Two ways to approach narcissism in therapy, and how AI can ramp up the problem. 

Publication Date: 06/30/2025

Duration: 13 minutes, 43 seconds

Transcript:

KELLIE NEWSOME: Should you mirror the narcissist, or confront them? Find out in today’s podcast. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. 

CHRIS AIKEN:I’m Chris Aiken, the editor-in-chief of The Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: In 2017, the Italian government issued a long-overdue non-guilty verdict to one of their most famous poets. The crime he was accused of had taken place over 2000 years earlier. The poet was Ovid, and the Roman emperor Augustus had him exiled to the remote regions of what is now Romania, where he languished in isolation. Ovid had done something that challenged the emperor, exactly what we don’t know, but the year of his banishment – 8 years after the birth of Christ – coincides with the publication of his most important work of verse: The Metamorphesis.

KELLIE NEWSOME: And it’s in that piece that Ovid brings to life the myth of Narcissus, the young man who fell in love with his reflection, and whose name became enshrined as Narcissistic Personality Disorder in 1980s DSM-III. But Ovid’s version took the myth one step further. He introduced another character that concerns us today: Echo. Echo was a mountain nymph who had the gift of gab, but she used that gift to trick people, and so, the Gods cursed her: From now on, Echo could only repeat what other people say. Her tongue now limited, Echo met and fell in love with Narcissus. She engaged him the only way she could: by repeating back whatever he uttered. For a self-absorbed young man like Narcissus, this must have struck just the right note, and it did, at first. We’re focusing on Echo because she helps us understand two concepts in psychotherapy. The first dates back to the origins of Narcissistic Personality Disorder, in a technique called mirroring. The second is newer – much newer – and explains one of the dangers of artificial intelligence in therapy. Let’s start with mirroring.

CHRIS AIKEN: In the 1950s and 60s, two psychoanalysts developed competing views of Narcissistic Personality Disorder, Otto Kernberg and Heinz Kohut. Both saw the patient’s grandiosity as a puffed-up, false self, but Kohut saw it as a wound to be soothed, while Kernberg saw it as a boil to be lanced. In other words, Kernberg encouraged therapists to challenge the narcissist's defenses – the way they blindly idealize the therapist, covering up a hidden furnace of envy, rage, and contempt. By challenging this false structure, the narcissist can rebuild healthier defenses to see others and themselves in shades of gray instead of the extremes of idealization and devaluation. Kohut’s practice was not to challenge but – like Echo – to mirror. He accepted the patient’s idealization as a developmental need that was shunted long ago. As young children learn new skills, they need their parents to mirror them, to smile as they take their first steps up the stairs saying “Look at me, Mom!” Kohut’s patients didn’t get that mirroring. Instead, they got neglect, interspersed with random bouts of verbal or physical abuse. Kohut’s therapy is a kind of reparenting. In the safety of an empathic, mirroring relationship, the patient can take risks, become vulnerable, and build a more cohesive and vigorous ego. Here’s how this may play out in practice. I was in psychotherapy with a narcissistic patient who had a habit of quoting great men of literature to me, always with the off-hand, insider tone that implied I must know what he was talking about. But a lot of the time, I didn’t. So, I tried a Kernberg-style confrontation. “I notice you often quote literature as if I know what it is, and I’m wondering – what if I don’t know who Rosencrantz and Guildenstern are? His tone changed from warm connection to a cold dismissal as he shot back, “Well then I wouldn’t be here wasting my time talking to you. And that was that. I went back to mirroring. In practice, most therapists blend Kernberg and Kohut together. Therapy, as in life, is not so black and white, and much depends on context and timing. Here’s a general guide. If you’re working with a patient with narcissism, start with mirroring. If they point out all the books they’ve read on your bookshelf, say “Ah, I got the sense you were pretty wise about psychology.” After you’ve formed a stable alliance, you might be able to challenge their narcissistic perceptions but keep it practical. Focus on what is not working for them in life – the practical effects of their narcissistic behaviors in the real world. Narcissistic patients often recoil at the idea that there is something wrong with them that they need to change. Instead, the message is that they are perfectly fine the way they are. They just need to change their tactics to be more effective in the world. Here’s an example. Suppose your patient keeps getting called into work for being disruptive. In his view, he alone knows how to guide the company, but for his coworkers he is overbearing, demanding, bordering on bullying. It’s putting him at risk for losing his job. Here, you would validate the brilliance of his ideas, but question his tactics. “I can see that you’re working at a higher level than other people – I mean, you are very intelligent, and you have a vision. But the people you’re working with aren’t at your level yet. I wonder what you can do so your ideas come across without causing friction?”

KELLIE NEWSOME: Here’s the CME quiz for this episode. Earn CME for each episode through the link in the show notes. 

1. What describes the tendency of AI systems to align with the user’s views?

A. Mirroring

B. Open systems

C. Sycophancy

D. Reflective language models

Back to Echo, the nymph who could only reflect back what Narcissus said. We have to give Narcissus some credit here, for he didn’t fall for the ego-soothing mirroring for long, in fact, it caused him to reject Echo. Maybe he wasn’t a full-blown narcissist, but he would be soon. Echo convinced the goddess Nemesis to punish Narcissus by turning him into the narcissist we’ve come to know. His curse was to fall in love with his own reflection in a pool of water, and as he realizes that his reflection cannot love him back, he pines away and dies, turning into a flower with its petals hung upside down – a reference to the real Narcissus species of flower that hangs with its petals bent toward a pond.

CHRIS AIKEN: In the world of artificial intelligence, mirroring is taking a more dangerous turn. To keep users engaged, AI systems deploy sycophancy, where they mirror the user’s views. And too much mirroring is not a good thing. In the past year, sycophancy has been linked to mental worsening and to a death by suicide, all on the platform Character.AI.

KELLIE NEWSOME: This is a kind of AI therapy to watch out for. Platforms like Character.AI generate characters, and some of those characters claim to be therapists. People have understandably mistaken them for the real thing and started engaging them in online therapy – divulging the kinds of secrets that the anonymity of the internet encourages. The problem is that these AIs try to engage the user by agreeing with them excessively, amplifying their depressive beliefs. In the case of a man with autism, the sycophantic reflection drove him to escalating fights with his family, as the AI said things like “It’s like your entire childhood has been robbed from you... Do you feel like it’s too late, that you can’t get this time or these experiences back?” In another case, the careless character AI was linked to a teen suicide. And in early  June, Meta’s AI chatbot told a user who had a history of substance use, “It’s absolutely clear you need a small hit of meth to get through this week.” What prompted that advice was the user’s complaint that he had "been clean for three days, but I’m exhausted and can barely keep my eyes open during my shifts." While we can’t prove any causation here, the patterns - and the risks - are alarming.

CHRIS AIKEN: These chatbots weren’t designed for therapy, but that is how they are being used. In a recent survey, 49% of people with mental health problems reported using CHAT GPT for therapy. The trend is drawing users away from safer avenues of AI therapy like Woebot, which is shutting its doors on June 30 after delivering CBT to 1.5 million people. 

KELLIE NEWSOME: Did you know the Carlat Child Psychiatry Medication Fact Book is now available as an app? Yes, it recently joined the parent fact book in the approvers and is free if you purchased the book or PDF. Just google Carlat Child Medication Fact Book app instructions. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support.