Key insights
Online discourse about NPD collapses into non-mentalizing. Public conversation tends to regress to teleological reasoning – judging people by their behavior rather than their internal experience – and as soon as one participant operates that way, the rest follow. This isn’t a constitutional incapacity; it’s a state-dependent collapse that anyone can fall into under emotional arousal.
Grandiosity and vulnerability are two facets of one construct, not opposites. When you actually examine the factor structure of the Pathological Narcissism Inventory, the two correlate strongly rather than oppose each other. Pathological narcissism needs both to be a coherent clinical construct: pure grandiosity isn’t a disorder, and pure collapse looks like almost any severe mental illness.
Trait narcissism is not pathological narcissism. The Big Five traits sometimes associated with “narcissism” (high extroversion, low agreeableness) are heritable but aren’t a disorder, and the DSM’s trait-style framing produces what amounts to “asshole disorder” research. Plus, the same Swedish twin sample yielded a 79 percent heritability estimate when NPD was measured categorically, but only 24 percent when measured dimensionally.
Most narcissistic presentations show disorganized, not dismissive, attachment. Mark’s dissertation found that disorganized attachment – intense ambivalence about closeness, being seen, and being a self – fits better than pure attachment avoidance for most of the people he sees.
Two NPD clusters map onto two attachment dimensions. A perfectionistic, externally validated presentation tends to be unstable and high in attachment peroccupation, because the standard of worth is external. A control-oriented, anti-helplessness presentation is more stable and high in attachment avoidance, because it relies on a self-sufficient internal model. See also Narcissism, Echoism, and Sovereignism: A 4-D Model of Personality.
Depressive personality is organized around loss; narcissism around deficit. In depressive presentations, something was had and then lost – either introjected as self-attack (Freud’s melancholia) or pined for externally. In narcissistic presentations, something was never gotten in the first place, and a compensatory structure forms around the gap. The narcissistic injury is sustained earlier than the depressive injury.
Idealizing transference shouldn’t be punctured prematurely. Idealization is a developmental fantasy that’s serving a function – like a four-year-old’s belief in the Tooth Fairy. The clinician’s job isn’t to live up to it (that’s impossible) but to refrain from interpretations that disrupt it before the patient has the ego capacities to tolerate reality.
A successful treatment is one that simply doesn’t fall apart. Mark’s working title for his clinical book is Staying in the Room. Ruptures most often happen when the patient’s internal pressure to perform becomes pressure on the therapist to perform, and the frustration outpaces the dyad’s capacity to metabolize it before the patient leaves.
Diagnoses are almost always mixed. If there’s one personality disorder there are usually several, and deciding which is “core” versus “stabilizing around the core” is a judgment call. The diagnostic constructs themselves are blunt instruments for what is essentially the most complex system in the known universe.
Sadism functions to expel intolerable parts of the self. What looks like “joy” in extreme online punishment fantasies is often projection: the bad object holds the disowned weakness, vulnerability, or sexuality, and is then righteously punished. The collective sadistic stance toward “the narcissist” online works the same way. See also The Sadism Spectrum and How to Access It.
Two etiological paths into NPD. An alien, impinging introject from a parent tends to produce more internal distress and a disorganized, dysregulated collapse. Pure neglect, where the child is effectively raised by the environment and finds validation through achievement, tends to collapse in a more depressive direction.
The lever for self-help is mentalization, not exercises. In place of homework, Mark recommends mindfulness or Vipassana-style practice that lets a person sit with the experiences typically projected or externalized – the ACT idea of self-as-context: I am the space in which valuations like “bad” and “good” occur, not the verdict itself.
Transcript
Introduction and Mark’s projects
Dawn: Hello, Flitterific listeners! I’m joined today by Dr. Mark Ettensohn, who runs the wonderful YouTube channel HealNPD. Please check it out and subscribe – with the notification bell – to both of our channels. Mark specializes in narcissistic adaptations, which of course are the best adaptations – well, depending on the environment. He has also written a book that’s visible in the background, Unmasking Narcissism – the one in yellow and black. That one is highly recommended too. Let’s jump into it. Do you have any new projects that you’re working on – any new books that are perhaps coming out?
Mark: I do, yeah. I don’t want to over-promise, but I’m currently in the last semester of the academic year. In addition to my clinical practice, since 2018 I’ve been in academia. I was an administrator helping to start what is now an American Psychological Association (APA) accredited program, and at some point I transitioned to a faculty member, so now I’m an associate professor in that program. But I’m stepping away – this is going to be my last semester as a professor. Although I really love teaching, and I find it immensely meaningful, and I really enjoy having an impact on developing clinicians, it just takes so much time. As my channel has grown, I’ve been having a hard time balancing those demands, so I’ve chosen to say goodbye to academia and reinvest that time into publishing and making more content for my channel.
As part of that, in May I’m going to take a week off and focus on finishing one of the writing projects I have in development. This one is a curated collection of clinical essays. Some of them have appeared on my channel, but in spoken form, so this will be reworking them so they’re appropriate for written format, adding things, and so on. The tentative title is The Villain We Invented. It’s going to be about narcissistic personality disorder (NPD) stigma, the “narc abuse” landscape online, the concept of popular narcissism, and the ways that all of that has been twisted up into this mangled construct that we’ve all probably encountered quite a bit online. It comes out soon – self-published, at least that’s the plan. We’ll see how that goes.
Dawn: I’m working on a self-help book for people with NPD, and I think you also mentioned something of the sort, so I’d be quite curious about your take on that. A lot of my friends with NPD want to be very self-determined, very independent, so it’s easiest for them, at least early in their recovery, to work on things by themselves – having a workbook to guide them could be helpful.
Mark: I agree. I have five or six projects in development – I’m a little scattered in that way. I’ve got the book I told you about, a clinical book focused on the therapy process working with pathological narcissism, another book focused on grandiosity, a workbook that’s half-finished, and some other stuff too. The California Psychological Association Convention is coming up, and I’ve submitted a proposal to introduce a new taxonomy of narcissistic self-states I’ve been working on. We’ll see if any of that ends up actualizing, or if it just stays in virtual development hell on my computer.
Dawn: How cool! I’m also working on an AI-based app for mentalization-based treatment (MBT): stillwater.coach hasn’t launched yet, but hopefully will in the next week or so – it’s still in the relatively early stages of development.
