11. TherapistFrustration/ClientAntagonism - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Scorpion in the Bed, The Narcissist in Couples and Couple Therapy
Chapter 11: THERAPIST FRUSTRATION/CLIENT ANTAGONISM


When there is a narcissist in the couple, the therapist can find therapy to be difficult almost immediately with pressure to intervene quickly and productively.  "There is widespread agreement that one of the main hurdles to overcome when treating narcissism is in the therapeutic relationship (Kohut, 1971; Kernberg, 1975). Clients with narcissistic features are prone to break the affective bond with their therapists (Modell, 1984), are not fond of hearing other points of view than their own, and make critical comments about them (Gabbard, 1998). This problem is common to clients with a Personality Disorder (PD) diagnosis (Livesley, 2003), who pose many problems for therapists. Clients with narcissism demand recommendations that are precise, correct, and immediately applicable, but simultaneously are quick to dismiss their therapists' feedback. Their therapists, in turn, often feel compelled to compete with such clients (Dimaggio, Semerari, Falcone, Nicol `o, Carcione, & Procacci, 2002), to underestimate their problems because they are taken in by their positive facade, to not feel involved in the relationship (Modell, 1984), or to wish to put an end to it" (DiMaggio et al., 2007page 23-24).

Common initial assessment inquiries that ask about the narcissist's inner feelings may activate emotional detachment intrinsic to the personality disorder.  The therapist is likely to feel pushed away and unable to access the narcissist's internal world.  The therapist is treated as if exploring feelings is inappropriately intrusive and possibly irrelevant.  This can make the therapist feel frustrated and somewhat incompetent (common narcissistic goals to maintain superiority over others).  The therapist needs to be aware of his or her counter-transference and recognize that the narcissist has just made him or her feel what the partner has been experiencing over the life of the relationship.  The partner will often say that the narcissist treats him or her with cold detachment.  The narcissist shows distain in response to the partner's interests in his or her emotions.  When the therapist shows interest in the narcissist's emotion, he or she often immediately denies feelings or diverts the discussion.  If the therapist persists, he or she may become antagonistic, arrogant, and impatient.  The narcissist may retort sharply implicitly or explicitly asserting that emotions discussed are transitory and not of any particular relevance.  In the session and over the course of therapy, the narcissist ignores the therapist's feedback and suggestions.  The narcissist insists that he or she is self-reliant, self-aware, and perfectly insightful.  However, "Despite narcissists' high opinion of themselves, their self-esteem is unstable, and they may react with extreme hostility to any perceived threat to their self-concept" (Bogart et al., 2004, page 36).  The narcissist may accept little if any of the therapist's interpretations without contention or without nit picking minor details or nuances.  Acceding to the therapist's wisdom, expertise, experience, or education seems to constitute admitting that he or she is common enough to be understood.  This threatens the narcissist's grandiosity and high fragile self-esteem.

The individual become increasingly negative while verbalizing a variety of disparaging comments.  As the therapist can be activated and hurt or angered by the negativity, "A therapist's reaction often is to underestimate the suffering of such individuals and the devastating impact their behavior can have on their affect and work.  He or she may feel that his or her self-esteem or competence has been offended and try, in turn, to gain such a client's appreciation or to take charge of the situation by imposing his or her point of view.  The therapeutic relationship takes on these negative characteristics from the initial sessions and, because of this, there is a high risk of early dropout" (DiMaggio et al., 2007, page 26).  Complications in therapy abound as interventions are driven from the therapist's reactive instincts rather than clinical clarity.  Such complications further increase in couple therapy when the therapist becomes concerned that his or her every interaction and response is negatively scrutinized by both partners.  All these therapeutic frustrations however may be useful for diagnosis.  "Because of an exquisite vulnerability to empathic misattunement, these patients, unlike borderline patients, will experience confrontation of their projections as an attack or criticism, the underlying aggressive fused unit will be activated, and defences will be fortified. As a consequence, it is the empathic interpretation of this narcissistic vulnerability and the defences against it that provides a portal to the real self of the narcissistic disorder" (Roberts, 1997, page 238). The therapist can apply a simple principle to his or her clinical experience with almost any client.  That is, if it should work, it will work… unless there is more to it.  Therapist frustration may be compellingly indicative for why common rapport building and therapeutic interactions are waylaid by an important diagnostic consideration- narcissistic personality disorder.

