Harmful Therapy on the PVR Triangle: When Therapists Encourage the Abuse of Labels Like "Narcissist"

The Boil-Down: People who seek trauma therapy are trying to make sense of painful, unfair things that have happened to them, often struggling to function due to daunting, crippling symptoms that make it hard to eat, sleep, think, or feel. They enlist caring professionals to help them find answers to why childhood events were so destructive, and often why their current friendships and intimate relationships make it seem like history is repeating itself. When well-meaning therapists are not properly mindful of triangulation, their attempts to guide and support can perpetuate defensive client grief avoidance, enable contempt, and inadvertently encourage destructive client interactions with loved ones. One of the worst things a helping professional can do is to move the "crosshairs" onto a human being in a client's life--often one the professional has never met--by encouraging or assigning labels to that person.

This therapy-abused label has become clickbait, even on reputable websites.

The Details: It was unbelievably easy to get fear-confirming biased results by entering the words "is my partner a narcissist?" into a popular search engine. In the top five results, PsychCentral and Verywell Mind offer a quiz and seventeen signs, respectively, to help the reader determine whether they are living with "a narcissist." Psychology today offers two tests in separate top-five links toward the same determination. To the credit of these websites and their respective authors/editorialists, all appear to be basing their quizzes and "red flag" signs of narcissism on diagnostic criteria from Narcissistic Personality Disorder (NPD), a bona fide diagnosis found in the psychiatrist's bible--the Diagnostic and Statistical Manual of Mental Disorders (DSM). Each webpage also manages to make a feeble cursory note, toward the reality of any human being's ability to display some of the tendencies identified on red flag lists and in quiz items. The consistent suggestion is that the more list items a partner lights up in the quiz-taker's mind, the more probable likelihood that the partner being surreptitiously analyzed "is" a narcissist suffering from NPD.

Virtually every single quiz or checklist is followed by advice on what to do if your partner "is a narcissist." It is good that they recommend seeking advice from a qualified professional. The ends of these articles also suggest seeking built-in support without gossiping, "drawing boundaries," carefully documenting conversations, and considering leaving the relationship. I award the advice trophy to Psych Central, whose closing comments dedicate a small manual of grounded neutrality toward helping the reader understand narcissistic tendencies, feel supported and normalized in their experience, and find resources (including an abuse hotline); Psych Central placed the decision to leave a relationship in the "if" position, offering a road map in the event the reader wants to exercise the choice to exit.

My main critique of this sample of viral links advising readers on life with "a narcissist" is this: virtually none of them encourage the mindset of examining the partner's participation in the relationship space; nor do they suggest the reader look inward at how their own traumatized lens might be influencing the way they experience the partner. Web experts' biomedical disease model stance completely overlooks the traumatized mind's tendency to automatically triangulate conflicted interactions, and in the process encourages that very kind of triangulation--which introduces sickness and harm to the helping space. Identifying "mental illness" (which the above sources do) commonly leads to identifying the patient as the one with the problem.  While people diagnosable with NPD chronically and persistently present problematically, many individuals growing and recovering from places lower on the "narcissism" continuum may only present that way in intimate space and/or when significantly distressed--especially when faced with unhealthy, unhelpful partner participation.  When the human being identified as the problem has been labeled and therefore placed on the PVR triangle, the loved one doing the labeling escapes the responsibility of having to look at themselves.

Upon the conclusion that our partner, or best friend, or parent is "a narcissist," we can continue our research at the risk of "false positives" to explore our experimental subject's fit with the other corners of the dark triad (Paulhus and Williams, 2002): Machiavellianism (think of a sociopath's suave cousin, with exquisite impulse control and adherence to social norms in the public eye) and psychopathy (you know, Hannibal Lecter--although often less homicidally hungry). When the subject is female, the query is more likely to focus on whether she "has Borderline Personality Disorder" (BPD) or, with the crosshairs squarely on her forehead, whether she "is borderline." (BPD is not included in the dark triad's psychological theory, but some of its signs feature prominently.)  With diagnostic zeal, the inquiring minds of wounded spouses and lovers are encouraged by even more hyped-up publications to obsess over their tilted observations of abuse, control, manipulation, secrecy, submarining, gaslighting, and other signs that the loved one who hurt them is "the problem"--so they don't have to search their own souls.

