Episode 250: Devaluation, Transference, Narcissism with Diana Diamond
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Introduction (00:00:00)
Puder:
I am joined today with Diana Diamond. She is an amazing author who has written a book called Treating Pathological Narcissism with Transference Focused Psychotherapy (Diamond et al., 2021). She's also the first author on some really amazing articles like “Attachment and Mentalization in Females with Comorbid, Narcissistic and Borderline Personality Disorder" (Diamond et al., 2014). And also the first author of another great paper called “Patient Therapist Attachment in the Treatment of Borderline Personality Disorder” (Diamond et al., 2003). She is truly a world expert in narcissism, borderline personality disorder, transference-focused therapy, and I've heard about her for years. It's great to finally meet you.
Diamond:
Thank you so much, David. Thanks for inviting me to be on this podcast. It has been very gratifying, the reception that the book has gotten. And I spent five years writing it, some of which were the COVID years, and I was kind of like a monk in a medieval monastery. I didn't have much contact with the world. And then my co-authors formed a pod. And I miss it; that time of just reflecting and thinking and talking about patients and writing. Then, of course, you send the book out into the world and you have no idea what kind of reception it's going to get. And I think because it was written during the COVID years, that was doubly isolating.
So it's been very gratifying that people have been so interested in it. It's currently being translated into eight languages, which is also a big surprise. And interestingly enough, some of those languages are from countries—I'm not going to put a label on them— but China, Iran, and Turkey, which have very different governments from what we have. And there is a chapter on malignant narcissism in leaders and groups. So that's been very gratifying that people have written from those countries and said, this has been very useful to us. Okay. That's a long answer to a short question.
Puder:
Right. And maybe we should put the caveat that all cultures in all countries have malignant narcissists.
Understanding Devaluation in Therapy (00:02:32)
Puder:
I'm actually very gratified when these episodes go out to people in other countries too. And I get messages from people around the world. I was watching an interview where you had multiple questions from places like Iran and Egypt, and how wonderful for that sort of reach with ideas. And there's so many lessons. I wanted to focus our time actually on one little area, because I feel like I may have you back a couple times. And I was thinking about devaluation specifically, and I almost feel like we could use that as kind of a way of talking about multiple things. But this podcast does go out to mostly mental health professionals. People in practice, therapists, psychiatrists, nurse practitioners, PAs. There's also other types of physicians, as well. And I think when I think about devaluation, I think that it can be a uniquely painful thing that kind of sticks with the provider. For instance, there's a couple patients in my mind, even as I'm thinking about this topic, where there's kind of this residue of this chronic devaluation that's happened towards me from them that's subtle. It’s insidious. Do you wanna kind of open up that topic and how it's linked to some of the things that you've written about?
Diamond:
I would say that that is a very apt place to start and also to focus because that is one of the single most difficult things about treating these patients. Otto Kernberg has a wonderful quote about that. The gist of it is that the single greatest challenging task in treating narcissistic patients is not to devalue the patient in response to their devaluation of you and to be able to sit with that and hold that and work with that. It often comes up again and again and again. It's not resolved necessarily in the earlier phases of treatment, and that's what makes treating these patients so incredibly challenging. It remains a primary defense. And there's a lot of reasons for that. But it's a primary defense that lasts well into even the later stages of treatment. Even into the termination phase. You can have devaluation of the treatment. Wasn’t what they expected. They didn't have the gains they wanted, and that has to be worked through. Now, that's not true of all patients, but it is the single most challenging issue.
Clinical Examples of Devaluation (00:05:20)
Puder:
Just to kind of give some visceralness to this: does any specific example come to your mind of devaluation where you felt devalued? Where maybe you even sought supervision or you saw the need to talk to some other providers about this?
Diamond:
Yes. I mean, I just have to be careful about confidentiality.
Puder:
I have the same fear. I'm even thinking of some examples. What if my patient were to listen to this? What would they feel towards me knowing that I brought up their specific example? Would I get further devaluation and would that even be worse? You know?
