Ask David: Featuring Matt May, MD 329: How can you deal with a “narcissist?” In today’s Ask David, we respond to a listener who requested a podcast on the topic of narcissism, including how to deal with them, so we will focus on these topics. The following show notes were prepared prior to the actual podcast to provide a structure. For more great information, listen to the podcast, as much more was covered! David

1. What is the definition of “narcissistic personality disorder”?

Narcissism involves:

• Grandiose fantasies and feelings, thinking that you are superior to others
• Lack of empathy for others
• Extreme self-centeredness
• Intolerance to criticism or disapproval
• Urges for revenge on anyone who crosses you.

We do not know whether these are just extremes of personality characteristics that everyone has in varying degrees, or whether it actually consists of a “disorder” that is qualitatively different and distinct. But it is definitely true that all of the characteristics I have bulleted above do exist to some degree in most, if not all, human beings.

2. How do you treat narcissistic patient?

I do not treat diagnoses, just human beings. This is a radical departure from the way many mental health professionals approach their work. No matter who I’m treating, I always start with the T and E of TEAM (Test and Empathy) and then move on to A = Assessment of Resistance (formerly called Paradoxical Agenda Setting.) The main idea is to find out what, if anything, the patient wants help with. It would be rare for someone with narcissistic qualities to want help with their narcissism. Generally, they want help with a troubled relationship or with feelings of depression, anxiety, or anger. Then I would ask them to zero in on one specific moment when they were upset and wanting help, and deal with Outcome and Process Resistance. If the patient can convince me that she or he does want help, then I move on to M = Methods, and the methods would have to do with the nature of the problem they want help with. I once presented a case illustrating rather dramatic and rapid recovery in a patient I was treating for depression and anxiety. To my way of thinking, it was a great outcome. However, during the Q and A I got an angry rebuke from a therapist in the audience who pointed out that I hadn’t treated the patient’s “obvious narcissism.” This is the “great divide.” I don’t feel like it’s my calling to evangelize for any model of “ideal mental health.” For the most part, and there are always exceptions to every rule, I do not impose my agenda on the patients, but try to work with what they want to change. I might suggest possible ways we could work together, but in the final analysis it is up to the patient. I liken my role to that of a plumber. If you’ve got a broken toilet, give me a call and I’ll fix it. But I don’t go from door to door promoting copper pipes!

3. How can you deal with narcissistic individuals in the real world?

Once again, it depends on the specific moment that you want help with. However, I always like to emphasize the value of the Disarming Technique and Stroking when interacting with someone with strong narcissistic tendencies. The goal, in my opinion, might be on “dealing with them skillfully” as opposed to “changing” them or “winning.” For example, (David can give example of Erik’s friend when growing up.)

4. What are the causes of narcissism? 

Scientists do not know, for the most part, what causes most of the so-called “mental disorders” listed in the Diagnostic and Statistical Manual of the American Psychiatric Association, but it seems possible, even likely, that there could be genetic and environmental causes, and the environmental causes could have to do with the past (childhood influences) and present. For example, when people begin to experience significant success, in academics, sports, or some other field, others begin to admire them and want to be with them. This can fire up our egos, and can feel good. And as they level of fame and status increases, the attraction of others intensifies, and eventually people fear saying no or contradicting the narcissistic person who has such power. So, the narcissistic person is constantly reinforced, even for bad behavior or irrational beliefs, with little or no negative feedback to correct his or her course of actions and thinking. Some experts also point to profound feelings of shame and insecurity under the surface, which might also be genetic, at least in part, or triggered by adverse childhood experiences.

5. What you have to let go of to relate to someone who is narcissistic?

To my way of thinking, you have to give up the idea that the narcissistic person is going to take you seriously or care about you, You may also have to give up the notion that you are going to “change” or “help” them. You may have to use a more manipulative approach, using lots of Disarming and Stroking, instead of being so sincere and serious. This involves “letting go,” and moving forward with your life.

6. What is “Malignant Narcissism?”

This is a severe form of narcissism where the person will resort to extreme tactics to get their way, including murder. You see this in politics and cults. Names like Jim Jones, Adolph Hitler, and even some politicians today around the world, and many despots throughout human history.

7. What does it mean when someone is “manipulative?”

David explain that he’s heard that term for years, decades really, but did not understand what it meant until a few weeks ago, based on a personal experience. The group contrasts a relationship based on using people, and seeing them as objects, vs a relationship based on warmth, vulnerability, trust, respect, and openness. Thanks for listening today! Matt, Rhonda, and David