9. Etiology - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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The course of the couple's relationship and the course of couple therapy follow the development of one partner's narcissism and the other partner's complementary psychology.  What must be dealt with in the present demands of couple therapy and the current relationship were determined in part by how and why each partner developed their cross-gratifying yet dysfunctional dynamics.  The narcissistic issues developed years or decades before the partners meet.  As a result, intrinsic to therapy and therapeutic strategies arises conceptual questions such as "…is narcissism due to parental rejection resulting in defensive withdrawal, distrust of love of others, and consequently self-love, or is it due to failure to idealize parents stemming from their indifference?" (Buss and Chiodo, 1991, page 182).  As the therapist recognizes key behaviors, he or she can begin examining for the possibility of underlying narcissistic tendencies, narcissism, or narcissistic personality disorder in the client or partner in a couple.  Partner behaviors and the couple's dynamics and relationship are then examined from another powerful lens. If narcissism in some degree or form is relevant, then the therapist's understanding and conceptualization of it becomes critical to the conduct of therapy.

Individual therapy for self-sufficiency, improvement from depression or anxiety, or substance abuse for example, may be seen as individual therapy for narcissistic frailty, rage, desperation, and acting out that harm self-sufficiency, depression or anxiety, or for manifestation of narcissist issues in self-medicating substance abuse.  Couples or family therapy for improved communication, greater intimacy, less enmeshed or rigid or inconsistent roles or boundaries, infidelity, or co-parenting for example, becomes reframed as couples or family therapy for communicating narcissistic demands, superiority/grandiosity needs, shifts from adulation to equality, or maintaining self as the idealized parent and punishing the critical co-parent and child.  How, when, and why narcissism or narcissistic tendencies developed directs the therapist not only in understanding the individual, but also in anticipating his or her behavior and in meeting the underlying needs that the narcissistic behaviors seek to serve.  Rather than stalling out at identifying narcissists as problematic and narcissistic energy and behaviors as dysfunctional to relationships, the therapist can use the etiology of the disorder to direct more effective therapy.

LACK OF MIRRORING
The narcissist is considered a creation of the lack of mirroring that is deemed more severely inadequate than what the person with borderline personality disorder experiences from his or her parents.  The wound may be created by severe emotional neglect.  The implicit message to the child is that "you don't matter".  On the other hand, over-indulgent parents can also create narcissism.  Essentially, they promise perfect mirroring such that the infant or child will not experience any pain or anxiety. The implicit message becomes that the infant or child cannot tolerate any pain or anxiety. Parents inevitably fail to be perfect mirrors, and thus foster the child's fundamental terror from being vulnerable in the world.  The neonate narcissist responds to this existential terror by seeking to prove his or her worth through extreme competence.  Narcissists are often driven to be highly successful academically, professionally, and financially, so that society and others mirror back his or her worthiness through recognition of accomplishments.  "The germs of the distinction between libidinal and destructive narcissism can be found in the history of the development of the concept. From its beginning two themes have run in contrapuntal fashion through the discourse on clinical narcissism. One theme is of narcissism as a defence against adverse object relations; the other theme is of narcissism as a manifestation of basic hostility to object relations" (Britton, 2004, page 479).

These two themes may play out in the couple's relationship.  Relational issues may arise from the narcissist behaving aggressively to defend against the vulnerability and risks of intimacy, and also to examine his or her cynicism or negativity about the viability of a secure mutually nurturing relationship.  The partner may experience narcissistic behaviors as rejection of his or her nurturing offerings, when they are actually mechanisms to avoid being enticed into intimacy the narcissist fears will be betrayed.  In addition, the partner may experience the narcissist's reticence, aloofness, and superiority as him or her not trusting the partner as an intimate mate, when the narcissist's disconnection is actually from his or her not trusting his or her own ability to maintain intimacy.  The partner's misinterpretation of the narcissist's presentation duplicates the inadequate mirroring by his or her parents hypothesized to be the root of the disorder.  The therapist can further replicate poor mirroring if he or she is unaware of the deeper motivations of the narcissist.

The Harvard Mental Health Letter (2004) offers further insight to the origins of narcissism from two leading theorists.  "According to Kernberg, our childhood inner worlds contain representations or images of people who are emotionally significant, especially ourselves and our parents. These 'objects' and our relationships with them are the keys to an understanding of narcissism. Kernberg believes that narcissistic personality is a response to coldness, indifference, or hidden aggression on the part of parents who, without being truly affectionate, try to convince a child of his or her own importance. Narcissistic personalities live in fear of these persistent internal images of parents to which they attribute their own anger at the treatment they received in childhood. They feel that they cannot be loved unless they are perfect. Their internal objects, representations that remain in the mind, are never assimilated and integrated, and their adult relationships are distorted. They cannot distinguish their real abilities from grandiose fantasies or live up to the internal image of an ideal parent. Their superficial self sufficiency is belied by their envy and craving for admiration..."

