Understanding Narcissistic Abuse When It Intersects with Chronic Pain - Insights from Pamela Madsen LPC
In our latest podcast episode, I had the privilege of speaking with Pamela Madsen, MS, LPC, ACS, RYT-200, a Licensed Professional Counselor based in Atlanta who specializes in narcissistic abuse recovery. As the clinical director of a group practice in Buckhead and a doctoral candidate researching narcissistic abuse, Pamela brings valuable insights into the complex relationship between childhood trauma and physical health.
Types of Narcissism and Their Impact on Children
Pamela identified four distinct types of narcissism that can shape a child's development in different ways:
Grandiose Narcissism: The "classic" type where parents demand high achievement from children, seeing them as extensions of themselves. Children might be pressured to excel in academics or sports to make the parent look good, with failure met with criticism rather than support.
Covert/Vulnerable Narcissism: A more subtle form where parents appear sensitive and seek validation through victimhood. This creates family systems where children become emotional caretakers for their parents, often leading to role reversals.
Malignant Narcissism: Characterized by aggression, cruelty, and a lack of empathy. Children may experience physical abuse and develop fear responses, though these situations might attract more outside intervention.
Communal Narcissism: Parents appear generous and helpful in the community but may neglect their children's needs, prioritizing their public image over family relationships.
The Complex Trauma Response
Children raised by narcissistic parents often develop complex PTSD, though they might not recognize it. Pamela noted that many of her clients are high-functioning overachievers who come to therapy for seemingly unrelated issues like alcohol use or chronic pain.
A common thread in these clients' stories is the disconnect between how they initially describe their families ("close-knit") and how they later characterize individual family members ("controlling"). This contradiction reveals the gap between the family narrative they were taught and their actual lived experience.
The Chronic Pain Connection
As we started to get into the relationship between narcissistic abuse and chronic pain conditions, Pamela explained three types of pain:
Nociceptive pain: Typical pain from physical injury
Neuroperceptive pain: Pain resulting from damage to the central nervous system
Nociplastic pain: Pain originating in the central nervous system itself (including conditions like fibromyalgia, IBS, migraines, and rheumatoid arthritis)
For people with complex PTSD from narcissistic abuse, the hypervigilance that developed as a survival mechanism doesn't just scan the external environment for threats—it also scans the body internally. This heightened internal awareness amplifies pain perception, creating a feedback loop that can manifest as chronic pain conditions.
As Pamela explains, "When somebody has PTSD, they're on high alert, very hypervigilant all the time... They are scanning their environment for danger... Those people are not just scanning the environment, they're also scanning inside of their body... and their perception of pain is heightened because they're looking for the threat of tissue damage as well."
I, Destiny, can confirm that the hypervigilant scanning is not only my personal experience with chronic pain, but for many people I work with as well. Personally, I find that learning how to pay attention to the sensations without dismissing them, criticizing them, or fearing them is the key to healing.
The Path to Healing
The foundation of recovery from narcissistic abuse requires repairing the relationship with oneself. People who've experienced this type of trauma were taught that their purpose is to benefit others, particularly their narcissistic parent. Healing involves:
Developing a strong sense of self and identity
Processing the grief of not having the childhood they deserved
Learning to respond to their own needs rather than constantly attending to others
Understanding that they deserve care and are worthy of good things
For those dealing with chronic pain as a result of complex trauma, addressing the underlying PTSD can significantly improve pain perception. As Pamela noted, "If we treat the post-traumatic stress disorder... their perception of pain improves."
This is NOT to say that trauma work heals all health conditions. Or any… but it absolutely can improve many of our symptoms. If you mix this work with treating your physical health conditions through medical treatments, the possibilities for improvement are endless.
Moving Forward
Whether you recognize these patterns in your own upbringing or in your parenting style, awareness is the first step toward change. For parents who notice themselves putting their image before their children's needs, we suggests redirecting attention from what others might think to what your child needs in the moment.
The work isn't easy—both recognizing narcissistic patterns and rewiring your nervous system require consistent effort. But as Pamela emphasized, the key is developing a relationship with yourself where you know you're "good enough" regardless of external validation.
In the end, healing from narcissistic abuse means learning that you exist for your own sake, not merely to reflect well on others. And that realization can transform not just your emotional well-being, but your physical health as well.
If you recognize these patterns in your life and would like support, consider working with a therapist who specializes in narcissistic abuse recovery.
Georgia residents: To work with Pamela, visit her website https://seachangepsychotherapy.com
This blog post is based on an interview with Pamela Madsen, MS, LPC, on The Chronic Illness Therapist Podcast. For more resources on navigating healthcare challenges, subscribe to our newsletter and follow us on social media.
Disclaimer: Everything we discuss here is just meant to be general education and information. It's not intended as personal mental health or medical advice. If you have any questions related to your unique circumstances, please contact a licensed therapist or medical professional in your state of residence.
Want to listen to the podcast interview? Listen to Pamela’s interview with me, Destiny Davis, on Ep 92: Narcissistic Abuse When It Intersects with Chronic Pain - Insights from Pamela Madsen
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Episode transcribed with AI and will contain errors that are not representative of the actual word or meaning of the sentence.
Pamela Madsen, MS, LPC, 200-RYT
Destiny Davis LPC CRC: [00:00:00] Just a reminder that the welcome to the Waiting Room membership is alive and active, and we meet almost every Friday at noon for our general support group and every other Thursday at 2:00 PM both Eastern Standard Time, to discuss the struggles that come along with trying to navigate intimacy while you live with chronic pain conditions, things like ehler's danlos syndrome. And this one is led by Jessica Sullivan Sanchez. She's a sex therapist here in Atlanta, and this isn't therapy, it's just a support group with education and, peer support while Jessica just kind of leads and holds space in the group. So if you have been interested in any of the work that I do, this membership is a really good place to connect more and do this work on a little bit of a more consistent basis and get some kind of direction and support around your chronic illness journey. Sometimes we are in the space of needing support around managing. How much we have to do with our illness, whether that's routines and supplements [00:01:00] and um, diet and exercise and medical appointments and all of those things that come along with it while also trying to have healthy relationships and manage the social responsibility that comes along with being in relationships.
