CAT and Narcissism: The Missing Chapter

Nehmad, A., 1997. CAT and Narcissism: The Missing Chapter. Reformulation, ACAT News Winter, p.x.

A great deal of attention has been given to understanding in CAT terms the experiences of Borderline personalities, and the particular difficulties of treating Borderline clients.

Far less attention has been devoted to understanding the experiences of Narcissistic individuals, and to the particular problems encountered by their therapists. In Tony Ryle's books and articles, Narcissists are lumped in with Borderlines. However, the experience of treating a predominantly narcissistic client is very different from that of treating a very fragmented Borderline. I hope that Tony Ryle's next book will give this issue the importance it deserves.


Narcissistic clients are often greatly helped by therapists using CAT - a remarkable achievement in view of the failure of so many other types of therapy, usually over a much longer time-span.


However, psychotherapists using CAT often fail with narcissists. This has led some CAT therapists to look for answers outside CAT itself. One source has been the work of psychoanalysts. Their work contains powerful descriptions, and some interesting ideas, but their obscure language, convoluted theorisations (which often run counter to those of CAT), idiosyncratic definitions, mutually contradictory theories, persecutory or collusive stances, and length of treatment advocated, make them at best a mixed blessing. In any case, their therapeutic results do not seem particularly impressive.


CAT has a clearer understanding of narcissism and its treatment than either psychoanalysis or the cognitive tradition.. However, some of the wisdom in CAT theory has remained implicit. The main aim of this article is to begin to spell it out. I will also offer some of my own thoughts about how the theory could be developed. But first it is worth reviewing narcissism, as seen from non-CAT perspectives.


A) Classical psychoanalytic theory. Rycroft summarised the confusing variety of meanings in 1968:

Primary narcissism [is] the love of self which precedes loving others, Secondary narcissism [is the] love of self which results from introjecting and identifying with an object. The latter is either a defensive activity or attitude, since it enables the subject to deny that he has lost the introjected object, or part of the developmental process. A major difficulty of the concept is that, on the one hand, the word "narcissism" has inescapable disparaging overtones, while, on the other hand, it is used as a technical term to categorise all forms of investment of energy (libido) in the self. Hence the not infrequent references to "healthy narcissism" to distinguish proper self-respect from "over-valuation of the ego".

[...] Narcissism also on occasion means egocentrism or solipsism, i.e. it can refer to the tendency to use oneself as the point of reference round which experience is organised. In this sense the discovery that one is not the only pebble on the beach and that the world was not constructed solely for one's

own benefit involves a loss of narcissism.) 1 :


B) Contemporary psychoanalysts: Kohut and Kernberg are two of the best-known exponents of new ideas about pathological narcissism. 2 As Tony Ryle has pointed out, Kohut is the Ideal Carer of Idealised Clients, while Kernberg is a harsh, critical, unempathic and rejecting figure to a resentful, resistant, hurt rejected and contemptible client. Despite their considerable differences with each other in theory and in practice, both Kohut and Kernberg see narcissism as serving a defensive purpose against acknowledging the vulnerable, weak, dependent, and devalued aspects of the self.


C) Cognitive-Behavioural: Freeman et al summarise Millon's social-learning hypothesis: several elements may combine to establish the early exaggeration and overvaluation of the self. If a parent is narcissistic, he or she will model certain behaviours and a general style for the child. Furthermore, narcissistic parents want their children to be special and wonderful and may exaggerate the child's accomplishments or their importance, and may fail to set appropriate boundaries.


Narcissistic Personality Disorder is characterised by the cognitive distortions of selective abstraction and all-or-nothing thinking.


Narcissists constantly scan the environment for evidence of their superiority and place great weight on the evidence they find. They may ignore any evidence that points to their being average, or they may respond to any indications that they are "normal" with anger, anxiety, or overcompensatory words or actions. In either case, their view of the data is quite selective and leads to extreme conclusions. These problems may be

exacerbated by poor problem-solving and reality-testing skills.


[T]he central dysfunctional belief underlying Narcissistic Personality Disorder is the assumption that the individual is, or must be, a "special" person. [...]


