Navigating Narcissism: Giving Our Clients a Compass

If I have learned anything from being on a sort of grassroots book tour for the past few months (for my new book Don’t You Know Who I Am?), it is that the world needs more information on narcissism, toxic relationships, difficult people, and what to do about this issue at both the personal and societal level. It is in this way that the mental health profession has in many ways missed the plot. In the obsession to “not diagnose someone we have never met," most clinicians still come at mental health advisement from a feel-good place of second chances, forgiveness, and a hopefulness that lacks any empirical proof. Calling someone’s behavior narcissistic is not diagnostic, it is descriptive (interestingly, we have no problem labeling behavior as inappropriate, stubborn, anxious or any number of other adjectives). But something about this word narcissism has become a third rail in mental health.

When I was in graduate school and through my post-doctoral fellowship and licensure examination, we would be given written cases. These cases would provide information about a “patient” (real or fake) and based on the information provided we were asked to render a diagnosis and to provide substantiation of the diagnosis. In these cases, I had obviously never met the person (in some cases the person was dead), and I am guessing if I squared off against my supervisor or professor and said, “Nah, I never met this person, I can’t render a diagnosis, it wouldn’t be right," that I probably would not be Dr. Ramani Durvasula at this time. We take the evidence and create a formulation. And we retain some dynamism and flexibility that as more evidence emerges that the hypothesis be shifted.

Many clinicians might argue the subjective experience of a client coming into a therapy room and describing another person is tainted, biased, and only one person’s perspective. Yep. That is what it is supposed to be (Carl Rogers’ work comes to mind). So if a client comes in, and for example, describes a partner who lacks empathy, is often invalidating, deceitful, behaves in an entitled manner, can be vindictive, chronically needs validation, denies the client’s reality, and prone to rage in the face of frustration—what would your hypothesis be? If they carefully detail this relational experience, provide detailed recollection of episodes and a history of this conduct in the relationship, and share their own personal feelings and responses (confusion, anxiety, depression, self-doubt), I’m willing to float the hypothesis that the person they are describing is narcissistic (and sometimes the unfortunate client, so accustomed to being doubted, will even pull up emails, texts, and recordings to substantiate their experience). If I am not willing to consider the client’s story, then what? Do we write our client off as prone to exaggeration and embellishment or as a downright liar? Not a great perspective from which to view a client.

Many therapists would stay focused only on the subjective experience of the client with little attempt to educate the client on the possibility that the pattern being evinced by the partner may be suggestive of an antagonistic, high-conflict, narcissistic style. And yet, the psychoeducation about narcissism may be the most important part of the treatment. Many clients just don’t know how narcissistic patterns work—they often fall into attribution biases and blame themselves (and it may be that very attributional style which made them vulnerable). Anyone who has read the literature on treatment of narcissistic personality knows that it is pretty bleak, and except for a handful of case reports and small-sample studies conducted on rarefied samples, there is little evidence of significant change. The other sacred canon in therapy is the belief that therapists should never give advice or guidance. It is a debatable point but bottom line, psychoeducation is not advice—it is information. In addition, there are myriad cultural factors at play—around courtship, marriage, and the incentivization of narcissistic patterns in cultures characterized by male hegemonies, authoritarianism, patriarchy, stratification, and economic disparity. From a cultural competence perspective, this must also be understood, so the conversation can be had in a way that is respectful but also recognizes that abuse is abuse—regardless of cultural sign-off.

Simple illumination of these issues, while simultaneously creating a safe space for sharing the feelings evoked by this relationship, can be the most humane thing we can do in the realm of mental health. If you don’t like a label, then use a term that feels “nicer” (antagonistic, high conflict, difficult), or if you have time to burn, just use the entire litany of adjectives every time: Your empathy lacking, invalidating, lying, entitled, vindictive, validating seeking, reality-denying, rageful, poorly regulated partner ... (that gets exhausting after a while).

In addressing narcissistic abuse in my practice, brutal “from the hip” clarity works. Many people have endured these abusive relationships for years and decades (and many are stuck due to children and finances). These are often intergenerational patterns—and understanding these vulnerabilities can provide invaluable insight and awareness that can protect individuals who are enduring these relationships in the future. Many narcissistically abusive relationships are not physically violent or manifest other “above the line” behavior that gets the notice of judicial or criminal justice systems. It ends up looking like a hybrid of low grade post-traumatic symptomatology plus anxiety plus hopelessness plus ruminative self-doubt. And because it is not an articulated phenomenon and there are no institutional structures to help, these clients come to therapy as their only line of protection and assistance.

Yes, it is dismissive to suggest that someone’s behavior cannot improve—and yet, by the time a client who has endured this type of psychological abuse shows up in a therapist’s office, trust me, they have tried other therapists, couple’s therapy, psychics, coaches, prayer, and read books, blogs and watched countless videos. Patterns such as narcissism, which are characterized by diminished self-reflective capacity and diminished insight are not amenable to change—radical acceptance and realistic expectations are about the only way anyone can safely ford these waters and avoid a lifetime of disappointment.

I recognize that this may not be a popular stance in the existing canon of psychotherapy. But sometimes all people need is a map and a compass, and someone to give them gentle guidance on how to use them.