Diamond:
Well, I can give you a general example of something that is going on with the patient I'm currently treating. She often tells me how much better she is. She's a musician and she was unable to perform in her graduate musical training because she was so self-conscious. Also felt she wasn't getting the kind of exposure from the faculty that she expected. So she kind of retreated and also had tremendous envy of her fellow students. She felt they were getting more adulation, et cetera. So a lot of the work was overcoming that sense of narcissistic injury. Her sense of paralysis, her withdrawal from the world which often happens with narcissistic patients. And that's an underestimated issue.
But as she began to get better and began to be able to perform again and began to work through the envy, the sense of narcissistic vulnerability and so on, she would say to me, “You know, I'm much better, but it doesn't have anything to do with the therapy. It's really about the fact that I was able to go out and start performing again and now I'm getting a lot of adulation that I had sought and so on.” And so sometimes it is quite overt, as in that case. As they begin to get better, they may not be able to give any credit to the therapy. That, of course, is very demoralizing for the therapist, even though you know that the therapy has helped them tremendously. And then of course that has to be taken up in terms of their object relations.
Why does there always have to be someone who's superior? Someone who's inferior? Because that's how we think in TFP (Transference-Focused Therapy) (see also episodes 41, 170, 185, 234, and 239). We think in terms of what is the dominant object relation that is being activated right now in the transference. So, I find that very containing, in terms of thinking about and asking why would this person need to devalue me at this particular moment? And let's talk about that, and let's use it as an opportunity for understanding their internal world of self and other representations. And often the devaluation is a way into that, but it comes up over and over again. So, that's one example. The other thing is you get a more subtle devaluation. So the patient will set up almost like an adjunctive therapy. They'll say, well, I have lunch with my best friend every week, and he or she is so insightful. And I learned so much from those discussions. Or I have a new trainer and I feel so salutary with that person. It’s so wonderful for me that this is being set up as a kind of alternative therapy/therapeutic relationship. Or they will say, you know, sometimes I think about my former therapist and I'm in dialogue with my former therapist (as though you don't really count). There are all kinds of subtle forms of devaluation that go on.
Recognizing and Responding to Subtle Devaluation (00:09:48)
Puder:
Or maybe something like, I read this new self-help book and I feel like this has really made the difference for me. And maybe it has helped to some degree, but how would that be different? How would we know it's devaluing? We don't want to err on the side of imagining devaluation when there's not devaluation, right?
Diamond:
Yes. And that's a very good point because sometimes we're not as effective as we would like to be and sometimes the person is getting a great deal from talking to their friend or their trainer. If they're on medication, it's the psychopharmacologist, right? So, one has to give that credence. One has to accept that those people are helpful for them. The way I approach that is usually through clarification. Well, tell me what is particularly helpful there and what is it about that person. And I don't immediately go into it as a devaluing comment. You want to know more about this other relationship or this other connection that they're finding salutatory. But the bottom line is these patients do feel that they have to do it and want to do it all by themselves. And in the beginning you are a sounding board for the most part. And they will either reject or incorporate your interpretations, which is another form of devaluation. By that I mean, when you make an interpretation, they will come back either in the same session or the following week or therein in close proximity to tell you the very thing that you said to them as though it came from them. We have to remember that introjection incorporation is a defense. It's a way of withdrawing from the relationship. So we have to really think about why these patients need to do that.
Puder:
What if you start giving an interpretation and the patients almost dissociate. Almost like the words don't even really register. You know what I mean? It's like their ideas are supreme and when you start talking, they kind of almost go hazy or feel disconnected or separate. Is that kind of another form of this?
The Link Between Devaluation and Attachment Styles (00:12:27)
Diamond:
That's another form of that. And I think that brings up something I know you're interested in, which is attachment.