So that is why I created this space. I think that there are a lot of programs out there that kind of. Tout a cure for chronic pain. And this is not one of those programs, um, but you will get a lot of support for managing what you're going through, which in my experience does help mitigate some of the intensity of the pain.
But that takes time. That's an individual journey, and it doesn't happen for everyone. So I always wanna be really honest and clear about that. And I do hope that you'll join the welcome to the Waiting Room membership.
The Chronic Illness Therapist Podcast is meant to be a place where people with chronic illnesses can come to feel, heard, seen, and safe. While listening to mental health therapists and other medical professionals talk about the realities of treating difficult conditions, this might be a new concept for you, one in which you never have to worry about someone inferring that it's [00:02:00] all in your head.
We dive deep into the human side of treating complex medical conditions and help you find professionals that leave you feeling hopeful for the future. I hope you love what you learned here, and please consider leaving a review or sharing this podcast with someone you love. This podcast is meant for educational purposes only.
For specific questions related to your unique circumstances, please contact a licensed medical professional in your state of residence.
Destiny Davis LPC CRC: Pamela Madson is the founder and clinical director of Sea Change Psychotherapy in Atlanta, Georgia. Pamela is a doctoral candidate for graduation with a degree in counselor education and supervision. She specializes in treating couples and adult individuals who are [00:03:00] overachieving professionals, experiencing eating disorders, substance use and anxiety disorders at the intersection of complex traumatic stress.
She specializes in narcissistic abuse and chronic pain as it accompanies PTSD. Pamela is certified in EMDR and is trained in internal family systems, radically open DBTD, BT, and ERP. She served the local eating disorder community as president and continuing. Education chair for the Atlanta Chapter of the International Association of Eating Disorder Professionals.
When I ask Pamela what her biggest pet peeve is about how people with chronic conditions are treated, she said, my biggest pet peeve is around the burden that clients have of constantly having to teach people about their illness and implicit bias of ableism increasing the allostatic load on these clients, and I'm inclined to agree.
So I hope that you enjoyed today's episode on narcissistic abuse and what that looks like when you're living with a chronic illness.
Destiny Davis LPC CRC: Thanks Pamela for being here. Um, [00:04:00] would you tell us a little bit about your practice and who you work with and, um, and what you're doing these days with within therapy?
Pamela Madsen, MS, LPC, 200-RYT: Sure. So I'm Pamela Madson and I'm a licensed professional counselor here in Atlanta. I have a group practice in Buckhead. Um, I'm, I work as the clinical director.
I also provide clinical supervision. Um, I'm finishing my doctorate degree right now and, um, writing my dissertation related to narcissistic abuse. Um, I specialize in, I'm just now really saying it out loud, but it's narcissistic abuse, um, the adult children who've experienced it. So I see adults, individuals, and couples, um, and they usually have another, um, a complex issue that I like to think of more of as like a.
A coping skill, um, that doesn't really serve them as well as it used to. So that's often like [00:05:00] alcohol use. Um, an eating disorder, OCD, um, and then a lot of my clients also have chronic pain or chronic illness. So I really like working with chronic pain in the context of post post-traumatic stress disorder.
Destiny Davis LPC CRC: Yeah. Yeah. Can you say a little bit more about that? About chronic pain and Yeah. This context of, of complex PTSD?
Pamela Madsen, MS, LPC, 200-RYT: Yeah, absolutely. So, um, but
there are three types of pain. Um, one we're all real familiar with. So that's, I. Nociceptive pain. So if you stub your toe, um, you know, you treat that with ice and rest.
Um, if real physical injury might have surgery, um, that is kind of real classic type of pain. There's, uh, neuro perceptive pain. Um, and so that would be, um, the end, the result of. Um, maybe some kind of damage to the central nervous system. One example of that is like phantom limb. Um, and we treat that often with, um, [00:06:00] SNRIs or TCAs, um, because um, this selective serotonin reuptake inhibitors, um, work on that same type of, um, neural pathway, which is kind of a crossover into our field.
But then no castic pain is a pain that's. That originates in the central nervous system. Um, and those are going to be, um, fibromyalgia, um, IBS migraines. Um, so these are often, you have clients that come in and they've kind of exhausted pain management, um, opportunities. Um, the medications they've been given don't really work.
Um, it's really generalized, not acute. Sharp pain, you know, it's just like kind of more broad, it can move around. Um, ra e is one rheumatoid arthritis. Um, so you have like, it's more of a systemic, um, algorithm [00:07:00] that's set in the brain that creates the pain sensation. And um, we have people who have post traumatic stress disorder develop this for the reason that, um, negative emotions.
Pamela Madsen, MS, LPC, 200-RYT: Um, cause us to experience pain at an amplified rate, whereas positive emotions, um, improve our subjective experience of pain. We've studied it. We've got proof that it has to be emotion re regulated. And then, um, the, the reason posttraumatic stress disorder here is so key. When somebody has PTSD, they're on high alert, very hypervigilant all the time, right?
Um, and they are scanning their environment for danger. Um, you know, like you see somebody goes into a restaurant, they sit with their back to the wall, they wanna be able to see the door, um, so they can observe everything that's going on. Um, then they're much more heightened state of awareness. They're tho those people are [00:08:00] not just scanning the environment, they're also scanning inside of their body.
So, um, they'll. Be hyper aware of any sensation of pain. Now pain is normal. We're actually always taking it on. That's why like someone laying in a bed can develop a bed sore and not realize it was coming, um, because the pain threshold is lower. But what you have happen is when somebody is looking for threat, they're also looking for pain, um, subconsciously, and their perception of pain is heightened because they're looking for the threat of tissue damage as well.
Um, and so that is where these particular disorders tend to come about. Um, so if we treat the post-traumatic stress disorder, um, that scanning for danger around them, scanning internally for danger, there's perception of pain improves. And uh, we've studied it. Did some great studies with internal family systems and rheumatoid arthritis that showed, um, [00:09:00] great improvements, uh, other.
Approaches that I use, um, EMDR and other, um, their CBT for pain. Um, but these clients, they come in and they've tried everything and they get really exhausted with it. So it's great that we could offer 'em that kind of hope.