It is naturally human to use labels. I love the way entities like Psychology Today redeem themselves; if you take significant exception to one article they've published, just wait a week, and a brilliant new article will arrive to outshine the last. In Adam Alter's writing on the use of labels, the author summons Benjamin Whorf's linguistic relativity hypothesis.  From 1930, this hypothesis asserts that the words we use to describe what we see actually determine what we see. As a case in point, Alter cites a 2003 study by social psychologist Jennifer Eberhardt in which subjects were asked to look at a picture of a racially ambiguous person, declare the person's race, and then draw the person in the photograph. Subjects who declared the person in the photo to be "black" drew the person significantly differently than those who declared the person to be "white." In skills "miraculous" enough to simplify the impossibly complex realities of the environment around us, we (often inadvertently, sometimes lackadaisically, sometimes defensively or contemptuously) contribute to enormous societal problems by boiling a human being down to one characteristic through the use of labels.

As with stereotypes, there are reasons negative labels exist. Many men and women have have welcomed investigation into their possible narcissism by behaving badly, over and over. Per the Centers for Disease Control, 41% percent of women and 26% of men report experiencing intimate partner violence (sexual contact abuse or physical abuse); sixty-one million women and 53 million men say they have experienced psychological aggression, or the use of verbals and non-verbals with harmful intent.   And although the media overhypes narcissism as part of the inherent drive to survive by creating viewer traffic, there are societal pockets of severe narcissism diagnosable as NPD.  According to The Recovery Village, the prevalence of NPD is only 0.5% in the United States; however, severe habitual tendencies diagnosable as NPD are present in 6% of forensic analysts, 20% of people in the military, and 17% of first-year medical students.

Many helping professionals are wounded themselves, not recovered enough to reliably help others.   I looked at some length for statistics on how many psychologists and therapists have depression or PTSD, but couldn't find any. What I did find was an AMA study on the incidence of depression in ten kinds of physicians, including family practitioners and psychiatrists. The rates ranged between 31.6% and 38.5% for mild to severe depression symptoms across all ten specialties. The ADAA suggests 21% of all adults in the United States will experience Major Depressive Disorder (MDD) at some point in their lives, and the WHO cites the prevalence of MDD as a strikingly lower 5% globally.  (WHOA, doc.) The AMA study attributed the cited rates of depressive symptoms for doctors to "adverse occupational experiences," noting that 24% of physicians responding endorsed at least one "adverse childhood event" (think ACE questionnaire) and that all of it increased risk for physician burnout. The Felitti study concluded that 64% of aggregate respondents had an ACE score of at least 1. 

Some providers are too emotionally unwell to objectively treat behavioral health clients.

Next, I looked for ACE questionnaire results on mental health clinicians but could not find any! The Society for the Advancement of Psychotherapy was very helpful in publishing study results about mental health clinicians. In one study, 36.7% of psychologists acknowledged that their own high distress adversely impacted the quality of care provided to clients. In another, 29% of mental health clinicians had been previously suicidal, and 59.6% of mental health clinicians found themselves still trying to treat clients when they were too distressed to be effective.

Helping professionals possessing reasonable mental health may still be "paradigm-blind."  A paradigm is a set of principles designed to shape the way scientific questions and answers are organized and understood. As I have mentioned in previous blog entries, my post-graduate supervision and instruction was heavily informed by psychiatry, marinated in the biomedical model of medicine. Anecdotally, the vast majority of psychiatrists, psychologists and counselors I have come to know either could not articulate the paradigm behind the way they treat clients, or they espoused pieces of the biomedical model via psychiatry or cognitive therapy. To illustrate the ill effects of practicing an ineffective paradigm, I hope you will allow me the digression of discussing a crisis in a parallel field--population health science.

