10. Therapy - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Therapy for any client or constellation of persons (a couple or a couple) can focus on running the client through a prescribed set of interventions and strategies that are assumed to facilitate appropriate change.  However, the assumption that a treatment process or modality has universal fit to the needs of the client can be highly inappropriate and perhaps, counter-productive.  Examination of the etiology or development of problematic processes, difficult characterological traits, insecure attachment, communication patterns, and so forth offers direction to interrupt, alter, and evolve such issues to foster healthier functioning and relationships.  Growth-change therapy should be tuned to disorders or unhealthy processes with their distinct attributes along with shared characteristics.  With regard to narcissism "…interpersonal aspects of this disorder may be prognostic and that developmental factors can have a large impact on producing change.  Ronningstam and colleagues outlined three events during the course of the narcissistic individual's life that might have had an important impact on effecting change in the narcissistic pathology: corrective achievements, corrective disillusionments, and corrective relationships.  Ronningstam and colleagues found that the narcissistic self-concept could be changed if a very valued achievement is attained and reflected upon.  This achievement may be college graduation or professional certification and the resulting establishment of independence.  Once this achievement is realized, there is often a more realistic self-evaluation and the diminished need for unrealistic fantasies and exaggeration of achievements.  The authors highlight how the subject's grandiosity is reworked with failures, disillusionments, or experiencing limitations or achievement"  (Links and Stockwell, 2002, page 523-24).

Some individuals who possessed early indications of narcissism may have had corrective achievements, corrective disillusionments, and corrective relationships that mitigated or interrupted full development of such tendencies.  The first and most obvious set of corrective processes would be experienced in the family-of-origin through the discipline and nurturing responses of the primary caregivers.  This would also be known as effective parenting- probably, authoritative parenting where boundaries were set along while integrating sensitivity to the child's feelings and needs.  The child's self-centered grandiose demands to be the center of the world are modulated with reality checks and balances, along with compassion for his or her distress.  On the other hand, if the primary caregiver response is overwhelmed, distracted, severely flawed, negligent, or corrupt, what should have been corrective achievements, corrective disillusionments, and corrective relationships may have instead been responses that perpetuated the narcissistic tendencies and encouraged development of the disorder.  The child needs to have accomplishments to gain a sense of mastery for healthy development of self-esteem, but not of omnipotence, which would tend toward narcissism.  In order to be endured productively, disappointment must be experienced in supportive contexts.  This happens when disillusionment of ones supreme power is counter-balanced with learning and appreciating the limits and extent of personal power and choice.  Secure attachment creates a safety net for ventures, adventures, and misadventures, while insecure attachment can trigger intensified narcissistic energy.

If the parental attention and support is missing or misattuned, then developmental grandiosity and self-centeredness can drive the child into behaviors that are socially punished.  The child may fail and get rejected in his or her attempts to fulfill needs.  "If these failures or rejections are too harsh, however, serious psychopathology can be activated.  In the narcissistic individual, in this circumstance, there is the risk of concurrent major depression, suicidal behavior or significant substance abuse.  In our clinical work, personal failure has been an important stimulus for change.  The establishment of a meaningful and durable relationship is also acknowledged by Ronningstam and colleagues as a way of correcting pathological narcissism.  The behaviors of self-aggrandizement often are a defensive maneuver, particularly to fend off the existing dependency.  With the establishment of a stable, mature relationship, the narcissistic qualities will be less prominent.  In our clinical experience, this reflects the maturation that occurs once a relationship is functioning at a more mature level a healing intimate relationship may foster... change" (Links and Stockwell, 2002, page 524).  The developmental process- a process of individualistic demands causing problematic character development, along with the three events that modulate narcissistic development suggest applying the principles underlying the three events in therapy.  The process of therapy needs to include corrective achievements, corrective disillusionments, and corrective relationships.  The progress of the couple as facilitated by therapy would also be to create corrective achievements, corrective disillusionments, and corrective relationships.. In therapy individually or as a couple, the therapist plays a key role in these corrective processes.

