The Depressive Patient - A Case Study

Excellent description of person diagnosed with Depressive Personality Disorder; having pervasive and continuous depressive thoughts and behaviors.

Notes of first therapy session with Edward J., male, 51, diagnosed with Depressive Personality Disorder

Edward has a lumbering, numbed presence. He walks as if in a dream, his gait robotic, his eyes downcast. Within minutes, it is abundantly clear to me that he is gloomy, dejected, pessimistic, overly serious, lacks a sense of humor, cheerless, joyless, and constantly unhappy.

How does he react to good news? - I ask him - What if I had just informed him that he has won a million bucks in a game of chance? He contemplates this improbable good fortune and then shrugs: "It wouldn't make much of a difference, Doc." A million bucks wouldn't make a difference in your life? - I am astounded. This time, he doesn't even bother to respond.

Let's try another tack: What would you have done with the money? "Probably fritter it away." - He laughs mirthlessly. I am no good with finances either, I confide in him. "I am not good at anything." - He counters. That's not what I hear from his wife and close friends whom I have interviewed, I try to reassure him. It seems that you are outstanding at your work, a loving husband, and a chess champion. "What do they know!" - He sneers - "I am a loser. The only thing I am really good at is disguising it."

Failing from time to time does not make you a failure, I try to reintroduce perspective into the fast-deteriorating conversation. He suddenly snaps: "I am worthless, OK? Inadequate, you get it? I consume scarce resources and give very little in return. I am too cowardly to put an end to it, is all. But don't give me these fake, sugary pep talks, Doc."

I am merely trying to understand, I reassure him. Can he provide examples of failure and defeat that prove conclusively his self-assessment and substantiate it? He slips into a bout of brooding and then reawakens: "I am afraid to lose my job." Why is that? His boss praises him to high heaven! He dismisses this contrary information: "When he finds out ..." Finds out what? "The REAL me!" - he blurts and averts his gaze.

Can he describe this stealthy, penumbral entity, the REAL he?

He feels - no, he knows - that he lacks perseverance, is hypocritical, obsequious, obstructive, and full of suppressed rage and violence. It worries him. He is very judgemental of others and, given authority or power over them, is sadistically punitive. He enjoys their writhing pain and suffering when he criticizes or chastises them but at the same time he hates and despises himself for being such a lowlife. He often apologizes to the victims of his abusive conduct, even crying as he does. He really feels bad about his behavior and because he is sincere, they forgive him and grant him another chance. He also claims knowledge, skills, and talents that he does not possess, so, in effect, he is a scammer, a con-artist.

That's a long list, I observe. "Now you understand." - He concurs - "That's why I will likely end up unemployed." Can he try to imagine the day after he is sacked? He visibly shudders: "No way. Don't even go there, Doc." I point out that he has been leading the conversation inexorably to this topic. At which point he sulks and then rises from his chair and walks towards the door without a word.

"Where are you going?" - I am genuinely surprised.

"To get myself a real psychiatrist." - He triumphantly calls out - "You are as much of a sham as I am, Doc. It's no use one fraudster trying to cure another." And he is gone.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"


 

next: The Paranoid Patient ~ back to: Case Studies: Table of Contents

APA Reference
Vaknin, S. (2009, October 2). The Depressive Patient - A Case Study, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/depressive-patient-a-case-study

Last Updated: July 5, 2018

Victim Reaction to Abuse by Narcissists and Psychopaths

Psychological aspects of how victims of abuse by narcissists and psychopaths end up in that position.

Personality disorders are not only all-pervasive, but also diffuse and shape-shifting. It is taxing and emotionally harrowing to watch how a loved one is consumed by these pernicious and largely incurable conditions. Victims adopt varying stances and react in different ways to the inevitable abuse involved in relationships with personality disordered patients.

1. Malignant Optimism

A form of self-delusion, refusing to believe that some diseases are untreatable. Malignant optimists see signs of hope in every fluctuation, read meanings and patterns into every random occurrence, utterance, or slip. These Pollyanna defences are varieties of magical thinking.

"If only he tried hard enough", "If he only really wanted to heal", "If only we find the right therapy", "If only his defences were down", "There must be something good and worthwhile under the hideous facade", "No one can be that evil and destructive", "He must have meant it differently" "God, or a higher being, or the spirit, or the soul is the solution and the answer to my prayers".

From my book, "Malignant Self Love - Narcissism Revisited":

"The narcissist and psychopath hold such thinking in barely undisguised contempt. To them, it is a sign of weakness, the scent of prey, a gaping vulnerability. They use and abuse this human need for order, good, and meaning - as they use and abuse all other human needs. Gullibility, selective blindness, malignant optimism - these are the weapons of the beast. And the abused are hard at work to provide it with its arsenal."

Read "Is Your Cup Half-full or is it Half Empty?"

2. Rescue Fantasies

"It is true that he is chauvinistic and that his behaviour is unacceptable and repulsive. But all he needs is a little love and he will be straightened out. I will rescue him from his misery and misfortune. I will give him the love that he lacked as a child. Then his (narcissism, psychopathy, paranoia, reclusiveness) will vanish and we will live happily ever after."

3. Self-flagellation

Constant feelings of guilt, self-reproach, self-recrimination and, thus, self-punishment.

The victim of sadists, paranoids, narcissists, borderlines, passive-aggressives, and psychopaths internalises the endless hectoring and humiliating criticism and makes them her own. She begins to self-punish, to withhold, to request approval prior to any action, to forgo her preferences and priorities, to erase her own identity - hoping to thus avoid the excruciating pains of her partner's destructive analyses.

The partner is often a willing participant in this shared psychosis. Such folie a deux can never take place without the full collaboration of a voluntarily subordinated victim. Such partners have a wish to be punished, to be eroded through constant, biting criticisms, unfavourable comparisons, veiled and not so veiled threats, acting out, betrayals and humiliations. It makes them feel cleansed, "holy", whole, and sacrificial.

Many of these partners, when they realise their situation (it is very difficult to discern it from the inside), abandon the personality disordered partner and dismantle the relationship. Others prefer to believe in the healing power of love. But here love is wasted on a human shell, incapable of feeling anything but negative emotions.

4. Emulation

The psychiatric profession uses the word: "epidemiology" when it describes the prevalence of personality disorders. Are personality disorders communicable diseases? In a way, they are.

From my book, "Malignant Self Love - Narcissism Revisited":

"Some people adopt the role of a professional victim. Their existence and very identity rests solely and entirely on their victimhood. They become self-centred, devoid of empathy, abusive, and exploitative. These victim "pros" are often more cruel, vengeful, vitriolic, lacking in compassion and violent than their abusers. They make a career of it.