So many narcissistic patients, not all, but many of them have what we call dismissing attachment. And those who have dismissing attachment really focus on their own strengths. They fear vulnerability. They avoid vulnerability at all costs. They avoid dependency. They have a sort of cool contemptuous attitude toward attachment. They often have lack of memory for their early attachment experiences. This is when they're given the Adult Attachment Interview (AAI), which is a 20-question semi-clinical interview about early attachment experiences and their relationships. And so they tend to not be able to remember very much or they give you very canned, idealized views of their attachment history, but often very truncated. And you realize that at some point, these are individuals who turned away from attachment figures and they form these very strong defenses. I think when there is give and take that therapy obviously challenges that, because it's a relationship, and when there's a give and take between therapist and patient they have a very difficult time with that. So it activates their dismissing devaluation of relationships.
Puder:
I was actually, I have that page turned open and this section alone is worth getting the book. This chapter on where you go through the dismissing attachment style and then the research on that. For a long time I was wondering why they call it dismissing? Because I think avoidant makes just so much more sense to me, right? The child is left alone in a room at one and a half years of age. Mother comes back, the child doesn't show reengagement with the mother, the child continues to play with toys. But the child is stressed, the child's cortisol is elevated, the child's stressed out in the mother's absence. But I like dismissing, because it's the words they use to negate the importance of attachment. But the anxiety and the stress are still there. It's just hidden (see also episodes 69 and 213).
Diamond:
Yes, exactly. We are just finishing a study of 52 borderline patients in transference-focused psychotherapy. My part of the study was to give the adult attachment interview at the beginning of treatment, and after 18 months of TFP, and we're just looking at the data of this now. I don't want to go into a long thing about the research, but it's really fascinating because some of the most disturbed patients, those who have malignant narcissism at the beginning of treatment. Which means that they have a grandiose self, but it's infiltrated with paranoia, antisocial features, and a lot of egosyntonic aggression. And those individuals can look very disorganized. They have lack of resolution of loss and trauma at the beginning of treatment. So their major classification is disorganized. But actually after 18 months, some of them look dismissing.
So we have to be careful with dismissing because dismissing can also show the development of better defenses. And instead of focusing on traumatic experiences and becoming disorganized or being preoccupied with those experiences in a very disorganized way, they actually then can talk about their attachment figures in an idealized way. And for those cases to become dismissing shows better defensive structure. Dismissing can mean very different things at different points in the treatment. And depending on how severely disturbed the patient is, generally we find that people who have dismissing attachment do have better working defenses, better capacity for repression as opposed to splitting. And so one has to be careful about assuming that this is always negative. Does that make sense?
Research on Attachment and Reflective Functioning in Narcissistic Patients (00:17:09)
Puder:
Absolutely. And I'm wondering if the reflective function is another way of seeing the nuance in this (see also episodes 205, 206, 214, 224, 227, 244, and 249). Are you measuring reflective function before and after? How is that shifting in your new study?
Diamond:
Well, I wish I could tell you that, but I can only tell you based on a very small group of cases that I've looked at with malignant narcissism. All I know from the statisticians is that reflective functioning is improving in our patients. I don't know exactly how much, but I can tell you, based on these two cases I looked at who have malignant narcissism at the beginning of treatment, their reflective functioning goes up substantially by 18 months to the near ordinary or above ordinary level. So I think this is a very good point because their capacity for mentalization for understanding and imagining the thoughts, feelings, conflicts, motivations of themselves and others is improving, even though they might still have dismissing attachment, which is still insecure, but it's organized attachment. Does that make sense?
Puder:
Yeah. I like the word disorganized attachment. It's not used in the AAI they use, they use unclassified [“cannot classify”]. They used unresolved [for loss/trauma]. I wish they used disorganized as a continuation of the infant attachment studies. Why do you think they've changed the word? Why do you think that it's different?
Diamond:
Well, let me just clarify something about the AAI, which is important. There's insecure attachment and there's secure attachment. Insecure is dismissing, preoccupied, and lack of resolution of loss and trauma. So those are the three insecure categories. Then of course there is secure, so there is insecure categories and secure. But then there's another way of looking at the AAI, which is the organized categories versus the disorganized. And the disorganized categories are lack of resolution of loss and trauma, or what we call cannot classify, where the individual cannot mobilize any consistent attachment strategy. They ricochet between, say, being dismissing, idealizing, cutting off all discussion of attachment, having lack of recall for early experiences of attachment, or on the one hand or being preoccupied. They get very caught up in involving anger at attachment figures. So they're going back and forth between those two positions. And that's called cannot classify and lack of resolution of loss and trauma, are both called disorganized. So you have the disorganized categories, and then you have organized, which is dismissing and preoccupied and secure. And so if you look at it that way, individuals who move from being disorganized to organized, that's an advance.
