CANTA ET AL.

NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA

Narcissistic Equilibrium in Paranoid Schizophrenia

Guilherme Rui Canta, Filipe Leão Miranda, Rui Paixão,

and Carlos Amaral Dias

Abstract: Several studies have stressed the relevance of family environment in

the course of schizophrenia and the perception of the pathology by both the
subjects and family members. The objective of the current qualitative study con-
sisted in the development of a grounded theory (GT) regarding narcissism and
the family dynamics of subjects diagnosed with paranoid schizophrenia. Semi-
structured interviews were conducted with five subjects in a state psychiatric
hospital in the urban catchment area of Lisbon and their respective families. A
diagnosis of paranoid schizophrenia had previously been established accord-
ing to DSM-IV-TR and ICD-10 criteria. The interviews were transcribed and
analyzed using the GT methodology, in order to identify the latent processes. A
basic social process of narcissistic equilibrium was identified as a way to protect
personal and familial identity, where three main processes were found: split-
ting, detachment and projective identification. These processes were developed
as a tentative solution for the existing narcissistic impairments in the self and/
or family, occurring both in an intrapsychic dimension and on a transactional
dimension within family relationships.

Keywords: paranoid schizophrenia, narcissism, grounded theory,

family dynamics, narcissistic equilibrium

Guilherme Rui Canta, MSc, Clinical Psychologist, Faculdade de Psicologia e Ciências

da Educação – Universidade de Coimbra, Coimbra, Portugal & Hospital de Dia – Centro
Hospitalar Psiquiátrico de Lisboa (CHPL), Lisboa, Portugal.
Filipe Leão Miranda, MSc, Clinical Psychologist in private practice, Lisboa, Portugal.
Rui Paixão, PhD, Clinical Psychologist, Associate Professor, Faculdade de Psicologia
e Ciências da Educação – Universidade de Coimbra, Coimbra, Portugal & Centro de
Estudos Sociais da Universidade de Coimbra [Centre for Social Studies – University of
Coimbra], Portugal.
Carlos Amaral Dias, MD, PhD, Psychiatrist, Emeritus Professor, Faculdade de
Psicologia e Ciências da Educação – Universidade de Coimbra, Coimbra, Portugal.
This study was supported in part by a PhD grant of the Portuguese Fundação para a
Ciência e Tecnologia (FCT) (Grant SFRH/BD/36872/2007).

Psychodynamic Psychiatry, 47(4), 373–401, 2019

© 2019 The American Academy of Psychodynamic Psychiatry and Psychoanalysis

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 374 CANTA ET AL.

In the past decades, substantial development occurred in the knowl-

edge regarding genetic and epigenetic factors, and also in psychobio-
logical conditions, including neuroanatomic, neurochemical, neuro-
physiological, neuropsychological, and neurofunctional mechanisms
of schizophrenia (Alanen, 1997; Avramopoulos, 2018; Cullberg, 2006;
Grotstein, 1995a, 1995b, 1996; Kesby, Eyles, McGrath, & Scott, 2018;
Lysaker & Lysaker, 2008a; Swerdlow, 2011; Williamson, 2006; Zucker-
man, 1999). Just as observed in other psychopathological conditions,
most scientific research shifted towards a reductionist biological ap-
proach focused on the brain, while substantial psychological questions
remained unanswered and a mind theory of people suffering from psy-
chotic conditions remained elusive (Alanen, 1997; Cullberg, 2006; De-
wan, 2016; Dimitriadis, 2018; Grotstein, 1995a, 1995b, 1996; Lidz, 1985;
McWilliams, 2015; Meloy & Yakeley, 2013; Read, Bentall, & Fosse, 2009;
Werbart & Levander, 2005). Nonetheless, and considering the funda-
mental nature of this knowledge, a need to understand the psychologi-
cal dimensions involved in schizophrenia persists, namely, for a theory
that could address the intrapsychic dimension of narcissism concomi-
tantly with family dynamics and interpersonal factors, including both
the present moment and the perception of developmental stages (Al-
anen, 1997; Dewan, 2016; Lidz, 1985; Martindale & Summers, 2013).
There are several studies on the impact of family dynamics and in-
teractions on the patient with paranoid schizophrenia as well as studies
on their disturbed self-concept and narcissism (Alanen, 1997; Auerbach
& Blatt, 1996; Hamm & Lysaker, 2016; Hesse et al., 2016; Lysaker & Ly-
saker, 2008b; Weinberg et al., 2012). Our study aims to explore these dy-
namics and develop a theoretical model through the use of qualitative
methodology. The recourse to qualitative methodologies in the study
of psychotic conditions allows the use of first-person experience and
can generate new meaning, knowledge, and hypothesis to further clini-
cal research or theoretical models (Boumans, Baart, Widdershoven, &
Kroon, 2017; Fenekou & Georgaca, 2010; Macnaughton, Sheps, Frank-
ish, & Irwin, 2015; Werbart & Levander, 2005). This methodology al-
lows for a theoretical structure to emerge from the raw data, objectify-
ing the profoundly subjective material under scrutiny.
The interest in family factors contributing to a schizophrenic patho-
logical condition mainly arose from psychodynamic clinical observa-
tion between the 1930s and 1950s, involving both the highly subjec-
tive narratives of patients in psychotherapeutic treatment and the
observation of those patients’ family interactions, leading to the con-
troversial concept of “schizophrenogenic mother,” where the negative
developmental impact of a specific pattern of familial interaction was
stressed (Fromm-Reichmann, 1948; Hartwell, 1996; Karon & Widener,

