This is the third part of a three-part exploration of narcissistic personality style at the neurotic level of personality organization.

In this episode, Dr. Ettensohn examines the defensive architecture of neurotic-level narcissism, including the characteristic defenses that allow individuals to manage conflict, preserve relationships, and maintain self-esteem without resorting to the identity fragmentation or reality distortion seen at more severe levels of personality organization.

Drawing on the Defense Mechanisms Rating Scale (DMRS), this episode explores obsessional defenses such as isolation of affect, intellectualization, and undoing, as well as neurotic defenses including repression, reaction formation, and displacement. Through clinical examples, personal reflections, and portrayals from film and literature, Dr. Ettensohn illustrates how these defenses shape emotional experience, interpersonal relationships, and the therapeutic process.

The episode also examines how narcissistic concerns manifest at the neurotic level, including struggles with self-worth, dependency, vulnerability, perfectionism, and grief. Particular attention is given to transference, countertransference, and the unique opportunities and challenges that emerge in psychotherapy with neurotic-level narcissistic personalities.

While neurotic-level functioning represents a profound developmental achievement, it also introduces new emotional realities. As the capacity for integration grows, so too does the capacity to experience loss, guilt, limitation, and sorrow. The movement toward greater psychological health is not the elimination of suffering, but the ability to bear it without abandoning oneself or others.

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Dr. Mark Ettensohn examines the experience of emptiness in narcissistic personality disorder and other forms of personality pathology.

Rather than approaching personality disorders as collections of traits or behaviors, the episode frames them as disturbances in identity. Dr. Ettensohn outlines how the sense of self is constructed through early relational experience and how disruptions in that process can lead to unstable, fragmented, or underdeveloped self-experience.

The discussion focuses on the role of dissociation and splitting in shaping identity, and how different self-states may become organized around incompatible relational experiences. In this context, emptiness is not simply a feeling, but reflects aspects of the self that were never fully recognized, mirrored, or integrated in development.

Dr. Ettensohn also addresses a common misunderstanding in public discourse, where narcissism is equated with observable traits such as arrogance or entitlement. He explains why these descriptions capture only one part of a broader system involving both grandiose and vulnerable states, and how focusing solely on behavior obscures the underlying psychological structure.

The episode concludes with a discussion of clinical implications, emphasizing why treatments that focus only on behavior often fall short, and why effective work with narcissistic pathology requires attention to identity, relational process, and the integration of dissociated aspects of self-experience.

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This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn, joined by his associates Deanna Young, Psy.D., and Danté Spencer, Ph.D.

In this session, the group discusses the paper “Living with Pathological Narcissism: A Qualitative Study” (Day et al., 2020), which examines narcissistic personality pathology from the perspective of partners and family members.

Unlike most research on narcissism, this study does not rely on self-report or clinician ratings. Instead, it draws on qualitative descriptions from over 400 individuals in close relationships with someone exhibiting high levels of pathological narcissistic traits. These accounts provide a window into how narcissism is experienced interpersonally, particularly in intimate and long-term relationships.

The discussion focuses on the study’s central finding: that pathological narcissism is best understood as a system characterized by the co-occurrence of grandiosity and vulnerability. Loved ones described patterns of entitlement, arrogance, and need for admiration alongside insecurity, hypersensitivity, emotional instability, and chronic feelings of emptiness. In the majority of cases, these features were not separate “types,” but fluctuating states within the same individual.

The group explores how these findings challenge common assumptions about narcissism, including the tendency to equate it with overt grandiosity or interpersonal abusiveness. Particular attention is given to the limitations of DSM-based models, which emphasize observable traits while underrepresenting the internal dysregulation and vulnerability that define the disorder.

The conversation also examines broader relational and developmental themes, including:

Finally, the group discusses the concept of “narcissistic abuse,” noting that while experiences of harm in these relationships are real and often significant, the term itself is not a well-defined clinical construct. The discussion emphasizes the importance of distinguishing between lived experience and explanatory frameworks, and of maintaining a nuanced, non-reductive understanding of personality pathology.

Key themes include:

This series is intended for clinicians, trainees, and viewers seeking a nuanced, clinically grounded understanding of narcissism beyond popular discourse.

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Citation:

Full Text Link: https://pmc.ncbi.nlm.nih.gov/articles...

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This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn, joined by his associates Deanna Young, Psy.D., and Danté Spencer, Ph.D.

In this session, the group examines the Alternative DSM-5 Model for Personality Disorders (AMPD), a dimensional framework introduced in Section III of the DSM-5 and retained in DSM-5-TR. The model was developed in response to longstanding limitations of the traditional categorical system, including diagnostic overlap, heterogeneity within disorders, and the absence of a clear framework for assessing severity.

The discussion focuses on the two core components of the model. The first, Level of Personality Functioning (Criterion A), assesses impairments in identity, self-direction, empathy, and intimacy. This portion of the model reflects a structural approach to personality and aligns with psychodynamic and developmental perspectives on personality organization.

The second component, Criterion B, introduces a trait-based system organized around five domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. These traits are derived from dimensional personality research and represent an effort to describe maladaptive personality features in a standardized way.

