The Case of Blanche Narcissistic Personality Disorder

Blanche E. is a 77-year-old woman who resides in a skilled nursing facility (SNF), where she has been living for the past year and a half. She is dependent on the staff for her full care. At this time, her only independent functions are those involving the use of her hands, with which she still has limited movement. She is cognitively intact, however, and able to use her mind and her verbal skills to reach far beyond the limited confines of her bed. Her sharp tongue has become her weapon, with the effect to slash and cut down those who provide her care. Her family has mostly been spared these attacks, but they have also responded to their own conflicts and struggles with Blanche.

A mental health consultation was requested because the facility had run out of staff who were willing to care for Blanche. The head nurse, in charge of staffing assignments, had exhausted her supply of bargaining chips for her staff. Being assigned the care of Blanche became not worth the value of whatever was being offered in exchange. Absenteeism and actual loss of staff became a major problem on this floor at the facility. An all-staff meeting was called, and chief among the staff complaints was Blanche E. She had managed, despite being nearly bedbound, to shake up a historically solid and well-functioning facility.

Blanche had been raised in an upper-middle-class family where she was the fourth child but first, and only, daughter. She was elevated to princess status at her birth. Her mother raised her to be a miniature replica of herself, and her father unabashedly adored her. Blanche was given everything. She seldom cried or complained as her wishes were anticipated before they were expressed. Blanche reports, "I walked late because my feet never touched the ground. I was always carried around in someone's arms."

Her academic career in a small private girls' day school was unremarkable. Although intelligent, she was never encouraged to work hard at her studies. It was assumed that she would marry well and that her husband would take over from where her father left off in terms of financial care and adoration.

Blanche attended a prestigious private college, achieving admission not on the strength of her application, but rather on the strength of family contacts and the promise of a major donation. Again her academic record was unremarkable, but she graduated with a major in general studies. This major was meant to provide young ladies with a broad basic knowledge of history, literature, and the arts.

In addition, Blanche's college years allowed her to further identify with young women of a high social class; those who descended from fine lineage, which she did not. She came to understand their experiences, their ways of thinking, feeling, and talking about life. Not being the prettiest, fanciest, most intelligent, or athletic—not standing out in any potentially competitive domain—Blanche was acceptable in all. This position made her an ideal dear friend, which Blanche became to many of her classmates.

College graduation ushered in the marriage season, and Blanche was an honored attendant at many weddings. Much of her time was spent shopping for the perfect dress or being fitted to an attendant's gown. Some she liked and others she loathed. But through this process, she became highly knowledgeable about fashion for the fashionable. Attendance and participation at these high society weddings reinforced her keen observations of the structure and meaning of these events to the participants.

Not especially romantic, she did, however, feel a pressure to marry from her family and friends. Her one beau had been a fellow her age from her hometown. He had been smitten by Blanche since their young teens. After college, he landed a job with an insurance company where it was anticipated he would rise in the managerial ranks. On Blanche's 22nd birthday, he proposed to her and she accepted the proposal. Blanche put off looking for a position, as the preparation for her wedding now consumed all of her time, and much of her mother's time. No detail was left unattended and each was considered an important decision. Blanche's recent experience with many weddings allowed her to reflect on what worked well and what did not. She gave far less attention to her marriage beyond the wedding. She expected that there would be little real change in moving from her parents' home to her own; from her father's adoration to her husband's. The rest of life, she assumed, would simply unfold. And it did. It unfolded and also developed; ultimately Blanche would be able to take responsibility for much of how it evolved.

The facts that organized her life for the next many years were the following. Her husband did not rise as far in the company as expected. He came to be regarded as a solid midlevel manager with no special creativity. He continued to adore Blanche; he put her on a pedestal and catered to her every wish. For her part, she was respectful and tolerant of his presence in her life. They had two sons. Blanche was fond of them, but did not care to be responsible for their daily care. The household was thus run by housekeepers and nannies. In time, the boys went off to boarding school and ultimately to prestigious colleges. They are now each married, with children and faring well. One lives nearby, the other out of state.

When the boys were very young, Blanche decided to work outside the home for the first time in her life. She had her fill of club work, and she knew she did not want to stay home and take on more domestic responsibility. She also recognized that she was not being included in the better social events of the society ladies. Although she had the social skills to be included, she did not have the genealogy.

Her career began with work at the Ladies League Thrift Shoppe, where society women came to donate their cast-off clothing. The shop had been started by League volunteers, and the proceeds from sales were donated to charity. College students were the major purchasers of these goods, with the occasional young socialite needing a fabulous gown for a special occasion. The Ladies League hired Blanche as the manager, the shop's only paid employee. She man aged it successfully for 5 years, learning how to run a business and making connections with the patrons. Blanche got to know them well, along with the history of each dress and gown brought in— what was in style, what made them select that gown, how frequently it was worn, and the like.