Mark: Are you technologically oriented in that way? You must be, if you’re developing an app.
Dawn: Yeah, exactly. I’ve been a software engineer for ages – professionally since 2010 – and more recently I’ve reoriented a bit in the direction of tech entrepreneurship, mostly because of AI and software engineering getting automated now. This was one of the things I felt very passionate about, because of all my involvement with personality disorders, and I’m hoping it will take off. There’s a niche there: currently there aren’t really any apps that focus on trauma-based adaptations like personality disorders. Some try to do EMDR for people with post-traumatic stress disorder (PTSD), so it goes a bit in that direction, but nothing that quite fits that mold. In particular, MBT seems sufficiently protocolized that I think I can teach an AI to do it, and also observe how the AI is doing and make sure it’s doing the right thing over time.
Mark: Which may be more challenging than it seems.
Dawn: Yeah, but if it’s totally open-ended psychodynamic therapy, I never quite know whether the AI is doing something that makes sense, whereas if it’s supposed to follow the MBT protocol, I have a better handle on that, and can review some chats – privacy permitting – and make adjustments.
AI assistants and online discourse on NPD
Mark: I have an AI chatbot that I trained on my own material. It’s a membership-tier offering on my channel, and it’s interesting – even with a thousand different safeguards to keep it from doing therapy or doing something that looks like therapy, I’ll still review the chat logs, and every once in a while it’ll pop over into, like, robot therapist mode, and then I have to figure out why it did that and how to keep it from doing that. From my perspective, that’s potentially a liability, especially as a licensed clinician. I don’t want to host a chatbot that’s trying to do therapy, for a number of different reasons.
Dawn: Yeah, but the question answering is super useful.
Mark: That’s what it’s intended for, and it’s got disclaimers all over the place: this is not intended to be therapy, this is not clinical advice, if you’re in crisis, call this number, and so on.
Dawn: I’ll probably also need to copy some of those crisis numbers – that’s something I consider relevant.
Mark: I just feel it’s important to have a number of safeguards in place, because most of the time the chatbots produce a reasonable response, but every once in a while they’ll pull in something that’s an outlier response and present it as though it isn’t. I worry that folks who are in a very vulnerable moment might be led in the wrong direction.
Dawn: That makes a lot of sense. I’ll probably also need to make sure the temperature is set really low, and run a lot of tests with one AI against another, so I have some protocols I can review of how well my AI is doing.
Mark: Sounds very complicated.
Dawn: On your channel, you’re not focusing only on the therapeutic or academic sides – you’re also engaging with what’s going on in popular culture. One thing I’m seeing in particular is what’s called teleological non-mentalizing, which is quite typical of NPD: people see some behavior and jump to a conclusion about what must have precipitated it, while ignoring the actual complexity of the underlying motivations and attitudes of the person who shows that behavior. If someone like Vaknin, who has NPD, does this on a YouTube channel, then it’s easily explainable for me. But if a thousand YouTubers do it – and this is what I’m seeing a lot – when they talk about people with NPD, they’re viewing them as if they were automatons of sorts, without any internal experience. They basically don’t worry about what precipitates these experiences, what’s actually going on inside of them. I’m confused what’s going on there, and why they’re doing that. If you encounter that, do you have any particular approaches or examples that help you explain to people the difference between teleological non-mentalizing and actually empathizing?
Mark: When I think about teleological non-mentalizing – reasoning about motivation based on the outcome of a behavior, right? “A person was mean, therefore they meant to be mean,” or, “I feel offended, therefore you meant to offend me” – I think about developmentally less mature ways of conceptualizing relationality. Little kids don’t necessarily even have a theory of mind, and even if they do, it’s inconsistently applied. There’s a tendency to just fill in the blanks about why something happened, based on how it landed.
In cultural discourse – popular conversations on social media and that sort of thing – I think people tend to regress to the lowest common denominator when it comes to the quality and complexity of the conversation. The nature of the beast is that as soon as somebody shows up who’s operating in that mode, everybody else tends to regress to that mode of operating.
When we’re talking about a group, I don’t think there is usually a capacity, or even a motivation, to treat people like complex, three-dimensional human beings with an internal world of their own. Especially online, where it’s all about how you can score in this argument or this debate, how you can most effectively shut down the other person, or walk away feeling like your worldview has been confirmed. So I don’t really think it’s primarily a problem of capacity – I think it’s partly a problem of motivation and context.
I see it on my channel a lot, although less so nowadays. Word has kind of gotten around that my channel isn’t really a forum that welcomes that sort of collapse of psychology into black-and-white categories of good and evil, narcissist and victim, or whatever. But whenever I venture out to take a look at another channel, especially the more popular ones – God, if I look at the comment section, it’s just chaos. Just projection, name-calling, scapegoating, a kind of piling-on of malice onto this fantasy boogeyman.
That kind of non-mentalizing also shows up in personality disorders and other forms of severe mental illness. I don’t think it’s a constitutional issue – I don’t think folks with those issues are incapable of mentalizing. I think it’s that it’s difficult to consistently mentalize, especially in states of high emotional arousal or distress. There are self-states that can be activated where those capacities are just less developed.
Clinically, part of the challenge is to withstand the accusation, because those self-states typically collapse into a do-or-done-to, victim–perpetrator dynamic, where it’s, “you did this to me.” That’s how it can show up in session, too. I make the wrong interpretation at the wrong time, I say the wrong thing, I don’t respond in a way that feels in alignment with what the patient wanted in that particular moment, and it can set off a rupture, where now I’m the bad object who did the bad thing to the patient.
Negotiating those moments – which are inevitable – is really where the work is. There’s so much of a psychotherapy process that’s basically just sitting around and talking about this and that. Okay, this thing happened at work, this thing happened at home. There might be some emotional arousal happening, but it doesn’t feel like the stakes are very high. And then all of a sudden, out of nowhere it seems, comes this moment where some part of the patient that holds a lot of trauma is activated right there, right then, in the dyad. Now the heat is on, and these are the moments where I think change can actually consolidate in a more substantial way.
