Pollard, C., 1997. Narcissism: From Kohut to CAT. Reformulation, ACAT News Winter, p.x.
An examination of some theoretical and practical issues
It seems that in our everyday work as CAT therapists at Guy's Hospital, almost every patient seems to exhibit either a narcissistic or a borderline structure. Why is this the case? Has there been an increase in the prevalence of narcissists? Does the inner-London population serving Guy's have an unusually high proportion of narcissists? Or have the CAT tools increased recogniton and description so that like anorexia and child abuse, we are now picking up many cases that would previously have remained undetected? There is also the possibility that we might have broadened the descriptive band to inlude many cases that might not fit a narrower set of criteria. The first step in beginning to answer some of these questions would clearly be to learn more about the concept.
The names of Kohut and Kernberg represented to me all that was incomprehensible, distant and idealized in the psychoanalytic establishment. I decided to peer behind their grandiose masks to understand what they were saying and to tease out the similarities and differences between them. To my dismay however, I soon discovered that there are as many interpretions of the gospel as there are of the Gospel. No sooner did I feel that I had grasped some of the central concepts than I found that other commentators had found other meanings. Had I got the wrong end of the stick or had they? I therefore offer the following as my personal idiosyncratic undestanding of some of the current views on narcissism.
Gillian Russell's straightforward, descriptive definition of narcissism as "self-adoration with an aloofness that denies a need for another person "(14) is perhaps the best starting-point for my exploration. It has taken its name from the myth of Narcissus in Ovid's Metamorphosis (8AD), the story of a Greek youth who fell in love with his own image. Havelock Ellis (1898) introduced the word Narcissism to describe a sexual perversion where a person takes himself as a sexual object. Freud, in his seminal paper "On Narcissism" in 1914 outlined primary and secondary narcissism, normal and pathological narcissism, and presaged structural and object-relations theory. From this time many writers provided colourful descriptions of the narcissistic personality. Jones (1913) called it the "God Complex", Fenichel (1945) talked about the "Don Juan of Achievement" and Tartahoff in 1966 wrote about the "Nobel Prize Complex". In recent decades, the writings of Kohut and Kernberg have dominated the psychoanalytic literature with the publicaton of Kohut's "The Analysis of the Self' in 1971 and Kernberg's "Borderline conditions and Pathological Narcissism" in 1975. This culminated in the introduction by the American Psychiatric Association in 1980 (24) of the diagnostic category Narcissistic Personality Disorder (NPD). many of the descriptions deriving from these authors.
The DSM-III lists five criteria for NPD:
1. a grandiose sense of self importance and uniqueness
2. preoccupation with fantasies of success, power, brilliance, beauty or ideal love.
3. a need for constant admiration and attention
4. cool indifference or marked feelings of rage, inferiority, shame, humiliation or emptiness in response to criticism or defeat
5. at least two of the following disturbances in interpersonal relationships: entitlement, exploitativeness, lack of empathy.
Rosenfeld represents the Kleinian view of Narcissism.
In his clinical practice, he became acutely aware of the presence of destructive forces which exhibit the power to pervert and block therapy and growth. Besides providing a defensive function in keeping the therapist at bay, they also provided an attacking function, devaluing and depreciating the analyst to the point of immobilizing him and rendering him useless. He made several helpful observations about the nature of narcissism in a clinical situation:
1. Overvaluation of the self - this is based mainly on idealism of the self which is maintained by omnipotent introjective and projective identifications with good objects and their qualities
2. Avoidance of awareness of Separateness from the Object - this leads to feelings of dependence on an object.
3. Independence - hatred of dependence. "In terms of the the infantile situation the narcissistic patient wants to believe that he has given life to himself and is able to feed and look after himself".(13,p173) In terms of the analytic situation the patient tries to withhold those parts of him/herself which want to depend on the analyst as a helpful person. Thus situations of loss evoke no feelings of mourning or pining. In the analytic situation this often feels as though the patient is doing all the work by himself and that the analyst is perpetually being kept at bay. Strategies such as monotonous ramblings inducing sleepiness and detachment in the analyst or powerful grandiosity inducing impotence create the effect of an "enormous resistance, almost like a stone wall, which prevented any examination of the situation".