NARCISSIST-THERAPIST DYNAMICS & PRESENTATION IN THERAPY
Many theoretical orientations emphasize the development of therapist-client rapport as a, if not the key to successful outcomes.  The corrective relationship may also be considered a reparative relationship, where the relationship with a new intimate figure- in therapy- the therapist corrects prior mistakes in interactions.  It is hoped that this simultaneously repairs the emotional, psychological, and attachment wounds suffered during early formative interactions with the primary caregivers.  Corrective or reparative relationships can happen throughout the lifespan.  Early in life, they would prevent the necessity of developing or intensifying various dysfunctional compensations such as narcissism, hypersensitivity, paranoia, insecure attachment styles, and so on.  Corrective or reparative relationships may be with another parent, another relative, a friend, teacher, coach, or other authoritative figure.  Later in life, corrective or reparative relationships can reduce the intensity and expression of such negative compensations.  The relationships may be with once again, a teacher, coach, but also a mentor, colleague, spiritual leader, the therapist, but most critically, with the intimate romantic partner.  It may be failure of the partner to adequately correct or repair unidentified subconscious early wounds that brings the couple to therapy.  Therapy often is based on the therapist genuinely liking and being interested in people in general.  Getting the client to like the therapist comes often from the therapist being interested in and liking the individual.  The initial phase of therapy in gathering basic intake information serves simultaneously to fostering the client's attachment to the therapist.  Dale Carnegie said, "The royal road to a man's heart is to talk to him about the things he treasures most" (www.brainyquote.com, 2012).

In individual therapy, the therapist can focus on one individual and only be concerned with the therapist-client relationship.  In couple therapy, the therapist asks about both partners' experiences and emotional worlds.  The therapist is aware that the partners may be competing with one another for the most rapport or greater credibility with the therapist.  Rather than only presenting oneself, the partners are also presenting self relative to the other partner.  In addition to being invested in the image that the therapist develops, each partner is concerned with any contradictory feelings and thoughts to that image created by the other partner's rendition of self and the relationship.  The therapist needs to balance all information and processes to develop nuanced assessment of individuals and the relationship.  Each person's presentation needs to be carefully attended to for egocentric versus equitable perspectives.  Along with non-verbal cues, the therapist is aware that "…speech as a form of expressive behavior reflecting the most dominant and consistent personality traits of an individual.  Language, perhaps more than any other behavior, gives form and expression to mental activity.  Moreover, individuals appear to possess distinctive sets of linguistic habits or traits that are generally stable over time (Moerk, 1972).  The consistently expressive nature of speech has led some to conclude that linguistic styles identify personalities (Hogben, 1977).  Personal pronouns are among the most frequently used parts of speech, and are of psychological interest because they are used in dialogue to distinguish between oneself and others (Ortigues, 1977).  Sanford (1942) and Weintraub (1981) view pronoun usage as an index of egocentrism indicating the relative extension of the self, in that highly egocentric people will use more first person singular pronouns such as 'I' and fewer first person plural pronouns such as 'we.'  Several independent lines of theorizing and research lend support to the hypothesized association between first person pronoun usage and egocentricity" (Raskin and Shaw, 1988, page 394-95).  The therapist listens for whether a partner's narrative casts both individuals as the co-stars, or has him or herself as the leading character with the other partner as a supporting cast member.  Both partners may vie for the therapist accepting him or her in leading role, or one partner may defer to the other as the star and see oneself as a minor character in the relationship narrative.