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 375

1994; Neill, 1990; Pao, 1979; Zuckerman, 1999). The etiology of schizo-
phrenia was seen as the result of disturbed early relationships, more
specifically with an overprotective and controlling mother that simul-
taneously was also a rejecting mother at an unconscious level (Fromm-
Reichmann, 1948; Hartwell, 1996; Karon & Widener, 1994; Neill, 1990).
To elucidate those observations, different research paths were taken.
Theodore Lidz and his group studied the childhood family environ-
ment of schizophrenic patients, concluding that the disease involved
severe emotional and cognitive deficiencies, resulting from the distor-
tion of parental nurturance and from the “transmission of irrationality”
or maladaptive abilities within the family (Alanen, 1997; Lidz, 1973,
1985; Lidz, Fleck, & Cornelison, 1965; Räkköläinen, 1977). Gregory
Bateson and the Palo Alto group of researchers described an under-
lying communication pattern involving a lack of maternal affection
and subtle rejection in the families of schizophrenic patients, leading
to the “double bind” concept, where two mutually incompatible mes-
sages are simultaneously conveyed: an explicit message of love and an
implicit message of hostility and rejection (Bateson, Jackson, Haley, &
Weakland, 1956). This continuous relational pattern created confusion
and intense intrafamilial conflict. Following a different approach, the
team led by Lyman Wynne developed the concepts of “pseudo-mutu-
ality” and “pseudo-hostility,” describing family atmospheres that deny
and isolate certain emotions (hostility or affection), operating either
without aggression or without the expression of closeness and where
the child feels an immense fear of expressing those emotions (Alanen,
1997; Wynne, Ryckoff, Day, & Hirsch, 1958). In later work with Mar-
garet Singer (Singer, Wynne, & Toohey, 1978; Wynne & Singer, 1963a,
1963b), the communication deviances of the parents of schizophrenics
were explored, identifying a relationship between disturbed parental
communication—that is, a lack of clarity in communication, particu-
larly when discussing conflicting issues—and the later occurrence of
schizophrenia, considering it a contributing factor to development of
the disorder as an expression of a constitutional vulnerability (Karon
& Widener, 1994). The family studies made by Alanen (1997) observed
two different groups described as “chaotic” or “rigid.” In the chaotic
families, parents suffered from psychotic conditions, either at a clinical
or subclinical level, with confused communication. The rigid families
presented extremely formal and confining attitudes, and children were
tightly bound by hopes and fears transmitted by their parents (Alanen,
1997). The author stresses the importance of projective identification
used for communicative purposes within the family and its impact on
the development of a schizophrenic personality (Alanen, 1997). Previ-
ously, Alanen had defined what should be called “transactional defense

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 376 CANTA ET AL.

mechanisms” as processes occurring in the family, both conscious and

unconscious, with defensive functions to protect the subject from anxi-
ety within family relationships (Räkköläinen & Alanen, 1982). These
defense mechanisms involve both conscious and unconscious mental
processes, and most psychic conflicts are of an unconscious nature and
related to the subject and to family history (Jureidini, 1990; Karon &
Widener, 1994; Martindale & Summers, 2013).
These studies brought remarkable insights into the family systems
of persons diagnosed with schizophrenia, but most of them were
criticized due to methodological or conceptual weaknesses (Alanen,
1997; Hamm & Lysaker, 2016). The use of a more solid measure re-
sulted in studies of expressed emotion (EE), observing the emotional
environment of families, namely the use of critical, hostile, or over-
involved communicative and emotional patterns that led to schizo-
phrenic pathology (Leff & Vaughn, 1985). Both parents and subject
contribute to a mutually interdependent relationship that influences
the onset of schizophrenia and also has an impact on the possibili-
ty of relapse (Leff & Vaughn, 1985). The expressed emotion concept
has already been compared to the psychodynamic concept of projec-
tive identification, which can bring a deeper understanding of the EE
process (Migone, 1995). A circular mechanism of projective identifi-
cation may be working within the family dynamics of schizophrenic
patients and their parents, with cross-projection of disturbing feelings
and thoughts (Migone, 1995). An example put forward by Jureidini
(1990) is when parents deny a quality in themselves (either an affect
or mental representation) and project it into a child. They then alter
their behavior towards the child and exert pressures, with the result
being a self-fulfilling prophecy as the child begins to behave in ac-
cordance with the projections. The work of Apprey (1987) shows the
developmental impact of the use of excessive projective identification
by disturbed mothers, where their intolerance of separation triggers
the use of projective identification, distorting the perception and com-
munication between mother and child (Apprey, 1987; Apprey & Stein,
1993). Grotstein (2005) stressed the pressure exerted by the subject as
a component of the intersubjective interaction associated with projec-
tive identification, renaming the mechanism “projective transidenti-
fication,” where intrapsychic projective identification (the splitting,
projection, and identification in the internal world of fantasy and men-
tal objects) is complemented by pressures exerted in the interpersonal
field (changes in the communication with the object of the projection to
generate changes in his behavior, mental states, and representations),
adding increased complexity to the process by underlining the impor-

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 377

tance of both the intrapsychic fantasy and the interpersonal procedure

involved. From a neuroscience standpoint, the mechanism of projec-
tive identification may involve the use of so-called “mirror neurons”
to represent affective states, activities, or ideas, imitate actions and
understand them (Greatex, 2002). So, the concept of projective identi-
fication that started with Melanie Klein as an intrapsychic mechanism
operating as an inner fantasy is currently conceived as an intersubjec-
tive process occurring in the dyadic interaction that can account for
developmental psychopathology (Apprey, 1987; Apprey & Stein, 1993;
Goretti, 2007; Grotstein, 2005; Seligman, 1999).
Family studies strive to understand a complex environment, and
even though they have been interpreted as an accusation towards the
parents, they are multi-person interactions with systemic influences
and reciprocal processes, where parents influence their children and
children also influence their parents (Alanen, 1997). More recent fam-
ily interaction studies have used different interpretative models, such
as the reciprocal hypothesis (Fort, 1990), where parents and their chil-
dren exert a mutual influence on one another. The parents’ distorted
communication may have an impact on the subject, but at the same
time, the distorted communication of the subject also exerts a powerful
influence on the parents’ mental functioning (Fort, 1990). It must also
be emphasized that the paranoid schizophrenic end-result has complex
causes, and etiological factors should not be restricted to familial rela-
tionships (Alanen, 1997; Grotstein, 1995a, 1995b, 1996).
Disturbances in reflexive self-awareness and self-representation are
central to the development of severe psychopathology such as schizo-
phrenia (Auerbach & Blatt, 1996). Schizophrenic patients suffer from
impairments in boundary representation and in the formation of a core
self, presenting what has been termed a need-fear dilemma: isolated
and desperately needing significant others to maintain precarious psy-
chological survival, longing for fusion as the only means of establish-
ing a sense of safety or security, but at the same time fearing the dan-
ger aroused by such proximity and fear of fusion (Auerbach & Blatt,
1996). Using a cognitive model, it has been suggested that a relation-
ship between aspects of the so-called family atmosphere (negative as-
pects such as criticism and resignation) and interpersonal self-concept
(negative self-perception) lead to an increase in paranoid delusions
(Hesse et al., 2016). Translating this into a psychodynamic model, the
experiences of family relationships with increased expressed emotion
or the use of higher levels of negative projective identification affect
the subject’s narcissism in a negative way and increases the paranoid
way of ­thinking.

