Religion and spirituality are increasingly recognised as important in the understanding of psychiatric disorders and in the clinical assessment and treatment of patients.^1,2,3,4,5 Yet there are also concerns about the role of religion and spirituality in psychiatry. Curlin et al. report that 82% of psychiatrists are of opinion that religion and spirituality can cause increased suffering, for example, guilt or anxiety.³ The suffering of vulnerable people under their harsh beliefs and understanding of God is one of many examples where religion has done a lot of harm.⁶

Religious faith can, however, also enhance well-being.⁷ It is associated with a higher sense of personal empowerment and can provide patients with a positive sense of self and can give meaning to their illnesses.^8,9

Religion initially referred to something dynamic. It was conceptualised as a verb, stemming from the Latin ‘re-ligare’, to re-connect,¹⁰ or ‘that which connects’ (p. 14).¹¹ Nowadays religion refers to the dogmatic contents of faith, in theistic religions the question of what one believes about God.¹² Spirituality is defined as the search for the sacred,¹³ a reaching out to something beyond ourselves.¹⁴

The use of the word spirituality as a term and construct in scientific discussions is relatively new.¹¹ In this context, spirituality is described in a positive, dynamic and personal way; it is growth-orientated,¹¹ a motivating force and ‘has come to represent individuals’ efforts at reaching a variety of sacred or existential goals in life, such as finding meaning, wholeness, inner potential and interconnections with others’ (p. 24).¹³

The recommendation for the integration of spirituality in the approach to psychiatric practice² emphasises the importance to further think about the role of spirituality and religion in psychiatry. Is religion merely a passive way of coping or is it a vital resource?⁷ And does an integrated approach to treatment that includes spirituality and religion enhance the effects of standard psychiatric care?⁷

The aim of this paper is to address these questions by asking whether psychotherapeutic help is sufficient in helping someone suffering from pathological narcissism, or whether religious and spiritual help can be of value or is needed. To pursue this question, the focus of this article is mostly on some of the ideas of the psychoanalyst Neville Symington and the theologian Paul Tillich.

The term ‘narcissism’ originates from the Greek myth of Narcissus, the beautiful youth who fell in love with an image of himself. Although Freud’s landmark essay On Narcissism: An Introduction appeared in 1914,¹⁵ the term and concept became more widespread in the 1970s, due in great part to the work of the psychoanalysts Kernberg and Kohut.¹⁶

Narcissism is a complex phenomenon and difficult to define because of the multiplicity of meanings it has acquired. In its colloquial usage, it is used to refer to self-centred persons, often in a pejorative way, but it also refers to a pathological clinical syndrome.¹⁷ For some, narcissism is synonymous with self-esteem, an indication of the strength of the self.¹⁸ According to Val, this causes confusion because self-esteem refers to an experiential state and narcissism to a functional concept.¹⁸ The distinction between healthy and pathological degrees of narcissism is, according to Gabbard, fraught with difficulty.¹⁹ A certain measure of self-love is normal and desirable. Hence, Kohut boldly defined narcissism as a desirable and even healthy dimension of mature selfhood.¹⁶

To complicate things, we live in a narcissistic culture,^19,20 in which ‘being number one is the most important goal of all’ (p. 484).¹⁹ ‘Making it’ has become more important than promoting values such as commitment, loyalty, integrity and interpersonal warmth (p. 484).¹⁹ Interpersonal exploitiveness is highly adaptive in our society and winning forgives everything.

Freud, in his introduction into the problem of narcissism, grappled with the problem of the relationship between the ego and external objects or people, leading him to distinguish between ego-libido (libido directed inwards) and object-libido (libido directed outwards).¹⁵ Narcissism, according to him, means that libido is withdrawn from the external world and instead invested in the ego; it is directed inwards.

