If given even a normal measure of reinforcement, most narcissists find an adequate foundation for their exaggerated self-image, allowing them to function somewhat successfully in society. Most are convinced they can get along well on their own, and their pride causes them to reject the defective role of patient. Chase is an exceptional circumstance, then, because narcissists rarely present voluntarily for therapy. Those who do search only for the "best doctor," someone of special status who might understand them. Anyone else is devalued. Either way, narcissists who seek therapy do so with the purpose of finding some relief from nagging feelings of emptiness and inefficacy, to be buoyed back to their former grandiose state, that is, to perfect the self, not to understand it (McWilliams, 1994).
The therapist has different goals. As this becomes apparent, narcissists may resist diagnostic testing or perhaps attempt to debunk the therapist's credentials. They may assume from the beginning that the therapist, whom they personally chose, will simply agree that all their problems are caused by the limitations of others. As the real purpose of therapy sinks in, they are likely to maintain a well-measured distance from the therapist, resist invitations of personal exploration, and become indignant over any comment that implies deficiency. As a result, some struggle for dominance and seek to triumph over their therapist in a war of interpretation: Who can see more deeply into whom? Others just quit outright and do not return. A history of narcissistic rage probably portends a poor outcome; evidence of some genuine concern for others is probably a good sign.
The nature of most therapeutic relationships, paradoxically, is the most significant difficulty in treating a narcissistic personality. Most therapists are accustomed to providing their patients with warm support and encouragement. The more narcissistic the subject, the more likely he or she is to respond to this staple of treatment. Admiration from a supportive therapist provides a warm womb in which the narcissist can successfully stretch his or her wings. And therein lies the problem. If the therapist is too supportive, narcissists may emerge suddenly from their cocoon of self-doubt and abruptly quit therapy. Perhaps other people can't handle their problems, but the narcissist can. Alternatively, they may continue indefinitely, glowing in the reinforcement the therapist supplies, thus perpetuating the very essence of the disorder. Worse, if the therapist is also somewhat narcissistic, the two may form a covert mutual admiration society, commenting on each other's enlightened intelligence and wit, while bemoaning the plight of other poor souls who form the remaining mass of humanity. When this occurs, change becomes impossible.
Interpretation, much less confrontation of their behaviors, often proves just as problematic. First, any interpretation implies that the therapist believes that an interpretation should be made, which implies that the narcissist has overlooked something important or needs to be educated in reality. Second, by attempting to make any interpretation at all, the therapist presumes to understand the narcissist, whose problems are unique and who is too sophisticated for ordinary mortals anyway. Thus, some narcissists quit therapy because they are hypersensitive, secretly fearful that their vulnerabilities will be laid open with each session; others quit because their superior attitude has been insulted.
Alternatively, they may continue but question and devalue the expertise of the therapist, who has now joined the ranks of the commoners (i.e., their critics). Such arrogance is both self-protective and interpersonally aggressive, either silencing the therapist through intimidation or shaping the behavior of the therapist to conform to the narcissist's version of therapy: "I talk, you listen and bask in my glow, admire me, and provide compliments. Anything less is not only aversive, but unrealistic." Or, because they assume others should anticipate their needs, an attempt at interpretation may itself be interpreted as a competitive struggle for control, whatever its content. In response, narcissists may become disapproving, angry, or even rageful. Given their obvious resistances, therapists must be very careful to consider their own countertransference reactions: How do I genuinely feel about this client?
For the same reason that therapy is almost a contradiction, it also walks a fine line. The initial phase of therapy must build a strong working alliance. Confronting maladaptive patterns prematurely will likely lead to termination. On the one hand, enough empathy and attention must be provided to motivate subjects to continue long enough for genuine change to occur. Moderate relief from depressive symptoms can be obtained by reviewing past achievements and allowing narcissists to focus on themselves. On the other hand, if the therapist reinforces subjects too much, they may abruptly reinflate to the point that real motivation to change no longer exists. The narcissist believes that he or she is cured when, in fact, only symptom relief has been obtained; what remains is the underlying personality pathology that drives symptom production in the first place.
From an interpersonal perspective, narcissists must decrease entitlement, envy, and arrogant grandiosity. Benjamin (1996) holds that such persons require gentle, consistent, accurate empathy that reflects their own unpleasant inner experience, while guiding their awareness toward the underlying cause of that experience. Narcissists may consider change if they believe it will produce more favorable responses from others. Determining what elements should be emphasized and validated, however, is crucial. For example, identifying with feelings of arrogance directed at rivals ignores the presence of unconscious envy, thereby enabling the narcissistic pattern.
