Narcissism and Its Discontents

Dr. Glen Gabbard (00:09): Narcissistic personalities that they don't feel distressed, that they only are bragging about themselves and ignoring their responses of others. But many narcissistically organized people are terribly sensitive to what people think and say or to being ignored.

Dr. Holly Crisp (00:30): And so I think to add to what Glen is saying, Laura, the idea of someone who isn't achieving what they had hoped to achieve in their life, someone whose relationships are failing or who is looking up in middle age and saying, "I'm never going to be able to achieve professionally what I had pictured for myself." Sometimes that gap can be really difficult for people to face.

Dr. Laura Roberts (00:59): Hi, I'm Dr. Laura Roberts, editor-in-chief for the books portfolio of the American Psychiatric Association. Welcome to the APA Books Podcast. The APA Books Podcast is an opportunity to hear the voices behind some of the most prominent psychiatric scholarship in the field today to learn about what motivates these authors and see how their ideas are making an impact in clinical research settings throughout the world.Today, we'll be talking with Dr. Glen Gabbard and Dr. Holly Crisp, who recently co-authored a wonderful book entitled, Narcissism and Its Discontents: Diagnostic Dilemmas and Treatment Strategies with Narcissistic Patients. This text is filled with clinical examples and rich narrative and guidance from really outstanding experts in the field, helping practitioners learn optimal strategies for caring for really complex patients with narcissistic personality disorder. And their approach is to help clinicians develop approaches that are very specifically tailored to the needs of their patients. Well, I wanted to thank you so much Glen and Holly for talking with us today. Let me start by reading this quite lovely quote from John Gunderson, who's a professor of psychiatry at Harvard Medical School, praising your book. What he says is that, "This book is compassionate, clear and wise and reflects perspectives that can only come from extensive clinical experience combined with illustrative vignettes and elegant prose. Clinicians will find it as absorbing to read as it is instructive to their practices." It's pretty high praise and I have to say I agree. I think it's beautifully written and a hard, hard topic. Really a tough patient population for the suffering that they experience in their lives and then also the kind of challenges that clinicians experience when they're caring for narcissistic patients. So can you just tell me a little bit about what led to the motivation for developing this book at this time?

Dr. Glen Gabbard (03:05): Holly and I have both treated a great many narcissistic patients and we have often been puzzled about what exactly do we mean by a narcissistic patient. And this is a term that is problematic because in a common parlance narcissism is almost always pejorative. You never hear anyone say, "Gee, that person has great narcissism," meaning that the person has high self-esteem so that it's a very difficult diagnosis to give to a patient or the patient's family because no one likes to hear that. So this is one of the things that has vexed us for a long time in our work with patients and we thought there needs to be a book that examines all the ways that the term is used and when it is misused.

Dr. Holly Crisp (03:58): One of the things that we found as we were discussing this over the months and years is that it was an extraordinarily complex topic that there are some narcissists or people with narcissistic styles of interacting with other people that are very belligerent and grandiose and over the top. And there are others who are much more sensitive. There are people where their narcissism is right out there where you can't miss it the moment they walk into a room and others where it's much more subtle. So we wanted to better understand all of those dimensions. I think one of the things I really felt is that we often have such a negative connotation when we think about these folks, but in talking with Glen or in Glen talking with me, it was clear that both of us really actually like working with patients with these kinds of struggles. There's something very satisfying as a clinician in getting to help someone get to the root of their esteem problems.

Dr. Laura Roberts (05:02): I'm going to read a paragraph to you from your preface that I think relates to the ideas that you're talking about and you say, "We recognize that narcissistic personality disorder is not well understood. It's a moving target that can vary from day to day in the same person. There's also a spectrum from healthy to pathological narcissism. Different approaches may be necessary to address the various locations on the continuum. Some forms of narcissism are regarded as developmentally normal at a particular age while appearing pathological another. Differentiating healthy from pathological narcissism is a difficult process." Could you comment just a little bit about healthy narcissism and developmentally appropriate narcissism and what we would think of as pathological problematic narcissism?