How Attachment Styles Shape Devaluation (00:20:025)
Puder:
That's a big advance.
Diamond:
It's a big advance. Yes. I know that's kind of a technical thing. Do you have any other questions about that?
Puder:
No, I think I wanna get back to this kind of like idea of devaluation and does someone with different attachment styles devalue in different ways? For example, does someone with more of a disorganized attachment style devalue in a different way than a dismissing or preoccupied?
Diamond:
Yeah, it's a really interesting question. I think the dismissing devaluation is more like the example I just gave. I'm much better, but it has nothing to do with our therapy or I don't want to hurt your feelings, but it's not really about our therapy. It's about the fact that I was performing more, that I'm getting a lot of adulation for that, that I feel more confident, but the therapy hasn't had that much to do with it. That's more the dismissing devaluation.
I would say devaluation from a preoccupied patient is a little bit different. And I think that would take more the form of a kind of angry vituperation. You haven't done anything for me. I've been coming here twice a week paying you all this money. Therapy's been a waste of time. I'm still having tremendous difficulties with my boyfriend. And now I think we're gonna break up. And so I don't know why I've been in this treatment. So periodic, really trashing the therapist and the therapy and blaming everything that's wrong in their life on the therapist or expecting a kind of perfect cure and being enraged when that doesn't happen. And threats to quit or often missing sessions which means it becomes more acted out in the person who's preoccupied. Often with those individuals, you also get what we call a paranoid transference. So they not only are devaluing the treatment, but they're fearful that the treatment could be harming them or might harm them because that's part of their internal world. Now, I know that the relational analysts will say, okay, but there's always co-construction.
The therapist always makes some contribution. And I agree with that. I think we have to be very careful to always be examining our countertransference. Our capacity to stay empathically connected to the patient no matter what they're bringing to us. We can get into that in a minute. That's very difficult with narcissistic patients. But on the other hand, these patients have such a maladaptive set of internalized self and object representations that it often will override any situation, particularly in therapy, which is where one develops a relationship with a patient over time. So the therapist is going to get those self and object representations are going to emerge in very powerful ways. And one has to accept that and be prepared for it and hold those projections until the patient can tolerate examining them and exploring them. We have certain techniques for doing that. But the main thing is to accept what's happening at the affective level in the here and now. So that's the preoccupied patient.
The disorganized patient who has lack of resolution of loss and trauma can also devalue the therapist. When they have that classification of unresolved, they always get a next best fitting organized classification. So they're unresolved dismissing, unresolved preoccupied, or you can be unresolved secure. You can have a lack of resolution of loss and trauma, but still have secure attachment, interestingly enough. And that just means that in the questions about trauma and loss, the person becomes disorganized in their capacity to give a coherent view of what happened, because lack of resolution of loss and trauma is not about whether the person experienced trauma or abuse. It's whether they can talk about it coherently. Whether they've put it in perspective. Whether it disorganizes them in the current situation. And so in those situations when somebody has a lack of resolution of loss and trauma, but they actually have secure attachment, often that will come out in the treatment again with distrust of the therapist, fearfulness of the therapist, or fear of loss of the therapist. And the devaluation could take that form as well.
Case Example: Addressing Devaluation in Treatment (00:25:59)
Puder:
So when someone devalues you, when are you going to bring that out into the open? And what do you say? I imagine it's different for different patients and where they are in the treatment. But I'm curious how you do that.
Diamond:
Okay. I'm going to give you a bit more of an extended case example now because you have to kind of understand a little bit more about the process. It will make it clearer when and how to address this situation. This is actually a case from the book. This was a patient I was treating and when he came to treatment, he had a very long analysis. And the analysis was helpful in terms of him dealing with certain anxieties. He had tremendous performance anxiety. He was highly placed in an architectural firm, and he was a partner who had to go make presentations to international clients.