The affected entertain the (false) notion that they can compartmentalize their abusive (e.g., narcissistic, or psychopathic) behavior and direct it only at their victimizers. In other words, they trust in their ability to segregate their conduct and to be verbally abusive towards the abuser while civil and compassionate with others, to act with malice where their mentally-ill partner is concerned and with Christian charity towards all others. They believe that they can turn on and off their negative feelings, their abusive outbursts, their vindictiveness and vengefulness, their blind rage, their non-discriminating judgment.

This, of course, is untrue. These behaviors spill over into daily transactions with innocent neighbors, colleagues, family members, co-workers, or customers. One cannot be partly or temporarily vindictive and judgmental any more than one can be partly or temporarily pregnant. To their horror, these victims discover that they have been transmuted and transformed into their worst nightmare: into their abusers - malevolent, vicious, lacking empathy, egotistical, exploitative, violent and abusive."

This article appears in my book, "Malignant Self Love - Narcissism Revisited"


 

next: The Interrupted Self

APA Reference
Vaknin, S. (2009, October 2). Victim Reaction to Abuse by Narcissists and Psychopaths, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/victim-reaction-to-abuse-by-narcissists-and-psychopaths

Last Updated: July 5, 2018

Psychosis, Delusions, and Personality Disorders

In-depth look at psychosis and the different types of hallucinatons and delusions as they apply to personality disorders.

Introduction to Psychosis

Psychosis is chaotic thinking that is the result of a severely impaired reality test ( the patient cannot tell inner fantasy from outside reality). Some psychotic states are short-lived and transient (microepisodes). These last from a few hours to a few days and are sometimes reactions to stress. Psychotic microepisodes are common in certain personality disorders, most notably the Borderline and Schizotypal. Persistent psychoses are a fixture of the patient's mental life and manifest for months or years.

Psychotics are fully aware of events and people "out there". They cannot, however separate data and experiences originating in the outside world from information generated by internal mental processes. They confuse the external universe with their inner emotions, cognitions, preconceptions, fears, expectations, and representations.

Similarly, patients suffering from Narcissistic Personality Disorder and, to a lesser extent, Antisocial and Histrionic Personality Disorders fail to grasp others as full-fledged entities. They regard even their nearest and dearest as cardboard cut-outs, two-dimensional representations (introjects), or symbols. They treat them as instruments of gratification, functional automata, or extensions of themselves.

Consequently, both psychotics and the personality disordered have a distorted view of reality and are not rational. No amount of objective evidence can cause them to doubt or reject their hypotheses and convictions. Full-fledged psychosis involves complex and ever more bizarre delusions and the unwillingness to confront and consider contrary data and information (preoccupation with the subjective rather than the objective). Thought becomes utterly disorganized and fantastic.

There is a thin line separating nonpsychotic from psychotic perception and ideation. On this spectrum we also find the Schizotypal and the Paranoid Personality Disorders.

 

The DSM-IV-TR defines psychosis as "restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature".

What are delusions and hallucinations

A delusion is "a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary".

A hallucination is a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ".

Delusion is, therefore, a belief, idea, or conviction firmly held despite abundant information to the contrary. The partial or complete loss of reality test is the first indication of a psychotic state or episode. Beliefs, ideas, or convictions shared by other people, members of the same collective, are not, strictly speaking, delusions, although they may be hallmarks of shared psychosis. There are many types of delusions:

I. Paranoid

The belief that one is being controlled or persecuted by stealth powers and conspiracies. This is common in the Paranoid, Antisocial, Narcissistic, Borderline, Avoidant, and Dependent Personality Disorders.

2. Grandiose-magical

The conviction that one is important, omnipotent, possessed of occult powers, or a historic figure. Narcissists invariably harbor such delusions.

3. Referential (ideas of reference)

The belief that external, objective events carry hidden or coded messages or that one is the subject of discussion, derision, or opprobrium, even by total strangers. This is common in the Avoidant, Schizoid, Schizotypal, Narcissistic, and Borderline Personality Disorders.

Hallucinations are false perceptions based on false sensa (sensory input) not triggered by any external event or entity. The patient is usually not psychotic - he is aware that he what he sees, smells, feels, or hears is not there. Still, some psychotic states are accompanied by hallucinations (e.g., formication - the feeling that bugs are crawling over or under one's skin).

There are a few classes of hallucinations:

Auditory - The false perception of voices and sounds (such as buzzing, humming, radio transmissions, whispering, motor noises, and so on).

Gustatory - The false perception of tastes

Olfactory - The false perception of smells and scents (e.g., burning flesh, candles)

Somatic - The false perception of processes and events that are happening inside the body or to the body (e.g., piercing objects, electricity running through one's extremities). Usually supported by an appropriate and relevant delusional content.

Tactile - The false sensation of being touched, or crawled upon or that events and processes are taking place under one's skin. Usually supported by an appropriate and relevant delusional content.

Visual - The false perception of objects, people, or events in broad daylight or in an illuminated environment with eyes wide open.

Hypnagogic and Hypnopompic - Images and trains of events experienced while falling asleep or when waking up. Not hallucinations in the strict sense of the word.

Hallucinations are common in schizophrenia, affective disorders, and mental health disorders with organic origins. Hallucinations are also common in drug and alcohol withdrawal and among substance abusers.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

 


 

next: Victim reaction to Abuse by Narcissists and Psychopaths

APA Reference
Vaknin, S. (2009, October 2). Psychosis, Delusions, and Personality Disorders, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/psychosis-delusions-and-personality-disorders

Last Updated: July 5, 2018

Empathy and Personality Disorders

One thing that separates narcissists and psychopaths from the rest of society is their apparent lack of empathy. Read about empathy and personality disorders.

What is Empathy?

Normal people use a variety of abstract concepts and psychological constructs to relate to other persons. Emotions are such modes of inter-relatedness. Narcissists and psychopaths are different. Their "equipment" is lacking. They understand only one language: self-interest. Their inner dialog and private language revolve around the constant measurement of utility. They regard others as mere objects, instruments of gratification, and representations of functions.

This deficiency renders the narcissist and psychopath rigid and socially dysfunctional. They don't bond - they become dependent (on narcissistic supply, on drugs, on adrenaline rushes). They seek pleasure by manipulating their dearest and nearest or even by destroying them, the way a child interacts with his toys. Like autists, they fail to grasp cues: their interlocutor's body language, the subtleties of speech, or social etiquette.

Narcissists and psychopaths lack empathy. It is safe to say that the same applies to patients with other personality disorders, notably the Schizoid, Paranoid, Borderline, Avoidant, and Schizotypal.