OBSERVATION & METACOMMUNICATION
The therapist may try to mirror back to the narcissistic client an interpretation of his or her experience.  The narcissist's self-interpretation is based on a rigid sense of self that distorts reality.  This distortion requires therapist re-interpretation.  "…according to Masterson (1981, pp. 31, 32), a `mirroring interpretation' of the patient's narcissistic vulnerability to the therapist's inevitable failures in perfect empathy in the moment is the key to accessing the patient's experience of the impaired real self.  As Kohut (1977, p. 92) emphasized the importance of an `understanding' phase of interpretation preceding an `explaining' phase in work with narcissistic disorders, Masterson (1993, pp. 76-69) suggests that an effective interpretation is comprised of the empathic mirroring of affect, an explication of the defence against this affect, and an articulation of the self-protective or self-regulating function of this defence.  For example, a narcissistic patient bristles in response to an interpretation by the therapist.  The therapist might then suggest, `It's so painful when you feel I don't understand you perfectly that you become angry at me and criticize me in order to soothe yourself'.  The interpretation, then, mirrors the painful affect ('It's so painful…'), notes the defence against it ('…you become angry at me and criticize me…'), and acknowledges the self-regulating function of the defence ('…to soothe yourself').  This is a paradigmatic intervention for the narcissistic patient who has experienced therapist misattunement within a mirror transference, that is, when the patient has experienced the therapist's failure to provide perfect mirroring as a narcissistic injury and has used devaluation of the therapist in an effort to soothe the resultant emotional pain" (Roberts, 1997, page 238-39).  The therapist is faced with defenses and counter-attacks for perceived criticism and misunderstanding that the partner and other individuals have experienced previously.  "Effective interpretation" with its combination of empathic mirroring, explanation of the defence, and articulation of the self-protecting and self-regulation of defence has usually been beyond the capacity of the partner to offer.  Or, the partner has been too triggered or cowed by the narcissist's anger that to feel much empathy, want or try to understand the defence, and thus unable to reflect on its protective and regulatory functions.  Unfortunately, both therapist attempts to be attuned when mirroring and partner efforts to reflect with empathy while asserting therapeutic or personal needs may be viewed through a hyper-sensitive lens.  Thus, attempts to offer interpretation are waylaid by a constant pattern of misinterpretation by the narcissist.

The therapist may find the narcissist shifting the focus of the therapy onto the therapist.  This may be inquisitive and charming initially, and may seem admiring.  Later it becomes challenging and antagonistic as the therapist insists on venturing towards more vulnerable areas.  "The individual with a closet narcissistic disorder… is more likely to establish an idealizing transference in which avoidance of displeasing the therapist assumes primacy.  In such cases, the vulnerability may be more apparent in the patient's observed difficulty in maintaining a focus on and expression of the self, attuning rather to the object, the therapist and his/her needs, feelings, or responses.  A mirroring interpretation in such a case might be framed as follows:  `I wonder if it isn't so painful to focus on yourself and your experience that you shift the focus to me and what I might think in an effort to protect yourself from those painful feelings'.  Again, such an interpretation mirrors the dysphoric affect and brings to the patient's attention the way in which defence against the feelings is mobilized in the service of self-protection and self-soothing" (Roberts, 1997, page 238-39).

When the therapist recognizes the interpersonal pattern of the narcissist seeking attention but not getting it as he or she desires, the therapist can bring this awareness into the session.  The therapist should consider his or her own cognitive and especially, emotional reactions in the therapy and towards the clients.  A truism of interpersonal exchange is that the other person makes one feel what he or she feels.  Whether that is specifically true for the therapist, his or her reactions can come from emotional signals that come from the one or both partners.  The therapist can frame the communication as challenging or potentially upsetting, including possibly involving angering the individual.  For example, the therapist may reveal his or her process responding to the individual's behaviors that draw attention.  Attempts to give acknowledgement, validation, and possibly nurturing over the course of therapy however were not accepted but treated with derision by the narcissist.  The therapist can feed back that the individual pushes him or her away, while simultaneously trying to draw in the therapist.  In fact, when the therapist attempts to give the individual the positive regard desired, the individual reacted with irritation, condescension, and rejection.  This can be identified to the individual as characteristic of his or her behavior pattern per his or her personal history.  The therapist can compare the individual's reaction and treatment of the therapist to his or her reaction and treatment to prior intimate and/or authority figures.  "This process is in line with Bowlby's (1988) observation that it is not easy for attachment to emerge in narcissism.  The success of this action, demonstrated by the clear progress obtained… is consistent with what occurs typically in therapy with these clients. Every attempt to bridge the relational gap risks unveiling the weak self and provokes negative reactions. The therapist's action was successful precisely because he realized that he was embodying the character kept at a distance, and he did not display any wish to get closer. His hypothesis was based on his own emotions and was supported by what had emerged from the earlier narratives: that when the patient was looking for attention, she was in fact afraid of being attacked or rejected" (Dimaggio et al., 2007, page 45).