Dr. Glen Gabbard (05:45): Well, first of all, healthy narcissism would be synonymous with healthy self-esteem. And we often talk about healthy self-interest, speaking up for yourself, advocating for yourself as opposed to pathological narcissism. And the two get blurred quite a bit. And certainly in a developmental sense it would be completely normal for a five-year-old to be saying, "I want this and I don't care what my brother wants." But also in adolescence, we would say there's an increase of narcissistic focus because adolescents are so acutely and they may Photoshop a picture of themselves to put on the internet for others to see in a way that many would see as narcissistic, but could be developmentally appropriate, versus a 50-year-old who would be Photoshoping a picture and putting it on the internet. So age has a lot to do with it and developmental hurdles.

Dr. Laura Roberts (06:50): Tell our listeners a little bit about what kinds of issues lead a person with narcissistic personality or narcissistic issues to come and see a psychiatrist.

Dr. Holly Crisp (07:01): Well, one of the things that we've observed is that it is sometimes not the actual person with the narcissistic struggles that is bringing him or her to seeing a psychiatrist. Sometimes it really is the parents of a young adult or the spouse or partner, or sometimes it's even the employer. It's other people in the person's external life who are saying, "Gosh, I'm really frustrated by feeling alone in this relationship because you're so self-absorbed. Or if things don't change in our relationship or in our work life together, I'm not going to be able to continue to be in this with you." Sometimes it's an outside force that compels the person to come. I do think we also see people who after a disappointment, we might call it a narcissistic injury. So a job loss, a series of relationship failures. Aging is really difficult for people who are narcissistic. These are some of the things that bring people in to try to understand and get some support about what's going on with their self-esteem regulation.

Dr. Glen Gabbard (08:13): A certain kind of person feels that they are going through life without being appreciated, without being understood, that everyone fails them. And this is a fairly common presentation of a patient where someone will say, "Nobody gives me the recognition that I deserve." Other people get recognition and I don't. This is an extremely important issue, Laura, because I think there is a stereotype of narcissistic personalities that they don't feel distressed that they only are bragging about themselves and ignoring the responses of others. But many narcissistically organized people are terribly sensitive to what people think and say or to being ignored.

Dr. Holly Crisp (09:05): So I think to add to what Glen is saying, Laura, the idea of someone who isn't achieving what they had hoped to achieve in their life, someone whose relationships are failing or who is looking up in middle age and saying, "I'm never going to be able to achieve professionally what I had pictured for myself." Sometimes that gap can be really difficult for people to face.

Dr. Laura Roberts (09:28): What I love about what you're saying is really developing an empathic connection with what may be considered to be, quote, the typical difficult patient or the hard to like patient. But really the essence of the psychotherapeutic relationship is finding that empathic connection that you're describing.

Dr. Glen Gabbard (09:46): And that's a critical factor in the treatment and informing some kind of therapeutic alliance with them. One of the things we say in the book is to slightly paraphrase Thoreau, "They live lives of noisy desperation." Not quiet desperation because often they're very vocal about what they're not getting and they can turn off other people. And when they finally come to see a mental health professional, this person can empathize, tune into what their dilemma is and they can feel understood for the first time.

Dr. Laura Roberts (10:20): And have an extraordinary sense of hope then.

Dr. Glen Gabbard (10:23): Yeah.

Dr. Laura Roberts (10:23): So would you say that when you approach the care of narcissistic patients, that you feel very hopeful?

Dr. Glen Gabbard (10:28): It all depends, I would say that because since there's this continuum, we know at the outset whether someone is likely to be able to use therapy. We have to say this, "There's a high dropout rate because many of the narcissistic patients feel they're not getting the recognition or admiration that they see." And another thing, and Holly you may want to speak about this, some narcissistic patients can't take the least bit of confrontation or the idea that they are responsible for some of their problems.

Dr. Holly Crisp (11:01): Well, I think one of the things that Glen and I had talked a lot about in working on the book is the idea that people, even with strong narcissistic vulnerabilities, can actually get better. Can feel better, can feel empathized with and understood by the psychiatrist even if they don't undergo a fundamental character change. We're not always in there to try to change the person's ability to look at themselves or to see how he or she may play a role in the struggles in his own life. Sometimes people really can't handle that, but can truly get better from feeling empathized with and understood. So in that way, Laura, I do think it's very helpful.

