By Philip Chanin, Ed.D., ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center
philchanin@gmail.com

Today I would like to present an ongoing psychotherapy case which illustrates some of the types of interventions that I typically make with patients suffering with narcissistic wounds, meaning deep wounds to their sense of self. I have his permission to talk about his treatment, during his individual counseling. His name has been changed to preserve his confidentiality.

I have chosen this case also because it includes many of the elements that I often encounter with patients, and particularly with men. These elements include chronic depression, chronic addictive behaviors in an effort to mitigate depression, a profound sense of shame, and a tendency to resort to grandiosity as a defense against shame. I also have picked this case because I believe it illustrates the particular power of Buddhist principles and relationship empowerment in helping a highly motivated patient, who is willing to utilize these tools, from a buddhist psychologist, in his life on a daily basis, to make dramatic changes in himself and his relationships.

This case begins with an email from the patient, whom I will call David, on June 19, 2019, in which he states, “I am looking for a psychologist near me and would like to set up an initial consultation for individual counseling. I am particularly interested in “existential” therapy and related ideas.”

David comes for his first appointment, on July 15th, 2019. He is married, in his early 40’s, with two young children. He is also very successful professionally, which enables his wife to be home with their children. In response to my initial question, “How can I help you,” David states, “I’m looking for ways to make life easier on myself. I want to change how I think, and reduce my anger. I can be hard to get along with. I affect others around me with my negative attitudes. My co-workers have told me, ‘You’re being a jerk!’ I’m a judgmental person by nature. I can be passive aggressive—bubbling resentment. I’m an iconoclast.”

David also presents with a history of depression, dating to his college years. He describes himself as “ruminative—not in the present. In my 20’s I acted emotionally. Depression and anxiety were bad—I asked myself, ‘Where am I going to go?” Then I met my wife, who is indispensable to my life. Family gave my life legitimacy. But I’m not always seeing the meaning in my daily life and career. I feel like an imposter and fraud in my job.

At this point I suggest to David that I am hearing about his “lack of inner peace.” He responds in the affirmative, adding, “My ego is my enemy.” He also describes “debilitating social anxiety,” which I often see in patients with chronically low self-esteem. He adds, “I go out of my way to not meet other people. It’s gotten worse, the past couple of years. I’m scared others will know who I am, which is terrifying.”

David says there is history of depression on his mother’s side of the family, which is not acknowledged, resulting in “a lot of damage, and also narcissistic and borderline behaviors.”
David received what he calls “rational emotional behavior therapy” in college, which was very helpful to him at that time. He adds, “Writing things down and debating my thoughts—I still use those techniques a lot.”

Despite this, David says, “I’m outraged constantly, which exhausts me. It exhausts others, when I verbalize it. How do I accept myself and the world? Everything affects me more than other people. I have a lack of hope for the future. I don’t want to be ‘Angry Dad.’” When I ask David why he decided to contact me for individual counseling, he answers, “My previous Nashville couples and individual therapist was a passive listener—more of a relationship expert. This time I Googled ‘Existential Therapist.’ I want to take a high-level view of how I’m perceiving the world.”

At the end of this first session, I gave David a copy of a chapter from Terrence Real’s book, How Can I Get Through To You: Reconnecting Men and Women. This chapter is something I give to almost every patient I work with, at some point in their treatment during individual counseling. Real describes how to develop an invisible psychic shield, which he calls an “internal boundary,” in order to not take what another person says or does personally. He presents this strategy as a kind of “internal technology.” He writes, “The lack of an internal boundary inevitably leads to control or withdrawal. If there is no membrane between you and whatever external stimulus gets thrown at you, then you attempt to regulate your own level of comfort or discomfort by managing the stimulus. (‘I could be happy, if only you were less angry.’). When control fails, the only other option is withdrawal.”

At his 2nd session, 4 days later, David told me that he had read the internal boundary chapter, and added, “I need a quieting of my mind. I need to spend less time being outraged. It’s really easy to get me going. It never makes me feel better—my negative verbalizing about things I don’t like. My wife is the main person who takes the brunt of this.”