A common corollary to this belief is the assumption that they deserve special treatment; angry sociopathic behaviour may ensue if they are thwarted.



This may be coupled with an insulting or denigrating manner and attempts to succeed by putting others down or actually destroying the productions of others. 3


D) "Schema-Focussed" Cognitive Therapy: Jeffrey Young expanded Beck's model of Cognitive Therapy, to take account of the personality disorders.' Early Maladaptive Schema' (EMS) are


themes that develop during childhood and are elaborated upon during an ind'ividual's lifetime. [They] serve as templates for the processing of later experience.


EMSs are stable, self-perpetuating and very resistant to change. There are several parallels with CAT, including the fact that Schemas (like SelfStates) are usually activated by triggers in the environment. Schema-focussed therapy for Personality Disorders differs from Beckian Cognitive Therapy in that there is greater use of the therapeutic relationship, and more time devoted to exploring childhood origins of problems.


According to Young, narcissists may have an Entitlement Schema, if they grow up believing that they arc special and do not have to follow rules that apply to others. However, they may also be seen as having "Schema Compensation" - i. e. cognitive or behavioural styles that seem to be opposite to their EMS -


some patients who have experienced significant emotional deprivation as children behave in a narcissistic manner as adults. Their apparent sense of entitlement obscures the underlying deprivation.


Because the vulnerability is usually unacknowledged, the patient feels intense pain when Schema Compensation fails.


E) DSM IV definition of Narcissistic Personality Disorder. The Fourth Edition (1994) of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders includes NPD in the "Dramatic-Emotional" Cluster, which includes three other phenomenologically similar Personality Disorders: Antisocial, Histrionic, and Borderline. The DSM-IV Guidebook discussion, and criteria for NPD, are an advance on previous editions. There is an awareness of the limitations and problems inherent in a classification of "Personality Disorders", because of the unclear boundary between them and personality traits, whose acceptance as "normal" is often culturally based. The Guidebook also recognises the problems of basing classifications on a mixture of overt behaviours, inner experience, and inferences by the assessor.


DSM-11I's criterion 1 for NPD, "Reacts to criticism with feelings of rage, shame, or humiliation (even if not expressed)" has been deleted in DSM-IVdue to low specificity for NPD, and a criterion which relates to the "Contemptuous" state of mind so clear in CAT has now been added. 5 6


F) Popular wisdom: people who do not use the terms "narcissistic" and "narcissism" understand the concept well enough. There are many examples in literature,' but the colourful colloquial language of ordinary people also describes the phenomenon with poetic vividness and economy of language: "selfimportant"; "full of herself', "blowing her own trumpet"; and my own two favourites, "smug" (an adjective which includes the Self-Admiring and the Contemptuous/Looking Down upon States of mind; it is the shortest possible expression of the Narcissistic stance); and "he fancies himselfi' (colloquially "to fancy" is to desire (those who coined the expression were probably unaware that far away and long ago, Narcissus fancied himself); "to fancy" also means "to imagine or suppose" (thus it could stand as the beginning of "he fancies himself to be something other (more?) than what he is."


The CAT Perspective

Within the CAT model, Narcissistic Personalities are often thought of as a subset of Borderline Personalities. In fact it is more accurate to consider Narcissistic Personalities as a subset of Poorly Integrated Personalities (PIPS), within which it form part of a continuum. At one end of this continuum are the most unstable "Borderlines", with the greatest



identity disturbance, very discontinuous experiences, intense pain in some States, impulsivity, a tendency to self-mutilation and other destructive acts. At the other end of this continuum are the Stable Narcissists, whose experience is less fragmented, and who are experienced less discontinuously (and therefore less confusingly) by others. They tend to have good social functioning, and impulse control. Though many Borderlines have Narcissistic features, and viceversa, the experience of treating Stable Narcissists is very different from that of treating severely fragmented Borderlines.


Poorly Integrated Personalities as a whole are on a continuum with "neurotic" and "normal" individuals. I shall refer henceforth to the "neurotic" and/or "normal" end of this continuum as Relatively Well Integrated Personalities (RWIPs).