Dr. Laura Roberts (11:46): Yeah, it's great.

Dr. Holly Crisp (11:47): What I would add, Laura, is we would see a whole spectrum of different kinds of psychotherapy as being useful depending on who the patient is. In the book, we say, you have to tailor the therapy to the person. And some do well with supportive therapy because they feel somebody understands them. Others can use highly expressive treatments like analysis or analytic therapy. It all depends on what capacity they have to look at themselves. Some people need a much more sort of assertive, confrontational approach and really need the therapist to hold a mirror up and say, "Look at what you're doing in your own life. Other people would run screaming if we approach them like that. So I think a big premise of what we're trying to argue is to really tune into the person as you're making the clinical assessment about what does he or she need in the treatment.

Dr. Laura Roberts (12:40): So you talked about the patient who comes because others in their lives are distressed, but they may or may not feel a high level of distress. How is that different in your initial approach from the patient who comes, who feels deeply misunderstood, unappreciated, and is in distress in seeking help?

Dr. Glen Gabbard (13:00): I wish we were experts at treating the person who comes because they are sent. One strategy I've used in the past is to have the spouse or partner come with the designated patient because if the spouse or partner has sent the person saying, "You have got to get treatment," they may feel victimized and may not be able to convey to the therapist why they're there. So if the spouse or partner is there, you get another point of view about what the problems are. And in fact, sometimes couples therapy can be very useful for these people.

Dr. Holly Crisp (13:38): I think it's critical to hear from the person what he wants to change. So after the initial assessment and the spouse comes in or the boss sends the person to hear what those concerns are, of course at the beginning, but then to really get into a private conversation with the patient in which we say, "What are your concerns?" It may not be what your wife is worried about or what your partner is worried about. What are you struggling with? Is there something that we could do together to address your concerns as well? I think we don't get very far with someone who doesn't want to be there.

Dr. Glen Gabbard (14:16): One of the things that we have done for years is evaluate physicians who get into trouble with hospital, risk management committees or licensing boards and they're sent for an evaluation. We've seen a fair number of narcissistic personalities in that group and one of the things that we try to do is help them mentalize how they are viewed by others. If a surgeon is screaming at someone who is much lower on the hierarchy of the hospital, during the surgery, we say that can make this person feel so distressed that they make an error in the surgical procedure so that we're trying to get them to think about how other empathize and mentalize would be too good words that we would use a lot with those kinds of people.

Dr. Holly Crisp (15:08): I think at the same time with Glen's example of the surgeon, we would also want to be talking to that surgeon about what are his experiences that are going on that are leading him to get so upset and angry. Because usually there is a combination of feeling somehow narcissistically injured or overworked or overburdened that is contributing to that. So we would want to get both perspectives.

Dr. Laura Roberts (15:30): I think in the very last paragraph, I think of the book, you talk about how life events can really facilitate a constructive milieu in which therapy can get traction, make a difference in the person's life. And what you say is a significant percentage of narcissistically organized patients are capable of rethinking who they are and what they're looking for. And many require more than one attempt at treatment before they can use what the clinician has to offer them. Moreover, timing may be of great importance. If they're reeling from a narcissistic wound, they may be more motivated to do the difficult work of treatment and drop their defenses for long enough to see what festers within them. We clinicians also need to remember that we are not only the vehicles for change and that life experience may be our ally in the long and arduous effort to help our patients know themselves. First of all, I think it's just beautifully, beautifully written, but a very, very important insight to leave the reader of this book with, which is to put the patient in context and think about their life situation and how you can align with the life situation to help the patient do well. Can you comment just a little bit about how did that become the final statement of your book in speaking to this particular readership?

Dr. Glen Gabbard (16:50): Well, it partially grew out of Elsa Ronningstam's study where she followed up changes in narcissism over a three-year period in a follow along study of 20 patients. And parenthetically, Laura, one of the real problems in the field as we don't have randomized controlled trials of the psychotherapy of narcissistic personality because it's been so difficult to identify who these people are and put them in into a study that's as random assignments. So we have to go with these follow along studies like Ronningstam's, which shows that even in the absence of treatment, people will have life experiences that change them. And it could be a lover rejecting a narcissistic person or-

Dr. Holly Crisp (17:41): Or the opposite.