With all new patients, I take a detailed history, usually beginning with the 2nd individual session. In doing David’s history, I learn that he looked up to his father but that his mother has become, in his words, “more difficult to deal with. Her sister is narcissistic and her mother is a borderline. My mother is trending that way, though she works really hard to fight against it.” David describes his younger sister as making ill-advised decisions, but that his mother “defends her to a fault. They remind me a lot of each other—not empathic of others. I can’t say anything critical about my sister. My mother takes anything I say as personal offense—she’s easily offended. I then ask David how he remembers his mother when he was growing up. He responds, “I don’t remember her being a narcissist.”

I always ask patients what they know about each of their parent’s childhoods. David says, “My mother was the middle child, and her mother was borderline and narcissistic, which was hard on my mother and her siblings—casual cruelty by their mother, with biting criticism. This imbued in my mother a tendency to find distasteful things in others. My mother’s family attack each other relentlessly—behind their backs. I come from two lines of complainers in my family. My mother is also prone to depression—I inherit my depression and skepticism from her side. My father is disappointed that my mother is so petulant.”

After doing a parental history, I then always ask a new patient about their memories of childhood and adolescence. David talks about “low level bullying all through 5th grade—I wouldn’t stand up for myself. In 7th grade, there were a lot of older, bigger kids—some were mean and bullies. I hated school bus rides—bullying from the older and the high school kids—the fear and anxiety I felt. My birthday is in August, so I was always one of the youngest in my class. I was emotionally behind my peers, all through life. I was more of a kid than others, at these ages—not knowledgeable about the world.” As I listen to this history, I am thinking to myself about the severe impact that this bullying likely had on David’s self-esteem.

During his junior year of college, David had his first debilitating bout of depression. He states, “Darkness came over me. By the end of college, I was a lost person—the guy I’ve been battling ever since. Lost in the world. Filled with anxiety, sadness, and hopelessness.” After college David took a job, and became more and more depressed. He did seek out psychotherapy, but refused medication. He adds, “My anxiety and depression, and not accepting sufficient help, solidified my bad thought patterns.”

At the end of this 2nd session, I suggested to David that I thought he would get a lot of help with his anger and resentment by listening to Pema’s Chodron’s 3 CD set Don’t Bite the Hook. As many of you know, Pema Chodron is one of the world’s most renowned and beloved Buddhist teachers. She resides at Gampo Abbey in Nova Scotia—the first Tibetan monastery for Westerners. She is an extraordinary teacher about thorny interpersonal problems like anger.

Pema Chodron states, “Someone criticizes you. They criticize your work or your appearance or your child. At moments like that, what do you feel? The Tibetan word for this is shenpa. It is usually translated ‘attachment,’ but a more descriptive translation might be ‘hooked.’ When shenpa hooks us, we’re likely to get stuck…At the subtlest level, we feel a tightening, a tensing, a sense of closing down…That’s the hooked quality. That tight feeling has the power to hook us into self-denigration, blame, anger, jealousy, and other emotions which lead to words and actions that end up poisoning us.”

In his 3rd session, 10 days later, David told me that he had listened to Don’t Bite the Hook and found it very useful. During this session and other individual counseling sessions it became clearer to me that David has a virulent “inner critic” voice, that he struggles with tremendous underlying shame, and that his aloofness is to a great extent his effort to hide his shame from discovery. I explained to him the narcissistic dynamic, particularly true for men, of converting the painful emotion of shame into grandiosity, of going from “less than” to “better than.”

During this session, I also introduced David to “the trance of unworthiness,” as described by Tara Brach, a Buddhist teacher and psychologist, in her book Radical Acceptance: Embracing Your Life with the Heart of a Buddha. She writes, “As a friend of mine put it, ‘Feeling that something is wrong with me is the invisible and toxic gas I am always breathing.’ When we experience our lives through this lens of personal insufficiency, we are imprisoned in what I call the trance of unworthiness. Trapped in this trance, we are unable to perceive the truth of who we really are.” (p. 3)

Tara Brach then describes an experience of one of her meditation students, at the bedside of her dying mother. Shortly before she dies, Brach writes, “the mother suddenly opened her eyes and looked clearly and intently at her daughter. ‘You know,’ the mother whispered softly, ‘all my life I thought something was wrong with me.’ Shaking her slightly, as if to say, ‘What a waste,’ she closed her eyes and drifted back into a coma. Several hours later she passed away.” Brach concludes, “We don’t have to wait until we are on our deathbed to realize what a waste of our precious lives it is to carry the belief that something is wrong with us. Yet because our habits of feeling insufficient are so strong, awakening from the trance involves not only inner resolve, but also an active training of the heart and mind.” This active training involves meditation and Buddhist teachings of non-judgment and self-compassion.