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The impact of developmental trauma can also account for paranoid

beliefs, since the experience of living in a continuous and chronic condi-
tion of victimization, powerlessness, and insecure attachment can lead
to paranoid delusions (Read et al., 2009). Paranoid beliefs may arise
as a consequence of severe problems with self-esteem (or narcissistic
impairments) and an external locus of control, where the subject may
defend himself from the feelings of low self-worth by attributing the
causes of misfortune to malevolent others (Read et al., 2009).
The concept of narcissism can be defined by an orientation toward
seeking out self-enhancement experiences from the social environment
to satisfy the need for admiration and recognition, presenting itself in
different forms, both adaptive and maladaptive (pathological narcis-
sism) (Kernberg, 2014; Roche, Pincus, Lukowitsky, Ménard, & Conroy,
2013). The differentiation between normal and pathological narcissism
resides in the type of self-regulatory mechanisms used and its impact
on psychosocial functioning (Kernberg, 2014; Roche et al., 2013). Patho-
logical narcissism may arise from early empathic failures by parental
figures, leaving a child with self-regulatory fragilities that lead to the
internalization of severe conflicts between the representation of self
and other. Kernberg’s view stresses the importance of conflict and ex-
cessive oral aggression, while Kohut’s perspective centers in develop-
mental deficits (Kernberg, 2014; Kohut, 1971; Potik, 2014; Roche et al.,
2013). Rosenfeld (1987) associated destructive pathological narcissism
with the impact of death drive. The concept of pathological narcissism
may be used either regarding exaggerated narcissism (grandiose ideas,
exaggerated feelings regarding the self, others being seen as having
low value) or defective narcissism (the subject sees himself as deserv-
ing contempt, having aspiration to nothingness, a lack of object rela-
tionships combined with self-destructive drives) (Green, 2002). The lat-
ter form of narcissism is the result of a combination of narcissism and
an orientation toward psychic death. Green (2002), therefore, called it
death narcissism as opposed to life narcissism, where life narcissism
is more oriented toward life and relationships, even if using extreme
forms of grandiosity. It is also extremely curious that the use of the
concept of narcissism started with Freud regarding what he had called
“narcissistic neuroses,” a term used to describe psychotic conditions,
especially what came to be known as schizophrenia (Green, 2002). In
terms of schizophrenic patients, the relationship with parents has been
described as marked by a narcissistic quality of interpersonal modes of
existence, with a tendency to intensive infantile dependency (Pao, 1979;
Räkköläinen, 1977). Kohut (1971) suggested the presence of a psychotic
potential as a consequence of defects in the self, due to an arrest in

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 379

narcissistic development, with a fixation in archaic forms of narcissism,

namely, the grandiose self and omnipotent other, leading to narcissis-
tic compensatory relationships with others. Recent clinical research on
narcissism has identified three relevant subtypes: grandiose/malignant
(equivalent to pathological positive narcissism), fragile (equivalent to
pathological negative narcissism), and high-functioning/exhibitionis-
tic (what may be called subclinical narcissism) (Russ, Shedler, Brad-
ley, & Westen, 2008). Kohut, according to Behrendt (2015), considered
schizophrenia, similar to narcissistic personality disorder, as a form of
pathology of the fragmented self, stressing the impact of early emo-
tional failures by self-objects.
Recent research from several authors within a humanistic-phenom-
enological perspective brought to attention the notion of self-disorders
in schizophrenia, suggesting that the essential feature of schizophre-
nia spectrum disorders is a disturbance of the “core self” (the intrinsic
structural basis of all experience and subjectivity) or “ipseity distur-
bance,” a term used to describe the disappearance of the basic sense of
“I-feeling” intrinsic to human experience (Davidson, 2019; Fuchs, 2015;
Nordgaard & Parnas, 2014; Parnas & Henriksen, 2014; Parnas & Zan-
dersen, 2018; Sass & Parnas, 2003; Stanghellini & Rosfort, 2015). People
suffering from schizophrenia maintain a sense of self but experience
a constant threat and occasionally feel themselves overwhelmed by
intersubjective and powerful subjective experiences, leading to a per-
ception of being alienated from both self and other (Lysaker & Lysa-
ker, 2008a, 2008b). So, schizophrenia involves a variety of first-person
phenomena, including a “widespread awareness of diminishment”
(Lysaker & Lysaker, 2008a, 2008b) or the perception of low self-esteem
and self as fundamentally ill (Davidson, 2019). Altered selfhood and
the associated alienating experiences can date back to childhood and
adolescence (Nordgaard & Parnas, 2014). Therefore, self-disorders
should not be considered a sequalae of psychosis but as a more fun-
damental and generative layer of psychopathology or an experiential
vulnerability phenotype specific to schizophrenia spectrum disorders
(Nordgaard & Parnas, 2014). Some authors have also described what
they call the “hyperreflexive self” or being self-aware to an extreme
degree, where persons with schizophrenia concentrate on themselves
with an intense and fixed gaze, a description close to Freud’s narcis-
sistic neuroses (Fuchs, 2015; Lysaker & Lysaker, 2008b; Sass & Parnas,
2003). In summary, the basic abnormality in schizophrenia is a particu-
lar disturbance of the sense of self that is implicit in, and constitutive
of, human experience and profoundly affects the person (Stanghellini
& Rosfort, 2015).

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Grotstein (1995a, 1995b, 1996) suggested a psychopathology of pow-

erlessness as an alternative to the classical psychoanalytic concept of
conflict, stressing the defects of self-regulation and interactional reg-
ulation. To explain the states of emotional dysregulation, the concept
of disorders of self-regulation and interactional regulation (Grotstein, 1996)
describes the internal state of affairs and the problems arising from re-
lationships with others. The author proposes the term disorders of self-re-
gulation to encompass the aspect of defect, deficit, and deficiency, where
mental states fall into dysregulation because of the failure of inherent
internal regulators and of external objects; this state of dysregulation
gives rise to tension and alarm in the organism, precipitating the emer-
gence of symptoms that directly reflect the alarm (anxiety, panic, de-
pression, etc.) or serve as a protection against extreme states of anxiety
(delusions, hallucinations, etc.). Mental symptoms, consequently, are
not merely the result of psychodynamic conflict but are also attempts
to restore balance to a critically imbalanced psyche (Grotstein, 1996).
Thus, schizophrenic psychopathology can be conceived of as a disorder
of the self and of relationships—psychopathology constituting primary
or secondary disorders of bonding and attachment. Self-deficits and
self-developmental defects lead to narcissistic forms of suffering, and
relational deficits are associated with internal object relations deficien-
cies, with a relation between these two sides of psychopathology that
form what Grotstein (1996) calls a double-track register. Our study ana-
lyzes this double-track to encompass both self or narcissistic pathology
and relational failures or object relations pathology.

METHOD

Participants

The data consisted of interviews with five subjects and their families
(Table 1). The subjects were treated at a major psychiatric state hospital
in Lisbon (Portugal). The treatment setting was diverse, including an
outpatient clinic (1 subject), a day hospital (3 subjects), and an inpatient
ward (1 subject). The selection deliberately included subjects from dif-
ferent settings to capture the widest variety of clinical situations. The
subjects all had a previous diagnosis of paranoid schizophrenia, based
on DSM-IV-TR and ICD-10 criteria, made by the attending psychiatrist
and confirmed in a brief clinical interview by the first author. The diag-
nosis had been established for at least six months at the time of obser-
vation, and the pharmacological treatment had reached a stabilization
plateau that allowed the interviews.