The therapist often considers his or her counter-transference but may not bring it overtly into therapy.  Therapeutic strategies and interventions may be based on considerations from self-examination but without their motivations shared overtly with the client.  It may be especially prudent with narcissistic clients to share the therapist's emotional-intellectual process.  The narcissist is often hypersensitive to be analyzed by anyone, including the therapist.  Sharing the process acknowledges the narcissist's hidden vigilance against being "figured out" and secretly manipulated or "played" with by the therapist.  Since the therapist is aware of this vigilance, open communication about his or her internal process may help therapy avoid the "I know that you know that I know that you know…" cyclical conundrum.  Therapy breaks a negative pattern of acting "as if" such issues do not exist or are not relevant.  "He self-discloses in order to make her understand that their relationship is tainted by a problematic pattern and to metacommunicate about this pattern (Aron, 1996; Rennie, 1998; Safran & Muran, 2000; Semerari, Carcione, Dimaggio, Nicol`o, & Procacci, 2004).  In self-disclosing, he reveals that he is embodying a dismissive position, vis-à-vis a dismissed one" (DiMaggio et al., 2007, page 40).  The therapist should be direct while making clear that the individual is not being rejected.  The focus is on the relationship.  "As regards therapeutic technique, it is to be noted that the therapist treats his own feelings of detachment and coldness as elements of discussion and stresses that he is talking about his own subjective experience and not a given fact, so as to avoid taking on a dominant position."  Through expressing the counter-transference, that is, the therapist not feeling connected to the other, the individual hopefully feels safe to express the deeper need to be cared for.  The individual may be able to hypothesize about a part of self that desires and seeks attention from another person who is able to give it.  The individual does not expect to be criticized for this.  For the moment this pattern only occurs in imaginal space and does not get activated in real relationships.  It is to be noted, moreover, that the voice emerging in this passage is a healthy part of the self and not to be found in the narcissism prototype" (DiMaggio et al., 2007, page 40).  Therapy and relational functionality takes a step forward if the individual is able to initially own a desire for a partner who can give what he or she wants.  Unfortunately, for some individuals expressing such a need or desire becomes tantamount to admitting an intolerable vulnerability.  This may be the key underlying narcissistic vulnerability that cannot be easily confronted.

Over the course of therapy, the individual may be able to tolerate more introspection and gain some insights to his or her processes.  The therapeutic process facilitates this with an artful blend of feedback and focusing attention to feelings as well as behaviors.  The therapist uses his or her interactions in session with the individual, the interactions between the partners, as well as the partner's descriptions of their interactions.  From these observations, the therapist can empathetically feed back how the individual maintains rigid boundaries between self and the partner (and the therapist) as protection from being harmed.  The therapist is challenged since the individual's presentation may be very curt, bordering on being rude and disrespectful.  The narcissist may assert verbally or through affect or behavior that no rapport exists between self and therapist.  And, that the therapist has little or nothing to offer to improve his or her life or the couple's relationship.  The therapist is caught in a dilemma.  If the narcissist complains about the therapist not giving him or her sufficient attention, not understanding him or her, or taking sides with the partner, any attempts to be more attentive or "fair" is dismissed with distain or accepted smugly.  Or, the therapist can argue that he or she is being equitable therapeutically with both partners.  Neither response has therapeutic integrity or serves the individual or the relationship.  Becoming a caretaker, ally, or the source of soothing or confirmation does not work and will be rejected anyway.  After repeated rejections, the therapist can become emotionally distant.  This would simultaneously confirm the narcissist's accusations and replicate the narcissist's prior and current experiences with intimacy.  The individual feels abandoned… again.  The frustrated therapist may eventually recognize his or her role in the problematic therapeutic relationship.  Attempting to promote therapeutic rapport with the narcissist who innately resists bonding without identifying the relational dynamics inadvertently reaffirms the narcissist defense mechanisms.  Seeking relationship with the narcissist is resisted as he or she has resisted the partner.

THIRD-PERSON OBSERVER
The advantage of couple therapy in metacommunicating about the communication and relationship dynamics is the availability of a third-person confirmation.  In the couple's relationship between partners, the narcissist can readily deny the dynamics to the partner.  His or her great skills in convincing the partner of errors of perception and interpretation make it easy to deny his or her avoidance behaviors.  In individual therapy, the narcissist can present a false self and also maintain any therapist interpretation as being incorrect.  The therapist will be getting what everyone else has gotten and not recognize it.  In couple therapy, however the therapist becomes the third-person observer for the partner, while the partner becomes the third-person observer for the therapist.  The partner can get confirmation from the therapist that his or her perceptions and interpretations of the relationship communication and relationship dynamics have validity… perhaps, for the first time.  When the narcissist denies his or her internal cognitive and affective process or engages the therapist in verbal manipulation, the therapist can use the partner to reinforce therapeutic interpretations and feedback.  For example, "Just right now, I experienced you telling me that what I saw and felt was incorrect… that my reality was wrong."  When the narcissist starts to rationalize, justify, or otherwise reassert his or her perceptions as valid (and the therapist's as invalid), the therapist can turn to the partner and ask, "What just happened here between your partner and me… is that what happens to you?  Does he or she do that to you too?"  Referencing to the partner for personal experiences and validation of the therapist's experience of the narcissist becomes a frequent and regular intervention whenever the individual reverts to narcissistic responses.  This powerful intervention places the partner in a psuedo-therapist role to comment on the narcissist-therapist dynamics.  As the therapist can validate the partner's experience with the narcissist, the partner validates the therapist's experience with the narcissist.  The therapist will of course have to deal with the narcissist feeling ganged up on, being exposed and made vulnerable, being made "wrong," and instincts to "kill the therapist or therapy."  Nevertheless, this is a critical intervention that fundamentally and directly confronts the omnipotence of the narcissist.

