Shame is Pride’s Cloke. A Gestalt understanding of narcissism.

Thesis: Introduction

If the fool would persist in his folly he would become wise.
Folly is the cloke of knavery.
Shame is pride's cloke.

Purpose

This thesis will develop a Gestalt understanding of narcissistic behaviour and experience and the psychotherapeutic treatment of narcissistic patients, building on Gary Yontef's work in this area. Various contributions to theoretical understanding and clinical treatment will be examined, principally from the D.S.M. IV and from psychoanalysts such as Mancia, Symington, Kohut, Kernberg and Hamilton. Consideration will be given as to how much can be integrated from the medical model of psychological distress and from the psychoanalysts into a Gestalt understanding of and approach to narcissistic patients.

Plan

Section One will briefly relate the myth of Narcissus.

Section Two will briefly describe the roots of Gestalt Psychotherapy and go on to examine the therapeutic relationship therein, making particular reference to dialogue, the I-Thou attitude and the I-Thou moment, presence, contact, awareness, confirmation, inclusion, authenticity, the phenomenological method, transference and counter-transference.

Section Three will begin to describe a Gestalt understanding of narcissistic styles of relating and experiencing and will touch upon Carl Hodges' Field Theory and the choice of language which Gestalt psychotherapists may use in describing narcissistic behaviour and experience. Yontef's advocacy of Gestalt psychotherapist's learning from 'the distilled wisdom of the fie1d' (1993) whilst also remaining committed to dialogue and the phenomenological method is stated.

Section Four will describe the range of narcissistic experience, from primary and healthy narcissism (subsection one), to narcissistic traits and style (subsection two), to Narcissistic Personality Disorder, as described in the D.S.M. 1V (subsection three). The 'distilled wisdom' to which Yontef refers will be drawn upon in this section, particular reference being made to Freud (1914) and Johnson (1987). At the end of each subsection, the Gestalt understanding of the narcissistic experience will be described.

Section Five will examine Yontef's contribution to a Gestalt understanding of narcissistic experience and the treatment of narcissistic patients.

Section Six will examine various psychoanalytic contributions: Mancia (1993), Symington (1993), Kohut (1971), Kernberg (1975) and Hamilton (1982). At the end of each subsection the possibility of an integration of the contribution into Gestalt Psychotherapeutic understanding and practice will be considered.

Section Seven will be a conclusion, which summarises the main points of the dissertation.

Section One: The Myth of Narcissus

The original story of Narcissus was first recorded by Ovid at the beginning of the First Century in Metamorphoses; such is its psychological power that it has been frequently reinterpreted in literature and song over the centuries. Scenes from the story, especially the reflection episode, have often been visually depicted, the painting by Salvador Dali being a well-known modern example. From Freud (1914) onwards, the story has fascinated and continues to fascinate psychotherapists, including Jungians (e.g. Schwartz-Salant, 1982) Psychoanalysts (e.g. Kohut, 1971, Kernberg, 1975, Mollon, 1993, Symington, 1993) and Humanistic Practitioners (e.g. Johnson, 1987, Yontef, 1993). Even within the D.S.M. IV, Narcissus gets a mention, giving his name to a Personality Disorder.

In Ovid's version, Narcissus is the issue of a rape: Cephisus, a river-god, ravishes Leiriope, a nymph. Leiriope asks Teiresias, the blind seer, if Narcissus will live to a ripe old age. The seer answers: 'Yes, if he does not come to know himself.' As a baby, Narcissus is loved by everyone for his beauty and he grows up to be a beautiful young man but is hardhearted and vain. He has many admirers who love him, but he never returns their love. He is cruel and sadistic, on one occasion sending a lover a sword with which to commit suicide. One of his admirers is the nymph Echo, who can only mirror him by repeating his words - Narcissus fears that responding to her love will lead to his own enslavement or exploitation and shouts at her: 'Hands off! Embrace me not! May I die before I give you power over me!' She despairs at his not responding to her and eventually fades away with sorrow, leaving only her voice.

Narcissus is punished for his cruelty by Artemis, who shows him his reflection in a pool. Narcissus becomes captivated by his own beautiful image and, realising that he will never love anyone as much as he loves himself, stabs himself to death in despair. The flower called narcissus springs up from his blood.

Mollon comments that 'violence, envy, sadism and masochism pervade the story which is one of repeated victimisations.' (Mollon, 1993: 34) He notes the sense of death and deadliness within the story and reflects that 'this deadliness might be understood as reflecting the cessation of growth as Narcissus becomes trapped in a developmental cul de sac.'

Narcissus cannot love another: he turns away from the world and the possibility of mutual love found with another and, preferring the illusory 'safety' of self- absorption, succumbs to despair and death.

Section Two: Gestalt Psychotherapy

Gestalt psychotherapy, as developed by Fritz and Laura Perls, Paul Goodman and others in the 40's, 50's and 60's is an integration of many different strands: Gestalt Psychology, Kurt Lewin's Field Theory, Wilhelm Reich and Body Work, Freudian Psychoanalysis, Theatre, Movement and Dance, Holism, Eastern Religion and Philosophy, especially Zen Buddhism, Existentialism and Phenomenology. (Clarkson & Mackewn, 1993) In the 70's, 80's and 90's it has been further developed and refined, by Zinker, the Polsters, Yontef , Hycner, Jacobs, Parlett, Latner, Kepner and many others.

We are born in relationship and develop our full humanness in relationship to other human beings. The child will learn how best to deal with the human environment in which he finds himself; he will creatively adjust his responses so as to get the most of what he needs from the people around him, especially his parents or other principal carers. As he grows up he may find that this once useful creative adjustment becomes rigid: a fixed way of relating to the world. This rigidity will cut him off from a full a range of behaviour and feeling. Psychotherapy is an opportunity to relate to another person who is willing, for the duration of the therapy, to set aside his own needs, opinions and desires and to offer what Hycner and Jacobs term 'the healing relationship' (1995).

Healing is through dialogue, the full, open, honest contact of one human being with another. Within Gestalt Psychotherapy, the therapist offers a dialogic relationship to the patient.