Destiny Davis LPC CRC: Yeah. Thank you for explaining that also clearly. Um, are there, did you find in, in any of the research and it's, it is okay if you didn't come across this, but were there actual, um.
Inflammation markers that were different or like physical blood markers that we see a difference in after figuring out how to find safety emotionally, even when pain is present.
Pamela Madsen, MS, LPC, 200-RYT: Um. Like as far as clinical studies measuring like physiological changes, um, there is a difference in cortisol levels in the blood, right?
Um, because it is really taxing on the body to be always scanning for risk, you know? [00:10:00] Um, and so we see changes there, uh, physiologically. Um, you're going to see. Sometimes you'll have clients that present with like OCD and um, they will have physiological changes as well, obviously. Um, when someone is less attuned to risk around them, they can provide more self-care, so they might eat more regularly.
There's a lot of factors that play into it. So, you know, if they're, uh, managing stress with an eating disorder, um, managing their nutrition. So their connective tissues and things also get the proper nutrition needed. Um, you're gonna see overall blood chemistry improve.
Destiny Davis LPC CRC: That makes sense. And I always say, um, when people are, sometimes people can get a little bit hung up on, especially on social media, you'll see a lot of, like, this thing cured me.
You know, I was missing, like, I tried everything until this thing worked. And I think my, my theory on that, tell me your thoughts. You can [00:11:00] disagree, agree, whatever. Um, but my theory on that is that. Everything else you were trying had probably likely had some benefit as well. This was kind of like the last missing piece.
So yeah, if you never paid attention to your nutrition, but you were always doing breath work for like the last five years, you've learned to regulate through breath, but you still are malnourished. Then you start to nourish yourself. Then of course the diet worked or if so, you know, and then vice versa.
If you did the perfect diet for five years, but your breathing, you still were always holding your breath or bracing your body a lot, or some of these more like physical coping mechanisms that we unconsciously engage in. So you're, you know, you're doing the perfect diet, but you haven't done that work.
Then the breath work is what worked. What are your thoughts on that?
Pamela Madsen, MS, LPC, 200-RYT: I absolutely agree. Um, and as you were describing that, what I was thinking about is like, you know, early eating disorders, when someone is restricting for just a couple weeks, they're not [00:12:00] really gonna show, um, like vitamin deficiencies.
In fact, like when you restrict, your body uses the glycogen, it stores in the body four times like that, right? Where you can't eat but need to. Um, but it's over time that you might start to see like. Profound deficiencies and osteoporosis, you know, where the body is taking minerals from the bones as a last resort.
Um, and that can't be reversed. So, um, you know, in these cases you might have a sense that, oh, it was, this was the thing that finally cured me. But in reality, what we see is just. Like trauma is really complex. It's like, well, in way the clients that I work with, um, it wasn't just one bad experience one day, one thing that somebody said negative to them, but it was a layering of experiences over time.
And, um, these types of clients have a core belief that they don't deserve good things. So they're typically not taking extra good care of themselves. Um, [00:13:00] physically, maybe they didn't have parents that. Taught them about how to eat regularly. Taught 'em about nutrition. I've heard, you know, maybe they didn't teach them how to bathe themselves.
They had to kind of figure these things out. Um, and so they're gonna have a multifaceted approach to their recovery. Uh, so it might be this vitamin supplement was the missing piece. Um, but they had to do a lot of other things leading up to that too.
Destiny Davis LPC CRC: Thank you for that. And so we are talking about complex trauma today, and with that, um, specifically your research and your, your area of expertise is within narcissistic abuse.
So maybe we can lay the foundation a little bit of how that. Even develops into growing up with somebody who maybe has the full blown narcissistic personality disorder or maybe even just traits, um, that are not, wouldn't be diagnosable, but maybe we can just differentiate between that as well and how that then leads to an adult [00:14:00] who is.
Scared of their body, scared of their world, doesn't know how to trust. You can name other symptoms, I'm sure.
Pamela Madsen, MS, LPC, 200-RYT: Yeah, absolutely. Um, so what we know, um, one of the hallmark traits of, um, narcissism is, um, there tends to be, uh, some antagonistic behavior. Um, and when I think about narcissistic abuse, and always think about like the motivation for those behaviors.
It really comes to like a core belief of, um, if someone loves me, they'll behave and do things in a way that make me look better because they really are focused on the self image. Um, and that's actually kind of a kinder way to think about narcissistic abuse, you know, um, those, they're people. Um, but that is their belief is that's kind of what love is to them.
Um, that. [00:15:00] You'll behave and achieve to make me look good. You won't criticize me. You know? Um, and then there's four types of narcissism. There's, uh, a grandiose narcissism. This is really the classic, um, one that I think a lot of people really think about. That's an inflated sense of self importance. Um, there's a sense of entitlement and a need for admiration.
So you can see like that. Self-image, they're really needing a lot of recognition for being great. Um, there's a covert, um, or vulnerable narcissism, and this is the one that's pretty, that's pretty sneaky. Um, it's hard to label. Um, it's actually hard to suss out clinically. Um, but this particular type is, they appear more sensitive and insecure and they seek validation through victimhood.
Um, and they, and they still exhibit these narcissistic behaviors. You see a lot of, don't hurt me responses. Um, you know, don't, don't criticize me. That hurts me. Um, [00:16:00] so you provide a lot of reassurance to them. Um, there's malignant narcissism. This is the more severe kindness, more antagonizing behaviors. Um, there's a aggression of maybe cruelty and a lack of empathy.
And, um, then communal narcissism. And this one in particular, I think most of us know, and, and like these people, um. They tend to not have their children show up in my office, um, because they're, they're just exceptionally generous and helpful in the community. Um, but the goal not being benevolence, instead of maintaining a, a very positive, grandiose self image, right?
Um, but they, they're able to, to channel that into a way that does good things for others. Um, and so those are the four kinds. Um, and then how those affect. Their children, um, can, can look a little different.
Destiny Davis LPC CRC: Would you like to [00:17:00] explore or would you like to kind of share how each of those types might affect, might affect a child?