"RWIPs" and "PIPs" are merely a convenient heuristic shorthand for thinking about extremes of a continuum, not discrete categories of people, each with its own "personality organisation" or rules of psychic functioning. However, it has been very useful to discuss Borderlines, and their therapies as if they were a discrete category. In the same way, though Narcissists are on a continuum with Borderline Personalities, it is worth discussing the Stable Narcissist end of the continuum as if they were a discrete category.


Understanding the similarities and the differences between RWIPs and PIPS, and between Borderlines and Stable Narcissists, will shed light on the therapeutic process, and the adaptations that we may need to make in certain cases.


What distinguishes RWIPs from PIPs is not the absence of extreme states of mind 9, or of particular Reciprocal Role Procedures, but rather: a) their predominant mode(s) are more stable, less extreme, more adaptive, less miserable and angry; b) they have better capacities for integrating, and reflecting on, their experience; c) their different Self-States are less split off from each other, so their experience is less discontinuous - when enacting one set of Role Procedures they are more in touch with the others, so that they are more able to select Roles and Procedures according to the situation and context, and more able to switch between them flexibly and appropriately; d) they are more able to tolerate criticism, rejection, etc, without needing to abruptly switch into a different state of mind or self-state.


Experiences such as idealisation, devaluing, projecting unacceptable or unrecognised aspects of the self onto others, are typical of PIPs, but by no means diagnostic - RWIPs also engage in them regularly (though less frequently or intensely).


The essence of Narcissism

Unlike Millon, Freeman et al, and the DSM IV, CAT is aware not only of the grandiosity of Narcissists, but of the precariousness of this grandiosity, and the fear, underneath it all, of being Contemptible.


Unlike the various psychoanalysts, CAT does not need to postulate envy, innate destructiveness, or any other complicated theorisings, which induce pessimism in the therapist, and "resistance" in the client.


The key to the difficulties encountered (and created) by Stable Narcissists in the real world and in the therapeutic relationship, is that they lack (or have only the most tenuous experience of) a Self State of "Ordinary Good-Enoughness, with mutual respect and reciprocity". Instead, their dominant experience is that of the Twin Self States "Admiring-Admired ('Special')" and "Contemptuous-Contemptible". Because they have not adequately internalised the healthy Self-state, they cannot stop striving to stay Admired or Contemptuous in order to avoid the unmanageable pain of being Contemptible. If a Narcissist feels weak and needy (part of their core pain which is located in the Contemptible pole), this may be too painful to bear, so the switch to Contempt is almost inevitable. They need to devalue us in order to remain in the safe Contemptuous pole. If we see Narcissists in this light, rather than as bearers of a "destructive mafia,"10 we may feel more understanding, more compassionate, less frightened, less irritated, and more hopeful. As a result, we may be more likely to recruit them into a healthier place, some of the time.


The Therapeutic Relationship

Is it useful to classify some clients as Narcissists? In some respects, it is very useful. We can avoid assigning them to a trainee as their first case. We can predict the main Reciprocal Roles that are likely to take place in therapy - and forewarned is forearmed. However, there is a downside. Could the classifying of a client as Narcissistic at assessment by us, or another, prejudice his chances? What expectations will we have about this client from the start? How might this affect the therapy?


How do we decide who is a Narcissist? For example, exactly how important should other people's opinions be to our client, in order for her to avoid categorisation as a Narcissist? Being overdependent on approval from others is a feature of narcissism. Yet "haughty indifference to the opinions of others" is also a feature of narcissism (indeed was a diagnostic criterion for NPD in DSM III). So Narcissism is partly in the eye of the beholder - accuracy and objectivity are likely to be comparable to that in the well-known definition of an alcoholic as "someone who drinks more than his doctor".


At what point does a client's high opinion of his own abilities become "realistic" self-esteem (as defined by us, of course); and at what point does it become "Low Self Esteem"? 11 The latter is not the opposite of Narcissism (though you might think so from reading DSM criteria, or if you adhere to Freeman et al's account). In fact people in whom Low Self Esteem is a prominent feature (and in whom grandiosity is practically absent) can be very good at occupying the Contemptuous Pole.