During this 3rd session I also outlined to David Eckhart Tolle’s concept of “the pain-body,” as described in his book The Power of Now: A Guide to Spiritual Enlightenment. The pain-body is Tolle’s way of describing shame. Tolle vividly describes what I call “a shame attack.” He writes, “Watch out for any sign of unhappiness in yourself, in whatever form—it may be the awakening pain-body…Catch it the moment it awakens from its dormant state…So the pain-body, when it has taken you over, will create a situation in your life that reflects back its own energy frequency for it to feed on. Pain can only feed on pain…you want to inflict pain, or you want to suffer pain, or both. (However) the pain-body is actually afraid of the light of your consciousness. It is afraid of being found out…So the pain-body doesn’t want you to observe it directly and see it for what it is. The moment you observe it, feel its energy within you, and take your attention onto it, the identification is broken…You are now the witness or the watcher of the pain-body. This means it cannot use you anymore by pretending to be you, and it can no longer replenish itself through you.” (pp. 29-31)

Having introduced these concepts to David in the first three sessions, I began to hear from him in his 4th session about his putting these into practice in his own life. He states, “I’m shocked at how effective I’ve been able to be at using these new skills. I’ve had plenty of opportunities to practice. Pema Chodron is wonderful in Don’t Bite the Hook. I’m catching the anger. Here are the tools. I feel committed to continue using them—making this a daily thing. Awakening to these things—I haven’t realized the damage they’ve done to me. A grand project. I see another way to think and go forth in life. It’s given me some hope for the future. I was unsure how I could relate to the world. Now I have a way I can process the things the world presents me with.”

David continues, “I’m so wired for outrage. Before, I couldn’t stop and be with the feelings. That sticky feeling—shenpa. Dead center in my chest. I feel the surge.” By this point I had also introduced David to Pema Chodron’s concept of “dropping the story line,” meaning the story I am going over and over in my head about how my partner has just said or done something that is so unkind, unfair, or unjust. As I keep going over these thoughts, it keeps me stirred up and angry.

David elaborates further: “Dropping the story line. Physically feel it first. I have released its power over me. The realization that I have that power—it’s really a big deal for me. I can’t think of a time before that I was able to do that. Trying to catch that rush—right when it happens. I’m unexpectedly able to calm down. I’m able to ‘not bite the hook.’ I can be in the middle of this swarm of things I don’t like, and not be reactive. I can name and get to know these feelings. But it is harder to do at home. Now I’ve been given the tools. It’s up to me to create the practice, and make it something permanent. Resisting the urge—shenpa—constantly pointing out shenpa to myself. There it is! It has a name! How powerful—to name the feeling. I’m constantly bombarded with it.”

During individual counseling, David begins to describe how others in his life may perceive the changes he is making.
“It’s a transition for me. People who know me well—they know how I’ve acted in the past. The incredible damage the anger does. People will have to forget the way I used to behave—that will take time. I’m thinking about the emergence of the pain-body—a purple blob, that pain awakening. That purple blob, taking me over. I also like imagining a physical barrier for the internal boundary. I haven’t had to take a Xanax this week. These Buddhist concepts  in Buddhist psychotherapy could change my mind enough to make it possible to not go down those old roads.”

In this 4th session David also reveals the extent of his marijuana use. He says, “I’m a very heavy marijuana user, throughout the day—heavier than anyone I know. Perhaps I have a cannabis addiction? But it’s such a fruitful one, helpful for my mental state. It helps me come into the present moment. I’ve never told my psychiatrist—I’m embarrassed about it. It seems like a dependence. I’m embarrassed to be a dependent drug user. I’m terrified he’d tell me to stop. It’s scary to think about stopping. I’ve been a daily marijuana user since I was 20. When I’m bored, I use it to pass the time. It would be a good idea if I used it less.” I then suggest to David that he has used marijuana in part to treat his depression. He responds, “Without a doubt. To augment my antidepressant.”

At the end of this 4th session I suggest to David that he read Terrence Real’s book I Don’t Want to Talk About It: The Secret Legacy of Male Depression. At some point in their treatment I usually end up recommending this book to almost all my male patients. Real give powerful vignettes of the exchanges that take place in his office between himself and the men he works with. I utilize so many of Real’s concepts in my psychotherapy with men. These include “covert depression,” which he describes as “mild, elusive, and chronic”; “performance-based self-esteem”; the conversion of shame to grandiosity; and the importance of stopping addictive behaviors if any real psychotherapy is to be accomplished.

