ILBS 27 | Narcissism


Substance use and addiction are not just born out of external and environment factors. There is often a deep-seated cause that we don’t treat—our personality. In this episode, Dr. Ramani Durvasula joins host Tim Westbrook to discuss how narcissism manifests itself and influences substance-related issues. Ramani is a licensed clinical psychologist, professor of psychology, author, consultant, speaker, and expert on narcissism. Her practice has focused greatly on highly antagonistic personality styles and their impact on mental health and relationships. She dives deeper into the many subtypes of narcissism and how each subtype should be addressed when treating patients recovering from substance use. Ramani explains the parallels between addiction and narcissism and further explains how narcissistic behavior can affect addiction and narcissism as a risk factor for the same.

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Dr. Ramani Durvasula On Narcissism And Its Influence On Addiction

I’m here with Dr. Ramani Durvasula. She is a licensed clinical psychologist, bestselling author, professor of Psychology, distinguished speaker, workplace consultant, and expert on narcissism. She has been sought out in various media outlets for her expertise on narcissistic personality disorder and narcissistic abuse including Red Table Talk, Bravo, the Lifetime Movie Network, National Geographic, Discovery and the History Channel. Her work has been featured at TEDx and on the TODAY show and Good Morning America. She also has a popular YouTube channel with over 700,000 followers and over five million views per month that focuses on narcissism and difficult relationships. Dr. Ramani and I are going to talk about substance use disorders and narcissism. Dr. Ramani, welcome to the show. It’s so good to see you again.

Thank you, Tim. It’s almost a narcissistic introduction.

I wrote the introduction. Take it. There’s a lot more to it than what I read. I’m so grateful and honored to have you here on the show. I’m looking forward to chatting with you. This is the second time I’ve had you here on the show. The first time, we talked about understanding narcissism in general. Now, we’re going to talk about substance use disorders and addiction. I got lots of good questions for you. Let’s dig into it. What gives you the right to claim you’re an expert on narcissism?

I don’t know if I have the right. I even hate calling myself an expert in anything. I always view that somebody who is in mental health. Ideally, you triangulate anything from three paths. I’ve done research on this. I’ve been funded by the National Institute of Mental Health to examine personality disorders as they link to HIV and substance use. I have clinically been practicing in this area, focusing on survivors of narcissistic relationships. In other words, those who have been harmed by people with these personality styles. I wrote my book on that in 2012 and had been doing the work for almost ten years before that. I’ve written two books about it. I’m very immersed in it and I teach about it all over the world. I teach to clinicians, laypeople and coaches. The combination of the three things qualifies me, but who knows? Anyone else is welcome to debate that. I would probably accept that I wasn’t. I’m fine with that.

You’re good with it regardless. I appreciate that you’re here. What specific incident inspired you to be so passionate about narcissism?

It’s interesting because I was writing something about the history of social media and narcissism. As I was writing that, it dawned on me that narcissism was almost like this backwater in the mental health field. Anybody who talked about it viewed it as an intractable problem, “We can’t do anything about it.” From a clinical perspective, no one cared. What was fascinating was if you might have had a difficult person in your own individual life, but it wasn’t at this population level, which things like reality television and social media have proliferated, those industries count on narcissism. They need and foster it. If you need something, you’re going to build more of it.

I do think we created platforms that cause a proliferation. What I was seeing, honestly, was in a clinical setting. How much havoc people who had difficult personalities were causing for frontline staff, nurses, reception staff, nurse practitioners, even for the nursing assistants who would have to take vitals. You have this busy clinic and one client would come in and ruin everyone’s day. Whereas most other clients were behaving well.

This patient population is not only causing undue stress for these hardworking healthcare employees, but nobody likes them. These people aren’t getting good healthcare. People would look on the schedule and say, “This person is coming in now.” I know it happens for us as mental health practitioners. We look at our schedule and we’re like, “I have to get through my 1:00 or 5:00 and I’m fine.” I thought, “This isn’t just happening in healthcare. This has got to be happening everywhere,” and so an idea was born.

Nobody would take on these difficult people in research. That’s how my research path got started here because I thought, “If they’re causing this much trouble in the clinic, these patients are causing this much trouble everywhere.” At the same time, in my clinical practice, more people were coming in with identical complaints about their marriage, invalidation, gaslighting, manipulation, not being heard and not being seen. Nothing they did, no matter how much couples therapy, how much they talk or how much they fix their communication, the other person wasn’t improving. It was seeing those two trends.

Remember, Facebook came around in 2004. This work started getting ahead of steam for me as I went into the mid-2000s. I started seeing the effects of social media and the social influences, watching clinical populations and then thinking about how it affects other settings like the workplace or healthcare was what I thought.

We’ve got a problem. The fact is we’ve been cutting difficult people in the past for a long time, often because difficult people had power, but also because we enable them, “They didn’t mean that. Let’s give them a chance. Everybody has an off day.” Every day is an off day? When we realized that they don’t change, I thought, “If we tell everyone this difficult person is never going to change, how will people proceed from there?”

Did you have any experiences with narcissism prior to being in a clinical setting like growing up?

It was a key part of my childhood. Every type of narcissistic abuse you could have experienced. I’ve had it in family relationships, intimate relationships, workplace relationships and friendships. It’s all four of what I consider the relationships you can have. Interestingly, I only have one sister and I adore her. I never had it in a sibling relationship, but in every other relationship, you could have had it.

What was interesting is I didn’t have a name for it. I look back on that experience, especially as a child. No seven-year-old is walking around and saying that a grandparent, a parent, an aunt, or an uncle is narcissistic. That’s not what a child says. A child blames themselves, “This has got to be me,” or you start sensing on, “My house is weird. There’s a lot of shame. I come from this shameful place.”

