When Certainty Crowds Out Curiosity: Mentalizing and Pathological Narcissism

Mentalization is the ability to “read,” access, and reflect on mental states in ourselves and other people. Mental states are all the invisible stuff of the mind: thoughts, beliefs, emotions, desires, needs, attitudes, values, feelings about yourself, and personality traits. Mentalizing is thus a fundamentally imaginative capacity. We cannot literally see such things, but we imagine them, and we make presumptions and conjectures about them.

Mentalization involves three different facets: reflecting on the content of mental states in ourselves and others (e.g., anxiety, sadness, anger, insecurity); considering the broader context of those states (e.g., history, external events, behaviors, or other feeling states); and contemplating the process of how people relate to mental states in themselves and others. We can remember these types of mentalizing with a simple formula: “what,” “why,” and “how.” When individuals are mentalizing effectively, they are able to “put words on” what they and others are feeling (content-mentalizing); they can think about “why” these feelings are arising (context-mentalizing); and they tend to approach situations with flexibility, curiosity, empathy, and connectedness to their own emotions (process-mentalizing).      

When mentalization breaks down, individuals struggle to reflect on mental states in themselves and other people. In therapy sessions, we see this when patients feel confused about what they are feeling, or when they fail to accurately read and understand what other people are thinking and feeling. They also might feel confused about “why” they or others are feeling a certain way, often missing that THEY are playing a role in other people’s feelings toward them. Empathic deficits also constitute problems in mentalizing. Patients might technically “understand” that another person is upset, but they find it difficult to put themselves in the other person’s shoes, or to fully care about what the individual is feeling and wanting. 

Perhaps the most clinically striking and intractable problem in mentalizing is patients’ tendencies toward CERTAINTY. They can lose sight of the fact that they are perceiving something; rather, their beliefs start to feel like facts. “If I think it, that makes it so.” Examples of this certainty include patients’ negative beliefs about themselves (“I am ugly, stupid, worthless…”), their negative judgments of other people (“This other person hates me, or doesn’t care about me enough…”), or their conviction that they need to take certain actions in order to regulate their emotional states (“I need to cut myself/use substances/yell at this person to make myself feel better…”).    

From the perspective of mentalization, grandiose narcissism and vulnerable narcissism are linked to different types of “problems in mentalizing.” Grandiose narcissism involves an elevated sense of self. This form of narcissism involves two core “non-mentalizing modes”: psychic equivalence mode, where patients are rigidly attached to their idealized self-concept (“I’m so attractive, intelligent, successful, charming”), and pretend mode, where patients are disconnected from facts about themselves and their lives that depart from their preferred manner of seeing themselves. For example, one patient views himself as an accomplished artist, but he has not painted in many years, and he has never achieved any objective success in the art world.  

On the other hand, vulnerable narcissism centers on a conditional sense of self-esteem, such that individuals base their self-worth on factors outside the self, thus experiencing vacillations in identity and emotions depending on whether they meet these conditions. This form of narcissism involves teleological mode—patients’ tendency to equate or “link” their internal states (e.g., pride, confidence, happiness, self-worth) with external factors (e.g., wealth, prestige, attractiveness, sex, power). For example, one patient bases her sense of self-esteem on issues of appearance and attractiveness, experiencing elevated mood when men show her positive attention and falling into shame and self-loathing when she feels like men are ignoring or rejecting her.       

In pathological narcissism, psychic equivalence mode includes patients’ grandiose beliefs about themselves, their achievements, or their positive qualities; a sense of self as different, superior, or separate from others; idealization of specific others (e.g., spouse, colleagues, friends); devaluation of other people or groups; patients’ self-judgments about their qualities, emotions, or desires; and a sense of self as bad, worthless, weak, or “a failure.” 

Interpersonal conflicts often entail some form of psychic equivalence. Patients feel convinced that they are RIGHT in their judgments of others—that they possess some objectively accurate view on other people’s defects and failings. Accordingly, they feel 100% justified in engaging in the problematic interpersonal tendencies that cause so many challenges in pathological narcissism: defensiveness, criticism of others, dismissiveness, giving people “constructive feedback,” argumentativeness, and even physical aggressiveness. This all can lead to interpersonal instability, broken relationships, inconsistent employment, and loneliness and estrangement in relationships. 