Acolin and Fishman (2023) describe basic concepts and underpinnings of the biomedical model in their scientific article examining population health. According to those authors, the biomedical model's role in population health is rooted in the success of germ theory (the idea that external microscopic pathogens cause disease). The given example of such success was John Snow's ending of the 1854 England cholera outbreak by closing down an infected water pump. (The authors also helpfully discern that a theory is a scientifically testable set of hypotheses, whereas a model is merely a simplified description of natural phenomena.) One of the most basic concepts of the biomedical model is causal determinism, the idea of independent variables (like the cholera toxin) set in motion to collide with dependent variables (e.g. a human being's physiology) like billiard balls. Two key principles within causal determinism are determinism and all else equal.  Determinism assumes that eliminating or staying away from the antecedent cause will prevent disease (something that has been solidly embraced by population health science; the practice of medicine is more focused on slowing the progress of existing disease through medical intervention). All-else-equal assumes that the only difference is the presence of cholera; this principle gave birth to the phrase "all other things being equal...". In the real world, all else is not equal. The authors launch their article by noting that from the time of birth, the life expectancy of an African-American person is six years less than that of a white person. Acolin and Fishman criticize the biomedical model in part for its reliance on causal determinism, because our exposure to causal "billiard balls" is not the same. Genes? Of course genes contribute to disease susceptibility. But what about neighborhood crime, social capital, relationship quality, air quality due to nearby industrial plants, access to health care, and the effects of health law? Because even the existing paradigmatic improvements to the biomedical model are not improving key indices of population health, the authors call for a paradigm shift in population health science, to what they call "the agentic paradigm."

Therapy with no clear paradigm is risky.  I am calling for a paradigm shift in the field of mental health; this includes medical general practice and specialties (physicians), psychiatry, psychology, counseling, family therapy, and social work. In my experience, the first problem is that many licensed helping professionals do not know what a "paradigm" IS.  Even if we were to loosely interchange the similar terms of model, theory, and paradigm, many therapists who can talk about these concepts can't competently apply them to the way they do therapy with their clients. This is my reality in my community, and I don't believe my community is an exception to the "rule" throughout the field in which I practice. To their credit, there are paradigm-free therapists who are naturally empathic and intuitive, and provide basic support to those they treat. But I am saying here that therapy conducted without a well thought out, compassionate, ethical paradigm to guide it is at risk for infection by triangles, biases and iatrogenesis (when wisdom intended to help does harm). This includes the use of labels like narcissist.

The most helpful clinicians are in good emotional health and come prepared.

Therapy within the limits of psychiatry can be very unhelpful.  Here in the Midwest, psychiatry loudly espouses, even if often by accident, the dogma of single gene, single disease theory. This is the testable idea that single genes or gene clusters in the human genetic code are solely (or mainly) responsible for the development of psychiatric disorders and their symptoms. Correctly identify which diagnostic label  to apply to the patient, and you (the clinician) will be able to prescribe the precise pharmaceutical treatment designed to ease symptoms and slow the progress of the patient's psychiatric disease. Beginning in the 1990s (in my community, anyway), the human genome project perpetuated this thinking with its work. Now psychiatrists send patient DNA to labs for testing, intending to match patient results with properly engineered chemical remedies. I have two arguments against the use of single gene/single disease thinking in mental health treatment. The first has to do with monumental errors of logic and scholarship, which is worthy of its own (eventual) article. The second is this: I built a 30-year thriving practice on helping all the people who got little or no relief from other clinicians who listened for an hour and then said "remember to take your (genome-designer) medicine." For one of the most thorough critiques of psychiatry and its single gene, single disease theory, read the work of Colin Ross. 1, 2

Traditional psychiatry is misguided by errors of logic, errors of scholarship and iatrogenic thinking.

If we take a half-step back, I can show you my reservations about psychiatry at large. Let me first express gratitude and respect for the psychiatric medicine experts who listen compassionately, prescribe wisely, calmly and faithfully taking after hours calls from suffering patients, and encouraging "adherence" to doses of medication that work.  In my experience, these practitioners are the exception, and many of them espouse a biopsychosocial lens regarding behavioral health, endorsing the benefits of therapy for their patients. In my region, the rest of psychiatry discounts psychotherapy as helpful for anything beyond increased medication compliance (now referred to in medical literature as adherence or "concordance"). 