Narcissists need to bolster their "Self-Esteem", through praise and admiration from others and/or from themselves. But all human beings need a level of self-esteem, of pride in who we are and what we achieve, and we all need recognition from other people.

People (RWIPs and PIPS) whose self-esteem is precarious - either because it is low (for whatever reason), or because it is too bound up with conditions (musts, ifs, high standards, etc) will inevitably resort to narcissistic procedures - sometimes quite benign and adaptive, sometimes dangerous and socially destructive. Individuals who are rich, powerful, famous, beautiful or talented, can more easily feel superior to others in socially-sanctioned ways. The rest of us can try and achieve modest successes, hoping for recognition by our colleagues, family and friends. Even individuals who have no particular talents or achievements have plenty of opportunities to engage in narcissistic procedures (i.e. Obtaining Admiration from self and others; looking down on others), in benign or malignant forms. We can feel better about ourselves by identifying with Nation, Race, Football Club, or brand of training shoes. (The underlying formula assumption being, "I may not be very worthwhile, but at least I'm better than [foreigners/black people/Arsenal Supporters/etc].12


It is quite difficult for anybody (at least in modern Western culture, which is based on competition) to ever simply feel good. We have to feel (and/or perceive ourselves as) better than our peers. "Johnny is good at maths" does not mean that he feels good when doing it (though this statement may also be true). It means that he is better than other children. Feeling, or perceiving ourselves as, better than others or superior to others is the most common way of "feeling good" in the culture we live in.


Most clients (RWIP or Borderline) who seek psychotherapy need our help or permission to appreciate their own worth, to give themselves credit for actual achievements, and to spend time and effort on themselves. So we encourage them to self-praise, to be less critical of their efforts, and to self-care and put their own needs first some of the time. They feel better, so they are grateful, and we feel good.


The therapist of a Stable Narcissist could be perceived as trying to achieve the opposite. We are irritated by their exaggerated self-concept and their contemptuousness of others, and disapprove of their self-centredness. Whether we make our thoughts and feelings explicit or not, the vibes in the room are not usually of the "approving, accepting, valuing" sort.


Stable Narcissists are very reluctant to abandon the Contemptuous or Special-Admired roles. This can be annoying and frustrating (especially when we are the butt of their contempt), but is quite understandable. First of all, if the only perceived alternative is the Contemptible role (with its attached unmanageable pain), it is not surprising that they cling to safer roles, which usually have little pain attached to them.


We should not take things away from people unless we are offering them something better instead. Until the client has started to experience a healthier SelfState within the therapy, he is most unlikely to let go of his tried and trusted Narcissistic procedures. Hopefully, the therapist offers the client a new experience, failing to be recruited into the usual roles, and modelling Respectful and Self-Respectful Ordinariness; Competence without Specialness, and so on. Problems arise when the therapist gets recruited into one of the twin self-states, and fails to use this fact in a way that is useful to the therapy - describing its occurrence and significance in ways that are acceptable to, and digestible by, the client. Problems can also arise if a therapist considers that Narcissistic Role Procedures are intrinsically bad, and need to be modified or eliminated.

For many Stable Narcissists, their ability to remain in the Admired or Contemptuous roles means that there is no problem - so they do not present for therapy. However, they may become depressed, and/or unstable, if they arc pushed out of their comfortable perches by experiences such as redundancy or divorce. It is precisely during such a crisis that they will be more open to therapy, because they are deeply unhappy, and feel they are "falling apart" (when Stable Narcissists become unstable, they veer at least temporarily toward the Borderline end of the continuum). But often, by the lime they reach the top of the waiting list, they are no longer depressed, as they have managed to rebuild their self-esteem (in CAT terms, they have once again achieved Stability within the Admired-Admiring self-state and/or the Contemptuous pole of the ContemptuousContemptible Self-States. At this point, therapy is much less likely to have an impact - because they have, once again, little reason to change.