Like just one example. Not like some, you know, it doesn't have to be definitive, but an example how that could
Pamela Madsen, MS, LPC, 200-RYT: look. Yeah, sure. So like a communal narcissism is probably an easy one to start with. Their parents would be like great benefactors, you know, in the community. Um, but maybe to a point where their own personal needs for their children aren't being met.
Um, funds may be reallocated in other places, or the child may just not be prioritized, like parent not going to their fifth grade graduation because, um, they had, uh, an event they were being honored at. For something like that, or having to attend an awful lot of, um, like galas and things with your family instead of being allowed to make time and plans with friends.
So that's, um, inconvenient a lot of times and, and can be difficult for the child, but, um, more, more easily [00:18:00] recoverable with some resiliency. Okay. Um, the malignant narcissism. This is going to be, again, that's more aggressive cruelty and lack of empathy. Um, these children may become like quite scared. Um, that's coming really close toward antisocial behavior.
Um, this one tends to pick up more attention from teachers and, and social help. Um, so there might be some intervention in the home. Um. So those children actually might get more support and help, um, than some of the other types, which can help. Um, but they might experience like physical abuse and things, um, the vulnerable narcissism, like, and then this is the really sneaky one.
So you've got. A family system built around where one parent's needs become the center of the [00:19:00] focus and the children experience role reversals and are recruited to take care of the parent. Um, so you often see like maybe medical neglect of the children because the children having. Strep throat becomes too taxing upon the mother who becomes overwhelmed by anyone else's needs, and they may even experience the needs of the children as an affront to them.
Um, and then this one is particularly difficult because the narcissistic parent actually appears to be really good. Um, there. More sensitive so they're able to experience cognitive empathy so they can say empathic things and outside of the family it might appear to be like this ideal family. Um, but on the inside, in the home, um, it's a very different situation.
And so you have, um. [00:20:00] Social gaslighting in effect, like where you'll have people maybe in the church around them telling them how great their parents are. Um, your parents are like Warden Jim Cleaver, you're so lucky. Um, the child is the one taking care of the parents' feelings instead. And then, uh, so the grandiose narcissism, that's real typical again, um, the child might be.
Required to achieve greatly be the best at sports, um, have to attain specific grades, um, because the parent sees the child as an extension of themselves. And so if the child is ever struggling, um, instead of being met with compassion, empathy, and like. Creative supports. So like tutoring the child might be yelled at instead and told, uh, you need to hit the books, work harder, you're grounded.
Um, instead of asking like intelligent questions to help understand what the issue holding them back from achievement is, that kind of thing. [00:21:00]
Destiny Davis LPC CRC: Does that make sense? Yeah, absolutely. I was wondering too, um, about more verbal abuse. 'cause in malignant, you'd mentioned maybe this was where you might see some more physical abuse.
Um. The verbal abuse that I would imagine it's probably in all four. It just looks different with each one.
Pamela Madsen, MS, LPC, 200-RYT: Yeah, it, it will. So like, um, the be the underlying message typically is, um, you're not good enough. And that keeps the child pursuing, um, taking care of the parent, always achieving, reflecting well on the parent.
You sometimes hear, um, maybe a little visitor here, you sometimes hear, um. This pervasive message, uh, from these clients that, um, they felt like they bring shame to the family. They'll often, um, hear statements like, we handle our problems here inside of the family. We don't [00:22:00] talk about our problems outside of the family.
Um, there's these types of family rules that show up in these family systems.
Destiny Davis LPC CRC: Yeah. Can we contrast that maybe with what a more, um, functional family looks like? What might it sound like when you're not experiencing this? And I don't, maybe functional is not the best word.
Pamela Madsen, MS, LPC, 200-RYT: Sure. Um, well, we can give a real classic example, right?
So you've got the child that, um, maybe isn't doing really great in a particular subject like math. Um. A narcissistic parent might feel like the child's additional needs are on a front, become angry. Um, tell them that they'll never get into any kind of a good college. Um, they'll be flipping burgers or pumping gas.
This is really like old school talk, right? Um, and instead what we might find to be more beneficial [00:23:00] to a child would be the parent to say, assume good of their child first, right? That they're trying. 'cause children are a work in progress. We're always a masterpiece in the making, you know? And, um, to ask the child, tell me about what goes on in the, in the classroom.
Is it difficult to concentrate? Can you see the board from where you sit? You know, so you're looking for, like, we wanna first always exclude, like, are there medical issues going on? Do we need glasses? Um, is there someone in the class that's bullying this child? Is it just before lunch and they're not getting to eat so their blood sugar's low.
You know, you wanna assume well of your child and start to suss out like, what are other issues? Because children typically aren't trying to not do good in school, especially one that's afraid of disappointing their parent, right? So, um, you might determine that your child needs additional educational supports.
So, um, setting up a tutor to help with math, um, or a quiet study space. That's [00:24:00] usually the most typical approach to these kind of problems.
Destiny Davis LPC CRC: Yeah, that makes sense. So moving into how this affects us long term, maybe we describe and, and define complex. I know C-P-T-S-D is not technically in the DSM, but how do we describe it?
How do we work with it, um, clinically, what do you think, what are you looking for when you're thinking about C-P-T-S-D within clients?
Pamela Madsen, MS, LPC, 200-RYT: Well, most of my clients are overachievers. Um, so they have those parents that they were always trying to make look good, right? Um, and they don't know it because they tend to have like a vulnerable, narcissistic parent, um, or like the, the grandiose classic approach, um, to narcissism because they come into the office and they're like.
I feel like I don't belong. They're a C-suite executive. Um, or they're using alcohol. They, they're wanting to reduce that. Um, [00:25:00] they have a partner that's complaining about how much they drink. These are the things they come in and talk about, and they start to listen to the way they describe their family.
So one of the, one of the questions I always ask early on is, what was it like growing up in your family? And I often hear. We are a really great close, tight-knit family. Um, it was great. My parents are still married, um, and they'll describe like kind of a, a framework, white picket fence, childhood. Um, and then I might follow up later.
I'll like, well use three words to describe your mom in three years to describe your dad. And like, um, that's when the narrative really shifts. You can see their face. They try to put words by mom. She's really controlling, like that didn't really sound like close and tight knit. Um, that's become like really key words to me when I hear that.