Kohut regards narcissism in a way that is similar, yet different.  His view is that from early childhood on we all have 'selfobjects,' internalized representations of people (mainly parents) who maintain the sense of a self by reflecting a child's wishes for recognition and praise —a process called mirroring. Selfobjects are also representative of a child's need to idealize, and they serve as models, creating a sense of what Kohut calls 'twinship' between child and parent. As a natural stage of development, we all start out with this 'grandiose self' and an idealized image of our parents. With good parenting, these primal narcissistic selfobjects are moderated and become the basis for a mature personality. Kohut believed that the parents of narcissistic personalities are capricious and unreliable, reject the child, or treat the child as an extension of themselves. The child grows up with a distorted view of what it means to be lovable. To defend themselves (unconsciously) against feeling unlovable, narcissistic personalities imagine themselves as perfectly lovable — a self-image they need in order to receive the admiration not supplied by their parents. They view themselves as having no needs they cannot provide for themselves. But because no one is self-sufficient, this belief only leads them to become vulnerable to disappointment. Their underlying feelings of worthlessness and emptiness force them into a constant search for recognition. They enter relationships expecting others to gratify all their unconscious wishes. They do not develop either rational self-esteem or a sense of responsibility and empathy for others" (page 2).

Key to therapy from either theory is how the therapist often triggers the negative internal images of parents and/or twinship needs doomed to be disappointed.  The therapist would not necessarily evoke such negative anticipation if the individual had attentive, nurturing, and supportive relationships with the original self-objects (parents).  Positive attachment would give confidence to risk adult intimate relationships.  For the injured person, problematic projections occur in any relationship involving trust, intimacy, or vulnerability: work relationships and hierarchies, peer and social hierarchies, and the intimate couple relationship.  The couple arrives in therapy after enduring narcissistic patterns of relationship that have become unfulfilling or triggering over time.  Some crisis may have arisen.  Or, the partner may have finally found the treatment intolerable.  Feeling ignored is a common complaint, since the narcissist has often been oblivious to the partner's suffering.  "Narcissistic personalities pay little attention to other people's feelings and wishes. They are interested in others mainly as mirrors in which they can admire their own features — the pool of Narcissus — or as instruments for satisfying their wants. They freely take advantage of others and expect gratitude in return" (Harvard Mental Health Letter, 2004, page 1).

These expectations and mechanisms are normal for the baby and young child.  Attentive caretaking energy of the parents encourages the infant's sense of being special.  His or her cries and outbursts require immediate response.  Caregivers respond with delight and praise over the infant's auditory and physical experiments in the world.  He or she is the center of the world… certainly, the center of the caregiver's world.  The caregiver essentially obeys the infant's demands or commands and strives to meet his or her needs.  The caregiver is the ideal self object who feeds the infant's grandiosity as special.  "To baby, mother is grandeur itself, omniscient, omnipotent, and gigantic. To be one with her is to share in this grandiosity; to separate from her means a loss of this quality. This is a peculiarly painful loss, indeed an intolerable one. In one way or another the child seeks to retain his connection with it. According to Kohut he has two alternatives—he can continue to ascribe the grandiose attributes to mother and then seek to please her, to win her, to obtain constant evidence of her approval. Or he can reserve this omnipotence for himself and ascribe to his self all manner of extraordinary qualities. Sometimes oscillating systems are set up where the grandiose quality passes back and forth, one moment attached to the child and then assigned out to the mother. Later on, one sees in adolescence a recurrent tendency to be haughty, supercilious, arrogant and superior one moment, and in the next instant to experience a crushing sense of total worthlessness. In the more fluid moments, the sense of grandiosity can give way to a conviction that everyone else is so secure and knowledgeable while one's own self seems so paltry and denuded. But whichever way it may be directed, the clinging to some major component of grandiosity is typical and continues to be a presence in the child's life throughout" (Noshpitz, 1984, page 30).