‘By the dialogical is meant the overall relational context in which the uniqueness of each person is valued and direct, mutual, and open relations between persons are emphasised, and the fullness and presence of the human spirit is honoured and embraced. It is more of a heartfelt approach than a theory Perhaps the most essential healing component in therapy is the dialogic attitude of the therapist.’ (Hycner & Jacobs, 1995:4-5)

The dialogic relation is offered by the therapist holding an 1- Thou attitude towards the patient (Buber) .This is different from the 1- Thou moment, 'the moment of fullest contact of a person's being with another person'. (Hycner and Jacobs, 1995:58)

This may or may not happen within the therapy; it will depend on both the therapist's and the patient's capacity to surrender to this possibility .It cannot be planned or sought as a goal but may happen in a moment of grace (Hycner). In that moment, the roles of therapist and patient become irrelevant; 'the I -Thou moment is a moment in which we are totally absorbed with another, which paradoxically puts us profoundly in touch with our humanity, with the knowledge of being; in this moment the meaning of human existence is revealed.' (Ibid p.58)

The therapist, as a precondition for dialogue, is present, in the sense of 'turning towards' the other, the patient.

'The preliminary, yet essential step in establishing the possibility of a genuine, dialogical connectedness is a 'turning' of my whole person to the other, in order to better engage this person. This 'turning toward the other' is inevitably a momentary turning away from being preoccupied with my self. This 'turning toward' is far more encompassing than what is ordinarily meant by 'attending'. It is viewing the other in his/her unique 'otherness' - which is different from me and any of my needs. Presence is a difficult quality to define. Yet its absence is readily apparent. More than a 'quality', it is an existential stance. It is bringing all of myself to bear in this moment with this person- No other concern is paramount. It is a letting go of all my technical concerns and 'goals'. The only goal is to be fully present -paradoxically a goal that is not achievable by technique. ' (Ibid p.15 -16)

The therapist 'turns towards' the patient and offer real, human contact (which may include being silent) within the therapeutic hour. The patient will, in various ways, block, distort or turn away from contact: with the therapist and with his own feelings. If he does not do this, he does not need to be a patient. The therapist's task is to assist the patient in becoming aware of how he refuses contact: this is the work of raising awareness.

Techniques or experiments such as the suggestion that the patient speak as aspects of a dream or fantasy, may be used to help the patient become aware of how he refuses contact, with the therapist and with himself. (Zinker,1978) Such techniques should always be introduced as a creative exploration of the actual situation, which is emerging. Automatic or mechanical interventions deaden rather than enliven the patient's experience.

The therapist practises inclusion towards the patient, this is 'a willingness to enter into the patient's phenomenological world' (Hycner and Jacobs, 1995:70) He also practises confirmation, which means that 'the person is apprehended and acknowledged in his or her whole being' (ibid p. 71 ). He is authentic, that is, he will be completely open and truthful, in word and spirit. This does not mean indiscriminate self-disclosure or that he says whatever comes into his head. He will choose to speak and act only in the service of the patient's growth and will bracket assumptions and judgments in order to attend to and respond to the patient's reality.

Phenomenology holds that we experience the phenomena of the world, rather than reality, which we cannot know directly. We construct our experiential world and imbue it with ever changing meaning. Although we share constructs and meanings with some or most other human beings (for instance that this page is white, that I am writing a thesis) our experience is unique and cannot be fully apprehended by another. Thus, writing this thesis has certain emotional meanings for me, which I could discuss with another but which no other person could fully understand.

The phenomenological method, as practised by Gestalt psychotherapists, amongst others, involves The Rule of Epoché, or bracketing our own prejudices and judgments, being open to immediate experience, The Rule of Description, where we refrain from interpretation or theorising and The Rule of Horizontalization, where whatever is described has equal significance (Spinelli, 1989). To express this simply, we are interested in how our patients construct and experience their worlds and seek, as far as possible, to understand their experience and to help them explore, clarify and deepen this experience Within the therapeutic relationship, we are also interested in our own phenomenology and may share this with the patient, where we believe that this will serve the patient's growth.

'It is impossible for there not to be transference.' (Ibid, p.110) Both therapist and patient will bring to the relationship ways of being, which are grounded in past experience and, especially, unmet, archaic needs. Hopefully these will be more pressing in the patient than the therapist. Their manifestation within the therapeutic relationship means that the affectively highly charged experiences of the past come alive in the here-and-now encounter and can be understood, worked through and transcended.

The therapist needs both to be fully present and also to be aware of and to understand transference. Other aspects of the therapeutic relationship: the working alliance, the developmentally needed or reparative possibility and the transpersonal dimension (Clarkson, 1995) must also be held in awareness.

Of course the therapist, being human, will sometimes fail to offer the high level of availability, understanding and openness that my brief discussion of Gestalt therapy has described. This inevitable failure is also important: the repair, which may follow, is one of the most healing aspects of therapy.

Section Three: A Gestalt Understanding of Narcissistic Styles of Relating

'You are an event.' Carl Hodges, personal communication.

Strictly speaking, a Gestalt Psychotherapist may not refer to 'a narcissist' or 'a Narcissistic Personality Disorder'. The first term implies that a certain attitude and behaviour pattern defines a whole person; the second implies that these attitudes and behaviour constitute a thing, perhaps analogous to a disease or a fracture. Carl Hodges, the second President of the New York Gestalt Institute, referred to 'man-ing' and 'race-ing', rather than people being men or being black (personal communication.)

By this, he intended to emphasise that everything, including all human beings, is constantly in flux, in process. A person who now is self-centred, shame-prone and has a tendency to treat others as things may be described as often relating to others in narcissistic ways rather than defined as being a narcissist or having a Narcissistic Personality Disorder.

The implications of this choice of language are firstly that people are not defined by one aspect of their behaviour and experience; secondly that change is possible. How one is defined depends on the perspective and philosophy of the definer and often rests on the definer wielding social and political power. 'Labelling is always a political act.' (Carl Hodges, personal communication)

A Gestalt psychotherapist is interested in the phenomenology of the patient, that is, how he experiences the world and himself. How, in the consulting room, does he experience the therapist, who, for the duration of the therapy, could be thought of as representing the other, the rest of the (human) world?

Much of what has been written about narcissistic experience is from the psychoanalytic tradition and often includes reference to a medical model of psychological distress.

The responsible Gestalt psychotherapist will study this wealth of experience and 'distilled wisdom' (Yontef, 1995:422) without compromising his commitment to dialogue, process and the phenomenological method, which defines Gestalt as a psychotherapy.

Yontef (ibid) urges us to be knowledgeable, to think, to be conversant with diagnostic classifications such as are listed in the D.S.M.. However, as Gestaltists, we need to acknowledge 'the centrality of dialogue and phenomenological focussing' (ibid p. 422) and to creatively integrate other traditions and approaches into this therapeutic core.

'I especially want to emphasise that Gestalt therapy is not, cannot and should not be a manualised or cookbook kind of therapy. It requires that the clinician make contact with the unique person who is the client with an openness based on centring, bracketing, focussing, dialoguing by the person who is the therapist. It requires art and dialogue, not application of technique or dogma. It is within this spirit that I share my treatment experience.

