3. Narcissistic Personalities in Cple Th - 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 3: NARCISSISTIC PERSONALITIES IN COUPLE THERAPY


Jaymes represents a major presentation of narcissism.  He is "largely invested emotionally in the grandiose self representation, in which case the more classical, exhibitionistic narcissistic personality disorder is expressed via a blatantly exaggerated sense of entitlement, self-absorption, and a demand for perfect mirroring in the form of admiration and adoration from the projected object representation" (Roberts, 1997, page 238).  The obvious presentation can be a clear relationship traffic yellow light or red light for most relatively healthy individuals.  Less fortunate individuals may find themselves stuck in social, work, or academic situations with such narcissists and have great difficulty changing organizational or institutional dynamics.  Depending on social, economic, or educational constraints however, they can quit the relationship.  They do not ordinarily knowingly choose to insert themselves in social, work, or academic situations with a narcissist.  Instead by ill luck, promotion, transfer, or change in management, they unexpectedly find themselves working with a narcissistic colleague or manager.  Or in some cases, they have naively either thought themselves able to handle the narcissism; or underestimated the intensity of the narcissism.  They may have thought themselves immune to being targeted by the narcissist; or had been otherwise desperate or without other options for employment or academics.  The illusion of being an exception to narcissistic mistreatment has parallel principles in individuals who are attracted to, and start and stay in relationships with classic exhibitionistic narcissists.  However, not all individuals with narcissistic issues are as blatantly obvious.   "…when the major emotional investment is in the omnipotent object representation, a hidden, covert (Wink, 1991) or `closet' (Masterson, 1993) narcissistic disorder is revealed clinically. In this case, the individual `basks in the glow' of the omnipotent object, seeking perfection via fusion with this idealized object. The transference acting out of these two expressions of the disorder are manifested by mirror and idealizing transference configurations, respectively, as described by Kohut (1971, 1977). Thus, there are… the transferences which arise from the therapeutic mobilization of the idealized parent imago (to be called idealizing transference)' and `…those which arise from the mobilization of the grandiose self (comprehensively referred to as mirror transference)…'" (1971, p. 28)" (Roberts, 1997, page 238).

The following description of the narcissist entering into therapy may reflect his or her entry into an intimate couple's relationship.  "The narcissistic patient typically enters treatment transference acting out the grandiose self/omnipotent object fused unit. In these cases the patient is projecting either the fused self representation and expecting perfect mirroring in the form of adoration, admiration, and precise emotional attunement (mirror transference), or the fused object representation is projected in an effort to experience a sense of specialness and perfection by association with that idealized object (idealizing transference). In either case, however, the patient's grandiosity and false defensive self are buoyed, and the experience of the impaired real self and the affects of the abandonment depression are avoided" (Roberts, 1997, page 238).  While the narcissist's needs are more or less met, the couple stays in an acceptable homeostasis to the narcissist and also to the partner.  Relationship homeostasis becomes unstable as either or both the narcissist's needs create acting out behavior or the partner's needs evolve and are no longer met in the relationship.  Due to her issues and needs, Cheri tolerated the relationship for years.  While the narcissist individually or as a couple enters into the therapy with the therapist, the therapist cannot accept a similarly fundamentally dysfunctional relationship as the partner has tolerated for so long.  While someone such as Cheri has personal issues that compelled accepting narcissistic minimization, anger, and mistreatment, the therapist must establish a healthy relationship for therapy to have integrity and to work.  The therapist cannot simply give the narcissist such as Jaymes, disingenuous adoration and validation that buoys his grandiosity and false self.  Cheri had set aside her needs to maintain the illusion of intimacy, but the therapist should not compromise his or her role for a false rapport with the narcissist.   The challenge to the therapist is how to build rapport with such an individual when narcissistic driven patterns of relationship are inherently problematic.