[bctt tweet=”Narcissism is a story developmentally that you can tell backward, but you can’t tell forward.” username=””]

It has been a part of my entire life which sucks for me. It’s interesting to see people who say they had a perfectly fine early life and a lovely extended family, then they get into adulthood. They fall in love or work with somebody, and they have no roadmap for what it is they’re encountering. Their cheerful family is saying, “Come on now. Anybody can get through anything. Everyone has got good in them.” I get to be the angel of death and say, “Not everybody does.” It has always been something that has plagued me, but I didn’t identify it as such until I was into my research and clinical work.

Since we’re talking about substance use disorders, addiction and narcissism, what are the similarities between a substance use disorder, addiction and narcissism?

There are a lot of similarities that can make it complicated. The similar use of defenses. Narcissists tend to use denial, rationalization and projection, so do substance users. People with substance use disorders will use denial and lots of projection and rationalization. You have very similar defensive portrayals.

When a person is deep in it with an addiction or substance use disorder, their empathy levels drop. At some level, it’s the drug above all else, above people and anything. The other people in their sphere will experience that as a lack of empathy. It’s not to say that all substance users or addicts don’t have empathy, but when they’re in it, they’re not aware of other people. People experience that as a lack of empathy and in some ways, even an entitlement.

In the throes of drug-seeking or resource-seeking behavior to acquire drugs, people will often say, “I need to get the money.” There’s an entitlement like, “Give me the money. Let me stay here. Let me have this and that.” It’s not the same entitlement we see in narcissism but it looks the same on the outside because the person just sees, “This person thinks they can have anything they want.” There’s that piece of it. There’s a manipulativeness we see in both patterns. In the narcissist, manipulation is a form of communication standard. People who have substance use disorders are being manipulative as a means to an end to acquire that end goal of using. That’s often a part of the clinical picture that we see, and then we can see those are manifest behaviors.

Many people would argue narcissism is a risk factor for addiction and substance use disorder, largely because narcissistic people can’t self-regulate. When they have a strong emotion, frustrated, disappointed and under stress, they can’t manage those negative emotions. At one level, they’ll do a lot of lashing out, screaming and yelling at people, but especially when the negative emotions are around disappointment because disappointment takes away a narcissistic person’s grandiosity. If everything is not going their way, then they’re not Superman or Superwoman. What do they do? They use substances to take away that feeling.

This is why we’ll see narcissistic people often have a penchant for stimulant drugs because those foster grandiosity, but I’ve seen every form of addiction you can find. You can even see a lot of narcissistic people will turn to marijuana use because it’s a very numbing substance and there’s like, “I don’t have to think about anything.” It’s that idea of regulation that is so devoid of a narcissistic person. Substance use then becomes a coping tool and then can escalate into a substance use disorder. There’s a ton of overlap.

In fact, anecdotally, what I’ve seen in many families is they will have an incredibly difficult, entitled, mean, cruel and arrogant addict in the family. They’ll find that person will finally go to rehab and the family is like, “We’re going to get our sweet person back.” The person who comes back is mean, arrogant, manipulative, cruel and sober. That is a sad moment for those families because the personality is the personality. They went to rehab and got cleaned. They’re going to twelve-step. They’re good and maintaining but they’re just as nasty to the people in their family as they always were. That’s when we know that narcissism was always the foundation and the substance use was the house. We managed to dismantle the house but the foundation remains.

There are different types of narcissistic personality disorders, correct?

There are different styles of narcissism. There is only one narcissistic personality disorder.

There’s covert narcissism and grandiose narcissism. What else would there be?

Let’s start with the term covert. There is a guy named Pincus who I read his piece on this. He is a heavy hardcore researcher in narcissism. He is like, “These words are being misused. Let’s call them grandiose and vulnerable narcissism.” Vulnerable narcissism is the form of narcissism that has only been talked about in the last 25 years. It was always a backwater issue. There were always people saying, “There’s a whole different kind of narcissism here,” but the Diagnostic and Statistical Manual of Mental Disorders, the DSM, never recognized the vulnerable form, yet it’s the vulnerable form that’s showing up in all the therapist’s office and rehab centers.

ILBS 27 | Narcissism

Narcissism: We’ve been cutting difficult people a pass for a long time, often because they have power but also because we enable them.


Grandiose narcissism is easier to explain because it’s what we consider as being garden-variety narcissism. If it’s pervasive and problematic enough, it’s what we traditionally think of as potentially even narcissistic personality disorder. Grandiose narcissism is your arrogant, entitled and grandiose, “I’m the ruler of the world. I’m so great,” deeply entitled, controlling, rageful, superficial, validation-seeking, callous narcissist, and very textbook.

The vulnerable narcissist on the other side is entitled but it’s a victimized entitlement, “Nothing ever goes my way because everybody gets a better start than me. I deserve to be the head of this place, but they’re not even able to see what intelligence is because they’re so stupid.” It’s this begrudging victimized like, “I should be the head but no one is smart enough to see how great I am.” It’s a victimized grandiosity like, “I could be Bill Gates or Steve Jobs. I’m not a good programmer but all these people just don’t know how to identify real talent and they had a leg up.” It’s a lot of that.

People who have vulnerable narcissism present with a lot more anxiety and depression. A lot of clinicians identify them as such out the gate. They tend to become a lot more self-effacing. If there’s disappointment or stress, they’re more socially anxious. They’re less socially skilled and less naturally extroverted like we see in the grandiose types. It’s a victimized, resentful and sullen narcissism. That’s the vulnerable narcissist. They’re very afraid of abandonment. They don’t do well in relationships and/or they get let go from a job. They get rageful at those times but they also get very passive-aggressive.