Inevitably as the infant becomes a toddler, he or she begins autonomous engagement further into the larger world.  While seeking greater independence, the toddler also checks in with the caregiver frequently for approval and validation.  "I'm doing this myself… I'm OK" is founded on seeking and getting affirmation that "You are watching me…right? You're making sure I'm OK… and will rescue me when my independence becomes stressful…right?"  The toddler… "self self…" "mine" and "no" has grandiose expectations and continues to explore them.  "And, inevitably, there are many moments when these unrealistic postures will be challenged. There will be frustrations, deprivations, arrests, abandonments, and all manner of wounds to the narcissistic perimeter. Then he is suffused with rage, that special rage that is incited by this kind of pain, and he throws himself to the floor and kicks, thrashes, and screams—he would seem in his towering passion ready to destroy the world. Indeed he is; a real tantrum is quite an explosion and a classic example of the venting of narcissistic rage" (Noshpitz, 1984, page 30).  The tantrum may initially be an emotional outburst from frustration and rage.  It can however become targeted at those who have disappointed or failed to gratify the child or individual.  He or she feels entitled to punish the betrayer.  It is betrayal that the world is not going to always please him or her.  Neither the toddler nor his or her agent, the caregiver can keep him or her omnipotent and free from frustration.  As the time passes, sooner or later in the larger family with siblings or at daycare or preschool with other children, the young child discovers that he or she is not special to everyone else.  Other issues including learning problems, identification as somehow different, or anxiety can further challenge the child's sense of omnipotence.  The caregiver's attunement to the child's feelings, especially those of frustration are critical to healthy responses.  The child is supported to endure frustrations, disappointment, and find alternative ways to meet needs.  And, he or she learns the limitations of his or her and the caregiver's capacity to meet such needs.  The child learns to suffer and survive disappointment… or not.  The child becomes the adult eventually who deals with life struggles, accepts what he or she can or cannot do, and makes choices hopefully, that make life better rather than make it worse… or not.

MISMATCH FOR TEMPERAMENT
The caregiver who is out of sync with the child's feelings will intensify his or her sense of isolation and loneliness.  A myriad of issues can cause the adult to misinterpret, miss, or ignore the child's needs.  On the other hand, the caregiver may be attuned to the child or overly tuned in and respond inadequately and inappropriately to the distressful calls.  The caregiver over-indulges or responds quickly and excessively, thus limiting the child's practice of suffering through and dealing with distress.  Intolerance of distress is accompanied with demands for immediate caregiver intervention.  Some children take  "narcissistic positions of unusual intensity.  From a remarkably early age they are giving orders to adults and setting the tone of the household.  They are early said to have 'a will of iron,' the parents are helpless to manage them.  They insist on having their own way, they will not permit mother to talk on the telephone, they are endlessly demanding (often precociously so in their choice of objects of interest), and they struggle mightily to be the continuing center of household attention.  When other means to achieve this fail, they turn to their own bodies and complain of illness or pain or symptoms of different kinds.  Or, more commonly still, when denied the rewards of narcissistic gratification, they fly into a towering rage and would destroy, obliterate the authors of their pain.  The angry demandingness, prolonged screaming, and, occasionally, physical violence of their behavior mark them out as exceptional from their earliest years.  Sometimes the rage is turned against the self and they throw themselves to earth, bang their heads, and will not be consoled" (Noshpitz, 1984, page 32).

Some individuals are born with much greater intensity and/or sensitivity- a constellation of temperamental traits that express regularly in inherently stressful ways to and towards others.  Infants and children may be significantly more passionate and persistent than others for no apparent environmental meaning.  The genetic roll of the dice caused them to come out this way.  When overwhelmed, unskilled, temperamentally mismatched, and/or psychologically injured, although well-intended parents have the ill luck to have temperamentally difficult children, the children are less likely to get the nurturing boundaries, guidance, and discipline necessary to avoid problematic long-term characterological consequences.  If caregivers are emotionally healthy, they tend to be more resourceful and skilled (or acquire the resources and skills) to manage precursor behaviors so they do not develop into narcissistic personality disorder.  The child or individual's instinctive response can exacerbate his or her problems, especially if initial and subsequent caregivers are not attuned to his or her frustration. Some children are doubly cursed with in-born difficult temperaments and emotionally and psychologically stunted or distorted parents and teachers.

The child or individual may try "to maintain a grandiose stance in a large number of areas, and exhausts himself in a running battle to protect an impossibly large periphery. He wants to be teacher's pet, first choice for games (and to be allowed to win at whatever he plays), to be marked right for any answer he gives, and to be an exception to rules. All these situations become sites of encounter, his every contact with his social world is embattled, and he is constantly having to struggle with issues generated at these several boundary points. For him, life is not easy and he becomes vulnerable everywhere" (Noshpitz, 1984, page 21-22).  Feedback comes that he or she is not special and that others are not interested in catering to his or her whims and needs.  Normal and healthy development directs the child to find a balance between individual needs and fitting into, being functional, and accepted in the community.  Egotistical self-centered drives are balanced with disappointment and frustration.  Deferring personal needs help counter-balance gaining social acceptance and rewards.  From dynamic interplay between a sense of individuality and a sense of belonging and being a part of, the non-narcissistic child becomes an adult with a positive sense of self that incorporates communal responsibility and intimacy based on shared equitable exchange.

