Whether it’s applied in popular culture to a politician, a difficult spouse, or an annoying friend, the label of narcissist has become ubiquitous lately. Narcissism alarms have been sounded more generally about predatory, powerful men, and about a selfie-obsessed, social-media-driven society. As the question of what constitutes clinical narcissism has begun reverberating through our society, clients have started paying attention to the diagnosis in new ways.
Most therapists understand that true narcissistic personality disorder affects only a tiny percentage of the population. But as narcissistic behavior becomes increasingly recognizable, and clients take a second look at the power-hungry manipulations of partners and family members, therapists are having to ask: Are we talking about a true clinical issue here? How can we help with clients who think they have a narcissist in their lives?
Ramani Durvasula, a clinician and professor of psychology at California State University, Los Angeles, gave a popular TEDx talk on this topic last year. The author of Don’t You Know Who I Am? How to Stay Sane in an Era of Narcissism, Entitlement, and Incivility and Should I Stay or Should I Go? Surviving a Relationship with a Narcissist, Durvasula treats both narcissists and clients struggling with the narcissists in their lives.
Ryan Howes: What drew you to study narcissism in such depth?
Ramani Durvasula: Initially, as a researcher, I was interested in personality disorders and health-sabotaging behaviors as they relate to HIV. At the same time, I was seeing lots of clients in my practice dealing with antagonistic, entitled people in their lives. I was struck by how little literature was available to draw from on narcissism that wasn’t psychoanalytic.
RH: Narcissists themselves don’t tend to come to therapy and say, “I’m dealing with narcissism and I need to change it.” Why can’t people recognize it in themselves?
Durvasula: For somebody to be diagnosed with a personality disorder, they must be experiencing subjective distress or social and occupational impairment. Often, the narcissist experiences none of that. Think of your stereotypical, narcissistic male CEO. He’s on his fifth wife, with the yacht and the house and the girlfriend on the side. There’s no external stressor pushing him into therapy. He’s feeling no distress because he has little regard for the harm he’s creating, and very little self-reflective capacity.
RH: But if a narcissist is pressured to go into therapy by others, or even mandated to be there for eight sessions, what do you do?
Durvasula: Good luck with that! But in all seriousness, my wish is that we could take everybody who experiences narcissistic patterns and give them access to a multiple-times-a-week, years-long course of therapy, because we don’t have a model that works over a shorter term.
Even still, if you do get a narcissist to stick with therapy, he’ll be 54 percent likelier than other clients to drop out when the therapist begins making incisive observations. Also, when my narcissistic clients are under stress, they’ll easily pop back to baseline. When things are going fine, we can create some reflection points of empathy, and some self-reflective capacity, but these are often such microchanges that the people around them still mostly have to deal with a tyrannical boss or husband or father.
Then there’s the issue of therapist burnout. A therapist can only endure the power struggles and yelling and name-calling for so long before thinking, This isn’t worth the money.
RH: When we talk about narcissists, are we talking primarily about men?
Durvasula: It’s difficult to measure narcissism as the true clinical pattern it is, but it’s often thought the gender makeup is about 80 percent male, 20 percent female. Still, the number of clients who struggle with a narcissistic mother, or sister, or mother-in-law, or wife definitely implies that this may not be as gender skewed as we once believed.
RH: When I think of narcissism as a pathological insecurity, I think of attachment issues and an early wound, which might lead clinicians to focus their approach on creating safety and secure attachment in therapy.
Durvasula: It’s true narcissists might’ve had absent parents or suffered trauma, but they’re very threatened by this way of working because you’re trying to go deep into their most vulnerable parts. With a residential, intensive treatment, maybe you could crack them a little bit, but that’s an expensive, rarefied space. And it’s important to mention that we know narcissism doesn’t discriminate fiscally. I work with domestic violence programs and see angry, entitled abusers. That’s narcissism, too. Often they don’t have the resources to participate in insight-oriented therapy.
Partners or children will often say, “I know that the narcissistic person in my life has a terrible backstory,” and a big thrust of my work is to not let people who’ve experienced abuse at the hands of a narcissist lose their compassion, even if they have no hope of rescuing their narcissist.
Trying to teach people to retain empathy, set boundaries, and be okay with walking away can sometimes feel like asking them to walk a tightrope with a piano on their back. But ultimately, if they say, “I feel very guilty walking away from this broken person,” my response will be, “Well, do you want to sign up to be their permanent punching bag? Because there’s no other option here.” Finding a way to help clients balance empathy with self-respect in this way is a conversation that mental health professionals aren’t having.
RH: A lot of your work is educating the general public about what narcissistic behavior looks like, and if you’re in a relationship with a narcissist, how to get out. Is getting out the best solution?
Durvasula: When I wrote Should I Stay or Should I Go, about half the people I was seeing in my practice had small children or were financially dependent and felt they couldn’t get out. Some would tell me that because of their religion, or community, or culture, it wasn’t possible to leave.
So I also work on what to do if you have to stay in these relationships. What if the narcissist is a mother or father? A marriage partner you can’t divorce? In these cases, it isn’t about walking away, but about not deriving your sense of self-worth from how a damaged person treats you. You set boundaries, create realistic expectations, and engage in radical acceptance that the situation isn’t going to change. You find a way to disengage and be as civil as you can, without remaining vulnerable. Some clients will tell me, “Well, that’s not much of a relationship,” to which I’ll respond, “It never was. But at least you’ll know what the truth is, and you’ll be less hurt.”