4. Destruction of Caring Self - their loving, dependent side is destroyed leaving them identifying with the destructive, narcissistic part that remains in control.
5. Need to Devalue Therapeutic Work in the Transference - there is a continual need to devalue the object and attempt to maintain an illusion of omnipotent superiority and self sufficiency.
6. Destructive Organisation of Narcissism - he points out that this destructive side may easily be missed in the tranference as it can remain silent and split-off which creates the effect of "obscuring" it's existence. However, once confronted, Rosenfeld describes these destructive forces as a kind of Mafia or gang suggesting an organised, underground force destroying and immobilising the basic organism.
7. Infantilization and Stunting of Psychological Growth - because of this defensive posture these patients remain locked behind a wall of hostility and superiority unable to take from objects who may be able to contribute towards their personal development.
Kohut's theory of narcissism as set out in his "The Analysis of the Self' (1971) established a revolutionary and radical concept of the self and in so doing challenged the whole psychoanalytic establishment. He developed the idea that the Narcissistic Personality Disorder originates as the result of a lack of of a "good-enough " mother-child symbiosis.
Sense of self
Kohut sees narcissism as having its own line of development along two axes based on two archaic narcissistic configurations with two largely independent but normal development lines of object-love and self-love, each subject to its own disturbances. The first is the "grandiose self', an exhibitionistic line which conveys the message "I am perfect" to others requiring of them a "mirroring" response. Kohut describes "the gleam in the mother's eye" which supports and encourages the development of the self. The second is the idealized parent image. This is the idealizing line which seeks a powerful and good figure whom the child can admire and in whose glory and perfection the child can bask. The message here is "you arc perfect and I am part of you." Kohut sees both of these as natural steps in the normal development of an adult personality. The grandiose self becomes transformed into normal self-esteem and selfconfidence, while the idealized parent becomes the idealized superego, providing the capacity for mature admiration of others. Healthy development needs the essential component of "self-objects". These are available figures who can either be providing maternal empathy and be responsively mirroring the child's greatness or else they carry the child's idealization. During development these are both seen as part of the child's self. Thus Kohut's notion of self-object refers to a dependence on psychological functions provided by others. This is a concept which must be distinguished from the object relations sense of projective identification with the other.
In normal development the two lines parallel one another and are gradually modified through nontraumatic contact with reality. The state of primary narcissism is thus disturbed by natural shortcomings' in maternal care as the child becomes aware of its own ordinariness and vulnerability. Pathological narcissism hovever results when "the transformation of the archaic configurations is arrested and they persist split-off continuing to press for expression in adulthood" (14, p144) This results from massive shortcomings in mothering. This could be either: a) a result of cold, rejecting unavailability to perform the "mirroring" role, or b) destructiveness. Also c) in situations where a child is born to a narcissistic parent it might then be used by the parent as a narcissistic object ensuring the mother's well-being and mirroring the mother's grandiosity, thus missing out on its own mirroring. The child's spontaneous development is then derailed in favour of the mother's agenda.
Implications for Treatment.
From the above account it logically follows that a Kohutian view of therapy would involve some form of repair of the narsisstic injury or self-object failure. Self-object linkages are achieved through empathic mirroring which serve to repair the self defect of the patient, leading to a decline of the symptoms of the disordered self. The therapist is thus used as a bit of the psychic structure needed for growth.
Russell notes that for Kohut "narcissistic rage arises when the self or object fail to live up to the expectations directed at their function [...] Aggression is therefore seen primarily in reactive terms, is secondary to narcissism and is a transient effect. There is no confrontation of rage in therapy" (14, p 145). Goldberg (1989) also points out that with Kohut there need be no "adversarial relationship between patient and therapist, since it is the union of self and self-object that is sought after." (1, p 736).
