Screen Shot 2017-07-14 at 9.07.51 PMThe legend is that Narcissus was a handsome Greek youth who rejected the desperate advances of the nymph Echo. As a punishment, he was doomed to fall in love with his own reflection in a pool of water. Unable to consummate his love Narcissus was said to stare at his image in the pool hour after hour and finally pined away and changed into a flower that bears his name Narcissus.Screen Shot 2017-07-14 at 9.12.22 PM

Screen Shot 2017-07-14 at 9.10.21 PMIn 1911, Otto Rank, a prominent psychiatrist, spoke of narcissism as being related to vanity and self-admiration. A few years later, Sigmund Freud thought narcissism was not necessarily abnormal. He distinguished between primary narcissism with self-love which is linked to self-preservation and secondary narcissism where there becomes limited ability to love others and the problematic development of megalomania.

In the 1970’s, Otto Kernberg wrote extensively on this subject and felt that there was a group of people who have an unusual degree of self-reverence in their interactions with other people. He noted that Screen Shot 2017-07-14 at 9.16.57 PMin these individuals, there was a great need to be loved and admired by others and a curious apparent contradiction between a very inflated concept of themselves and an inordinate need for tribute from others. He believed that their emotional life is usually shallow and that they tend to experience little empathy for the feelings of others. Such people obtain very little enjoyment from life other than from the tributes they received from other people or from their own grandiose fantasies and they feel restless and bored when external glory wears off. Dr. Kernberg wrote about techniques for approaching such patients in psychotherapy.


Screen Shot 2017-07-15 at 10.54.33 AMThe latest version of the Diagnostic Criteria Manual (DSM-5) from the American Psychiatric Association stated that a Narcissistic Personality Disorder is a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and a 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 recognize 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 associated 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 favorable 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 recognize 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 behaviors or attitudes.

It is possible and in fact is often the case that other mental health conditions may be simultaneously occurring along with a narcissistic personality. This might be depression or other mood conditions, or variations of psychosis, et cetera. The criteria stated above are provided for mental health professionals to make a psychiatric diagnosis. Different professionals may disagree whether an individual meets a particular criteria. Also, it should be obvious that only five criteria are necessary to make the diagnosis. Therefore, people with the same diagnosis might be quite different from each other. For example, an individual theoretically could be quite empathic and not be arrogant or have haughty behavior and still meet the criteria.

Any diagnosis should not be a derogatory value judgment of an individual. It is true that some of the above-criteria deal with being self-centered and not relating well to others which usually makes a person unlikeable. This is not always the case, sometimes a person with these characteristics may be quite charming and liked by others, as well as having other positive and endearing characteristics.

From my experience, it is true that people with narcissistic personality do not seek therapy as much as others do. But certainly that is not always the case. In fact, such a person may be particularly susceptible and even devastated by a “narcissistic injury” which would be circumstances which gives the person insight into their weakness, faults and vulnerabilities. Such a person may very well feel that he or she need help in dealing with these overwhelming feelings. Nevertheless, it still requires a set of specific circumstances for a person with narcissistic personality to decide to seek psychotherapy. Treatment of such of individual is often difficult and requires special techniques.



How We Heal and Grow: The Power of Facing Your Feelings by Jeffery Smith, M.D.

How We heal and Grow : The Power of Facing Your Feelings by Jeffery Smith, M.D.

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How We Heal and Grow: The Power of Facing Your Feelings by Jeffery Smith, M.D.

