In my previous article on narcissism, I featured Dr. Josh Miller, a professor of psychology at the University of Georgia and an expert on narcissism, who graciously accepted my request for an interview. I asked him a variety of questions about the popularity of narcissism, grandiose narcissism and its relationship to psychopathy, the relationship between self-esteem and narcissism, and more. In today’s article, I present the second part of my Q&A.
Emamzadeh: What does the term pathological narcissism mean? Does it refer to a form of narcissism that meets the criteria for narcissistic personality disorder (i.e., associated with dysfunction and vulnerability)? If so, is there such a thing as adaptive or healthy narcissism?
Miller: I don’t know, to be honest, because it’s not a term I use myself. I assume that this is meant to refer to narcissism as more broadly associated with distress and vulnerability and that it refers to a broader breakdown in the self-regulatory processes associated with narcissism. 1 I dislike the idea that there are different types of narcissism—pathological versus adaptive or healthy—because I think these distinctions confuse issues of different presentations in terms of grandiose versus vulnerable narcissism and issues of severity. A person can be more or less disturbed on any one dimension of narcissism or a combination of both. Healthy narcissism, if it exists, probably means that a person is slightly high in grandiose narcissism but not so high that they are impaired in important areas of functioning (e.g., romance; work). Vulnerable narcissism, on the other hand, cannot be confused with “health” because it involves significant and pervasive negative emotions and low self-esteem and is thus largely synonymous with the distress criterion that is a crucial aspect of mental disorders.
Emamzadeh: Well, I would like to change the subject a little bit and ask you about intentionality in narcissism. A fellow student once joked with me: “When a depressed person says, ‘You don’t care about me at all,’ we assume that the illness is talking; when a narcissist says the same thing, we assume that the message is a calculated and malicious attempt at manipulation.” Do you think there is a fundamental difference, in terms of behavioral intent, between narcissistic personality disorder and other mental health conditions (including other personality disorders)? Miller: This is my guess, but my point is that we don’t have good evidence to suggest that one is more or less intentional or deliberate than the other in terms of these behaviors. I would argue that individuals with depression and narcissism may make such statements out of a genuine perception that a significant other doesn’t care about them, as well as making such statements to provoke the same person into getting more of what they want (e.g., attention, support, etc.).
Imamzadeh: Interesting. What about self-awareness in narcissism? You’ve noticed that sometimes, such as when a narcissist is motivated by his or her own competitive spirit or desire for power, or during bouts of narcissistic rage, he or she may act in ways that harm even those whom the individual seems to value highly. In your opinion, how much insight and awareness do people with clinically high levels of narcissism have about how their behavior affects others? Miller: The clinical wisdom has long been that individuals with personality disorders do not have a great deal of insight into themselves. However, some of our work and other work has challenged this by showing that self-reports of narcissism, psychopathy, and other pathological traits converge reasonably well with informant reports. In fact, they converge with informant reports to the same degree that we find in normal personality traits such as neuroticism, agreeableness, and openness. When these ideas do not converge well, the lack of convergence may represent disagreement rather than a lack of knowledge. That is, if you phrase the questions in what is called a metacognitive format (self-report: I believe I deserve special treatment; metacognitive: Others believe I think I deserve special treatment), you often get higher agreement with the informants. This higher agreement may mean that narcissistic individuals know how others perceive them but may simply disagree with that person’s assessment. Other work suggests that narcissistic individuals have accurate perceptions of themselves such that they understand that their self-perception is more positive than others’ perceptions of them, that others tend to think less of them over time, and that they recognize that their hostile traits (e.g., grandiosity, callousness, entitlement) cause them some vulnerability. This is not to deny that narcissistic individuals cause pain and suffering to others, including those who might value and love them (e.g., romantic partners; friends; family members), as they often do. Instead, I would argue that these behaviors may not stem from a complete lack of insight, but rather are emotional and behavioral responses that can follow a perceived threat to the ego, the importance of status, hierarchy, and dominance for narcissistic individuals, and a general lack of connection with others that makes these behaviors more likely.
Emamzadeh: Well, this certainly paints a more complex picture of narcissists. Of course, whatever the motivation, narcissistic behavior does not lead to good relationships. In the clinical literature, narcissism has been associated with significant dysfunction (e.g., in romantic and work relationships). Even inherent narcissism has been associated with “a selfish and exploitative approach to interpersonal relationships, including game-playing, infidelity, lack of empathy, and even violence” (p. 171). 2 So what are the latest treatment options for narcissism? Can narcissism be successfully treated with psychotherapy?
Miller: Unfortunately, there are no empirically supported treatments for narcissism at this time—so what follows is speculative in nature. In general, it is relatively unlikely that we will see many “pure” cases of grandiose narcissism in clinical settings, unless it is a court order. This means that the narcissistic individuals most likely to appear in clinical settings will have more vulnerable narcissistic features (e.g., depression, anxiety, selfishness, insecurity, and entitlement). Because vulnerable narcissism overlaps so much with borderline personality disorder (BPD), it is possible that some empirically supported treatments for BPD may be successful in treating the former (e.g., dialectical behavior therapy or schema-focused therapy). In general, I think one should expect that significant improvement will require a relatively lengthy form of treatment given the importance and challenges of developing understanding with narcissistic patients. 3 In my own view, individuals with disorders that are externalizing in nature (e.g., vulnerable but not necessarily distressed) may benefit from focusing on what they have lost as a result of the disorder as a means of motivating change. That is, I am not sure how easy it is to teach and change empathic capacity, but I think that patients can recognize, for example, that their narcissistic traits have negatively impacted their status and performance at work and learn new strategies to reduce the behaviors that have caused these outcomes at work, and that they care about (e.g., not getting a promotion). In our new book on hostility4 (Miller & Lynam, 2019), which we consider to be the core of narcissism and psychopathy, Don Lynam and I have been fortunate to have several scholars write about how one can make changes in such an area from a variety of perspectives, including cognitive behavioral, motivational interviewing, psychodynamic, and dialectical behavior therapy. Imamzadeh: Many of us find it difficult to tolerate their exploitation, jealousy, and lack of empathy in our relationships with narcissists. So my final question is for practical advice on how to deal with narcissists. For those of us who have family members, relatives, romantic partners, coworkers, or colleagues who are highly narcissistic, can you offer any suggestions or resources (articles, books, support groups, etc.) on how to manage these relationships? Miller: I can’t offer much empirical advice, unfortunately. One option is to limit one’s interactions where possible (e.g., try not to date or marry narcissistic individuals; limit your interactions with narcissistic coworkers when possible). This, of course, doesn’t help those who have little say in such relationships (e.g., have a narcissistic parent, child, or boss). Some suggest not challenging narcissistic individuals in ways that threaten their ego and thus increase the likelihood that they will respond with anger or aggression. Of course, this strategy also has its challenges because it may require a level of caution or submission that may not work well in long-term intimate relationships. Another approach is to give the narcissist some clear and explicit feedback about how his or her behavior is affecting him or her and to set firm boundaries (again, when possible) regarding expectations for interpersonal interactions. For example, a romantic partner might explain to their more narcissistic partner that it is annoying to spend 30 minutes each day talking about the narcissistic partner’s day without any reciprocity from the other partner. If this strategy does not produce any change, the non-narcissistic partner might explain that they will not engage in such discussions until they have a two-way relationship. Again, this may not be possible in situations where the narcissist is threatening or has a history of violence that would make setting such boundaries difficult and dangerous.