On the other hand, some children are unable to find a balance.  Early caregiver experiences may predispose them to seek egocentric goals to counter-balance deep invalidation.  Depending on how others, especially the first caregivers' respond, sometimes "the grandiose stance is so rewarding, the child seeks always to maintain and to maximize it.  A number of supplementary mechanisms are thereupon called into play. For one thing, he seeks out relationships, which will serve this end.  His friends are his admirers, people who will reinforce this sense of self and help maintain feelings of esteem.  If he does have a special talent then he will indeed utilize this to the utmost, and seek to capitalize on it.  To the extent that circumstances permit, he will be a snooty, stuck-up show-off, a snob, and a vain, self-centered, self-congratulatory peacock.  After all he has something others want, and they will have to pay to get it in the only coin that counts; they must laud him, be obsequious, fawn upon him, heap adulation on him, or otherwise act to reinforce the sense of specialness and vanity" (Noshpitz, 1984, page 22).  Instead of temperamental challenges, some children are fortunate to have inherently attractive interpersonal qualities. It may be physical attractiveness, a sense of humor, a quick mind, an intuitive sense of others, and so forth.  This child can be the teacher's pet, the star student, or the playground prince or princess whose skills socially, athletically, or otherwise are coveted by others.  His or her natural aptitudes and skills get amplified, but his or her greatest skill becomes the ability is to use aptitudes and skills to charm and impress others.  His or her attention or approval become the social currency aspire to among the community- first, the playground and later at work and socially.  Narcissistic charm and performance become ever more enhanced in to adulthood as he or she continually draws adulation to deposit in a psychically bankrupt account.  Others, who are unaware of the black hole of self-worth, believe him or her to be flush with self-esteem and confidence.  They are thus often shocked when seemingly inconsequential acts trigger the narcissist's intensely reactive and highly fragile sense of self into rageful vindictive aggression.

GENDER CONSIDERATIONS
When considering narcissistic behaviors, common perception is that men are more likely to be the culprits.  Narcissistic behaviors are sometimes considered to be on the outer range of a spectrum of socially acceptable, tolerable, and/or questionable male behaviors.  Women who behave in similar fashions may be looked at from dissimilar perspectives.  On the one hand, "Many acts are conceived of as more centrally narcissistic when performed by men than when performed by women" (Buss and Chiodo, 1991, page 196), and be judged more harshly.  There may be a certain expectation that such behaviors are typical of men or some men.  On the other hand, while such behaviors may be considered atypical of women, the judgment against female perpetrators may be subsequently harsher.  He might be a manly asshole, but she is a stuck up bitch.  Such derogatory labeling may represent differences in where and how grandiosity manifests or what is important due to gender training.  "Males appear to perform (page 201) a higher frequency of acts signifying lack of empathy (e.g., throwing stones at animals; displaying no emotion during the sad movie). Indeed, this cluster is the only one of the seven that shows significant sex differences at the composite level within both data sources...  (a table), showing acts for which female performance is reported by both data sources to be greater, reveals acts almost exclusively centered around physical appearance.  This includes asking others about her appearance, dressing extravagantly, sunbathing, showing off her figure, strutting around in sexy clothes, and commenting about how much weight she had lost.  The marginal exceptions to the greater female frequency of acts centering on appearance occur with the acts of spending a long time in the bathroom and getting mad when she did not get appropriate attention" (Buss and Chiodo, 1991, page 204).