Dr. Glen Gabbard (17:42): Or the opposite. Someone who loves them or a boss that fires them that because of a major crisis, they start to think inwardly reflecting about themselves for the first time. And that does give some hope. These are not totally hopeless people at all.

Dr. Holly Crisp (17:57): I think part of how this made it to the last paragraph is I think our own efforts to be humble in our ability as psychiatrists and mental health professionals to make changes. Sometimes these things happen very slowly. The treatments with narcissistic patients are some of the longest treatments in our practices. There can be moments both for the patient and for the psychiatrist that it's difficult to hang in there or that the patient may drop out or that we may wish we could pull back. And to remember that we aren't in this alone that the patient also is dealing with her own struggles in her own life that are also leading to change. We do feel this hopeful.

Dr. Laura Roberts (18:43): So tell me a little bit more about the structure of the book, about your writing process, how you worked through the particular structure of the book and then wrote it together.

Dr. Glen Gabbard (18:54): Well, the way we had the idea together is we were discussing the problem of narcissistic patients that we see and we decided that we didn't want a lengthy textbook that provide some kind of definitive way of treating these people. We wanted to talk about it more as diagnostic problems that arise and then treatment strategies for common problems so that it's more of a monograph with very specific issues rather than the global way of treating narcissistic people. We divided it into the diagnostic dilemmas like how do you make the diagnosis. Especially given a culture of narcissism that cyberspace has certainly contributed to. Everybody is famous. And then also the treatment problems of transference, counter transference, termination, how you begin the treatment and tailoring the treatment to the individual, which often takes trial and error.

Dr. Holly Crisp (19:55): One of the things that was delightful from my perspective, was having a chance to write with Glen as someone who has so much experience writing many, many books over years. It was great fun to spend the time brainstorming together, to throw a bunch of ideas out and watch how that coalesced into different chapters to read various sections that both of us have written and to give feedback and think about what we have missed. Being people of two different generations and two different genders, it was also really interesting to see how we had different perspectives on working with the same population of patients.

Dr. Glen Gabbard (20:32): Laura, Ethel Person once said that she wrote to figure out what she thinks. And I think Holly and I would endorse that same notion because it was hard to say exactly what we thought about the phenomenon of narcissism until we sat down, read what Elsa has been written and thought very specifically about what do we mean by that word, and who are these people, and what do they feel inside?

Dr. Laura Roberts (20:59): One of the great strengths of the book, I think, is that you do try to include whatever research is out there. It is an underdeveloped area, but I think you do a wonderful job of bringing in what's known. Can you tell me a little bit about how you've seen the research in this area inform your thinking and perhaps change your thinking about the care of narcissistic patients?

Dr. Glen Gabbard (21:21): Well, first of all, there is a body of empirical research that looks at subtypes. That was very helpful. The research is consistent in showing the difference between a grandiose narcissist and a vulnerable narcissist. They require quite different treatment. The grandiose narcissist is someone who is entitled, boastful, who is oblivious to the needs of others. The vulnerable narcissist is someone who is acutely sensitive to reactions of others and may constantly feel wounded by the way that people are treating him or her. So on top of that, that's the major difference. But research has also identified a third type called the high functioning narcissist. Do you want to comment on that?

Dr. Holly Crisp (22:12): We think this is one of the newer subtypes that we're seeing in the research that we've both seen a fair bit clinically. This third subtype is a higher functioning narcissist who may be initially charming and well-spoken and engaging for the therapist to work with. But over time, what the therapist starts to feel is a sense of there's not the mutuality here that I was expecting. Or a sense that it's difficult for the patient to maintain a narrative continuity over time. So week after week, you feel like you're starting over.

Dr. Glen Gabbard (22:54): May I add some?

Dr. Holly Crisp (22:55): Yeah, please.