In later developments, the work of Kohut and Kernberg helped to coin the concept of a narcissistic personality disorder,¹⁶ defined in DSM-5 as people showing a pervasive pattern of grandiosity, need for admiration and lack of empathy.²¹ Their work also demonstrates something of the continuum of narcissistic personality disorder – Kernberg described an envious, greedy type, whereas Kohut described a vulnerable type, prone to self-fragmentation.¹⁹ According to Kernberg, at the deepest level the self-concept of the narcissist is one ‘of a hungry, enraged, empty self, full of impotent anger at being frustrated, and fearful of a world which seems as hateful and revengeful as the patient himself’ (p. 57).²² Kernberg is of the opinion that self-hatred rather than self-love lies at the root of pathological narcissism.¹⁷ Narcissism is linked to feelings of inferiority and the inability to accept oneself.

Kohut sees a weakened or defective self at the centre of a narcissistic personality disorder.²³ Faulty interaction between the child and his self-objects leads to a damaged self. (The term self-object, coined by Kohut, refers to an object experienced as part of the self. He described two types – the mirroring self-object, representing the need for affirmation, and the idealised parent imago, representing the need for being like the parent or later like the therapist.)^19,23 Nurturing self-object relationships with parents or significant others helps the child develop a healthy self-esteem.

For Kohut, empathy was the cornerstone of psychotherapy or psychoanalysis.²⁴ The goal was to help the patient identify and seek out appropriate self-objects.¹⁹ Initially, the therapist would function as a positive self-object in relation to whom the person could resume narcissistic development arrested in childhood.²⁵

Paul Tillich (1886–1965) served as a military chaplain in World War I. This shattering experience was for him a stark reminder that autonomy as a sole guide for human action was indeed questionable.³⁰ He was an early critic of Hitler and the Nazi movement, and in retaliation he was barred from German universities in 1933. He then accepted an invitation to join the faculty at Union Theological Seminary in New York.³⁰ Tillich, who was deeply rooted in Lutheran theology, has been described as the greatest twentieth-century theological representative of the psychology and theology dialogue.²⁹ He played a leading role in the New York Psychology Group, which met regularly from 1941 to 1945 and included prominent psychotherapists such as Erich Fromm, Rollo May and Carl Rogers.²⁹

Tillich sees man as estranged and alienated from his essential being. This separation is threefold: separation of man from himself, separation amongst individual lives and separation of all men from the Ground of Being. Sin, for Tillich,³¹ does not mean an immoral act; sin rather refers to this estranged state of being. Sin is separation (p. 154).³¹ Sin is the universal and tragic estrangement and alienation of man from his essential being, from that to which he really belongs; sin is the ‘fall’ from essence into existence. Existence is separation! (p. 155).³¹

This estrangement from the Ground of Being and from ourselves leads to aggression, hate and despair.³¹ It leads to selfishness and self-hate, which Tillich sees as our real enemy. He joins Jung, who stated that no one can boast that he has fully accepted himself.^29,32 Feelings of inadequacy associated with self-preoccupation are the problem. Only a person who has overcome self-contempt and learned to love him- or herself will be able to love and to overcome contempt for others.³¹

In discussing the link between psychoanalysis (or psychotherapy) and theology, Tillich is of the opinion that psychoanalysis has much to offer theology and that psychoanalysis and theology need not be seen as being in opposition to each other but rather as being intimately interwoven. Psychoanalysis is about the existential situation of man and the theology about the relationship between this existential situation and the essential nature of man.^29,33

Tillich writes that psychoanalysis and existentialism have the common goal of describing the existential position of man, an existence of existential alienation, estrangement and finiteness.^33,34 Existentialism and psychoanalysis furthermore share common roots based in the protest against the growing influence of the philosophy of consciousness. In opposition to this, existentialism and psychoanalysis see man as being driven by unconscious impulses and irrational urges. Existentialism, however, describes a situation of existential anxiety and alienation valid for everyone, whereas psychoanalysis explores the different ways in which man tries to escape his existential problems ‘by fleeing into neurosis and falling into psychosis’ (p. 118).³³ Being neurotic means not being able to bear with reality as it really is.³⁵ According to Tillich,³⁵ mental illness implies that a ‘centered being, a person as a centered being, disintegrates’(p. 142). ‘They [the mental illnesses] are all related to the center. … This can be healed’ (p. 142). Tillich implies here that healing through psychotherapy or psychoanalysis is about the re-establishment of a centre, it can lead to the re-integration of a person.

