The Deluded Self – Narcissism and its Disorders

This book is a distillation of Dr Gwen Adshead’s many years of work in the fields of psychiatry and psychotherapy where she has worked extensively with the issues encompassing the whole concept of narcissism.

Looking at narcissism on a continuum from healthy to pathological, Dr Adshead uses research, theoretical ideas and her own extensive clinical experience to delineate and disentangle some of the apparent conundrums in both the concept itself and its cultural context.

Although noting that research in the area is at times contradictory, Dr Adshead brings together what is known about narcissism, stripped of its pejorative implications. This leads to an effective, practical guide for practitioners to evaluate the degree to which the narcissism they may discern in their clinical work is likely to be decisive in the conduct of, and prognosis for, the case before them.

The book contains a section on the key aspects of narcissism, as part of an unhealthy presentation, which is both descriptive and further clarifies for the clinician what to look for and what to take seriously. Dr Adshead points out that there is a paucity of systematic information about this in the psychotherapy profession: although clinicians may have a strong sense of when they may be in the presence of something pathologically narcissistic, this is an intersubjective judgement and often a question of degree. Dr Adshead accordingly provides additional insights to help clinicians towards a sense of perspective and deeper understanding of such cases.

The book goes on to discuss what is known about the causes and origins of unhealthy narcissism in general and narcissistic personality disorder in particular. Again, we are cautioned against easy answers and sweeping generalisations. She notes that unhealthy narcissism is likely to have its roots in infancy and early childhood, when the normal narcissistic stage of development has not, for whatever reason, been successfully navigated; and that very often the narcissistic presentation covers its opposite – a fragile and diminished sense of self, which has to be defended against, sometimes at any cost. In the words of the book’s title, the self can be deluded and the individual unable to make realistic judgements about themselves or to make plans which take reality into account. This makes it almost impossible for such sufferers to truly learn from experience. It also makes it very difficult for them to form intimate relationships: where there is unhealthy narcissism, there is inevitably a problem in seeing the other as separate, and tolerating that they are different.

Dr Adshead also explores the dynamics of the relationships of the narcissistic person. Noting that this seems often, but not inevitably, to follow gendered lines – with males more likely to exhibit an overt, and females more likely to exhibit a vulnerable, narcissism – she discusses what has been recently called ‘echoism’. This is a counterpart to narcissism in which the other person in some way moulds themselves to what the narcissist requires.

Finally, Dr Adshead considers clinical work with people who suffer from the extremes of narcissism. She notes that, as narcissism is understood to be an element of personality, change, if at all possible, will be very slow. The clinician’s work is not to return someone to a place of health, pre-crisis or pre-trauma; it is to make something new. Finishing with some thoughts about the challenges for the clinician in this process, Dr Adshead manages to provide a hopeful message which is at the same time profoundly realistic.

Above all, throughout this book is the respectful understanding that the sufferer is just that – suffering. They can also make others suffer with them. Overall thus, this book is an overview, full of insights, of the concept, the condition and the clinical challenges of narcissism.

Dr Jan McGregor Hepburn

London, 2020

Dr Gwen Adshead is a Forensic Psychiatrist and Psychotherapist. She trained at St George’s Hospital, the Institute of Psychiatry and the Institute of Group Analysis.  She is trained as a group therapist and a Mindfulness-based cognitive therapist and has also trained in Mentalisation-based therapy. She worked for nearly twenty years as a Consultant Forensic Psychotherapist at Broadmoor Hospital, running psychotherapeutic groups for offenders and working with staff around relational security and organisational dynamics. She is the co-editor of Clinical topics in Personality Disorder (with Dr Jay Sarkar) which was awarded first prize in the psychiatry Section of the BMA book awards 2013; and she also co-edited Personality Disorder: the Definitive Collection with Dr Caroline Jacob. She is the co-editor of the Oxford Handbook of Forensic Psychiatry (2013) and the Oxford Handbook of Medical Psychotherapy (2016). She is also the co-editor of Munchausens’s Syndrome by Proxy: Current issues in Assessment, Treatment and Research.

Gwen was visiting professor at Yale School of Psychiatry and Law in 2013; and also honoured with the President’s Medal for services to psychiatry that same year for her work on ethics in psychiatry. She was awarded an honorary doctorate by St George’s hospital in 2015; and was Gresham Professor of Psychiatry 2014-2017. She now works in a medium secure unit in Hampshire in a service for high risk offenders with personality disorder; and in a women’s prison.

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