I was recently asked by my colleague and friend Dr. Jeffrey Smith, to write the Foreword for this new book that he has written. I was pleased to find it an excellent book. He offers a fresh and sensible way to look at how people develop dysfunctional patterns and facing feelings that have been avoided is the pathway to healing growth. He covers the full range of human problems from quirks to serous personality issues. He discussed the work of Freud, Mahler, Kernberg and many others including his own work. Interestingly the book is directed towards the lay public and I am sure will be received. However it really also belongs in the hands of therapists and any mental health professional who is involved with therapy. Dr. Smith has been teaching this subject to psychiatry residents and other psychotherapists for many years and is always very well received. He approaches the subject from a developmental point of view. He points out how most of us have pockets of immaturity and how to outgrow them. Dr. Smith  discusses how and why the minds resist change. One of the central themes of Dr. Smith’s explanations is the phenomenon of catharsis where our underlying raw unprocessed feelings emerge and lose their power over us and are transformed when we share them with a therapist in the context of connection and safety. He describes this process and how it brings about an almost immediate change to the pathological emotions. I tend to look at the need for catharsis as something that has to occur over and over again which we often refer to as working through process. We do both agree that catharsis is an ongoing part of therapy. While this therapeutic work does require the empathic presence of the therapist. Dr. Smith also examines how some of this work may be able to done singularly when the person is trained in mindfulness in the Yoga and Buddhist tradition. The range and scope of the book is quite wide. He includes discussion of anxiety symptoms, trauma and depression although I felt he was little light on this latter subject particularly in regard to the role of loss. There is fascinating discussion on the dynamics of Multiple Personality Disorder in which he is a one of the few therapists with significant experience treating patients with this condition. Dr. Smith also brings his rich  experience in treating addiction into the book. He shares where dynamics and developmental experience is important and where the here and now social interaction is crucial. Included in the book is one of the best discussions of conscience and superego that I have ever come across. There is also and excellent section on the narcissistic personality and a description of how to understand a parent who had this condition and how to deal with important people in your life who have it. This is really a unique book that should have great appeal to therapists, students learning therapy and people interested in understanding their own emotional issues as well as those around them. I can also picture how this book may be very useful for people entering therapy, It will alert them to what to look for in themselves. It may very well facilitate the therapeutic process. In fact, I plan to give a copy of it to some patients who enter therapy with me. I am very pleased to conclude that Dr. Smith has made an outstanding contribution to our profession as well as to the education of the public about mental health and the therapeutic process.


60,000 Empathic Responses

There is a website titled Postsecrets to which people send artistic postcards with a secret on it. Recently someone from San Francisco wrote a postcard indicating an intention to jump off the Golden Gate Bridge.
There was an outpouring of responses which resulted in special page on Facebook linked to this postcard on which over 60,000 people have responded with words of support. This phenomena as a form of social empathy is discussed.

In a recent blog I wrote about empathy and how we might try to teach medical students to be empathic physicians. Psychiatrists, other physicians and therapists try to put ourselves into our patient’s shoes (or skin) in order to understand how they are feeling in regard to the things which are troubling them. When we do psychotherapy we often approach this with an added dimension. We know that the patient will usually experience the therapist in a similar manner to how they experienced important people in their early life, most probably their parents and/or siblings. Freud has dubbed this situation as transference and for certain types of psychotherapy understanding the transference and using it in the therapy can be very helpful. In fact, for psychoanalytic and much of psychodynamic therapy, it becomes the essence of the treatment.

Social Empathy

I was recently made aware of another aspect of empathy which I never thought about before and which I would now label  “social empathy” . My consciousness to this form of empathy was raised when I read about a blog called Postsecrets which weekly displays anonymously mailed-in secrets on artistic postcards from across the country. It has been around for several years and has long been known for revealing suicidal secrets. It has set up a phone hotline in response since the blog began in 2004. Recently a postcard read, ” I have lived in San Francisco since I was young…I am illegal…I am not wanted here. I don’t belong anywhere. This summer I plan to jump off the Golden Gate Bridge.”  According to a blogger Kristi Oloffson .within 24 hours nealry 20,000 people had signed up for a Facebook group titled “Please Don’t Jump, which was later linked beneath the secret on the Postsecrets blog , linking in thousands of supportive comments. On the group’s page, sympathetic users posted comments ranging from simply “I want you here” to “If I knew when you’d be at the bridge, I’d drive all the way from Ohio to meet you there, and hold you until you changed your mind.”  A video about this phenomena has become the most viewed video on the Time Magazine web site.  ( For information about the issue of suicide from the Golden Gate Bridge please see two previous blogs I have written on this subject , Suicide Jumpers From the Golden Gate Bridge and  More on Jumpers, The Movie ).

