A 17-year-old male student was asked to take a leave of absence from school after being caught using marijuana. As a consultant for the secondary school, I was asked to assess him on consideration for readmission. The drug issue was trivial; he was no more involved than his classmates. However his leave of absence resulted from his apparent disinterest in concealing his behavior. Our interview revealed that he had a serious narcissistic personality disorder with grandiosity, little capacity for empathy, and a general aura of haughty disdain. He had no sense of any personal problem, no desire for help, and he made clear that he viewed me as a minor bureaucrat whom he had to suffer because of a silly rule. However, his pathology was serious. What should I do?
Reply from Robert Michels, M.D.
The existence of psychopathology, even serious psychopathology, is not always an indication for treatment. One of the characteristics of patients with personality disorders is that they often bother others more than themselves, and are likely to come to the attention of psychiatrists not because they seek help but because they are referred by others—employees, police, spouses, or in this case school administrators. The psychiatrist finds himself in the role of an organizational consultant rather than a healer.
However the psychiatrist is still a physician and tries to help and, above all, not to harm. Personality disorders are long lasting, often lifelong, and the pain and suffering associated with them often comes late in life. Further, it is likely that this will not be the patient’s only, or final, contact with a psychiatrist. Confrontation or challenge to such a patient, a common countertransference impulse, is unlikely to be of any value. The patient has no apparent interest or motivation for treatment. The task of the psychiatrist is to help prepare the groundwork for when, in the future, such motivation may develop. The psychiatrist often does this by providing a professional, interested, nonjudgmental relationship. In addition, the psychiatrist explores the areas in which it is anticipated that the patient might experience pain and unhappiness. For example, his relations with friends and the stability of his friendships, loneliness, his satisfaction with how others regard him and respond to him, his envy, his response to disappointment and failure. These are often sources of suffering in individuals with narcissistic personalities. The goal in such a consultation is not to attack the defenses that protect the patient from pain, but rather to begin a process that may continue over many years with many therapists and many interruptions but, sometimes, lead to the capacity to experience pain, share feelings, accept help, participate in treatment, and grow.