David begins his 5th session saying, “These techniques of fighting off anger with awareness are helping at work. It’s hardest at home, applying the same detachment to things my wife says, or I want to say. It’s a lot harder. These patterns we’ve established over the years. It’s a lot harder to hold back the instantaneous flick of the switch and apply the internal boundary forcefield. It continues to be a challenge. But at work, I’m shocked at how effective it’s been in controlling my social anxiety.”

David continues: “I’m reading I Don’t Want to Talk About It, about covert depression versus overt depression. I’m trying to become sensitive to the grandiosity I may be applying, because of shame. Long-term, learning to slough off these patterns. A matter of practice. Having an enthusiasm for changing my thoughts and patterns. It’s exciting to be introduced to these concepts. I never understood their value until now. The enthusiasm for wanting real change—not temporary relief. This has given me some comfort in being in the world. I want to teach my children these concepts, as young as they can understand.”

David adds, “The mental illness in my family—I fear it being passed on to my children. I want to give them a new perspective. I want to help my children avoid their own quarter life or mid-life crisis. I want to give them the tools to deal with it better than I did. I want to help them to avoid the internalization of shame, the sense I’ve had ‘that the way I live is wrong.’ It’s so hard to not care what other people think. When I was younger, it was so hard for me to genuinely not care. I’m realizing how this was created by me—I remember how hard it was.”

“I worry about my happy children becoming these dark teenagers, and not having a healthy mindset, and feeling secure and having a place in the world. I want to make sure that I model this type of behavior. I’m trying to control my emotions with awareness and the cultivation of detachment. I’m not sure how to convey these lessons to my children. I hope that I can change myself enough to demonstrate to my kids. I have demonstrated my anger at home in the past.”

“My 7-year-old—I will think she is repeating my wife’s words: ‘Daddy is getting mad again.’ I’m very annoyed by it. It makes me mad at my wife. A trigger—so hard not to follow. I don’t want to be that Dad. I don’t want my 7-year-old to be aware that her father has a temper. It will take some training to change this dance.

I’m reading a great article in the Buddhist magazine The Lion’s Roar. I want to be this way. I want to be a student of these concepts—wherever that will lead me. A way to live in the world—there’s no other way that I’ve seen, without doing self-harm. I haven’t had to take a Xanax in weeks. Before starting therapy, I had a week when I took one every day.

By this point in his treatment, I had also introduced David to the Buddhist concept of metta or lovingkindness. I have found this an immensely useful approach in assisting patients with reducing their virulent “inner critic” voice and substituting a practice of self-compassion, self-acceptance, and self-regard. I encourage patients to develop their own lovingkindness phrases, and I give them examples such as “Lovingkindness and compassion towards myself. May I be free from suffering, free from ill will. May I be happy. May I love myself completely, just as I am.”

Nine days later, David came for his 6th session. He began the session stating, “I’ve been very effective at controlling my opinions and attachments at work. I’m still having trouble at home, in showing lovingkindness to my wife and not becoming judgmental and angry. It’s more difficult to not become attached at home—there are decisions to be made—picking up the kids, grocery shopping. When I’m away from home, my wife develops ways she’d like to do things. As an analytical person, I think I can improve on her decisions. I don’t do a good job of adjusting my tone. She’s still reeling from years of my having no concept of how I sound. She’s used to the way I am—quick to react in a defensive way, which gets her going. Now I’m trying, in the moment, to just feel the anger (and not act on it).

At this point in the session I introduced to David a saying by Sengstan, the 3rd Zen patriarch: “Do not search for the truth; only cease to cherish opinions.” David responds: It’s hard for me to let go of opinions. I’m good at logistics—figuring out a process. It’s who I am as a person. I’m an organized person. I can figure out the best way to handle a situation. When I see a process that I deem inefficient…I’m constantly looking for ways to be efficient.”

“At home, she’ll do some organizing. I won’t think it’s very organized, like in the kitchen. I immediately address the situation. I want to find the balance, in letting go of my opinions and at the same time not being blown around the world by everybody’s whims. There are times when a preference is called for. Buying a new car—I’d have very strong opinions about what kind of car, or house. How do I square that with my letting go? It’s a lot of money. My wife and I would both have really strong feelings about that. We don’t like to waste money. To give up my opinion about that—an insurmountable challenge.