Empathy lubricates the wheels of interpersonal relationships. The Encyclopaedia Britannica (1999 edition) defines empathy as:

"The ability to imagine oneself in anther's place and understand the other's feelings, desires, ideas, and actions. It is a term coined in the early 20th century, equivalent to the German Einfühlung and modelled on "sympathy." The term is used with special (but not exclusive) reference to aesthetic experience. The most obvious example, perhaps, is that of the actor or singer who genuinely feels the part he is performing. With other works of art, a spectator may, by a kind of introjection, feel himself involved in what he observes or contemplates. The use of empathy is an important part of the counselling technique developed by the American psychologist Carl Rogers."

This is how empathy is defined in "Psychology - An Introduction" (Ninth Edition) by Charles G. Morris, Prentice Hall, 1996:

"Closely related to the ability to read other people's emotions is empathy - the arousal of an emotion in an observer that is a vicarious response to the other person's situation... Empathy depends not only on one's ability to identify someone else's emotions but also on one's capacity to put oneself in the other person's place and to experience an appropriate emotional response. Just as sensitivity to non-verbal cues increases with age, so does empathy: The cognitive and perceptual abilities required for empathy develop only as a child matures... (page 442)

In empathy training, for example, each member of the couple is taught to share inner feelings and to listen to and understand the partner's feelings before responding to them. The empathy technique focuses the couple's attention on feelings and requires that they spend more time listening and less time in rebuttal." (page 576).

Empathy is the cornerstone of morality.

The Encyclopaedia Britannica, 1999 Edition:

"Empathy and other forms of social awareness are important in the development of a moral sense. Morality embraces a person's beliefs about the appropriateness or goodness of what he does, thinks, or feels... Childhood is ... the time at which moral standards begin to develop in a process that often extends well into adulthood. The American psychologist Lawrence Kohlberg hypothesized that people's development of moral standards passes through stages that can be grouped into three moral levels...

At the third level, that of postconventional moral reasoning, the adult bases his moral standards on principles that he himself has evaluated and that he accepts as inherently valid, regardless of society's opinion. He is aware of the arbitrary, subjective nature of social standards and rules, which he regards as relative rather than absolute in authority.

Thus the bases for justifying moral standards pass from avoidance of punishment to avoidance of adult disapproval and rejection to avoidance of internal guilt and self-recrimination. The person's moral reasoning also moves toward increasingly greater social scope (i.e., including more people and instituhttp://www.healthyplace.com/administrator/index.php?option=com_content§ionid=19&task=edit&cid[]=12653tions) and greater abstraction (i.e., from reasoning about physical events such as pain or pleasure to reasoning about values, rights, and implicit contracts)."

"... Others have argued that because even rather young children are capable of showing empathy with the pain of others, the inhibition of aggressive behaviour arises from this moral affect rather than from the mere anticipation of punishment. Some scientists have found that children differ in their individual capacity for empathy, and, therefore, some children are more sensitive to moral prohibitions than others.


 


Young children's growing awareness of their own emotional states, characteristics, and abilities leads to empathy--i.e., the ability to appreciate the feelings and perspectives of others. Empathy and other forms of social awareness are in turn important in the development of a moral sense... Another important aspect of children's emotional development is the formation of their self-concept, or identity--i.e., their sense of who they are and what their relation to other people is.

According to Lipps's concept of empathy, a person appreciates another person's reaction by a projection of the self into the other. In his Ästhetik, 2 vol. (1903-06; 'Aesthetics'), he made all appreciation of art dependent upon a similar self-projection into the object."

Empathy - Social Conditioning or Instinct?

This may well be the key. Empathy has little to do with the person with whom we empathize (the empathee). It may simply be the result of conditioning and socialization. In other words, when we hurt someone, we don't experience his or her pain. We experience OUR pain. Hurting somebody - hurts US. The reaction of pain is provoked in US by OUR own actions. We have been taught a learned response: to feel pain when we hurt someone.

We attribute feelings, sensations and experiences to the object of our actions. It is the psychological defence mechanism of projection. Unable to conceive of inflicting pain upon ourselves - we displace the source. It is the other's pain that we are feeling, we keep telling ourselves, not our own.

Additionally, we have been taught to feel responsible for our fellow beings (guilt). So, we also experience pain whenever another person claims to be anguished. We feel guilty owing to his or her condition, we feel somehow accountable even if we had nothing to do with the whole affair.

In sum, to use the example of pain:

When we see someone hurting, we experience pain for two reasons:

1. Because we feel guilty or somehow responsible for his or her condition

2. It is a learned response: we experience our own pain and project it on the empathee.

We communicate our reaction to the other person and agree that we both share the same feeling (of being hurt, of being in pain, in our example). This unwritten and unspoken agreement is what we call empathy.

The Encyclopaedia Britannica:

"Perhaps the most important aspect of children's emotional development is a growing awareness of their own emotional states and the ability to discern and interpret the emotions of others. The last half of the second year is a time when children start becoming aware of their own emotional states, characteristics, abilities, and potential for action; this phenomenon is called self-awareness... (coupled with strong narcissistic behaviours and traits - SV)...

This growing awareness of and ability to recall one's own emotional states leads to empathy, or the ability to appreciate the feelings and perceptions of others. Young children's dawning awareness of their own potential for action inspires them to try to direct (or otherwise affect) the behaviour of others...

...With age, children acquire the ability to understand the perspective, or point of view, of other people, a development that is closely linked with the empathic sharing of others' emotions...

One major factor underlying these changes is the child's increasing cognitive sophistication. For example, in order to feel the emotion of guilt, a child must appreciate the fact that he could have inhibited a particular action of his that violated a moral standard. The awareness that one can impose a restraint on one's own behaviour requires a certain level of cognitive maturation, and, therefore, the emotion of guilt cannot appear until that competence is attained."

Still, empathy may be an instinctual REACTION to external stimuli that is fully contained within the empathor and then projected onto the empathee. This is clearly demonstrated by "inborn empathy". It is the ability to exhibit empathy and altruistic behaviour in response to facial expressions. Newborns react this way to their mother's facial expression of sadness or distress.

This serves to prove that empathy has very little to do with the feelings, experiences or sensations of the other (the empathee). Surely, the infant has no idea what it is like to feel sad and definitely not what it is like for his mother to feel sad. In this case, it is a complex reflexive reaction. Later on, empathy is still rather reflexive, the result of conditioning.


 


The Encyclopaedia Britannica quotes some fascinating research that support the model I propose:

"An extensive series of studies indicated that positive emotion feelings enhance empathy and altruism. It was shown by the American psychologist Alice M. Isen that relatively small favours or bits of good luck (like finding money in a coin telephone or getting an unexpected gift) induced positive emotion in people and that such emotion regularly increased the subjects' inclination to sympathize or provide help.