Dr. Glen Gabbard (22:55): Another characteristic of this is they don't really take the treatment seriously. They act like they do. They go, "Oh yes, good point." But like Holly says, they don't work on it between sessions. What they end up doing is telling stories that have themselves as the centerpiece of the story often in this heroic kind of position of being the person who saved the day. It grows on you very slowly because they can be quite charming and they look you in the eye like they're really listening intently. But it's very similar to what is known as the false self by Winnicott, the idea of someone pretending to be an interested party who cares about you, but it's really all about them.

Dr. Holly Crisp (23:39): And you can imagine that the relationships of people in their lives with these different types of narcissistic personalities will have different qualities. Just like in the psychotherapy or the mental health treatment, our counter transference will have a different quality. So for example, with this third subtype, we're talking about the high functioning variant. The therapist may initially feel charmed by this patient, which shifts over time to more feeling chilled or feeling distant, versus with someone who's the more grandiose subtype, the therapist may feel demeaned or condescended to, or as if they're getting shut out of the therapy. And with the hypervigilant subtype, the therapist may feel like he or she's walking on eggshells trying not to hurt the feelings of this very sensitive person. So a part of what we are trying to address is to put together the research data with the clinical data so that we as clinicians can figure out how best to approach these different types of patients and to help them also with their external relationships.

Dr. Glen Gabbard (24:45): And one other comment I'd like to make about research is that research is way behind the clinical writing and clinical knowledge. You may recall, Laura, that when DSM-5 was organized, there was consideration of changing the personality disorders and the initial work group thought we should throw out the diagnosis of narcissistic personality disorder because the data were confusing. It wasn't clear what we really meant by it. What happened was there was a backlash of clinicians who thought, "Well, we see these patients constantly in our practice. Just because we don't have systematic research that clarifies the diagnosis, let's keep them in DSM-5 because clinicians are seeing them all the time." That captures something about the difference between the clinical view and the research view. Our goal was to sort bring these two different worlds together so that our book features both clinical practice and what research knowledge we have.

Dr. Laura Roberts (25:49): That's wonderful. I mean, as you're describing it though, the subtypes do seem very different. Their lived experiences is different, how they interact with other people is different. What would be your best advice in terms of the core element that exists across all of these subtypes of narcissistic personality? And also what you might foresee in the future as we begin to differentiate them more completely?

Dr. Glen Gabbard (26:18): Well, a succinct answer to that would be difficulty regulating self-esteem. That would run across all of the subtypes that would appear differently to some degree. And that's what you listen for when you're evaluating somebody. Here's a difficult thing about it. Almost everybody that you know will have narcissistic injuries at times and feel their self-esteem is suffering. And then the issue is, "Can they bounce back from that? Can they take a reflective look at what that's about versus fall apart completely?" Even though the grandiose type may appear oblivious to what other people are thinking, you have to realize that's a defense against seeing or hearing criticism. And underneath, they may be quite fragile. And sometimes it takes a while to get to know them well enough to see that the person has a narcissistic core. It's a common experience of therapist to be working with somebody for quite some time before they really see how everything revolves around a self-esteem regulation issue.

Dr. Holly Crisp (27:26): I think your question, Laura, reminds me of one of the struggles we had in working on the book. It does feel like there are three very different distinct subtypes. But the more we talked about it, the more we also realize that they morph into one another sometimes. And so for example, a very vulnerable hypervigilant patient who is mostly quite avoidant and anxious, and shame prone when enraged and in the face of a narcissistic injury can become that grandiose, oblivious, angry version.

Dr. Glen Gabbard (28:02): And vice versa.

Dr. Holly Crisp (28:03): And vice versa. As Glenn was just saying, that someone who's more grandiose, often when you really get underneath the surface, there can be a more vulnerable person in there. So we think that this is one of the both exciting but also challenging opportunities this presents us for the future in trying to sort out some of those distinctions. And part of the argument that we make in terms of tailoring the treatment to the person.

Dr. Laura Roberts (28:32): Okay. I want to go back to the new world that we're in.

Dr. Glen Gabbard (28:38): Yes.

Dr. Laura Roberts (28:39): Okay. So in chapter two together you write, "There can be little doubt that the internet has had more profound changes in the way we live our lives in the past few decades than any other influence. Narcissism is fundamentally about difficulties regarding how we see self and other and how we relate to one another. The internet has contributed to these dimensions of existence in far reaching ways." Can you comment a little bit more about that with that very insightful passage?