At this point I interject, “We are looking for a better balance.” David responds, “I have been thinking about that—the various things you have to do.” I add, “We are looking for a different default position.” “Yes,” David says. “But other people I deal with are very assertive. If you don’t have a strong stand, you will get run over. I say, “We are looking for a default position that reflects better self-esteem.”

David responds, “I am still fighting off the shame pangs and grandiosity on a daily basis. People can pick up on your shenpa, even if you aren’t saying anything. I utilize a grandiose way of subverting shame. I have been reading more from the book I Don’t Want to Talk About It. The stories are illuminating.”

At this point in the session, as we are working with the tension David feels between having strong opinions or being a doormat. I decide to share with him some reflections from Terrence Real, in his book The New Rules of Marriage. Real writes about “…why neither of the relationship strategies of the previous century—acquiescence or personal empowerment—gets the results that women want.” Instead, Real offers a new model that he calls “relationship empowerment.”

I share with David what Real calls “The five losing strategies in marriage: needing to be right, controlling your partner, unbridled self-expression, retaliation, and withdrawal.” I elaborate for David what Real says about needing to be right: “Instead of focusing on Elizabeth and her needs, their debate centers on the burning question: Which one of them was ‘out of line.’ They each feel the need to be right, marshalling their evidence and arguing their case, two lawyers before the court…Like many couples, they try to ‘resolve’ their differences by eradicating them. Faced with contrasting views…, the way to end the argument, they think, is to determine which version is the more accurate. They are in an objectivity battle…Instead of being a battle for the relationship, it is a constant war about who is right and who is wrong…Objective reality has no place in close personal relationships…From a relationship-savvy point of view, the only sensible answer to the question ‘Who’s right and who’s wrong?’ is ‘Who cares?’…’You can be right or you can be married. What’s more important to you?’…Letting go of the need to be right is a core principle of relationship empowerment.” (pp. 38-41)

David then responds, “I could become aware of ‘I think I’m right’ and then just stop—don’t do anything. Keep the pain-body from arising. I don’t have to care about being right. But it’s so much harder to apply in my marriage. If I could successfully let go of caring about being right, it would smooth out a lot of things. It would pretty much solve all five of those “losing strategies.”

“I feel really committed to the change right now. I think I could do it—I think it will be hard. I would rather not fight than be right. One of he biggest reliefs I’ve gotten from this training relates to my fear of the future, that my marriage will end, because I will eventually become insufferable. I imagine the end of the marriage as my fault—me not being able to be a loving partner. I’ve gotten some relief from these types of fears, realizing my emotional pain. I can choose to not ruminate, choose to stay ‘here in the moment.’”

“I never believed I could do it. I don’t know why it took me until I was in my 40’s to realize this. It’s just so simple, when you realize, that attachment is at the root of so many things. As I try to change, I hope to be a more loving person. Tell the people I love that I do love them. I’m so ingrained to staying closed, and not expressing those types of things. Discomfort to imagine it—irrational discomfort. The idea of a very romantic gesture toward my wife—something I’m afraid to do. Simply afraid of it, for some reason.”

I ask David if he has a guess as to why this would feel so uncomfortable. He answers, “An abstract thing in my brain judges me. She’s such a warm, nice person. This fear: What would my friends say if they found out that I did something very romantic—my buddies—a flowery, feminine expression of love? Before I had the tools to evaluate this way of thinking, there was something I couldn’t face. Something about being true to the person that people think I am, over the years–an opinionated, emotionally unavailable person.”

“That’s who my family and friends see me as. I still feel some responsibility to live up to that person. I’m afraid to be a different person! I’m aware of that now. I wasn’t, before. Now that I’ve realized this, I can start to make changes, and face the fear—simply feel it. It’s a challenge—not defaulting to that person I’ve been. The past is controlling me. Some part of me likes being known as a tough person. I’m being a modern, tough person, like I’m supposed to be—society says it’s okay. It’s not okay! It leads me to pain. I realize how hard I make my own life. Opinionated. A cantankerous old man. Alone. Driving everyone away. Just hoping those around me would not abandon me as I continue to be a crank.”