Idealization, devaluation, and staying in the room
Dawn: This is a good segue to another question that was on my mind yesterday. A while back – this might have been in the handbook for mentalization-based treatment for pathological narcissism – I read the advice that when patients idealize you early in therapy, it’s important to try to moderate that to some extent, so that the devaluation doesn’t lead the patient to drop out afterwards. Basically, to stop the undulations from being quite so intense. Now I’m reading in Eleanor Greenberg’s book that she actually advises trying to live up to the idealization, trying to give the person that idealized therapist model when they want it – which seems to be the opposite advice. Where do you fall on that?
Mark: I’d be curious where she’s coming from. Do you remember the rationalization for trying to live up to or deliver on the idealization?
Dawn: Patients want reparenting from an ideally supportive parent, and she wants to provide that for them for as long as they need it, then wait for them, by themselves, to decide at some point that they don’t need it anymore – that they can recognize her with her flaws.
Mark: I see. I think it’s important as a clinician to recognize that you can never actually live up to or deliver on whatever the idealization is. It’s by definition a distortion of reality.
That said, in a Kohutian framework – a self-psychology framework – there is an idea about not disrupting an idealizing or mirroring transference, partly because the patient might not yet be developmentally ready for that. It might be traumatically disruptive to a developmental process that’s trying to get some traction in the therapy.
But I wouldn’t put it in terms of trying to deliver on the idealized transference. I’d put it more in terms of trying not to prematurely disrupt that transference with an interpretation that undermines it.
It’s like little kids who believe in Santa Claus and the Tooth Fairy. Different people have different ideas about it, but broadly, the idea is that it’s fun and sort of magical to be suspended in that fantasy – this fantasy where there are these benign, benevolent beings that come and shower you with gifts. I don’t know if it serves a legitimate developmental purpose to have that fantasy, but I think most parents have the sense that you don’t want to tell your four-year-old, “You know what? None of it’s real.” That would be traumatic in a way – it would be the constraints of reality intruding on a fantasy that’s serving a function. Now the four-year-old has to deal with the fact that there’s marketing, and what is that, and are parents lying to their children, and if so, why, and does that mean I don’t have to listen to my parents anymore? The world becomes less magical.
That’s true for all of us as we age and grow – the world gets less magical and reality becomes more and more the rule, and we have to deal with that. But ideally, we deal with it as we develop the ego capacities to do so.
In self-psychology terms – and maybe this is what Dr. Greenberg is talking about – if you see an idealizing transference, you don’t want to take it and turn it upside down, because it is serving a purpose. It may ultimately be a maladaptive one in the person’s life, but from a developmental perspective, it is maladaptive because they have not yet matured out of using it. The reason they haven’t matured out of using it is because they haven’t gotten enough of what they need to let it go and embrace the constraints of reality – of their own limitations and inadequacies.
Dawn: On the flip side, there’s the risk of exacerbating the disappointment when the client finds out that the therapist is fallible after all. How often does this happen to you? At what rate do patients drop out of therapy because of devaluation, prematurely?
Mark: I’m sure there’s a dropout rate, but I haven’t quantified it. The clinical book I’m working on – the tentative title is Staying in the Room, but the title I was tossing around before that was Three Failures and One Success – is about all the different ways the therapy relationship can just blow up.
You’re working with a personality configuration that is exquisitely sensitive to feeling devalued or criticized, where there can be an awful lot of interpersonal pressure that the patient puts on themselves – pressure to live up to the ego ideal, or whatever grandiosity might be at work. But that pressure is also extended to other people: pressure to live up to the idealizing expectations, to deliver on certain gratifications or entitlements that the person might have but isn’t necessarily consciously aware of.
There can be a real deficit in negotiating feelings like disappointment or frustration in a way that preserves a relational connection. Instead, the person dumps all of their bad feelings onto the other person and then throws them away – and in fantasy, this house is purged, this house is cleansed. Of course, over time that becomes a cyclical pattern, and there’s a string of broken relationships left in the individual’s wake.
I’ve come to feel that a successful treatment – and there are lots of different ways we could define success – is one that just doesn’t fall apart. We were able to stay engaged and connected long enough that those developmental deficits began to heal themselves, and the person began to develop the parts they need to cope more effectively, to sustain a realistic and stable self-image more consistently.
So yes, I’ve had it happen a number of times. There are a couple of forms it takes. One is an idealizing transference that collapses: I say or do something that undermines the idealization too soon, too early, and the person just – I go from good object to bad object, and they’re gone.
The other thing that can happen is when that pressure to perform that the patient feels – their own internal pressure – becomes pressure in the treatment for me to perform. I try to slow that down and push back on it a little, but there’s this critical zone where the frustration is rising and I’m trying to metabolize it, help them metabolize it, to realize that this is pressure that has always been there, that has never actually produced the feeling of happiness or well-being the person is seeking. They’re asking me to live up to some kind of idealized image that is impossible for me to live up to, so effectively the two of us are doomed as long as this frame holds – this frame of, “give me… why aren’t you giving me what I need?” If we can’t figure out a way to metabolize that quickly enough, then the frustration rises above that optimal threshold, and the person leaves.
Dawn: Is the mechanism behind that something like: they make you part of their identity, so their own expectations on themselves become expectations on you, and then you suddenly have the same pressure they have?
Mark: That’s one of the things that happens. There can also be some developmentally less mature expectations about the world, and perhaps a lower frustration tolerance around those issues. They might be great at tolerating frustration in lower-stakes settings, but when we’re talking about core needs that are beginning to present themselves in the treatment, it becomes this dance.
I can start to see what’s happening, but if I just try to say it, they might not be ready yet to have it verbalized, and it just won’t make sense to them. So I can’t say it – but I also can’t live up to the expectation. Then it becomes about reframing to process: “I’m noticing that frustration showing up again. Can you tell me how it’s showing up? Can you tell me how it feels?” We start to explore the fantasies surrounding the frustration, to play together with it instead of feeling like it’s a whip we’re laboring under.
Sometimes that works, and sometimes it doesn’t. Sometimes there’s just too much pressure. Often a third variable is the person’s partner. If they have a partner who’s saying, “you need to go get better,” the partner might start to get frustrated: “Okay, well, it’s been six months of therapy, and I’m still noticing all the things.” And it’s like – yes, and this is a lifelong issue. It’s going to take… honestly, the first year of treatment we’re often just getting a lay of the land. This is a process that takes a significant period of time. It’s not that nothing happens during those early parts of treatment – it’s that we’re setting the stage for all the changes that are going to happen.
