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The following is an entry I wrote for the blog at the Valley Community Counseling Clinic, where I had the privilege of doing some of my clinical training.

“Do you think I’m a narcissist?” Patients have been asking me this question lately. As they await an answer from me, there is, I think, an intermingling of dread and hope — the dread that I might deem them officially mentally ill, tinged with a perverse hope for relief that a diagnosis can bring. If they are a pathological narcissist, at least that lends their suffering a coherent explanation.

And yet, patients don’t routinely ask me, “Do you think I’m an alcoholic?” because they had a few beers the night before their session. Somehow narcissism has become a bogeyman word in our current discourse about mental health. It’s all too easy to connect this phenomenon to current events, but I think patients’ fears about this particular syndrome are more than modish: fear of capital-N Narcissism speaks to a deep existential doubt about a patient’s right to own their grievances.

I try to draw my patients’ attention to the moment right before they were compelled to appeal to me for diagnostic condemnation. What happened in their mind just then? Whatever had been stirred up — wherever the therapy session had taken us — it became intolerable for the patient to bear on their own: I had to be recruited to help make sense of their distress.

Usually a patient feels they have crossed some line in expressing negative feelings or grievances about their traumas and privations; an internal alert starts to sound: “You’ve become too caught up in your complaints and bad feelings. You’ve ceased to have compassion for other people, who also suffer. You must be a narcissist.” It has become such a dirty word, such a damning label, that its baggage can interfere with our (that is, patients and therapists, separately and together) thinking about narcissism — what it is and what it is for.

We all have narcissistic defenses, or narcissistic states. It’s a misconception that narcissism means self-involvement, or self-obsession, to a degree that excludes all others. Indeed, quite the opposite. “The hell of the narcissist is the tyranny of his need for other people,” writes the essayist and psychoanalyst Adam Phillips. The narcissist, who never learned how to be alone with himself, is always seeking to fill a void within. He cajoles other people into giving him affection and care, which reassure him that he is worth something.

One way to think about psychoanalytic psychotherapy is as an exploration of pain and defenses against that pain. Every patient has their own cluster of defenses, constructed over a lifetime to help them survive. And the narcissist has a lot to defend against: he is, in his core, the loneliest person in the world, which is why he is addicted to filling himself up, so to speak, with people. Just as some patients use alcohol to make the pain go away (or put it on hold), so too will the narcissist use people. People and their adulation — their obvious pleasure at being in the company of the narcissist — help him to deny, for a little while, the sense of being empty at his center. And while it is true that the narcissist experiences pleasure at making other people feel good about themselves — that is, it is a two-way street — still, the narcissist is the one who (unconsciously) controls the pace of traffic.

But a dalliance with narcissism does not a narcissist make, just as the beer you drank last night does not necessarily mean you’re an alcoholic. We all have paranoid states, manic states, depressive states, and, yes, narcissistic states — which is why, in the psychoanalytic tradition, we don’t diagnose. Rather, the tasks of the therapist are, first, to distinguish the defense from the pain, and then to explore the pain that drives the narcissistic maneuver.

Eventually, this helps patients have greater compassion for all parts of themselves, including their narcissistic selves. In her book On Adolescence, the psychoanalyst Margo Waddell offers a poignant defense of narcissism:

"...we might construe [the Narcissus myth] as Narcissus needing to bolster his self-esteem by seeking a relationship with someone who looks like himself. Could this not be with a mirror image that might restore a fragile self-conception, a kind of intensely experienced twinning relationship, serving as a defence against feelings of isolation, and possibly of smallness and humiliation?"

Isn’t this a version of what we seek in all our intimate relationships? To see and be seen back? This is a defining characteristic of our narcissistic modes: they are, by definition, interpersonal. (By contrast, paranoia, obsessiveness, depression — these are all solo, internal defensive projects.) And so it is vital to look at the longing that fuels narcissism, because that will help us answer the question, “Am I a narcissist?” One way to hand the question back to the patient might be to respond, “What does your ‘narcissism’ consist of?” Their answer will likely be some version of a desire to be seen and understood. That doesn’t make the patient sick; it makes them human.

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Alex Lewin, LMFT