But we can learn from past experience and the experience of others. To do artful therapy does not mean generating understanding without reference to the distilled wisdom of the field.' (Ibid, p.422)

This thesis will examine part of the 'distilled wisdom' to which Yontef refers by surveying descriptions and definitions of narcissistic experience, ranging from Freud's reflections on primary narcissism and healthy narcissism, to narcissistic traits and narcissistic style and finally the D.S.M IV's description of Narcissistic Personality Disorder. A Gestalt perspective and understanding will be offered at the end of each description.

Section Four: Descriptions of Narcissistic Experience

Primary Narcissism and Healthy Narcissism

Freud (1914) describes the phase-appropriate narcissism of infancy, when the baby experiences himself as omnipotent, the cause of his mother's existence and responses, her warmth, her voice, her breast and so on. Gradually, as reality impinges on the infant, causing discomfort, frustration and pain, he learns that others exist as separate entities, that he cannot control everything and he relinquishes the illusion that he is omnipotent.

Narcissism is still part of the psyche but has been transmuted, through the infant's response to good enough parenting, into a healthy, lively sense of self worth, pleasure in achievements, a sense of what is right and a sense that life has meaning and is worth living. This is made possible by the child tolerating disappointment and frustration in manageable amounts; this is painful but not catastrophic. He may wait ten minutes for his mother to feed him, not be left every day to cry for hours. He may be smacked on the hand when naughty, not beaten into unconsciousness. His parents are ordinary, fallible, mostly loving but sometimes hating, mostly fair but sometimes unreasonable; broadly, they have his best interests at heart. They regard him as a separate human being with preferences and behaviours of his own, rather than an extension of their own egos. When he grows up he knows he is ordinary and not special; he knows that others love and hate, hurt and take pleasure, as he does. He is able to empathise with others, know they are separate from him, love them and receive love from them.

Ordinary observation of infants and children indicates that in the early stages of life, we are often self-orientated. A three month old baby will cry in the night and we will not expect him to consider his mother's tiredness but to express his own needs without reference to the needs of the other. At two, children will often have tantrums if thwarted in what seem to adults to be trivial matters. Children of three, four and five obviously enjoy showing off their achievements to their mothers and being praised for them.

Gestaltists will understand that we have different needs according to our developmental stage and that in early life our organismic needs will include a higher level of self-reference than would be healthy in later life.

The child grows: the organism/environment field changes. More expectations are made of the child: that he be civil, refrain from violence, do his homework, help in the house and so on. Even with loving and responsible parents there will be disappointments, losses, pain, anger, conflict and mistakes.

In adult life, if the person's organismic needs have been adequately met, we would expect a diminution of such self-reference and an increased capacity to recognise and respond helpfully to the needs of others. For example, a reasonably healthy baby may wake his mother at 3.00 a.m.; a reasonably healthy patient will not telephone his therapist at the same time.

We would expect also that a healthy person is able to be reasonably assertive, being aware of his own organismic needs (for love, privacy, stimulation, sex and so on) and is able to reach out into the environment to satisfy them, tolerating the inevitable frustrations and losses that this will entail. He can allow himself to feel his feelings, including uncomfortable ones, without deflection, projection, retroflection, proflection, egotism or other interruptions to contact with the world and with himself.

He can take pleasure in his achievements and creations and has enjoyment in life. He is not a slave to the opinions others may hold of him.

Narcissistic Traits and Narcissistic Style

For those whose upbringings have been unfortunate, perhaps involving huge frustration and pain and who have responded to these frustrations in a certain way, then there may be narcissistic traits of various intensities, causing various problems. A person may be particularly preoccupied with his/her appearance, perhaps being perfectionist about weight, fitness, make up or clothes. Losing one's looks and sexual appeal through aging may be particularly distressing. A person may strive excessively for material success, academic achievement or promotion. Praise, approval and the esteem of others may assume undue importance. Painful narcissistic affects such as shame, embarrassment, humiliation and impotent rage may be felt when the person feels ignored, unsuccessful or dismissed (Mollon, 1993). The person may be arrogant or selfish or feel they are 'special' and deserve particular consideration.

Yalom (1980:125) refers to Fromm's story describing the self-reference which is the essence of narcissism. A patient telephones a doctor requesting an appointment that day.

He is told that unfortunately the doctor has no space in his schedule. 'But, doctor' the patient exclaims, 'I live just a few minutes from your office!’.

Narcissistic qualities clearly will impair a person's ability to love and to work (Freud); others may find them irritating or demanding and they may suffer a good deal of internal distress of which others are unaware, as they usually dislike being vulnerable. Nevertheless, we are talking here about a normal range of impairment, the person may be described as neurotic, rather than character disordered. Such people will be able to form relationships of some kind; albeit less fulfilling than they might be.

Johnson (1987), writing about the narcissistic style, rather than a full-blown disorder, emphasises the phenomenology of the narcissist, his pain and insecurity . His tone is compassionate: '(Narcissists) are too busy proving their worth - or, more properly, denying their worthlessness -to feel the love, appreciation and joy of human connectedness which their good works could potentially stimulate in themselves and others. These people are not character disordered. They are people tortured by narcissistic injury and crippled by developmental arrests in functioning which rob them of the richness of life they deserve. They are good people, contributing people who are hurting - and often very badly.

They are living and suffering the narcissistic style. ' (Ibid p.3)

People with narcissistic style are more or less incapable of forming intimate relationships with others, as they cannot see other people as separate from them. They will often have a succession of failed relationships, or maintain a loveless relationship out of convenience or propriety. Others are seen as instruments or things, giving the person narcissistic supplies of praise, approval, encouragement and envy, or being the source of money or status. Narcissists are often very hard-working and may be extremely successful in the arts, business and the professions. There is also a sense that their achievements are never enough, that the enjoyment of success is always hollow and transient; the person immediately presses on to the next venture, the second million, the next mountain to climb. They may feel empty, lonely and depressed, even when surrounded by friends, or in the midst of obvious success. Others might be amazed to discover they are deeply unhappy - 'But you have everything'. It is likely however, that they will go to great pains to hide their unhappiness, viewing vulnerability as weakness and feeling ashamed of such feelings.

Johnson assumes that the over-achieving of such people is necessary to them to cover their inherent sense of worthlessness, that it is a compensation. He writes with compassion about their plight: 'In a good deal of the literature the narcissistic style' has been given a bum rap. Largely the focus has been on those very disagreeable characteristics of the narcissistically disordered person rather than on the nature of his injury, the phenomenology of his pain, and the fragility of his self. A focus on these more phenomenological aspects of the narcissistic experience will promote for more empathy and understanding, an attitude which must be the touchstone of our therapeutic approach to all narcissistic persons.' (Ibid p.4)

In Gestalt terms we would say that the narcissist is, in some respects, confluent with others, being dependent on their praise, approval and agreement and unable to withstand the separateness of others not having a good opinion of him.