I checked it out and sure enough and as of this writing there are more than 60,000 people  who have tuned in to this secret and obviously felt an empathic response which they posted on the Facebook site. It may have been that this group comes from a populations which were drawn to the  Please Don’t Jump Facebook page because  they themselves are in touch their own secrets and feel for someone who has this one.  Others without being aware of their own secret may also just want to reach out to someone else whose pain they can feel. It is also clear that people responding to the would be San Francsico jumper are not mainly other immigrants who are in a similar plight. They seem to come from all age groups, geographic areas and different backgrounds as best as I could tell scrolling through a sample of the now more than 60,000 responses.  I believe that it is the identification with loneliness  and isolation which  is the universal  piece that many people have felt at some time in their life which is connecting people with the San Francisco postcard sender.

Implications For Psychotherapy

I don’t believe that social medial will replace the role of psychotherapy. However, it does appear that there is a natural role that it is playing in the support of people who are feeling psychological pain. This new media is clearly interdigitating with other  forms of psychological support and there is no reason whey they can’t overlap. We should be asking patients if they have had  previous psychotherapy, whether they have been treated by any self help groups as well as including an an inquiry whether they  have been interacting with the social media in regard to their current or other problems.

Can We Teach Empathy?

It may be possible to identify medical students who have good empathic qualities during the medical school admissions interview. A technique is described where video clips of simulated patients interviews are shown to students in the classroom in order to teach them the best empathic responses. An empathic response can also be demonstrated to students during the teaching of medical interviewing at the bedside with real patients.
Medical students can show resistances to being taught how to respond empathically. Life experience may be the best teacher of this important quality for physicians.

This week’s blog is based on a blog I recently wrote for “Couch in Crisis” which is on the website of Psychiatric Times. It was reprinted as an essay in the printed edition of Psychiatric Times.

Please note: During the summer period June 16- September 22 this blog will appear biweekly and then will resume as a weekly blog on September 22nd

Some Have It and Some Don’t

Empathy is the ability to put yourself in someone else’s shoes and understand what they are feeling. This is something that psychiatrists try to do in our everyday work. Those of us who have worked in medical schools have struggled with the question of whether or not we can teach this to young men and women who are learning to be doctors or whether it is something that they either have or do not have. Certainly I have seen medical students who seemed to be decidedly lacking in this quality just as I have seen students to whom it came very naturally and some who were far more empathic than I was as a student or even after years of experience.

Choose Empathic Students in the Admission Process

I have gone through many phases in trying to figure out how medical schools can graduate doctors who have this empathic quality. My first thought was to try and influence the selection process so students who seemed to have this natural quality would be chosen. I had the opportunity to join the admissions committee of the medical school where I taught and participated in the interviewing and selection of prospective students.

Actually there were a few psychiatrists already on the committee along with other medical specialists and basic scientists who would be training the students in their preliminary non-clinical years. It was relatively easy to determine which students had this quality in abundance and which students did not.  I could see the tears in a student’s eyes as they told me about experiences which they had known someone who had been ill or disadvantaged and how this had motivated them to want to be a doctor. I remember the caring response of one student to me as I was suffering with allergies with my eyes running on a particular day that I was interviewing her.  On the other hand I could detect the intellectual response of students who ticked off their many volunteer activities or told of their dedication to finding the cure of cancer because it  would then increase life expectancy. However when it came down to the votes on the committee, despite my efforts,  a student being the most empathic would never trump the one with potential to become a world famous doctor.