I'm like, tell me more about how close, what does close feel like to you? Um, close became more enmeshed over [00:26:00] involved and controlled versus emotionally attuned and safe. So that is the. The truth that my clients were taught is the close is always involved. Um, you may, they're in contact multiple times a day.
They, if their parent calls and they don't answer, they start to feel like they're gonna be angry at them for not responding right away. Um, it's this internal message of, I'm not enough, or I need to do more to keep this person happy. Or in the neutral zone, not angry with me, that, that they most often complain about and they won't have any idea about, um, their relationship with themself being impaired until we start to take these beliefs apart,
Destiny Davis LPC CRC: which is why people think that.
Therapy like causes the problem because you go to therapy and you start to, [00:27:00] you might feel a little worse when you, when you open this up and you realize that this is happening. Um,
Pamela Madsen, MS, LPC, 200-RYT: yeah. Yeah. There's a, a period of grief, um, when you come into awareness that you had experienced like narcissistic abuse or emotional abuse.
Um, and then also sometimes when people feel relieved to know, oh, it's not 'cause I'm all bad or I'm of perpetual failure. Um, but there usually is some grief that they didn't have the childhood that they were taught. The narrative was like, that was the mantra of the family. Um, but then when they realized they actually didn't have that, that it's, it's sad.
It's really heartbreaking. That's a, a loss that can take a long time to process, but it's also like a new identity for them.
Destiny Davis LPC CRC: Yeah. Um, let's bring this a little bit into the experience of, of chronic pain [00:28:00] and chronic illness. Um, because I think one of the tricky parts of, of the conversation with like trauma and chronic pain and illness is whether the trauma causes the chronic pain or whether it was maybe there before.
And then that. You know, the illness contributed to the trauma, or there's so many, I think there's so many directions from which it can start. It's a little bit of a chicken or an egg, I think. Um, what is, do you tend to, to see kind of one presentation of that and, and your framework in your mind as from one presentation?
Or are you always looking at it from these multiple angles as well?
Pamela Madsen, MS, LPC, 200-RYT: It's like. In my mind as my clients are talking and you know, in the session they'll start just, they'll talk for like 45 minutes and they're always apologizing after that. Like, oh, I'm just rambling. But what, what they don't know is, in my mind I'm making this map.
I'm drawing everything out. Um. Every piece they give me, I put [00:29:00] somewhere I'm categorizing it to see what is the system that created, um, what they're coming in to, to work and improve on. Um, always with the belief that my client, um, is striving for wellness. 'cause they're, they're, well, they're just struggling.
Whatever the, the goals are, they, they want good for themselves and, and a peaceful life most of the time. And to feel loved in a sense of belonging. That's what we all want, right? So. There can, there's typically, um, some epigenetics involved. You know, if you've got, um, someone who is experiencing narcissistic abuse in early childhood, um, there's gonna be some trauma if it's mom more often passed on to the child in mitochondrial, DNA.
Um, so you're gonna have some, and that's a utero, so you're gonna have some. Early predisposition to trauma. Um, if it's the parent and the mother is [00:30:00] experiencing narcissistic abuse from like the father, um, while the baby's in utero, mom's ex experiencing more cortisol in the blood that can affect the baby, um, and the development.
And so genetics can change based on these, these contextual factors going on. Um, and then once the child is born. That kind of stress on an infant in utero is going to, there are going to be some kind of changes to like connective tissue and things like that. Science is still coming to understand that.
Um, but you can see like all of the, the data and studies that we're doing now are starting to point right towards proof. Like what we, what we are have a theory about happening. It's becoming to be clear and supported by, um. Quantitative research, which is really exciting to see.
Destiny Davis LPC CRC: It is. It is. I think it's also a little bit scary 'cause there's so much not within your control.
What, um, that's where my [00:31:00] brain goes with all of this. So, um, I, I, I do, I agree. It's, it, it is exciting. Um, but I also think there's a lot of people right now who are using this research in a way that's like, so therefore by my like, nervous system healing program and you'll be healed. And so maybe we can just talk a little bit about like epigenetics, what it means.
Um. Be like what it means to maybe have been in utero with a parent who was constantly stressed and then if they were constantly stressed in pregnancy, chances are it didn't just stop when you were born. You know, that continued to to go on throughout your life. So, which leads us still, this is within the context of complex PTSD because it's.
Complex PTSD is, it's all of these experiences layered on top of each other and melding in with each other, which is, and I am like you with clients in session. It's like my brain is mapping every, like when actually when clients apologize for talking, sometimes it even throws [00:32:00] me off a little. 'cause I'm mapping what they're saying and then I have to like come out of that map and be like, wait, no, it's okay.
Please keep talking. Um, but yeah, like. So, yeah, it, it's complex and that, and that's different than just trying to heal from trauma. Can you speak to that healing piece for a moment?
Pamela Madsen, MS, LPC, 200-RYT: Yeah. Well, I wanted to like point out something. Some of the, the apologizing, they often come in apologizing from the get go.
Oh, I'm sorry. I, I'm sorry. I was really, I'm sorry I was late. And that is really a, a behavior that's typical of someone who's experienced narcissistic abuse. They're always apologizing for themselves for things because the hour with us, that's their hour. How, if they wanted to color for the whole hour, it's theirs.
Um, we're gonna try to make it therapeutic, but if that's what they need in that hour, we're gonna do it. Um, but yeah, so I'm always fascinated by the, like, over apologizing. Um, but going back to, um, the epigenetics. Yeah. Abuse doesn't stop once the child is born. Um, and we see a lot of, uh, the proof here about [00:33:00] that is.
Um, you know, children that are born and given up for adoption or in foster care, um, you know, they are going to, it's not an ideal situation to be moved into foster care. Um, but those children have disproportionately a lot of, um, like atypical, um, neurological presentations later. Um, so we can see the patterns.
It's there in the, in the data. Um, but a child that is experiencing an infusion of cortisol in utero and then is also going to even as like a newborn, that's like sleeping a lot, right? All about being a newborn is co-regulation with your parent. So if you have a parent mom who is taking on abuse, emotional abuse from an abusive partner, baby resting on her chest is going to.
