The Therapeutic Relationship in High Functioning Adult Narcissism and Asperger’s Disorder

Mark Thorpe Ph.DAUT University

AUT

Rhodes UniP.B.H.S.Magaliesberg

Tauranga BOPDHB Soren Larsen

Kaituna

Singapore Airlines1994

High functioning, adult, psychotherapy clients with traits of Asperger’s Syndrome are frequently misdiagnosed with Narcissism.

The therapeutic relationship may assist in the differentiation of Asperger’s syndrome from Narcissism.

Cluster B: Dramatic, emotional, erratic, Cluster B: Dramatic, emotional, erratic, impulsive, reduced empathyimpulsive, reduced empathy

• AntisocialAntisocial - - History of conduct disorder before History of conduct disorder before age 15, disregard for & violation of others rightsage 15, disregard for & violation of others rights

• BorderlineBorderline - - instability of interpersonal instability of interpersonal relationships, self-image, and affects, and relationships, self-image, and affects, and marked impulsivity.marked impulsivity.

• HistrionicHistrionic - e - excessive emotionality and xcessive emotionality and attention seeking.attention seeking.

• NarcissisticNarcissistic - - grandiosity (in fantasy or grandiosity (in fantasy or behaviour), need for admiration, and lack of behaviour), need for admiration, and lack of empathy.empathy.

Narcissism

Narcissistic Personality Disorder -DSM IV-TR

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five of the following:

• Grandiose sense of self-importance • Preoccupied with fantasies of unlimited success, power, brilliance, beauty

or ideal love• Believes they are "special" and can only be understood by, or should

associate with, people (or institutions) who are also "special" or of high status

• Requires excessive admiration • Sense of entitlement • Interpersonally exploitative • Lacks empathy • Often envious of others or believes others are envious of him/her • Arrogant, haughty behaviors or attitudes

Famous narcissists?

Neville Symington

Otto KernbergHeinz Kohut

James Masterson

Sigmund Freud On Narcissism 1914

Jeffrey Young

Some theorists on narcissism

Narcissism: therapeutic implications

Client is charming but takes up all the oxygen in the room and squeezes therapist out.

Kohut recommends empathic attunement and exploration of therapist’s empathic failures.

Kernberg recommends focus on systematic exposure of defenses against shame, envy and dependency. Important to challenge the client’s defenses.

Therapy better after mid-life when grandiose investments in beauty, fame, wealth and power have bumped into realistic limits.

Asperger’s Syndrome

Dr. Hans Asperger called them "little professors" because of their ability to talk about their favorite subject in great detail"

Dr Hans Asperger (Viennese physician)

History of Asperger’s Syndrome

1944 Hans Asperger; boys pattern of behaviour with normal intelligence & language development, but who also exhibited autistic-like behaviours.

Virtually unknown in English literature until 1981 when Lorna Wing published her review .

1994 added to the DSM IV

Only recognized by professionals & parents in the past few years

Many adults have been undiagnosed or misdiagnosed.

DSM-IV Diagnostic Criteria

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

Mental Retardation

Learning Disorders

Motor Skills Disorder

Communication Disorders

Pervasive Developmental Disorders

Autistic Disorder

Rett’s Disorder

Childhood Disintegrative Disorder

Asperger’s Disorder

Pervasive Developmental Disorder (NOS)

Andy Warhol

Albert Einstein

Emily Dickinson

Michael Angelo

People with possible Asperger’s Syndrome?

“It seems that for success in science or art, a dash of autism is essential. For success, the necessary ingredient may be an ability to turn away from the everyday world, from the simply practical, an ability to re-think a subject with originality so as to create in new untrodden ways, with all abilities canalised into the one speciality (Asperger 1979)

“If the world was left to you socialites, we would still be in caves talking to each other”. (Temple Gradin, an Aspie that became a successful engineer, author and academic)

Implications for the training of psychologists?

Diagnostic criteria for Asperger’s Syndrome Szatmari, Bremner and Nagy (1989)

1. Solitary No close friendsAvoids othersNo interest in making friendsA loner 2. Impaired social interaction (at least one of the following)Approaches others only to have own needs metA clumsy social approachOne-sided responses to peersDifficulty sensing feelings of othersDetached from feelings of others 

3. Impaired Nonverbal Communication (1 of the following)Limited facial expressionUnable to read emotion from facial expression Unable to give message with eyesDoes not use hands to express oneselfGestures are large and clumsyComes to close to others 4. Odd speech (1 of the following)Abnormalities in inflectionTalks too muchTalks too littleLack of cohesion to conversationIdiosyncratic use of wordsRepetitive patterns of speech 5. Does not meet the DSM criteria for Autistic Disorder.