The therapeutic intake interview may be difficult for some individuals who are other-focused, lack introspection, lack articulation, and/or hold cultural inhibitions to express self openly.  On the other hand, initial assessment often activates the high egocentricity of the narcissist.  "Narcissistic individuals are by definition highly self-centered.  They tend to display an unusual degree of self-reference in their interactions with other people (Kernberg, 1967), tend to use language in an autocentric manner in order to regulate well-being or self-esteem rather than in an allocentric manner for the purposes of communicating with or understanding others (Bach, 1977), often display absences of 'I-Thou' feelings (Horowitz, 1975), lack empathy, and dislike being dependent on others (Stolorow, 1975)" (Raskin and Shaw, 1988, page 396).  An early indication in therapy of narcissistic issues may be the extensive personal story of one partner without complementary references to others, including the partner.  Or, such references may lack substance and depth while serving the individual's egocentrism and grandiosity.  Another indicator of potential narcissism would be patient deference to the other person's story followed immediately with the "real story" or "truth," that effectively dismisses the other person's credibility.  The narcissistic individual would expect the therapist to be highly enraptured by his or her story.  He or she would be receptive to inquiry about details and nuance of the story, but not as effusive about details and nuance about other characters in the story.  This may be the beginning of inaccurate perceptions that need to be corrected.  The individual did not have sufficient corrective disillusionments previously that would have guided the individual to stop seeing and expecting oneself to be the center of everyone's story.  Attempts to shift the session's focus to the other partner's story may be resisted or sullenly accepted.  More probably and more commonly, the narcissist responds by taking over the telling of the partner's story with "clarifications" and more "accurate" memories that often embellish a positive image of the narcissist.  This is his or her false illusion of self and self with others.

In individual therapy, the therapist often has greater latitude to initially allow narcissistic presentation and then gradually challenge perceptual distortions.  The therapist has only their dyadic therapist-client relationship to develop and monitor.  However in couple therapy, the therapist must also monitor and develop each relationship with each partner.  If the other partner observes the therapist seemingly being entranced with or allowing the narcissistic partner dominate the early stages of therapy with his or her story, the other partner can easily be discouraged about the therapist, therapy, and the relationship changing.  Essentially, the partner sees the narcissist duplicate with the therapist the problematic relationship and dynamics that he or she has grievance about.  He or she may think, "How can it or we be different, if the same thing is happening again?  The therapist can't resist my partner's charm or shenanigans either. How can I hope that the therapist can help us be better?"  On the other hand, the therapist may not be charmed by the narcissist and recognize the domination or manipulation of the initial assessment process.  The therapist is at risk to be immediately put off by it- that is, not like the individual.  If the therapist can manage his or her negative counter-transference, he or she still must therapeutically manage the individual's charming egocentrism.  The therapeutic challenge arises in how to not replicate the couple's negative dynamics and thus, gain credibility with the other partner, while doing so in a manner whereby the therapist gains respect or deference from the narcissist.  Or at least, not strongly trigger narcissistic defenses and prevent narcissistic rage from blowing up the therapy immediately.

A common therapeutic recommendation is for the therapist to be the unconditionally attentive and nurturing parental figure for the narcissist to work through his/her issues.  The therapist directs initial interactions and building of credibility or rapport to duplicating some aspects of the partner's early behavior in the first attachment relationship before it broke down.  Early in the couple's relationship, the other partner is entranced by the narcissist's charisma, accomplishments, and status.  The narcissist has genuinely impressed him or her.  The therapist could duplicate this by being supportive and admiring of the narcissist's achievements.  The therapist may not find this that difficult, since a narcissistic individual is often very successful socially or vocationally and possessing significant intelligence and charisma.  The difficulty is to find a way to do this with integrity versus being clinically disingenuous.  The therapist also knows that the same qualities have led to dysfunctional and abusive treatment of the partner.  The therapist can honestly appreciate the intellectual, financial, career, and social status achievements of the narcissist.  The therapist can shift to the childhood experiences and parenting the narcissist experienced.  The narcissist is often quite willing to identify negative parental experiences as indicative of his or her achievements surmounting his or her handicaps.  If this is discussed, the therapist can identify and appreciate the individual's achievements in surviving challenging childhood experiences or inadequate parenting.  Using conceptual understanding of narcissistic compensation, the therapist can identify additional achievements in forming relationship boundaries to protect him or herself from disappointment or hurt.  The therapist tactically shifts appreciation from familiar but grandiose areas for the narcissist to areas relevant to psychological processes, intimacy, and the relationship.