The therapist needs to recognize and understand typical defensive responses by most individuals to being attacked are:

1) To attack back;
2) To get defensive;
3) To placate;
4) To disassociate.
5) To take the high ground intellectually or morally.

Being the third-person observer for the partner and using the partner as a third-person observer are likely to trigger one or more of these responses.  Whenever the narcissist attacks his or her partner however, the therapist can assert being a third-person observer and name his or her behavior.  "I noticed that when your partner complained about how you treat him (or her), you responded in this characteristic way (name one or more of his or her typical defensive response).  You pretty much respond this way instinctively virtually every time... or at least, too often.  It causes more problems.  It hurts or dismisses your partner."  If the narcissist attacks or criticizes the therapist either from some exchange found threatening or when the therapist makes such an observation, the therapist again can use the partner as the third-person observer.  "When I commented or criticized your words or behavior towards your partner, you shifted to criticizing me... or making me wrong.  (turning to the partner) Isn't that what he (or she) does to you too?  Is how he reacted to me familiar to you?"  This can be such a powerful intervention that shifts the partners' dynamics, that the therapist should purposely draw an attack from the narcissist!  Rather than trying to please the narcissist and avoid his or her negativity, provoking angry belittling, disrespectful, or dismissive behavior may be the key to therapeutic change, individual growth, and couple's functionality.  Only then can an alternative interactional dynamic be introduced and facilitated.  Bring it on!

While the narcissist's attacks are essentially defensive in nature, the therapist's experience remains feeling attacked.  His or her natural defensive instincts will be triggered.  The therapist needs to be aware of his or her personal defensive style and which of these five styles is his or her- the therapist's instinctive response or combination of responses.  Without qualification, each of the responses above serves to distance the therapist from a challenging/attacking person in a comparable manner the person distances from intimate others, including the partner and the therapist.  If the therapist believes that at some deeper level, the narcissist is still seeking attachment, a nurturing caregiver, or authority figure, then unsophisticated defensive responses- unexamined counter-transference reactions become counter-therapeutic.  The partner of the narcissist has almost certainly either ranged through the various defensive responses and/or become stuck with one response style.  When the therapist finds him or herself instinctively caught up with a characteristic personal defensive response, he or she should step back and comment on the process as a third person observer.  This is the therapist observing him or herself.

"I notice that while I'm neither person's partner, that I start to not like you when you do certain things.  I experience what you say to me as disrespectful... as you questioning and challenging my credentials.  Since I don't like that, my non-professional instinct is to avoid you or hurt you back.  However, as your therapist... your couple therapist, instead of rejecting or abandoning you, I'm telling you how you affect me.  And how you affect me is how you affect your partner... right? (quick look to partner for confirmation).  And how you've affected others.  Despite feeling in the right... self-righteous is a more accurate term, it doesn't really work for you over the long haul.  It kinda works to get various gains, but in terms of relationships you lose out.  Your partner is questioning the relationship.  You aren't getting the intimacy you desire.  This has happened to you over and over in personal and professional life."

Another delicate and challenging variation of this strategy references ones professional therapist experiences to address the narcissist's grandiosity and sense of being special.  The therapist may consider introducing the clinical definition of narcissistic personality disorder (DSM or other professional definition) to identify the pattern of the narcissist's behaviors.  Whether or not the therapist actually tells the person, "You have narcissistic personality disorder," or "You have a lot of narcissistic traits and behaviors," the therapist would need to manage the different potential reactions from the narcissist.  Some individuals, especially those with significant but not rigid narcissistic traits, significant ego strength, previous reparative and corrective experiences, high potential loss or gain from accepting the diagnosis, or some combination of these and other factors may find being normalized reassuring.  Within such individuals, there would have been some consciousness of the destructive consequences of their compulsive narcissism and a self-condemnation of such negative unproductive behaviors as unhealthy.  The therapist is challenged to present the pattern of narcissistic response as one normal style of response compelled by certain given options being available in reaction to extremely chronic psychic stress.  In other words, the psychological disorder of narcissism that he or she suffers is somewhat common not unprecedented attempt to survive shared by many others.  The difficulty of this feedback is that it makes the individual not special, but beholden to his or her humanity as shared by others.  High grandiosity may make this unacceptable to the narcissist.

Some individuals may be receptive to being validated for the "brilliance" of developing a narcissistic defense style that accrues so many benefits (other than relationship intimacy).  Another potentially beneficial reframe would be for the therapist to assert an ability to transcend the early narcissistic wounds after being deeply invested and practiced with narcissistic values and behaviors as being exceptional.  In may ways, it is exceptional and very special for a narcissist to re-adjust his or her life philosophy and practice to a more mutual respectful bi-directional relationship exchange, become more vulnerable, and gain intimacy here-to-for not experienced.  Being special and superior is redefined not as competitive with others, but in respect to his or her to be former narcissistic self.  The narcissist's competitive nature may be triggered to surpass him or herself rather than to destroy others.  The therapist's presentation of this paradigm shift must be skillful and artfully executed.  Gaining the authoritative, expert, and leadership role would be an essential prerequisite to this intervention.