Philipson (1985) looks at narcissism from the perspectives of both psychological and social pathology to explain the greater occurrence of males diagnosed as narcissistic in therapy samples.  Narcissism is considered to develop in early childhood from the difference between how boys and girls experience maternal treatment.  "The key to this problem may be in the social construction of the asymmetrical development of women and men in the period of early childhood, when the foundation of pathological narcissism takes form… it is possible to understand men's disproportionate appearance in the case material on narcissism as a reflection of the fact that narcissism—as a personality type and pathological disorder—denotes a way of being in the world that is primarily if not exclusively experienced by men" (page 215).  Philipson asserts that the professional conceptualization of narcissism "generally excludes women's developmental and intrapsychic experience."  Female development in the family and the resulting relationship needs of women may have important distinctions from male development and relationship needs.  This may result from how mothers view and experience their girls and their boys differently.  "Faulty empathy is premised on an inability to tend to a child on the basis of her or her own needs as they are expressed through verbal and nonverbal cues and signals.  Such inability is frequently the result of unconsciously viewing the child as another person (e.g., a brother, mother, father, husband), as an extension of oneself, or as embodying salient characteristics of a significant other.  When mothers view their children in such a manner, they seem to do so in a gender specific fashion.  That is, sons are most likely to be seen as husbands, fathers, and brothers, while daughters are seen as women's mothers or as extensions of themselves.  What this means is that a son is more likely to be seen as the other in his mother's unconscious projections, and daughters are more likely to be viewed as extensions of a self that is, to some degree, an extension of its own mother's, given woman's more fluid boundaries with the woman who was her primary caretaker (Chodorow, 1978)" (Philipson, 1985, page 220).

The therapist should be careful not to jump aboard onto a classic "blame the mother" theory of psychopathology.  There are other relevant possibilities and each individual may have a unique history or composite of experiences that have lead to his or her development of narcissism.  Nevertheless, Philipson's theory states that when a mother has poor empathetic connection and perception of her children, it has different meaning for her sons versus her daughters.  In the development of male identity, i.e., a masculine identity, the son needs to emotionally and psychologically reconcile ego boundaries about the female that he has initially bonded with.  "This otherness from the mother allows or requires a son to play the part of the object in his mother's unconscious fantasies and their actual emotional and behavioral manifestations.  He is the long-for father, the resented husband, the erotic object that replaces the absent or inadequate mate" (page 222).  In contrast, the daughter is the same gender as her mother.  Her process of individuation and establishment of boundaries with her mother do not have the same degree of separation nor usually require the same degree of intensity as the son's opposite gender process.  Since she shares her gender with her mother, the "process of separation from the mother retains a greater sense of connection and continuity than that which persists between mother and son.  Daughters therefore develop more fluid or permeable ego boundaries than sons and have a greater tendency to define themselves, or find their identity in relation to others."  Girls and women foster their relationship needs through establishing and sustaining intimacy through being close and staying in contact with important other people.  This is relatively simpler for females versus males since they are not challenged by the need to break the original bond with their mothers as part of developing their identity. Since a girl is the "same" as her mother, she can be "an extension of the mother's self or as a substitute for a woman's own mother, to whom the woman is still attached.  This asymmetrical situation therefore provides sons and daughters with different psychological and emotional resources with which to respond to a mother's faulty empathy.  A son may use his 'otherness' to rigidly defend himself against what he perceives as his mother's erratic or unempathic behavior, while a girl may fail to develop the ego boundaries that permit her to be psychologically autonomous from the mother whom she finds to be emotionally unpredictable" (Philipson, 1985, page 222).

While boys and girls may suffer similar disconnect due their mothers' emotional erratic responses or faulty or limited ability to empathize with them, gender issues may direct them to respond in different ways.  Low self-esteem, a deficient psychic structure, and "the deeply unconscious hunger for love that is at the root of the narcissistic dilemma is shared by both women and men.  But because women are reared primarily by individuals of the same gender, they develop ego boundaries that allow or compel them to feel esteemed and loved through identification or 'fusion' with others, prompting them to deal with this psychological impoverishment by acting as an extension of another.  Because men erect rigid ego boundaries in order to establish their gender identities in opposition to the women who rear them, their manner of managing such impoverishment is different" (page 225).  However between genders, it is more characteristic of men to exhibit grandiosity, high self-absorption, and desire to be admired by those around him.  "Through such display, the male reenacts the experience of being an other to his mother, dependent upon the praise and admiration that he cannot supply himself from internal sources."  The individual's assertion of being separate manifests in being self-centered and demanding outside admiration.  Being a separate self, including being admired moreover is a defensive strategy to identify mother and son as discrete entities.  In contrast, females are more prone to respond to the same needs through over investment and over identification with important intimate others.  Women with insecure and fractured psychological issues are more likely to soothe themselves by vicariously identifying with significant others' lives and achievements.  This duplicates the unhealthy mother whose sense of self was not clearly separated from but instead enmeshed with her daughter.

