Notes of first therapy session with Sam V., male, 43, diagnosed with Narcissistic Personality Disorder (NPD)


The following is about ten years old, I think. I’m not going to editorialize this further, but let the therapist’s words speak for themselves. (I do not know who the therapist was). Pretty interesting stuff and a vivid picture of how NPD can manifest itself in one person, in this case a well known author who writes about his own disorder. Sam Vaknin suffers from the cerebral form of narcissism; the other type is somatic.

Notes of first therapy session with Sam V., male, 43, diagnosed with Narcissistic Personality Disorder (NPD)

Sam presents with anhedonia (failure to enjoy or find pleasure in anything) and dysphoria bordering on depression. He complains of inability to tolerate people’s stupidity and selfishness in a variety of settings. He admits that as a result of his “intellectual superiority” he is not well placed to interact with others or even to understand them and what they are going through. He is a recluse and fears that he is being mocked and ridiculed behind his back as a misfit and a freak. Throughout the first session, he frequently compares himself to a machine, a computer, or a member of an alien and advanced race, and talks about himself in the third person singular.

Life, bemoans Sam, has dealt him a bad hand. He is consistently and repeatedly victimized by his clients, for instance. They take credit for his ideas and leverage them to promote themselves, but then fail to re-hire him as a consultant. He seems to attract hostility and animosity incommensurate with his good and generous deeds. He even describes being stalked by two or three vicious women whom he had spurned, he claims, not without pride in his own implied irresistibility. Yes, he is abrasive and contemptuous of others at times but only in the interests of “tough love.” He is never obnoxious or gratuitously offensive.

Sam is convinced that people envy him and are “out to get him” (persecutory delusions). He feels that his work (he is also a writer) is not appreciated because of its elitist nature (high-brow vocabulary and such). He refuses to “dumb down”. Instead, he is on a mission to educate his readers and clients and “bring them up to his level.” When he describes his day, it becomes clear that he is desultory, indolent, and lacks self-discipline and regular working habits. He is fiercely independent (to the point of being counter-dependent – click on this link: ) and highly values his self-imputed “brutal honesty” and “original, non-herd, outside the box” thinking.

He is married but sexually inactive. Sex bores him and he regards it as a “low-level” activity practiced by “empty-headed” folk. He has better uses for his limited time. He is aware of his own mortality and conscious of his intellectual legacy. Hence his sense of entitlement. He never goes through established channels. Instead, he uses his connections to secure anything from medical care to car repair. He expects to be treated by the best but is reluctant to buy their services, holding himself to be their equal in his own field of activity. He gives little or no thought to the needs, wishes, fears, hopes, priorities, and choices of his nearest and dearest. He is startled and hurt when they become assertive and exercise their personal autonomy (for instance, by setting boundaries).

Sam is disarmingly self-aware and readily lists his weaknesses and faults – but only in order to preempt real scrutiny or to fish for compliments. He constantly brags about his achievements but feels deprived (“I deserve more, much more than that”). When any of his assertions or assumptions is challenged he condescendingly tries to prove his case. If he fails to convert his interlocutor, he sulks and even rages. He tends to idealize everyone or devalue them: people are either clever and good or stupid and malicious. But, everyone is a potential foe.

Sam is very hypervigilant and anxious. He expects the worst and feels vindicated and superior when he is punished (“martyred and victimized”). Sam rarely assumes total responsibility for his actions or accepts their consequences. He has an external locus of control and his defenses are alloplastic. In other words: he blames the world for his failures, defeats, and “bad luck”. This “cosmic conspiracy” against him is why his grandiose projects keep flopping and why he is so frustrated.

8 thoughts on “Notes of first therapy session with Sam V., male, 43, diagnosed with Narcissistic Personality Disorder (NPD)

  1. This might be retitled, “Failed engagement with a sociopathic humorless clown”

    His level of disconnection from his own emotions, and lack of positive emotional investment in others in general, is more like what I’ve read about sociopathic individuals, and very far from the limited but real emotional engagement of many narcissistic individuals I’ve read about in some of the books by Masterson, Kohut, Johnson, etc.

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    • He does not engage, is extremely disconnected from his emotions (except in his journals/poetry/writings) and has no sense of humor (all this could be seen in “I, Psychopath”),but I don’t think he is actually sociopathic/psychopathic, even if he insists he is. I do think he is a malignant narcissist but not at the top of the continuum, just high on it.
      I don’t think he can be cured of his disorder, even though he’s self aware enough to be able to write about it in such a subjective way. I think the hopelessness he conveys about NPD is because he actually demonizes people with his own disorder. No one hates narcissists as much as Sam Vaknin. It’s because he hates himself.