KOHUT AND KERNBERG
Kohut and Kernberg represent two major strategies of working with someone with narcissistic personality disorder.  The Harvard Mental Health Letter (2004, page 3) summarizes each approach.  "According to Kohut, narcissistic personalities develop three kinds of responses, corresponding to their mental representations of key childhood relationships. In mirroring — the purest sense of narcissism — the therapist provides a reflection in which they can admire themselves. A narcissistic patient also may identify with an idealized therapist to gain strength. Finally, in twinship, the therapist becomes an alter ego on which they can model themselves. Kohut believes that in the beginning, narcissistic patients need the therapist as what he calls a primitive or archaic selfobject — the function served by parents in early childhood. Therapists should let themselves be used in this way because it creates an environment in which they can temporarily serve as a good parent and allow arrested emotional development to resume. The therapist should allow feelings of mirroring, idealization, and twinship to develop without interpretation or criticism until the time comes to show their limitations. Once the self has been strengthened, the narcissistic transference can be gently challenged so that the psychotherapist is acknowledged as an independent person — no longer unconsciously conceived as identical to the patient — whose limitations are not a betrayal of trust. This allows the patient to achieve a form of self esteem that is not illusory."  This approach is core to the relatively unconditional acceptance of various narcissistic behaviors despite their annoying and often disrespectful experiences for the therapist.  The partner who has lived with the narcissist may have essentially already tried to live this dynamic.  The problematic nature of this approach for some partners may be seen in the couple deteriorating to the degree that couple therapy is attempted.  The adverse consequences of this approach in therapy may be identified in the numerous therapists who abhor working with narcissistic clients.

In contrast, "Kernberg thinks the therapist must be more challenging from the start. He believes that the narcissistic self is not simply immature but distorted and in need of correction. The idealizing transference and the underlying envy and contempt must be confronted immediately and interpreted as a result of the patient's yearning for loving care from a parent. Kernberg treats idealization as a defense against fear of attack from a therapist to whom the patient has attributed his own anger. Psychoanalysis and psychodynamic therapy also require an analysis of the countertransference — the feelings of the therapist for the patient, which reflect both the patient's and the therapist's unconscious emotional conflicts. Narcissistic patients can be difficult to treat. Ungrateful, dismissive, demanding special treatment, they can make psychotherapists uncomfortable, angry, or ashamed of their limitations and defects. Psychotherapists may begin to feel ineffectual and incompetent, or on the contrary, may become too fond of being idealized. The therapist must recognize these feelings, put them in context, and use them to better understand the patient."  The difficulty to following Kernberg's recommendations and approach is that it requires managing the narcissist's acting out behaviors directed at the therapist.  Narcissists will often compulsively try to assert superiority over the other person, including the therapist.  Jaymes did this by questioning the therapist's credentials at the onset of couple therapy. Anyone who the narcissist perceives as inferior is dismissed.  As Jaymes threw the therapist off and triggered defensive responses, the therapist lost credibility and was likely to be dismissed.  And the therapist sensed this as clearly.  However, the narcissist will respect anyone who unequivocally proves or establishes his/her superiority, especially in another non-competing realm.  Any competitor is perceived as a threat to his or her alpha competence.  This then is also perceived as a threat to his/her basic worth.  Thus the therapist must challenge distortions without igniting the narcissist's competitive hypersensitivity.  If anyone ignites his or her hypersensitivity, then the narcissist will respond with ego syntonic self-righteous intensity… even cruelty to the perpetrator.  In therapy, the therapist becomes the perpetrator.