“It takes a lot of courage. I’ve got to be brave. I’m thinking, ‘They’re going to be very surprised by this thing you’re going to do.’ What does it feel like physically? The pain-body arising. I’ve got a choice right now. I need to relax. Stop having to be right. Stay with my emotion. Not ruminate. This hope, that eventually it becomes easier to express love and receive love.”

A week later David came for his 7th session. He begins the session saying, “I’m trying to catch myself. It’s still hard at home. I’ve been able to knock the edge off it. Every now and then I’ve been successful—I’ve felt the release—tried to not react. It’s harder, dealing with a subject where I think I’m right. Constantly trying to remind myself throughout the day to be mindful. When I’ve driving around, these are very effective teachings to use in traffic. I want to call out the other drivers—I get close to an utterance. I keep practicing.”

During this session David recalled the period when he had returned home after college. He says, “I had started into deep despair. I hated Christmas—a chance for people to figure out that I’m not doing anything. My own shame. They weren’t persecuting me. A shame-filled period. Absolute doldrums. An embarrassing period. I was a cold and arrogant person, to my coworkers. I never cultivated any relationships. Stagnation. I didn’t know what to do with myself. A low point. I realized, I’m heading towards suicidal ideation.”

Eventually David relocated to Nashville and met the woman who became his wife. He elaborates, “I had no steady girlfriend before her. I never understood why. I wasn’t outgoing. I was not really trying too hard. I wasn’t compromising. A lot of my depression was based on the belief that I would never find a relationship—how I’m supposed to live. My wife is the only person I’ve ever fallen in love with. She legitimized my entire existence. Maybe there’s not something wrong with me! She gave me a great deal of hope. Such a supportive person.”

After they married, David was still depressed. He says, “I was stuck in jobs I hated. I wasn’t treating the depression at all. It was very cyclical. I’d go way down and then up again. Every few weeks. My wife told me, ‘You have to explore treatment.’ I had been adamantly against taking any antidepressant. I told her, ‘I don’t want to be dependent on a drug.’ We ended up doing couples therapy and I did some individual therapy and I started Wellbutrin. Since being on it, I’ve been pretty free of overt depression—my brain chemistry evened out.”

Since starting this therapy with you, I have tools—things I can do. In the work environment, it’s easy. When I peel back the judgment—I’ve used the tools for everything that’s come along, that I’d have to take a Xanax for, in the past. In the past, I was scared—it was fight or flight. But there was no flight, so I would be in fighting mode—I’d ruminate all day. Now, I’ve successfully not done that, several times.”

Almost three weeks later, I met with David for his 8th session. He had been out of town, and said, “The initial thrill of these new tools—I’ve had to challenge myself to be vigilant. A couple of times, I’ve caught myself slipping back into that habitual pattern. I’m trying to stay inspired. I’m reading more in the book I Don’t Want to Talk About It—a great book—it hits on so many things for me. Makes me realize that I need to talk in here about something I don’t want to talk about—addiction.”

“ Terrence Real says that covertly depressed men will self-medicate, because you don’t feel anything. Putting yourself into a state so you will feel something. Exactly what’s going on with me! I want to take steps to address this. I’m not getting a lot out of it. My tolerance. It doesn’t accomplish my stated goal, of being in the present moment. I do want to stop my daily marijuana use. But I’ve been doing this for years. I don’t have the strength at this point to do it. I don’t want to have to have a dramatic episode.”

“Reading I Don’t Want to Talk About It makes me think about how I’m raising my son. My addiction. I’ve always known I’ll have to change this. I’m arriving at that point. What kind of Dad do I want to be? No questions it’s an addiction. With alcohol, it’s similar, but I don’t like it as much. I don’t happen to have the alcoholic gene. But with marijuana, I don’t know if there’s a way I can do this and not go cold turkey. I wish I could use it more responsibly, not depending on it. I’m looking for resources—ways to guide me through this. I’m ready to make a change. I’m not yet ‘scared straight,’ but it’s not sustainable.”

At this point I ask David, “How will you manage your boredom if you’re not high?” David answers, “Physical activity. I started playing golf with my coworkers a few years ago. Some of them also use a personal trainer. I opted out of that. I get enough exercise on my own, and I eat healthy. It’s a rebellion thing, setting myself apart. I don’t care about my appearance—a dumb value. I could do yoga. That trainer is actually a pretty good yoga teacher.” I ask David, “Are you addressing your grandiosity?” He responds, “Yes—I don’t need to make this grandiose point that I don’t care about my appearance. I have to break that. I am prone to judge—I latch onto that.” “Self-defeating grandiosity?,” I ask. “Yes, to me, I’m doing the noble thing—this lone warrior, with honor. I won’t fall prey.”