He would get very anxious. The analysis was very helpful for him. He got promoted to partnership and did very well. He was in a relationship with a woman that he had met. She was from a different culture and they were living together for a long time, but he chose her because she made him feel safe. And she was from a different social class, not as well educated, but over time, he began to devalue her. Now we did find that he idealized her initially and was very sexually attracted to her, but over time, he felt she didn't really measure up and he couldn't decide whether he should stay in that relationship or leave it. In the meantime, he was having relationships with women online, which she didn't know about. He was referred to me by the analyst, and the presenting problem was, he's so much better in every respect, but he can't leave this relationship.
Now, I always get suspicious when there's only one problem being presented by the patient such as his view that he was so much better, he'd be able to do that on his own. So I agreed to take him on for TFP. And it's not unusual for a patient with grandiose narcissism to be in a relationship with someone they devalued and they feel stuck in that relationship because they project the devalued part of themselves onto the other. And that holds the devalued part of themselves. And so they can't understand why they can't leave. But that's because that's projection. When one projects an aspect of one's own experience that one dreads and is trying to get rid of onto the other, that other holds a part of the self and it's not so easy to separate. So it was pretty clear to me early on in the treatment that this is what was going on.
He came in saying, I've had a long analysis. I just want to deal with this one thing about whether I should leave my relationship. So I said, okay, well, let's give it a try. Usually, I tell patients that with TFP, they should commit for a year. Our research shows that there's real change after a year. They don't have to sign on the dotted line, but we make a contract that they will try to see the treatment through. If they feel like quitting, they'll come in. So this patient who chronically devalued the treatment in the first two or three months would evaluate every intervention or observation I made. This patient would tell me I was good on interpretation, but not so good on empathy. He'd read a lot and he would sometimes say it sort of in an off-the-cuff way as he was walking out. Well, that interpretation actually was very helpful to me. But, you know, I didn't feel that you were so connected to me emotionally in this session. So it was always a kind of an evaluation.
Puder:
Interesting on the way out the door. When I hear that, it feels like maybe it's painful to leave. There's something about it that's so painful to leave that it might be easier to get angry at me while you leave or to be unsatisfied, or as a way of coping with the distress of leaving.
Diamond:
I think that's a really good point, because this person did have trouble leaving. But I think it's also about reasserting his superiority.
Puder:
And I don't want to devalue your thousands of moments with this particular person. You know him a lot better than I do. So the superiority was kind of being exerted from intellectual psychological mindedness.
Diamond:
Exactly. Just to make sure that I knew that he had his own sort of tape going on of evaluating the treatment. So this went on for I'd say the first two or three months of treatment. And then I actually was feeling kind of restless.
Like this treatment isn't taking off. And maybe it was just hubris to think that I could treat someone who'd had this long analysis and really make headway in this. And so I made an interpretation. It was the first major interpretation I made. He came talking about the woman he'd met online. He'd met a particular woman who was trying to decide should he actually meet her in person? Should he actually venture out and try to have a real relationship with her, not just a virtual relationship? And I said to him, it seemed to me that that was the conflict. The conflict was not between two women, his long-term partner and this person he'd met online, but it was whether he wanted to have a real relationship in depth with somebody, versus staying sequestered in the fantasy world.
And he said to me, wow, I think that really makes sense. I'll have to think about that. And then he came to the next session and said he was thinking of leaving treatment. In fact, and this is an interesting thing about your point about leaving, he came early to the next session, and he knocked on the door to let me know he was there. But I was with another patient. He came early in the morning, but I had a very early session that day. And so I told him I was with another patient. We still had another five minutes. Then he came in and he was just bursting at the seams to tell me that he was gonna quit treatment. And I was so confused because I thought we had gotten somewhere.
