Grandiose Narcissism and Depression…

Friday, November 17, 2023.

In this post, I want to discuss Grandiose Narcissism and a potential new treatment from Germany that might indicate a fresh new approach for depressed grandiose narcissists.

We’ve known for some time that Grandiose Narcissism is characterized by two separate and discrete self-regulating processes:

• The Need for Rivalry. I must vanquish my perceived enemies. It is not enough that I win, the others must lose.

• The Need for Admiration and Significance. I must be respected, admired, and looked up to. Some see this as a process which is inherently more social.

Anecdotal evidence by clinicians over the years has created a clinical folklore that believes that narcissistic clients do better with a healthy focus on the quality of the therapeutic relationship.

Here’s some interesting new research about how narcissists tend to respond poorly to cognitive-behavioral therapy (CBT), long considered the gold standard for treating clinical depression.

• The problem is that crushed and defeated narcissists tend to be hostile humans, rendering depression more challenging and resistant to treatment.

• In other words, the personality trait of narcissism itself is an impediment to treating depression, according to this new study.

• Here’s what I found fascinating given the solipsistic age we live in…Even humans who are simply high in narcissism, without having a narcissistic personality disorder, tend to respond poorly to talk therapy for depression.

Why is the narcissist so fu*king hostile? Because they believe that’s what it takes to maintain their social status, and grandiose view of themselves.

The concept of Narcissistic Rivalry

This was a study that included over 2,000 humans in Germany. They were all in psychotherapy for depression.

The findings suggested that humans on the high side of the continuum for narcissistic rivalry tended to be more depressed.

What is Narcissistic Rivalry?

Narcissistic rivalry is a top-line, go-to behavior in which narcissists seek to maintain their social status. They often seek to do this by attacking and putting down others.

• Humans who are prone to narcissistic rivalry tend to be aggressive in pursuing their goals.

• It’s not enough that they should win, others must be humbled, and lose….

My “colleague” owns a huge group practice, and knew that her blog post would be read by high-value, potential clients who tend to read both of our blogs.

But because she has lower self-esteem, she tends to feel more annoyed…more often, and, not surprisingly, has higher levels of ongoing conflict with other clinicians and thought leaders.

On the other hand, narcissistic humans high in the need for admiration had less severe depression symptoms before treatment...

This type of narcissist relies on shameless self-promotion to defend their social and professional status.

When it came to treatment for depression, though, narcissism was a significant impediment either way, explained Ms. Maike Richter, the study’s first author:

“In the group of patients treated with cognitive behavioral therapy, narcissism was associated with a poorer response to treatment, even when a narcissistic personality disorder was not fully developed.”

The reason, explained Dr. Nils Opel, another study co-author, was a lousy therapeutic relationship:

“We found evidence that the negative effects of narcissism are based on a weaker therapeutic relationship.”

• Wow. That plays directly into what the common factors advocates say about effective therapy!

• If humans are hostile during the therapy process, it’s pretty difficult to promote any sort of useful insight.

• But the problem remains… the world is teeming with narcissistic rivals!

• Is there a better therapy emerging for our teeming hordes of depressed narcissists?

• Perhaps.. enter PIT from Germany.

Comparing CBT and PIT…How the study was conducted

• One cohort of humans in the study had their depression treated with Cognitive Behavioral Therapy CBT, and another group was treated with a type of treatment common in Germany, but less well-known in the rest of the world, Psychoanalytic-Interactional Therapy (PIT)

• PIT is a psychodynamic therapy that was developed for assholes, …that is to say, humans who have serial difficulties with many of their interpersonal relationships.

• The strategic sleight of hand with PIT is that the therapist is endeavoring to help the client-patient perceive the collateral damage of their decisions and behavior… and how it is affecting others while confronting them more obliquely than directly about it.

Here’s what’s interesting about PIT as opposed to CBT. It doesn’t work by noticing your own thoughts, like CBT, but by improving the ability to understand the reactions and responses of other humans.

What I found most intriguing was how narcissistic clients in the PIT cohort responded just as well to the therapy as those humans who were measurably low in narcissism!

• It sort of looks like, when being treated for depression, the narcissistic client had a better therapeutic bond when they used PIT compared with CBT.

• This makes sense given that psychodynamic therapies as a whole tend to focus more on the therapeutic alliance — the relationship between patient and therapist — as compared with CBT, which subordinates that dimension to a consistent protocol.

I admire this research as an interesting line of inquiry.

• But I’m also wondering if PIT, as a form of therapy, is working better for “narcissists” because it focuses on the theory of mind.

• I know from working with the neurodiverse that, as a population, they are often conflated with those humans who have a personality disorder in both therapy and research.

I’m going to want to learn more about PIT, and I'm curious about the possibility of a hidden neurodiverse cohort, perhaps present in both groups.

Be well, stay kind, and Godspeed.

RESEARCH:

Leichsenring, Falk, et al. “Psychoanalytic-Interactional Therapy versus Psychodynamic Therapy by Experts for Personality Disorders: A Randomized Controlled Efficacy-Effectiveness Study in Cluster B Personality Disorders.” Psychotherapy and Psychosomatics, vol. 85, no. 2, 2016, pp. 71–80. JSTOR, https://www.jstor.org/stable/48516665. Accessed 18 Nov. 2023.

Richter M, Mota S, Hater L, Bratek R, Goltermann J, Barkhau C, Gruber M, Repple J, Storck M, Blitz R, Grotegerd D, Masuhr O, Jaeger U, Baune BT, Dugas M, Walter M, Dannlowski U, Buhlmann U, Back M, Opel N. Narcissistic dimensions and depressive symptoms in patients across mental disorders in cognitive behavioural therapy and in psychoanalytic interactional therapy in Germany: a prospective cohort study. Lancet Psychiatry. 2023 Oct 13:S2215-0366(23)00293-6. doi: 10.1016/S2215-0366(23)00293-6. Epub ahead of print. PMID: 37844592.