We would understand that an early experience that lacked warmth, respect and empathy would result in the child carrying unmet needs into adulthood, there would be much 'unfinished business', probably involving emotional hunger and pain and also rage at the care-givers.

In some respects the narcissist is retroflective, that is, he is not reaching out into the environment for genuine love or closeness but seeks to 'love himself', through continual self-reference. This can be understood in Gestalt terms as having been the best option for the child, a creative adjustment to the environment. That it may no longer be the best option is something a person may be able to learn within the therapeutic relationship, where the therapist is warm, respectful and empathic and does not treat the patient as a thing but as a person. The unfinished business may be re-enacted within the transferential relationship, the therapist being sometimes experienced as cruel, frustrating, manipulative and so on. The therapist's truthfulness, compassion, understanding and help in releasing these difficult feelings may result in the patient choosing to genuinely risk reaching out and to being met in a new way which will change the patient's perception of the world and himself. Ideally, the transference is worked through and the therapist is increasingly perceived as a helpful, though fallible, human being.

Narcissistic Personality Disorder

In the case of a clinically recognised disorder, the impairment must be severe and incapacitating.

The D.S.M. IV lists the behavioural criteria by which a Narcissistic Personality Disorder might be clinically diagnosed: 'A pervasive pattern of grandiosity (in fantasy or behaviour), a need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognised as superior without commensurate achievements);

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love;

3. Believes that he or she is 'special' and unique and can only be understood by, or should associate with, other special or high status people ( or institutions) ;

4. Requires excessive admiration;

5. Has a sense of entitlement, i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations;

6. Is interpersonally exploitative, i.e. takes advantage of others to achieve his or her own ends;

7. Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others;

8. Is often envious of others or believes that others are envious of him or her;

9. Shows arrogant, haughty behaviours or attitudes.'

The stress in the D.S.M. IV is on the grandiosity, arrogance and lack of empathy shown by the narcissist. Within the text, mention is made of the underlying vulnerability, which is masked by the presentation of the grandiose self; however, this is not listed in the criteria. However I it would seem to be important and so I quote here: 'Vulnerability in self-esteem makes individuals with Narcissistic Personality Disorder very sensitive to 'injury' from criticism or defeat. Although they may not show it outwardly, criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow and empty.' (D.S.M. IV, p.659)

In Gestalt terms, we would understand personality-disordered people to have formed especially rigidly fixed patterns of relating to themselves and the world, so that a flexible, curious and creative response to different situations is difficult, if not impossible. Their gestalten are fixed; little that is new and exciting can happen. This is a kind of death-in-life; there is very little growth or change.

Very careful work is needed with such patients. As Yontef notes (see below) confrontative and abrasive work, which is particularly associated with the later work of Fritz Perls and some of his close followers, will tend to induce excessive shame in extremely narcissistic patients and they will often get worse. Techniques which abruptly and dramatically raise awareness (see, for instance, Perls, 1969) may be experienced as an attack.

Section Five: A Gestalt Approach

Gary Yontef (1993) has made an important contribution to the Gestalt understanding of narcissistic experience and behaviour and the helpful treatment of narcissistic patients.

Yontef looks back on early Gestalt work and notes that character disordered patients were often made worse by Gestalt (as other) forms of therapy: they were frustrating to work with and consequently sometimes written off by therapists as untreatable. However, recent work by Kohut and others in the analytic world has led to a renewed sense of hope for these patients.

Yontef notes that this willingness to learn from Kohut and others has led some Gestaltists 'to abandon the beauty of the Gestalt therapy process theory for a Newtonian, mechanistic frame. In that frame these patients could be said to have a fractured or broken core self.' He adds:

'Of course I prefer not to conceptualise it as: people 'have' a self, but rather prefer a process view -they are themselves, they are living processes and not things that can be broken and mended ln field process terms the patient who is suffering from a character disorder doesn't and can't yet maintain a cohesive sense of self through a succession of here-and-now moments, especially in certain kinds of interpersonal contacts.' (Ibid p.425)

He writes of the necessity for Gestalt therapists to learn from other clinicians and theorists: this is because of the harm that can befall such patients if wrongly treated and also because of the harm that can befall the therapist. Whilst fully acknowledging and using the contributions made by psychoanalysts such as Kohut, Kernberg and Masterson, he does warn Gestaltists that we must assimilate and 'chew over' and integrate our learning from the analysts, rather than their being 'introjected piecemeal into the Gestalt therapy system.' (ibid, p.421).

Writing of people with both narcissistic and borderline character disorders, Yontef states:

'In general they do not maintain the ability to continue self-observation that takes responsibility for behaviour, meets others when there are differences or conflict, struggles with awareness of that which is threatening or painful, or connects the person they are in their present experience with other moments (past or probable) in which they experience themselves differently.' (Ibid p. 426)

Yontef describes the characteristics of narcissists, as discussed above, their grandiosity, exhibitionism, vulnerability to praise and approval by others, propensity to shame, sense of entitlement, selfishness, lack of empathy with others and the tendency to idealise and devalue. Describing these behaviours from a Gestalt perspective, Yontef comments that narcissists are 'self-centred' but are not centred on their 'true selves'. The true self is 'of the organism-environment field' (ibid, p.426); that is to say, it takes both self and other into account. Narcissists are 'confluent and field dependent' (ibid, p.429); they depend totally on the good opinion of others and believe that others are there to support them. They do not differentiate themselves from the environment in a healthy way.

Even when inflated, the narcissist's experience consists of a ground of shame and worthlessness, pride being temporarily figural. When he is deflated, the shame is figure and the pride ground. Perception can shift as quickly as one's perception of the chalice and the profiles in the famous Gestalt psychology picture.

Yontef notes that when inflated and surrounded by friends and admirers the narcissist may appear to be contactful; when deflated and rageful or ashamed he may appear to be in touch with his feelings. Yet neither is true: there is neither real contact with others nor real contact with oneself.

Yontef agrees with Kohut that a gentle empathic attunement usually works best with narcissistic patients and that premature confrontational approaches lead to unmanageable shame and what Yontef terms the four D's: deflation, depletion, depression and despair. It is not surprising that in the early days Gestalt therapists viewed these patients as impossible to treat, as with very abrasive methods they get worse or leave.