Several studies have demonstrated that positive emotion facilitates creative problem solving. One of these studies showed that positive emotion enabled subjects to name more uses for common objects. Another showed that positive emotion enhanced creative problem solving by enabling subjects to see relations among objects (and other people - SV) that would otherwise go unnoticed. A number of studies have demonstrated the beneficial effects of positive emotion on thinking, memory, and action in pre-school and older children."

If empathy increases with positive emotion, then it has little to do with the empathee (the recipient or object of empathy) and everything to do with the empathor (the person who does the empathizing).

Cold Empathy vs. Warm Empathy

Contrary to widely held views, Narcissists and Psychopaths may actually possess empathy. They may even be hyper-empathic, attuned to the minutest signals emitted by their victims and endowed with a penetrating "X-ray vision". They tend to abuse their empathic skills by employing them exclusively for personal gain, the extraction of narcissistic supply, or in the pursuit of antisocial and sadistic goals. They regard their ability to empathize as another weapon in their arsenal.

I suggest to label the narcissistic psychopath's version of empathy: "cold empathy", akin to the "cold emotions" felt by psychopaths. The cognitive element of empathy is there, but not so its emotional correlate. It is, consequently, a barren, cold, and cerebral kind of intrusive gaze, devoid of compassion and a feeling of affinity with one's fellow humans.

ADDENDUM - Interview granted to the National Post, Toronto, Canada, July 2003

Q. How important is empathy to proper psychological functioning?

A. Empathy is more important socially than it is psychologically. The absence of empathy - for instance in the Narcissistic and Antisocial personality disorders - predisposes people to exploit and abuse others. Empathy is the bedrock of our sense of morality. Arguably, aggressive behavior is as inhibited by empathy at least as much as it is by anticipated punishment.

But the existence of empathy in a person is also a sign of self-awareness, a healthy identity, a well-regulated sense of self-worth, and self-love (in the positive sense). Its absence denotes emotional and cognitive immaturity, an inability to love, to truly relate to others, to respect their boundaries and accept their needs, feelings, hopes, fears, choices, and preferences as autonomous entities.

Q. How is empathy developed?

A. It may be innate. Even toddlers seem to empathize with the pain - or happiness - of others (such as their caregivers). Empathy increases as the child forms a self-concept (identity). The more aware the infant is of his or her emotional states, the more he explores his limitations and capabilities - the more prone he is to projecting this new found knowledge unto others. By attributing to people around him his new gained insights about himself, the child develop a moral sense and inhibits his anti-social impulses. The development of empathy is, therefore, a part of the process of socialization.

But, as the American psychologist Carl Rogers taught us, empathy is also learned and inculcated. We are coached to feel guilt and pain when we inflict suffering on another person. Empathy is an attempt to avoid our own self-imposed agony by projecting it onto another.

Q. Is there an increasing dearth of empathy in society today? Why do you think so?

A. The social institutions that reified, propagated and administered empathy have imploded. The nuclear family, the closely-knit extended clan, the village, the neighborhood, the Church- have all unraveled. Society is atomized and anomic. The resulting alienation fostered a wave of antisocial behavior, both criminal and "legitimate". The survival value of empathy is on the decline. It is far wiser to be cunning, to cut corners, to deceive, and to abuse - than to be empathic. Empathy has largely dropped from the contemporary curriculum of socialization.

In a desperate attempt to cope with these inexorable processes, behaviors predicated on a lack of empathy have been pathologized and "medicalized". The sad truth is that narcissistic or antisocial conduct is both normative and rational. No amount of "diagnosis", "treatment", and medication can hide or reverse this fact. Ours is a cultural malaise which permeates every single cell and strand of the social fabric.


 


Q. Is there any empirical evidence we can point to of a decline in empathy?

Empathy cannot be measured directly - but only through proxies such as criminality, terrorism, charity, violence, antisocial behavior, related mental health disorders, or abuse.

Moreover, it is extremely difficult to separate the effects of deterrence from the effects of empathy.

If I don't batter my wife, torture animals, or steal - is it because I am empathetic or because I don't want to go to jail?

Rising litigiousness, zero tolerance, and skyrocketing rates of incarceration - as well as the ageing of the population - have sliced intimate partner violence and other forms of crime across the United States in the last decade. But this benevolent decline had nothing to do with increasing empathy.

The statistics are open to interpretation but it would be safe to say that the last century has been the most violent and least empathetic in human history. Wars and terrorism are on the rise, charity giving on the wane (measured as percentage of national wealth), welfare policies are being abolished, Darwinian models of capitalism are spreading. In the last two decades, mental health disorders were added to the Diagnostic and Statistical Manual of the American Psychiatric Association whose hallmark is the lack of empathy. The violence is reflected in our popular culture: movies, video games, and the media.

Empathy - supposedly a spontaneous reaction to the plight of our fellow humans - is now channeled through self-interested and bloated non-government organizations or multilateral outfits. The vibrant world of private empathy has been replaced by faceless state largesse. Pity, mercy, the elation of giving are tax-deductible. It is a sorry sight.

Click on this link to read a detailed analysis of empathy:

On Empathy

Other People's Pain - click on this link:

Narcissists Enjoy Other People's Pain

This article appears in my book, "Malignant Self Love - Narcissism Revisited"


 

next: Psychosis, Delusions, and Personality Disorders

APA Reference
Vaknin, S. (2009, October 2). Empathy and Personality Disorders, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/empathy-and-personality-disorders

Last Updated: July 5, 2018

The Narcissistic Patient - A Case Study

What are the traits of a narcissist? Read therapy session notes from man diagnosed with Narcissistic Personality Disorder (NPD).

Notes of first therapy session with Sam V., male, 43, diagnosed with Narcissistic Personality Disorder (NPD)

Sam presents with anhedonia (failure to enjoy or find pleasure in anything) and dysphoria bordering on depression. He complains of inability to tolerate people's stupidity and selfishness in a variety of settings. He admits that as a result of his "intellectual superiority" he is not well placed to interact with others or even to understand them and what they are going through. He is a recluse and fears that he is being mocked and ridiculed behind his back as a misfit and a freak. Throughout the first session, he frequently compares himself to a machine, a computer, or a member of an alien and advanced race, and talks about himself in the third person singular.

Life, bemoans Sam, has dealt him a bad hand. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves, but then fail to re-hire him as a consultant. He seems to attract hostility and animosity incommensurate with his good and generous deeds. He even describes being stalked by two or three vicious women whom he had spurned, he claims, not without pride in his own implied irresistibility. Yes, he is abrasive and contemptuous of others at times but only in the interests of "tough love." He is never obnoxious or gratuitously offensive.