But people get frustrated, especially in a cultural mindset where it’s, “you’re the doctor, you fix it.” And I’m like, yeah, but I’m not that kind of doctor. Fixing it is a much more complicated proposition than it seems.
Dawn: The reason this is all so dear to me is that I’ve basically lost a friend that way. There was the idealization cycle – I didn’t recognize it – and then the sudden devaluation, which I started to recognize because I was reading up on things at that point, but it was too late. This friend had a very interesting presentation: very obviously emotionally dysregulated, borderline-style, but she also used defenses that would be more typical of pathological narcissism. She was very concerned with self-esteem and status, had a lot of shame, was very sensitive to that, and was thinking very hierarchically – a lot of her coping was related to hierarchical thinking. I was wondering: what is going on there? I’d call it a mixed presentation of borderline personality disorder (BPD) and NPD.
Mixed presentations, echoism, and the structure of pathological narcissism
Dawn: When you encounter a presentation like that, would you treat the patient as someone with pathological narcissism, or rather as someone with a mixed presentation – or as someone with borderline, and maybe refer them out to someone who specializes in borderline?
Mark: I tend to treat all presentations as mixed presentations. I tend not to conceptualize in terms of just one category of disorder. I do a lot of diagnostic assessments, and those involve a kind of exploration of all the different personality styles or prototypes that might be involved. Then there comes a point where I need to provide a diagnosis, and that is far less exact than one might imagine.
Looking at the different personality profiles and their scores – if there’s one, there are always more than one. It’s never been the case that there’s just been one peak personality disorder and everything else was below threshold. If there’s one, there are many.
So the question becomes: how do I conceptualize this in a way that gets closest to what I think the subjective experience of the person is, but also captures the function of these adaptations? One usually seems to be more core, and the others seem to provide a stabilizing function around that core.
Not too long ago I assessed somebody, and it was like you’re describing – there’s a BPD piece, and there’s a narcissism piece. The door could have swung either way: I could have said, “this is NPD with some BPD-like dysregulation happening,” or, “this is BPD with NPD-like defenses that have developed.” That’s the direction I went, because it seemed to me that the individual was more fundamentally oriented around abandonment anxiety and abandonment trauma, and that this false-self adaptation had developed around it to stabilize it – as opposed to a fundamental narcissistic injury where, because of their experiences, things had gotten dysregulated in a BPD-esque way.
But honestly, that’s a judgment call. It’s highly individual, and in a lot of these situations a plausible argument could be made either way. It speaks to the complexity of the variables and the inexactness of the constructs. To quote Hannibal Lecter, we’ve got these blunt little instruments that we use to try to understand what is essentially the most complex system in the known universe – just one individual mind. So yes, it’s necessarily inexact, where things are right now.
Dawn: This is also very interesting because I have a thesis about what’s called echoism. Craig Malkin has a model of narcissism and echoism at opposite poles of a spectrum. I liked the book Rethinking Narcissism – lots of things in it made a lot of sense to me – but the spectrum didn’t make sense to me, because I know so many people who are really high on both narcissism and echoism, and also something else I call sovereignism, which is probably relatively close to malignant narcissism. But let’s bracket that.
If these things are so structurally similar, and the same person, depending on their social context and who they’re interacting with, switches between echoism and narcissism in their expression, then what’s going on there? To me, it seemed more like people with disorganized attachment.
One model is: people with disorganized attachment, depending on the other person or the social context, either try to collapse that into avoidant attachment, which looks more narcissistic, or try to collapse it into preoccupied attachment, which looks more echoistic.
The other idea is that it might depend on where they feel they are in the social hierarchy. If they’re very low, they take a people-pleasing approach to try to appeal to all the people higher up, which is most of them. If they find themselves very high, they can take a dismissive approach to the people below them and the people-pleasing approach only with the very few who are above them. In the first case they come off as more echoistic, in the second case as more typically narcissistic. What do you think of this seeming dichotomy of two relatively similar things?
Mark: Well, I think of the dichotomous model of pathological narcissism itself. It loses its coherence if you have just a grandiosity factor, or just a vulnerable, depressive, anxious factor – you need both to have the coherent construct of pathological narcissism. If you just have grandiosity, then someone is just grandiose – there’s no disorder there, necessarily. And if you just have the collapse, then that looks like almost any mental health issue in its more severe form. It is the unique combination that makes a usable, clinically relevant construct.
It would seem that these two constructs are strictly dichotomous, or, to use a research term, orthogonal – one measures one direction, the other measures the other direction. But when you actually look at the factor structure of instruments like the Pathological Narcissism Inventory (PNI), which includes both grandiose and vulnerable factors, what you find is that these two constructs intercorrelate in a very meaningful way. It’s not, “the more grandiosity you have, the less vulnerability you have.” No – these two constructs correlate with each other about as far as they can without starting to superimpose. The more grandiosity you have in a pathological-narcissism context, the more vulnerability tends to go up – and vice versa. They are two facets of the same construct.
To the extent that what Malkin is talking about with echoism is something more defined by a kind of preoccupied attachment, or a preoccupation with being too visible or too “out there,” it would seem to be the opposite of grandiosity. I don’t know about that. I think these are two facets of a conflict around being seen, and around what it is to be a self – the subjective building blocks of self-experience.
In NPD, the person is actually deeply conflicted about being visible, about showing up. There are often really inflexible contingencies around when it’s okay and when it isn’t. The same individual, if they feel they’re getting really positive feedback from a group, can launch into untethered grandiosity, and then maybe the next day have the opposite experience and collapse under the shame hangover about how much of themselves got seen, and how conflicted they actually feel about that in the after-party self-state.
I don’t know if I’m answering your question, but I find that in narcissistic presentations – this was my dissertation, actually – yes, there are some that are strictly dismissing-avoidant in their attachment style, but most seem to correlate with something more like fearful avoidance, which would be the disorganized attachment, where there’s intense ambivalence about closeness, about being seen, about being a self. There’s a desire to affiliate, but the stakes can feel really high when that actually happens, and it rarely lives up to all the different internal expectations the different parts of the person might have.