The partner experiences the narcissist's boundaries as rejecting and abandoning usually without conscious awareness that they serve to protect the narcissist's great vulnerability.  The partner, on the other hand often has some instinct- often sub-consciously of the vulnerability and compassion for the narcissist's needs for self-preservation.  The therapist can prompt the partner to identify and honor the narcissist's vulnerability and intimacy needs, despite his or her long held inhibitions.  Within the therapy the therapist should affirm as an achievement any openness or expression of vulnerability that transcends or moves towards transcending narcissistic habits.  This approach, including the expectation of rapport developing between the individual and therapist gets complicated since often gets circumvented by the narcissistic personality. Clients are expected to form a positive transference relationship with the approving authority figure of the therapist.  However, this is problematic for narcissists, since "they cannot, at least initially, function in analysis in an ordinary way because they cannot form an ordinary transference relationship" (Britton, 2004. page 478).  Or the transference may be of having another supplicant charmed by his or her impressive qualities.  Another therapeutic approach directs interactions and interventions to the narcissist's need for a love and approval of a parent substitute.  This is also challenging since the narcissist will also be resistant to owning or revealing any need as that would indicate vulnerability that is dangerously ego dystonic.

THIN-SKINNED
Since all diagnostic classifications are generalizations of an identified section of a spectrum of behaviors, it is useful to further "distinguish between three types of narcissistic disorder: borderline (thin-skinned), aloof (thick-skinned) and as-if (false-self) personalities.  The differentiation is not based on symptoms but on the transference/countertransference, particularly on the reaction to sharing mental and physical space.  In the first the transference is adherent and the analyst's psychic space is colonized.  In the second the analyst is excluded from the patient's mental space and the feeling of exclusion is projected into the analyst.  In the third category refuge is sought in transitional space (Winnicott 1953).  This Winnicott envisages as a space between subject and object that is not the personal space of either; so there is then no impingement.  He also described it as the resting place of illusion; these patients make the resting place a permanent residence" (Britton, 2004, page 479).  The borderline thin-skinned narcissist may hide his or her vulnerability with volatility.  Chessick (1976) says "the psychiatrist father and husband with narcissistic pathology is constantly on the lookout for 'criticism' from his wife's or child's psychotherapist, and can be expected to frequently 'pump' the patient for details about each session.  At the first hint of criticism an explosion can be anticipated, including attempts to end the treatment or to force a change of therapists, or refusal to pay the fee or bring the patient to the sessions, and so forth."

The therapist should anticipate the possibility or probability of a narcissist attempting to manipulate the business practices of the therapy, especially about payment and fees.  "The therapeutic contract and fee should be carefully spelled out at the beginning of treatment, and should be no 'favors,' as this represents to the patient a tacit alliance between the psychotherapist and the husband or father of the patient."  Chessick references a circumstance when the husband or father is a professional within the same circle as the therapist, or has some comparable status.  "The psychotherapist must be prepared with strategies if there is a refusal to pay the bill, for the psychiatrist husband or father here projects his narcissism onto the psychotherapist, and assumes he is wounding the narcissism onto the psychotherapist in revenge for the narcissistic wound inflicted on him by the psychotherapy of his wife or child" (page 521).  Chessick notes that a direct confrontation or individual consultation by the therapist with the narcissistic individual precludes the other family members from recognizing and working through understanding the narcissistic individual.  Worse, it would create the appearance of the two authorities: the therapist and the narcissistic individual creating an alliance against the other family member(s).  "Generally speaking, a crisis often occurs when the psychiatrist husband or father of this type realizes he is not going to be able to control the psychotherapy of his wife or child.  At this point, he may become outraged, severely criticize the psychotherapist, and try to stop the treatment" (page 521).  In couple therapy, the colonization of the therapy may be attempted by taking over the direction and thrust of the process.  As the therapist asserts his or her therapeutic prerogative and judgment about the course of therapy- i.e., repeals the invasion into the professional space, the narcissist shifts to cruder verbal aggression and threats as Chessick has described.