Kohut's attitude to aggression, rage and the negative forces of narcissism are a benign and marked contrast to those of the Kleinian camp.
Kohut excludes the notion of instinctual drives, putting the total emphasis on parental failure to match the child's needs. What Kohut appears to be saying is that what the mother fails to supply between the ages of one and three by way of empathic mirroring, the father will supply between the ages of four to six in the form of idealised parenting. If there are failures by both parents, the Psychotherapist will then aim to provide a "corrective emotional experience".
Otto Kernberg defines "Normal narcissism" as "the libidinal investment of the self' (4, p 315). - a normal part of pre-Oedipal development. On the other hand, "Pathological narcissism" is seen as a sub-category of the Borderline Personality Organization - since both narcissistic and borderline patients employ mechanisms of splitting or primitive dissociation as reflected in the presence of mutually dissociated or split-off ego states. The essential difference between the two is that the narcissistic personality is characterized by "an integrated although highly pathological grandiose self' (4, p 332).
Thus the narcissistic patient is relatively more stable with good social functioning and better impulse control whereas the borderline patient is more destructive, impulsive and displays greater capacity for affect.
Kernberg defines the main narcissistic characteristics as grandiosity, extreme selfcentredness and an absence of empathy and interest in others in spite of the fact that they need others for their supplies of admiration and approval. They tend to display an incapacity for experiencing depressive reactions such as sadness and mournful longing. Their relationships with others are often
exploitative and parasitic, often experiencing intense envy.
Structure of pathologic narcissism
For Kernberg, pathological narcissism is the result of the development of a different and pathological self-structure. This differs from "ordinary adult narcissism and fixation at or regression to normal infantile narcissism. Pathologic narcissism reflects libidinal investment not in a normal integrated selfstructure but in a pathologic self-structure" (5. p 723) This is characterized by pathologic forms of self love and pathologic forms of object love.
Central to Kernberg's theory is the idea of a "defensive refusion" (borrowed from Jacobson). He suggests that at a point at which the ego boundaries have become stable, sometime between the ages of 3 and 5 years, there is a fusion of ideal self, ideal object and actual self images. This is in response to "intolerable reality in the interpersonal realm" (4, p 231) and the aim is to deny normal dependency on external objects.
Along with this process there is also a devaluation of internalized object images who will often be presented in therapy as "lifeless shadows or marionettes"- specially those who are not idealized. This process by which the pathologic grandiose self contains real-self representations, ideal-self representations and ideal-object representations while devalued self and object representations are repressed or projected constitutes the pathologic self structure or the"purified pleasure ego".(5, p 724).
This represents a severe pathology of object relations as the individual loses not only the, normal self structure but also the capacity for normal object relations. Fostering the development of a pathologic or "grandiose self' are parents who are admiring but cold and rejecting.
Thus the grandiose self represents the building up of an inflated self-concept to conceal feelings of worthlessness and a defence against rage and envy. At the same time unacceptable aspects of the self are projected onto others who are devalued. This combination of inflation of self on one hand and devaluation of others on the other hand enables a denial of feeling dependent upon anyone.
So for Kernberg the goal of treatment is to expose the defensive purpose of the grandiose self thereby integrating the narcissistic with the healthier parts of the personality. He emphasises the necessity of interpreting, in a systematic way, the positive and negative aspects of the patient's grandiosity which presents itself in the transference. By so doing and avoiding the expectation of admiration the patient may be provoked into anger or rage. Kernberg insists that rage must be confronted in therapy.