David continues, “I’m trapped in my own prison, a cycle of my own making. “Sounds like what in AA is called ‘terminal uniqueness,’” I suggest. David responds, “That’s a great descriptive phrase. It takes two forms. I’m desperately wanting to be unique, while also wanting to fit in and not be an outcast. My kneejerk is to do the opposite of what I’m really wanting. “So you can be special?”, I ask. “Yes,” David answers.

David returns to talking about the book I Don’t Want to Talk About It. “Performance based self-esteem—that’s the way I have figured out how to feel I’m achieving whatever the standard is—hard to come off that competitive, performance-based aspect. But I don’t want my self-esteem to be based on my last performance, or if it’s better than the others. It’s a challenge to break that way of thinking.”

“Mindfulness—I want to use it to break out of the judgment. My life has been built around performance-based self-esteem—that’s so far from enlightenment. I have to work to eventually get out of that mindset. It always has stood in my way. My own judgment. Clearly I have enough skills.” Then I ask, “Being good enough isn’t an acceptable category?” David answers, “I have to be the best. Not ‘good enough.’ But I’m so far from the best. Perfectionism—the shame wrapped up in it. I’m so wrapped up in my insecurity.”

“It has cost me. The grandiose thing I do is say, ‘I don’t care about this!’” “So you do the opposite?,” I ask. David responds, “I’m shameful about how much I can do. But I act like I really don’t care, to throw everybody off the track. This attachment I’ve struggled with for a long time. Status anxiety—really suffering with that. I’ve never been able to step back from the grandiosity long enough to be a person who works on this.” “Without grandiosity or shame?,” I ask. David immediately responds, “It’s all grandiosity or shame.”

“This grandiose effort to set myself apart and be special. That would be a different thing—to not sometimes be special. My type of upbringing—my parents—sending me down that road, that got into me. I want to be special, or I am special and different. I’ve walked around with that attitude, pretty much my whole life.”

I ask about David’s peer interactions, when he was growing up. He responds, “I was always the youngest in my class, emotionally behind my classmates. How far behind I was, throughout high school and college—not ready to be an adult or young adult. No romantic relationships, all through high school and college. ‘What’s wrong with me?’ This drove me into overt depression, by the end of college.”

“I was completely unwilling to put myself out there—a huge fear of failure, early on. Most of my decisions were driven by this fear of failure. I always felt that I could be dominated by others. In college, shame—‘I’m a loser.’ Then, “No, you’re special—better than—you’re better.” What do I fall back on, if I don’t have that? If I don’t do well, then I’m free falling, being like garbage.”

“By now, I have enough obvious success in my life. I have a beautiful family and wife. I have a complete life that I’m proud of. It assuages some of the desire to be special. But there’s still my baseline level of non-contentedness. I want to get to a spot where I feel content just being. I don’t want to need external stimulation, like marijuana, to feel okay. I want to achieve a sober equilibrium.”

“My life got so much more complicated after I started using drugs. Depression crept in. Everything was not okay.” “So then you were using marijuana to deal with depression?”, I ask. “Yes,” David answers. “I used marijuana as a refuge. It enhanced any leisure activity. It took me out of my head. But it doesn’t work that way anymore. Marijuana has always been bound up with depression. I may have decided to try it, because I was starting to feel the pain coming into my life. Inextricably linked to battling depression. Wellbutrin—if I had gone on it in college, I wonder how my life would be different. It’s been such a permanent help for the cyclical depression.”

An hour after this session, David met with the psychiatrist who currently sees 50 of my patients. As I always do, I had, several weeks earlier, sent the psychiatrist a long email, summarizing my clinical impressions of David. That same evening, I received a detailed email back from the psychiatrist, with his observations from his 90-minute evaluation. Among his observations were these:

“He reports negative ruminations and feelings of inadequacy. The latter likely also accounts for his tendency to use denial and projection; he is harshly judgmental of others. Although not suicidal, he has long had intermittent thoughts of ‘being better off dead.’ Anxiety is more prominent than depression. His biggest complaint is about his anger which is hard to suppress. David’s marijuana addiction may well be associated with his problem with anger. Anger can be linked to the right amygdala. Marijuana selectively primarily affects the temporal lobes where the amygdala is located…The lack of vegetative symptoms (anergy/apathy/anhedonia) despite the presence of cognitive depressive ideation usually means a person is partially treated with exercise…David said he feels sure he would have the other symptoms of dysthymia if he stopped exercising because he has seen evidence of such in the past…If adjustments to his current medications do not resolve his symptoms, then I will start David on Prozac 20 mg each day…Hopefully with some improvement, especially with the feelings of anger/irritability, David can let go of his marijuana addiction. He is bothered by the fact that he is an addict. Psychotherapy is key to all.”