Trying To Teach Empathy in the Classroom

I had opportunity to see if it were possible to teach students to be empathic. It was traditional in our medical school for psychiatrists to teach students interviewing technique both in formal lectures and at the bedside. In preparation for a formal lecture I made a video tape (we were not yet using DVDs) in which I had some senior students act as doctor and patient in a hospital room in various scenarios. In one of them the “doctor” asked the “patient” if anyone in their family had a cancer. The patient began to cry and said her daughter died of cancer. I then showed three possible responses. In the first one the doctor just continued with the interview and kept asking questions. In the second scenario, the doctor got up and excused himself and said he would come back later when the patient was feeling better. In the third case the doctor offered the patient a tissue and said that he was sorry. Obviously the third  vignette was meant to be the correct one and most students seemed to get it. However, a group of Asian students approached me after the lecture and told me that they did not agree with the choice of the best vignette. In their particular culture it was a sign of respect to let a patient be alone by themselves in that particular situation. Excusing one self and walking out of the room was the correct response as far as they were concerned.  So I began to realize that this was not an easy task.

Trying To Teach Empathy at The Bedside

Each week I would take a group of three students to an actual patient’s bedside to practice doing an interview. The patients knew they were “students in training” but usually responded to them as if they were doctors taking a history from them. On a particular day, before  we entered the room, I told the student who was to do the interview that sometime during the interview he must use the following words, “ that must have been very difficult.”  The student proceeded with the interview with the other two students and myself standing by the bedside. At one particular point in the interview the patient started to talk angrily about how she hated to go through all these tests when she knew she was going to have an operation anyway. The student was a little flustered by the patient’s emotion but then he remembered and said, “That must be very difficult.” The patient’s demeanor changed and she continued in a very friendly and cooperative manner. At the end the interview the patient remarked to all of us that “this doctor was the most caring physician that I have seen in the hospital.” In our post interview discussion the student was beaming (his overall interview actually was quite poor). I asked why did he think that the patient thought he was so good. He couldn’t answer, apparently feeling he had just done a good job. The other students understood and were able to appreciate the value of the comment that he had made at the right time. However the next week I suggested the same technique to another group of students who objected to this approach. They felt it was artificial, phony and they did not want to be actors when they were trying to be doctors. Other groups had similar responses. This was another indication of how teaching medical students to be empathic was quite complicated.

Life Experience Teaches Empathy

After several years my teaching and clinical work took me away from this particular type of medical student teaching. One day however, I encountered the following situation. I was a psychiatric consultant called to difficult situation in the medical emergency room.  A male patient in his thirties with multiple traumas did not survive a motor vehicle accident and died in the Emergency Room. The mother of the patient became hysterical and out of control. Nobody could calm her down. A first year medical resident (two weeks out of medical school) was the only one to stay in the room with her while she screamed and berated the hospital, the doctors and the medical system. After he patiently stayed with her during the tirade, he gently asked if there was anything he could do for her. She said, “Yes, remove the damn tube from his mouth” (the breathing tube from her son). While he knew this was not usually the procedure because of the preference of the medical examiner, he did so in her presence and then turned to her and asked if she would like to help him clean up the body. She agreed to do so and he asked the nurse for a basin of water allowing her to clean her son’s face. He stayed with her  until she was ready to leave. When I asked him later how he felt and how he was able to do this, he told following story. Recently his best friend had died. In his own grieving, he repeatedly thought of how painful it was for his friend’s mother and how he had imagined such a loss would affect his own mother. He also recalled how his friend’s mother said many times that she was bothered by seeing the IV lines  in her son’s arm after he died.

The  capacity for empathy does vary from person to person . We need to provide teaching and mentoring to our students on this subject  and we need to listen and be empathic to them in regard to their previous experiences. It is no different than our obligation to be empathic to our friends, family and especially our children. This will make future generations, better doctors and better people.