These various strategies and interventions become only possibly viable if the therapist can move him or herself into a new client-accepted "objective" position that surveys and assess interactions between self and the narcissist.  This is often a necessary strategy to maintain the therapist's role correcting distorted perceptions and cognitions. The therapist can assert his or her professional competence (superiority) in this domain—assessment and evaluation of interpersonal processes.  "Let me comment on what's has just happened (or has been going on) between us.  I notice that you need to challenge or question any feedback I give.  From my professional experiences with individuals similar to you, that behavior has some general origins and some major relationship consequences."  Sometimes, someone with less rigid narcissistic issues (less thin-skinned or fragile) is able to defer to this.  He or she is able to benefit from the feedback and use it in the relationship.  In couple therapy, the narcissist may not agree and continue to argue.  Depending on how fragile he or she is and how rigid the narcissism, he or she may not be receptive and remain unmoved.  Irregardless however, the partner gets to see the dynamic with someone else being the antagonist to the narcissist for the first time.  The therapist may introduce his or her emotional reaction ("I felt dismissed by you") and ask if that is what the narcissist has intended to happen, or simply if he or she is aware of it.  The therapist can comment again on the process (arguing and superiority)- "I experience you as being unable to accept my being 'right' as if it makes you 'wrong.'  If I wasn't your therapist and was in some personal or work relationship with you, I would start to be really annoyed with you."  The individual may be able to reflect upon this and respond to it and the following additional inquiry, "Have you ever gotten feedback about your interactions with others like this before?  Have you loss relationships or jobs because of something like this before?  How many times?  Who?  When?"

In individual therapy, the therapist acts as both the second-person in interaction with the narcissist and the third-person persona/role to comment on the interactions.  In couple therapy, the therapist is still a second person in interaction along with the other second person (the other partner), as well as the third-person observing the narcissist and the other partner's interactions, plus observing his or her counter-transference.  In addition, the therapist is able to use the other partner as a third-person observer or reference when the individual engages in his or her narcissistic tactics.  This strategy should be readily in reach in the therapist's clinical toolbox in anticipation of such behaviors.  When the narcissist continues to dispute the therapist, the therapist then can refer to the partner for confirmation "Does he or she do this to you too?" "Do you find him/her making you wrong all the time too?" "Is this just me, or do you see him/her interacting with others like this too?"  The therapist-narcissist interaction creates the context, which allows the partner to express his or her frustration and other feelings dealing with the narcissist as mutually confirming with the therapist's experience.  Between partner and therapist, there develops a bi-directional mutuality of how they experience the narcissist.

In the face of two collaborated experiences rather than two isolated experiences, the therapist can ask the narcissist, if he or she is aware how he or she affects the other person.  Do not ask, "Is this what happens?"  That question allows him or her to argue for his or her interpretation of reality and to again deny the partner's experience.  The therapist can assert that what the partner feels is existentially unarguable.  The therapist can readily assert his or her experience with the narcissist in the moment and over the course of therapy.  This is a very powerful stance by the therapist.  That the partner or the therapist should or shouldn't feel this way is also (for the time being) placed out of bounds by the therapist.  Ask how the narcissist feels about hurting, dismissing, etc. his or her partner.  The narcissist will respond by explaining, rationalizing, dismissing, etc.  Interrupt the explaining and ask again, how he feels about hurting the partner.  Repeat as he/she avoids.  Repeat again as he or she avoids.  Insist on the question.  "I know you disagree with me or your partner interpreting you this way, but the feelings are what they are.  How do you feel about dismissing or hurting me or your partner?"  Feed back observation (metacommunication) that he/she seems to have real problems with acknowledging the suffering or hurt of the partner.  "You seem to be unable to acknowledge that you hurt me... or more importantly, that you hurt your partner."  Switch back to the partner to ask the partner what he or she feels about feelings being ignored.  The therapist can continually use the partner as affirmation of the basic therapeutic evaluations… the power of the therapist and the partner being aligned through having the same experience makes it more likely (but not absolutely certain) that the narcissistic person will begrudgingly, accept the feedback.  This is a very challenging approach and tactic for the therapist.  It takes significant clinical skills and therapeutic agility.  Unfortunately, despite great therapeutic skills and sophistication, the depth of the narcissism or of the frailty may still subvert this approach.