Dawn: There is a bit of a connection between the vulnerable expression and echoism. But the Maladaptive Covert Narcissism Scale has items that go in the direction of, “I have enough problems of my own, I don’t care about other people’s problems,” which are probably what the scale is meant to capture as expressions of the vulnerable side – but they’re basically the opposite of echoism. With echoism, it would be: “Yes, I’ll happily make myself useful to help you with all of your problems, because that’s where I derive my self-esteem from. If I can make myself useful for someone, that’s what builds me up.”
Mark: What’s interesting about that, though, is that from a Pathological Narcissism Inventory lens, that’s considered a form of grandiosity – self-sacrificing self-enhancement, on the grandiose factor. Yet if we looked at it through a different framework, that would be considered something more like an oral personality, where the person is giving of themselves to the point of depletion and collapse. There’s some meaningful component of that which is an old conflict, an old place of developmental impasse.
Different words can apply equally well to different constructs. The word depression or depressive is almost ubiquitous in psychology, and it’s like – what do we mean? Do you just mean feeling sad, or something more like anhedonia, the absence of pleasure? Or can we understand it through a pathological-narcissism lens, because of all the distortions of self-esteem that tend to accompany depression? Is it introjective or anaclitic depression? There are so many variables. Same thing with narcissism – I just wrote a piece on my Substack about how there are at least four different constructs that all have the same name. Everybody’s using them interchangeably, and nobody knows what anybody else is talking about, but everybody thinks we’re all talking about the same thing.
Dawn: You mentioned a study that found that, up to a 3 on the scale, narcissistic grandiosity and vulnerability are uncorrelated, and then they become correlated suddenly once the grandiosity becomes high enough. That study was based on the Five-Factor Narcissism Inventory short form (FFNI-SF), whereas the scale you mentioned several times now is the PNI. Which of these do you prefer for which purpose?
Mark: I don’t use the Five-Factor scale. I don’t subscribe to trait narcissism as a meaningful clinical construct, at least not in my work. I can see how it’s a necessary component of personality research, but I think it’s easy to misinterpret trait-narcissism research.
My main critique of the Diagnostic and Statistical Manual (DSM) model is that it is essentially a trait framework. It treats grandiosity as a trait, and as a result you end up with these nonsense research studies that are essentially saying NPD is not in any way meaningfully correlated with mental disorder – that it’s not a form of psychological dysfunction. If you have dysfunction, you’d expect there to be distress, you’d expect there to be problems in the person’s life, beyond just that people in their life don’t like them. That’s not, to my mind, a meaningful enough standard to call something a mental disorder. But that’s how you end up with the asshole disorder, which is how NPD is treated in most settings, because the DSM model collapses – if you do a factor analysis of it, it’s essentially one factor: grandiosity.
Grandiosity, if you treat it that way as a trait, is probably heritable. That’s where you get these high heritability estimates that use the DSM model. Trait narcissism, on the Big Five, is defined as high extroversion and low agreeableness. And what is that? I don’t know – it’s not a disorder.
This is yet another way in which we seem to be talking about different things using the same words. When I talk about narcissism – pathological narcissism, and there’s a reason we have to attach the word “pathological” to it – it’s because narcissism itself, as a construct in psychology, is neutral with respect to health or disorder. Narcissism is just how the person relates to themself. You can relate to yourself well, in an adaptive way, and we’d call that healthy narcissism. Or you can relate to yourself in a pathological way, and we’d call that pathological narcissism. The fact that we need to attach the word “pathological” to it says that the construct itself is neutral.
So when you talk about trait narcissism, is this a disorder? Is this a construct that can meaningfully be used to understand disordered states? To my mind, not so much. So I don’t tend to use instruments derived from that model. When I feel that model is imposing itself on our ability to understand this disorder, I tend to push back. Let’s define our terms.
I debated Peter Salerno on YouTube a number of months back. I didn’t really have my thoughts straight about this yet – I wasn’t that familiar with his framework. But he’s written prolifically about the supposed high heritability of narcissism. If we’re talking about it as a collection of traits, absolutely – highly heritable. But that’s not the same thing as a disorder. Once we start thinking about it as a form of pathology, all of a sudden there’s identity disturbance. Where does that come from? Is that genetic? Probably not – identity disturbance tends to be more experientially grounded.
Dawn: This is certainly a very important message to get out there. When I look at the FFNI-SF, I see a whole bunch of subscales, and among them a grandiosity and a vulnerability subscale. The PNI has nice validation studies where they tested how well it captures all sorts of facets of mental health, and how much better it does that than the Narcissistic Personality Inventory (NPI). I haven’t seen something like that for the FFNI, but at least from the subscale structure, it seems to capture both the vulnerable side and the grandiose side, so it already seems to be doing a better job than the NPI.
Mark: Well, that’s good. The way the DSM is going with their alternative framework for personality disorders – that’s a combination of a more dimensional approach (degrees of mental illness, essentially) and a trait-based approach. For NPD, the alternative-framework trait is that the person is admiration-seeking, essentially. So it’s this trait model in combination with a dimensional approach.
Any measure that includes something like a severity scale – which in the instrument you’re talking about, which I’ll admit I’m not that familiar with, is likely what they’re talking about with the vulnerability subsection – I think you already have a more robust instrument there, because it includes a component of disorder and dysfunction. As opposed to something like just implausibly high self-esteem – is that a disorder? That’s where things like the NPI go off track.
Depressive vs. narcissistic injury and the two faces of NPD
Dawn: I think we can agree the NPI is not a good model for pathological narcissism. You mentioned earlier introjective and anaclitic depression, so that’s a good segue, because there’s something I find very confusing about the Psychodynamic Diagnostic Manual (PDM) – now in its third version since last year – and also about Psychoanalytic Diagnosis by Nancy McWilliams. There’s a separation where she has the narcissistic style as something very, I don’t know, anaclitic – something that’s empty, free of introjects, or something. And then she has all sorts of other things that are sort of similar – the depressive style, the hypomanic style, the masochistic style – completely separate from that. The depressive style, for example, comes in an introjective version.
What I’m seeing a lot of the time is that, in a way, the folks with NPD I’m friends with are very introjective – they just have introjects that really suck, sort of along the lines of your “harsh introjects” video. They have introjects that tell them they must never show any kind of vulnerability, so as not to make themselves manipulable or exploitable to others. Or introjects that tell them they must perform and never sleep and be the best at everything. These count as introjects in my mind. I suppose there are some presentations of NPD that are pretty psychically empty, but when there’s a presentation – which is the more common one I see – that is introjective like that, do you have a handle on how Nancy McWilliams or other people who use the PDM would classify that? Would they classify it as NPD versus depressive personality disorder, or something else, when someone has such an introjective presentation of NPD?