Yontef recommends therapist's attunement, which is, in a sense, responding with the wanted, wished-for response. Thus, pain is met with compassion, anger with respectful addressing of the problem, vulnerability with support, withdrawal with respect for distance and so on.

Yontef recommends treating each patient as an individual and responding sensitively to their individual needs. Some patients are soothed and helped by considerable openness on the part of the therapist, this makes them feel less exposed and vulnerable. Others have no interest in the therapist's experience and feel threatened by any disclosure, as if they might be expected to take care of the therapist and respond to his needs.

Yontef approvingly quotes Lynne Jacobs, who recommends that the experience of the patient that the therapist is a perfectly attuned parent-figure should not be challenged as fantasy but should be allowed to naturally shift as the inevitable disappointments and repairs of therapy proceed. If the 'experience of exquisite, perfect attunement from me' (ibid p.456) is challenged, then the patient will often leave therapy; if however, the patient is permitted to enjoy this idealisation, it will be relinquished as and when the patient is ready to integrate his real experience of the therapist as a fallible, ordinary human being.

Where others (Miller, 1986; Johnson, 1987) speak of the necessity for the narcissist to grieve for the actual pains and abuses of childhood, Yontef speaks of the need to grieve the loss of the fantasy of a perfect world. In this perfect world he is absolutely understood and immediately responded to by a selfless mirroring parent. Initially in therapy, the patient may experience the therapist as this perfect parent and the experience of therapy as a brief glimpse of this perfect world. However, as in any real relationship, there will be inevitable failures and disappointments and it is the continual repair of these (similar to Kohut's conception of optimal frustration), which forms the work of the therapy.

'Contact only approximates that desire (i.e. for exquisite, perfect attunement), at best. What is not possible must be mourned. To heal, one must acknowledge the loss, the limits of what is possible, grieve that loss, and go on. The pace of this with the narcissistic patient must be determined by the patient.' (Ibid p.456)

Section Six: Psychoanalytical Approaches to Narcissism

Mauro Mancia

'Hate, as a relation to objects, is older than love. It derives from the narcissistic ego's primordial repudiation of the external world.’ (Freud, 1915, cited in Mancia, 1993:11)

Mancia, discussing the development of Freud's understanding of narcissism, describes how Freud gradually conceived of narcissism being 'dynamically linked' to the death instinct and to masochism.

'Narcissism (is inevitably linked) to masochism and to all the clinical manifestations resulting from the actions of the death instinct, especially whenever this instinct is not externalised in the form of aggressiveness but remains internalised and somehow attached to the libido.' (Mancia, 1993:15)

Narcissism is a kind of death choice, a turning away from the world and contact with others. The self-sufficient, enclosed world of the self gives pleasure and security, with the sense that nothing can be lost, nothing taken away. There is a knowledge that reaching out into the world will inevitably entail vulnerability, pain, and loss. The loss may consist of being left or rejected by others; there is also loss of omnipotence and self-control in allowing oneself to love another. The narcissist refuses to lose control, refuses to be vulnerable, refuses to risk loss and pain.

'Pleasure is identified with the narcissistic situation, whereas pain is identified with the object relation. Mental pain (is) taken as an experience primarily associated with the renouncing of narcissistic pleasure and auto- erotic satisfaction. ' (Ibid p.16)

Gestalt psychotherapy does not postulate a death instinct, a 'primordial repudiation of the external world' in the sense of a biologically determined, inevitable and original way of relating to the world. Rather, the Gestaltist assumes that we, as human beings, have inherent needs to be in satisfying, fulfilling, mutually loving relationships with others as well as having needs for privacy.

'The human heart yearns for contact - above all it yearns for genuine dialogue. Dialogue is at the heart of being human. Without it, we are not fully formed - there is a yawning abyss inside. With it, we have the possibility of our uniqueness, and our most human qualities emerging. Each of us secretly and desperately yearns to be 'met' - to be recognised in our uniqueness, our fullness, and our vulnerability. We yearn to be genuinely valued by others as who we are, even that we are. The being of each of us needs to be revered - by ourselves, but also by others. Without that, we are not fulfilled - we are not fully ourselves.' (Hycner and Jacobs, 1995: ix)

The turning away from life, which is the way of being for the narcissist, would be understood by a Gestaltist not as an expression of the death instinct but as a response to the environment. This response might be the most creative and satisfying which could be found under the circumstances, for instance if the adults who care for the child are cold, hostile, mystifying or cruel.

If this way of relating to the world becomes fixed and inflexible, then the person is cutting himself off from his true, buried and most profound needs - to be met and recognised in authentic relationship with other people. It is the task of therapy to begin to make possible this longed for experience of being met and understood.

There is a commonality in Gestalt understanding and Mancia's description of narcissism as a turning away from contact with others because the risk of pain, frustration and loss which this entails will not be borne by the narcissistic person. Where Gestaltists will disagree with Mancia is in his attributing the cause of this response to a death instinct; Gestaltists will rather think of this choice as an initially creative response to the environment, which has, in adulthood, become fixed and unproductive and which can, within therapy, be re-evaluated and changed.

Neville Svmington

'A person's inner life is not a given, it is a construction. My life is ultimately my own creation; narcissism smothers that creation, does not allow it, prevents energy from being available to make it possible.' (Symington, 1993:124)

Symington finds this concept of the death instinct muddled and unnecessary; for him, narcissism arises because people make a choice. In his book Narcissism - A New Theory,
Symington postulates the existence of a mental object which he calls the lifegiver - 'that the mind can opt for or refuse at a very deep level'. (Symington, 1993:3) He writes that for many years he believed that his patients' narcissism was caused by psychic trauma; however, his current understanding, which he has found very helpful in his therapeutic practice, is that whilst it is true that most or all narcissistic patients have been psychically traumatised, it is their response to the trauma which constitutes narcissism, not the trauma itself. In his description, narcissistically disordered people have turned away intentionally, at a very early age, from the lifegiver as represented by the mother, the breast.

As narcissists live their lives they continue, on a moment to moment basis, to choose to reject the lifegiver which presents itself in their life in the form of the other - the partner, the friend, the colleague, the therapist. They are emotionally dishonest, they hide their feelings from themselves and others, they refuse to feel the pain which real contact involves. They project unwanted aspects of themselves (their jealousy, spite, sadism, etc) into others; in particular, narcissistic therapists do this to their patients. They do not know themselves; self-knowledge is too painful and they refuse it.

'As with all realities, the self is inherently relational. It is always in relation to other selves in the human community - from birth, even from conception, this is so.

