Fink! Still at Large: A Recent Study of Psychiatric Outpatients Showed a Link between Failure to Complete Treatment and Narcissism. What Strategies Have You Used with These Patients?

By Fink, Paul J. | Clinical Psychiatry News, March 2009 | Go to article overview

Fink! Still at Large: A Recent Study of Psychiatric Outpatients Showed a Link between Failure to Complete Treatment and Narcissism. What Strategies Have You Used with These Patients?


Fink, Paul J., Clinical Psychiatry News


The study, published online in the Journal of Psychiatric Research, describes how difficult it is to treat patients with narcissistic character disorder, or NCD. I agree.

Like many other words in the psychiatric lexicon, narcissism is imprecise and used in many contexts that make its diagnosis and treatment quite difficult. In lay terms, narcissism means self-love, and all humans have some level of narcissism.

The first section of Freud's paper, "On Narcissism: An Introduction" (The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. XIV. London: The Hogarth Press, 1957) reads as follows:

"The term narcissism is derived from clinical description and was chosen by Paul Nacke in 1899 to denote the attitude of a person who treats his own body in the same way in which the body of a sexual object is ordinarily treated--who looks at it, strokes it, and fondles it till he obtains complete satisfaction through these activities. Developed to this degree, narcissism has the significance of a perversion that has absorbed the whole of the subject's sexual life, and it will consequently exhibit the characteristics which we expect to meet with in the study of all perversions."

Such terms as self-love, self-regard, and self-importance are applied to people when we try to explain the "pathology" of narcissism. There is clearly an idealization of oneself and a feeling of having the power, the attractiveness, and the enormous capabilities--mental and physical--to deal with all issues in a positive manner. This overestimation of self is the essential aspect of NCD that makes it so difficult to treat successfully. I have found that psychodynamic treatment is long and complex. For example, if the patient is unable to transfer some of his self-love to the therapist, the creation of a utilizable transference is made much more difficult. Such patients expect you to respond according to their wishes and expectations--much as their mothers may have responded when they were taught as babies about their perfection and omnipotence.

Patients with NCD expect the therapist to fulfill their wishes and react in ways that will only gratify them. One of my patients wants an 8:00 a.m. appointment, and if I cannot give it to him, he will not come until he can get what he wants.

Freud calls the narcissism of infants and children "primary narcissism," which is fed by the overweening adoration of parents who see no flaws in their child. This stage of development is universal, but most of these children learn to accept the reality that they are not perfect. When this overestimation of the child continues for years, it sets the stage for NCD. It is tragic when these patients are forced as adults to face the painful reality that no one gets everything they want in life.

The play "First Love" by Samuel Taylor, which is based on a memoir by French writer Romain Gary (New York: Dramatists Play Service, 1998), describes a boy raised by a mother who told him repeatedly that he would grow up to become the president of France. When that did not happen, he became seriously depressed. The play details the tragic life story of many people who have NCD and who have to face facts. Depression that results from terrible disappointment is difficult to treat, and the narcissist can experience an especially deep disappointment.

The fact that narcissists have interpersonal problems should not be a surprise. Their self-love is so deep that such people often do not have room for another person to love and adore. Narcissists who fall in love often do so with someone much like themselves, a person who fulfills the wishes that they cannot fulfill for themselves.

I treated a narcissistic patient who was enamored with his own penis. He had to have sex or masturbate at least once a day, and he found a woman who seemed to adore his penis as much as he. Men and women who have NCD often spend a great deal of time in front of the mirror admiring themselves, so to find a sexual partner who seems to do the same things is a big turn-on. …

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