamental, yet unattainable part of her identity. It is through this lens that she projectively identifies with the therapist. We are told that “The object relationship sought is to a God-like figure… In such a state of mind, the desire is for identification with an ideal object, there is no room for humanity, neither in her, nor in the therapist” (Taylor-Thomas and Lucas, 2006, p.228). Thus, if the treatment fails, it reinforces the phantasy that the therapist was not good enough to cure her, or conversely she is too sinful to ever be fixed by the god-like therapist. This black and white identification of the analyst with a god-like ego ideal leaves the therapist marooned on a pedestal in the patient’s psyche. It seems she has little choice but to be a godly therapist who cannot work with such a “bad” patient, or to be a “false-god” incapable of curing anyone. Either way, the patient will not allow herself to be helped. It is interesting to note that it is only through supervision that Taylor-Thomas is able to wrest some form of autonomy from the grip of the patient’s monologue. This restores a modicum of separateness which, in turn, allows the therapy to progress:

‘‘The therapist needs support in moving from a domination by a critical superego, instigated by the patient, to a more reflective superego. This is turn helps the patient to move into a more reflective rather than self-critical mode of functioning” (Taylor- Thomas and Lucas, 2006, p.218)

The supervision of Lucas allows her to “develop a framework of understanding in which to keep one’s bearings” (2006, p.233). This framework reminds her that the therapy is a process of “converting a psychotic monologue into a dialogue” (2006, p.218), not a process of “fixing” Mrs A (as the patient might wish). This highlights the insidious temptation of acting out what Cartwright calls the “phantasy of the ideal container” (Cartwright, 2010, p.171). Moreover, it shows that working with narcissism in the clinical setting demands a periodic re-calibration of the understanding of the therapeutic relationship by reference to an external framework. It is through this process that “the patient becomes able to entertain the idea of being ill, rather than bad and this produces a palpable relief” (2006, pp.218-9).

Freud emphatically asserts that the purpose of psychoanalysis is only ever “the translation of what is unconscious into what is conscious. Yes, that is it!” (1917, p.453). If we understand Narcissism, in the clinical sense, to be an innate force of human consciousness manifest in the urge to annihilate otherness, we see how it can result in both self-admiration and self-denigration, despite being the mechanism through which we fundamentally define our identity. However, what is unconscious in the narcissistic patient is their pathological attachment to an ego-ideal, an illusory self-representation. Thus, when working with narcissism in the clinical setting, if we aim to “fix” the patient, we risk participation in the patient’s phantasy as if it were a reality by acting out the illusion of their ego-ideal existing. We become an accomplice in reinforcing that there is some defined self hood from which the patient has become estranged. We are particularly susceptible to this illusion since it is created by the same mechanism through which we ultimately develop our own identity, and it something against which we must consistently strive in the clinical setting. The aim of the therapist should be to maintain some autonomy within the therapeutic space. Spurling points out that, similar to a map that will allow you to get your bearings if you are lost, “theory provides a conceptual framework by means of which the counsellor can think for himself” (2017, p.86). Given that narcissism is such a foundational issue in the psychoanalytical canon, it is easy to conclude that it is well-understood and therefore beneath the our well-informed perspective to revisit with a beginner’s mind. I believe this is a fatal flaw and ultimately what makes narcissism difficult to work with clinically. Before we have walked into the therapy room there is a good chance we have already failed our patient through our own narcissistic assumption that, even unconsciously, we understand narcissism already. However, through personal analysis, supervision and a constant ‘beginners mindset’ approach to understanding of psychoanalytic theory, the therapist maintains an external conceptual framework. This should allow them to work within the phantasy of the patient without being either engulfed, or rejected for their otherness thus “furthering the move in the sessions from a monologue to a dialogue” (Taylor-Thomas and Lucas, 2006, p.232). In doing so, the analyst proves that neither the patient nor analyst are a reflection, or even a failed reflection, of an ego-ideal, but that both are human, fully capable and even prone to mistakes, failures and contradictions. Far from making them something to be rejected and disavowed, it is something to be aimed at. In this way the therapist in not aiming to be more of a cold mirror, but to embody a separate self, an example of humanity in all its faults and contradictions that can be a model, a guiding light to the patient. Any sign of disappointment in the humanity of the therapist, brings that unconscious belief in the ego ideal directly into the space of the therapy where the client can become aware of its existence as a formative part of their unconscious understanding of the world. Thus we use the narcissistic rejection of otherness in the process of the therapy by bringing it under the microscope of the therapeutic space.


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