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Canta.indd 381
TABLE 1. Participants’ Characteristics
Participant Age Sex Education Time Since Diagnostic Subject Inter- Family Interviews
views
Subject 1: Ward 26 F College Undergraduate (Law) 3 Years 3 Parental Interview (Mother and
Father) – 2
Subject 2: Day Hospital 29 M High School 8 Years 4 Father – 2
Subject 3: Day Hospital 18 M High School < 1 Year 7 Mother – 2
Subject 4: Day Hospital 17 M High School (Incomplete) < 1 Year 7 Father – 1; Mother – 2; Parental
Interview (Mother and Father)
–1
Subject 5: Outpatient 38 F College Graduate 12 Years 2 Mother – 2
(Management)
NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA
381

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Data Collection

Ethical and administrative permissions were obtained from the eth-

ics committee and clinical board of a major psychiatric state hospital in
Lisbon (Portugal). The hospital serves an urban catchment area with a
total of 300,000 people.
The subjects were selected based on the requirement of a diagnosis of
paranoid schizophrenia, with family members available to participate
in the study, and were referred by the attending psychiatrist in each of
the clinical settings.* The first interview was dedicated to a brief assess-
ment of the diagnostic criteria and clinical characteristics. Of the seven
referred subjects, five were included in the study and two were exclud-
ed, due to the presence of acute psychotic symptoms that compromised
the narrative and consequently the interview. Substance abuse and ma-
jor cognitive impairments were also considered as excluding criteria.
The research procedure was explained to each subject, ensuring the
anonymity and confidentiality of the data. Each subject and family
member signed an informed consent agreement to participate in the
interviews. The interviews were conducted by the first author and took
place in each of the clinical settings (ward, outpatient clinic, day hospi-
tal), with a duration between 30 and 50 minutes. The length and num-
ber of interviews varied due to subject characteristics and clinical state
and tried to cover the same extension of life data in each subject.
Semi-structured interviews, with each subject and with the family
members, were conducted in an open-ended and exploratory way, us-
ing several questions to obtain detailed information regarding several
dimensions. Subjects were asked questions about how they perceive
themselves (own characteristics, and feelings and ideas about self and
others), how they believe they are perceived by others (parents’ feelings
and ideas about the subject), how they perceive the family dynamics
and remember their own development (emotional family environment,
developmental milestones, past and present relationships with fam-
ily and peers, and significant memories of family dynamics), and how
they perceive the disorder (development, experience, and evolution). A
similar procedure was used to interview the parents, where they were
asked about their offspring’s characteristics, family dynamics, develop-
mental issues, and current situation considering the disorder.
The method included interviews with subjects, father or mother
alone, and a joint interview with mother and father when both were

*The participants signed an agreement allowing the use of the text from the interviews.
All patients names and detils have been changed to protect privacy.

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 383

available (death or refusal of one of the parents precluded the possibil-

ity of an individual or joint interview). The use of this approach aimed
to achieve greater variability, to allow access to different types of fam-
ily interaction, and at the same time to focus different perspectives (of
subject, individual parent, and parental couple) on the same theme and
the perceptions of relational dynamics. It was hoped that this strategy
might enhance and deepen an understanding of the problem being
studied and the emerging theory.

Data Analysis

All interviews were transcribed verbatim so they could be carefully

analyzed and systematically coded using a qualitative data analysis
methodology: grounded theory (GT) (Glaser, 1978; Glaser & Strauss,
1967). Interview analysis consisted of a thorough line-by-line evalua-
tion, with the objective of defining codes for each incident (substantive
codes) and to develop its conceptualization, a process defined as open
coding (Glaser, 1978). Thereafter, selective coding enabled the identi-
fication of similar incidents, which were compared to each other, and
resulted in the definition and generalization of broader concepts, ar-
ranged in theoretical codes that are higher order concepts which ac-
count for the relationship between substantive codes. Concurrently to
this data analysis, memos were written in order to systematize ideas,
and as the analysis expanded and became more complex, a core cat-
egory emerged and was identified. To delineate the emergent knowl-
edge, theoretical sampling was used, allowing the characterization and
definition of theoretical codes and a core category with its properties
and its relationships with significant categories. Since the core category
is responsible for the explanation of the major variation of the phenom-
ena at study, there was an effort to achieve theoretical saturation of the
core category (i.e., exhaust all data that may contribute with new prop-
erties to a single category) (Charmaz, 2014; Glaser, 1978, 2004, 2005,
2007).
Memo sorting took place at the end of the analysis, when all memos
were organized and grouped according to their similarities, in order to
obtain more inclusive and complex categories with a higher level of ab-
straction through the development of new relationships between them-
selves and the core category. This step allowed the definition of the
underlying processes, the emergence of the substantive theory, and its
schematization through a visual diagram (Charmaz, 2014; Kelle, 2007).

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In order to ensure the thoroughness of the analysis and to maintain

theoretical neutrality, the literature review was delayed until the final
stages of the analysis. The coding and memoing procedures involved
a team approach, where two authors independently coded and wrote
memos, and later compared and discussed each finding until a con-
sensus was reached in order to safeguard potential biases (Wiener,
2007). The interviews were conducted, transcribed, and analyzed in
Portuguese, and the selected extracts and code labels were translated
to ­English.

RESULTS

The analysis of each incident in the interviews resulted in the codi-

fication of a total of 49 substantive codes, which were systematically
compared in order to descriptively define their essential characteris-
tics. Simultaneously, memo writing took place, allowing us to attain a
certain level of abstraction and to group those codes into more abstract
conceptual categories, which led to seven theoretical codes: narcissistic
impairments, projective identification, splitting, detachment, drives, loss and
trauma, and family relationships. The process of saturating and consoli-
dating each of the codes, through comparative analysis and memo writ-
ing, allowed the emergence of a core category (narcissistic impairments),
which is modeled as a basic social process and allows the emergence of
a substantive theory (Glaser, 2005, 2007).
The narratives were permeated by an ominous paranoid state of
mind, sometimes explicit in the form of behavior patterns and inter-
personal relationships that led to persecutory content and to the feeling
of ontological insecurity that was denominated as family paranoid dyna-
mics. This resulted in a model characterized by a defensive interplay
of narcissism within the family of paranoid schizophrenics. Each fam-
ily member strives to achieve a narcissistic integrity of the self, which
implies maintaining a feeling of value and self-esteem, a feeling of au-
tonomy and individuality, a sense of belonging to one’s own family,
a feeling of temporal continuity, and an experience of existence and
psychic survival.
In order to preserve the narcissism, three main processes were identi-
fied: projective identification, splitting, and detachment. These process-
es strive to achieve a balancing solution for existing narcissistic impair-
ments in the self and/or the family, operating both in an intrapsychic
dimension and on a transactional dimension within family relation-
ships, such as is observed in the following example:

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 385

My mother is completely unbearable. Completely. She is completely

schizophrenic, for god sake. She tried to attack me and attacked me, fuck,
for god sake. And people believe her, obviously. She is like this every day,
she’s either against people outside the family or against my father or sister.
I even think that our problems with violence are originated by her. She
starts by controlling something and she doesn’t allow me to be free, and
then if I don’t go along, she puts my father against me, and he decides to
go against me. With eyes that want to kill me, because he takes my mother
side, and she always wins. I am never listened to and I am always put in
the garbage. These are the things that shake me. – Subject 4

The use of these processes results in a relational distortion that as-

sumes a central relevance on the family dynamics. These intrapsychic
processes (projective identification, splitting, detachment) are not di-
rectly observed and can only be reached by abstraction based in the
observation of other categories (incoherent narrative, encapsulation,
persecution and grandiosity), that is, these main categories (theoretical
codes) emerge from their expression in raw data.
Narcissistic Impairments and Narcissistic Equilibrium. The central or
core category, narcissistic impairments, emerged from several ways of
expression (narcissistic devaluation, narcissistic privation, narcissistic
humiliation, narcissistic grandiosity) constituting a background of the
narratives. Therefore, we identified the presence of a significant sense
of narcissistic fragility in the subject that is shared by each family mem-
ber. Subsequently, a basic social process of constant search for narcissi-
stic equilibrium was identified as the main purpose of the subject and
within the family. There is a continuous effort to achieve equilibrium,
oscillating between a state of narcissistic fragility and a state of narcis-
sistic stability, as a strategy to overcome developmental and recurrent
narcissistic deficit experiences—narcissistic devaluation, narcissistic
privation, and narcissistic humiliation.
Narcissistic devaluation results from an active criticism, either in in-
tensely traumatic action or a continuous and cumulative process, that
leads to an internalized feeling of anger and conflict. The continuous
criticism of the other may lead to a narcissistic deficit in the subject that
in an extreme and distorted way constitutes a delusional idea of pov-
erty and of severe disvalue and unworthiness (narcissistic devaluation
is associated with projective identification).
Narcissistic privation emerges from an absence of narcissistic positive
investment, generating a sense of being distant and disconnected. The
relationship lacks investment and may lead to relational avoidance, or
there may be an investment but it is of a poor quality or of negative
traits (narcissistic privation is associated with detachment).

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 386 CANTA ET AL.

I think that the others have expectations that are simply wrong… are far
from what is real, because I, that have to deal with myself inside of me,
think that I don’t have value… the things that I do don’t have rationality,
credibility, basis. I think that the others have a lot of expectations about my
capacities… they even give me compliments, but I know in reality that is
not true. When people think that you don’t have capacities, they don’t tell
you, and I don’t think that society will accept me. I was never prepared to
live, and suddenly I have life, and that is aggressive. A person feels alone
in the world, even though there are others, they cannot understand the
person, and the person can never show himself entirely. – Subject 4

Narcissistic humiliation is a very severe and traumatic experience of

narcissistic devaluation, with feelings of shame, of being excluded, and
a reaction of anger and aggression. The subject feels himself attacked,
and considering the intensity of the experience, different defensive
modes may be used (projective identification, splitting and detach-
ment).

My parents treat me in a childish way and criticize me to prepare me for

the criticism that I have to face in the outside world. – Subject 1
Processes of Narcissistic Equilibrium in Paranoid Schizophrenic Subjects.
In order to maintain a state of relative narcissistic stability, compensat-
ing for narcissistic impairments, the subject reverts to certain psycho-
logical processes that were transactionally developed within family re-
lationships. These strategies are used both at an intrapsychic level and
on an interpersonal level. As mentioned before, three main processes
were identified: projective identification, splitting, and detachment.
These processes may assume a normative or a pathological degree de-
pending on the severity, intensity, or inflexibility of their use and lead
to a relational distortion, where the other is perceived under the exces-
sive influence of subjective representations and emotional content.
Projective identification is a process that entails communication be-
tween the self and the environment, and it is used to externalize or
evacuate specific elements of the self or emotional states and to project
certain elements inside the self, leading to an identification mechanism.
Narcissistic equilibrium is attained by expelling something that may
be threatening or cannot be signified in terms of the subjective experi-
ence, and in this process, there is a denial of reality or a distortion of its
perception.

Once I saw a boy in the street, in the train station, but I never met him.
And then when I was in the supermarket where I worked, the idea I had
or the voices told me that the boy was interested in marrying me, he was

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 387

in love with me, and that started messing up my ideas, and the voices said
that I had to marry him and I didn’t want to marry, neither with him nor
with anybody. I never had ideas of marriage, it was the voices that said
that and then that I was going to die, this was all in my head. They said
that I was going to die because I had cancer, and then the voices started
to say that my parents were also going to die, that was an idea of death
and passion and I was completely messed up, it caused me tremendous
anxiety. – Subject 5

When aggressive traits are projected in the other or the environment,

they may acquire a persecutory quality, becoming something that may
be threatening to one’s narcissism. If they are projected into the self,
the person feels internally persecuted by his own drives, and simulta-
neously those drives are out of his control. By expelling the negative
qualities, and at the same time protecting the positive ones, the sub-
ject attempts to preserve his narcissistic integrity, but everything else
is transformed into an enemy or persecutor. This process also ensures
narcissistic inflation, since in order to be persecuted, one must possess
intrinsic value. This state of affairs generates an atmosphere of insecu-
rity and distrust, with the attribution of negative intentionality to the
other. The process of persecution includes a spectrum of severity, which
spans from a state of general alert to severe persecutory delusion with
hallucinatory activity. Fear is the dominant affect, generating intense
vigilance and mobilizing a state of fight or flight. This affect becomes
dominant in the psychological functioning of certain individuals and is
activated in periods of acute crisis.

I was disoriented, and I heard the outside world in a distorted way… I

thought it was strange to see a van looking too much at me, waiting for me
to get out. I thought that I was being tracked by my cellphone chip, and I
left it behind. I went to the subway to run away from them… I established
a connection with my neighbor that uses elicit substances. I don’t know
which ones, but I felt the smell. – Subject 3

A diminished sense of self value, narcissistic impairment, is associ-

ated with intolerable ideas that the person or family may try to counter
by inflating the self with narcissistic compensation. Positive traits are
projected onto the self and negative traits are denied and projected onto
the environment, generating a sense of superiority of the individual
or family group. Grandiose ideas protect the perception of narcissistic
impairment, avoid frustration, and may act as a form of reparation of
traumatic events or pain, thus interfering with the perception of reality.
The existence of a grandiose idea within the family, or of a family myth,

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 388 CANTA ET AL.

may contribute to cohesion in the family and provides a narcissistic

unstable balance for the psychological development of the individual.
The existence of a shared delusional belief protects the family from in-
ternal conflict and creates a sense of narcissistic grandiosity, albeit at
the risk of detachment from reality. But at the same time, grandiosity
may be used in conflicts inside the family environment: For one to be
grandiose, the other must be denigrated. The amount of narcissism to
be distributed is scarce and the battle is ferocious.