The grandiose narcissists tend to be more overtly aggressive in your face. The vulnerable narcissists tend to be more passive-aggressive. The idea of covert and overt narcissism is more of how it’s displayed. Overt narcissism is more of a behavioral display, “I’m so great. Look at my sports car, my watch and my fancy girlfriend.” Whereas covert narcissism is a bit more of the thoughts like, “Everyone is out to get me. Nobody likes me. Nobody sees how great I am.” That’s the covert part.

With the covert, is there some delusional thinking associated with that?

It’s always like that fine line between delusion and reality. I would call it illusional thinking because it’s not frankly psychotic. It’s very distorted. It’s very black and white. It almost feels like a borderline defense in that way. It’s all-or-nothing, “Nobody likes me. Everybody is out to get me.” What they mean by out to get them isn’t like a tin foil hat out to get them. It’s not like the FBI is monitoring their television but it’s more of, “Everyone else has it better than me. Everyone was born with a trust fund. I wasn’t born with a trust fund.” I don’t know that we call that delusional. They feel persecuted.

Is there a type of narcissist who will be addicted to substances or process addictions?

Let’s go back to your original question, “Are there other forms of narcissism?” We talked about grandiose and vulnerable. There are all these other kinds of subtypes. There is malignant narcissism. Malignant narcissism is characterized more by not only the grandiose stuff but also exploitativeness, much more manipulativeness and callous, much more likely to harm other people, be abusive and maybe even be violent.

There are communal narcissists. Communal narcissists are pseudo-humanitarians. They do what looks like lots of charitable endeavors but the only reason they do them is so people think that, “What a savior you are.” The only reason they’re doing those charitable things is so they get lots of attention and validation. It’s not for the love of the game. They need the attention and won’t do something charitable unless they get lots of credit for it.

There are neglectful narcissists. To some people, they can almost feel like they’re on the spectrum but they’re not. They literally view everyone through an instrumental lens like, “I wouldn’t even notice you unless I needed something from you. If I was in a room with you, you wouldn’t even talk to me until the moment you needed something from me.” They’ll do that in their relationships. They completely neglect everyone. If you’re in a relationship with them, it’s like being in a relationship with a ghost. There’s nothing you can do that can get you to notice them. They don’t notice their kids and anyone.

There are the self-righteous narcissists who think they’re somehow morally superior to everybody else. They’re almost strange and can seem loyal. They play by the rules to a fault but they play by these heavily rigid moral rules to lord that over everyone. They can be rigid with money and rules. There’s no openness, flexibility and empathy in the face of that. There are all these different corners you can go into that explain the different subtypes of narcissism.

Your next question is, “Are there certain forms of narcissism that are more associated with a risk of a substance use disorder?” Probably what I consider more of the big three disorders are the grandiose, vulnerable, and then potentially the malignant narcissist. I would say that because vulnerable narcissists are so not able to cope with all of the negative mood states they’re experiencing. They’re always feeling let down, disappointed, and the world is against them. They’ll want to self-medicate against all that persecutory negativity.

The grandiose narcissistic person always has to seem like a superhero. When that grandiosity is getting chipped away, they don’t like it. They will use to always be able to keep up that false facade. A malignant narcissist is hit-or-miss. A lot of malignantly narcissistic people can be fringed. They’ll sometimes be shady with even how they run their businesses. That shadiness may translate into almost keeping company with people who are more likely to engage in behaviors that are more off-the-grid, even as younger people because we know in the majority of cases, substance use behaviors initiate in adolescents. The malignant narcissistic people as adolescents are already hanging out with the kids. They want to fit in and be the alpha kids. With the other types, it may be a yes or no, but these are the types where we’re more likely to see it.

[bctt tweet=”If narcissism doesn’t at least get somewhat addressed, you’re all but guaranteed that there’s going to be a relapse.” username=””]

I would classify drugs as stimulants, “I want to go faster. I want more.” You have the downers, opioids and heroin. I would think that grandiose narcissism would be more associated with stimulants.

Absolutely, however, with the vulnerable narcissistic people, not so much. With vulnerable narcissistic people, they’re trying to squelch those negative emotions. They may be just as likely to use central nervous system depressants, whether that’s alcohol, opioids or even marijuana as a systemic bring it down and be in another world than would people who are grandiose narcissists who want the up, “I’m the king. I’m so great.” I’m seeing this left and right with a vulnerable narcissist using marijuana. It’s a real thing. The vulnerable narcissist is all angry at the world, sullen and feeling victimized, “How come nothing is going my way? How come I’m not an influencer? How come my startup is not working?” They go home and smoke a ton of weed.

They say that alcoholism and drug addiction is a progressive disease. Would you say that narcissism is also progressive?

Narcissism is developmental which intercede into a progressive realm. No child, adolescent or even an emerging adult can fully use that label. We might see narcissistic adjacent patterns in those people. I always say to people, “Narcissism is a story. Developmentally, you can tell backward but you can’t tell forward.” What I mean by that is if you have a 19 or 20-year-old who is entitled, arrogant and all of the things that adolescents are, a lot of parents out there say, “I’m going to have a narcissistic adult on my hands.” I’ll say, “Maybe, but maybe not.”

If that same adult parent tells me the child at 30 or 35 is behaving in this way, they’re in trouble. That 35-year-old was like that when they were twenty, but not all twenty-year-olds are going to be like that when they’re 35. Something happened in those mid-twenties that demands how a person steps up to the demands of real life. The kinds of adult relationships people create oftentimes is how they find their own identity, professional identity and social identity.