And so I thought, why? Why now? Why is he going to quit now? Just when we're starting to make progress? I held onto that and I basically just made a comment about the nonverbal. I said, well, I understand that you want to leave, and we'll talk about that. But you know, it seems interesting to me that you came early to tell me that. So maybe there's part of you that really wanted to come to the session and talk about what's going on. So let's try to understand this. As the session went on, he told me I had missed something very important in the last session. That I hadn't understood that his girlfriend was actually beginning to push him away. And he was quite anxious about that. And instead, I'd focused on this conflict that he has about a real relationship versus a fantasy relationship.
And I said, well, fair enough. I did remember him mentioning that earlier in the session before he was obsessing about the girlfriend that he'd met online. I'll have to really think about why I didn't pick up on that and explore that. And that's something we can talk about today. Now, this is very important. It sounds like a minor thing, but one has to be willing to accept the projection. One has to be willing to also acknowledge one's own errors.
Puder:
Culpability.
Diamond:
Right. And so I acknowledged that it could be the case that I didn't hear the distress that he was expressing, because he mentioned it in a very matter of fact way, without much affect. That the girlfriend was visiting her family, and she hadn't gotten back to him. And he was getting very anxious about that. So we talked about that. And I said to him, it must be very difficult to have a therapist who didn't hear your distress. Now, this is called a therapist-centered interpretation. So we really focus on the immediate affect that the person is feeling towards the object, whether it's the therapist or somebody else, and validate that it must be very difficult and very painful to have a therapist who didn't hear his distress. And perhaps that was similar to how he was feeling with the girlfriend, that she was pushing him away and he felt in some way pushed away by me, the therapist, as well.
And so that's something that he's very vulnerable to. And then I said, you know, when he feels rejected or he feels not attended to it arouses all these feelings. And no wonder he came in and said he wanted to quit. Perhaps that had something to do with it. And then there was a very long silence, and he turned away from me. And he turned, and I thought to myself, well, this is the moment when he is going to tell me that he's going to quit. I gave it my best shot, but when he turned back, he said to me, well, I was very anxious about coming today because I have to do a major presentation this morning, and I'm really worried that I'm not going to do a good job. And I really wanted to talk to you about that, but I felt that since you missed this important thing last week, maybe you wouldn't be able to hear me.
I realized that that's the moment when the treatment began and the treatment really took off. And then I said to him, it sounds like you are telling me that you felt really vulnerable and you felt exposed and fearful that I wouldn't be able to hear that. That I would dismiss that. And so instead, you came in and said you wanted to dismiss me and fire me as a therapist. And then where we wound up in that session was talking about how that seemed to be the way his relationships went. That there was always a superior one, always an inferior one. Somebody who was humiliating someone or who felt humiliated. And he had felt humiliated by me. And so he came in and said, I'm going to quit treatment. And that's when the treatment took off.
So does that begin to address the issue about how to address devaluation? You address it by getting into the internalized object relation that it's connected to and trying to help the person see. This is the beauty of the object relations model is that there's a self-representation—the one who's being rejected—and there's an object representation—the one who's doing the rejecting. Let's just stay with that particular representation, and a linking affect of distress or fear or anger about it. You try to show the person that is an object relation that exists, a model in their mind. And sometimes they live out one side of it, and other times they live out the other side of it. And that's most effectively done when you have an in vivo situation like that with where it's alive in the transference and you can work with it.
Puder:
One thing that occurs to me is that you are also a real person in this, but you could have been a fantasy at the beginning of treatment. Here you are an expert. You have written many books. You have high respect from this analyst who referred the patient to you. And so you're in this idealized place which is kind of a fantasy of sorts, right? And then by saying to him that this is really a conflict between wanting to live in a fantasy versus a real relationship. There was something about that and then this other missing piece was when he said you're not perfectly attuning to every bit of his distress. That popped him out of that fantasy model with you into a real relationship.