Nine days later, I met with David for his 9th psychotherapy session. David told me, “The Prozac has eased my transition to coming home. I’m less agitated. Usually, when I come home, I’m unable to sit still, I start cleaning, and my wife feels it’s an indictment on the condition of the house. This time, I didn’t feel the need to do any of this. It also has seemed to ease my marijuana use—I’ve used less marijuana and alcohol. A step in the right direction. Not having that base level of agitation or lack of stimulation, that I’ve been trying to address all the time with marijuana.”

“I’ll be out of town for a few weeks. I want to maintain my stability and not go into judgment. Catching myself with the feelings that lead to negative judgments, anger, and resentment. Just feeling the feelings arising, acknowledging them, and not doing anything about them. The awareness of feelings—works really well with anger. It’s harder to be content with embarrassment, which drives my discomfort in a pubic setting. I’m doing a semi-regular meditation practice. I probably need to meditate every day. I’m using the ‘Calm’ App. Naming of the feelings—an important tool. Staying in ‘the watching place.’

“On my father’s side, the way they converse is to complain about things, and negatively judge things. It’s a family tradition. There’s an element of comfort—I’m so well practiced at it—I’m really good at complaining creatively. It structures my mind.” At this point I say to David, “Your complaining has the flavor of an addiction.” He responds, “Yes, the comfort element. I’m acting like my Dad—I’m ‘one’ with that part of him. His one negative aspect is his tendency to complain. It’s a way he makes conversation—but it becomes very detrimental to me. It’s very detrimental to him, too—it drives my mother crazy. It can get tiresome, listening to him complain.”

“It’s a part of my father’s identity that I’ve felt obliged to live up to. I’m an incisive complainer—it’s a point of weird pride. It sometimes drives people around me crazy—they want to get away from me. I realize that I should stop. But then I’d feel guilty, and I’d crush myself for it. Though I realize it’s not my fault. I tell myself, ‘I’m not broken, and I can learn to be kind to myself.” At this point I suggest to David that breaking his addiction to complaining means experiencing loss, grief, and a partial loss of identity. He responds, “The addictive, comforting quality of complaining—I never thought of it as an addiction.”

I entitled this talk “Healing narcissistic wounds and learning to love.” I see these two as central long-term goals in much of the psychotherapy that we do. I hope this case demonstrates David’s sincere and daily efforts to heal his deep narcissistic wounds and learn to love himself and his wife and children more deeply. I would like to close with some profound words about the difficult of learning to love, from Thomas Merton, a Trappist monk who lived for almost 30 years at the Abbey of Gethsemani in Kentucky. Merton is known for having built a bridge between mystical Catholicism and Buddhism, in his writing and in his dialogues with such Buddhists as the Dalai Lama and Thich Nhat Hahn.

One of my favorites of Merton’s many books is titled The Wisdom of the Desert. It is about the words of the desert fathers, who were monks who lived in caves in Palestine in 4th century. In his introductions to their words, Merton writes: “Love takes one’s neighbor as one’s other self, and loves him with all the immense humility and discretion and reserve and reverence without which no one can presume to enter into the sanctuary of another’s subjectivity. From such love, all authoritarian brutality, all exploitation, domineering and condescension must necessarily be absent…The charity of the Desert Fathers is not set before us in unconvincing effusions. The full difficulty and magnitude of the task of loving others is recognized everywhere and never minimized.”

“It is hard to really love others if love is to be taken in the full sense of the word. Love demands a complete inner transformation—for without this we cannot possibly come to identify ourselves with our brother. We have to become, in some sense, the person we love. And this involves a kind of death of our own being, our own self. No matter how hard we try, we resist this death: we fight back with anger, with recriminations, with demands, with ultimatums. We seek any convenient excuse to break off and give up the difficult task.” (pp 18-19)

 

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