Sam is convinced that people envy him and are "out to get him" (persecutory delusions). He feels that his work (he is also a writer) is not appreciated because of its elitist nature (high-brow vocabulary and such). He refuses to "dumb down". Instead, he is on a mission to educate his readers and clients and "bring them up to his level." When he describes his day, it becomes clear that he is desultory, indolent, and lacks self-discipline and regular working habits. He is fiercely independent (to the point of being counter-dependent - click on this link: The Inverted Narcissist ) and highly values his self-imputed "brutal honesty" and "original, non-herd, outside the box" thinking.

He is married but sexually inactive. Sex bores him and he regards it as a "low-level" activity practiced by "empty-headed" folk. He has better uses for his limited time. He is aware of his own mortality and conscious of his intellectual legacy. Hence his sense of entitlement. He never goes through established channels. Instead, he uses his connections to secure anything from medical care to car repair. He expects to be treated by the best but is reluctant to buy their services, holding himself to be their equal in his own field of activity. He gives little or no thought to the needs, wishes, fears, hopes, priorities, and choices of his nearest and dearest. He is startled and hurt when they become assertive and exercise their personal autonomy (for instance, by setting boundaries).

 

Sam is disarmingly self-aware and readily lists his weaknesses and faults - but only in order to preempt real scrutiny or to fish for compliments. He constantly brags about his achievements but feels deprived ("I deserve more, much more than that"). When any of his assertions or assumptions is challenged he condescendingly tries to prove his case. If he fails to convert his interlocutor, he sulks and even rages. He tends to idealize everyone or devalue them: people are either clever and good or stupid and malicious. But, everyone is a potential foe.

Sam is very hypervigilant and anxious. He expects the worst and feels vindicated and superior when he is punished ("martyred and victimized"). Sam rarely assumes total responsibility for his actions or accepts their consequences. He has an external locus of control and his defenses are alloplastic. In other words: he blames the world for his failures, defeats, and "bad luck". This "cosmic conspiracy" against him is why his grandiose projects keep flopping and why he is so frustrated.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

 


 

next: The Sadistic Patient ~ back to: Case Studies: Table of Contents

APA Reference
Vaknin, S. (2009, October 2). The Narcissistic Patient - A Case Study, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/narcissistic-patient-a-case-study

Last Updated: July 5, 2018

Misdiagnosing Personality Disorders as Eating Disorders

Comparison of eating disorders and personality disorders symptoms and why their similarities sometimes leads to a misdiagnosis.

The Eating Disordered Patient

Eating disorders - notably Anorexia Nervosa and Bulimia Nervosa - are complex phenomena. The patient with eating disorder maintains a distorted view of her body as too fat or as somehow defective (she may have a body dysmorphic disorder). Many patients with eating disorders are found in professions where body form and image are emphasized (e.g., ballet students, fashion models, actors).

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (pp. 584-5):

"(Patients with personality disorders exhibit) feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, perfectionism, and overly restrained initiative and emotional expression ... (Bulimics show a greater tendency to have) impulse-control problems, abuse alcohol or other drugs, exhibit mood lability, (have) a greater frequency of suicide attempts."

Eating Disorders and Self-control

The current view of orthodoxy is that the eating disordered patient is attempting to reassert control over her life by ritually regulating her food intake and her body weight. In this respect, eating disorders resemble obsessive-compulsive disorders.

One of the first scholars to have studied eating disorders, Bruch, described the patient's state of mind as "a struggle for control, for a sense of identity and effectiveness." (1962, 1974).

In Bulimia Nervosa, protracted episodes of fasting and purging (induced vomiting and the abuse of laxatives and diuretics) are precipitated by stress (usually fear of social situations akin to Social Phobia) and the breakdown of self-imposed dietary rules. Thus, eating disorders seem to be life-long attempts to relieve anxiety. Ironically, binging and purging render the patient even more anxious and provoke in her overwhelming self-loathing and guilt.

Eating disorders involve masochism. The patient tortures herself and inflicts on her body great harm by ascetically abstaining from food or by purging. Many patients cook elaborate meals for others and then refrain from consuming the dishes they had just prepared, perhaps as a sort of "self-punishment" or "spiritual purging."

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (p. 584) comments on the inner mental landscape of patients with eating disorders:

"Weight loss is viewed as an impressive achievement, a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control."

But the "eating disorder as an exercise in self-control" hypothesis may be overstated. If it were true, we would have expected eating disorders to be prevalent among minorities and the lower classes - people whose lives are controlled by others. Yet, the clinical picture is reversed: the vast majority of patients with eating disorders (90-95%) are white, young (mostly adolescent) women from the middle and upper classes. Eating disorders are rare among the lower and working classes, and among minorities, and non-Western societies and cultures.

Refusing to Grow Up

Other scholars believe that the patient with eating disorder refuses to grow up. By changing her body and stopping her menstruation (a condition known as amenorrhea), the patient regresses to childhood and avoids the challenges of adulthood (loneliness, interpersonal relationships, sex, holding a job, and childrearing).

Similarities with Personality Disorders

Patients with eating disorders maintain great secrecy about their condition, not unlike narcissists or paranoids, for instance. When they do attend psychotherapy it is usually owing to tangential problems: having been caught stealing food and other forms of antisocial behavior, such as rage attacks. Clinicians who are not trained to diagnose the subtle and deceptive signs and symptoms of eating disorders often misdiagnose them as personality disorders or as mood or affective or anxiety disorders.

Patients with eating disorders are emotionally labile, frequently suffer from depression, are socially withdrawn, lack sexual interest, and are irritable. Their self-esteem is low, their sense of self-worth fluctuating, they are perfectionists. The patient with eating disorder derives narcissistic supply from the praise she garners for having gone down in weight and the way she looks post-dieting. Small wonder eating disorders are often misdiagnosed as personality disorders: Borderline, Schizoid, Avoidant, Antisocial or Narcissistic.

Patients with eating disorders also resemble subjects with personality disorders in that they have primitive defense mechanisms, most notably splitting.

The Review of General Psychiatry (p. 356):

"Individuals with Anorexia Nervosa tend to view themselves in terms of absolute and polar opposites. Behavior is either all good or all bad; a decision is either completely right or completely wrong; one is either absolutely in control or totally out of control."

 


 


They are unable to differentiate their feelings and needs from those of others, adds the author.

To add confusion, both types of patients - with eating disorders and personality disorders - share an identically dysfunctional family background. Munchin et al. described it thus (1978): "enmeshment, over-protectiveness, rigidity, lack of conflict resolution."

Both types of patients are reluctant to seek help.

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (pp. 584-5):

"Individuals with Anorexia Nervosa frequently lack insight into or have considerable denial of the problem ... A substantial portion of individuals with Anorexia Nervosa have a personality disturbance that meets criteria for at least one Personality Disorder."