THE CAT APPROACH
Cognitive Analytic Therapy is an integrated timelimited therapy developed by Anthony Ryle. It draws both from cognitive psychology and from an adaptation and modification of psychoanalytic Object Relations Theory. Ryle (1993) notes that those O-R concepts that have been "rejected include the emphasis on drive theory and the notion of the death instinct, the belief that splitting and projection are primarily defensive, the emphasis on very early experience and the neglect of later events in development". (20)
In CAT's view of personality development, an infant's first experiences are seen as its first interactions with the objects in its life. From the outset these relationships involve expectations and predictions. What begin as biologically programmed attachment behaviours are replaced by learned "role procedures" formed in the interaction with the mother and other caretakers. Thus a role procedure requires that the consequences of one's actions are predicted in terms of responses by the other. These "reciprocal roles" are acquired and maintained unconsciously. In this way, personality becomes structured on the basis of internalised parent-child interactions which form the basis for both self-self and self-other procedures. The crucial task of childhood is seen as "the integration of part procedures into complex whole personal procedures". (17) A reasonably mature personality will have a self within which a range of reciprocal role procedures can be mobilised. These reciprocal roles are the basic units of all intra- and interpersonal functioning.
However, adverse circumstances such as loss, abuse or deprivation may prevent this process of integration, so that the individual may grow up with an extremely disconnected way of viewing the self and the world. In narcissistic and borderline personality structures, the subsystem might be split into two or more subsystems with little awareness of one while in the other.
The narcissistic personality structure is thus seen in CAT terms as essentally similar to, and a subdivision of, the borderline personality disorders. The weak, vulnerable and frightening aspects of the self are protected by grandiosity and the introjection of idealized others. At the same time unwanted feelings may be projected onto others by means of projective identification leaving the self empty and depleted. Thus those who are not idealised may be dismissed as weak and contemptible and the self becomes contemptuous of them. Such individuals presenting for therapy are seen as having problems stemming from the self-reinforcing nature of the damaging procedures. "On this basis the prime therapeutic task is to describe these sequences accurately and to avoid at all costs colluding with the patient's role repertoire".
These processes of splitting and non-integration are seen as "failures to complete integration rather than being primarily dcfcnsivc"(15, p 88) as is understood by most psychoanalytic writers. In his reply to Ann Scott (1994), Ryle expands on his ideas of "splitting as a developmental failure" (20, p 2) He considers the idea that "splitting is pre-Oedipal in timing and defensive in function, as overdue for revision" (20, p 2). He suggests instead that when unmanageable traumas such as loss, abuse or deprivation cannot be assimilated, they continue to exist as "partial self-states" with reciprocal roles and defence mechanisms of their own. In addition, because there is little or no capacity for selfobservation the individual has no insight into what is wrong and how to put it right.
Very little emphasis is placed on precise diagnostic categorization and labelling in CAT. It is necessary to recognise the splits to inform treatment but in the inevitably hazy areas between narcissism and borderline it is quite possible to work with a patient without making that discrimination. Diagnoses are made by way of simple, straightforward descriptions of procedures.
Implications for treatment
The therapist responds to the emergence of idealising, dismissive and grandiose procedures by, description and demonstration rather than interpretation. Interpretations are regarded as critical and undermining. Tony Ryle (1994) states categorically "criticism from the therapist is, in my view not justified". Thus maintaining a non-judgmental stance is essential for the process of forming joint descriptions, joint monitoring and joint reflection. Allowing oneself as a therapist to get caught up in the patient's dance is often the first step in understanding the patient's procedures.This very often entails the toleration of countertransference feelings of helplessness and uselessness evoked by the patient's grandiosity.
As therapy progresses this might well be replaced by idealization. Collusion in both states needs to be recognised and avoided.
One of the chief interpersonal problems with narcissistic patients is their inability to relate to people. A therapeutic alliance in which the therapist succeeds in refusing to be drawn into the reciprocal roles of Admiring/Admired, or Contemptuous/Despised may be the patient's first experience of a more " real" way of relating.