One thing I run into a lot, when I’ve lectured on these topics in South Africa and India, and with diverse communities in the U.S., is the issue of collectivism. From my perspective, collectivism is not an absolute virtue. It’s those collectivist mindsets that lead families to offer advice like, “We must be loyal; don’t speak against him.” That kind of intergenerational enabling has done more harm than we can imagine.
RH: How does a narcissist respond to not having access to your inner world any longer?
Durvasula: They don’t care about your inner world. They liked the conflict and tears because it helped them feel powerful. When the partner slowly starts to disengage and the patterns working in the narcissist’s favor are gone, they don’t suddenly realize, “Oh, I mistreated this person.” Instead, they’ll often gaslight them and accuse them of being cruel. And because narcissistic abuse can wear people down until they’re riddled with doubt and self-blame, the partner will often succumb to this, and the endless cycle of an invalidating, abusive relationship will continue.
RH: Is there any truth to the idea that people with borderline personality disorder and people with narcissism tend to end up together?
Durvasula: I see the relationship between the two personality disorders as one of those old-school, sliding volume buttons. On one end, the borderline personality is characterized by negative affect, danger of self-harm, instability, and self-invalidation. There still may be some manipulation, but it’s not as sophisticated. When their calls aren’t returned, for example, they’ll often think, Nobody loves me, so I think I’m going to hurt myself. In therapy, we teach those with a borderline personality style to tolerate negative moods and find better ways of creating interaction.
The pure narcissist, in contrast, is unempathetic, entitled, and arrogant. Once you move the slider over, you start getting into a middle ground between the two, where the fragile sense of self and the invalidating, entitled self get mixed. That mashup is often where that more negative view of borderline personality comes from.
When asking whether and why those with borderline personality disorder and narcissistic personality disorder go together, we can go back to your model of attachment. Borderline individuals, because of the paralytic terror of their abandonment, are a sure thing for the narcissistic personality, which likes to stockpile people; however, narcissistic individuals lose patience with the borderline personality style, which wants far more of them than their contempt and intolerance for intimacy will allow. Then the devaluation phase happens. It’s a roller coaster that plays to the anxious and disorganized attachment style in BPD.
When I’ve worked with couples in this mashup, there’s been a sense that their relationship is exciting and other relationships are boring. We’ve ended up talking about trauma bonding—the idea that abuse, neglect, and rejection constitute love.
RH: What about the idea of the closet narcissist. Does that hold any weight?
Durvasula: That idea has morphed into what some now call a vulnerable narcissist, someone with a more victimized, resentful, and sullen mindset. Their grandiosity is about opportunities missed—“the world doesn’t see how great I am.” This is versus the impresario grandiose narcissists, where it’s “Here I am; the show can begin!” People see the vulnerable narcissist as someone to rescue, and in the early phases of the relationship, there’s often a plenitude of empathy for them.
We’re starting to understand that each style of narcissism has uniquely appealing features. We’ve all been socialized to find a charming and charismatic person desirable. I spend my days telling people that charisma is actually one of the most dangerous qualities out there. Charismatics may look lovely and alive, but pay attention, because it could be masking something.
RH: Gaslighting has become a popular cultural topic lately. How does gaslighting benefit a narcissist?
Durvasula: The real crime of gaslighting is it hijacks someone’s internal emotional awareness. People start thinking, “Maybe I have no right to feel what I feel.” This leads them to have trouble making sense of what they’re going through. This is especially true if someone’s had a narcissistic parent, because from an early age their entire emotional world has been doubted, denied, trivialized, or otherwise invalidated.
RH: How can therapists who don’t have a background in working with narcissism learn enough about these issues to be of help?
Durvasula: First, the mental health establishment has got to get its act together. There should be an entire course in every master’s and doctoral-level training program on these high-conflict personality styles, because this is the stuff that brings therapists to their knees. They don’t understand it, were never taught it, and often didn’t get decent supervision, because the supervisors didn’t understand it either.
Second, we need to understand that trauma and systems issues need to be addressed when we’re working to understand the developmental sequence that leads to an antagonistic personality like narcissism, as well as the developmental sequence that makes a person vulnerable to entering a relationship like this, and staying in it. We need to explore what happens when you have a parent who gaslights and invalidates a child, and how it plays out in that person in adulthood.
You need a solid understanding of how this personality evolves and where it comes from, because that will imbue you with compassion for your narcissistic clients and the long, lonely life they have ahead of them if they don’t change. Then, from an interpersonal perspective, when the narcissist’s loved one is your client, you need to be willing to talk about the person who’s not in the room and do a deeper dive to understand what their patterns are. You have to be managing co-occurring conditions. Clients going through narcissistic abuse may have experiences with depression, anxiety, and other issues of dysregulation, including using substances to cope.
RH: Some therapists will find it against their training to talk about a person who’s not in the room.
Durvasula: Only talk about your client? That’s ridiculous! If my client is coming in and talking about how her reality is being doubted 15 times a day, then I’m throwing the manual out. I think you need to give the client the opportunity to understand gaslighting, the damages of being in a narcissistic relationship, and the resistance of the narcissistic personality to change, so she can truly explore her options.