Since the [00:34:00] tensioning in her nervous system hear her heart rates increase, um, even dad. So if mom is, um, emotionally abusive toward dad, um, there's like high conflict in the house, um, our nervous system is gonna give that away to the infant. And that's setting the algorithm for, um, that nervous system regulation that infant is gonna carry forward.
What do we see when we have a child whose nervous system is dysregulated? We see like impulsivity. Um, so a 2-year-old might be acting out and a narcissistic parent will see that as my child is misbehaving and it's reflecting badly on me, and they respond with anger instead of my child needs a nap, um, or a snack, or, let me hold them and help them feel my calm so that we can, um, move through this tough moment.
This just how it starts out real small. You can see that that belief, that one belief that you do. You exist to reflect well on me. It doesn't really work out well if you have a 2-year-old.
Destiny Davis LPC CRC: [00:35:00] Yeah. If someone is listening to this and they actually recognize some of the, like some of that behavior in themselves as the caregiver, what, um, what are some of the things that they could even start to do now that will help?
Maybe move for themselves, but more, I'm a parent, so I always think like. I was gonna say, more importantly, the child because my mom brain is like, my kids are the most important thing in my life. But, um, yeah. So I was gonna say, more importantly, for the child, it's important for both people, but I also think you have such a chance with young children to rewire them at such a young age if you're doing this work.
And so it might take a lot longer for the parent to kind of get to this place of feeling healed. I think you can help your child like way before you feel healed. Is that, can you speak to that?
Pamela Madsen, MS, LPC, 200-RYT: Yeah, absolutely. Because I hear this a lot, um, where clients are worried that they're going to transfer these things maybe they experienced onto their [00:36:00] kids.
Um, and the truth is, like in a restaurant, if our kid is. Having a tantrum, we, we are concerned about disrupting people around us. Right? Um, and so this is a spectrum of behavior and that is in like a normal range. Um, if, if it's not pervasive in all the time, but if you're noticing it's going on a lot, I.
The fact that you have this awareness really speaks to a strength you have. Um, and we can work with that strength. It doesn't mean that you're narcissistic, like on a pathological level. We all have narcissistic traits. They're healthy. Um, but that. Kind of clues a sin that you were taught that the job of a child is to reflect well on the parent, and that might have been what you were taught as a child and you wanna adopt a different role in your family going forward.
Um, if you're always worried about how other people are perceiving you, um, you're not really attuned to like your relationship with your child actually. [00:37:00] And. You know, if a child is getting really fidgety instead of getting angry at them, 'cause they won't sit still in church, it might be fun to color together while you sit there or help them look through, um, uh, a magazine or a book, um, that they can touch and feel so that you can attend to both, um, so situations at once.
Does that make sense?
Destiny Davis LPC CRC: Yeah. What I'm hearing is going back to that scanning the environment that we talked about earlier, instead of scanning the environment, which you do when you're feeling unsafe because. Evolutionarily, like if you feel unsafe, you are looking around to see where the danger is coming from.
And so when your child is acting out in public or sitting at church or you know, one of these spaces where children are supposed to be quiet, um, and it's really not appropriate for them, but that's what everyone expects around us. Your scanning the environment to see what people are thinking and feeling.
But if you. Just redirect your attention to your child. One, what I'm hearing is that that requires you to be aware [00:38:00] of the fact that, yes, I feel this is dangerous, but I'm choosing actively to stop scanning the environment and to just maybe scan my child and be with my child. Um, and so that is an active but really difficult choice to do when your nervous system is screaming that there are fire alarms like everywhere.
Pamela Madsen, MS, LPC, 200-RYT: Yes. And that comes from what we're scanning for is criticism, who's criticizing me? Who's judging me.
Destiny Davis LPC CRC: Yeah.
Pamela Madsen, MS, LPC, 200-RYT: Yeah. And that is truly the hallmark of narcissistic abuse is the be to be ready for criticism instead of curiosity. Yeah. Yeah.
Destiny Davis LPC CRC: I wonder too if, um, yeah, there's so many, there's so many. My mind is going into so many, many places.
There's many questions about this. Um. Because it is such a nuanced, like a layered, complex experience. It's so forever. Who, for whoever is listening to, I [00:39:00] think it's important to just note like. We might say something that, that hits a, a nerve or, or makes you think something or feel something or, or remember something.
And we do really encourage you to talk to a therapist about who really understands narcissistic abuse in order to get a better picture. Because the one thing that we say that that kind of hits you may hit you in a way that. We intended or didn't intend. And so it's just important to work with somebody who knows you and you in your specific circumstances.
I always have a disclaimer on these podcasts, but sometimes I think the middle of a podcast deserves an extra one. This is, this is a very hot topic, so, and, and, um, hard topic. So it's important.
Pamela Madsen, MS, LPC, 200-RYT: Yeah, it really is. Um,
you never know what might be triggering for someone that has this. Level of developmental trauma. Um, but we always try to meet it really compassionately. That's really the only way we can work effectively with it in our roles. Know.
Destiny Davis LPC CRC: Yeah. Yeah. And [00:40:00] compassion doesn't mean condoning, right? It's just looking at the problem with an understanding, an accurate understanding of why what's happening is happening and then figuring out what to do with it.
Right? Like I think I actually. I even remember. So in my somatic experiencing training, this was something that came up over and over again. Um, in se training, they're very big on which I. There's a lot, there's a lot about that. But they, they are very big on like, not criticizing, like in your role play when you're practicing, they're very big on not criticizing and only saying kind of what you did right in order to kind of learn and do more of what's right.
Um, and people really struggled with that. Like people, there were people that would get mad. I remember one person in particular who would, who got pretty upset because they were like, I think they felt gaslit in the moment, to be honest.
Pamela Madsen, MS, LPC, 200-RYT: Um, yes, you're right. That is, you said that people really struggle with not just noticing what they feel like they're failing at or doing wrong. Um, [00:41:00] and oh my gosh, that's just really, um, some training for a way to think about ourselves.
We probably picked up early on from some early relationship. Right. Um, and, and that's really how can I keep people from noticing that I'm not perfect. And it protect. That's a self-protective behavior. Um, but it also, when we're busy like protecting ourselves, um, from threat, it's really difficult to learn.