Mark: Well, I don’t know how Nancy McWilliams would classify it. In one of the classes I teach, the students and I use the PDM and McWilliams’s Psychoanalytic Diagnosis, and one of the projects is group presentations around different personality styles and how you would do differential diagnosis.
So, analytically, the depressive personality style has a kind of direct line from Freud’s work Mourning and Melancholia. Interestingly, when Freud introduces the idea of melancholia, he describes it as a narcissistic object, essentially. The idea is that the individual sustains a loss, and in order to defend against the loss, the ego is split – this is the first introduction of the idea of splitting in the literature. The ego is split, and one piece of the ego is identified with the lost object. The lost object is introjected into the ego, and the ego begins to direct its own rage at the lost, abandoning object internally. That’s what produces the symptoms of melancholia, which was the precursor to the word “depression.” Anger turned inward, essentially. The individual is attacking themselves in lieu of the lost object, which remains idealized.
Freud discussed this as a form of narcissistic object because, in his original model, you’ve got primary narcissism, which is the infant’s omnipotence – the world is me, essentially. Then, once you go through the Oedipus complex, you learn that’s not true, and that sets the stage for the possibility of loving external objects – libido can be transferred externally. But Freud says that when the object is traumatically lost, that libido is pulled back into the self, and this represents a form of secondary narcissism.
Why am I saying all of this? I think what I’m trying to say is that, analytically, the idea of a depressive personality is one organized around loss. That loss can either be introjected in the way Freud is describing – the introjective style of depression, where the person is self-hating, essentially – or it can remain a loss that has been sustained out in the world, and the person is constantly grieving (well, not really grieving, because it’s not productive – but constantly pining for a kind of reacquisition of the lost object).
Whereas narcissism is something where there is a kind of loss, but it’s more like a deficit. It’s more like the person never got what was needed – not that it was gotten and then lost. There’s a compensatory internal structure built around this deficit, as opposed to a way of coping with something that was there and is now gone.
Dawn: So, if it used to be there and was then lost, that must have happened before the Oedipal stage – or at what age would those occur?
Mark: If we’re talking Freud, that would actually be post-Oedipal – it would be a regression. The libido that had been cathected to the internal object is now pulled back into the self.
Dawn: Okay, so at a relatively old age already – four years plus or so?
Mark: If we were to plot these injuries on a developmental continuum… and there might be people watching this who are like, “this guy has no idea what he’s talking about,” and that’s fair – I’m not an analyst, I’m an analytic therapist. I’ve read a bunch of this literature, but I’ve not been through formal analytic training. That said, I’m willing to be wrong. So if we put it on a developmental continuum, the narcissistic injury is sustained earlier than the depressive injury.
Dawn: Interesting – that’s also a useful distinction. Something else I wanted to pick your brain on: I just alluded to all these different kinds of introjects that friends of mine have. To me, it seems like those friends fall into two pretty different groups. Both camps have NPD, and some of them have a mixed presentation of both, but by and large there are some who are very perfectionistic, usually have some pro-social values, and when they make mistakes, they try to hide those mistakes from themselves – to reframe them so they’re not mistakes – and they struggle a lot with very obvious self-deceptions. They always strive to prove their worth to other people, to compete with certain nemeses who are sort of close to their level.
Then there’s a very different camp. These people are much more about never feeling helpless, trying to control everyone else, having maximal power and control over every situation. Their self-esteem is much more stable. The first group usually oscillates between vulnerable and grandiose states and seems really fragile and sensitive, whereas the second group usually has a really stable, high level of grandiosity. They don’t so much compete with any individual person, or seek the admiration of any individual person, because they don’t even respect people enough to seek their admiration a whole lot.
They usually don’t have pro-social values – they’d rather have a kind of false self that’s all around being perfectly selfish, sometimes being evil or something of that sort, and they are sometimes (or often) sadistic. When they make mistakes, they tend to reframe them as something they’ve done intentionally, to maintain this idea of having had control in that situation. Very much about control and selfishness.
These seem very different to me, but both have been diagnosed with NPD at different points. Which of these do you encounter more, and how do you make the distinction? Does it have something to do with attachment styles? Is it the particular false-self adaptation they form that pushes them in one direction or another?
Mark: Gosh, I don’t know. One thought I had: when you were talking about the stability of one group versus the other, that makes some sense, given that the group that is more defended around feeling helpless probably has more of something like an internal locus of control, even if it’s just a defensive one. That would likely result in a more consistent experience, as opposed to the variable one you notice in the group that is trying always to be the best, or live up to – because implicitly there, the standard is external. You’re only the best if everybody says you’re the best. That way of organizing self-experience would be inherently less stable, more reactive to circumstances – whether or not you got the trophy or the prize.
We could loosely map those onto attachment style, where the one that’s more about external validation is a little hungrier – along the dimension of attachment anxiety. “Will I be the best? Will I be accepted? Will I get the accolade? Am I good enough?” There’s an other that’s needed to provide that feedback. So it’s higher in attachment anxiety – something more along the lines of a preoccupied dimension.
The one that’s more about not being helpless – there really isn’t a lot of attachment anxiety there. There’s much more attachment avoidance. “Don’t get too close, don’t trust” – like you said, which I think was an insightful read. That would be more toward a dismissing-avoidant experience.
When you look at how those attachment dimensions… I’m not saying these are styles, necessarily – these are dimensions of attachment. I see attachment as more of a continuous variable than a categorical one. The higher you are in anxiety and the higher you are in avoidance, the more you move into these categorical dimensions of attachment style. But if we think about them more as continuous variables that are constantly fluctuating depending on the circumstance, that’s a better model for understanding a person’s behavior in the moment.
When you look at the correlations of various kinds of psychopathology with these different dimensions of attachment, you find that the preoccupied style is much more highly correlated with measures of distress, whereas the dismissing-avoidant style is hardly correlated with measures of distress at all, because the person has this very well-established internal, self-sufficient model of self: “I don’t need anybody, I’ve got it covered. Even if I needed your help, I wouldn’t accept it, because I can’t trust you, essentially.” That’s probably why you notice less symptomatic variation in that subset.