I received an inheritance and I had to solve the problem with both the
Communist Party and the Muslim church, and had to buy fifty war tanks
for the Ministry of Defense, I had to invest a few million. In the Communist
Party, they have a file on me that they call “The Messiah Case” and they
took it to the parliament. I never had the opportunity to read the file they
have on me but they talk about the Messiah. – Subject 2

So, to protect narcissistic integrity and attain a certain level of narcis-

sistic equilibrium, the subject or the family may use the process of pro-
jective identification as previously described. This process possesses an
interpersonal dimension as well as an intrapsychic dimension. The use
of these defenses occurs in a dialectic tension between two positions:
persecution and grandiosity. The two are present in family paranoid
dynamics, but their level of salience varies according to family subtle-
ties that may focus on protection against perceived enemies (within or
outside the family) and/or a need for narcissistic compensation against
a sense of impairment or deficit. Grandiosity is the narcissistic basis
of this process, where it compensates the perceived narcissistic misery.
Splitting is a process where two mental elements are separated so
that the integrity or unity is broken apart. This may serve as a useful
mechanism to separate elements with different qualities but when used
exaggeratedly, it produces a barrier between the elements and between
mental processes. In family paranoid dynamics, it seems to be used
with great intensity to internally split the subject or his thoughts and
is characterized by a predominance of aggressive ideas and feelings.
In an extreme, it may lead to the destruction of the protective barrier
between self/other, inside/outside, and a total disconnection from re-
ality, affecting the symbolic process and language that appears in an
incoherent manner.

A person does not know himself and the others in front of him. You have a
carcass where you live but I don’t feel my carcass to be myself. It is a body.
It is a bit torturing, life is torturing. I could never live in this body and can-

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 389

not admit that I am a person. My head sometimes does not have a notion of
reality. I see things in a way that is not real, a distorted thought. – Subject 4

Fragmentation is the result of either the continuous use of splitting

or of multiple simultaneous splits, generating a confusional state or a
withdrawal from reality. This process is tangible in the discourse of the
patient and acquires the form of an incoherent narrative: changes in
the subject of the discourse; associations made without an understand-
able reason; loosened associations; confusion between past and pres-
ent, external and internal, and reality or fantasy. In an extreme mode,
discourse becomes completely incoherent to the point it may be un-
clear which idiom is being used; it may be overloaded with neologisms
and with words that possess a subjective meaning far from the usually
significant. Destroying the coherence of the narrative also destroys the
perception of unwanted feelings, ideas, or memories and doesn’t allow
the other to fully grasp the disturbing experience the person is going
through. The question is: Does the person destroy the coherence of the
speech or is the speech destroyed by the intensity of the experience?

I wanted my son to be educated by my parents in their way. I wanted him

to have a part of their education also. It is the way they educated me, it is
not the way they educated me, a different way from how they educated
me. They want to educate him in a different way from how they educated
me. I want him to be educated the same way I was. – Subject 1

We may reframe this question by using a model of defect or deficit,

where an intrusion of environmental elements may be excessive for the
defensive capacities of the self, generating a state of loss and trauma,
and marked by a passive stance; or we may use a model of conflict
where the self may try to counter threats coming from within or from
the outside, maintaining or even exaggerating the defensive processes
in use and creating a sense of fight against the elements and keeping an
active stance. Therefore, we have two forms of fragmentation: passive
fragmentation (deficit) and active fragmentation (conflict).
Passive fragmentation is characterized by a narcissistic deficit (a de-
ficiency in narcissist investment from the other and at the same time
a depletion of self-narcissism), leading to a narcissistic disinvestment
and consequently a loss of vitality of the discourse, with the absence
of symbolic material and the increase of incoherence, disorganization,
and progressive detachment. There is diminished expressed emotion,
a tendency toward a loss of emotional processing of experience, and
there is a connection between this form of fragmentation and detach-
ment. Active fragmentation is caused either by an excess of drives or as a

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 390 CANTA ET AL.

reaction to intense conflict that acquires an unbearable dimension and

causes disorganization. There is a predominance of aggression, which
may rise to the level of violence, or sexuality, with an intense and dis-
turbing fantasy life. This is associated with high expressed emotion,
and there is a connection between this form of fragmentation and the
process of projective identification.
Detachment is a process occurring at the level of the protective bar-
rier that blocks exchanges and generates encapsulation to protect the
narcissism, enhancing the differentiation between self/other, inside/
outside. So, narcissistic equilibrium is attained through encapsulation
as a form of avoiding painful emotional experiences (e.g., aggression,
sexuality, fear, loss, narcissistic devaluation), and social retreat may
be compensated, for example, through an investment at the cognitive
level. Encapsulation may assume different themes: intellectual, where
cognitive processes are overinvested in detriment of subjective and
emotional experience; delusional of a grandiose or persecutory nature;
ritualistic, where autistic mechanisms are dominant; or void and emp-
ty, where it is difficult to grasp any mental activity.

Because of receiving a very cold education, I never established contacts

with the outside, and that reflected in my social life until now. – Subject 3

I almost had no relationships. I was very introverted, didn’t speak with

anybody, almost didn’t exist, seemed like I was in a coma. I can’t explain.
I had no idea of things and had no interest in things, didn’t speak with
people, didn’t know what a society was. I was always a refugee inside my-
self. I was never extroverted, never much communication with other. Was
very unsecure. I thought that I had no capacities and others were much
better than me. I always thought that I could not follow their thoughts and
stuff. – Subject 4

When I am alone, I can do a lot of things without having the opinion

of others and I am sure that I am doing the right things. When I am
with others, I get insecure and I don’t trust myself, because I think that
the others know more than I do. And maybe that is not true. – Subject 5
Detachment is a process of narcissistic equilibrium, highly specific,
and with a broad effect—the subjects that mainly use this defensive
strategy scarcely use others—and ensures that the narcissism is highly
protected against external events (protected from reality), and being
solipsistically controlled. In the process of detachment, we find three
main strategies and expressions: non-socialization, characterized by an
avoidance of contact with the other as a form of evading unpleasant
feelings, narcissistic devaluation, or aggression; withdrawal, a form
of actively suppressing contact with others to preserve intense con-