She began to fantasize and then to think more actively about setting up her own shop, which would carry special-occasion attire for women. She knew that she had the skills and the connections to make a go of it. She shared this idea with some of her most valued patrons, and they encouraged Blanche to go ahead. Blanche became more passionate about this and opened her shop, named Blanche's; it became the love of her life. She was the star and everyone around her sought her advice about clothing, certainly, but also about entertainment ideas, people, places, and things. Her photo often appeared in the Lifestyle or Society section of the newspaper. The name Blanche became synonymous with haute couture and social standing. She was gifted at finding just the right gown to suit the occasion and the wearer. Her patrons used her as their therapist, coach, and confidant. They eagerly awaited her return from the New York and Paris shows semiannually. And they adored her.

Blanche had remarkable energy and retained youthful vigor until her early 70s. Then she started to feel weak and fatigued. At first she attributed this to aging, but in time sought medical attention as she was having increasing difficulty walking. On several occasions she felt that her legs would buckle under her.

After an extensive medical workup by the very best doctors, Blanche was diagnosed with a disease causing multiple spinal tumors. Initially, these were addressed surgically, but inexorably progressive and irreversible cord damage occurred, with corresponding motor impairment. Ultimately, Blanche came to need extensive skilled care and was admitted to the SNF as a permanent resident.

Initially, she was charming and pleasant. Before long, however, she began to be snippy to the aides as they cared for her. She would lean on her call button repeatedly, and chastise the person who responded for being too slow, and for making her wait. If the person explained that he or she was tending to another resident, Blanche would become furious.

She remained fastidious about her nail care, demanding that the manicurist who came to the facility take care of her first and only use a special polish. On one occasion when the manicurist had run out of this particular polish, Blanche flew into a rage, verbally assaulting and terrifying her.

She was equally imperious with the dietary staff. Nothing they served was acceptable. Although the staff made efforts to meet her demands, the SNF food could not measure up to Blanche's discriminating palate.

Blanche's personality disorder had been kept under wraps for most of her life due to many favorable circumstances. However, within the context of the SNF, and without the checks and balances of her gratifying career, her hostile edge became dominant and her charming side had all but disappeared. She constantly berated the aides, admonishing them for their ineptitude and ignorance, being fiercely demeaning. One after another of the aides requested not to be assigned her care, and some flatly refused the assignment.

The initial phase of the consultation included meetings with Blanche to learn her story and to hear her side of the conflict. She was pleased by the consultant's attention. The fact that the staff was so troubled by her situation that they called in a consultant was consistent with her belief that she was a special resident. She expressed a keen, and accurate, awareness that the staff was avoiding her and that she was receiving less actual care than she had received earlier. Her desire for more care and her belief that she was entitled to it allowed the consultant to engage Blanche in a cooperative effort to revive and revise the special care she deserved. She was also able to endorse the fact that interacting with others was very difficult for her. "Take, take, take. I can barely move, so what can I give?"

The challenges of the consultation included how to reduce the hostility felt by the staff so they would be open to a renewed treatment contract with Blanche. To that end, the consultant told them her story, and how she came to be the person she was. They were led to an understanding of just how high she believed she was and what this fall felt like to her. Her imperious behavior was reframed as her way of reestablishing the hierarchy with which she felt most familiar. If Blanche couldn't raise the pedestal, then she would lower the floor.

Another challenge was how to enable the staff to reflect Blanche's specialness so that she would not feel the need to debase them. They were asked what they could authentically admire about Blanche, and they were able to identify her lovely fingernails, certain of her possessions, and her exciting social experiences. It was requested that Blanche ask her family to bring in her publicity scrapbooks of her career, including photos of her at many glamorous events. The staff were encouraged to look through these before beginning a care procedure and during it to talk with Blanche about one of these wonderful occasions. This would allow Blanche to feel that she was giving and not just taking during their necessary interactions.

In long-term care facilities, photographs of the residents representing their preaged, preinfirm life often are affixed to the doors of their rooms. This practice has several purposes, not least among them being that they remind all who enter that the residents, in their current condition, were at another time in a very different condition and a different place in life.

In addition to a photograph of Blanche in a beautiful gown, looking elegant and most special, a large business card was on her door:

Blanche E., Fashion Consultant Social Events Planner "Please Allow Me to Help You While You Help Me"

Blanche would always need much admiration from others, but her grandiosity and lack of interest in the phenomenology often denied her the very attention and mirroring of her specialness that she desperately sought.

The results of this intervention were quite remarkable. The staff, at first cautious and skeptical, but willing to try again, responded to the consultant's request to select a page from the scrap-book and ask Blanche about something in the picture while carrying out the care procedure. Blanche was happy to reminisce, and she offered colorful stories, often in dramatic detail, for at least as long as the procedure lasted. Questions and comments from the staff member followed quite naturally and each became engaged with the other in a real way. Blanche felt validated that her experiences and talents continued to have value. When her caregivers asked her advice about something in their own life, she was able to make appropriate suggestions. In time, Blanche became one of the staff's favorite residents, assuming the special status she had always believed befitted her.

There was a nice secondary gain to this as well. Blanche's family members visited more often and stayed longer during visits. Her narcissistic needs now gratified, her charming self was allowed to reemerge.

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  • iggi
    Does blanche have narcissistic personality disorder?
    2 years ago

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