Diamond:
Yes. It made me a real person, a person who was fallible. And who also could hold that imperfection. This is very hard for narcissistic patients. They either highly idealize you or, of course, the flip side of that is a devaluation. And so for you to say, hey, I can acknowledge maybe I missed something. I'm imperfect. I'm not that idealized figure. Or, I can acknowledge that, but not feel incredibly distressed or devalue others. This is very important for them to see you model for them. That you can have imperfection and still go on with the relationship. This person was highly perfectionistic, highly self-critical. There are no patients in my experience who are more self-critical than narcissistic patients. Yes, they devalue others and they are severely critical of others. But when they turn that on themselves, they can be absolutely scathingly devaluing, to the point of self-annihilation. We have to think about that part of narcissistic pathology. And that, of course, is in the myth of Narcissus.
From Fantasy to Reality: The Narcissus Myth and Its Clinical Meaning (00:41:46)
Puder:
I know you wanted to maybe read the myth.
Diamond:
Yeah. I can read you just one passage from it.
Puder:
Let's go. Yeah. I love it.
Diamond:
The myth is about Narcissus and it's from the Ted Hughes translation (2010). Narcissus was the son of a nymph and the river god, and the river god raped the nymph. So Narcissus was the product of a traumatic experience. And people rarely talk about that, but there's a lot of interesting material now about trauma and narcissism. And, in fact, we know that if you look at the histories of these individuals, quite a few of them have a particular kind of abuse. It's not so much sexual and physical abuse. It's emotional abuse and neglect.
Puder:
Are there any unique identifiers of the type of emotional abuse, would you say?
Diamond:
Yes, there is parental influence, where the child is used as an extension of themselves. Basically, investing their own narcissism in the child, where the child's real self is overlooked and their need for nurturance, and they become a narcissistic complement to the parent. Not to move to popular culture, but you see it, for example, in Succession if you know that miniseries. So you see a patriarch whose children were just narcissistic extensions of himself. The protagonist had very little sense of his children as real people. So there's the over-involvement, but in the context of using the child as a narcissistic extension of self, sometimes there's just rejection and coldness. That's the opposite of over-involvement, under-involvement. I had one patient whose mother was severely narcissistic. Her mother would have tea parties and entertain her friends, whereas the child, the patient, was left outside in a wet diaper just to run around on her own or left alone in the house while the mother went out.
So these are parents who can be quite neglectful on the physical and emotional level. Anyway, let me just read you this passage, which is very short. So, the myth of Narcissus. So Narcissus was the product of this rape between one of the river gods and the nymph. And he was particularly attractive. As he got older, the river goddess, his mother, was quite concerned about him and went to see a seer. The seer, god, I think it was Tireseus, and said, how will he fare in life? Will he be okay? And Tireseus said, he will be okay if he never comes to see himself. The mother was worried that he was so attractive that he would never be able to get beyond that. They said, well, if he never knows himself, he will be okay.
So then of course, we know that Narcissus had all these admirers, including Echo, whom he kept spurning. And then there was one male admirer. And the male admirer was spurned by Narcissus. And he went to the god who does revenge, I'm sorry, I can't remember his name. And basically what he said is we're going to give him a taste of his own medicine and know what it feels like to be spurned. So then Narcissus looks into the river, the pool, and sees himself. And he falls in love with his own image. So what's interesting about the myth is that he falls in love with his own image, but in the beginning, he does not know that it's his image. He really truly believes it's a being in the water. A separate being.
So here are the lines from the myth. “He lay like a falling garden statue, gaze fixed on his image in the water, comparing it to Bacchus or Apollo, falling deeper and deeper in love with what so many had loved so hopelessly. Not recognizing himself. He wanted only himself. He had chosen from all the faces he had ever seen, only his own; he was himself the torturer, who now began his torture.” So he mistakes this image for a stranger who could make him happy. There are all kinds of lines in the poem about how he couldn't believe the beauty of the eyes that gazed into his own. But then, of course, what happens is that he realizes after a period of time that he cannot grasp this other being. It is an image of himself, but this becomes a torture.