Those things in the mid-twenties can correct out because, let’s face it, adolescents’ brains, especially their frontal lobes, are still very much under construction. A lot of that impulsive disinhibited, “I’m only about me and my friends. I don’t care about anybody else,” that’s developmentally on point. As some of that falls away, we’re left with a normal functioning adult, but it doesn’t fall away for everyone. The ones that don’t fall away go into adulthood narcissism.

Once we hit adulthood narcissism, what you’ve got to remember about the vulnerable and grandiose narcissistic types, people like Kernberg and Ronningstam, these big-name narcissism researchers, would argue, “It’s two faces of the same coin but it’s like a weird, distorted coin.” Some people are majorly grandiose narcissists. I’ve worked with these people clinically. When life doesn’t go their way, their partner leaves them, the lawsuit comes or they’re publicly humiliated. The coin flips and they look very vulnerable, victimy, sullenly, resentful and angry, “Everyone is out to get me.” They start looking vulnerable. There are vulnerable narcissists who every so often, the world goes their way, and then they look like grandiose narcissists.

It’s circumstantially how life is treating them that would show what phase they’re going to lead with. Again, two faces of the same coin of narcissism. What we do see is that narcissism probably stays pretty flat throughout adulthood. It manifests in a variety of situations in interpersonal relationships, self-concept and self-regulation. In the professional world, as the narcissistic person gets older, we start seeing different sets of problems. Number one, as people in our society get older, they have less societal power. Unless you’re that rarest of people who have so much money that you can still dangle it and puppeteer people in your 80s or even 90s, by and large, normal people lose. They have to retire. They’re not considered as attractive. They can’t get a young and attractive partner unless they purchase them.

If an older narcissist has the purchasing power, they’ll still be able to engage in all the transactional relationships. As a normal person gets older, they don’t have that power anymore. What you can see is a real ramp-up in irritability at the loss of societal power that they no longer hold. When you add dementia into the mix, then it starts getting messy because it tends to take those narcissistic traits and now they’re mean. You often have a very difficult and almost impossible to manage older adults, where the kids have already been so hurt by this parent as it is, and now they’re going into the dementing process. A lot of times, the kids will say, “Welcome to your assisted living. We can’t do this anymore.” They’ll often get kicked out of multiple assisted living facilities because they’re so cantankerous.

When does narcissism typically become evident? With alcoholism and drug addiction, a lot of times, it starts early at 12, 13, 14 or 15 years old and sometimes it starts later. I heard you say that potentially, a person has narcissistic traits at 19 or 20, but you don’t know yet.

With narcissism, me personally, knowing what we know about the human brain, all bets are off for me until a person is 25. I’m not using 25 as your 25th birthday but if you show me a 28-year-old, we’ll talk. If you show me a 22-year-old, I’m still hedging my bets. I’ll tell someone, “You may have a problem.” For example, in your role, you might see a person who has got a thirteen-year-old who is not just experimenting on the weekends but now it’s every day. While they’re not going to school intoxicated, you might say to that parent, “The everyday part is concerning me.” That might escalate into something that’s diagnostic by the time they’re getting into mid or later adolescents.

With narcissism, we could already see in a 22 or 23-year-old that these patterns are concerning, but for every single parent out there who has a 22-year-old, arrogant, entitled, lack of empathy, the whole list and they’re like, “They got a job. They had to wake up in the morning. They fell in love.” That 22-year-old is unrecognizable. It’s like, “I’ve got the best and most responsible 30-year-old on my hands.” There’s also a bunch where they’re like, “They’ve been a jerk since they were twenty.”

My biggest concern has always been not to panic parents if they have a real jerk of a twenty-year-old to not say, “All bets are off. I have a terrible kid.” You might have a real problem on your hands but you also might not. You’ve got to let the frontal lobes do what the frontal lobes do, and give it a chance to see if they’re able to get that impulsivity and lack of self-awareness in check.

ILBS 27 | Narcissism

Narcissism: For narcissistic people, shame is a massive trigger. If that shame gets tripped, they’re going to relapse inevitably.


It’s like you’re going up into emerging adulthood. We get into adulthood and then we see as their peers are settling into careers, normal relationships, independent life, being able to pay some of their bills if not all of their bills. This is a 28-year-old that says, “You still owe me and have to pay for my stuff.” That’s a problem.

Is it more likely for a narcissist to be male or female?


Do you have a percentage-wise?

The data has been mixed on this. I’ve seen everything from 80/20 to 75/25. That’s usually where it sits, 3/4 and 1/4 thing. A lot of this has to do with socialization. We socialize boys for aggression and unemotionality. We shame boys and men for showing emotion. Not being in command of one’s emotions, not being able to process that, be self-reflective and be valued for empathy. Those are core pillars of things that are not present in narcissism.

If we’re socializing and developing them out of boys, it’s no wonder that this is happening to the degree we get to similar socialization processes on the basis of gender, then we’re going to see more of an equivocation. We’re also entering an interesting time in conversations about what gender is, going away from a gender binary, and how gender identity development is not just by society but it’s also what’s happening as an internal process.

That’s very new work that we had to let evolve, but I’m going with a traditional binary format, which is how most of the research has been done. Here’s what’s interesting. I read a study. In this research group, what they found was that when it was grandiose narcissism, it was 80/20. It was the guys all day, all night. When it was vulnerable narcissism, it was equal. For men and women with vulnerable narcissism, the rates are similar.

If a person grows up in an alcoholic home, they’re more likely to have the alcoholic gene or they’re just in that environment. Is the same true with narcissism?

