In my previous post on narcissism, I introduced Josh Miller, Ph.D.—Professor of Psychology at the University of Georgia, and an expert on narcissism—who graciously accepted my request to interview him. I asked him a variety of questions about the popularity of narcissism, grandiose narcissism and its relation with , the relation between and narcissism, and more. In today’s post, I present the second part of my Q&A.

Emamzadeh: What does the label pathological narcissism mean? Does it refer to a form of narcissism that meets the criteria for (i.e., is associated with dysfunction and impairment)? If so, is there such a thing as adaptive or healthy narcissism?

Miller: I don’t know to be honest, as it isn’t a term I use myself. I would surmise it is meant to indicate narcissism that is more broadly associated with distress and impairment and that it signifies a larger-scale breakdown in the self-regulating processes associated with narcissism.1 I dislike the notion that there are different kinds of narcissism—pathological vs. adaptive or healthy—as I believe these distinctions confound issues of different presentations in terms of grandiose vs. vulnerable narcissism and issues related to severity. One can be more or less severely disordered on either dimension of narcissism or a combination. Healthy narcissism, if it exists, would probably mean one is mostly a little elevated on grandiose narcissism but not so much to be suffering impairment in important functional domains (e. ., romance; work). On the other hand, vulnerable narcissism would never be mistaken for “healthy” in that it comprises substantial and pervasive negative affectivity and lower self-esteem and thus is largely synonymous with the distress criterion that is a critical aspect of mental disorders.

Emamzadeh: Okay, I would like to switch topics a little and ask you about intentionality in narcissism. A classmate once joked: “When a person says, ‘You don’t care about me at all,’ we assume it is the disease talking; when a narcissist says the same, we assume the message is a calculated and malicious attempt at manipulation.” Do you believe there is a fundamental difference, in terms of the intentionality of behavior, between disorder and other mental health conditions (including other )?

Miller: This is speculative but my own take would be that we have no good evidence to suggest that one is more or less intentional or premeditated than the other in terms of those behaviors. I would argue that depressed and narcissistic individuals could make such statements out of a genuine perception that an important other doesn’t care about them as well as making such statements to get a rise out of that same person so as to get more of what’s needed (e.g., , support, etc.).

Emamzadeh: Interesting. How about self-awareness in narcissism? I have observed that sometimes, such as when a narcissistic person’s competitiveness or desire for power is stimulated, or during episodes of narcissistic rage, he or she may behave in ways that damage even those this individual appears to value highly. In your opinion, how much insight and awareness do people with high clinical levels of narcissism have into how their behavior affects others?

Miller: The clinical lore has long been that individuals with personality disorders don’t have a great deal of insight into themselves. Some of our work and others' has questioned that, however, by showing that self-reports of narcissism, psychopathy, and other pathological traits converge reasonably well with informant reports. In fact, they converge with informant reports to the same degree that one finds for normal personality traits like , , and . And, when they don’t converge very well the lack of convergence may represent disagreement rather than a lack of knowledge. That is, if you frame questions in what’s called a meta-perception format instead (self-report: I believe I deserve special treatment; meta-perception: Others think I believe I deserve special treatment), you often get higher agreement with informants. This higher agreement may mean that narcissistic individuals know how they are seen by others but may simply disagree with that person’s evaluation. Other work suggests that narcissistic individuals have nuanced perceptions of themselves such that they understand that their self-perception is more positive than others’ perceptions of them, that others tend to think less highly of them over time, and that they have some awareness that their antagonistic traits (e.g., grandiosity, callousness, entitlement) cause them some impairment.

This is not to deny that narcissistic individuals cause others pain and suffering, including those who they may even value and like (e.g., romantic partners; friends; family members), as they often do. Instead, I might argue that these behaviors may not stem from a lack of insight entirely but rather the affective and behavioral reactivity that can follow perceived ego threat, the importance of status, hierarchy, and dominance to narcissistic individuals, and a general decreased to others that makes these behaviors more likely.

Emamzadeh: Well, that certainly paints a more complex picture of narcissists. Of course, whatever the , narcissistic behavior is not conducive to good relationships. In clinical literature, narcissism has been linked with significant impairment (e.g., in romantic and work relationships). Even trait narcissism is linked with a “self-centered, selfish, and exploitative approach to interpersonal relationships, including game-playing, , a lack of empathy, and even violence” (p. 171).2 So what are the latest therapeutic options for treating narcissism? Can narcissism be treated successfully using ?

Source: Photo by courtesy of Dr. Josh Miller

Miller: Unfortunately, there are no empirically supported treatments for narcissism at this time—so what follows is speculative in nature. Overall, it is relatively less likely that one is going to see many “pure” cases of grandiose narcissism in clinical settings, unless it is court-mandated. That means that the narcissistic individuals most likely to be seen in clinical settings are going to have more vulnerably narcissistic presentations (e.g., depressed, , egocentric, distrustful, sense of entitlement). Given that vulnerable narcissism overlaps tremendously with (BPD), it is possible that some of the empirically supported treatments for BPD could work for the former (e.g., or DBT; schema-focused therapy). In general, I think one should expect that significant improvement would require a relatively prolonged form of therapy given the importance and challenges of developing rapport with narcissistic patients.3 It is my own opinion that individuals with disorders of a more externalizing nature (e.g., are impaired but not necessarily distressed) may benefit from a focus on what they’ve lost as a result of the disorder as a way to motivate change. That is, I’m not sure how easy it is to teach and change ability but I think patients can recognize, for instance, that their narcissistic traits have negatively impacted their status and performance at work and learn new strategies to diminish the behaviors that have caused these outcomes at work, which they do care about (e.g., not getting a promotion). In our new book on Antagonism4 (Miller & Lynam, 2019), which we see as core to narcissism and psychopathy, Don Lynam and I were fortunate to get several scholars to write about how one might make changes in such a domain from various perspectives, including , , , and DBT.

Emamzadeh: Many of us in relationships with narcissists find their exploitativeness, , and lack of empathy difficult to tolerate. So my last question concerns practical advice on how to deal with narcissistic people. For those of us who have highly narcissistic family members, relatives, romantic partners, coworkers, or colleagues, could you offer any suggestions or resources (articles, books, support groups, etc.) on how to manage these relationships?

Miller: I can’t offer much advice that is empirically based, unfortunately. One option is to limit one’s interactions where possible (e.g., try not to date or marry narcissistic individuals; limit interactions with narcissistic co-workers when feasible). This, of course, doesn’t help those who have little say in such relations (e.g., have a narcissistic parent, child, or boss). Some suggest not challenging narcissistic individuals in ways that will threaten their ego and thus increase the likelihood that they react with anger or . Of course, this strategy has difficulties too in that it may require a level of cautiousness or subservience that may not work well in long-term, intimate relations. Another approach is to give the narcissistic individual some clear and explicit feedback as to how his/her behavior affects oneself and set firm boundaries (again—when possible) regarding expectations for interpersonal interactions. For instance, a romantic partner could explain to her/his more narcissistic partner that it is upsetting that 30 minutes are spent each day talking about the narcissistic partner’s day with no reciprocity for the other partner. If this strategy doesn’t yield change, the non-narcissistic partner may explain that he/she will no longer engage in such discussions until they have a more bidirectional quality. This, again, may not be feasible in situations where the narcissistic person is threatening or has a history of violence that may make such limit-setting difficult and dangerous.

Emamzadeh: Thank you very much for your time and insights, Dr. Miller. I really appreciate it.

Miller: Thanks for asking such great and pressing questions!