If when the baby was born there was no tendency in it to find its way to the mother, the breast, it would die. This relational nature permeates all the parts of the self in the way that gravity permeates all matter. We shall come to see, as we go on, that the core of narcissism is a hatred of the relational - a hatred of something that is inherent in our being.' (Ibid p.18)

Symington observes that we all have narcissistic currents within us and that, as therapists, it is essential that we subject ourselves to the most rigorous self-examination in order to address and confront these currents. The methods he advocates are familiar to any Gestalt therapist. It is necessary, he writes, for us to own our projections and integrate them into the self, in other words we really need to know and experience and confess our own hate, sadism, spite and so on. It is also necessary to be emotionally open to others with whom we are in relationship, being honest about our dirty feelings, bad feelings, shame, pain, anger and so on.

He emphasises that being truly alive (not only in the biological sense) involves a choice and describes the narcissist as psychically dead: 'the origin of narcissism is self-murder, a psychological suicide' (ibid p.48). This choice is not just a one-off decision arrived at in infancy; it is a moment to moment choice:

'This turning away from the lifegiver is a turning against the self. Life is potential for growth. Mystics and spiritual writers say that you either advance or regress - you cannot stand still. You can never say 'Well, now I have arrived at my goal, and I can stay here for the rest of my life.' The psychoanalyst Wilfred Bion said that it is a fateful day when someone 'settles into middle age'. Choice is always confronting the individual.' (Ibid p.41)

Symington seems to allude to a moral choice facing us at every moment: whether to live authentically and courageously, with all the pain that this involves or whether to be false and live a kind of death-in-life. Authentic living, if we have the courage to undertake it, brings relief, intimacy and the ability to work creatively from the wealth and goodness, which we find within ourselves.

Symington's terminology of the lifegiver is unfamiliar in Gestalt; however, the concepts of choice, self-responsibility and authenticity are not only familiar but central to the philosophy underpinning Gestalt Psychotherapy.

Gestalt, as an Existential Therapy, holds the belief that we are responsible for our actions, and feelings:

'Knowing about oneself and not owning that it is chosen is a form of self-deceit'. (Yontef, 1993:27)

'Alienated from his own impulses, yet unable to obliterate the feelings and acts to which they give rise, man makes 'things' out of his own behaviour. Since he does not then experience it as himself-in-action, he can disclaim responsibility for it, try to forget or hide it, or project it and suffer it as coming from the outside.' (Perls, Hefferline and Goodman, 1951: 215)

Also central in Gestalt philosophy is the belief that man is 'inherently relational' (see Section Two) and that narcissism involves a turning away from what is most profoundly needed: contact with the other .

Symington stresses the necessity for therapists to confront the painful truth of their own narcissism and to heal this through owning projected aspects of themselves. The importance of personal therapy in the training of Gestalt psychotherapists is widely recognised; for instance, at the Gestalt Centre, London, weekly psychotherapy with an experienced and qualified Gestalt therapist is mandatory throughout the five year training. Through this rigorous process of personal therapy, it is hoped that trainee therapists will be able to own their projections and integrate their disowned aspects into themselves.

Heinz Kohut and the 'self-obiect'.

As well as the behaviours and attitudes described above, Kohut (1971) describes other indications of Narcissistic Personality Disorder, namely hypochondriacal concerns about mental and physical health, lack of interest in sex, perverse fantasies, a sense of emptiness, depression and lack of meaning, a tendency to search for a perfect other to complete one's self. Narcissists, according to Kohut, often dream they can fly: this symbolically represents their sense of not being bound by ordinary human, physical constraints. They also often dream in technicolour .

In Kohut's view when in analysis, the patient will invariably form or defend against an idealised transference. This will involve seeing the analyst as a perfect, god-like figure, whose empathy, approval and praise are needed for the patient to be able to conduct his life in a satisfactory way. When the supplies of approval, empathy and so on are disrupted - by weekends, holidays, illnesses or failures of complete empathic understanding, the patient will feel devastated and this may well have serious effects on his day to day life: he may feel unable to function. He does not wish for the analyst's empathy, as does a neurotic patient in a positive transference; he requires it, in the same way as a small child requires the love and approval of his mother. The patient who has formed an idealised transference is hungry for - or, rather, demands to see - the 'gleam in his mother's eye', that sign of joy and pride that a mother shows when she sees her small child's efforts and achievements. When this 'gleam' is absent, the patient may feel humiliated, devastated and either rageful or depressed.

As well as the idealised transference, the patient will also form a mirror transference, demanding to be perfectly understood and mirrored by the therapist and not wishing to hear interpretations which indicate that the therapist knows more than the patient but wishing only to hear his own words and feelings reflected back to him (like the reflecting pool!) and a twinship transference, where the patient wishes to believe that the therapist is just like himself (another 'reflection').

The narcissist's demands for empathy, mirroring and twinship are different from the usual human wish to be understood and cared for and to experience commonality with the other. The demands are altogether more insistent and failure is altogether more outrageous for the narcissist than with the neurotic. It is as if (in Kohut's understanding) his arm or leg did not obey him, when the therapist fails to give the desired response.

The therapist's emotional response to the patient - the counter-transference - may be characterised by boredom or sleepiness and also a sense of annoyance or outrage at being used as a thing by the patient.

Kohut writes of the correct (analytic) approach to narcissists and has developed a theory of causation of narcissism, a description of the psychology of narcissism and a detailed exposition of methods of treatment, sometimes, rather disparagingly, called a 'cookbook' approach.

In Kohut's view, the narcissist has missed the opportunity, in his childhood, to transmute the archaic idealised parent imago into a real person. Ideally, this happens gradually, through optimal frustration, i.e. repeated manageable disappointments, held and supported and made tolerable through the love, empathy and responsiveness of the 'good enough parent'.

How does the narcissist miss this opportunity? Probably through the personality of his parents (rather than their death or illness, for example, or other accidental factors, although these naturally do not help). Especially, the parents' own narcissistic disturbances, their own inabilities to regard the infant and child as a separate person, having feelings and responses of his own, their own inabilities to love and empathise with another, will deprive the infant and child of the opportunity to grow up able to relate to others as real, separate people.

For Kohut, adult narcissism is an arrested development, caused by failures of parental (usually maternal) empathy. The narcissist, as a child, has suffered massive, unmanageable frustration. There has been repeated and unrepaired failure in empathy. He has been used as an object by his parents, rather than being responded to as a person. This will have begun before the Oedipal stage, although naturally may continue beyond it.

The narcissist has a depleted self; he is unable to feel whole and separate but holds on to what Kohut terms the archaic idealised parent imago, looking to the outside for love and approval, terribly sensitive to slights, being ignored, not being praised and successful, in other words, 'narcissistic wounding'. In this he is extraordinarily dependent on others for narcissistic supplies, yet people as such mean little to him. He cannot love or really receive love: others are perceived as instruments for him to use to get what he needs, primarily a sense of being superior to others. He may wish to feel more intelligent, more physically attractive, richer, more creative, harder working, better liked, thinner, fitter, more compassionate - any factor at all, provided it is better than other people.