The group explores the strengths of this combined model, as well as its limitations. Particular attention is given to the tension between structural and trait-based approaches, and to the question of whether personality pathology can be adequately captured through trait descriptions alone.

Using narcissistic personality disorder as a focal example, the discussion examines how the model emphasizes grandiosity and attention-seeking traits while underrepresenting vulnerability, shame, and fluctuations in self-state. The conversation highlights the importance of understanding pathological narcissism as a system of self-esteem regulation rather than a fixed set of traits.

Key themes include:

Throughout, the discussion situates the AMPD as a meaningful step forward in personality disorder classification, while also identifying areas where the model remains conceptually limited. The session emphasizes the value of structural and developmentally informed approaches in understanding personality pathology.

This series is intended for clinicians, trainees, and viewers seeking a nuanced, non-moralizing understanding of narcissism and personality disorders.

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Citation: 

Link to alternative model:   https://psychiatryonline.org/doi/10.1...

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Dr. Mark Ettensohn addresses a question that frequently arises in discussions of narcissism and abuse: Is it possible to maintain accountability without dehumanizing? Can someone preserve firm boundaries without abandoning empathy?

Dr. Ettensohn clarifies a distinction he often sees misunderstood. When he speaks about compassion toward pathological narcissism or narcissistic personality disorder, he is referring to a cultural and societal stance, not advising individuals to remain in unsafe or harmful relationships. He emphasizes that safety must always come first. If someone is being harmed, the primary question is not whether the other person “knew what they were doing,” but whether the situation is safe and what steps are necessary to ensure protection.

The episode explores the gray area between total innocence and calculated malice. Dr. Ettensohn discusses how dissociation and shifting self states can impair consistent self-awareness in personality disorders, while also making clear that impaired awareness is not the same as blamelessness. He examines how behavior driven by triggered trauma states may later be rationalized from a different organizing center of experience, and why this dynamic is often misinterpreted as deliberate manipulation.

Finally, the discussion turns to boundaries. Dr. Ettensohn distinguishes kindness from niceness and empathy from permissiveness, arguing that the most empathic stance can sometimes be a firm refusal of access. The episode concludes by asserting that accountability does not require demonization, and that it is possible to reject harmful behavior without reducing a person to a monster.

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About Heal NPD: Heal NPD is a clinical practice specializing in the assessment and treatment of pathological narcissism, narcissistic personality disorder, and related personality difficulties. We offer comprehensive diagnostic assessments, individual psychotherapy, and consultations for partners and family members.

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This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn, joined by his associates Deanna Young, Psy.D., and Danté Spencer, M.A.

In this session, the group examines a recent empirical study titled Coercive Control and Intimate Partner Violence: Relationship with Personality Disorder Severity and Pathological Narcissism (2025).

The discussion responds directly to common claims in online discourse that narcissism inherently causes abuse, and asks a more precise question: What does the data actually show about the relationship between narcissism, personality dysfunction, abuse, and coercive control?

The study reviewed draws on informant reports from long-term partners and family members of individuals perceived as highly narcissistic. Importantly, narcissism was rated by loved ones rather than self-reported, addressing a frequent critique of prior research.

The findings showed no significant association between overall pathological narcissism and abuse, and only weak associations with coercive control. In contrast, overall personality disorder severity showed stronger and more consistent relationships with both abuse and coercive control, but these associations were still mostly weak.

The group explores what this means clinically, emphasizing the distinction between personality style (such as narcissistic features) and personality organization or severity. The discussion clarifies why certain narcissistic subcomponents, such as exploitative behavior, entitlement-related rage, and grandiose fantasy, show limited associations with specific forms of harm, while many other narcissistic features do not. Key themes include:

Throughout, the conversation situates abuse as a highly overdetermined phenomenon influenced by many overlapping factors, rather than the inevitable outcome of narcissism or any single diagnosis.

The session concludes by emphasizing the importance of dimensional, developmentally informed models of personality over reductive and stigmatizing narratives.

This series is intended for clinicians, trainees, and viewers seeking a nuanced, non-moralizing understanding of narcissism, personality disorder severity, and relational harm.

To learn more about our work, visit: www.HealNPD.org

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Article Cited and Discussed: Day, N. J. S., Kealy, D., Biberdzic, M., Green, A., Denmeade, G., & Grenyer, B. F. S. (2025). Coercive control and intimate partner violence: Relationship with personality disorder severity and pathological narcissism. Personality and Mental Health, 19, e70038.

Full text link: https://onlinelibrary.wiley.com/doi/p...

In this episode, Dr. Mark Ettensohn examines a common defense of online “narcissistic abuse” content: the claim that, even if imperfect or inaccurate, it ultimately helps people leave harmful relationships.

Rather than focusing on whether such content feels validating or empowering, Dr. Ettensohn explores the ethical and psychological implications of justifying misinformation, stigma, and moralized diagnostic narratives on the basis of perceived outcomes. He argues that this form of reasoning relies on a utilitarian logic that is fundamentally incompatible with responsible mental health communication.