So like when you're learning somatic experiencing, or for me internal family systems, um, you have to find a way to give yourself permission to be a work in progress. That and to trust, like, I will learn this skill. Um, I'm just getting better at it. That way we don't have to scan for thread all the time.
There's so much work to that. Like when I think about the amount of energy we spend, um, looking for risk around us, if we have like a history of emotional abuse, it's exhausting. [00:42:00] Yes. I.
Destiny Davis LPC CRC: Yeah. And it's also exhausting to try to retrain yourself not to look for that risk, um, because it is such an automatic behavior that you don't even realize you're engaging in.
And so when you're actively trying to like rewire that it's, it feels really difficult and really unsafe, and that's exhausting to try to constantly remind yourself to kind of come back inward or come back centered. Um, and with chronic pain too, there was something. You said around, um, I think just always like needing that perfect response or maybe the perfect, like, and you wanna know exactly what's wrong.
Like why am I feeling this pain here or that pain there, or what is your working model with chronic pain? Is it around, do you work specifically with like pain? Um, meaning we are actually looking at or feeling what you're feeling or. Or do you kind of always bring it back into the emotional, like [00:43:00] the psycho-emotional lens?
Pamela Madsen, MS, LPC, 200-RYT: Um, I do work specifically with pain. Um, I provide a lot of psychoeducation about, um, that no CPL pain and what is the core issue around it. But a lot of this is changing our relationship with pain. Um, and like the current definition for pain is the. Perception, the subjective perception of risk of tissue damage.
That doesn't necessarily mean there is tissue damage, it's just the perception of risk of it. Sometimes there is tissue damage, right? But there are also those of us that like when we get like our blood drawn, we don't even feel pain from the needle stick. Other people will pass out. You know, like they have a real strong emotional response to that.
Um, and. I'm pretty scientific if you haven't noticed. Um, so I use a lot of, uh, and my [00:44:00] clients tend to be, uh, overachievers themselves. They like to hear about, like the studies and things. It helps them feel safe enough to buy into care with me and, um, they begin to trust me that. And that's important, right?
I can stop being on guard because she's got it under control. She won't hurt me. She knows what she's doing. Um, so that they don't have to guard themselves. And then we really work on the emotional work. Um, I really like to just focus on the trauma piece, um, and then, um, help them find adjunctive self-care.
I like, I work often with consult with dieticians and, um. Uh, like PCPs or specialists, depending on what they're specifically needing because it is a holistic approach to the whole body care.
Destiny Davis LPC CRC: Yeah, absolutely. Um, What else comes to mind about narcissistic abuse and how that plays into life with a chronic illness or chronic [00:45:00] pain?
Pamela Madsen, MS, LPC, 200-RYT: One of the key pieces, um, that can be kind of a reinforcement for having these chronic issues, um, is that less can be expected of them, right? So if you have a family where there's. Three children and one has a chronic, like usually more of this shows up in adolescents than really young children. Um, and even adults, you know, if a child has chronic pain, they probably experienced obviously this then emotional abuse.
But often that can create resentment between the siblings, um, which is one of the constructs of narcissistic family systems. That nobody can be close, the siblings turn against each other. The parents really feel that. Um, and that can be one of the ways that a parent instigates that, you know, you need to do this for your brother 'cause he [00:46:00] says he is hurting.
Um, you know, he says he is too tired. Um, that being more of a criticism and used as a weapon. Um, and so the, when you have a chronic pain. Condition coming into adulthood, you might see yourself as more burden. Um, and that's just heartbreaking to hear, you know? Um, it's so common that, um, they weren't able to do enough for their parents and that can have 'em over-function in other ways too.
Like I've seen clients that come in. Who aren't able to do more physically for their parents. So they give them a lot of financial support or are constantly taking 'em to lunch or sending them flowers and things. Um, just trying to contribute in the ways they can to their parents' happiness that they could.
And that's such a role reversal.
Destiny Davis LPC CRC: Yeah. Yeah. The complexity there I think is how do we know when. If we're thinking [00:47:00] more to more functional families now, I do think there's the, there is a proper time and place for role reversal as our parents age, but I think that's really tricky. When you grew up in a dysfunctional family, how do you conceptualize that?
What, what thoughts do you have about that?
Pamela Madsen, MS, LPC, 200-RYT: Well, even by the time that they have, um, come to adulthood, they're exhausted from taking care of someone else and then feel a lot of anger and sometimes this is really the first. Time they come into therapies, they don't understand why they're feeling so angry at their parent who has cancer now and they're in their seventies.
Um, and now they are, we would, I, uh, I think they feel social responsibility and this is within their personal integrity that they should, it's what they say care for their, their aging parents. And I think a lot of us feel that way. Um, and, but they also feel this disproportional burden, like no one's ever done this for me.
They like left me at home alone with the flu for an entire [00:48:00] week, um, when I was eight or something like that. You know, like you might hear these kind of explanations of like, this isn't just, no one's ever cared for me. I've got children I'm taking care of. And now my parents, um, in the work, they're in therapy I do with those clients is it's important for them to live within their values.
We have to help them determine like, okay, what part of this is your values and which parts of these are driven by guilt and shame? So it might be, I take my mom to her chemotherapy, but I also don't spend all weekend with her just sitting with her or, um, you know, I arrange transportation for her. Um. If it's, I truly cannot do it all, um, I share some of this with my siblings.
Um, maybe they get snow at their parents' house instead of shoveling it themselves. They might say, I feel like I'm supposed to help with this, but I don't wanna be in proximity, [00:49:00] so I'll pay a snow removal service. Um, because that's what my values tell me to do. Um, but often the message from the parent is like, oh, you're just so busy.
You don't have any time for me. Um, and that. Compels them to do more. Just really sorting through that, what is the message I'm getting from my parents versus what I need to do to be in integrity with myself.
Destiny Davis LPC CRC: Yeah. Perfectly said. Yeah. It's, it sometimes can take a while to get to that, to clarify values and understand the difference between guilt and shame versus what's important to me and, and leading from a place of, yeah.
What, how I want to live rather than how I don't want to live. Um, it can take a while to get there.