The therapist must determine within the process of therapy when, if, and how any therapeutic strategy or intervention may be appropriate.  The balance between working on the interpersonal level and the intrapsychic level must come from assessing each individual's issues and the couple's dynamics.  While successful therapy may eventually require addressing the emotional core, confrontation without judicious consideration may be counter-therapeutic.  "In general we consider it inadvisable to point out narcissists' needs for care at too early a stage.  As well as activating the attachment system, it is likely that this type of comment will provoke a feeling of being threatened and a defensive shutting off from emotional states.  In our work we find it useful for therapists to adopt a solid and competent position for a long period and to use this to help clients with narcissistic features to describe episodes from their daily lives, rather than expressing an abstract theory about the world.  They should then help them to identify those emotions in which they are often lacking.  When clients' descriptions of their relationships improve and a therapist wishes to stimulate their metaknowledge of them, it is useful to adopt the clients' preferred position (detachment from relationships) as a starting point and then get closer to them only as much as they allow" (Dimaggio et al., 2007, page 45).  From this perspective, the traditional admonition to delay couple therapy until the individual has had sufficient personal therapy to lessen narcissistic instincts and problematic behaviors seems wise.  Couple therapy and participation in a couple's relationship may inherently confront and activate attachment issues, trigger experience of being threatened, and shutting down.  However, as stated earlier the individual and the couple may not tolerate waiting for individual growth and healing.  The individual and the couple may be in crisis.  And, couple therapy may be the one and only opportunity over an extensive time within the couple's history that the narcissistic wounds and characterological issues are available to be addressed.  The therapist may not be able to wait or defer to problematic characterological issues improving over time and must often "do it anyway."  The couple may need the therapist to conduct highly skillful therapy despite all negative indications against it becoming successful couple therapy.

ASSERTING THERAPIST SUPERIORITY
The third-person observing position for the therapist is not an equal position.  It enables the therapist to step away from an egalitarian relationship to observe and comment on the person-to-person or equal dynamics between the narcissistic client/person and the therapist/person.  The observing role is purposely detached and therefore asserts authoritative credibility to comment on the person-to-person dynamics.  The third-person observer role is part of an effective strategy for the therapist taking a therapeutic style or strategy of superiority as the expert in the realm of relationships and psychology.  The narcissist can be acknowledged as expert or superior in many other realms, but not these.  Facing or experiencing a therapist who is overtly assertive as being superior and expert can activate the false self persona of the narcissist.  As the therapist observes and gives expert interpretation and metacommunicates about their interactions, this strategy also invites the narcissist to likewise comment and analyze both his or her and the therapist's behavior.  Since the therapist places their interaction outside of the two of them, it allows the narcissist to likewise step aside and self-examine from the outside as well.  This can be a safer transitional position for the narcissist to experiment with.  It allows for some distance as a second-person observer of his or her own first-person emotional needs, especially vulnerabilities.  Analytical consideration of self can move towards eventually becoming introspective and insightful about his or her vulnerabilities- that is, emotional ownership.

The strategy can make it safer for the narcissist to "submit" and accept the therapist as an authoritative object.  The narcissist asserts a special superiority that leads to self-righteous entitlement to exclude self from others rules or judgments.  And further entitles him or her to make judgments about and against others.  However, the therapist who successfully asserts an authoritative and expert leadership role takes over the entitlement to make judgments from the narcissist.  The therapist is the expert on relationships and has been successful hopefully with personal relationships (more on this later), rather the relationship deficient narcissist stuck in couple therapy.  The therapist has been there and traveled there successfully while the narcissist by definition of being in couple therapy, has not.  The "fact" or logic of the therapist's omnipotence about relationships is based on quantifiable observable reality, whereas the narcissist's case is based on an internal psychic need.  Confronting this can be delicate with the narcissist, but necessary.  The therapist presents him or herself as an experienced guide in the narcissist's metaphorical wilderness of lions and tigers and bears... oh my!  That is in his or her unexplored lost world of feelings, needs, and fears... oh my!  Once again, growth is offered through a reparative or an authoritative (boundaries and sensitivity) re-parenting relationship of baby steps not safely taken previously.

In addition, the partner is identified and offered as a fellow traveler or explorer in this journey.  If... a big if, the narcissist accepts and therefore, empowers the partner as a caring invested collaborator, their relationship shifts fundamentally. A further positive evolution may be if the narcissist can also accept and empower the partner as more expert on certain emotional dynamics of nurturing and caretaking.  This would be monumental shift, that if achieved would turn the somewhat less narcissistic partner towards his or her partner as a resource or guide.  While this may sound like a fanciful unlikely change in a narcissist, in some couples it may not be that difficult.  Often, the narcissistic partner can readily acknowledge the greater emotional, nurturing, and caretaking skills of his or her partner.  It is the narcissist's assumption that his or her activation of such skills creates vulnerability that creates his or her aversion. Of and as vulnerability is identified and redefined, the narcissistic partner may be willing to seek advice and model oneself with his or her more soothing partner.  The superior therapist-as-relationship-expert stance is necessary to offering corrections to the perceptual distortions that at the core of  narcissism.  The therapist must still be aware of communicating honestly while being artfully aware of the narcissist's hypersensitivity to criticism.

