Narcissism in Two Forms: Implications for the Practicing Psychoanalyst

There has been a great deal of controversy expressed in the recent psychoanalytic literature as to the etiology and treatment of patients with narcissistic personality disorders. The most intense disagreement has been centered around the largely contradictory theories of Heinz Kohut and Otto Kernberg. The clinically important distinctions between these two theories are outlined in this article. They include the differential importance each theory places on aggression in the etiology of narcissism and resistance in the treatment of narcissistic patients. A basic difference between these theories is the model they adopt for the understanding of the development of narcissistic pathology generally; with Kohut advocating a developmental arrest point of view, and Kernberg advancing a theory more consistent with classical psychoanalysis, that of an instinctual or structural conflict.

This article contends that the understanding of the narcissistic patient can be greatly aided by recognizing that each of these theories correctly assesses and treats a specific form of narcissistic pathology. Clinical data from the psychoanalytic treatments of two narcissistic patients are presented. As is indicated by this clinical material, cues that the practicing psychonalyst can employ in making the important distinction between the two forms of narcissism are offered. They include (a) the patient's response to the analyst's empathic interventions, and (b) the analyst's countertransference in relation to being an “audience” to the narcissistic patient. It is also suggested that there is a difference between patients with these two forms of narcissism in the way they convey aggressive material in the treatment situation.