Within the therapy, via optimal frustration (every empathic failure, holiday break and so on) -being held by the therapist's concern, empathy, reliability and genuineness, the patient can bit-by-bit relinquish the archaic idealised parent imago and form his own self (which has been lacking). The therapist is the necessary self-object (Kohut, 1971). Thus, genuine humour, wisdom, creativity and an idealised super ego, giving meaning, standards and values to life, can be formed.

The archaic, idealised, parent imago, through disappointment, becomes a real love object -a person, who the patient can love and hate and with whom he can be truly intimate (Winnicott). Therefore, in the patient's life, people are no longer objects (in the sense of being things or instruments), gratifying or frustrating his narcissistic needs, but can be separate people, with needs and responses of their own: there is the possibility of mutuality. Thus the patient is free to love and be loved.

Although the terminology which Kohut uses and that used by Gestalt therapists differs, there is much in common between the two approaches. Kohut sees that the narcissist can be helped by being in relationship with an attuned, empathic other, that this (therapeutic) relationship is, in and of itself, curative. This is very similar to the Gestalt concept of the healing power of inclusion and confirmation within a dialogical relationship.

Like Kohut, Gestaltists such as Yontef, Hycner and Jacobs allow idealised transference, advocate mirroring and empathy and expect the patient to gradually change his
experience of the therapist, himself and the world. This change would broadly coincide with Kohut's expectations: the patient will hopefully become more realistic in his perception of the therapist as a fallible, though helpful, human being; he will feel less lonely, less rageful, less shame-prone; he will be more empathic, more creative and be capable of a sense of humour.

Kohut and the above mentioned Gestaltists believe that it is the therapeutic relationship that heals, through which psychological repair is made and new ways of being are experienced which transform the person.

Otto Kernberg

Otto Kernberg writes of pathological narcissism and believes that, whether for constitutional or environmental reasons, pathological narcissists suffer from intense oral aggression, a desolate internal world peopled by shadowy objects which are unsatisfying, envy and hatred of others and a fear of others because this hatred is projected onto them, leading to paranoid attitudes. His descriptions of these patients paints a chilling picture, they are manipulative, heartless, unprincipled, emotionally empty, full of rage and unacknowledged pain.

'The narcissistic character defences protect the patient not only against the intensity of his narcissistic rage, but also against his deep convictions of unworthiness, his frightening image of the world as being devoid of food and love, and his self-concept of the hungry wolf out to kill, eat and survive.' (Kernberg, 1975:276)

Kernberg differs from Kohut in some maior ways; firstly he states that pathological narcissism develops from early pathology and that patients who go on to develop this pathology are markedly aggressive and unempathic from an early age - crudely, it if as if they have 'always had something the matter with them.' The adult disorder is not a fixation to early or primary narcissism but different in nature: '...narcissistic idealisation is a pathological process rather than a normal develpmental stage.' (Ibid p.278)

He goes on to refer to 'a condensed, pathological self. This self stems from the fusion of some aspects of the real self 1 the ideal self 1 and the ideal object. This condensation is pathological and does not simply represent fixation at an early stage of development.' (Ibid p.279)

Kernberg agrees with Kohut that the nature of the transference is in itself a diagnostic indication, but describes the transference differently. Where Kohut stresses how dependent the patient will be and how deeply affected by breaks in empathy and also real breaks at weekends, holidays and so on, Kernberg describes patients who will not depend on anybody, including the analyst, and are notably indifferent to breaks in the treatment, as if they didn't care at all for the analyst.

Many commentators have noted that a counter-transferential indication of narcissism in the patient is that of persistent sleepiness and/or boredom on the part of the therapist (Mancia,1993). Kernberg (1975) indicates that work with such patients is frustrating at best; he recommends attempting treatment however (except where the pathology also includes anti-social features) noting that the emotional suffering of the narcissist is extreme. He also notes that, unlike borderline conditions, which tend to remit with age, narcissistic disorders tend to become worse with age. This is because the narcissistic compensations and satisfactions of beauty and success are often less available.

As old age approaches, agonising existential realities loom and cannot be denied. Death is certain. There is the likelihood that one will be helpless, will lose one's faculties, will become dependent on others and that one's death may be in pain and indignity .If a person has never learnt to give or receive love, has never built up an internal sense of goodness and health, this can be impossibly hard and suicide is a real possibility.

Kernberg understands of the cause of narcissism to possibly be constitutional factors such as an inherently high level of oral rage and aggression, or possibly to be caused by maternal empathic failure:

'It is an open question to what extent inborn intensity of aggressive drives participates in this picture, and that the predominance of chronically cold, narcissistic and at the same time over -protective mother figures appears to be the main etiological element in the psychogenesis of this pathology.' (Kernberg, 1975:276)

Gestaltists would tend to regard narcissistic behaviour and experience to be a response to unfavourable early experience, a process of creative adaptation to the environment, rather than being caused by ‘an inborn tendency of aggressive drives'.

Gestaltists would rather tend towards Kohut's view (which Kernberg also considers) that maternal empathic failure has something to do with a person becoming narcissistic.

Gestaltists however would not view this in a rigidly deterministic sense: a person could have a cold, narcissistic, over-protective mother and yet not respond by becoming themselves narcissistic. Like Symington, Gestaltists view narcissism (or any fixed personality structure) as being a choiceful response to a set of circumstances. A famous quotation from John-Paul Sartre comes to mind: 'Freedom is choosing what to do with what's been done to you’.

Kernberg tends to stress the aggressive and sadistic aspects of the narcissist's personality, the 'narcissistic rage' and 'his self-concept of the hungry wolf out to kill, eat and survive.' His psychotherapeutic technique stresses the necessity of interpretation of these aggressive aspects:

'The analysis of all these components of this pathological structure reveals defensive functions against the emergence of direct oral rage and envy, against paranoid fears related to the projection of sadistic trends on the analyst (representing a primitive, hated, and sadistically perceived mother image), and against basic feelings of terrifying loneliness, hunger for love, and guilt over the aggression directed against frustrating parental images'. (Kernberg, 1975: 280-281)

This sounds as if it could be a confrontational therapy. If Yontef is right, this might present dangers: the patient could feel shamed and insufficiently understood and may leave the therapy.