The therapist is often very skilled at analyzing and giving feedback about the individual's experiences internally and socially, as well as identifying the dynamics of behavioral choices.  Moreover, the therapist is often a third-person observer and critic of the individual's interactions with another person or people.  Correcting the individual's cognitive distortions moreover involves a first-person to second-person interaction in a two-person dyad.  For non-narcissistic clients, the corrective interactions often facilitate a reparative course in healing problematic attachment experiences or prior relationship stress or trauma.  That depends however on the relationship and dynamics between the two persons tolerating confrontation and disagreement.  The established or developing rapport or bond between therapist and client modulates any difficulties.  Or, the development of rapport, attachment, and trust may be the essential process of therapy.  Poor rapport, distrust, competitive superiority needs, and grandiosity intrinsic to the personality disorder, however make the narcissist fundamentally antagonistic to being corrected or critiqued by the therapist.  While Kernberg's basic strategy may be conceptually sound, its therapeutic execution is often intensely complicated and dramatic.  The therapist, who favors Kohut's strategy may experience frustration getting criticized despite being supportive and become antagonistic towards the narcissist.  Should or can the therapist tolerate Jaymes' criticisms? Such a therapist yet must then resist both the frustration and antagonism to maintain an accepting holding parental container.  The therapist who favors Kernberg's strategy may experience similar frustration and antagonism, but is theoretically empowered to bring them overtly into therapy.  Should Jaymes be confronted in couple therapy or individual therapy?  The therapist faces a significant challenge to be emotionally resilient, mentally agile, and clinically sound yet clear in confronting the narcissistic behavior.  And, the therapist must simultaneously manage the almost certain triggering of, repetition, and intensification of the narcissist behavior, so that the relationship and therapy can continue.   Moreover difficulties intrinsic to either major strategy in individual therapy are often exponentially intensified in couple therapy.

CRISIS
"For the most part, individuals with narcissistic personality disorders are uncommon in clinical settings.  They make up less than one percent of outpatient samples.   These individuals, however, come to attention when their marital or significant relationship runs into difficulties.  At the threat of losing their significant other, the narcissistic individual becomes acutely distressed and turns for help" (Links and Stockwell, 2002, page 525).  Working with an individual with narcissistic personality disorder in therapy is often uncommon and also, uncommonly challenging.  The core issues of the disorder, for example a need for asserting superiority and avoidance of implied inferiority make presentation for therapy counter-indicated.  Placing oneself in a supplicant or equal relationship with a therapist overtly or symbolically acknowledges the authoritative role of someone with greater skill, resources, experience, education, and/or expertise.  The individual with strong narcissistic issues thus would ordinarily have difficulty if not outright resistance to seeking professional help.  To be helped may imply helplessness and inferiority despite non-authoritative, non-directive, and humanistic based attitudes and behaviors by the therapist.  Arrival in therapy is tantamount to a psychic crisis.  The denial system may be broken down and/or the practical consequences irrefutable: loss of partner, loss of job, and/or acute and chronic dysfunctionality in other important areas of life.  

While some individuals may access individual therapy when faced with chronic life dysfunction, many individuals with narcissistic personality disorder will continue to deny personal responsibility or need, and resist therapy.  The crisis of relationship breakdown, especially imminent divorce may finally bring some such individuals to therapy.   However, his or her focus may continue to be on blaming the partner for transgressions or inadequacies.  Or, the partner with narcissistic issues may not own personal issues or needs, but assert the need for therapy to fix the "relationship" or "marriage" or "the family."  The presentation is that there is something akin to the relationship becoming a third-person entity to be fixed.  This allows for some psychic separation of personal qualities from the dysfunction of the relationship.  While narcissism makes resolving issues as couple more difficult (and therapy more difficult), narcissism may be the primarily source of dysfunction in the first place. "Glickauf-Hughes and Wells stated that the narcissistic spouse often carries the aggressive rage in a couple, while the masochistic partner carries the sadness.  It is crucial to assess the narcissistic individual's ability to handle the rage in a constructive way.  Typically, at the time the couple presents, the narcissistic individual has handled his or her rage by infidelity or other forms of acting out… An essential element to assess is whether the narcissistic spouse can deal more openly with his rage and anger" (Links and Stockwell, 2002, page 525).  In the phone conversation setting up the first session or in the first session/intake with the therapist, one or both partners may present an affair, financial problems (excessive spending by one partner, poor investments, bankruptcy), in-law conflicts, vacation planning, parenting, or other behavior- especially "communication difficulties" as triggering their problems and their need for therapy.  The therapist may be drawn to problem-solve a presenting issue and miss considering the relevance of history, underlying dynamics, and core potential personality disorder creating and perpetuating a problem- the presenting issue.

