Sheldon Bach - Narcissistic States and the Therapeutic Process

Narcissistic States
and the
Therapeutic Process

PART I
The Narcissistic Condition

PART II
The Narcissistic Object

PART III
Treatment of the Narcissistic Disorders

Thou art a soul in bliss; but I am bound

Upon a wheel of fire, that mine own tears

Do scald like molten lead.

King Lear

Suffering is not always objectively visible, although it may be expressed through such objective correlatives as psychosomatic symptoms, addictions or even overt depression. Suffering is often silent, hidden from the outside world and in order to be aware of and understand this suffering one must approach it from a subjective point of view.

Our professional literature has often enough tended to characterize patients suffering from narcissistic disorders as grandiose, exhibitionistic, preoccupied with fantasies of power, envious, unempathic, cooly indifferent or intensely enraged, or behaving as if entitled to special privileges. Although many of these traits are without doubt objectively present, such descriptions tend to slight the subjective suffering and other complementary features which would round out the picture and help to keep us from either disparaging or idealizing this particular character type which, in its very description, already suggests the specific countertransference reactions it so frequently elicits.

It is the subjective, phenomenological approach that I have taken in these studies and, like any other approach, it has certain consequences. I speak less of aggression, exploitiveness and sadistic sexuality than of necessary self-assertion, hard-won autonomy and boundless love, for although I expeience the former every day as an analyst, the latter is, initially, the experiential counterpart of the patient. How to bring these two experiences together through analytic therapy is the subject matter of this book.

Perhaps, in an effort to further understand the narcissistic disorders and the concept of narcissism in all its complexity and elusiveness, we might begin by returning to the original case history. Narcissus was the son of Leiriope, a Nymph whom the river god Cephisus had once encircled with the windings of his streams and then ravished. Abandoned by his father, he was brought by his mother to the blind prophet Tiresias, who predicted that her son would have a long life provided that he never looked upon his own features.

As a remarkably beautiful adolescent, Narcissus was pursued by the nymph Echo and other male and female suitors whom he rejected, thereby drawing upon himself the wrath of Artemis, goddess of childbirth and chastity. It was she who caused him to fall in love, though denying him loves consummation. One day he came upon a spring, clear as silver, and, casting himself down exhausted to quench his thirst, he fell in love with the reflection and lay enraptured, gazing into the pool hour after hour. The suffering of this impossible passion is difficult to imagine, for he both possessed yet could not possess, nor could he even speak of his yearning to anyone.

Slowly he pined away from grief (in another version he suicides) and was transformed into the white narcissus, a flower whose name derives from the Greek narke, narcotic, by virtue of its power to assuage pain. In yet another version of the myth, Narcissus, in order to console himself for the death of a beloved twin sister, his exact counterpart, sat gazing into the pool to recall her features by contemplating his own.

This beautiful and engaging story seems far more complex than many of our current clinical descriptions of the syndrome, for it plunges us immediately into the complementarities of mirror symbolism. Is Narcissus searching for himself, for his sister, for the echo of a nymph, or perhaps even for his long-lost father? Is the story about the sight of life, the sight of death, or the transformations from one state to another by passing through the mirror of consciousness?

The Greeks believed that it was unlucky or even fatal to see ones own reflection in the mirror, a superstition about the mirror image or double which Freud also entertained with respect to Schnitzler. And Freud explained that just as the double acts as an assurance of immortality in the narcissistic state, it becomes an uncanny harbinger of death at later stages of development (Freud 1919, p. 235). Thus, one may read the myth as yet another story of the loss of innocence, an innocence which we both envy and admire.

Indeed, when Freud speaks of the narcissism of beautiful women, children, cats, great criminals, and humorists, he mentions both our fascination with and envy of them for maintaining an unassailable libidinal position which we ourselves have since abandoned (Freud 1914, p. 89). In his later description of the normal narcissistic libidinal type, he notes that People belonging to this type impress others as being personalities; they are especially suited to act as a support for others, to take on the role of leaders and to give a fresh stimulus to cultural development or to damage the established state of affairs (Freud 1931, p. 218).

Of course, Freud was talking about a normal libidinal type, whereas the literature generally deals with narcissism employed pathologically to defend against profound feelings of defectiveness. And, of course, Freud was speaking primarily from an instinctual viewpoint, which may put narcissism in a more favorable light than when seen primarily from an object relations viewpoint, which emphasizes its deficiencies. But that very self-centeredness which creates problems in object relations may be necessary for exceptional creative capacity, and who is to say if grandiosity and fantasies of power may only appear pathological when unaccompanied by worldly success? Apparently, such distinctions are not always easy to make, and we cannot necessarily assume that healthy narcissists become darlings of the gods while only the unhealthy ones become patients.

The crucial element here is psychic pain, whether it be in the form of anxiety, depression, or somatization. For while the narcissistic syndrome seems designed primarily to deny psychic pain and recapture a sense of well-being, what eventually surfaces in almost every treatment is, in fact, a most pervasive experience of intense and even excruciating pain. Perhaps that is why Narcissus left behind a plant whose narcotic powers are reputed to alleviate suffering.

With respect to treatment, it has always seemed to me that the atmosphere of the consulting room is to some degree affected by the metaphor one employs in thinking about the clinical process, and that this has the most profound impact on the day-to-day work. Metaphors influence both our perception and understanding of the situation as well as our attitudes towards it. Freuds analogies, for example, have become living metaphors for anyone trained in psychoanalysis; we feel ourselves to be archeologists when we uncover an early experience hidden behind a screen memory; we live (with difficulty) the metaphor of the surgeon when we put aside personal feelings and therapeutic ambition; we are caught up in a military struggle when we repeatedly engage the patients defenses or confront his anger.

But while Freuds archeological and investigative metaphors have vitalized our work with the conflicts and defenses of the neurotic patient, they may not always evoke the most useful attitudes for working with the ego defects, unusual sensitivities, and regressive states we find in the more severe disorders, particularly at the beginning of treatment. One reason, of course, is that with these patients the mutuality of the investigative effort can never be assumed. I recall one patient who, whenever I made even the mildest of comments would, soon thereafter, have blinding headaches and fantasies of being tortured by having molten lead poured in his ears or being hung out the window by his feet. It took some months before these fantasies could be convincingly connected to my interventions and much longer before any interpretation could even be heard, let alone assimilated. Indeed, with many of these patients, the more dynamically correct the interpretation, the more hurtful, humiliating, and alienating is the experience. Here we have a seeming therapeutic paradox and one which, at early points in the treatment, may not yield even to persistent attempts at reducing the defensive positions.