Hope for Narcissism and Other Personality Disorders

I remember sitting in the basement of a large academic building in an undergraduate psychopathology class. The topic: personality disorders. The outlook: bleak. I found it tricky to separate the person from the disorder. After all, what is the difference between one's personality, and self?

Years later, after working in depth with several individuals given a diagnosis of a personality disorder, I personally believe that our core self cannot be disordered. What we call personality disorders represent significant disruptions in our relationships with self and others. Alterations to these relationships are not the same as changes with a person at their core. People diagnosed with personality disorders ranging from narcissistic personality to schizotypal personality are first and foremost people. Like others, those diagnosed have dreams, fears, pains, joys, and often a desire to recover.

I have come to view these more as adult presentations of attachment disorders than as character or identity problems.

Mentalization-Based Therapy

Mentalization-based therapy (MBT) is a psychotherapy option for individuals living with personality disorders (Bateman and Fonagy, 2016). Mentalization is the ability to keep our and others' mental states in awareness as we interact. We all struggle with this at times, but personality disorders create immense difficulties in these areas.

In personality disorders, an attachment style has formed wherein a person is relating in problematic ways. Such styles are often shaped through one's childhood. These patterns are typically outside a person's awareness. Through MBT, the clinician and client collaboratively explore these. The therapist often takes a 'not-knowing' stance, presenting themselves as a sort of fellow traveler rather than an expert who is quick to assign judgment. The hope is that such a stance will maintain effective mentalizing on behalf of the practitioner. When we are stressed, all of us, including therapists, tend to land in non-mentalizing modes.

In MBT, non-mentalizing modes are described as traps that prevent us from fully relating with ourselves and others. While everyone falls into these at times, when such patterns become pervasive, severe problems can occur in our relationships and sense of self. Non-mentalizing modes include psychic equivalence, pretend mode and teleological mode.

Psychic equivalence is an experience where one's perception is seen as the absolute truth. Although there might not be good evidence, when we are in a mind frame of psychic equivalence, whatever we see on the inside becomes so on the outside. One way this might manifest is during certain expressions of fear of abandonment in people with borderline personality disorder. For example, one person might have an almost unshakable sense of being unloveable and project that into believing a single person is planning to leave them.

Pretend mode is a space where someone may paint a picture of what they or others are experiencing without grounding. It often involves the creation of a narrative based on little evidence. In a sense, it is a sort of fantasy. One image that comes to mind would be an incarcerated person sharing a story that "everything is fine."

Lastly, the teleological mode requires something physical on the outside in place of internal states. A teleological overfocus on the tangible stops us from perceiving the more complex interaction between ourselves and others. One possible way these could show up would be someone making a special request for a sense of 'proof' that they are indeed exceptional. Such a need for concrete evidence is seen in a variety of settings, but a persistent desire for special status is a hallmark of a narcissistic personality.

Another way that teleological mode might show up would be dismissing something another person is experiencing as something physical. For example, if a person's partner expresses concern about the relationship think, "Well, she must just be overtired" rather than looking any deeper.

These non-mentalizing modes describe just a few of the relational processes considered in MBT.

Rather than focusing on behavior, MBT is more attachment-focused, seeking the objective of improving relationships with one's self and others. Constellations in interactions are approached in slow motion to reveal patterns and needs. As well, the therapist takes specific measures to understand, as best they can, the world from their client's eyes. The therapy is complex, often involving individual, group, and even family elements over 18 months or longer. The results are promising.

Personality Essential Reads

Why Some People Are More Easily Creeped Out Than Others

Fun-Lover or Go-Getter: Which Fits Your Personality?

MBT originated with a highlight of borderline personality disorder. One study showed improved outcomes up to eight years following treatment, as evidenced by an 87% remission rate (Bateman and Fonagy, 2008). Since, it has been adapted for a range of personality disorders, including antisocial personality disorder and, more recently, narcissistic personality disorder (Drozek and Unruh, 2020). A randomized controlled trial of MBT for individuals diagnosed with both antisocial personality disorder and borderline personality found a reduction in anger and improvement in social outcomes in the group receiving MBT (Bateman et al., 2016) compared to when they received another intervention.

MBT gives reason for hope to individuals seeking recovery from personality disorders.