Pamela Madsen, MS, LPC, 200-RYT: Yeah. And that, that's often communicated with like, um, uh, so and so's son, uh, always comes and takes him to lunch on Saturdays. And that really speaks to the taught value that children are expected to behave in a way that makes their parents look [00:50:00] good.
Um, whereas maybe so and so's um, mother is a lot more pleasant to eat lunch with.
Destiny Davis LPC CRC: Yeah. Or they've got them wrapped in, in the guilt too, and they haven't, that son hasn't done their work yet to untangle from that. Yeah.
Pamela Madsen, MS, LPC, 200-RYT: Yeah. Could be either one, we don't know. But it doesn't become, um, that adult's son's responsibility to always take his mom to lunch on Saturdays.
Destiny Davis LPC CRC: Last thing here, um, can we talk a little bit more specifically about maybe the sciencey part of how. How, in my mind, conceptually, visually, I see complex PTSD and chronic illness as the same. And whether that's C-P-T-S-D 'cause you had a narcissistic parent or for some other reason, there are other reasons.
One can have C-P-T-S-D, but that's narcissistic abuse is just what we were talking about today. But, um, I conceptualize the two, like [00:51:00] I'm very visual and so for me it's just. It is just watching like a ping pong in the body and the mind kind of all just doing the same thing. Can we just, how do you kind of then put that into a more science-based phrase framework?
Pamela Madsen, MS, LPC, 200-RYT: Well, you're really testing me today. The truth is, we have not fully determined that scientifically. Um, there is. But it's been a real focus of research in the past years, uh, past five years. Um, but how I would conceptualize it is, um, we have internal and external factors that will affect, um, our physiological system on the inside.
What we know is the brain neurotransmitters work on an algorithm that gets set by those factors. Um, and so if we're al always, if we're taught consistently that we're not good enough, [00:52:00] just hearing that over and over again would make you feel depressed. Right? Are you like helpless, hopeless? All of those feelings, um, drowning.
If you feel that way, you're gonna actually experience depression and the algorithm in the brain is gonna be set Those neurotransmitters. To this lower setting. So most of these clients have a low level depression to a point where their greatest hope is to feel safe. They can't even imagine joy and happiness.
Like that's not, that's like a figment to them of their imagination or like something meant for other people. Their greatest hope is to feel safe. Um, and that's just neutral really. Right? So they always have this low level. Low, like a sense of self, they're gonna feel physically kind of low. Um, and then the physiological expression within the body is also going to mirror those same emotions, right?
[00:53:00] Because the chemicals in the body are being expressed in response to those emotions. That makes sense. Yeah. Coming soon with more research. I think it's gonna be so exciting.
Destiny Davis LPC CRC: Yeah. Yeah, absolutely. Um, remind me, are you are doing research right now or you already finished your research?
Pamela Madsen, MS, LPC, 200-RYT: I actually have two things I'm working on right now.
I'm writing my dissertation, um, and fixing two. Um, it's actually gonna be a study on, um, mental health professionals who have experienced narcissistic abuse by a parent. And the implications that it have in their clinical practice. So, um, I'm doing that, but also I have written an assessment for scaling the severity of narcissistic abuse that I'm doing a Delphi study on to get it substantiated so we can use it clinically.
Um, yes, I know. It is so, so fun to have kind of [00:54:00] tools.
Destiny Davis LPC CRC: Yes, because really the whole time we were talking too, and I couldn't put the question into words, was like. It is about severity and about, you know, you mentioned very briefly too, we all might have some nar, we all have some narcissistic traits that are healthy, right?
And then it's this level, the severity. Is that what your scale is gonna be looking at?
Pamela Madsen, MS, LPC, 200-RYT: Yeah, the severity of it. Um, and you know, I've have had people look at it and I've had some, a couple people take it, clinicians, um, that were really curious about. I said, you know, this is not. Evidence-based and they're really shocked by the severity level that they end up at.
Um, because again, these are over-functioning people like really overachievers a lot of the time who they're like, I didn't realize that it was, this was affecting me as much as it is.
Destiny Davis LPC CRC: Yeah.
Pamela Madsen, MS, LPC, 200-RYT: This is so,
Destiny Davis LPC CRC: oh no, it's really cool. Oh, science. Yeah. Well, thank you for doing that work. And is there anything else that you wanna leave people with today about this topic?
Pamela Madsen, MS, LPC, 200-RYT: [00:55:00] Yes, I. The, the key to healing this is really about repairing the relationship with the self because this, people who experience this, they're taught their role and their purpose is for the benefit of others. Um, and we do some of that I think socially. Um, but we have to take care of ourselves first and that you deserve good and good care, um, to be work in progress.
And working on your relationship with yourself, no matter if you have a strong sense of self and a strong identity and a belief that you're good enough, when someone gives you a message that doesn't not align with, that, you won't internalize it or you'll be able to accept it as maybe contextual feedback in that moment, but not tied to your identity or worth.
Um, and so really focusing on that is. So that's what the work is in therapy, but it's actually the root of the healing. [00:56:00] Yeah. Well, thank you so much. Um, thanks for, this was fun. Good, good. I'm glad.
Listen to Pamela’s interview with me, Destiny Davis, on Ep 92: Narcissistic Abuse When It Intersects with Chronic Pain - Insights from Pamela Madsen
Pamela Madsen, MS, LPC, is the founder and clinical director of Sea Change Psychotherapy in Atlanta, specializing in relational trauma, narcissistic abuse, and chronic pain conditions. With advanced training in EMDR, Internal Family Systems, and other evidence-based therapies, she works primarily with high-achieving adults who struggle with self-image and relationship challenges. Currently completing her doctorate with research focused on narcissistic abuse, Pamela brings both clinical expertise and academic rigor to understanding the complex connections between childhood trauma and adult health outcomes.
Meet Destiny - The host of The Chronic Illness Therapist Podcast and a licensed mental health therapist in the states of Georgia and Florida. Destiny offers traditional 50-minute therapy sessions as well as therapy intensives and monthly online workshops for the chronic illness community.
Destiny Davis, LPC CRC, is solely responsible for the content of this article. The views expressed herein may or may not necessarily reflect the opinions of Pamela Madesn.