8. DSM Partner Diagnoses - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Scorpion in the Bed, The Narcissist in Couples and Couple Therapy
Chapter 8: DSM PARTNER DIAGNOSES


Pleaser, Victim, Martyr… or Fool- the subjective characterizations of likely partners to the narcissist can be enhanced by considering theoretical conceptualizations.  The partner to the individual with narcissist personality disorder may not justify a Diagnostic and Statistical Manual designation as a personality disorder, but have significant tendencies at least at some period of his or her life.  The therapist may observe the following pairs of members in a couple:

BORDERLINE PERSONALITY DISORDERED PARTNER
The individual with a narcissistic personality disorder can be in a couple often with a partner with borderline personality disorder.  The hypothesis is that borderline desperation for attachment and fear of betrayal, abandonment, and rejection would cause the person to tolerate periodic narcissist annihilation.  Despite being devastated by narcissistic treatment, staying rejected, abandoned, or alone causes the person to risk further annihilation.  The partner's borderline desperation simultaneously makes excuses for the treatment while condemning it.  And when the narcissistic rage is quiescent, the charm and skills of the individual may be very nurturing and fulfilling.  The partner convinces him or herself over and over that it is okay and the abusive treatment was an anomaly.  By staying, he or she functionally gives the individual with narcissistic personality disorder permission to eventually continue his or her abusive behavior.

DEPENDENT PERSONALITY DISORDERED PARTNER
The individual with a narcissistic personality disorder can be in a couple often with a partner with dependent personality disorder.  The hypothesis is that dependency desperation for attachment and need for approval, and abandonment fears would cause the person to tolerate the periodic narcissist annihilation.  Risking periodic annihilation is preferred over risking being alone and without the parental figure of the narcissist.  This partner desperately craves validation but doesn't feel deserving of positive treatment.  The person with dependent personality disorder thinks he or she deserves the negative treatment.  And, the individual with narcissistic personality disorder is very compelling in convincing the partner that he or she is wrong, was wrong, and will always be wrong.  The implicit or explicit threat of final rejection keeps the dependency fears activated, and the partner in the relationship.

NARCISSISTIC PERSONALITY DISORDERED PARTNER
The individual with a narcissistic personality disorder in can be a couple with a partner also with narcissistic personality disorder.  The hypothesis is that the two superior-beings-in-kind align and hold individual and joint omnipotence over inferior others.  The contract between members is based on limited intimacy with acceptance of respective competence or superiority over others.  Accepting the other partner’s superiority is more tolerable if his or her competency is in another non-competitive other than ones own field- for example, a narcissistic psychiatrist coupled with a narcissistic businessperson.  Neither member fully invests deeper vulnerability with the other.  The members are wary allies, much like nations with mutual enemies aligning in a treaty of convenience and suspicion.  The mutual enemies so to speak are the rest of the world that can threaten either person's high fragile self-esteem. The two maintain what may be in some ways, a psuedo-relationship to meet functional needs- often power and status needs without risking the vulnerability required of true intimacy.  Pairing with another narcissist may be relatively common for each partner in relationships, as healthier individuals would not tolerate or stay with them.  Healthier individuals would make intimacy and relationship demands that neither partner is prepared to meet.  Not surprisingly, the two-narcissist couple may be fragile and unstable... or either or both individuals going through a series of narcissistic pairings and dissolutions.

HISTRIONIC PERSONALITY DISORDERRED PARTNER
The individual with a narcissistic personality disorder can often be in a couple with a partner with histrionic personality disorder.  The hypothesis is that the person with histrionic personality disorder with weak ego strength will accept a paternal/maternal mentor/superior who offers access to areas and experiences- audiences or social circles for example, for which he or she cannot otherwise gain entry.  The individual with narcissistic personality disorder accepts the person with histrionic personality disorder as someone to condescendingly "mentor," guide, dominate, and show off or exhibit.  The person is like a pet or trophy- not unlike owning a painting by Picasso that the individual can show off.  For example, rich and powerful (and narcissistic) men have often decorated their throne room, mansion, social galas, and award ceremonies with pretty arm candy- young, beautiful, and bereft of other skills and intelligence, but entertaining.

Personality disorders are by definition long-term habitual characterological patterns of functioning (feeling, thinking, and behaving).  They are deeply ingrained and maladaptive patterns of behavior, that cause enduring difficulties in personal relationships or in social functioning.  The challenge of couple therapy is sometimes not only to treat one but two personality disorders simultaneously, while dealing with the interactional dysfunction cause by the two disorders' interaction.  Or, conversely the challenge is to treat to treat the interactional dysfunction cause by their interaction, while dealing with not one but two personality disorders simultaneously. The therapist thus needs to incorporate conceptualization and strategies for working with the respective personality disorders into theories and strategies of couple therapy.  Aspects of the personality disorder make otherwise effective therapeutic communication, interventions, and instruction confusing, intolerable, highly difficult, and sometimes impossible.  In addition to partners with a personality disorder, there is an intriguing partnership of the individual with narcissistic personality disorder with a certain type of non-personality disordered person.