The work on this is evolving. I wish I had read it before. The article just got pulled up and I haven’t read it yet. I did encounter one article suggesting potentially a genetic element to narcissism. I’m loath to say that we found a narcissism gene as it were. What is more likely to be happening is that there are more likely genetic influences around things like impulsivity, disinhibition, executive functioning, and certain sorts of emotional expression. There might be a genetic piece there since all of those things are parts of narcissism.

Think about it. This is the case without any substance use disorder. In one family, you can have a child who is an addict and a child who is not despite having a biological parent who has a history of addiction. None of these things is a slam dunk, but what we do see is that most of the research points to the evolution of narcissism being a largely developmental process. There are temperamental elements that are believed to be present. Temperament is almost like the genetic part of personality. It’s why people will have a temperament.

Even in childhood, they’ll say, “The way you respond to that is just how your uncle would respond.” Everything from how they get angry to how they cope, it’s similar to a biological relative. Temperament is our biological personality. My hypothesis is that there are kids who are coming to the world temperamentally difficult. They tend to be harder to soothe and are behaviorally dysregulated. Honestly, they’re not likable children. They’re more work for the parents, caregivers and teachers. The child is frequently getting a message of, “Stop. Don’t do that.”

The child wants to be liked like all children and may find it to be more of a challenge. It almost becomes bigger in trying to get this attention to attempt to soothe themselves. There’s likely a temperamental piece. Whereas kids who often come into the world a bit softer, more gentle, play by themselves more, easier to soothe, if you pick them up, they’re often happy sitting there, those kids are probably a little less vulnerable to this narcissistic turn.

When we look at narcissism, we see issues around all kinds of developmental issues like attachment issues. They often tend to have anxious or avoidant attachments. There can be trauma histories. They’re often brought up in homes that are characterized by chaos, inconsistency and instability. They are often shamed for showing emotion. There are a lot of elements or interestingly, they’re spoiled. They were never told no, “You’re my prince. My prince gets anything he wants.” You have the grandiose dad who then turns the child into the crown prince. The child never learns regulation and then they go into adulthood like that. A range of things can set up this narcissistic arc.

[bctt tweet=”We’re all working with systems we didn’t design, and yet we have to get remunerated within.” username=””]

The grandiose narcissist, if you have a father-son relationship, that’s more likely to happen in a father-son situation as opposed to a father-daughter or mother-daughter situation.

I’m not so sure about that. I’m going to be frank with you and I’ll tell you why. It’s the consistency of messaging. There’s no reason if a father is like, “This is my girl. Everything is about my girl. I’ve got the girl who is the best, whatever the heck she is the best at.” Especially if her own interests are aligned with the dad. Dad loves soccer. The girl is a great soccer player. He coaches a team. He goes with her everywhere. They go to soccer matches together.

It can start having an interesting vibe because it’s almost as if it’s a hetero relationship. It’s almost like they’re hanging out together more than he is hanging out with mom. He might even become quite disparaging towards mom and daughter may follow suit like, “Mom, you don’t know a darn thing about soccer.” Now, they’re best buds.

I don’t mean it in an inappropriate way at all. It’s almost like you triangulate it against the mom. I’ve seen that happen in father-daughter. Think of mother-son. The cuddled son with the mom was like, “This is my prince. Everyone has to love my prince. He is the best son who ever lived,” and then the mom who is obsessed with the daughter. I’ve seen it in every dyadic combination.

If there are two kids and let’s say one is male and one is female, is the father more likely to have that type of a relationship with his son or daughter? I would imagine with the son. If there’s not a male kid, then it’s less likely that type of relationship would exist.

That’s where it gets settled. This is where narcissism is an interesting game. It’s almost like the gender of the kids wouldn’t matter as much as which kid is delivering the best narcissistic supply. By narcissistic supply, which kid is more attractive, resembles the parent more or has the skillset that that parent wants? Probabilistically, because most narcissistic people do tend to be a little bit simple on this and it’s all very gendered and societally supported, you might be more likely to see that. I have to be honest with you. If he feels his son is a dud because his son can’t catch a ball or hit the straight line but the girl is quick with this stuff or the girl looks like dad and the mom doesn’t, who is the better supply?

Who is the better athlete, better looking, more popular, funnier and smarter?

That’s who the narcissistic parent is going to gravitate towards. It’s where are they’re going to get the best public show from this kid.

Let’s talk about treatment. Can narcissism and alcoholism be treated simultaneously?

They have to be treated simultaneously. One place that substance use treatment comes up short is in the incapacity to manage both of those agendas. This is what I’m saying. The family who has their family member returned to them sober and mean. The problem is that if the narcissism doesn’t at least get somewhat addressed, you’re all but guaranteed that there’s going to be a relapse. The next time there’s frustration, disappointment or stress, that person is going to start using again because they can’t cope.

Remember, for a lot of narcissistic people, there’s also this other problem. Going to rehab is window dressing, especially for people who work in industries where you slept and showed up high to work. “In good faith, I’m going to go do my 28 days.” They do their 28 days to great fanfare, “Look how heroic I am,” but they get the 28 sober days which is easier to do if there are people watching you around the clock. I’ve had clients who have managed to still sleep in rehab. By and large, the facilities do a good job of stopping that. Now, they’re back in the real world with all the real-world problems or feeling ashamed. For narcissistic people, shame is a massive trigger. If that shame trigger gets tripped, they’re going to relapse inevitably. They have to be addressed simultaneously.

The challenge though is this. The majority of clinicians are not trained in how to deal with these patterns because the treatment literature on narcissism, which is sparse and as much as people are out there saying, “We figured out how to treat narcissism,” but you go and read this literature. You’re saying, “You met with this person twice a week for eighteen months. They always showed up and you had a team of clinicians.” I don’t know many people in the United States who can afford that for eighteen months. You might only have them for 4 to 6 weeks. You’re not going to move the needle on narcissism in 4 to 6 weeks.