This theory has implications for couple therapy as well as for individual therapy.  When the couple fits into a classic pairing of a narcissistic male and a non-narcissistic female where each partner has the underlying psychic motivations described by Philipson, then therapeutic strategy seeks to guide the individuals towards developing more functional strategies to meet mutual needs.  The therapist should take care not be driven by gender assumptions about male narcissism- also known as prejudice, which can become therapeutic bigotry or blindness.  If however a male client seems to fit the theory, then therapy may attempt to facilitate his separateness within a healthier process in the couple's relationship.  His need to be validated by his partner's admiration and to be the center of attention may be supported to evolve into self soothing mechanisms that are not competitive with his partner.  His fear of being absorbed and submerged in the couple's relationship and losing individual identity can be more overtly addressed, and relational negotiations can be instigated.  The partner that submerges her identity to his needs, while originally deferring to his specialness can be exposed as also simultaneously threatening his independence and separateness.  The narcissistic individual feeds off of the adulation, but may also feel being absorbed by his partner, as he may have felt absorbed by his mother.  His childhood resistance activates against his partner as it activated against mother's incorrect assumptions of his feelings and needs being synonymous with her feelings and needs.  Ego separation for both partners then becomes a critical and viable goal of the relationship and therapy, as long as it supports the mutually acceptable and functional dynamics between them.

The therapist should be alert to similar dynamics resulting in narcissistic tendencies and character that do not fit the gender stereotypes discussed.  A woman can experience faulty maternal empathy that may not have been mitigated by same gender identification.  Family, cultural, individual, and environmental experiences can cause problematic maternal influences that overwhelm potential gender influences.  Women with narcissistic personality disorders or otherwise strong narcissistic tendencies may have been formed by faulty maternal empathy.  In addition, both male and female individuals can develop narcissistic compensations from highly faulty paternal empathy.  And, it can happen also from faulty parental empathy in families with same sex parent-couples.  The value of this theory comes in not only its possible application to a stereotyped constellation in a couple, but also the principle that parent to child misattunement for one or more reasons can lead to long-term or characterological emotional and psychological problems.  Identification of the process of misattunement can direct a healing, reparative, or restorative process of re-attunement for the individual and the couple.  Gender dynamics can be a relevant area to explore to find how misattunement began or persists.  Gender dynamics however is not the only area to explore.

CULTURAL INFLUENCES ON NARCISSISM
Rivas (2001) notes that the DSM-IV includes some discussion of cultural factors in its descriptions of disorders.  The clinician is encouraged to consider the influence of the client's cultural background when considering the relevance of a disorder.  "Cultural factors may be relevant to the likelihood of narcissistic personality disorder.  For example, Smith (1990) reported that Asian American women have significantly lower narcissism scores than Caucasian American women, explained by cultural values of modesty, respect for authority, and collaboration as opposed to individualism and other traits consistent with a narcissistic personality.  Martinez (1993) addressed the deliberately exaggerated sense of self (e.g., 'flamboyance') present in some Mexican-American adolescents, which could be mistaken for narcissistic personality disorder traits" (page 29).  The therapist must be wary of equating statistical or observational tendencies and probabilities with diagnostic determinism, i.e., if someone is male, then he must be narcissistic, or if someone is from a particular ethnicity, culture, society, or country, then "he" must be narcissistic or "she" must not be narcissistic.  On the other hand, the core attitudinal and behavioral characteristics of narcissism as is true of other sets of characteristics, will be valued and supported differentially within disparate communal contexts.  Gender expectations and models within mainstream American society, for example often value the assertive, outgoing, and charismatic qualities of narcissism among men, but less so traditionally for women.  The therapist should consider cultural expectations among the influences that create the personality, including narcissistic tendencies of an individual.  However, the therapist must also be aware of potentially multi-cultural influences within each individual, their interactive cross-cultural dynamics, and their interplay with other influences: experiential (including stress and trauma), family, economic, political, and so forth.  Any one influence may be a… or the key to change, or a mitigating factor to other influences.