Counter-Transference issues

States of Mind (or roles) may be enacted or avoided; one way to avoid them is to expect them and/or elicit them in other people. Could it be that some of our difficulties with narcissistic clients have to do with not being at peace with our own narcissism? Seeing ourselves as "powerful caregivers" or "wounded healers" is, for most of us, more ego-syntonic than seeing ourselves as brittle snobs, or needing approval and recognition from our clients. It is hard to be accepting about the behaviours or attributes in clients that we are loath to recognise in ourselves.


Narcissists tend to lack not only the ability to empathise, but also the ability to elicit empathy in their therapists. We do not find smug and ungrateful people endearing. But when faced with a therapy client, in order to be helpful to them we have to be able to "see the humanity in them" - we have to be able to see something that we can relate to. And at some level we have to understand what it is like to be them. The latter is difficult, if we are not at peace with our own narcissism. We can usually make an imaginative leap when faced with a survivor of a neglected and abused childhood - because we can connect to the neglected and abused aspects of ourselves, with a degree of acceptance. It is harder (for most of us) to connect to the "Inner Narcissist" than it is to connect to the "Inner Child". Yet if we cannot connect to the relative precariousness of our own self-esteem - and to our own need for approval and, yes, even admiration, then our Narcissistic client will remain The "Other" - a different type of being, with whom we cannot collaborate, and from whom we expect only stereotyped behaviour. If we expect certain behaviours, we may well elicit them. Clients are not the only people capable of recruiting another into an unflattering split-off Role, and keeping them there.


We can forget that it is often painful to be a narcissist. It is not easy always having to be AdmiredAdmiring or Contemptuous, in order to avoid - desperately - the Contemptible pole. If we are lucky enough to usually inhabit a more normal Self-State (e.g. "reasonably competent; Respectful of-Respected by others; relaxed about being Ordinary"), can we find compassion for Narcissists who have not achieved this? Can we, furthermore, offer them an understanding based not only on CAT theory, but also on our own experience of not having bullet-proof selfesteem? If we manage to inhabit this more normal self-state, it is because it is currently self-reinforcing, i.e. our healthy procedures manage to keep us in it. But what if others failed to respond? What if our new employer consistently failed to recognise our competence? Or our spouse left us, despite, or because of, our respectful and relaxed ordinariness? What if we had never had a job that was valued by society? And are we never tempted - despite our current relative success - to further bolster our self-esteem by asserting to each other our superiority over others (for example "unreconstructed Kleinians")?


A few of us may content ourselves with being a good therapist, or a good Christian (with pats on the back from our Internal Supervisor or our Conscience - in other words, Internalised Other People); but in reality most of us, deep down, hope, want, need our colleagues (or the priest and congregation) to notice (and preferably comment upon) our good work or good deeds. We may even wish that they will notice that our work or deeds are better than those of others. If, as you read this, you are thinking "Speak for yourself!" pause, and examine your discomfort at the very thought that you (or indeed any decent therapist) might be guilty of such thoughts, of such needs...


Many narcissistic clients deny satisfaction to our normal human need for recognition of our efforts. When they not only fail to praise, but fail to use, the diagram we have so painstakingly prepared, it's not easy to simply say or feel "Ouch!" - because they are hurting a part of us that we are not proud of, and may not have fully acknowledged as being there at all.


Of course both this "blindness", and the scope for counter-attack, by the therapist, is far less in CAT than in (neo)Kleinian psychoanalysis. In the latter, "interpretations" about "primary envy" or destructiveness, are considered a normal and apt way to deal with the client's perceived lack of appropriate gratitude or dependence.


CAT works by describing and naming, not "interpreting". The latter can sound not only critical and rejecting, but inaccurate and off beam. PIPs are less likely than RWIPs to tolerate "interpretations", especially if these do not connect to their actual experience. (e.g "interpreting" the client's not pining for the therapist during the latter's holidays).


Should the therapist address mainly the symptoms, or the underlying personality, i.e. pathological SelfStates?