ILBS 27 | Narcissism

Narcissism: All of these attempts to internally regulate will be outsourced to substances.


In some ways, we’re setting up an impossible bar for a rehab center, but in treatment planning, in team meetings, and how any center does their coordinated care, this personality piece has to be considered and recognized as a high-risk relapse factor and not just like, “He is spirited. This person has gotten irritable because they’re using.” It’s very hard to split out the two.

In some cases, you would have to get releases to talk to the clinicians who have talked to this person. I know when I have it over the many years. I’ve had clients go to rehab and they have the good sense to get the release to talk to me. I could say that to the center and the center was like, “Thank you.” One center was so sweet. They were like, “There should be a stained-glass window with your face on it for having been willing to work with this person for so long.” I was like, “Thanks. I don’t want a stained-glass window, but I’m glad that this is your problem for a month.”

A lot of times, even the staff of the rehab centers do not blame themselves like, “Why are we getting nowhere?” You’re getting nowhere because this is hard. To have much more realistic expectations and different kinds of goals around the maintenance of sobriety, think about how the family is involved in treatment. It has to be they’re informing it for no other reason than relapse prevention. That’s it.

Working in the field, I don’t think I’ve ever heard anybody in our intake process like, “What are the disorders?” They’ve got mental illnesses, anxiety, depression, alcoholism and drug addiction. They’re addicted to crack cocaine, heroin and fentanyl. All of those things are listed. I don’t think I’ve ever heard anybody say, “By the way, this person is also a narcissist.” It’s never talked about. What I’m hearing you say is that it’s imperative for the treatment team to know that narcissism exists.

It’s what I call the workaround model. This is what I see people saying about these people who are narcissistic. They’ll say they have ADHD, oppositional or impulsive. They’ll use every word but the word. What you and anyone who works, runs, and has an affiliation with substance use treatment centers say is, “When we’re getting these referrals that have this laundry list of ADHD, oppositional defiance, intermittent explosive stuff, anger management issues, and dysregulation, they’re all trying to say in this coated way, narcissism, because it’s the consistency of all of that.”

In some ways, the word has taken on such a bad brand. It’s fascinating to me. I read this article. There’s this article that came out on this idea of D which stands for the dark factor of personality. It takes in some interesting territory like callousness, entitlement and lack of empathy. It’s a trait that takes in all of this dark and icky stuff. D is seen in psychopaths, sociopathy and narcissism. Even if they’re not handing you the client saying, “This is a narcissistic client,” let them at least say, “This client has an antagonistic personality.”

Talk about the client’s personality. We’ve all got one, “I’m a neurotic and agreeable person.” I know that about me. Someone should know that about me because it’s easy to play me. I’ll often agree to do things I don’t want to do. If I was a clinician, I would say, “Ramani is going to often agree to take on more than she can handle.” That’s mine. To know somebody who has this heavy D, dark factor or antagonism, simply means that you’re better prepared to treat this client.

Part of this has to do with the insurance industry. People don’t want these personality terms on the paperwork because to the insurance companies, it becomes a big glaring, “There’s nothing that can be done with this client.” I understand that we’re all working with systems we didn’t design and yet we have to get remunerated within. You’ll see that the personality stuff is often left off transfer paperwork for no other reason than the insurers are against it.

Not having that piece is a big problem because what happens is it’s like you’re buying a house and the inspector leaves out the part about the leaky roof. There’s a storm and you spent $1 million on something and there’s water everywhere like, “Whoops, I left that one out.” That’s a big whoops. That doesn’t work. These are the unacceptable whoops.

Is a narcissist more or less likely than the average person to be an addict?

More. The dysregulation and impulsivity, for those two reasons. The incapacity to regulate uncomfortable internal states, whatever they may be, sadness, abandonment, disappointment, frustration or stress. Anytime the world is not perfect in the way they wanted to be, they become dysregulated. They need that not to be the case. Anytime somebody brings up feelings of inadequacy for them, they get criticized, they get the feedback they don’t like, or something doesn’t go their way, when that inadequacy gets triggered, then they’ll have a shame reaction and they won’t like that. All of these attempts to internally regulate, they don’t have a self-soothing mechanism that will be outsourced to substances.

The substance is the solution.

The substance is much easier than sitting with the pain. The hardest element of working with narcissistic clients is that they don’t want to be uncomfortable. The hard work with them is getting them comfortable with feeling uncomfortable. Why would you want to feel uncomfortable when you know there’s something you could do immediately and make it stop? That would also help you feel grandiose. The other piece is impulsivity, and this has to do more with substance use initiation. They’re very impulsive people.

That’s why behaviorally, in a relationship, they’ll often say whatever they want. They’ll say things that are mean and harsh because they’re disinhibited and impulsive. The lack of empathy means you don’t take a moment to say, “If I say this, will I hurt him?” You just say it. Later on, when somebody says that was terrible or the reason they’re quitting is because you hurt them, then they’ll come up with some half-cocked apology like, “Sorry about that,” but it’s really, “I can’t afford to lose you as an employee.” It’s not even an empathic recognition that they hurt you.

[bctt tweet=”Substance is much easier than sitting with the pain.” username=””]

Apologies for them are very instrumental. It’s a way to keep people where they need them, but that impulsivity can also be related to substance use of like, “Let’s party and do this. It sounds like fun. I deserve to have fun.” There will be the impulsive initiation, and then maintenance in terms of soothing negative emotion.

There’s impulsivity which is also associated with a lack of awareness. The apology is a band-aid for the other person, as opposed to amends where a true amend is much different. Amends is for the person making amends, and apology is the band-aid. It’s an excuse for the behavior.

