Jane Fjermestad-Noll heads the outpatient clinic for specialized personality disorder treatment at Oslo University Hospital. She now feels ready to accept more people with narcissistic personality disorder for treatment. Research shows that they can be helped.

More people with narcissistic personality disorder should get help

They often behave so unpleasantly that therapists are not comfortable having them as patients. But people with narcissistic personality disorder need help. And treatment can help, says researcher.

It may sound like a contradiction. Why would a person with a grandiose self-image seek help?

But some do.

People with a narcissistic personality disorder have two sides to their personality: grandiosity and vulnerability.

“These patients come to therapy when they’re in a vulnerable phase,” says Jane Fjermestad-Noll.

She is a psychiatrist and researcher and heads the outpatient personality clinic at Oslo University Hospital.

Her field of specialty as a clinician and researhcer is the understanding and treatment of narcissistic personality disorder.

Help often sought when depressed

Fjermestad-Noll believes depression is perhaps the most important reason that a person with this disorder gets connected to psychological health services.

Patients often seek help when they experience a crash between their own sense of self and an external reality, such as when a job application is rejected.

In her doctoral work, Fjermestad-Noll examined the link between narcissism and depression.

Most narcissistic patients are referred for treatment with another diagnosis, like borderline personality disorder, or because of additional problems, she says.

“Anxiety and substance abuse are also common among these patients.”

Hard to spot

In depressive periods, the depression overshadows the grandiose self-image, making it difficult for the therapist to spot the underlying disorder, says Fjermestad-Noll.

After some time in treatment, the depression eases. Then the narcissism emerges.

“You can start with a very sick patient, only to find out that the illness is worse than you thought. But in a different way,” she says.

Challenging to treat

Treatment of these patients can take a long time. It is also very challenging to have them in therapy, says Fjermestad-Noll.

Rejecting patients with this disorder for treatment has been commonplace.

“A lot of therapists have a great aversion to this patient group. The patients sometimes act arrogant and belittle you. Many therapists don’t feel safe or competent enough to treat these patients.”

The risk of treatment interruption is high because the relationship between patient and therapist is put to such extreme tests.

Many therapists have also believed that this condition is permanent and cannot be treated.

As a researcher and clinician, Fjermestad-Noll does not share this opinion.

Limited understanding

Fjermestad-Noll believes we - including practitioners – still know too little about narcissistic personality disorder. Increasing our understanding is important to be able to treat people with the disorder.

“If we understand the loneliness, frustration and pain of being narcissistically disturbed, it becomes easier to accept these patients,” she says.

However, being left alone with patients with narcissism is not advisable. The therapist needs guidance during the therapy, according to Fjermestad-Noll.

When you are being devalued and perhaps even upbraided during therapy, you need to understand why the patient is behaving so abusively.

You also run the risk as a therapist of being seduced by the patient, she says.

People with a narcissistic personality disorder fight very hard to hold on to a grandiose sense of self that is normal when we are four or five years old, but which for the vast majority of individuals develops as we receive corrective guidance from the outside world.

Jane Fjermestad-Noll

Treatment can help

These patients can be helped by a combination of individual therapy and group therapy.

In group therapy, patients have the opportunity to practise social interaction that occurs in everyday encounters with other people.

They can develop a better understanding of how their feelings and thoughts impact their own and others' actions.

In connection with her doctorate at the University of Copenhagen, Fjermestad-Noll spent time at Harvard Medical School in the USA. There she learned how to provide both individual treatment and group therapy to patients with narcissism.

Ready to accept more patients

At Harvard, Fjermestad-Noll received guidance from Elsa Ronningstam, a pioneer in research on narcissism. Oslo University Hospital organized a recent professional day on this personality disorder, at which Ronningstam said their research shows that treatment works.

Fjermestad-Noll now feels ready to receive more patients with narcissistic personality disorder for treatment at the Oslo University hospital personality clinic.

“Right now we are treating a handful of patients with a purely narcissistic personality disorder,” she says.

Treatment also offered in Sweden

Sweden has started a project where they will use the same methods that have been developed at Harvard Medical School, according to Swedish newspaper Dagens Nyheter.

Psychiatrist Peder Björling stated that clinicians at Psykiatri Sydväst in Stockholm plan to use both individual therapy and group therapy.

Björling says that many people are afraid to take part in group therapy because they are afraid of feeling shame.

But when the treatment is over, most people say that the group therapy was the best, he says.

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    Shame is common

    Fjermestad-Noll says that the feeling of shame is often strong in this disorder, as in other personality disorders.

    She explains it like this: “The core of personality disorders is that the ego structure has not developed harmoniously. Something has gone wrong.”

    “Children start to show shame at the age of four or five. But for some children it doesn’t develop further. This may have something to do with their care environment in childhood,” Fjermestad-Noll says.

    “It might be that the child gets an unnuanced image of him- or herself – either by being praised for everything and told that they’re the smartest and best at everything, or the opposite, by the parents not being interested in their child at all.”

    Shame regulates social systems

    Either of these parenting styles could result in children not gaining a nuanced reflection of themselves.

    By not feeling shame, they miss out on learning to regulate themselves socially, says Fjermestad-Noll.

    She gives an example of a situation where a child is instead corrected by the parents in a healthy way.

    “If your child burps at the table and the parents say, ‘We don't do that at the dinner table,’ the child will understand that it isn’t right and will feel a little ashamed. But if the parents say, ‘It's ok, it's fine, but we don't usually do that,’ the child gets a more nuanced picture of the situation and learns that it's okay to make mistakes.”

    Can be life-threatening

    People with a narcissistic personality disorder fight very hard to hold on to a grandiose sense of self that is normal when we are four or five years old, but which for the vast majority of individuals develops because we receive corrective guidance from the outside world.

    People with this disorder will thus do whatever they can to avoid bringing on this feeling of shame.

    “None of us likes to be ashamed, but we tolerate it one way or another. Shame works in a socially regulatory way for most of us, but is completely intolerable for individuals with this disorder. An important part of the therapy is therefore to help patients tolerate shame,” says Fjermestad-Noll.

    People who have a self-image that is strongly characterized by feelings of shame don’t feel that they have done anything wrong. They feel they are wrong, she explains.

    “This feeling is potentially life-threatening.”


    Read the Norwegian version of this article at forskning.no

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