The first high level description is the written reformulation which has the effect of containing patients and making them feel understood. The act of naming the reciprocal roles and ensuing procedures begins the process of recognition before which revision and then change can take place. The process of naming "all aspects of the patient including those that are initially disavowed" has the effect of setting everything up for joint examination and consideration for revision. The Reformulation process is then completed with the introduction of the Sequential Diagrammatic Reformulation which provides a graphic account of the narcissistic structure with its split core and failure of integration.
"Where repeated interpretation slowly dismantles the defences around the beleaguered ego, or fragments of ego, reformulation offers the garrison a new resource; as a result the doors are opened." (20, p 55)
With integration as the aim of therapy, emphasis is placed on putting the patient in touch with his/her unacceptable feelings of inadequacy, humiliation and emptiness. These can then be incorporated into the patient's increasingly more realistic sense of self. Target Problems and Target Problem Procedures provide the goal and focus for therapy. Rating Sheets provide a focus for the weekly sessions and as such serve to keep both patient and therapist on course. In a classic narcissistic therapy it would not be unusual for a contemptuous patient to dismiss disparagingly such seemingly facile tools. They have been known however to serve as an invaluable aid in keeping the therapy on a descriptive rather than interpretive level thus helping to avoid collusion or annihilation.
DISCUSSION AND COMPARISON OF CAT WITH ABOVE THEORIES
Origins and Theoretical Issues
Symington (1993) roughly divides most theories of narcissism into two camps - trauma theories and phobia theories. Rosenfeld and Kernberg have developed phobia theories. The central focus for these clinicians is an anxiety within the personality. "The anxiety is fear of annihilation, and its source is the death instinct within." (23, p 110). The subject deals with this anxiety by expelling it and locating it in external objects or things.
Trauma theorists such as Kohut and Mollon assert that narcissism is nearly always the result of some shock or change of circumstances. Trauma can take the form of loss, abuse, deprivation or even the accumulation of interactions from emotionally cold parents, "the most traumatizing experience of all is the absence of emotional giving from a mother or father." (23, p 79).
In CAT, loss, abuse and deprivation are seen as the chief causes of the failure to integrate. Ryle acknowledges that people arc born "with different thresholds to harm [but] it is insulting and misleading to explain their destructiveness and damage in terms of ego weakness or large doses of the death instinct". (20, p 1)
Theory and practice go hand in hand. Just as clinical work generates hypotheses that eventually become woven into the fabric of theory, theory can provide the guiding light to inform clinical practice. Nowhere does this beacon become more necessary than in work with difficult narcissists. In this section I would like to examine some of the different attitudes to the treatment of narcissistic disorders represented by the five theorists selected above comparing them to current practice in CAT.
Aims of therapy
Karl Abraham said that the aim of psychoanalysis was to put things right at the foundation of personality, to ensure the individual against future mental illness. In order to achieve this end, Kernberg states his aim of therapy with patients with NPD is "to expose the defensive purpose of the grandiose self thereby integrating the narcissistic with the healthier parts". For Kohut it is-a question of creating a corrective emotional experiedce. The aim for a CAT therapist is integration. Tony Ryle points out that the aims of a 16-week CAT therapy are modest. It tries simply to open the doors so, that further development can be freed to take place in the context of the person's life. "What CAT can achieve, I believe, is a clearing of the road blocks; self-maintained obstacles are identified and untapped personal resources are freed " (20, p5).
Kohut and Kernberg represent the two poles of thinking regarding technique and style. Kernberg believes in the "systematic analysis of the negative transference" and the confrontation of Narcisstic rage. Kohut thinks that the therapist provides the emotional experience that can make up for the deficient self-object attunement in childhood. In CAT our chief therapeutic tool is that of description - through the Prose Reformulation, the SDR and in the repeated recognition of reciprocal roles and procedures. Sometimes the juxtaposition of inconsistent or illogical descriptions will take a confrontational form ie. in confronting a client with the consequences of his/her behaviour.