It’s what I call instrumental. It’s to get to what they need like, “I don’t want this person to quit. I need this person to still work for me.” To me, it’s an apology from the sense of, “There’s no awareness that I’ve hurt this person, nor do I care that I hurt this person. I just need this employee in this seat.”

You just want them to feel better.

I don’t even think they want them to feel better or care about them feeling better. They just don’t want them to leave. It’s even worse than you think.

It’s believed that once an addict, always an addict. Is there a same like, “Once an alcoholic, always an alcoholic?” It’s like, “Once you cut off your legs, you’ll never grow new ones.” Is that the same thing with the narcissist, “Once a narcissist, always a narcissist?”

I think so. I’ll tell you why. It’s a personality. I’m going to give a personal example. I’m very agreeable. It’s a strong part of my personality. I like to get along with people. I want to get along but as more bad things have been happening to me, it’s not that I’m less agreeable. I’m still agreeable but I’m finding it harder to trust. I know people can harm me. I’ve become more withdrawn because I can’t be my agreeable self.

My agreeableness has always been there but now, I’m like, “This is getting me into trouble.” My personality hasn’t changed. I might have just pulled back from people. It’s similar to narcissism. It’s their personality. You got to remember personality is like a psychological fingerprint. It ain’t going anywhere. I don’t think there should be a narcissistic personality disorder. I think they should scrub it.

I wouldn’t be surprised if they do scrub it. It shouldn’t exist. It serves no purpose and does more harm than good. Nobody gets the diagnosis. The epidemiology rates are somewhere between 1% and 6%. It’s a pointless and harmful diagnosis. Let’s not make it a disorder. Disorder implies, “I can treat you.” If I tell you someone has a personality style high in neuroticism, agreeableness or openness, I know this person is always going to be like this. If you tell me someone has a personality style high in antagonism, antagonism is the opposite of agreeableness.

That’s what narcissism is. I’m like, “This person is always going to be antagonistic. Now, I know this.” Instead of, “I can treat them.” You can’t. This is why I don’t think lumping narcissism with alcoholism makes sense because alcoholism is a behavior that somebody acquired. There’s a lot more to it. I understand addiction has a lot more nuanced than that, but the fact of the matter is that you know it. You work in this field. People can be successfully treated for this. It’s a pretty significant proportion and achieves lifelong behavioral sobriety but perhaps always have the mindset of the addict.

Some people are making the argument. I would be curious to see where this work goes in the next 10 or 20 years, that narcissism and addiction, they think it’s the same. They view narcissists as being addicted to validation. That’s their model and how they think about it. They’ll always be addicted to validation. Much like an alcoholic, that will never go away, but that you can smooth out the behavioral top parts, figure out the workarounds, and teach them.

For example, an alcoholic person could be around alcohol, still order a soda and be able to function in that space. A narcissistic person could be in a space where they’re not the one getting the validation and still be able to function in that space without raging at people. You can have that behavioral shift. The data doesn’t support the idea of an addiction model because addiction to validation-seeking is only one very small band of what narcissism is.

Addiction and narcissism are also a lack of regulation. The people making these arguments, they’re not crazy arguments. The arguments have some potentiality to them. If in that way, then the narcissist is always a narcissist. You’ve just addressed the behaviors. I have worked with some clients on this for over ten years. I have known people for decades. Their personalities haven’t changed. Your personality is pretty darn similar to the way it was when you were in your mid-twenties. Your behaviors are different because you’re older, but your personality is the same.

The recovery rate from any type of addiction is very low. When a person is a narcissist, are they more or less likely to recover from their addiction?

ILBS 27 | Narcissism

Narcissism: Addiction to validation seeking is only one very small band of what narcissism is.


Almost completely, so much less likely. I remember once working with a person who was narcissistic and had been sober for 33 years. This was a person who I would almost argue, at some level, had an almost obsessive relationship with twelve-step. It governed this person’s days and nights and their every day. Everything in their life was organized around twelve-step to a point where other things were not possible in their life. Human relationships weren’t possible. Everything was affected. This person could only work with people in twelve-step.

Is that recurring? They put years on their life by no longer using, but it still went into an obsessive space. That’s the one when I’m thinking about a narcissistic person off the top of my head. When the person has both of these things, the likelihood of long-term sobriety and recovery is so low because you’ve taken away their main tool of regulation.

Is there a question that you’ve always wanted to be asked, but the interviewer never got around to it?

The question I would want to be asked is, “Is this problem getting worse?”

Let’s know your answer. Is this problem getting worse?

I’m not kidding you. Eight clients have said it to me. It stuck with me. Not all of them work. Some of them work. Some of them don’t like unemployment out of the house kind of thing. They’re all saying, “The difficult people in my life are taking up about 80% of my psychological resources. It’s not 80% of my job. They’re not even people I like, but they’re taking up the bulk of my psychological resources. It has never been like this in my life.”

People are encountering more of these people in their lives, at work, as they date, in their family relationships, and they’re saying, “Is it because I’ve been watching your videos and I noticed this or is it becoming more proliferated?” Two things are happening. People are getting educated and saying,

“This is not okay. I’m not going to make an excuse for your bad behavior.” Over the years, it’s like what I call playground rules like, “Let’s give everyone a chance.”

People think this is ridiculous but our society is starting to normalize this behavior that the more outlandish, rude and abusive behavior is, we’re tilting to a point where incivility is normal. The problem is that people are having to devote more resources because narcissistic people are very expensive. They suck up legal resources. They can result in lawsuits in the workplace. God forbid, you hire one, you are going to be in employment litigation for months, if not years. That’s the big question. Yes, it does seem to be getting worse. It’s because we’re enabling it. Whether it’s billionaires, world leaders, celebrities or athletes, everyone is behaving badly. We often look to them to be our behavioral kinds of norms. Our behavioral norms are distorted.