Dawn: That makes a lot of sense. I also noticed how much attachment is dependent on the state. One friend of mine very readily, all the time, goes into what I would call the vulnerable victim mode, or the grandiose victim mode – there are these aggressor-versus-victim roles you can take, and you can take them in both grandiose and vulnerable states. That friend very happily goes into the victim side. Another friend told me, “Oh my god, no, I would be extremely hesitant before I cast myself in any kind of victim role, regardless of whether I’m actually a victim in any given situation.” I also saw this in another case where a friend tried to recall instances in her past where she was actually in a victim role, and it was very difficult for her to acknowledge that in the first place. I asked her to do the Attachment Style Questionnaire short form, and it came out as extremely low preoccupied attachment, extremely high avoidant attachment. She was in a grandiose state at the time when she took the questionnaire, so it’s kind of expected. The same difference also shows itself in the attachment styles, as far as I can see.
Mark: Yeah. Attachment is a really useful model for understanding a lot of things about a person. I sometimes run into this with my students, where there’s a tendency to think about things only in terms of attachment. Yes, these underlying dimensions of attachment illuminate so much about how we are interpersonally, but we still need the other concepts as well. It’s one of those things where, when a new lens comes into vogue, everybody is using it. Internal Family Systems (IFS) is a good example. People are like, “Whoa, parts!” – and then everything is about parts.
Dawn: I also find that lens very useful. When it comes to attachment styles, they have exactly the same problem you mentioned earlier: they make so much more sense when you see them dimensionally. By definition, most of the population is around the 50th percentile on both axes, and that is generally considered secure attachment. But when I have a friend who is around the 50th or 60th percentile on both dimensions, that friend feels super different to me from a friend who’s around the 25th percentile or so. Even with insecure attachment, there’s a huge difference between people who are more on the insecure end of secure attachment and people who are more on the secure end of it.
Mark: Absolutely. It reminds me of that Substack piece I told you about, on the different ways we use the term narcissism. What it was really about is: how heritable is NPD? The same researcher used the same sample – a sample of twins, in Sweden, I think. The first time, they defined and measured NPD as a categorical variable. The question was, among these twins, how many of them have NPD, and they found this crazy high number – like 79 percent heritable.
Seven years later, using the same sample of twins, they measured NPD as a dimensional variable – like what we were just discussing, where you’ve got, say, avoidance and anxiety, and you rate it that way. The heritability estimate dropped to 24 percent. It’s crazy how different the results can be from how you frame the question. If you introduce a continuous variable of severity – which is how they looked at it the second time, “okay, you’ve got these traits, but how severe are they?” – suddenly the heritability estimate drops to 24 percent, as opposed to just saying, “do you have these traits, yes or no?”
Dawn: Yeah – when you have a scale like that, and you project it onto just above or below some threshold, a lot of information is lost. Taking a dimensional approach is probably always better.
Mark: I think so. That’s how I think about it.
Dawn: I also noticed that when people have disorganized attachment – but, for example, the preoccupied dimension is around the 75th percentile and the avoidant is a bit higher – just the difference between those two is very informative. People who have slightly higher avoidant than preoccupied attachment, even though both are very high, will default to this very control-oriented presentation, with the internal locus of control, in almost all cases.
Mark: For a lot of people, that is just a more stable developmental solution. You see kids do this all the time, where they’re like, “My parents split up. Why? Because I’m bad.”
Dawn: Are they proud of being bad?
Mark: No, but it provides a stabilizing explanation that’s within their control. “If I weren’t so bad, then the bad thing wouldn’t have happened” – as opposed to the much harder thing to metabolize, which is that sometimes bad things happen and there’s nothing you could have done, it has nothing to do with you.
Sadism, etiology, and self-recovery
Dawn: I was also wondering, in that context: fetishes develop super early in life. There are some people who already have whatever fetishes they have around age two or three. Personality disorders take their final shape around puberty, usually. To me, it seems plausible that fetishes that form very early have an influence on what personality disorder a person forms in the end. For example, when someone has a sadism fetish – forms that sadism fetish around age two or three – that leaves them maybe a decade or so until puberty, or a bit less than a decade in many cases, for that aspect of their personality to have an effect on the rest of their personality.
Some people probably try to push that away – “Oh my god, that can’t be me. I need to hide that from everyone, I need to be the exact opposite and totally overcompensate for it.” Other people probably resolve the cognitive dissonance the other way around – they endorse it and are like, “Okay, apparently I am evil. Let’s take all those movie villains as role models and see what evil people do.” Then they also have a more coherent self-experience, just in the opposite direction. I’m wondering: to what extent does sadism, very early in life, have an effect on the development of sovereignism or malignant narcissism?
Mark: That’s a good question. I’d be curious about the idea of fetishes developing that early, and how that’s understood, because – obviously, infantile sexuality (to use the old analytic idea) is a thing. But it’s not necessarily genital sexuality. For that to be a thing, outside of normative play, it’s usually a result of traumatic intrusion of adult genital sexuality into the child’s world. So I’m curious to understand better what you mean by the early establishment of fetishes.
Dawn: More objectively speaking, I recently listened to an interview on Psychology in Seattle, and someone argued that fetishes form so early in life because children are no longer exposed in the way they were in our ancient environment. At some point, there were not really rooms or anything of the sort, and so children early on saw regular sexual intercourse very early in life. Since that’s no longer the case in today’s society, they latch onto something else. For example, when they’re crawling around on the ground underneath some table and see a bunch of feet, they develop a foot fetish in some cases. That’s one possible way it can emerge. I don’t know where a sadism fetish comes from – perhaps television or something. But it seems pretty frequent.
Mark: When I think about fetishes, to my mind that is a category of experience organized around genital sexual expression. “I can get off, but only this way.” So I have a hard time connecting that to pre-latency, very early childhood experiences.
That said, I do think we all have key experiences around which significant aspects of our internal world organize. I wouldn’t call it a fetish necessarily, but maybe it becomes one. So with something like sadism: when I think about what sadism seems to be, it’s the punishment in someone else of intolerable experiences the sadist can’t deal with. Being weak, being vulnerable, being helpless. There’s a tendency, in a sadistic worldview, to identify somebody who appears to embody some of those intolerable qualities, and then punish them – getting a feeling of gratification from seeing, via projection, the bad object punished.
