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Narcissist Therapy Notes

Uploaded 9/10/2010, approx. 4 minute read

I am Sam Vaknin, and I am the author of Malignant Self-Love, Narcissism Revisited.


What would the notes of a therapist upon a first encounter with a narcissistic patient look like?

Let us try to imagine.

Notes of a first therapy session with Sam V, male 49, diagnosed with narcissistic personality disorder. The therapist would have written the following.

Sam presents with anhedonia, failure to enjoy or find pleasure in anything, and dysphoria bordering on depression.

Sam complains of inability to tolerate people's stupidity and selfishness in a variety of settings.

Sam admits that as a result of his so-called intellectual superiority, he is not well placed to interact with others or even to understand them and what they are going through.

Sam is a hermit, a recluse, and fears that he is being mocked and ridiculed behind his back as a misfit and a freak.

Throughout the first session, Sam frequently compared himself to a machine, a computer, or a member of an alien and advanced race.

He talks about himself in the third person singular.

Life bemoans Sam has dealt him a bad hand. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves.

But then, he says, they fail to rehire him as a consultant. He seems to attract hostility and animosity, incommensurate with his good and generous deeds and intentions. He even describes being stalked by two or three vicious women whom he had spurned, or so he claims.

When he makes this claim, it is not without pride in his own implied virility and irresistibility.

Yes, Sam is abrasive and contemptuous of others, but only in the interest of tough love. He is never obnoxious or gratuitously offensive.

The therapist continues to note his impressions on his first encounter with Sam V, the narcissist, writes the therapist.

Sam is convinced that people envy him and are out to get him, persecutory delusions. He feels that his work is also a workaholic. He is not appreciated because of his elitist nature, high brow vocabulary and such. He refuses to dumb down. Instead, he is on a mission to educate his readers and clients and bring them up to his level.

When he describes his day, it becomes clear that he is desultory, indolent and lacks self-discipline and regular working habits. He is fiercely independent, to the point of being counterdependent, and Sam highly values his self-imputed brutal honesty and original, non-herd, outside-the-box thinking.

Sam is married but sexually inactive. Sex bores him and he regards it as a low-level activity practiced by empty-headed folk. He has better uses for his limited and precious time.

He is aware of his own mortality and conscience of his intellectual legacy, hence his sense of entitlement.

Sam never goes through established channels. Instead, Sam uses his connections to secure anything, from medical care to car repair.

Sam expects to be treated by the best but is reluctant to buy their services, holding himself to be there equally in their own field of activity.

He gives little or no thought to the needs, wishes, fears, hopes, priorities and choices of his ostensible nearest and dearest.

Sam is startled and hurt when they become assertive and exercise their personal autonomy, for instance, by setting boundaries.

He continues the therapist in his notes of the first session with Sam V, a patient diagnosed with narcissistic personality disorder.

The therapist says, Sam is disarmingly self-aware and readily lists his weaknesses and faults, but only in order to preempt risk scrutiny or to fish for compliments.

He constantly brags about his achievements but feels deprived. He says, I deserve more, much more than that.

When any of his assertions or assumptions is challenged, he condescendingly tries to prove his case.

Ifcase. If he fails to convert his intellect, he sucks and even rages.

Sam tends to idealize everyone or devalue them. People are either clever and good or stupid and malicious. But everyone is a potential foe or a potential source of narcissistic supply, at least for a short while.

Sam is very hypervigilant. He expects the worst and feels vindicated and superior when he is punished. He feels smarted and victimized.

Sam rarely assumes total responsibility for his actions or accepts their consequences. He has an external locus of control and his defenses are alloplastic.

In other words, he blames the world for his failures, defeats and bad luck. This cosmic conspiracy against him is why his grandiose projects keep flopping and why he is so frustrated.

End of the first session of therapy with Sam V, patient with narcissistic personality and soul.

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