How can people find support if they have someone in their life that has co-occurring narcissistic personality disorder and substance use disorder?

To me, as a clinician, the primary treatment focus has to be the substance use disorder because of the potential of physiological health issues, overdose, health issues secondary to substance use, and public health dangers. The addiction from a priority and acuity standpoint and triage has to be the substance use disorder. The focus has to be detox and stabilization and then relapse prevention. Anyone in the field would be clear on that.

The challenge then becomes that it’s not just about behavioral sobriety. It’s about long-term wraparound care. I would say a couple of things. Anybody who has a narcissistic personality style should always be worked up for their trauma history. Not all have trauma histories. Some are just spoiled kids. That’s all the spoiled, dysregulated, impulsive, never heard the word no kids. They’re not going to be helped. For some, they can be.

This is why all substance use and rehab centers should have a great trauma team in place because trauma assessment, trauma treatment, and bringing that into as part of substance use treatment is essential. It also could be useful in getting this person set on their care post-rehab in terms of their therapeutic care. They need one hell of a good outpatient therapist. I can count on one hand the number of therapists out there that can handle narcissists. I’m barely one of them. I’m done. I’m not taking any more narcissistic clients. My practice is loaded at this point.

[bctt tweet=”We’re tilting to a point where incivility is normal. ” username=””]

I could not and most people won’t take them. They’ll say, “No, thanks.” If you tell a referral source, “I’m sending over a narcissistic client,” they’re like, “I’m not doing it. There’s no amount of money you can pay me to take this client.” Nobody wants to take these clients on. Nobody specializes in this. There are maybe people who work at Cornell Medical Center in New York. You’ve got a handful there. That’s the only place I can think of that has got a team focused on working on this. That’s where Kornberg was through all those years.

You are talking about those people. It’s often the work of psychoanalytically trained people. That’s often long-term therapy with people who are very articulate and want to do this kind of work. It’s finding that needle in the haystack of somebody who could be a long-term therapist with a client like this to build rapport. My work with narcissistic clients involves me putting months if not years into the rapport-building stage. We have enough trust that they don’t want to lose me, so then I can call them out and literally say to them, “You just did such a shitty thing. What you did was so shitty,” which I know invoke shame in them, but they don’t want to lose me. They’re like, “How dare you.” I said, “Raise your voice to me one more time, session is done. Raise your voice to me in more than one session, we’re done.” They don’t want to lose me.

That’s not okay because if I did that the first time out the gate, I never would have seen them again. Part of the trick with these people is maintaining consistency to understand there’s accountability in this relationship, but that requires massive trust-building which takes a long time. Frankly, a lot of people don’t have the money to be in therapy that long with somebody and paying for that out of pocket.

I’ve worked with people who work in jail and prison settings and taught them about narcissism. Sometimes they get this person maybe twice like, “What do you do there except to establish a little rapport, but you’re not going to change this.” The kind of treatment we’re talking about here is a lot, but if you could find that good outpatient person, then you are off to the races.

Dr. Ramani, thank you so much. I appreciate you so much and your time. I got a lot out of it and our readers did as well. Where can people find you?

Please go to my YouTube channel. It’s DoctorRamani. We have probably 600 videos. There’s nothing about narcissism you can’t learn about there. We put out new videos every day and it’s very crowdsourced. If people want a topic and they send it in, we will research it and see if it will work. You can go to my website, which is That’s not just a way you can access my videos but also, it’s a library of things I’ve written and other things we think to be timely. I have Instagram you can follow. That’s also @DoctorRamani, where we’ll put on interesting information, articles and whatever we find. I’m everywhere and easy to find out. I have two books and you can find those on my website.

Thanks again so much. Enjoy the rest of your day.

Thank you too, Tim.

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About Dr. Ramani Durvasula

ILBS 27 | NarcissismDr. Ramani Durvasula is a licensed clinical psychologist in Los Angeles, CA and Professor of Psychology at California State University, Los Angeles. She is also a Visiting Professor at the University of Johannesburg. Additionally, she is the founder of LUNA Education, Training & Consulting, LLC, a company focused on providing content and education about high conflict and antagonistic personality styles such as narcissism and their impact on mental health, relationships, families, and the workplace.

Dr. Durvasula is also the co-founder of the Narcissistic Abuse Awareness Alliance, a collaborative professional group of therapists and coaches working with clients experiencing these relationships. She takes on entitlement and incivility in “Don’t You Know Who I Am”: How to Stay Sane in the Era of Narcissism, Entitlement and Incivility . She is the author of the modern relationship survival manual Should I Stay or Should I Go: Surviving a Relationship With a Narcissist, and of You Are WHY You Eat: Change Your Food Attitude, Change Your Life.

She also has a popular YouTube channel that focuses on narcissism and difficult relationships. The focus of Dr. Durvasula’s clinical, academic and consultative work is the etiology and impact of narcissism and highconflict, entitled, antagonistic personality styles on human relationships, mental health, and societal expectations (and vice versa!).

Her work has been featured at SxSW, TEDx, and on a wide range of media platforms including Red Table Talk, the Today Show, Oxygen, Investigation Discovery, Bravo, and she is a featured expert on the digital media mental health platform MedCircle. Dr. Durvasula’s research on personality disorders has been funded by the National Institutes of Health and she is a Consulting Editor of the scientific journal Behavioral Medicine. Dr. Durvasula is an honest, authentic, and brutally honest voice on the struggles raised by narcissism in the US and globally.