The emphasis in recent years on drawing out the SDR , and describing the shifts between Self-States, rather than concentrating simply on Traps, Dilemmas, Snags and Target Problems, especially in PIPs, is a considerable advance, both in terms of theoretical understanding, and in practice. However, there is a potential (but avoidable) dangerous downside to this, especially in relation to Narcissistic clients. The danger is that we may see "the real problem" as being their personality structure - which we have accurately described in the Reformulation, and drawn out on the Sequential Diagrammatic Reformulation - whereas the client sees "the real problem" as his depression, or his inability to achieve his goals or realise his potential. If this happens, a dysfunctional therapy is likely to ensue, with both client and therapist feeling rejected and devalued, though each has done their best to explain themselves to the other. Accuracy of Reformulation and SDR is necessary, but not sufficient. Unless the client can see that the Self-States he inhabits are part of maladaptive loops that lead to the perpetuation of the problems he is complaining of, what we say will not make sense. So the emphasis has to be carefully located. Of course this is true with any type of client. But it is particularly true with narcissists. When we draw in the core pain of a RWIP, and explain its relationship to their constant striving and never feeling good enough, the likely feeling is of relief. When we encourage a client to spend less time in the Striving Insecure Placator state of mind, this is likely to feel liberating and enabling - they are likely to feel better. When we draw out the several Self-States of the very Borderline, and help them to make sense of their fragmented and frightening experiences, once again, they usually feel better, relieved, contained. On the other hand, with a Narcissist, our main aim can seem to be to stop them feeling Special (and therefore good about themselves). They understandably find this puzzling, and even attacking, and not surprisingly they attack us in return, for having "rattled their constructs" in ways which threatened their self-esteem.


There is nothing intrinsically wrong with being Admired-Admiring. The problem is its precariousness - and the fact that the only perceived alternative is despicable and intensely painful contemptibility (so it becomes part of a Depression and Despair loop). There is nothing intrinsically wrong with feeling superior to others. The problem is that if we convey this to others (making them feel inferior) we are likely to sabotage our goals (love, friendship, promotion at work, etc.) There is nothing wrong with putting your

own needs first - it's only a problem if, as a result of it, your girlfriends keep leaving you (so it becomes part of an Abandonment Loneliness and Despair loop).13 Unless we pose things in this way, the Narcissist may well feel criticised and attacked by the therapist, and hang on ever more tenaciously to tried and trusted procedures, especially Contemptuous ones.


It is not easy to avoid sounding critical when describing Narcissistic Role Procedures. We are more likely to succeed if we try to connect with our own narcissism, and if we ask ourselves questions such as, "When I feel despair about the possibility of collaborating or truly connecting with him, what is he likely to be feeling - beyond the fleeting triumphalism of having `won' this particular encounter?" "Would a transference interpretation' at this point be helpful - or might it increase `resistance'?" "If we seem unable to collaborate, could it be that we have different agendas or goals, and this needs to be made explicit, and perhaps re-negotiated?" Rather than getting into arguments about the worth or accuracy of our Reformulations, ask the client to produce his own version which includes his criticisms.


The Twin Self States Admired-Admiring and Contemptuous-Contemptible, are typical of Narcissistic clients, but by no means exclusive to them. They are usually present in some form in Borderline Personalities, and indeed in RWIPs. Many instances are validated by the prevailing culture.


Often the narcissistic individual will seek out kindred spirits who will participate in a "mutual admiration society". They may well believe that they should only have to relate to "special" people like themselves and see others as beneath them either socially, financially or intellectually. They will tend to join only those clubs or organisations that offer them prestige, status, or the opportunity to associate with people who are seen as special, being very conscious of the trappings of status. [They] may also select spouses or partners who admire them greatly or who can be exploited.14


The implication here is that all members of elites are narcissistic. I have no objection to this formulation - but I do wonder whether it is helpful. It offers no clues as to why only a proportion of these people suffer psychological distress, and/or seek psychotherapy.