The narcissist has great difficult considering, much less accepting corrections to his or her emotional distortions.  It only becomes tenable if the narcissist's instinctive grandiosity and omnipotence can flex sufficiently to accept the therapist's superiority or omnipotence in relationship and intimacy matters.   Allowing the narcissist to be a third-person observer may prompt some beginning self-criticism and ownership of his or her behavior.  There are also many potential consequences of this approach for the partner of the narcissist.  The partner and his or her feelings and experiences may be validated for the first time.  The therapist can be a third-person observer and validater for the partner who has always been made "wrong."  The partner can also validate the therapist, which essentially functions as validating that "it" happens to both of them… therefore, it is real.  And, the partner is not crazy or illogical.  As and if this process develops, the partner gains more faith in the therapist, the therapy, and in the possibility of the narcissist changing.  The narcissist also gains more hope (a deeply unconscious hope) that he or she has found a nurturing authoritative parental authority figure who is not annihilating or smothering.

If the narcissist can accept the therapist as an authoritative person and be willing to defer to him/her to some degree, the structure and role of therapy is fundamentally reset.  Without acceptance of the therapist in a role of authority or expertise, therapy has not and cannot be successful.  Otherwise, therapy is just another venue for the narcissist to assert his or her grandiosity, superiority, and omnipotence.  And couple therapy is just another place that the partner is diminished and dominated.  This would be a major corrective achievement that should be overtly acknowledged in therapy.  "I'm impressed that you are able to consider my feedback without automatically becoming antagonistic and defensive.  Or, that you became antagonistic and defensive and were somehow able to restrain or modulate some instinctive aggressive responses.  That's quite remarkable considering the habits you developed to protect yourself from some pretty nasty ego attacks from childhood."  Therapy can pursue how this achievement contrasts with failures in trusting and investing in vulnerability and introspection.  The therapist however should not be deceived with some change.  The narcissist instinct will still be to try to take the therapist down or test him or her over and over.  The therapist needs to stay one step ahead… in a sense, by keeping the narcissist off balance.  That can mean keeping him or her on the therapist's therapeutic territory.  Re-asserting a territory the narcissist is unfamiliar with or unsuccessful with eventually leads him or her to unequivocally defer to the therapist (hopefully).  And, that territory again, would be the therapeutic realm, or the realm of healthy relationships.

This runs counter to the instincts of therapists who are philosophically egalitarian in how they may regard clients.  However, the narcissist, who will not feel valued or reciprocate an accepting egalitarian approach with respect since his or her issue is superiority, will eat up egalitarian therapists.  The narcissist maintains a grandiose stance of specialness and an omnipotence of superiority, which turns an offer of egalitarian status into a threat to drop down in status and distinctiveness.  Rather than using the authoritative stance to dominate the narcissist however, the therapist uses it to respect his or her needs.  Gently but firmly affirming the underlying need to be valued and respected, addresses the original wounding of the infant/child (rejection or failed attempts to be a "perfect mirror" by parents).  Therapy and the therapist can be corrective and reparative relationships to counter the deep narcissistic wounds.  The therapist must remember that he or she is the therapist and the narcissist is there because of his/her failure to do relationships well.  At some point… but a much later point in the growth and development of the individual's ability to risk vulnerability and forgo narcissistic behaviors, the therapist can hand over the expert role to the less or formerly narcissistic individual.  However, this gradual transition is highly comparable to that of parents to only gradually let go of monitoring and regulating their children as they gradually mature and can effectively self-monitor and self-regulate.  The authoritative role and position should not be let go quickly, since narcissistic instincts and behaviors are characterologically embedded.  Those therapists who are very careful not to pathologize clients may also be reticent about asserting this position.  It can be a difficult choice because of personal philosophy and alliance to certain theories.

Ironically, a narcissist may be more receptive to the more classic psychoanalytical styles that place the therapist in a superior mode if the therapist can establish clearly superior credentials.  The narcissist will challenge cognitive, analytical, insight oriented, psychodynamic, or psycho-educational interventions presented for consideration.  The narcissist is likely to draw the therapist into arguments, as he/she continually criticizes therapist feedback or interpretations.  His/her energy is to make the therapist- the rival for supremacy "wrong" all the time.  If the therapist is aware of his/her counter-transference, the therapist should realize that the experience of criticisms and attacks are the same experience the narcissist's partner continually has.   Although, the narcissist will attack a rival and, dismiss an inferior, he/she will defer to and respected clearly superior individual especially in a non-competing field.  This is often true despite research that states "individuals high in narcissism displayed amplified responses to social comparison information, experiencing greater positive affect from downward comparisons and greater hostile affect from upward comparisons.  Along a similar vein, individuals high in exploitiveness or entitlement reported greater levels of positive affect and self-esteem from downward comparisons. These results suggest that individuals who feel entitled to special favors are especially bolstered when their experiences match this worldview, but may feel angry and upset when others seem to be getting more resources than they are. The effects for positive affect and self-esteem were larger than the effects for hostile affect, suggesting that social comparison may primarily be used for self-enhancement purposes for those high in narcissism" (Bogart et al., 2004, page 42).