Giving the diagnosis of narcissistic personality disorder (NPD) can be challenging on multiple fronts. Most clinicians lack experience with giving the NPD diagnosis, so they often feel intimidated and anxious about broaching such topics. There is also a tremendous amount of misunderstanding about NPD, so patients often enter these conversations with a conception of NPD that is caked with misinformation and stigma. Patients with NPD are also highly sensitive to rejection and criticism, so they can struggle with defensiveness and emotional reactivity in these conversations.

By and large, it is most helpful to approach the diagnosis collaboratively, rather than presenting it as a categorical judgment about the patient’s personality. First explore the patient’s own experience of their difficulties, their relationships and functioning, and the narcissistic processes underlying them. Then introduce the diagnosis in experience-near, patient-specific terms, linking their expectations, self-esteem regulation, and characteristic responses to interpersonal triggers with the difficulties that brought them to treatment. Throughout the conversation, validate the patient’s perspective while also introducing your own observations, and invite the patient to reflect on whether the formulation fits their experience. The goal is not simply to give a label, but to use the diagnosis as a starting point for greater self-reflection and a shared understanding of what they hope to change.   

“Mentalizing breakdowns” take two primary shapes in psychotherapy: excessive certainty and excessive disconnection. So the first step is to ask yourself: “Is my patient overly certain, or are they overly disconnected from themselves and others?” If they seem overly rigid or certain in their views, respond in three steps. First, empathically validate the patient’s perspective, mainly by putting words on your understanding of what the patient is saying, and especially by emphasizing how it is reasonable and understandable that they see things the way that they do. Then express curiosity about the patient’s process of arriving at their view: “What clues you in that your boss is so incompetent?” Finally, once the patient has articulated their rationale for their outlook, make sure to share your own view on the issue. This encourages the patient to reckon with someone else’s mind about the matter, thus helping them to attain a broader outlook on the emotionally charged area. “I know that you have completely lost faith in your boss, but I keep thinking about how much compassion he showed to you after the divorce….”       

If the patient appears to be overly disconnected from themselves, other people, or reality, avoid talking more about the topic under discussion—this will just lead to more disconnected dialogue! Instead: FLIP THE SCRIPT. That is, make a comment (or ask a question) that (a) surprises the patient, (b) directs their attention to their emotional experience in the current moment, or (c) calls attention to your feelings or viewpoint. Such communications function like throwing a bucket of cold water onto the patient. They wake up, they get connected, and then you can explore their experience in a more grounded, emotionally engaged fashion.      

Narcissism brings us directly into a foundational arena of human experience: issues of identity and self-esteem, and the need that we all have to maintain a positive sense of ourselves, even as we navigate the narcissistic landmines that surround us on a daily basis. Even when our patients do not meet criteria for narcissistic personality disorder, thinking about patients through the lens of narcissism reminds us to ask ourselves the following sorts of questions:

• How does this patient feel about themselves? Where do they stand at the level of self-worth and self-esteem?  

• What does this patient base their sense of self-esteem on? What are the conditions for their self-worth? To what extent do they ground their identity on factors outside of themselves, vs. embracing a more intrinsic sense of their own value? 

• What triggers this person’s narcissistic disruptions? When their self-worth is threatened, what steps do they take—internally and behaviorally—in order to maintain and enhance their positive sense of themselves?

Mentalization provides us with an elegant but powerful tool to help patients address these broader challenges with self-esteem regulation. Mentalizing enables patients to get connected to themselves—to know “what” they are feeling, to access their emotions and desires, and thereby to lay the foundation for developing a more solid sense of self-worth. When patients feel like their self-esteem is under threat, they can work to empathize with the other people in their lives, thus building up a source of meaning that is independent of success and performance. And when patients—like all of us—focus extensively on external factors for their self-esteem, we can encourage them to bring an attitude of curiosity to their conditional sense of self-worth—questioning this rigid link between external factors and their own value, while also envisioning the possibility that they might possess unconditional, intrinsic worth as a person, regardless of how they see themselves in the moment. On this view, mentalization provides a pathway to develop a more robust, stable sense of self-esteem.