THICK-SKINNED
It may be characteristic of the aloof (thick-skinned) narcissist to try to assert superiority over the therapist.  If the therapist is passive (unconditional, agreeing, seeking to facilitate without offering substantive feedback), he or she will be dismissed.   A therapist may be highly vulnerable to becoming anxious to please the narcissist; the therapist will feel the need to "prove" his or her professional competence.  Chessick described the specific situation of providing therapy for wives and children of psychiatrist, which included a subset of individuals who are narcissistic.  "This brings us to the special countertransference problems involved in the psychotherapy of the wives and children of psychiatrists.  The special problems clearly revolve around the narcissistic use of the patient as a self-object to demonstrate to the colleague-husband or father that one is a fine psychotherapist indeed.  'How will I do? What will he think of me?' become countertransference preoccupations especially if the husband or father (a) has a more lucrative practice with an overflow of patients that he refers to other psychiatrists or (b) is in an important political position in local psychiatry, with the power to influence others" (1976, page 522).  The narcissist is often quite adept at asserting high status and comparably hyper-attuned to vulnerability around self-esteem in others, including the therapist.  Individuals including therapists should expect questions …even challenges about their credentials and experience.  If they try to please the narcissist, satisfy his or her inquiries about their credibility or competence, or accept his or her superiority, they will be dismissed.

Getting beyond counter-transference or investing it with greater depth may be essential for the therapist.  "A clinician will probably be more likely to identify with somebody whom they see as different only in the degree to which they experience something as opposed to a 'disordered' individual whom they differ in the way they experience things.  Thus, it becomes a very important for the clinician to conduct a self-assessment and know where they fall along each of the dimensions that they will be using to work with their clients.  This is particularly the case in a disorder like narcissistic personality disorder, where a clinician's need for success in the therapeutic relationship may interact with the client's need for success and accomplishment.  Working with an individual with a narcissistic personality disorder is therefore not only challenging therapeutically but also developmentally as a clinician and as a person" (Rivas, 2001, page 32).  The therapist needs not only to be a competent therapist, but also a securely competent therapist to withstand challenges to his or her credibility and skills and not be drawn into a competitive need to be successful.  Humanistic existential therapists may be highly vulnerable to narcissistic manipulation, since they often present themselves as equal partners in a caring helping process.  The narcissist does not want the therapist to be an equal!  As an equal, the therapist will be perceived as a rival, dangerous to the narcissist's need to feel superior.  And, the therapist will be attacked.  Any latent insecurities about his or her competence, credentials, being accepted or respected, or status are likely to be sensed and provoked by the narcissist.  These considerations need to be anticipated and handled or the therapy will be sabotaged either in session or through termination after the session.

FALSE-SELF
The narcissist individual may speak to the therapist in a pseudo-collegial manner about him or herself, as if he or she was a third-person entity rather than the first-person actor.  The narcissist may refer to the partner and the relationship using a third-person perspective rather than as a first person participant or a second-person antagonist, or from being fundamentally embedded in the relationship.  The false-self may, especially if he or she is a professional slide into a psuedo co-therapist stance to analyze self, partner, and relationship... and therapy itself.  In this manner, the narcissist puts everything into a middle space as if he or she does not personally occupy.  He or she invites the therapist to jointly analyze and anthropolize the relationship as an interesting creature, chemical reaction, or growth.  This disconnected assessment is safer than risking any personal ownership, investment, or self-evaluation.  It is also extremely presumptuous to attempt absconding with the professional expertise and role of the therapist.  Yet, the narcissist may seem completely unaware of the audacity of the behavior or how disrespectful it is of the therapist.  It is after all who and what he or she is... is entitled to be and do.  The therapist may be but should not be surprised.  "It often is difficult for a given observer to empathize with the grandiosity of another person.  For one thing, such self-aggrandizement is so often accompanied by the need to diminish the self-dimension of everyone about (including that of the observer) that there is a quality of threat involved.  For another, often enough, the grandiose person does not feel himself to be such; he merely experiences a righteous sense of entitlement. This is his territory, this is him.  What may seem to the observer to be egregious and excessive and even unprincipled, may be felt by the grandiose one as merely the just retention (or assertion) of what is his by right, what is in fact a part of himself" (Noshpitz, 1984, page 26-27).  The denigration of others including the therapist may be intentional or unintentional.  Regardless, the narcissist feels entitled to doing it.  The cool false-self may honestly deny intentionally trying to disrespect the other person.  It is something outside of his or her consciousness.  It is just something he or she does.  It happens.