"A substantial amount of literature suggests that narcissistic personality disorder is a culture-bound disorder. Therefore, clinicians must assess and diagnose individuals from different cultural backgrounds accordingly.  Integrating cultural sensitivity and dimensional conceptualization may help the clinician better understand how a client's narcissistic trait fits with their background experience.  For example, an individual from a cultural background where collectivism and cooperation were encouraged may present for treatment distraught because of a need for success and admiration from others.  They may exaggerate accomplishments and show arrogant attitudes.  While they could certainly be exhibiting signs of a narcissistic personality disorder, they could also be struggling with acculturation issues and may be doing the best they can to fit in and be accepted by others around them" (Rivas, 2001, page 31).  This clinical scenario may be characterized as a cross-cultural dilemma.  The individual may have learned collectivist and cooperative values that conflict with personal needs for acknowledgement and/or a cross-cultural valuing or practicality of expressed self-esteem, confidence, and individual accomplishment in a mainstream American academic or vocational world. Susan Cain, for example in "Quiet: The Power of Introverts in a World That Can't Stop Talking" (2012) describes an implicit valuing of assertive extroversion that permeates the American business, political, and academic worlds.  Many behavioral expressions of extroversion are comparable to behavioral expressions of narcissism.  The introvert may be characterized as culturally misfit in an extroverted encouraged society.  While certain cultures may validate and magnify narcissistic tendencies, cultures that validate deference and submission (especially, for subsets of the population: women or working class, for example), may encourage accepting being in a relationship with a narcissist.  It would be interesting to see if women from collectivist, cooperative, and non-confrontational cultures are more likely to become hyphenated American partners to narcissistic men.  For such individuals, there are multiple cultural influences that make accepting the narcissism to be more likely.

In addition to identifying cultural patterns based on ethnic communities, social groups, and countries, the therapist should be aware of how economic class validates patterns of behaviors and attitudes.  Specifically, upper class or privileged classes are more supported or indulged to exhibit narcissistic behaviors and attitudes.  Privilege may be from caste systems that are hereditary from generation to generation.  For example, someone may have aristocratic inheritance and thus, feel entitled to greater status, financial benefit, and deference from members of lower castes or classes.  Privilege may be a consequence of financial resources either acquired or inherited.  Privilege may be the result of academic, business, or intellectual status… or of media notoriety.  Privilege may also be the consequence of socially desirable physical or skill attributes, including physical domination and popularity.  Social forces asserting inherent genetics , determination by blood inheritance, or facilitating a meritocratic process may promote any or all of these privileges,.  The narcissist asserts a personal meritocracy where he or she has earned and/or deserves his or her entitlement.  The therapist often experiences high-achieving narcissists in couple therapy.  They may be CEOs, professors, highly affluent, leaders or pillars of the community, and other high status professionals.  They tend to present somewhat differently than socially, academically, or vocationally low achieving narcissists.  They are often more smug and assertive in expressing their sense of grandiosity and entitlement.  Their successful lives, status, and money confirm their specialness.  It is easier for them to be charismatic and they are often more interpersonally adept.  Society has confirmed their omnipotence.  They have proved their specialness with their accomplishments.  Communal values and models of high status whether inherited or earned tend to support the narcissistic drive to prove personal worth… and disprove personal insignificance.

The therapist should explore for any relevant communal cultural influences that encouraged or intensified narcissistic compensations for the individual.  This includes possible such influences over the course of the couple's relationship.  The therapist should also recognize the hierarchy in the narcissist's meritocracy or social aristocracy.  As highly as the narcissist places him or herself in the social hierarchy, the therapist can still assert the role of therapist as having higher status.  This is acceptable and appropriate in cultures with strong emphases on hierarchy (narcissistic culture is all about hierarchy!).  The role of the minister, shaman, wise person, or expert is greater than the aristocrat or the meritocrat.  Even the emperor defers to the specialized wisdom and skills of his doctor.  The therapist may be able to culturally assert him or herself as the doctor of relationships- the expert in the field of intimacy where the narcissist is not succeeding.

ETHNOCENTRISM AND NARCISSISM
In examining cultural influences on the development of narcissism, an important consideration is the relationship of ethnocentrism to narcissism.  An individual can have a strong sense of affiliation to some group or community.  The attachment can be very meaningful beyond functional benefits.  "This can include his family (however extended), his city, his city's athletic team (of whatever character), his gender, his profession, his religion, his university, his club, his nation, his race, and on and on for the myriad affiliations that characterize Western man. At the same time, all of these in fact form a part of the self, and their perimeters somehow come to lie within his own. For the European, an attack on Europe by an American may be experienced as a personal slight—suddenly he contains all Europe within him and fends off the intruder" (Noshpitz, 1984, page 19).  The attack may be verbal, symbolic, or it may be a military or terrorist attack with significant fatalities.  Americans motivated and activated by an attack on an overseas embassy, a Navy ship, a hotel frequented by Americans, or on American soil, can and have turned to vengeful responses.  Other individuals in other countries who perceive another nation violating their psychic or physical boundaries also can feel entitled to righteous retribution.  To a non-invested observer, the intensity of the sense of violation and the severity of the response may seem disproportionate to the harm suffered.  However, the injured is often adamant about the justice of the retaliation, and unable to consider alternative interpretations or responses.  Ethnocentric rage, righteousness, and striking out at perceived enemies appear very similar to narcissistic rage, self-righteous, and vindictive lashing out at partners.