However, there might be learning from Kernberg for Gestaltists. Certainly, people who are narcissistic are definitively rageful, envious and unempathic. To overlook these aspects and only to stress their suffering could lead to sentimentality and collusion. To offer only support and no challenge would be a poor therapy. Perhaps in the early stages of therapy, attunement and mirroring will need to be offered for most of the time; however, as the therapy progresses and the relationship deepens and trust is built it may be helpful to confront the patient.

Gestaltists do not, on the whole, interpret to their patients in the manner of psychoanalysts. Perls disapproved of interpretation as a psychotherapeutic technique:

'(The patient) has not learned to chew up and work through what is nourishing and necessary. He will drink down his analyst's words as something new with which to identify, rather than mulling them over and assimilating them. He expects his therapist to do the work of interpretation for him, and he will later spew out these very interpretations to his bored friends. Otherwise, 'intellectually accepting' the interpretation - without conflict, suffering and disgust - he merely imposes on himself a new burden, a further complication of his concept of himself.' (Perls, Hefferline and Goodman, 1951 :202)

The Gestalt psychotherapist may however confront the patient by disclosing his own emotional response to the patient ('when you said x I felt y') or by suggesting an experiment to raise awareness (Zinker, 1978). As the therapy progresses and the patient is able to relinquish some of his narcissistic behaviours and attitudes, this may become increasingly possible.

Gestaltists will have no argument will Kernberg's stress on the desirability of helping the narcissist face existential realities: the prospect of diminishing powers and the certainty of death. If a person has no capacity to give and receive love, this is a terrible future to face. Gestaltists will hope that through the dialogical relationship this incapacity can be redressed and .the person will have the internal resources to face the ultimate concerns of life.

Victoria Hamilton

Hamilton (1982) gives an overview of different psychoanalytic theories of human development. She herself disputes the classically Freudian view that the human infant is originally narcissistic and believes that research undertaken by Bowlby and others such as Ainsworth (not to speak of everyday observation and common sense) demonstrate to us that babies, from the beginning, seek enjoyable and playful relationship with their mothers and others. This enjoyment of reciprocal, mutual dialogue is not reducible to needs for relief from pain, discomfort, hunger or anxiety, but is enjoyable for its own sake and is as much part of the infant's instinctual responses to the world as the sucking reflex or the tendency to cry when hungry.

Hamilton, following Bowlby and others, believes that people are, from the very start of life, relational.

For Hamilton, childhood and adult narcissism is defensive rather than regressive, that is, it forms a protective 'shell' which is not a return to normal infancy nor a return to a womb-like state, but a new (and pathological) mechanism to protect the child against unbearable reality. Writing of autism, which she considers an extreme variant of narcissism :

'Reality is disappointing and harsh. Similarly, a child who has lost his autistic shell, needs a therapist who is able to withstand the child's volcanic eruptions and disappointments. The therapist must also endure repeated retreats into the painless fog or brittle shell of the autism The swings from elation to despair can be very exhausting and test the therapist's trust. Some patients may try to destroy the therapist or themselves rather then face the initial surrender or the enormous task of reparation which follows breakthrough.' (Hamilton, 1982: 133)

Hamilton's belief that human beings are inherently relational is identical to the Gestalt view. Yontef (1993:17) refers to 'the vital Gestalt notion that everything and everyone is inherently relational.' This also coincides with Symington's view (above).

For the Gestalt therapist, as for Hamilton, narcissistic pathology is a failure in relationship, a failure of dialogue. It is a process, rather than a thing. It is what someone does, rather than who they are. There is the implication and hope that the person can do things differently, that is, can relate to others and himself differently.

For the Gestalt therapist, as for Hamilton, one way to learn how to relate differently is here and now, in the consulting room with the therapist. The therapist is a person who can cope with distress, fear and anger, both in himself and another I can think constructively about what is going on between the two people who are meeting and who offers himself to be used by the other for the other's growth and health. He is empathic, thoughtful, honest and emotionally available. He maintains the boundaries of the therapeutic relationship so that the patient may be held and contained and the shared space is safe enough for anything to be said.

Section Seven: Conclusions

Gestalt practitioners, like psychotherapists from other disciplines, do well to be informed of the medical models of psychological distress, such as the descriptions of behaviour listed in the D.S.M.1V. This makes for ease of communication with other professionals and patients' patterns of behaviour may be discerned.

However, Gestaltists will regard the disorders so described as processes, rather than things.

Narcissism, the subject of this dissertation, is listed in the D.S.M. as, in its severe form, a disorder: Narcissistic Personality Disorder. Although some disorders in the D.S.M. may be regarded as diseases if they are organically caused and are not treatable by a talking therapy (Alzheimer's, for example), Narcissistic Personality Disorder would not be regarded as a disease but as a behaviour pattern indicative of psychological distress and difficulty and treatable by psychotherapy.

Gestalt psychotherapy is underpinned by a philosophical and theoretical belief that all human beings are inherently relational. The work of Martin Buber has been inspirational to the dialogical Gestaltists frequently referred to above: Gary Yontef, Richard Hycner and Lynne Jacobs.

This view is supported by some psychoanalytical writers whose work has been considered in this thesis. In particular, Symington, Kohut and Hamilton stress this belief.

Hamilton acknowledges her debt to the research of John Bowlby and others in developing this perspective.

Narcissism is understood by Gestaltists to be a turning away from relationship and to be a decision which was once a creative adjustment to adverse environmental factors, these often being related to empathic failure by the mother.

Symington shares the Gestalt view that narcissism is a choice, a response to early trauma and environmental failure. This choice is not a once and for all decision but is a process, a continuing choice to be inauthentic and not to face the pain of loss, which true engagement in relationship entails.

All the writers considered above agree healing is possible through various types of 'talking cure', i.e. narcissistis patients can change through engaging in a relationship with a psychotherapist.

There are different emphases and vocabulary, nevertheless there is agreement that patients can benefit from an empathic, understanding other, who is willing to bracket his own concerns and responses if they are unhelpful and to devote himself to the patient's experience and the patient's growth for the duration of the therapy. This would seem in some way - the details of how this works are various - to allow the development that was impossible in infancy and childhood to become possible within this relationship.

Thus, arrogance becomes a healthy enjoyment of achievement, the tendency to use others as objects changes to allow a capacity for intimacy and genuine closeness, a tendency to crippling shame and rage becomes a normal manageable vulnerability to disappointment.

There is some agreement that the tendency of the narcissistic patient to idealise the therapist should be tolerated and that this is gradually worked through to a relationship where the therapist is perceived as a fallible, helpful human being. The disappointments in therapy are important: the expression of rage and pain are permitted, the patient learns that the therapist remains constant and does not abandon him, he learns that no-one is perfect but that help and care can be offered and received.

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