The Neurotic Neighbourhood

Elia, I., 2002. The Neurotic Neighbourhood. Reformulation, Autumn, pp.18-19.


The Neurotic Neighbourhood

Irene Elia

Recently, sitting in my kitchen in New York City, I was wondering about the high prevalence here of narcissism, as a personality disorder, not as vanity about clothes. A client of mine once protested, having been told by a therapist 'friend' of his that he was a complete narcissist, "But I wear casual clothes and I don't spend all day looking in the mirror. Why did she say that?" Why indeed? Maybe we in the mental health professions haven't made it plain what this oddly named disorder is. Maybe that's why there is so much of it around.

People know that those of us who are always self-defensive have a problem: with continuous, contemptuous criticism of anyone who does not agree with or admire us; with stubborn, proud resistance to hearing another point of view; with a 'hidden' shame and disappointment, which lashes out as angry blame of others, and an apparent inability to acknowledge what we are doing, apologise, or accept responsibility for change. What people don't know is that this is an illness with a name - Narcissistic Personality Disorder (NPD), causes, and, hopefully, someday, with more cultural and parental awareness, a reliable prevention or cure. Right now certain psychotherapies can help some sufferers get better. The proportion who are helped is unknown. But knowing how to relate to and train children, with patience, collaboration, and positive discipline (see Nelsen, 1987), might prevent NPD from developing at all.

You would think that after Death of a Salesman, revived three years ago (1999) on Broadway for its 50th anniversary, New Yorkers would be clued in to the dangers, the disasters for self and others, that NPD exposes us to. But that's just it. Audiences, critics, we all didn't get it (see Miller, 1989). We knew that Willy Loman was stressed-out and nutty, but we didn't know he was ill, or at least we didn't clearly see how or why he was (see Elia, 1999). Most of us fell into one of two groups of misunderstanding of the sick hero:

1. those who blamed the culture too much for what they saw Willy doing, and so, unwittingly, colluded with his disorder (as his younger son and wife did) by admiring and excusing him-- "Well, it's understandable. He did his best. He really loved his sons. What can you expect, he worked so hard." and

2. those who blamed the man too much, and so, unwittingly but very understandably, colluded with the disordered pattern by being nasty and critical (as the other salesmen and Willy's younger boss did) and, at last, dismissing him as not worth our attention.

But in my neighbourhood, no one is worth more attention than Willy, and in my practice, as at home, no one seems harder to help than the client or relative with NPD. There is a predictability and intractability about NPD behavior, which, if we could understand its causes better, might be amended. (I see Borderline Personality Disorder (BPD) as an extreme form of NPD because of the similar way that I think of the two disorders arising. I think that the reason we see the BPD diagnosis in patients' notes so much more often than NPD is that the dramatic problems caused by the robust acting out in BPD and the short-circuiting of sensed behavioural continuity (dissociation and blanking) distract us from the underlying narcissistic wreckage of the personality).

In an interview (Murphy, 1995), Arthur Miller mentions the predictable statements and actions of an unfortunate uncle of his, who was the model for Willy and who, like Willy, committed suicide. In Cognitive Analytic Therapy terms, his statements would swing between 'admiring---admired' and 'contemptuous--contemptible'. He was in a state of constant competition and in constant fear of comparison, ever ready to be affronted, never ready to be confronted. (To me the 'perfectly caring--perfectly cared for' and 'abusing--abused' reciprocal roles are intensified operational variants of 'admiring--admired' and 'contemptuous--contemptible', with similar narcissistic meaning.)

And why? Why do those of us with NPD behave predictably in this way? We speculate (and I think with good reason, although it would be unethical to do the experiments needed to prove the speculation) that NPD is caused by repeated insults to the maturing self: everything from constant criticism, nasty mockery, coldness, etc all the way to physically abusive expressions of contempt, sometimes alternating with exaggerated boasting about the child's abilities to others, without direct, sincere appreciation of the child by 'caregivers' (parents, siblings, teachers and others). They also show how to manage the insults and live with the injury: with pride that cannot hear, with 'toughness' that will shut off expressions of 'soppy' feelings, with an inner voice that subtly deprecates the self and an outer voice that loudly deprecates the other. In other words, NPD is learned, but the learning process starts so early and is so insidious that it comes to be seen by many of us as the norm. We don't even know that we have 'caught' an illness.

There is a nagging, paradoxical feeling that goes along with NPD. It is the feeling of being 'not good enough - but, if truth were known, actually superior to others'. Very superior. And some with NPD are impelled to really superior achievements (which makes it very difficult indeed not to collude with the disorder in the 'admiring' way). So what distinguishes the 'really superior achievements' of a non-sufferer from those of a sufferer? High achievement for those without NPD is just the natural, unstrained level of performance; it is just what is done. With NPD, an achievement is often not felt as one; it's 'never enough', echoing the 'never good enough' stance and comments of the critical, conditional caregiver. There may be a momentary thrill and opportunity to boast about an achievement, but very soon the need to excel arises again. If we have NPD, we are as obsessed with success as the person with eating disorder is with food and shape, or the borderline is with control through excessive caring or hurtig. The hallmark of the NPD achievement, whether an intended 'good' one or a suffered 'bad' one due to an insurmountable personal destiny, is grandiosity.

And so I think of the friend who 'can't' stop smoking after three strokes and 'couldn't possibly' start drinking water to prevent the dehydration that might cause a fourth; of the cousin who self-reports being the fifth best Scrabble player on the Net while chain smoking and regularly getting drunk in front of her 11-year-old, whom she vaunts loudly as far more able than other children; of the psychiatrist friend who fantasises that he will become a lawyer (at 52) and 'take on' Blue Cross, becoming the Fourth Horseman of the Apocalypse of change that he will launch upon the US healthcare system; and of myself (especially years ago): a little grandiosity may be a dangerous thing, but a lot is very probably a sign of a serious mental health problem, called Narcissistic Personality Disorder. Even if everyone in the neighbourhood seems to be suffering from it.

References

Nelsen, J. Positive Discipline. NY: Ballantine. 1987.

Miller, A. Plays: One: Death of a Salesman. NY: Methuen. 1989.

Murphy, B. Miller: Death of a Salesman. Cambridge: CUP. 1995.

Elia, I. 'Using CAT to hear the voice of narcissism in Death of a Salesman'. Dissertation for Advanced Training in CAT. London: Guy's Hospital, Dept. of Academic Psychiatry files. 1999

Irene Elia

Full Reference

Elia, I., 2002. The Neurotic Neighbourhood. Reformulation, Autumn, pp.18-19.

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