The Deeper Tragedy of Narcissism (00:47:37)
Diamond:
And he winds up just collapsing on the river bank, not eating, and he turns into the narcissus flower. That's in one version of the myth. There's another version of the myth where he actually stabs himself in the breast and dies. And as he crosses into the River Styx, which is the river that separated the land of the living and the dead in Greek mythology. He continues looking for his image, still believing he can find that other. So I often say the myth expresses the tragic life course and the tragedy of narcissistic pathology, but I don't think we focus on that enough. We focus on the grandiosity of these patients, how we know that this, of all the personality disorders, we know that narcissistic personality disorder is the personality disorder that most harms other people or distresses other people around them.
There have been studies in social psychology of this even more than borderline patients. So we know it's the people around the narcissistic patient who are distressed and feel it more often than the narcissists themselves. But narcissistic personalities have a rate of completed suicides greater than that of borderline patients. So they can be very self-annihilating and very self-abnegating. And so you see in the myth, all these kinds of things that we know about narcissism. You see the exaltation of the self, and then the plunge into paralyzing states of rage and shame and loss when the narcissistic illusions are shattered. And the extent to which the self-exaltation or self-aggrandizement that you see in the grandiose states often can be accompanied by states of severe disappointment, self-criticism, even self-torture and self-destruction.
Puder:
That is powerful. I'm cognizant that, if you're a listener at this point, you're probably wanting this to go on or that's my own experience. I want to fully value your expertise. And I have appreciated hearing all of this. I want to continue this conversation ideally in the future. And so maybe we'll do a part two not too long in the distance.
Diamond:
Sounds good. Very happy to do that.
Puder:
Yeah. There's so much to go into, and it's exciting to meet you and get a little taste of this. Any final comments as we kind of wrap up our time?
Diamond:
Well, I think that what we didn’t get into in depth, we began to get into is how do you work with these patients?
Puder:
Yeah.
Closing Reflections and Future Discussion (00:50:53)
Diamond:
I believe that is the biggest challenge, which is why we wrote the book. We wrote the book because those of us who are part of a research group, which includes treatment of patients with personality disorders, at the Personality Disorders Institute at Weill Cornell are in supervision groups. And we found that as we were presenting cases to each other, it was the cases with pathological narcissism that were giving us the most trouble, interestingly enough. About 15 years ago, we formed a study group, and the book really came out of that. And so it comes right out of our clinical experience. And I imagine there are many people out there who will listen to this podcast because they have a lot of narcissistic patients in their practice at all levels of organization. They can be high functioning and on the cusp of neurosis, they can be at the borderline level, or they can be more severely disturbed, like patients with malignant narcissism, where they can actually lose touch with reality. So I think maybe if we continue, we should talk more about how you treat these patients and what the dilemmas are. You asked me about the devaluation, which was a very good question for the beginning stages of treatment because that's often what you run into, but you can also run into extreme idealization. A whole other trajectory. So much to talk about. And thank you for inviting me.
Puder:
Much to talk about. Okay. Thank you so much for your time. Maybe a good place to leave this is if you're listening to this and you have specific things that you would like sort of drawn out in terms of the treatment, maybe a case that we could de-identify and kind of ask her, shoot me an email. You can find me on psychiatrypodcast.com and we'll leave it there for today.
References
Diamond, D., Stovall-McClough, C., Clarkin, J. F., & Levy, K. N. (2003). Patient-therapist attachment in the treatment of borderline personality disorder. Bulletin of the Menninger Clinic, 67(3), 227–259. https://doi.org/10.1521/bumc.67.3.227.23433
Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-Kern, M., Cain, N. M., Doering, S., Hörz, S., & Buchheim, A. (2014). Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder. Personality disorders, 5(4), 428–433. https://doi.org/10.1037/per0000065
Diamond, D., Yeomans, F. E., Stern, B. L., & Kernberg, O. F. (2021). Treating pathological narcissism with transference-focused psychotherapy. Guilford Press. https://dianadiamondphd.com/books/treating-pathological-narcissism-with-transference-focused-psychotherapy/
Hughes, T. (2010, February 8). Echo & Narcissus (Ted Hughes, Tales from Ovid) 2/3: Pride, Curse, A Face in the Water [Video]. YouTube. https://youtu.be/91CAsoRuSYo