Dr. Glen Gabbard (29:06): I think that the impact of the internet is so profound. It's hard to zero in on one aspect, but certainly the phenomenon of Facebook and Instagram and-

Dr. Laura Roberts (29:18): Snapchat.

Dr. Glen Gabbard (29:20): ... Snapchat. There's a tendency for everyone to look on screen better than they actually are. It's like puffing oneself up to say, "Look at my wonderful life and my wonderful family." Hardly anybody goes on Facebook and says, "I feel rotten and my marriage is rotten, and my kids are rebellious and obnoxious." Everyone is on Facebook saying, "We've just come back from this wonderful trip to Rome. Here I am by the coliseum." It's sort of like promoting envy in others and presenting a false self, for lack of a better word.

Dr. Holly Crisp (30:02): And to go back to what Glen was saying about Winnicott's false self, that idea that here is how I want you to see me versus how I really feel inside. I think watching this newest generation that have grown up with the technology at their fingertips all the time, I'm curious to see how it unfolds over the years, how they develop their own sense of self-esteem regulation that is outside of how many likes did I get on a particular photo?

Dr. Glen Gabbard (30:33): There's also the phenomenon of instant gratification. You can carry around this object in your hand and any bit of knowledge you want to know, anybody's picture you want to see, you can get it automatically without delay. I think for years parents have brought up their kids on the principle of delayed gratification that being a marathon runner may be better than a sprinter in terms of ultimate rewards. It's hard to make that case anymore, Laura.

Dr. Laura Roberts (31:05): Good, wonderful, rich comments. And this will be a wonderful podcast. I can just tell. So let me just take a moment. As you imagined doing the podcast, was there some idea that you wanted to be sure to share? Is there some special guidance that you would offer, say to early career people just thinking about how to develop their psychotherapy practice? Is there something about working together that you'd like to say? So just take a minute and think if there's anything more you'd like to share.

Dr. Glen Gabbard (31:36): I think a central point is that the narcissistic patient does need help. We have to overcome whatever negative feelings we have for narcissistic patients to try to see the suffering individual underneath that brash surface and recognize that they are in your office because like other patients, they suffer. So that's a very important point to not be just turned off and think, "This person can't be treated, forget it."

Dr. Holly Crisp (32:10): One of the pieces of advice that Glen and I give to their residents when we teach together an ongoing psychodynamic psychotherapy case conference in the third year of residency, and one of the things we talk about is trying to find some way that you can connect to or empathize with that patient. And particularly for someone who's narcissistic, if I have a person with a big booming voice standing up over me telling me how much better he is than I am, it's really hard for me to empathize with that person. But if I remember that inside that person with the big booming voice is a really scared 10 year old kid, that's an easier person for me to connect to. I do think that can be really helpful. I think that though narcissistic patients can take a long time to treat, sometimes having those long empathic relationships can be some of the most valuable relationships to us in our practices. Both Glen and I get a great deal of professional satisfaction out of working with this type of patient. So we would encourage people just developing their careers to hang in there and try to find a person in there that they're able to empathize with and help.

Dr. Laura Roberts (33:24): Yeah. I often talk about how wonderful it is to take on the hardest problems because then you can make the biggest difference. Could you characterize the source of professional satisfaction that you get from working with narcissistic patients?

Dr. Glen Gabbard (33:38): I think it's exactly what you said, Laura, that you have a real challenge with the person who is in big trouble in their lives. They usually have lots of problems with every relationship they have. So you have a chance to make a difference so that person might enjoy life more and the other people in the sphere of that person might be able to have a better relationship with the designated patient. So that's encouraging. That's why we do this work. I think I've always felt that treating patients gives meaning to my life.

Dr. Holly Crisp (34:10): And which of us doesn't have narcissistic struggles. We all have our own struggles with self-esteem. I think there is a certain amount of wanting to be able to help someone else with that same problem that all of us deal.