THE NON-DISORDERED PARTNER TO THE NARCISSIST
In therapy and in other social situations, the therapist might meet a person who is just a really neat, intelligent, and heartful individual who is or had been married to someone with a personality disorder. In particular, the person was or had been paired with an individual with narcissistic personality disorder- or, sometimes, a borderline personality disorder or a paranoid personality disorder.  Frequently, it was a woman in a relationship or marriage with a man with narcissistic personality disorder.  Diann was such a person.  She was in her early fifties and had divorced her husband of twenty years about ten years earlier.  He was an author and professor of literature at a prestigious university.  He had written some well received short stories in his twenties.  She had been a poetry student in one of his graduate seminars.  While she had postponed her writing career to get married to him and raise their two children, she never stopped writing.  Professor husband encouraged her "diversion" and "hobby."  When she eventually submitted her poetry for publication, she became an "overnight" sensation in her late thirties.  Professor husband was reluctantly supportive of her sudden acclaim.  As long as she took care of the kids and continued being his escort to his professional and academic functions, he was tolerant of her success.  The fissures began when Diann started getting more attention for her current and ongoing at his functions than he got for his old achievements.  By the time the therapist met Diann at a charity function where she read from her poetry, the marriage had long ended.  She shared her story with the therapist who readily recognized the narcissistic characteristics of her ex-husband.

At first, it does not make sense to the therapist why such a fabulous spiritually and emotionally attractive individual (and obviously, intelligent) would hook up with and tolerate the abuse of someone with narcissistic personality disorder.  Upon further examination, it turned out that Diann had suffered significant emotional abuse from her parents and siblings.  Other individuals with similar characteristics and partnerships with narcissists suffered similar emotional abuse if not also sexual or physical abuse in childhood from their parents- the authoritative figures.  Part of the methodology of every abuser is to teach and indoctrinate that the abused person deserves the abuse.  The child or person is indoctrinated that he or she is fortunate that the abuser even tolerates him or her.  The person is told that he or she is loved, but that he or she would appreciate how difficult it is for the abuser to keep loving such a flawed, unworthy, and problematic person.  Diann was trained to believe that she deserved her abuse and that she was lucky to have such loving parents who cared enough to discipline her.  Without conflicting perspectives from healthier caring authority figures, the child or person habitually abused absorbs the accusations.  With internalized minimizing or dismissal of his or her fundamental worth, the person later is especially vulnerable to the individual with narcissistic personality disorder.  As the new authoritative figure, the narcissist such as Professor husband replicates childhood denigration by rationalizing and justifying the current abusive behavior.  Used to accepting a life long sense of "wrongness" including doubting and denying personal actual experiences and memories, Diann as the re-abused person was unable to hold her experience of the new abuse as real.

For Diann as can happen with other abused people, however other positive relationships (with friends, professional peers, and others), achievements (getting published and receiving awards for her poetry), and therapy where his or her experiences and worth were validated and valued, can be reparative.  As Diann became more able to dispute and resist being always at fault, continued acceptance of narcissist assaults became less and less acceptable and finally, unacceptable.  When someone like this arrives in couple therapy with the narcissistic partner, the previous equilibrium of the relationship has often been already highly altered because the person's rebalancing of self-worth and responsibility.  Therapy shifts to supporting his or her continued sense of self-worth and intolerance of mistreatment while focusing on changing the narcissistic behavior of the other partner… or seeing if such change is possible.  If the narcissistic energy is too powerful, the ever more healthy partner may then choose to terminate the relationship.  He or she does so, knowing it is healthier for him or her to leave than to attempt to revert to the prior submissive role.  In other words, there is only one personality disorder to manage and treat in such therapy.

For Diann, it never came to therapy.  Her transformative reparative process occurred in life without the benefit of therapy.  She had tried to engage Professor husband in changing the relationship, but he had been unavailable.  It became clear to her that she was a good decent person who deserved positive treatment.  Her friends and colleagues treated her well.  It become more and more clear to her that Professor husband was an asshole!  She did not make him be an asshole.  That was all about him.  Diann had chosen to leave rather than revert to her prior diminished deferential self.  In contrast, someone with deeply embedded anxiety that calcifies in a personality disorder often is not able to integrate positive messages of affection and worth from others that Diann absorbed.  For Diann who was relatively less damaged, reparative relationships and experiences empowered her to finally break off from narcissistic abuse and the individual with narcissistic personality disorder.  The therapist who encounters this person in couple therapy can easily align with him or her and actively promote not merely boundaries and refusal to take narcissistic abuse, but also actively prompt terminating the relationship or divorce.

The therapist however who sets the therapy agenda to separate the members violates the therapeutic principle of client self-determination. The partner with emerging self-esteem does not need another authoritative (or authoritarian) figure (the therapist this time instead of the narcissistic partner) making choices for him or her. While the therapist may have little or no hope for the couple to be functional or stay together, or instead believes that it is in the best interests for a member or the couple to separate, the integrity of therapy requires working within the expressed goals of the two members.  The therapist has to be stay conscientious of his or her counter-transference and interact with the couple often in a personally- that is, socially counter-intuitive manner.  As the therapist trusts in the therapeutic process, he or she also trusts that the partner will make the choice that he or she is ready to make.  If Diann had come to couple therapy with Professor husband, the therapist would need to trust in the therapeutic process and the partners' self-determination.  A healthy or newly healthy person may never make it couple therapy.  Diann's growing changes may have disrupted the equilibrium of the couple and antagonized her narcissistic husband's omnipotence so severely that the relationship became severed.  The narcissist has to want and need the relationship with an equal (or more equal) partner more than he or she wanted or needed maintaining his or her narcissistic urges to have tolerated the shift in attitude and interactions.  This may be unlikely for a calcified narcissist. This may be why the therapist more often meets the fabulous spiritually, emotionally attractive, and obviously intelligent individual outside of therapy after having left the narcissist, than as a client while practicing couple therapy.  It had been too late for the relationship to survive, but not too late for the individual to move forward towards a healthier life.  Go Diann!


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Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
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phone: (510) 614-5641
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