It is certainly true that all these individuals are able to engage in Narcissistic Procedures - they can feel superior to others by virtue of the fact that they belong to "superior" groups. Not all narcissistic procedures are maladaptive. You can strive to be admired - and as a result produce work of a high standard. You can get on quite well in life if you feel superior to others - as long as you manage not to come across as arrogant and alienate people who matter to you. The Maladaptive Narcissist is someone who has such an overpowering need to make the other feel contemptible (projecting his own unacceptable "pole") that this goal will take precedence over others (such as advancing his career - or making use of therapy). As I have tried to show above, we all engage in Narcissistic Role Procedures. In fact, it is probably more useful to think, not of narcissistic individuals (as if they constituted a separate species) but of narcissistic Role Procedures. So, next time you are referred a client who fulfils DSM criteria for NPD, dont think, "She is a Narcissist", which is likely to generate dislike, anxiety, pessimism, and dread, but rather "She currently needs (quite desperately) to engage in Narcissistic behaviour, or Role Procedures, because she hasn't yet developed a relatively healthy and stable Self-State", the problem may seem more manageable, and the main pitfalls may be predicted, if not avoided.


The aetiology of Narcissism:

Narcissism is the name we give to a syndrome, a particular constellation of Role Procedures. While this constellation is a response to life experiences (and to a lack of certain other life experiences), there is no single "cause" or explanation for it. The Cognitive account quoted above ("Narcissistic parents are likely to have narcissistic children") is perfectly sensible, and no doubt holds true in many cases, but it is inadequate. Narcissistic parents do provide a particular model of behaviour which their children are likely to internalise. And just as importantly, they often fail to provide a healthier set of Reciprocal Roles. Empathy, acceptance, and mirroring, are likely to have been absent. However, this type of parenting does not always result in narcissistic children - some of them become unhappy people with "Low Self Esteem"; others may become fragmented Borderlines. It also fails to account for why Adaptive Narcissists may have children who are Maladaptive Narcissists, and vice-versa. And who engendered the first Narcissist?


CAT does not yet have clear ideas about these questions - and my guess is that there isnt a simple answer. Severe Borderlines arc more likely to have suffered physical, emotional or sexual abuse, while the childhood of narcissists has usually been more "normal". (This fact doesnt help narcissists in therapy, as we are less likely to feel compassionate for the haughty offspring of a "normal" upbringing than for a survivor of awful abuse).


We do not need to speculate for too long on "the" aetiology of Narcissism. Making sense of each person's procedures and self-states on an individual basis is what CAT is best at. And in any case, the aetiology does not need to determine the treatment. Regardless of how an individual client (RWIP or PIP) came to be where she is, we can use CAT to help them change, by describing what they are doing, and helping them to explore alternative and healthier procedures, and experience alternative Self-States, at first (usually) within the session.


Before taking on a Stable Narcissist, be sure that they have some clear realistic problems and goals. (This is especially important if they have been on the waiting list for several months; goals and goalposts may have changed). Ask yourself whether CAT is what they need at this time 16. If they do not appear distressed, consider whether it might be better to postpone CAT till their next crisis. Be prepared (at least initially) to work on simple maladaptive procedural loops (which happen to contain Narcissistic self-states), rather than trying to address their "Narcissism" per se.


In conclusion, I would like to suggest that in the CAT therapy of "Narcissists" (by which, of course, I really mean "People with a strong perceived need to enact Narcissistic Procedures") there are factors in the client which might help to predict a good outcome. This list is based on my own failures and successes, and those of my supervisees. It is highly impressionistic, and would need to be tested out through properly conducted research. Here are my predictions:


The number of DSM Criteria probably has no bearing on the outcome. On the other hand, t1 Stability of the Narcissistic Role Procedures does. Thus, the presence of Borderline Features probably makes therapy easier - because they are more miserable and confused, and there is greater motivation to change. The therapist's amount of experience doesnt matter much (as long as they are not absolute beginners).


Good prognostic factors include: currently feeling miserable, and/or in crisis; inhabiting a healthyish Self-State at least occasionally; having a sense of humour about himself; having the capacity to experience sadness, however fleetingly, within the session.