Adult Asperger’s Assessment (AAA) (Baron-Cohen et al. 2005)

Qualitative impairments in verbal or non-verbal communication: Tendency to turn any conversation back to self or own topic of interest.Marked impairment in the ability to initiate or sustain a conversation with others. Cannot see the point of superficial social contact, niceties, or passing time with others, unless there is a clear discussion point/debate or activity.Pedantic style of speaking, inclusion of too much detail.Inability to recognize when the listener is interested or bored. Frequent tendency to say things without considering the emotional impact on the listener (faux pas).

Impairments in imagination:Lack of varied, spontaneous make believe play appropriate to developmental level.Inability to tell, write or generate spontaneous, unscripted or unplagiarised fiction.Lack of interest in fiction.

Tony AttwoodGoal of psychotherapy - understand and accept who you are

Therapy helps client achieve a realistic appreciation of who they are and to recognize their strengths more than their weaknesses.

Stages of therapy1) Understand the nature of AS and which characteristics are expressed in their personality2) Develop a greater understanding of the client’s self-representation.3) Develop a vocabulary and understanding of characterization and personalities.

Difficulties in making comparisons

NPD Theories developed since 1900

Diagnosis of NPD only starts in young adulthood

NPD people seldom enter therapy but just persecute the community in which they live. Second half of life or at times of severe crisis.

Professionals only aware AS since 1994 (DSM IV)

AS first diagnosed in childhood.

Therapists primarily treat children with AS referred by parents or teachers.

Many adults are undiagnosed.

The therapeutic relationship

Owen WalkerPleaded guilty; Criminal hacker to cyber-crime consultant.

Clayton Weatherston Blamed Sophie Elliott for taunting him

World famous in New Zealand

Therapist’s reactions (CT) – NarcissismFear and tensionSense of walking on eggshells to avoid precipitating narcissistic injury and rageAnger and desire for retaliationDiscomfort with intense scrutiny accompanying idealizationWish for client to terminate treatmentBoredom

Therapist’s reactions – Asperger’sFear of not meeting demands??Bored/detachedFrustration – shut out/disconnectedIgnored (no reciprocity)Desire to advise & communicate in an instrumental way

Empathy, Theory of Mind & Metalization

Mentalization Ability to understand the mental state of oneself and others based on overt behaviour. Imaginative mental activity, which allows us to perceive and interpret human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons). Linked closely to attachment.

Theory of mind Ability to attribute mental states (beliefs, intents, desires, pretending, knowledge, etc) to oneself and others. Understand that others have beliefs, desires and intentions that are different from one's own. Able to attribute thoughts, desires, and intentions to others, to predict or explain their actions, and to posit their intentions. Understand that mental states can be the cause of, and thus be used to explain and predict, behaviour.

Asperger’s

Mindblindness – inability to predict the beliefs and intentions of others.

Alexithemia – inability to identify and interpret emotional signals in self and others

Difficulty articulating perspectives and intentions of self & others.

Define personality by what they like to do or collect, rather than social network of family and friends.

Describe people using visible characteristics rather than describing and appreciating their mind.

Narcissism

Able to provide a complex, layered and differentiated description of own personality but not of others. Identity integration with concept of self (grandiose) but identity diffusion with concept of others.

Cannot link to deep inner feelings and thoughts (eyes closed exercise).

Asperger’s

Have a limited ability to express inner thoughts and emotions eloquently using speech. Difficulty processing the therapist’s speech and intentions. Therapeutic interaction is more confusing and stressful.

Reaction to intervention/advice - Narcissism

Double bind. Feel entitled to adoring, warm support - reinforces narcissistic pattern. Yet confrontation, even in the slightest degree, will be experienced as devastating criticism.

Reacts to the smallest hint of criticism from others with an attitude of “How dare you” and counterattacks recklessly. Indignant if not praised enough for accomplishments. (Benjamin 2003. p152)

Seductive & manipulative with an underlay of menacing aggression that comes to the fore when needs are not met.

Experience envy and resentment of those able to teach/help him. To depend on therapist is a terrible humiliating defeat (Kernberg)

Reaction to intervention/advice: Asperger’s

Appear to be more accepting of boundaries, limits and instruction. Need structure in their lives and therapy.

More accepting of own difficulties and able to request and receive assistance (recent inc in autobiographies self referrals)

Demand what is needed with no awareness of the negative effect on others. Therapist feels as if speaking into a black hole and had to be rude to put point across. Client becomes anxious and ignores therapist when needs not gratified, but gradually accepts the situation. Apparently not narcissistically wounded, do not collapse or become furious.

Overt similarities

Both may appear arrogant, aloof, rude, unfriendly and behave badly.

Difference lies in the reason/motive for behaviour.

Asperger’s: Neurodevelopmental deficit, lacks social skills, ‘does not know better’, unaware of reason and impact on the other. Intent – experimenting with social reality.

Narcissism: Defensive reaction to narcissistic injury. Actions are purposeful with (planned) sadistic intent to control and hurt. Aware of effect on others.

Impact on therapist/other is markedly different