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 391

tact with one’s internal world but at the same time not communicating
one’s own thoughts or feelings; and externalized description, where
the subject concentrates his attention on describing events or objective
characteristics in a pragmatic way, thus avoiding the subjective experi-
ence. This last category is highly prevalent in the narratives of the sub-
jects and encompasses a dominant strategy that leads to encapsulation.
It may seem like a simple strategy, but it is a powerful way of avoiding
thoughts and feelings, while at the same time eliminating the traces
of subjective experience. It may be the way in which subjects become
more like robots, an image frequently used to describe persons with
schizophrenia or the discourse they use. This radical detachment from
emotional and subjective life preserves the self and its minimal narcis-
sism, while at the same time it may inadvertently eliminate its most
humane characteristics. When used as a family communicative mecha-
nism, it generates a sense that everyone is talking about a third person,
even though that person is in the room. The narrative of the parents be-
comes more of a transcript than a proper discourse, and it seems more
like a business meeting than an exploration of lived happenings. Under
the banality of this mechanism, a violent narcissistic attack is hidden,
where subjectivity is threatened.
Defensive Processes in Family Relational Distortion. The above-men-
tioned defensive processes were observed at a transitional level in the
family or as a form of implicit communication between members of
the family, with the purpose of attaining narcissistic equilibrium and
resulting in relational distortion. These may assume the shape of in-
tense conflict, where projection is dominant, and active fragmentation
may occur between family members or psychically between conflicting
representations. On the other hand, they may assume the shape of re-
lational distance and a deficit of emotional investment, where detach-
ment is dominant and passive fragmentation may occur, generating a
sense of void and an absence of representation.
When observing the schema generated from the GT analysis in Fig-
ure 1, in the middle and lower section we find the defensive processes
(projective identification, splitting, and detachment) involved in the
search for narcissistic equilibrium and their expression in the commu-
nication and interaction of the subjects (grandiosity and persecution,
incoherent narrative, and encapsulation). In the upper section of the
schema, we find the features associated with relationships, external
and internal events that have an impact on the narcissistic equilibrium
(drives, loss and trauma, family conflict, and fusional relationship).
Relational Features. Aggression and sexuality are drives that find expres-
sion in the narrative of the subjects. Aggression is strongly related to

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 392 CANTA ET AL.

FIGURE 1

narcissism, where experiences of narcissistic humiliation or fragility

generate intense anger and hatred that can lead to aggression. We have
found two different modes at use: aggression as a reaction to negative
experiences (conflict model) and aggression as an expression of a deficit
in regulation (defect model). Drives are associated with ideas and rep-
resentations, both at an intrapsychic and an interpersonal level within
the family. Narcissism plays a central role in the modulation of aggres-
sion. The origin of aggression seems to be related to an experience or
perception of narcissistic humiliation or deficit, and the three different
defensive processes may be used: 1) Narcissistic humiliation leads to
aggression and splitting is used, leading to a state of confusion and the
loosening of associations; 2) Narcissistic humiliation leads to aggres-
sion which is encapsulated to contain any expression of the drive, even
though you can sense a latent anger; and 3) Narcissistic humiliation
leads to aggression that is projected, and the other or the environment
acquires the characteristic of being aggressive and so is felt as being an
enemy or persecuted.

My mother said that I was homosexual and I had to hurt her. I ripped off
some hairs and hit her with the iron, I think I broke it and then I also took

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 393

a frying pan, took from the stove with some steaks on it and I hit her head
with it. She lost her senses and stood there for a while. When she got sick,
I think it was in the spot I hit that she developed cancer, but she had called
me a faggot and I was very disturbed. – Subject 2

Sexuality is a less dominant theme in the subject’s discourse and

when present is associated with strong restlessness in the emergence of
sexual experience or with the idea of incestuousness (sexuality within
a symbiotic relationship). So, sexuality is experienced in a regressive
way and may be represented in a confusional state entangled with ag-
gression.

I have an obsession with my mother. I like to kiss her a lot and I am very
attached to her, it’s not her fault, it is me that wanted a stronger connection
with my mother but she was never receptive and I understand. I wanted a
more passionate relationship with my mother. I never abused her, because
she also didn’t want it. I would behave like an animal. I like to kiss her
in the neck and to grab and feel her, things that are not normal. I feel too
much excited, and have an erection… I am very attached to my mother,
really, in a way that is extreme, really. And I think that my father is like an
adversary. He is like a villain, a traitor that stole the person that I loved and
imposes me limits, so that I cannot love that person. He doesn’t allow me
to stand close to that person. – Subject 4
Loss and Trauma. The expression of the disorder is strongly related
with the experiences of loss, especially death of a close relative, with a
powerful impact on the family. To deal with this emotional experience,
mechanisms of projection and encapsulation are the main resource,
hindering the mourning process and resulting in a narcissistic decline.
The loss acquires special traumatic significance when the relationship
was of a symbiotic quality, where the narcissistic equilibrium was pro-
foundly dependent on the experience of contiguity, becoming severely
unbalanced upon the disappearance of the other. The other traumat-
ic experiences are related to separation, negligence, and abuse (both
physical and sexual).

The guy was a mess and his self-esteem crumbled, yeah, and the guy I at-
tributed all that mess to the recent death of his mother, yeah, because that
happened when the mother died. I think that it all started since that and
he came to live with me after his mother died. I think she had the protec-
tive relationship with the son, the guy was there and he felt protected, he
felt protected in that environment. He continues with a neediness thing.
– Subject 2 Father

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 394 CANTA ET AL.

Family Relationships mainly possess a fusional quality where narcis-

sism is developed as a copy of the parents’ narcissism, in a mirror-like
relationship. Fusionality occurs in the spectrum between extreme iden-
tification, with striking confusion, and less intrusive identifications to
certain characteristics of the other. In extreme identification, confusion
may lead to a loss of identity. We find an expression of these phenom-
ena in incoherent narrative.
In the analysis of the narratives, we found evidence that fusionality
occurs with the closest of parents, generating a kind of collusion within
the family. This process may lead to family conflict interfering in the
development of a stable identity. Family conflict is characterized by a
high level of aggression in the family, with the use of projective iden-
tification that has been described by several authors as high expressed
emotion.

My mother is always with me. She is always over me … My mother is

bipolar, and has moments of sadness, so that she needed to be with me.
I have to try to cheer her up. – Subject 3

I think that I can’t do anything else besides taking care of him.

– Subject 3 Mother

Fusionality and family conflict, as well as the use of narcissistic equi-

librium processes (projective identification, splitting, and detachment),
may result in experiences of relational distortion, where two levels of
representation converge and interact: internal representations and re-
lational representations. So, the way a person is represented influences
the type of relationship developed and vice versa. A parent relationally
perceived as persecutory generates fear, leading to an internal model of
a persecutor and a sense of narcissistic vulnerability; or the subject fears
devaluation and acts in an arrogant way; or the subject feels dimin-
ished and has a grandiose delusion; or the subject feels grandiose and
becomes unstoppable; or loss may lead to an incoherent narrative and
grandiose idea. To deal with these phenomena and maintain narcissis-
tic equilibrium, the subject may use different strategies, such as detach-
ment or conflict. This has an impact on the formation of the internal
representation, in the narcissism of the subject and in the relationship
developed with the parent and subsequently with the other, creating a
cycle of increased conflict.