Annie Nehmad


I Rycroft, Charles, A Critical Dictionary of Psychoanalysis, Penguin 1985, p 94


2 Their ideas, and those of Rosenfeld, are summarised in Cynthia Pollard's Narcissism: from Kohut to CAT, in this Newsletter.


3 Freeman, A, Pretzer, J., Fleming, B., & Simon, K. Clinical Applications of Cognitive Therapy, New York, Plenum Press (1990), p 238-240.


4 Young, J. Cognitive Therapy for Personality Disorders, Professional Resource Exchange, Sarasota, 1990.


5 DSM IV Criteria for 301.81 Narcissistic Personality Disorder:

1. Has a grandiose sense of self importance (eg. exaggerates

achievements and talents, expects to be recognised as superior

without commensurate achievements)

2. Is preoccupied with fantasies of unlimited success, power,

brilliance, beauty or ideal love

3. Believes that he or she is "special" and unique and can only be

understood by, or should associate with, other special or high

status people (or institutions)

4. Requires excessive admiration

5. Has a sense of entitlement, i.e. unreasonable expectations of

expecially favourable treatment or automatic compliance with

his or her expectations

6. Is interpersonally exploitative, i.e. takes advantage of others to

achieve his or her own ends

7. Lacks empathy: is unwilling to recognise or identify with the

feelings and needs of others

8. Is often envious of others or believes that others are envious of

him or her

9. Shows arrogant, haughty behaviours or attitudes.


6 DSM III criteria for NPD are listed on page 10 of this Newsletter.


7 In this issue of the Newsletter, see John Marzillier's Reading Scott Fitzgerald: Literature and the Psychology of Narcissism, and Annie Nehmad's Narcissism Destructive and Disowned Shakespeare's Troides and Cressida


8 I dont know when or where this expression originated: 1 first heard in London in the mid 1970's


9 The fact that therapists can be recruited into almost any Self-State, however briefly, implies that we all have them already within us somewhere, though they may not be activated often, or intensely.


10 The expression belongs to Rosenfeld, a Kleinian psychoanalyst


11 "Low Self Esteem" is a fuzzy concept which has crept into our vocabularies and our thinking, offering an illusion of diagnostic precision. In fact low self esteem can be due to one's upbringing, with overly critical parents; it can be the flipside of narcissistic grandiosity; or it can simply be what a RWIP (especially male) feels when he has lost his job, and cannot get another one. (We live in a society which devalues the unemployed, and blames them; and a man's worth and self'esteem are usually bound up with his working self; his output, his social role, the money he brings home, and so on, so one's "Selfesteem" responds to internalised voices of society, not just parents). However, it is the very fuzziness of the term which makes it useful in this context.


12 Hitler understood this well; the parades, uniforms, and bullying of "inferior" others would "burn into the little man's soul the conviction that though a little worm he is part of a great dragon. Since the "self-esteem" [in 1990's psycho-jargon] of many Germans was at an all-time low (because for historical, political and economic reasons), there was a receptive audience.


13 An obvious comparison is with a client who is using alcohol or recreational drugs. They have no reason to stop, unless they can see how this consumption fits into their maladaptive and unhappy loops. Until they have seen it for themselves (by participating in the drawing of the relevant loops; self-monitoring; etc) they are likely to perceive the therapist's efforts as the oppressive application of her own values as to what is "problem" as opposed to "normal" behaviour. Narcissistic procedures and States of Mind are also "addictive", in that they are a habitual "false solution" (they provide temporary relief from unmanageable pain, but serve to perpetuate underlying problems rather than resolve them).


14 Freeman et at, op cit, pp 239-240


15 ?


16 Solution Focused Brief Therapy is probably more usable by a Stable Narcissist. The client is meant to take all the credit for any improvement; the client's world view is never explicitly challenged; the therapist utilises the client's attributes rather than attempting to change them. See The Essence of Effective Psychotherapy: A CAT Therapist's reflections on learning Solution Focused Brief Therapy, in this Newsletter.

Annie Nehmad

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Full Reference

Nehmad, A., 1997. CAT and Narcissism: The Missing Chapter. Reformulation, ACAT News Winter, p.x.

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