Dr. Glen Gabbard (34:25): Can I just add something with Holly reminded me of? It's very easy when you're treating a narcissistic patient to project your own narcissism on to the patient. There's only one person in the room with narcissism. It's the patient. When actually, we've struggled with self-esteem, most of us in a way that hopefully is healthy. Not always, but we can relate to the person's need for self-esteem and try to make improvements in the patient. But we're also working on ourselves to be tolerant of this person who has difficulties.

Dr. Laura Roberts (34:58): Beautiful. Really beautiful. At the very beginning of the book, you talk about how this is not a book about public figures with narcissism, which seemed to be a topic front and center on many people's minds. It was a very clever side step. Good job. But would you comment on the tendency, I think, we have to be fascinated with celebrities, fascinated with other people, but also to begin to see narcissistic patterns in others and what dangers there might be in perhaps speculating too much about that. But just a little bit about popular culture at this time.

Dr. Glen Gabbard (35:42): Well, this is a longstanding issue in the literature, dating back to Christopher Lasch when in 1979 he wrote The Culture of Narcissism. There's certainly something about the media. We don't have to get into cyberspace. Just watching TV, movies that makes us assume that certain public figures, whether politicians or movie stars are different than us and have certain qualities that we can observe from afar that are alien to us. So we are trying to get something by worshiping figures in the culture and it doesn't usually work very well. But there's a wonderful movie way back in the '80s that Martin Scorsese made about Robert De Niro and Jerry Lewis actually played a Johnny Carson character. In this film, he had a wonderful look at the celebrity culture and how people will stand outside, fans waiting for the movie star or the TV star to come out. They often feel like their lives are enhanced by being in the shadow of this idealized person.

Dr. Laura Roberts (36:52): So Glen, you've talked a little bit about what you characterize as the celebrity culture that we are living in right now. What do you think the impact is for psychiatrists who are working in a culture that has this kind of distorting influence for young people who are growing up in a celebrity culture? Could you just comment a little bit on how that may influence our thinking about narcissism?

Dr. Glen Gabbard (37:18): I think that humility is something very important to bring up in therapy with young people or older people, and they see everywhere around them lack of humility in the celebrity culture. So I think the therapist and other, any mental health professional can try to lower expectations, try to help everyone see that perfection is out of reach, that we're all flawed and to recognize our humanity.

Dr. Holly Crisp (37:45): One of the things I would add is the part of having narcissism so at our fingertips in the culture, whether we're talking about the internet or the media or politics, or movie stars, or YouTube stars for that matter, part of the challenge is what is cultural narcissism versus what is an individual's problem with narcissism? I think we're still trying to figure that out. That I think is really where we as mental health professionals are sitting in the offices or clinics with people trying to determine the unique struggles that they have with this rather than just the broader cultural themes of narcissism.

Dr. Laura Roberts (38:38): I know it's a little anxiety provoking if you haven't done a lot of this, so I appreciate making the time for it and trying it out.

Dr. Holly Crisp (38:47): Well, thank you so much. You made it easy.

Dr. Glen Gabbard (38:51): Yeah, you made it easy because you were very tuned in and empathic to our dilemma of trying to be clear and succinct.

Dr. Laura Roberts (38:58): But thank you again and have a wonderful day.

Producer (39:02): Our host is Dr. Laura Roberts. She is the Katharine Dexter McCormick and Stanley McCormick Memorial Professor and chairman of the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. She is also editor-in-chief of the books program at American Psychiatric Association Publishing. A little bit about our guest today, Dr. Glenn O. Gabbard is clinical professor of psychiatry at Baylor College of Medicine in Houston, Texas. He is also training and supervising analyst at the Center for Psychoanalytical Studies in Houston. He also maintains a full-time private practice. Dr. Holly Crisp is clinical associate professor at Baylor College of Medicine in Houston, Texas. She is on the faculty at the Center for Psychoanalytic Studies in Houston and she also maintains a full-time private practice. Our original music is by Willow Roberts. Our coordinating producer Kyle Lane-McKinley. Our executive producer Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing John McDuffie, publisher. To purchase copies of this book or other books by our guest or host, please visit www.appi.org. That's A-P-P-I.org. If you'd like to contact us, drop us an email at [email protected] We hope you enjoyed this podcast and thank you for listening.