The discussion addresses why narc abuse frameworks often feel compelling to people in distress, how diagnostic language becomes moralized and expanded beyond its clinical meaning, and how this process reshapes viewers’ understanding of themselves, others, and psychology itself. Dr. Ettensohn distinguishes between recognizing real harm and adopting explanatory models that flatten psychological complexity, foreclose on nuance, and encourage rigid, adversarial interpretations of relational experience.

The episode also clarifies common misunderstandings about pathological narcissism, emphasizing that narcissism is not synonymous with abusive behavior and that even when narcissistic pathology is present, it does not explain behavior in a deterministic or morally absolute way. Drawing on clinical ethics, developmental theory, and real-world examples, Dr. Ettensohn outlines why anger and moral clarity can be mobilizing without requiring diagnostic distortion or dehumanization.

This video concludes with a reflection on boundaries in public mental health discourse and the importance of maintaining accuracy, restraint, and humanization when discussing stigmatized conditions.

Referenced video:    • From Validation to Isolation: The Narc-Abu...  

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In this video, Dr. Ettensohn examines the online narc-abuse ecosystem and explores how content that initially feels validating and supportive can, over time, become thought-constraining and socially isolating for some viewers.

Drawing on clinical experience and established research on high-demand systems, Dr. Ettensohn analyzes the rhetorical patterns commonly used across narc-abuse channels: the elevation of the viewer as a lone truth-seer, the narrowing of acceptable interpretations, the use of loaded psychological language, and the gradual erosion of trust in ordinary relationships. He shows how these dynamics can reshape identity, undermine critical thinking, and foster increasing dependence on content creators rather than encouraging reflection, complexity, or professional consultation.

Throughout the video, Dr. Ettensohn carefully distinguishes between genuine abuse and the expanding, imprecise use of narc-abuse language online. He emphasizes that acknowledging harm and seeking clarity are legitimate and necessary, while also warning that one-size-fits-all narratives can distort meaning, escalate conflict, and contribute to unnecessary social rupture. The focus is not on dismissing people’s pain, but on examining how certain explanatory frameworks operate psychologically and what they may unintentionally cost the people who adopt them.

This video continues Dr. Ettensohn’s clinically grounded effort to bring nuance, rigor, and psychological depth to public conversations about narcissism, offering a perspective that prioritizes complexity, reality testing, and relational context over certainty, moralization, or ideological alignment.

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This video continues the Heal NPD Seminar Series, featuring Dr. Mark Ettensohn with his associates, Deanna Young, Psy.D., and Danté Spencer, M.A.

In this session, the group discusses Empathy and Narcissistic Personality Disorder: From Clinical and Empirical Perspectives (2014), examining the long-standing assumption that narcissistic personality disorder is defined by a lack of empathy. Drawing on the article’s review of empirical findings and clinical case material, the conversation explores empathy as a multidimensional and context-dependent capacity rather than a fixed trait.

Key themes include the distinction between emotional and cognitive empathy, the variability of empathic functioning across grandiose and vulnerable narcissistic states, and the ways shame, threat, and affective overload can disrupt empathic engagement in intimate relationships. The discussion highlights how empathy may appear intact or even robust in some contexts, while collapsing in situations that feel most emotionally consequential.

This video continues the Heal NPD Seminar Series, featuring Dr. Mark Ettensohn with his associates, Deanna Young, Psy.D., and Danté Spencer, M.A. In this session, the group discusses Empathy and Narcissistic Personality Disorder: From Clinical and Empirical Perspectives (2014), examining the long-standing assumption that narcissistic personality disorder is defined by a lack of empathy. Drawing on the article’s review of empirical findings and clinical case material, the conversation explores empathy as a multidimensional and context-dependent capacity rather than a fixed trait. Key themes include the distinction between emotional and cognitive empathy, the variability of empathic functioning across grandiose and vulnerable narcissistic states, and the ways shame, threat, and affective overload can disrupt empathic engagement in intimate relationships. The discussion highlights how empathy may appear intact or even robust in some contexts, while collapsing in situations that feel most emotionally consequential. The seminar also addresses common misunderstandings of neuroimaging findings related to empathy, emphasizing the limits of biological reductionism and the importance of viewing brain-based data as correlates of experience rather than determinants of destiny. Throughout, the group reflects on clinical implications for treatment, including the differentiation between motivation-based and deficit-based empathic disengagement, the role of affect tolerance and reflective capacity, and the relational conditions that support the gradual restoration of empathic availability.

This series is intended for clinicians, trainees, and others interested in a nuanced, non-moralizing understanding of narcissistic personality disorder, empathy, and psychological development.

To learn more about our work, visit www.HealNPD.org

Additional Resources:

Purchase Unmasking Narcissism: A Guide to Understanding the Narcissist in Your Life: https://amzn.to/3nG9FgH

LISTEN ON APPLE PODCASTS: https://rb.gy/cklpum

Citation for the article discussed:

Full text link: https://pmc.ncbi.nlm.nih.gov/articles/PMC4415495/