Dawn: That’s one framing. But I could also see the framing that, when you learn from early on that it’s bad – when you’re being taught by your parents that it’s bad to show vulnerability – you introject that. Just as I learned that certain things are moral and other things are immoral, like that if someone is sad I need to comfort that person, these people learn the opposite: being sad is bad. Then they just feel righteous about executing that kind of punishment on the person.
Mark: I don’t know that those are substantially different. You’re right that that is a moral framework many of us carry around inside of us anyway. You see it all the time online, especially around things like pedophilia or child molesters, where everybody’s just sadistic – “burn them alive, cut off all their skin, hang their eyeballs off the…” And it’s like, what? I get that this is morally abhorrent behavior, but where does the seeming joy that this commenter is deriving from this ultra-violent fantasy come from? Is this a sadistic person, or is this one of the few contexts in modern life where sadism is sanctioned?
I do think that part of the function of that communal sadism is to expel or purge something that is unthinkable or intolerable in the self. Not that everybody’s a pedophile, but there are aspects of human sexuality that we don’t like to entertain. “It’s not in me, it’s in them, and now we’re going to torture them” – it’s a way of confirming to the self, “Yes, I am righteous, and they are the bad one.” That same process plays out in all kinds of different ways, and we see that too with narcissism. The “evil narcissist with shark eyes” and all the rest – they’re demons, monsters from hell. What are we really punishing there? I don’t know – it’s different things to different people, but it’s clear there’s some kind of collective sadistic stance toward “the narcissist.”
Dawn: You see that a lot in prisons. There are sadistic inmates, and then there’s someone who’s a child molester coming to that prison, and that particular transgression is used as a kind of Schelling point – a signal that now it’s okay to indulge the sadism. Some of my sadistic friends are quite self-reflective about that – if they want to have fun with their sadism, they’re basically waiting for someone to transgress against them in a particular way to give them an excuse.
Mark: Sadism might just be something I’m particularly defended against. It is one category of human experience that I find difficult to empathize with. It’s not that I can’t sort of get it, but it’s just one spot where it’s hard to really get into the mind of somebody who’s in the throes of a sadistic experience.
Dawn: I have an article where I’ve tried to come up with exercises that teach a non-sadistic reader what it is like to experience any one of, I think, six different types of sadism, so perhaps that’s interesting.
Mark: That is interesting – I’d be interested in seeing it.
Dawn: Yeah, I’ll link it to you, and I’ll link it in the show notes – I love saying these things. I’m a new podcaster, so I love saying those things.
Mark: Perfect.
Dawn: We’re sort of talking about etiology a bit, and there I was also thinking: there’s the model of the etiology of NPD that’s along the lines of what the MBT people write about. There’s some kind of influence they call the alien self, and projections from parents, and then the child – who still tries to find themselves and doesn’t really have a self yet – has this alien self projected onto them. They try to become the person who lives up to those projected expectations, because they don’t yet know that that is not actually them. It’s a failure of contingent marked mirroring – not contingent, but very much marked – and the child forms a false self into, basically, people-pleasing the parents.
But I’ve also noticed that there’s an etiology of NPD that’s basically just neglect. The parent was either emotionally absent or completely absent, and people developed NPD somehow, because they were seemingly parented by their environment. They recognized that certain actions produce something a bit like a love surrogate, even if it wasn’t coming from their parent, because the parent wasn’t there. Somehow the environment takes over a kind of parenting role, which is also not contingent at all, because the environment also does not actually do any kind of mentalization with the child. Are those two different etiologies of NPD?
Mark: That’s a really good question. I think the higher levels of internal distress – and this is just an intuitive sense, I don’t know that I have a theoretical justification for it – likely come from that sort of alien, introjected, impinging phenomenon, where what is “not self” is imposed on self in a way that creates disorganization and a kind of internally punitive, introjective experience.
Versus something more like neglect, and then finding a kind of validation – because you’re good at baseball or something like that. That would probably be more prone to a depressive collapse, but not a dysregulated, disorganized kind of collapse, like you might see in something more like… well, if I think about the etiology of borderline personality disorder, I think there’s often the felt intrusive presence of some introject that the person is consistently trying to both expel and also experience a kind of merger with.
Dawn: That makes a lot of sense. I don’t have a good segue, but I’d also be really interested in seeing whether you have ideas for exercises. When I’m writing this self-help book for people who want to recover from NPD, a large problem is that they don’t automatically have a therapist there to train relational things, so they need to find another person – a partner, a friend, or an AI, perhaps – with whom they can train the relational things. Are there any kinds of exercises you’ve already had good experience with that your patients can do between sessions, or anything of the sort that can help generate some of those experiences?
Mark: That’s a good question, too. I don’t really give homework in my practice. To the extent I’ll recommend an exercise or something like that, it’s mostly around the idea of mindfulness meditation, or a Vipassana kind of meditative experience – one focused on being with internal experience without necessarily having to identify with it, or react to it, cling to it, or push it away.
Things like journaling can be helpful, of course, in articulating what a person is experiencing and holding up a kind of mirror to themselves. But I think the main challenge, especially early in treatment, is just being able to take ownership, in a sense, of these different kinds of experiences that are typically projected or externalized – to be able to sit with the idea that “I feel like I didn’t do a good job,” and just be like, “okay, that’s an experience that’s passing through,” to be able to acknowledge it and then let it go.
This is a kind of Acceptance and Commitment Therapy (ACT) model – there’s a contextual self versus something that’s, maybe, more immutable. Self-as-context versus a conceptual self that’s labeled “this is bad,” versus, no, I am actually the space where valuations like badness and goodness occur.
I realize I’m coming up against my hard stop here. These are great questions, I really appreciate them, and the chance to speak with you. I’m excited for your channel, and I can tell that you do some really deep and intricate thinking about these ideas, so I appreciate the level of sophistication you’re asking about.
Dawn: Thank you so much for sharing all your knowledge. I really love it when people with extensive experience in some field actually share that in-depth knowledge that you can’t just get from books, because that’s always so much more fine-grained and nuanced than the more compressed versions in books and papers.
Mark: I’m happy to do so. If you ever want to talk again, let me know.
Dawn: Yeah, thank you so much! Have a good day!
Mark: Yeah, you too.
Dawn: Bye!