      This isn’t a defense of Vaknin’s pessimistic views–I would love to believe some narcissists can get better or even be cured. I believe some who are not too high on the spectrum can, but they will have to work very hard and endure a lot of pain. Most will leave if that starts to happen. (I’ve written about this in depth–see my page in the header, Healing NPD)
      But I have hope for them, at least the non-malignant ones. For those higher on the spectrum, miracles can and do happen. We just don’t really know. I do hold onto some skepticism though, probably due to the near-consensus there seems to be that no narcissists can be cured.

      Believing NPD cannot be cured ever is probably a healthy view to have if you are presently living with a narc and wanting to escape, because if you think they can get better you will keep trying to “fix” them–and we all know what a hopeless and frustrating (and dangerous) task that can be.


      • The “near-consensus” idea that “no narcissists can be cured” (which was not your view here) makes no sense. Cure is an all-or-nothing medical concept that is ill-suited to discussing human emotional-relational problems like narcissism. People with narcissistic conditions can improve to lesser or greater degrees depending on many factors, and some can become truly mature, normal, and non-narcissistic. I hope you will get to check out Masterson’s series of books on narcissistic patients in treatment on depth. Also, try to check out the book Narcissistic Patients and New Therapists (by Huprich), Stephen Johnson’s Humanizing the Narcissistic Style, Heinz Kohut’s Analysis of the Self, etc. I really think you will have a sea-change in your thinking if you were to read quite a number of these cases. You would see how different they are from Vaknin, and how what Vaknin calls narcissism really is not narcissism as good psychotherapists understand it.
        Almost anyone can get well given sufficient help. We should have more faith in our fellow human beings, as difficult and infuriating as some of them may be at times.

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        • I really like your positive views about this, i’s actually a breath of fresh air after I read so much negativity about how they are hopeless monsters who are all destined for hell.
          I don’t know what your views about God are, but I could never understand a God who would allow that. Why wouldn’t he just “kill them off” and put them out of their misery now? Eh…I know I’m not explaining what I mean too well.

          I certainly haven’t done as much research into healing methods of NPD, BPD, and Cluster B disorders as much as you have, and I really do need to finish Masterson’s book and read some of the others. I’m very interested in Kohut’s methods and even wrote about that here:

          My understanding is Vaknin has sort of combined ASPD and NPD into something called “narcissism” (which is really “malignant narcissism”) and muddied the waters, but I also think ASPD is on the same spectrum as NPD–but higher than it (ASPD = psychopathy, sociopathy). I definitely have a lot more reading to do and I could become even more optimistic than I am now. I do think I’m more optimistic than the usual ACON (Vaknin would call that “malignant optimism”) but I’m not sure how much of that is wishful thinking. I hate to see anyone suffer, even people with NPD–because they do suffer even if they will never tell you. I really admire your attitude about the hope of healing.


          • Thanks, yes I think things can be better for narcissistic people than many think, if they get appropriate help and if they can feel some optimism/hope. I am not religious but understand your thinking about God.
            Regarding antisocial people, those problems also exist on a spectrum. I wanted to find out a long time ago whether they could be hehlped, because it didn’t sound right to me that there was some category of people that was beyond hope in any circumstance. There are actually several books reporting how antisocial criminals can be engaged and helped in prison environments. I remember Donald Rinsley (Masterson’s colleague, who worked at the Menninger Institute for treating Personality Disorder/Psychosis in Kansas) had experience working with antisocial people in prisons. He wrote that they actually could respond positively to treatment, to whatever degree some narcissistic or borderline transference predominated in part of their personality (i.e. to whatever limited degree they had emotional investment in other people, which some criminals do, often in unusual ways), but only in a controlled setting where their acting out (e.g. drug use, violence, denial, projection) could be rigidly controlled. He noted that unfortunately the prison, despite being good at controlling people, is a very antitherapeutic environment in other ways, and that rarely are sufficient therapeutic resources available there. So, the myth persists that all antisocial people are beyond help.
            Here is another book that talks about how difficult antisocial people are to help, but also how they can be helped:

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            • That’s very interesting. I would never think someone with ASPD could be helped, but I see your point about finding it difficult to accept that there’s a certain group of disordered people who are beyond all hope. I want to believe, as long as someone is alive on this earth, that no one is beyond help or hope.


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