In clinical practice, co-morbidity of an eating disorder and a personality disorder is a common occurrence. About 20% of all Anorexia Nervosa patients are diagnosed with one or more personality disorders (mainly Cluster C - Avoidant, Dependent, Compulsive-Obsessive - but also Cluster A - Schizoid and Paranoid).

A whopping 40% of Anorexia Nervosa/Bulimia Nervosa patients have co-morbid personality disorders (mostly Cluster B - Narcissistic, Histrionic, Antisocial, Borderline). Pure bulimics tend to have Borderline Personality Disorder. Binge eating is included in the impulsive behavior criterion for Borderline Personality Disorder.

Such rampant comorbidity raises the question whether eating disorders are not actually behavioral manifestations of underlying personality disorders.

Additional resources

Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR) - Washington DC, The American Psychiatric Association, 2000

Goldman, Howard G. - Review of General Psychiatry, 4th ed. - London, Prentice-Hall International, 1995

Gelder, Michael et al., eds. - Oxford Textbook of Psychiatry, 3rd ed. - London, Oxford University Press, 2000

Vaknin, Sam - Malignant Self Love - Narcissism Revisited, 8th revised impression - Skopje and Prague, Narcissus Publications, 2006

This article appears in my book, "Malignant Self Love - Narcissism Revisited"


 

next: Empathy and Personality Disorders

APA Reference
Vaknin, S. (2009, October 2). Misdiagnosing Personality Disorders as Eating Disorders, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/misdiagnosing-personality-disorders-as-eating-disorders

Last Updated: July 5, 2018

Misdiagnosing Personality Disorders as Anxiety Disorders

Certain symptoms of anxiety disorders resemble those of people with personality disorders - which can sometimes lead to a misdiagnosis.

What is Anxiety?

Anxiety is uncontrollable and excessive apprehension, a kind of unpleasant (dysphoric), mild fear, with no apparent external reason. Anxiety is dread in anticipation of a future menace or an imminent but diffuse and unspecified danger, usually imagined or exaggerated. The mental state of anxiety (and the concomitant hypervigilance) has physiological complements. It is accompanied by short-term dysphoria and physical symptoms of stress and tension, such as sweating, palpitations, tachycardia, hyperventilation, angina, tensed muscle tone, and elevated blood pressure (arousal). It is common for anxiety disorders to include obsessive thoughts, compulsive and ritualistic acts, restlessness, fatigue, irritability, and difficulty concentrating.

Personality Disorders and Anxiety

Patients with personality disorders are often anxious. Narcissists, for instance, are preoccupied with the need to secure social approval or attention (Narcissistic Supply). The narcissist cannot control this need and the attendant anxiety because he requires external feedback to regulate his labile sense of self-worth. This dependence makes most narcissists irritable. They fly into rages and have a very low threshold of frustration.

Subjects suffering from certain personality disorders (e.g., Histrionic, Borderline, Narcissistic, Avoidant, Schizotypal) resemble patients who suffer from Panic Attacks and Social Phobia (another anxiety disorder). They are terrified of being embarrassed or criticized in public. Consequently, they fail to function well in various settings (social, occupational, interpersonal, etc.).

Narcissism, Obsession-Compulsion, and Anxiety

The personality disordered often develop obsessions and compulsions. Like sufferers of anxiety disorders, narcissists and compulsive-obsessives, for instance, are perfectionists and preoccupied with the quality of their performance and the level of their competence. As the Diagnostic and Statistical Manual (DSM-IV-TR, p. 473) puts it, GAD (Generalized Anxiety Disorder) patients (especially children):

"... (A)re typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries."

This could apply equally well to subjects with the Narcissistic or the Obsessive-Compulsive Personality Disorder. Both classes of patients - those suffering from anxiety disorders and those tormented by personality disorders - are paralyzed by the fear of being judged as imperfect or lacking. Narcissists as well as patients with anxiety disorders constantly fail to measure up to an inner, harsh, and sadistic critic and a grandiose, inflated self-image.

From my book "Malignant Self Love - Narcissism Revisited"

"The narcissistic solution is to avoid comparison and competition altogether and to demand special treatment. The narcissist's sense of entitlement is incommensurate with the narcissist's true accomplishments. He withdraws from the rat race because he does not deem his opponents, colleagues, or peers worthy of his efforts.

As opposed to narcissists, patients with Anxiety Disorders are invested in their work and their profession. To be exact, they are over-invested. Their preoccupation with perfection is counter-productive and, ironically, renders them underachievers.

It is easy to mistake the presenting symptoms of certain anxiety disorders with pathological narcissism. Both types of patients are worried about social approbation and seek it actively. Both present a haughty or impervious facade to the world. Both are dysfunctional and weighed down by a history of personal failure on the job and in the family. But the narcissist is ego-syntonic: he is proud and happy of who he is. The anxious patient is distressed and is looking for help and a way out of his or her predicament. Hence the differential diagnosis."

Bibliography

Goldman, Howard G. - Review of General Psychiatry, 4th ed. - London, Prentice-Hall International, 1995 - pp. 279-282

Gelder, Michael et al., eds. - Oxford Textbook of Psychiatry, 3rd ed. - London, Oxford University Press, 2000 - pp. 160-169

Klein, Melanie - The Writings of Melanie Klein - Ed. Roger Money-Kyrle - 4 vols. - New York, Free Press - 1964-75

Kernberg O. - Borderline Conditions and Pathological Narcissism - New York, Jason Aronson, 1975

Millon, Theodore (and Roger D. Davis, contributor) - Disorders of Personality: DSM IV and Beyond - 2nd ed. - New York, John Wiley and Sons, 1995

Millon, Theodore - Personality Disorders in Modern Life - New York, John Wiley and Sons, 2000

Schwartz, Lester - Narcissistic Personality Disorders - A Clinical Discussion - Journal of Am. Psychoanalytic Association - 22 (1974): 292-305

Vaknin, Sam - Malignant Self Love - Narcissism Revisited, 8th revised impression - Skopje and Prague, Narcissus Publications, 2006

This article appears in my book, "Malignant Self Love - Narcissism Revisited"


 

next: Misdiagnosing Personality Disorders as Eating Disorders

APA Reference
Vaknin, S. (2009, October 2). Misdiagnosing Personality Disorders as Anxiety Disorders, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/misdiagnosing-personality-disorders-as-anxiety-disorders

Last Updated: July 5, 2018

Reforming the Abuser

Trying to get your abuser to stop the physical, emotional or psychological abuse can be dangerous. Discover why?

How to get your abuser to see reason in the first place? How to obtain for him the help he needs - without involving law enforcement agencies, the authorities, or the courts? Any attempt to broach the subject of the abuser's mental problems frequently ends in harangues and worse. It is positively dangerous to mention the abuser's shortcomings or imperfections to his face.