Yet, he also says that our real enemy, selfishness or self-hate, cannot be overcome through a Pelagian attempt to muster self-love (Pelagius, 354–418 AD, emphasised the essential goodness of human nature and the freedom of the human will).³⁶ Tillich described Fromm’s belief that humanity can overcome its problems without any outside help as lacking depth and insight about the irrational side of man. Man is too alienated, estranged and sick to be able to accomplish this on his own.²⁹ A larger experience of acceptance is necessary before self-acceptance and self-love is possible. This larger experience is one of grace:³¹

Grace is however not the willingness of a divine father to forgive the weakness of his children. Such a belief needs to be rejected as it is a childish destruction of human dignity. It is thus not about sins in a moral sense but about overcoming separation, which, as mentioned, is how Tillich defines sin. This separation is overcome through acceptance: ‘You are accepted, accepted by that which is greater than you…’ (p. 162).³¹ Grace means unconditional acceptance. The courage to be is the courage to accept oneself as accepted in spite of being unacceptable, in spite of existential guilt.³⁷ This is the basis for the courage of confidence. Only this larger experience of acceptance, and the belief in it, can lead to self-acceptance, and only acceptance, never commands, can lead to transformation.

Self-acceptance is only possible if one is accepted in a person-to-person relation.³⁷ The objective power of acceptance is always embodied in a person, here the therapist, who can recognise guilt, who can judge and who can accept in spite of the judgment. Tillich writes that the psychotherapist should not have spiritual counselling as prime focus, but that in the Christian tradition of Protestantism everyone can be a priest to the other.³⁸ In this situation, the psychotherapist does not act in a psychotherapeutic sense but ‘appeals to the center of the personality to actualize an ultimate concern’ (p. 142).³⁵ Healing of the whole person not only involves bodily, psychological and sociological healing but also spiritual healing, that is, addressing the matter of ultimate concern, which is finding ‘the ultimate center in which our center can rest’ (p. 143).³⁵

The psychoanalysts Kernberg and Kohut represent two contrasting approaches to the understanding and treatment of narcissism. For Kohut, narcissism is the result of the parent’s empathic failures, parents not responding with enough validation and admiration to satisfy the child’s needs.¹⁹ In his treatment of such patients, empathy was a cornerstone and acceptance by the therapist of vital importance. Kohut believed that the therapeutic relationship and the internalisation of the other as a transformative self-object could facilitate the resumption of healthy narcissistic development arrested in childhood.²⁵ Kernberg’s approach is in general more confrontational.¹⁹ Interpretation and confrontation, especially of idealisation, greed and envy, play an important role. For Kernberg, it is important that the patient recognises and develops an understanding of his child’s contribution to his problems, and that the patient integrates idealisation and trust with rage and contempt, and develops concern for others.¹⁹

Symington extends the boundaries of psychoanalysis; for him, it becomes a spiritual quest. Self-transcendence means to curb narcissism, to internalise ‘the good’ and to establish constructive relations. Reason is the tool needed to define ‘the good’. This psychoanalytic struggle is an act of virtue.²⁸ In this struggle, the bits and pieces of a disintegrated individual can be integrated into an organised unity with as result the formation of a person.^26,27

It is interesting how primitive hatred and self-hate, linked to a lack of love and self-love, are seen as central problems of narcissism and emotional problems by Kernberg, Symington and Tillich.

The aim of this article is not to promote a specific religion but rather to think about the borders of psychotherapy, religion and spirituality. This paper also suggests that the basic, unspoken existential stance of the therapist and his or her thinking about the essence of being will silently speak in the therapeutic process.

Narcissism, the result of early, severe deprivation and a lack of secure attachment, is an ever-present and pervasive problem – a defence against man’s underlying anxiety and fragility. In the struggle to get a grip on this, good nurturing experiences, transformative self-objects, a confrontation with the darker sides of the self and the message of ultimate acceptance or grace are all needed. Religion and spirituality thus have an important contribution to make to psychiatric or psychotherapeutic treatment:³¹