The individual may not present consistently in any pattern but instead act in ways that look uncharacteristic unless viewed from a greater timeframe.  Behaviors may lay dormant invisible to most other people, but get triggered unpredictably.  Or, other people may observe overt behaviors erupting occasionally, but not be able to identify the internal dynamics underlying them.  "…narcissistic personality disorder also contains components that are less readily characterized in dispositional terms, such as the oscillation between overvaluing and devaluing others. These oscillations as well as phenomenological states such as a sense of humiliation, precarious self-esteem, shame, rage, and yearnings for uniqueness (Morrison, 1986; Reich, 1960) are not well captured by the current approach, which instead focuses on the act manifestations of narcissism in everyday life" (Buss and Chiodo, 1991, page 183-84).  The narcissist's partner who has experienced emotional patterns over an extended period of time may have some insight to the deeper vulnerabilities that may be triggered.  One of the difficulties working with the narcissist is that he or she is often highly reticent to share such vulnerabilities and/or is cognitively disconnected from awareness.  The therapist may be more able in couple therapy versus individual therapy to recognize narcissistic vulnerabilities.  The therapist does not only experience the narcissist's behavior but also observes his or her interaction with the partner, plus notes the partner's descriptions of fluctuating narcissistic actions.   The partner may describe behavior that may sound very much like the thin-skinned narcissist, while the therapist may have only initially experienced the thick-skinned aloof behavior or a false self in therapy.  Or, the individual may present an involved, caring, and charismatic persona in the initial stages of therapy only to become highly activated to lash out at the therapist when some feedback is perceived as challenging.  The longer therapy persists, the more the therapist should be able to recognize narcissistic behaviors and patterns despite attempts to hide them.

The narcissist who has a compelling false self or feels he or she must be a certain way… and be perceived a certain way.  The individual may be extremely adept at eliciting patterns of communication and behavior he or she desires from others.  This happens in the couple's interactions.  It is also likely that the individual will try to get the therapist to respond, think, and feel in a manner that fits into his or her comfort zone.  "It often happens, therefore, that interpersonal cognitive cycles get activated during sessions (Safran & Segal, 1990), with individual construal processes leading to standard gestures and messages, eliciting predictable responses in others.  Individuals have expectations about how a relationship will go and are conditioned by this when they enter into one, so that they expect certain responses.  Their expectations provoke behavior consistent with their desires.  Therapists driven by such action tendencies contribute to making the relationship dysfunctional" (DiMaggio et al., 2007, page 24).  The partner may watch with some trepidation if the narcissist is able to manipulate the therapist into familiar patterns that have been increasingly difficult if not traumatic for him or her.  If on the other hand, the therapist recognizes the manipulation and responds differently- in particular in some challenging manner, the narcissist can be activated.  When the false self is contradicted or questioned by the therapist or the therapist gives credence to the partner describing the individual as less than the idealized personality, the narcissist can shift from praising the "wonderful" partner to damning the partner as lying or corrupt.  The consistency of the behavior may be in its inconsistent presentation unless triggered.  Even then, the context or social situation may decrease or increase inhibition.  Alone with the partner, the narcissist may be more than willing to engage in classic intellectual manipulations and/or emotional or verbal assaults.  However, in the presence of a third-person observer (i.e., the therapist), the narcissist may be much more circumspect.  Over time in therapy, familiarity with the therapist, and the peeling away of exterior veneers of the false self, the narcissist will show more of these behaviors.  Since successful therapy often involves the therapist purposefully redirecting or altering the individual's or couple's communication or behavior patterns, the narcissist may become suddenly contentious.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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