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 395

DISCUSSION

Study Limitations

The small sample size of this study requires a cautious approach to

the results, and it would be important to gather a larger clinical sam-
ple in the future. Using a qualitative method such as grounded theory
allows in-depth study of the available clinical material and the emer-
gence of a coherent theory. However, in order to consolidate the find-
ings, it would be interesting to develop a questionnaire and confirm
these results with larger samples in quantitative research. With this
procedure, the generalizability of the findings could be expanded (El
Hussein, Hirst, Salyers & Osuji, 2014).
Psychodynamic and psychoanalytic contributions have often been
criticized for the lack of consistency in the constructs and terminology.
To tackle this criticism, an exhaustive, descriptive, and systematic ap-
proach was adopted to make our ideas accessible to others and allow
for discussion. So, the present use of the concepts must also be tested
against previous theories, and conceptual research is a needed supple-
ment (Alanen, 1997; Martindale & Summers, 2013).

Study Discussion

This study observes the dynamics of subjects diagnosed with para-

noid schizophrenia and seeks to analyze both the intrapsychic (as ex-
pressed in the participants’ discourse) and the intersubjective dimen-
sion (representation of the relation between family members). There-
fore, it must be emphasized that this is not a study about the etiology
of schizophrenia. Although pathological and dysfunctional patterns
are identified, we do not argue that these are the causes of schizophre-
nia, since arriving at such conclusions would be a simplistic way of
approaching such a complex pathology and is beyond the scope of this
research. With this in mind, it is important to define methods of evalu-
ation and treatment of pathology within the family dynamics (Alanen,
1997), as well as to develop quantitative measures that can evaluate
some of the aspects suggested in this study.
Our results show that the family core process revolves around the
dynamics of narcissism that we defined as narcissistic equilibrium.
Therefore, this oscillating process results in a continuous search for
narcissistic balance and a continuous struggle against narcissistic im-
balance or impairments. This precarious narcissistic stability leads to a

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 396 CANTA ET AL.

delicate self-representation in the schizophrenic subject as stressed by

Auerbach and Blatt (1996), and a family atmosphere where criticism
and dependency issues easily contribute to paranoid distortion (Al-
anen, 1997; Hesse et al., 2016; Migone, 1995).
The impact of these processes and the quality of the atmosphere in
the communication between members of the family result in severe
distortions. These distortions are derived from the interactions within
the family, with reciprocal influences. Parents’ thoughts, emotions, and
communication exert an impact, possibly at both a developmental and
a present moment, and simultaneously, the projections from the schizo-
phrenic subject influence the thoughts and emotions of the parents.
This circular process we described had already been hinted at by sev-
eral authors (Alanen, 1997; Fort, 1990; Karon & Widener, 1994; Migone,
1995; Pao, 1979).
To gain a deeper understanding, we analyzed the elements involved
in this process. In order to maintain narcissistic equilibrium, splitting,
a process characterized by the capacity to separate elements with dif-
ferent qualities, is used to preserve the traits felt as positive. When ex-
cessively used, splitting may generate confusion and a disconnection
from reality, affecting the symbolic process and language that appear
in an incoherent manner. The other process involved is detachment,
which we observed as a protective barrier for narcissism by separating
and encapsulating the self from the relational environment that felt ag-
gressive and threatening. Through projective identification, narcissistic
equilibrium is attained by externalizing the emotions or representations
felt as dangerous, providing a sense of narcissistic compensation and
security, since positive traits are projected onto the self and negative
traits are denied and projected to the environment, generating a sense
of superiority or grandiosity of the subject. This defense also involves
the intersubjective interaction with the other, together with the previ-
ously described intrapsychic mechanism (Grotstein, 2005).
So, both splitting and detachment are communicative and defensive
processes (Apprey & Stein, 1993; Grotstein, 2005; Migone, 1995; Räk-
köläinen & Alanen, 1982), trying to find a balance and to face narcis-
sistic impairments; they are also processes of communication between
family members—the defensive processes are interactive and shared
between family members. Curiously, the same processes were used
both by the subject and by one of the parents, normally the one with a
closer relationship, what we often call a symbiotic quality. We may hy-
pothesize that these processes are somehow transmitted or taught in
an implicit way (unconscious transmission of defensive and relational
modes), constituting a communicative matrix within the family since
early developmental stages. Sometimes, they get exaggerated and be-

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 NARCISSISTIC EQUILIBRIUM IN PARANOID SCHIZOPHRENIA 397

come pathological. We observed the end product of this developmental

trajectory (family paranoid dynamics) and a dramatically exaggerated
mechanism that is conceptualized as a disease (paranoid schizophre-
nia). The family dynamic, designated as family paranoid process, is in-
ternalized by the subject, and the narcissistic arrangements are a result
of family resources and not at just an individual level. So, what may be
felt as a narcissistic attack can be a simple questioning of the subject’s
reality by others, which is perceived as violent aggression towards the
self. Questioning the subject’s reality is felt as questioning his existence,
therefore the most basic aspects of his identity. For example, when men-
tal health professionals stress the idea of disease, illness, or disorder
associated with a patient’s perception, they might inadvertently be im-
posing narcissistic wounds, because they are already mentioning the
pathological value of those ideas and of the subject’s identity.
When examining the family relational distortion, we found that de-
fense mechanisms, such as projective identification, splitting, and de-
tachment, are regulatory processes being used at an intrapsychic and
interpersonal level to modulate instinctual, emotional, and affective ex-
changes occurring either in the individual psyche or between persons,
with the purpose of finding narcissistic equilibrium or fighting against
the imbalance that leads to the paranoid process.

CONCLUSIONS

Our study suggests the relevance of family interactions and the

need to further understand the interpersonal psychological processes
involved, in order to better understand schizophrenic disorders and
to improve the treatment of these conditions. The results obtained
suggest the important role played by defensive mechanisms and the
need to understand their use by paranoid schizophrenic patients and
their families as mentioned above. So, further research must deepen
a comprehensive approach to family processes and design treatment
plans that involve the family. The need-adapted treatment (Alanen,
1997) found a way to integrate the treatment of both the patient and
the family members to optimize treatment efficiency and results. Re-
cent research has shown the impact of factors such as prenatal stress,
disturbances in early bonding-attachment, physical and sexual abuse
during childhood, emotional neglect, and parental loss (Read, Bentall,
& Fosse, 2009); narcissistic impairments, narcissistic imbalance, and the
excessive use of projective identification may also be important factors
that can be targeted by adequate psychological and psychotherapeutic
interventions. There is a need for research considering the central role

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 398 CANTA ET AL.

of narcissistic impairments and to target narcissistic equilibrium as a

central feature in the treatment of schizophrenic psychopathology.

REFERENCES
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