Steeped in the biomedical model, these practitioners seem to disregard the evidence that brings "magic bullet" pill treatments down from their pedestal. In one article, a literature review by Dr. Michael Thase reveals that as many as forty percent of patients with Major Depressive Disorder (MDD) do not respond to prescribed antidepressants--they receive no helpful main effect from the medication. In a separate study on SSRI antidepressants, thirty-eight percent reported side effects; one out of four side effects experiences were "very" or "extremely troublesome." The results with mood stabilizers and antipsychotics are not notably better. Psychiatry via the biomedical model is not creating a world where mental health problems are going away. To reiterate, psychiatry is the practice of medicine, which by definition is simply slowing the progress of disease. How does "germ theory" successfully apply to posttraumatic stress disorder? How does single gene/single disease theory come to the assistance of a depression survivor who has no family history of depression, but has an extensive history of traumatic family-of-origin events and military service events which the clinician never even asked about?

Here are my final forehead-slapping observations about a number of psychiatrists, psychologists, and counselors who swear by the biomedical model and all its proper testing and labeling: (to borrow from Jay Haley) many present as though they don't seem to know "practically anything"; in my professional experience, these are the clinicians who are most likely to express iatrogenic contempt for the human beings they're labeling, while living in complete denial of their own mental health problems. I've informally interviewed and read the publications and chart notes of perhaps hundreds of these psychiatrists, psychologists, and counselors. The vast majority conduct an impeccable initial diagnostic assessment (unless they're in too big a hurry because they see twenty-five to forty patients a day), but from session two on, almost none know what to show tell their clients to do to get well. This is the kind of therapeutic space at greatest risk for being unhelpful, for being triangulated (instead of neutral when talking to a client about the patient's own condition or a loved one's behavior), and for applying toxic labels.

Conclusions: Assigning labels is a human tendency. We do it to simplify our understanding of a complex universe, and to communicate more succinctly. In and of itself, when spoken from a place of empathy and non-judgmental mindfulness of others, the use of labels is not inherently harmful.  On the other hand, when used from a place of unhealed wounds, from a place of contempt on the PVR triangle, labels--including harsh clinical titles--can serve to sacrificially slaughter the character of unwitting human beings who most likely do not meet criteria for such low-percentage diagnoses as Narcissistic Personality Disorder or Borderline Personality Disorder. In the process, the persons uttering such toxic labels automatically escape responsibility for mate choice and their own ineffective participation in relationship space, having scapegoated the people they have labeled as "the problem."

What You Can Do: If you are a therapist, make sure you are competently wielding an ethical, coherent set of principles for examining human problems and the mental health symptoms that result. Maintain a stance of neutrality whenever possible--even for human beings who are discussed but not in the room. Seek peer (or superior) supervision regularly, and in sentinel cases when neutrality/objectivity is in jeopardy. Manage your own mental health before trying to help others; spend more effort on yourself than you're asking of your clients. (I am not above my own wounds and making the mistake of labeling; I work on it regularly, with ardor.) Bring triangulation into your clients' awareness and show them how to resolve it. Discourage pathological labels; in unresolved conflict (when there is no physical danger or persistent severe mental abuse), encourage your client to separate the humanity of their partner from the partner's behavior, and to exhaust all constructive avenues of problem-solving.

If you are a client in therapy, start by enlisting the services of a therapist whose expertise is clearly organized by an identifiable approach to therapy--one that can be explained, and one that recognizes client humanity. Become a knowledgeable consumer of therapeutic approaches, with a competent understanding of human systems and the pitfalls triangulation, which remains an inevitable infection if we don't know enough to watch for it. Read the work of Brene Brown, Terry Real, or Wendy Behary--the lattest of whom actually uses the term "narcissist" in the title of a best-selling book, but gives compassionate, effective advice for surviving the poisonous habits of the offending loved one. If you begin to detect unhealed mental health or traumatic wounds in your therapist, or unhealthy biases, have the courage to bring it up and request adjustments in what your therapist is doing. 

Above all, create a habit of moving the crosshairs of your internal thoughts and spoken words off humans and onto their actions. Choose to see every person's core humanity and protect it. Whenever possible, do your best not to define human beings by their worst moments. Carry a principled promise to diminish no one with your own words or actions. If you conclude that you are in a relationship that is habitually toxic, take steps to ensure space where you can think things through away from the toxic gravity of that space. You may choose to make a relationship decision. Either way, you are faced with a long hard look at your own wounds and ineffective decisions.  Finding yourself in a sick relationship is an opportunity to shamelessly acquire greater wisdom about yourself.