Questioning the therapist's credentials and maintaining intellectual domination over the partner reflect the need for downward comparisons with others.  However, while this behavior is instinctive and serves immediate compelling psychic needs of the narcissist, the therapist's acceptance of the narcissist's superiority and the corollary acceptance of inferiority subverts therapy.  Asserting superiority moreover addresses the narcissist's deeper need for an authoritative caretaker, who is also sensitive and nurturing.  The therapist can rationally assert a realm of superiority in relationships as clear and obvious, just as much as the narcissist's inferiority is clear and obvious.  Therapist superiority is compatible with Kernberg's approach.  The distortions and inaccurate interpretations of the narcissist are accepted if he or she is allowed to be superior.  If the individual is so intellectually and otherwise superior in these areas, then what is he/she doing in therapy- in particular, couple therapy!?  Something… many things have not worked, including who and why the individual has made choices in the relationship. Being in therapy is a de facto deference to the therapist or an acceptance of incompetence or inability.

The individual with narcissistic personality disorder or with significant narcissistic tendencies may interestingly respond well to the therapist who asserts leadership.  Narcissism manifests in various ways and degrees among different individuals.  Leadership or authority subscales of narcissism can express more positively than other aspects.  "Individuals high in leadership or authority tended to experience lower hostile affect from upward comparisons than did those low in leadership or authority.  These seemingly contradictory results can best be interpreted in light of Emmons' (1984,1987) observation that the leadership or authority subscale measures the healthier aspects of narcissism, whereas the exploitiveness or entitlement subscale of the NPI measures the maladaptive and pathological aspects of narcissism.  In the naturalistic situations measured by the diary, individuals high in leadership or authority may have chosen their comparison to others strategically, by targeting those individuals whose better-off standing was most likely to result in assimilation, not contrast.  By interpreting comparison to better-off others in a positive fashion, that they, too, could attain a better state, individuals high in leadership or authority were able to maintain an upbeat mood" (Bogart et al., 2004, page 42).  The therapist may be able to establish him or herself as an upward comparison, especially if personal credentials of success in healthy mutually beneficial long-term intimate relationships reinforce professional credentials.  The therapist who becomes perceived as having "better-off standing" may become a target not to be taken down, but as someone to aspire to joining.  

Functionally, that may disqualify a thrice-divorced single therapist as a viable leader when seeking couple therapy.  On the other hand, a happily partnered therapist or a previously divorced therapist who is in or has successfully "gotten it right finally... or this time" has the appropriate credentials to be an authoritative leader about relationships.  Therapists who refuse to disclose personal information to clients may find themselves automatically under suspicion or dismissed.  If queried about being in a relationship or being married, a confident response of "I have a great relationship," or "I've been married and divorced, so I know how to do it badly.  I learned from it... the hard way," asserts the therapist's credibility.  The additional assertion if applicable of "And now, I have an excellent relationship" further increases credibility.  While the narcissist will seek any issue to assert superiority and inflict feelings of inferiority, there is at least arguable validity that a therapist who is not or has not been in a functional fulfilling intimate relationship does not have the requisite experience or expertise to guide partners seeking a functional fulfilling intimate relationship.  Theoretical knowledge not manifested in a personal real world relationship becomes suspect when offered to clients.  The therapist who has a history of unfulfilling relationships will be challenged to assert the required confidence and leadership.  At the very least, he or she should seek consultation if not personal therapy about both his or her counter-transference in couple therapy and his or her personal process in relationships.

Given the narcissist's hypersensitivity to insecurity and instinct to exploit it through dominating and dismissive behaviors, any perceived therapist inferiority or equality becomes counter-productive to therapy.  If the narcissist discovers or suspects, "If you are worse than me... if you are no better than me, why should I listen to you?"  If the couple therapist has poor relationship history and/or a current problematic relationship, the narcissist is likely to sense the therapist's discomfort.  The therapist may think, "If I don't have a better relationship than you, why should you listen to me?"  And thus, the narcissist becomes unlikely to accept the therapist as a leader.  On the other hand, getting or having what he or she wants, including having been "there" negatively and "figuring it out" makes the therapist more likely to bee seen as a leader.  As a "superior equal," the therapist addresses deeper needs for leadership or parental authority... for attachment and for a role model, while mitigating the characteristic narcissist sense of threat from a competitor.  Narcissists cannot tolerate competitors in the same realm of expertise but are more amenable to an authority in a non-competitive realm or if the other person is clearly acclaimed in some manner.  In some competition of healthy functional intimate relationships, therapy is served if the therapist can assert being the clear "winner" over the partners in couple therapy.  Nevertheless, the therapist must still be vigilant that "Individuals high in overall narcissism, however, may have found it difficult to ignore unfavorable upward comparisons in their environment, resulting in contrast with better-off targets and an increase in hostile mood" (page 42).


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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