As I wrote elsewhere, "Abuse is a multifaceted phenomenon. It is a poisonous cocktail of control-freakery, conforming to social and cultural norms, and latent sadism. The abuser seeks to subjugate his victims and 'look good' or 'save face' in front of family and peers. Many abusers also enjoy inflicting pain on helpless victims."

Hence the complexity of trying to prevent or control the abuser's behavior. His family, friends, peers, co-workers, and neighbors - normally, levers of social control and behavior modification - condone his misbehavior. The abuser seeks to conform to norms and standards prevalent in his milieu, even if only implicitly. He regards himself as normal, definitely not in need of therapeutic intervention.

Thus, the complaints of a victim are likely to be met with hostility and suspicion by the offender's parents or siblings, for instance. Instead of reining in the abusive conduct, they are likely to pathologize the victim ("she is a nutcase") or label her ("she is a whore or a bitch").

 

Nor is the victim of abuse likely to fare better in the hands of law enforcement agencies, the courts, counselors, therapists, and guardians ad litem. The propensity of these institutions is to assume that the abused has a hidden agenda - to abscond with her husband's property, or to deny him custody or visitation rights. Read more about it here.

Abuse remains, therefore, the private preserve of the predator and his prey. It is up to them to write their own rules and to implement them. No outside intervention is forthcoming or effective. Indeed, the delineation of boundaries and reaching an agreement on co-existence are the first important steps towards minimizing abuse in your relationships. Such a compact must include a provision obliging your abuser to seek professional help for his mental health problems.

Personal boundaries are not negotiable, neither can they be determined from the outside. Your abusive bully should have no say in setting them or in upholding them. Only you decide when they have been breached, what constitutes a transgression, what is excusable and what not.

The abuser is constantly on the lookout for a weakening of your resolve. He is repeatedly testing your mettle and resilience. He pounces on any and every vulnerability, uncertainty, or hesitation. Don't give him these chances. Be decisive and know yourself: what do you really feel? What are your wishes and desires in the short and longer terms? What price are you willing to pay and what sacrifices are you ready to make in order to be you? What behaviors will you accept and where does your red line run?

Verbalize your emotions, needs, preferences, and choices without aggression but with assertiveness and determination. Some abusers - the narcissistic ones - are detached from reality. They avoid it actively and live in fantasies of everlasting and unconditional love. They refuse to accept the inevitable consequences of their own actions. It is up to you to correct these cognitive and emotional deficits. You may encounter opposition - even violence - but, in the long-run, facing reality pays.

Play it fair. Make a list - if need be, in writing - of do's and don'ts. Create a "tariff" of sanctions and rewards. Let him know what actions of his - or inaction on his part - will trigger a dissolution of the relationship. Be unambiguous and unequivocal about it. And mean what you say. Again, showing up for counseling must be a cardinal condition.

Yet, even these simple, non-threatening initial steps are likely to provoke your abusive partner. Abusers are narcissistic and possessed of alloplastic defenses. More simply put, they feel superior, entitled, above any law and agreement, and innocent. Others - usually the victims - are to blame for the abusive conduct ("see what you made me do?").

How can one negotiate with such a person without incurring his wrath? What is the meaning of contracts "signed" with bullies? How can one motivate the abuser to keep his end of the bargain - for instance, to actually seek therapy and attend the sessions? And how efficacious is psychotherapy or counseling to start with?

These are the topics of our next article.

 


 

next: Contracting with Your Abuser

APA Reference
Vaknin, S. (2009, October 2). Reforming the Abuser, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/reforming-the-abuser

Last Updated: July 5, 2018

Contracting with Your Abuser

Here's a practical guide on how to drag your abuser into treatment and into a contract of mutual respect.

How can one negotiate with an abuser without incurring his wrath? What is the meaning of contracts "signed" with bullies? How can one motivate the abuser to keep his end of the bargain - for instance, to actually seek therapy and attend the sessions? And how efficacious is psychotherapy or counseling to start with?

It is useless to confront the abuser head on and to engage in power politics ("You are guilty or wrong, I am the victim and right", "My will should prevail", and so on). It is decidedly counterproductive and unhelpful and could lead to rage attacks and a deepening of the abuser's persecutory delusions, bred by his humiliation in the therapeutic setting. Better, at first, to co-opt the abuser's own prejudices and pathology by catering to his infantile emotional needs and complying with his wishes, complex rules and arbitrary rituals.

Here's a practical guide on  how to drag your abuser into treatment and into a contract of mutual respect and cessation of hostilities (assuming, of course, you want to preserve the relationship):

1. Tell him that you love him and emphasize the exclusivity of your relationship by refraining, initially and during the therapy, from anxiety-provoking acts. Limiting your autonomy is a temporary sacrifice - under no circumstances make it a permanent feature of your relationship. Demonstrate to the abuser that his distrust of you is misplaced and undeserved and that one of the aims of the treatment regimen is to teach him to control and reduce his pathological and delusional jealousy.

2. Define areas of your common life that the abuser can safely - and without infringing on your independence - utterly control. Abusers need to feel that they are in charge, sole decision-makers and arbiters.

3. Ask him to define - preferably in writing - what he expects from you and where he thinks that you, or your "performance" are "deficient". Try to accommodate his reasonable demands and ignore the rest. Do not, at this stage, present a counter-list. This will come later. To move him to attend couples or marital therapy, tell him that you need his help to restore your relationship to its former warmth and intimacy. Admit to faults of your own which you want "fixed" so as to be a better mate. Appeal to his narcissism and self-image as the omnipotent and omniscient macho. Humor him for a while.

 

4. Involve your abuser, as much as you can, in your life. Take him to meet your family, ask him to join in with your friends, to visit your workplace, to help maintain your car (a symbol of your independence), to advise you on money matters and career steps. Do not hand over control to him over any of these areas - but get him to feel a part of your life and try to mitigate his envy and insecurity.

5. Encourage him to assume responsibility for the positive things in his life and in your relationship. Compliment the beneficial outcomes of his skills, talents, hard work, and attitude. Gradually, he will let go of his alloplastic defenses - his tendency to blame every mistake of his, every failure, or mishap on others, or on the world at large.

6. Make him own up to his feelings by identifying them. Most abusers are divorced from their emotions. They seek to explain their inner turmoil by resorting to outside agents ("Look what you made me do" or "They provoked me"). They are unaware of their anger, envy, or aggression. Mirror your abuser gently and unobtrusively ("How do you feel about it?", "When I am angry I act the same", "Would you be happier if I didn't do it?").

7. Avoid the appearance - or the practice - of manipulating your abuser (except if you want to get rid of him). Abusers are very sensitive to control issues and they feel threatened, exploited, and ill-treated when manipulated. They invariably react with violence.