Instead, Benjamin (1996) suggests the therapist identify individuals in the subject's upbringing who were emotionally centered on the narcissist, connecting their regard to the current situation. If the mother was completely devoted to the client, the therapist might ask, "What would your mother say if she knew your competitor had just been featured in the newspaper?" The idea here is that the subject has failed the mother by failing to become what she treated him or her as: the center of the universe. By increasing awareness of this connection, envy should decrease, if only because the narcissist will not wish to give anyone that much control over his or her own internal world. Benjamin presents another example of a narcissist who becomes enraged at his wife one evening for not greeting him at the door when he arrives from work. If the husband can understand that dinner was burning, he may be able to overcome the vulnerability of requiring her constant attention and admiration.
Many of Benjamin's (1996) suggestions are rooted in the paradoxical approach to therapy, dividing the pathology against itself. By painting grandiosity as a need, it becomes incongruent with a self-image of strength and self-determination. The tendency of the narcissistic personality to externalize blame, according to Benjamin, can be countered by the therapist's taking responsibility for small errors. The narcissist thus sees a status person who is comfortable with his or her own human imperfections, with no need to project blame onto others. The therapist's model allows narcissists an avenue for escape from their early learning history, in which most were unconditionally praised for "perfection" and feel like utter failures if seen as lacking perfection. Other interpersonal strategies may also be effective. Couple and family therapy provide an opportunity for guided negotiation with significant others to help break patterns that support narcissistic behavior, leading to new and more genuinely gratifying interactions.
Interpersonal techniques should be combined with cognitive strategies applied simultaneously toward similar goals. D. Davis (in Beck et al., 1990) suggests that the automatic thoughts of narcissists with depressive symptoms revolve around unfulfilled dreams and expectations, the shortcomings of others, and the uniqueness of their despair, as if the narcissist were the first human being to ever become depressed. She suggests that though long-term treatment goals vary with each subject, they are likely to include "adjustment of the patient's grandiose view of self, limiting cognitive focus on evaluation by others, better management of affective reactions to evaluation, enhancing awareness about the feelings of others, activating more empathic affect, and eliminating exploitive behavior" (p. 248). Grandiosity and fluctuations from all-good to all-bad conceptions of self represent cognitive distortions that should be corrected, creating a more realistic, solid, and integrated self-image.
Likewise, Davis maintains that unrealistic fantasies should be replaced by thoughts about the rewards inherent in more readily obtained accomplishments. Rather than become a rock star, for example, the individual might play in a local band. Such fantasies become realistic rehearsals that desensitize the subject to the possibility of failure while raising self-esteem. Alternative beliefs may be incorporated as functional replacements to maladaptive ones. For example, "One can be human, like everyone else, and still be unique" (quoted in Beck et al., 1990, p. 249). Davis further suggests that rather than elevate themselves above others, narcissists should search for personal similarities. Finding common ground creates the necessary foundation for empathy with others. To further develop empathy, role playing can be used to help narcissists accurately identify the emotions of others and develop beliefs about their significance. Moreover, alternative ways of relating effectively can be suggested, perhaps beginning with something as simple as giving someone a compliment.
Psychodynamic therapy of the narcissistic personality is generally based on the formulation of either Kernberg or Kohut. Kernberg (1984) describes an expressive psychotherapy that tends to be more confrontational, with the goal of helping subjects understand the origin of their conscious and unconscious anger, examining negative transference toward the therapist, and addressing the use of defenses such as splitting, projection, and projective identification. This approach follows the essence of Kern-berg's theory, whereby the grandiose self serves as a defense against the incohesiveness of a borderline level of personality functioning but conceals oral rage directed at early attachment figures. Accordingly, therapy focuses on how the consequences of these early relationships are recaptured in the relationship with the therapist. Presumably, once individuals understand the connection, the way is open for insight into the pathologies of their other relationships as well. In contrast, Kohut's model predicts that grandiose narcissism is a developmental arrest caused by inadequate or defective empathy during infancy. As such, the therapy seeks to recreate early frustrations, with the therapist providing constant empathy and appropriate mirroring, thus helping the subject move beyond the need for the grandiose self.
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