Kohut is often criticized for ignoring the destructive and conflicted sides of the narcissistic personality. Rosenfeld, on the other hand, seemed to concentrate on those aspects. Kernberg believes in the confrontation of rage and envy. Russell (1985) points out the problems of placing too much emphasis on the role of confrontation in therapy:
"Confrontation may effectively mean that the narcissistic personality's fears are realized, merely perpetuating his/her illusion that the conflict is between him/her and the outside world. It may be experienced as unempathic and critical as the therapist becomes confused with the rejecting parent. Patients can respond in two ways only: Marshalling their narcissistic grandiosity or suffering the pain of assault at the hands of someone upon whom they are dependent for their well-being." (14, p 147)
In CAT we aim to name and accept the presence of previously disavowed negative emotions such as envy, rage and destructiveness.
Kohut's policy of empathic mirroring leads to collusion with the idealised, grandiose self thus making it difficult to move forward. Kernberg and Rosenfeld both "interpret" the transference. CAT's idiosyncratic view is to repeatedly describe and recognise reciprocal roles to avoid collusion and so endeavour to promote a more authentic mode of relating. In addition, the brief and structured nature of a CAT provides a momentum that prevents the therapist from remaining too long in the immobilized, dismissed, useless state.
In this paper I have tried to explore the theory and practice of Narcissistic Personality Disorders by presenting the ideas of three current psychoanalytic theorists and demonstrating how they have informed, influenced, and differ from, CAT. Although this process has afforded me a clearer understanding of many of the concepts, viewpoints and philosophies of the Psychoanalytic world, my "observing eye" tells me that 1 have only just begun to scratch the surface. However, my hope is that this new framework will provide a more focussed perception when tackling the convoluted prose of
Kohut and Kernberg. Certainly in my practice, when locked into an immobilising countertransference by a frightened, angry narcissist, I shall remember Rosenfeld's "Mafia" and Kernberg's "grandiose self'.
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3. KERNBERG,O. (1968) Factors in the Psychoanalytic Treatment of Narcisstic Personalities
4. KERNBERG,O. (1975) Borderline Conditions and Pathological Narcissisn. Jason Aronson.
5. KERNBERG,O. (1989) An ego Psychology Object Relations Theory of the Structure and Treatment of Pathologic Narcissism. An overview. in The Psychiatric Clinics of North America, vol 12, no.3.
6. KERNBERG,P.(1989) Narsisstic Personality Disorder in Children. in The Pschiatric Clinics of North America vol. 12,3.
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14. RUSSELL, G.(1985) Narcissism and the Narcisstic Personality Disorder: a Comparison of the thoeries of Kemberg and Kohut. British Journal of Medical Psychology. 58,137-148.
15. RYLE, A and COWMEADOW, P.(1990) Cognitive Analytic Therapy. in Handbook of Integrative Therapies. ed. Dryden,W. Open University Press.
16. RYLE,A (1990) Cognitive Analytic Therapy: Active Participation in Change. A New Integration in Brief Psychotherapy. John Wiley.
17. RYLE,A (1992) Critique of a Kleinian Case History. Brit. J. Med. Psychol. 64
18. RYLE,A. (1993) Addiction to Death Instinct? A Critical Review of Joseph's Paper "Addiction to Near Death". British Journal of Psychotherapy Vol. 10, No. 1
19. RYLE, A (1991) Reformulation in Cognitive Analytic Therapy. A Revised Manual. UMDS.
20. RYLE,A (1994) Psychoanalysis and Cognitive Analytic Therapy. British Journal of Psychotherapy, 10 (3) p.402 -404.
23. SYMINGTON, N. (1993). Narcissism - A New Theory. Karnac
24. American Psychiatric Association, Diagnostic and Statistical Manual of mental disorders, 3rd edition, 1980
This article is based on the author's much longer essay produced for the Advanced CAT Course, and on her presentation to the ACAT Conference, February 1995.
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