"Ethnocentrism and narcissism have, therefore, very clear and explicit parallels, and ethnocentrism can be, and has often been, seen as group narcissism" (Bizumic and Duckitt, 2008, page 440).  If ethnocentrism may be seen as narcissism at the group level, narcissism within individuals of the group may be therefore considered an important contribution to ethnocentrism.  Ethocentrism, "a social attitude that incorporates the belief that one's own group is of supreme importance" (page 441) may be related to the grandiosity of the narcissist that he or she is the center of importance.  "Because narcissistic self-esteem regulation emphasizes self-importance and superiority (Bushman & Baumeister, 1998; Post, 1993), narcissists tend to see anything that is closely associated with themselves as grandiose, important, and superior. Thus, they should be likely to see their groups as important and accordingly may be ethnocentric. Evidence does suggest that narcissism seems to be positively associated with some facets of ethnocentrism, such as in group preference (e.g., Jordan, Spencer, Zanna, Hoshino-Browne, & Correll, 2003; Stangor &Thompson, 2002). Similarly, historical accounts suggest that some narcissistic leaders, such as Hitler and Stalin, also believed their groups were superior to other groups (Hershman & Lieb, 1994)" (Bizumic and Duckitt, 2008, page 442).

The narcissist uses his or her group to satisfy his or her own needs.  The attitude is exploitive and selfish and not reciprocal.  Little is given to the group.  While the ethnocentrism emphasizes the negative aspects of other groups and discourages fraternization, the narcissist is not particularly oriented to being close to those within his or her supposed group.  "Overt narcissists were likely to see their group as better than outgroups and to approve of exploitative attitudes towards outgroups, but were not particularly likely to approve of group preference and purity.  On the other hand, overt narcissists did not endorse group cohesion and were not particularly devoted to, or likely to sacrifice for, the ingroup.  The effects of covert narcissism were stronger and more consistent possibly because it is a purer expression of what is usually considered to be a narcissistic personality disorder given the presence of negative affect, psychological maladjustment, and low self-esteem (cf. Rose, 2002; Wink, 1991).  Covert narcissism may therefore reflect a stronger sense of personal self-centeredness than overt narcissism" (Bizumic and Duckitt, 2008, page 448-49).  The narcissist is in alignment with the group when there are conflicts with other groups.  The narcissist expects to gain personal benefit when his or her group gains an advantage and the other group losses out.  However, the narcissist will turn on his or her group if his or her personal interests may be diminished.  "This in particular has implications for narcissists as political leaders, given that in some situations they may have negative effects on their groups. Many narcissists strive for positions of political power, but their legacy and influence on their groups is often not positive (see Glad, 2002; Hershman & Lieb, 1994; Volkan, Itzkowitz, & Dod, 1997)" (Bizumic and Duckitt, 2008, page 448-49).  While such leaders provoke and exploit the nationalism of their citizens, emphasizing their specialness while pathologizing other people, they still hold themselves as more special.  "…to paraphrase the comments attributed to Hitler on the German people (Hershman & Lieb, 1994), seems to be: 'My group is better and more important than other groups, but is still not worthy of me'" (Bizumic and Duckitt, 2008, page 450).

The narcissist leader holds his or her needs as synonymous with the group's needs.  Narcissistic logic asserts that if it serves him or her, then the group must be benefited as well.  In practice, this can play out where the narcissist cannot distinguish his or her personal interests when they contradict and are even devastating to the well-being of the group.  The chairman of the board, the chief executive officer, the prime minister, or the narcissistic parent or spouse (the self-appointed and heretofore, uncontested leader of the couple or family) will commit or continue misdeeds that destroy the organization, business, government or country, or family or family members.  Unable to separate personal from group benefit, the narcissist will insist on what "we" must do and need and advocate strongly "in the best interests" of the group or family despite the harm it causes to the group or family and its members.  When the therapist directs the narcissist to the frustrations and injury suffered by a partner or family member, he or she will have difficulty seeing it.  It may be outright denial or the narcissist's inability to consider their interests being out of line with his or hers.  The attempt to activate narcissist's empathy fails because his or her "empathy" remains egocentric.  This is of course, a seeming contradiction to others but not to the narcissist.  Connection to the narcissist would be more likely if the therapist frames feedback from the egocentric self-serving orientation of the narcissist.  The best interests of family members or of the partner needs to be framed as serving the best interests of the narcissist- or at least, showing that others interests if not clearly compatible, are not antagonistic.


ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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