8. Treat your abuser as you would like him to behave towards you. Personal example is a powerful proselytizer. Don't act out of fear or subservience. Be sincere. Act out of love and conviction. Finally, your conduct is bound to infiltrate the abuser's defences.

9. React forcefully, unambiguously, and instantly to any use of force. Make clear where the boundary of civilized exchange lies. Punish him severely and mercilessly if he crosses it. Make known well in advance the rules of your relationship - rewards and sanctions included. Discipline him for verbal and emotional abuse as well - though less strenuously. Create a hierarchy of transgressions and a penal code to go with it.

Read these for further guidance:

10. As the therapy continues and progress is evident, try to fray the rigid edges of your sex roles. Most abusers are very much into "me Tarzan, you Jane" gender-casting. Show him his feminine sides and make him proud of them. Gradually introduce him to your masculine traits, or skills - and make him proud of you.

This, essentially, is what good therapists do in trying to roll back or limit the offender's pathology.

From "Treatment Modalities and Therapies":

"Most therapists try to co-opt the narcissistic abuser's inflated ego (False Self) and defences. They compliment the narcissist, challenging him to prove his omnipotence by overcoming his disorder. They appeal to his quest for perfection, brilliance, and eternal love - and his paranoid tendencies - in an attempt to get rid of counterproductive, self-defeating, and dysfunctional behaviour patterns.

By stroking the narcissist's grandiosity, they hope to modify or counter cognitive deficits, thinking errors, and the narcissist's victim-stance. They contract with the narcissist to alter his conduct. Some even go to the extent of medicalizing the disorder, attributing it to a hereditary or biochemical origin and thus 'absolving' the narcissist from guilt and responsibility and freeing his mental resources to concentrate on the therapy."

But is therapy worth the effort? What is the success rate of various treatment modalities in modifying the abuser's conduct, let alone in "healing" or "curing" him?

These are the topics of our next article.

 


 

next: Your Abuser in Therapy

APA Reference
Vaknin, S. (2009, October 2). Contracting with Your Abuser, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/contracting-with-your-abuser

Last Updated: July 5, 2018

Your Abuser in Therapy

Most court-ordered therapy programs don't help the domestic violence abuser change his abusive behaviors. Is there treatment for the abuser that works?

Your abuser "agrees" (is forced) to attend therapy. But are the sessions worth the effort? What is the success rate of various treatment modalities in modifying the abuser's conduct, let alone in "healing" or "curing" him? Is psychotherapy the panacea it is often made out to be - or a nostrum, as many victims of abuse claim? And why is it applied only after the fact - and not as a preventive measure?

Courts regularly send offenders to be treated as a condition for reducing their sentences. Yet, most of the programs are laughably short (between 6 to 32 weeks) and involve group therapy - which is useless with abusers who are also narcissists or psychopaths.

Rather than cure him, such workshops seek to "educate" and "reform" the culprit, often by introducing him to the victim's point of view. This is supposed to inculcate in the offender empathy and to rid the habitual batterer of the residues of patriarchal prejudice and control freakery. Abusers are encouraged to examine gender roles in modern society and, by implication, ask themselves if battering one's spouse was proof of virility.

Anger management - made famous by the eponymous film - is a relatively late newcomer, though currently it is all the rage. Offenders are taught to identify the hidden - and real - causes of their rage and learn techniques to control or channel it.

But batterers are not a homogeneous lot. Sending all of them to the same type of treatment is bound to end up in recidivism. Neither are judges qualified to decide whether a specific abuser requires treatment or can benefit from it. The variety is so great that it is safe to say that - although they share the same misbehavior patterns - no two abusers are alike.

In their article, "A Comparison of Impulsive and Instrumental Subgroups of Batterers", Roger Tweed and Donald Dutton of the Department of Psychology of the University of British Columbia, rely on the current typology of offenders which classifies them as:

"... Overcontrolled-dependent, impulsive-borderline (also called 'dysphoric-borderline' - SV) and instrumental-antisocial. The overcontrolled-dependent differ qualitatively from the other two expressive or 'undercontrolled' groups in that their violence is, by definition, less frequent and they exhibit less florid psychopathology. (Holtzworth-Munroe & Stuart 1994, Hamberger & hastings 1985) ... Hamberger & Hastings (1985,1986) factor analyzed the Millon Clinical Multiaxial Inventory for batterers, yielding three factors which they labeled 'schizoid/borderline' (cf. Impulsive), 'narcissistic/antisocial' (instrumental), and 'passive/dependent/compulsive' (overcontrolled)... Men, high only on the impulsive factor, were described as withdrawn, asocial, moody, hypersensitive to perceived slights, volatile and over-reactive, calm and controlled one moment and extremely angry and oppressive the next - a type of 'Jekyll and Hyde' personality. The associated DSM-III diagnosis was Borderline Personality. Men high only on the instrumental factor exhibited narcissistic entitlement and psychopathic manipulativeness. Hesitation by others to respond to their demands produced threats and aggression ..."

But there are other, equally enlightening, typologies (mentioned by the authors). Saunders suggested 13 dimensions of abuser psychology, clustered in three behavior patterns: Family Only, Emotionally Volatile, and Generally Violent. Consider these disparities: one quarter of his sample - those victimized in childhood - showed no signs of depression or anger! At the other end of the spectrum, one of every six abusers was violent only in the confines of the family and suffered from high levels of dysphoria and rage.

Impulsive batterers abuse only their family members. Their favorite forms of mistreatment are sexual and psychological. They are dysphoric, emotionally labile, asocial, and, usually, substance abusers. Instrumental abusers are violent both at home and outside it - but only when they want to get something done. They are goal-orientated, avoid intimacy, and treat people as objects or instruments of gratification.

Still, as Dutton pointed out in a series of acclaimed studies, the "abusive personality" is characterized by a low level of organization, abandonment anxiety (even when it is denied by the abuser), elevated levels of anger, and trauma symptoms.

It is clear that each abuser requires individual psychotherapy, tailored to his specific needs - on top of the usual group therapy and marital (or couple) therapy. At the very least, every offender should be required to undergo these tests to provide a complete picture of his personality and the roots of his unbridled aggression:

  1. The Relationship Styles Questionnaire (RSQ)
  2. Millon Clinical Multiaxial Inventory-III (MCMI-III)
  3. Conflict Tactics Scale (CTS)
  4. Multidimensional Anger Inventory (MAI)
  5. Borderline Personality Organization Scale (BPO)
  6. The Narcissistic Personality Inventory (NPI)

These tests are the topic of our next article.


 

next: Testing the Abuser

APA Reference
Vaknin, S. (2009, October 2). Your Abuser in Therapy, HealthyPlace. Retrieved on 2024, October 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/your-abuser-in-therapy

Last Updated: July 5, 2018