As the therapist proceeds without awareness of narcissistic dynamics, therapeutic feedback and guidance for the couple will often be ineffective.  One or both partners may respond with verbal and non-verbal affirmations of therapist feedback, but fail to integrate it into their communication and relationship.  The therapist can be extremely frustrated by the lack of progress.  The response, rather than cooperative and affirming may instead be highly negative and oppositional… and highly persistent.  Therapeutic guidance and interventions may be criticized and the therapist's credibility and expertise impugned.  It can continue or resurface over the course of therapy if not addressed. It is not surprising that many therapists do not like to work with individuals with narcissistic personality disorder and avoid them whenever possible.  Some therapists and theorists may find this client response counter-indicated to successful couple therapy.  "In our experience, individuals who continue to respond with distain and anger to any kind of interventions will not be able to make progress in couple therapy.  Having their spouses listen to interpretations that they see as denigrating and humiliating heightens the defensiveness even more.  If they are not able to demonstrate some vulnerability and express some of their fear of separation or loss of the spouse, then individual therapy is indicated as the first step.   Sometimes concurrent individual therapy will allow these patients to feel more protected, and will allow them to be more vulnerable" (Links and Stockwell, 2002, page 526).  The therapist may find that feedback or interpretations that are intended to be relatively benign and non-confrontational will be experienced as denigrating and humiliating.  In fact, the therapist may take extraordinary effort to frame feedback carefully… therapeutically bending over backwards to the point of bending therapeutic honesty and integrity.  The therapist may find him or herself therapeutically "walking on eggshells" from fear of drawing an attack by narcissistic anger.  In other words, the therapist will experience the same intimidation the other partner has possibly lived with for years.

ONE OPPORTUNITY
While referring the individual with strong narcissistic tendencies to individual therapy to prepare or develop him or her to handle couple therapy is a common strategy, it may not be therapeutically practical or maintain therapeutic integrity.  If the narcissism is the or one of the major roots of the couple's problem, including how and why the other partner has joined in the relationship, then "fixing" the narcissist first is problematic.  The narcissist may not be willing to be in individual therapy.  Only the crisis in the couple has brought him or her to therapy in the first place.  He or she may be highly resistant to self-examination.  Narcissistic vulnerability and hypersensitivity to being blamed would be activated by the referral to individual therapy.  In addition, the relationship may not be able to tolerate the "timeout" from couple's work, while the narcissistic partner is getting "fixed."  The relationship may be on the precipice of dissolution already.  Couple therapy may be the one and only opportunity to engage the reluctant individual with narcissistic personality disorder.  Narcissistic personality disorder should not be considered and perhaps, not treated solely as an individual's isolated issue, but considered and therefore, treated in its most compelling and important context- in an intimate partner relationship.  Manifestations of the narcissism may be destructive or problematic to relatively productive or highly successful in other situations or relationships: with colleagues at work, with fellow students at school, with friends socially, and among competitors with rewards, achievement, and status at stake.  However, it is in the intimate partner relationship that narcissism most closely replicates the family-of-origin dynamics that constitute its roots.  As such, couple therapy may be the most relevant opportunity to deal with narcissism manifesting in its most compelling relationship forum- the couple.  

Another vital clinical perspective looks at the compatibility between the narcissistic personality and the other partner.  Inconsistency practicing positive behaviors such as the seven caring habits and painful disappointment from negative behaviors such as the seven deadly habits should preclude attraction to such a partner, or trigger termination of the relationship with such a partner.  However, the partner of a narcissist… inevitably a long-term partner was attracted to and stayed in the relationship despite the emergence of repeated negative treatment.  Other individuals would have probably not been attracted (perhaps, been sensitive to cues of negative characterological patterns) or upon having been the target of narcissistic rage, then abandoned the relationship.  The therapist needs to recall that a pattern of narcissistic behavior in a couple is matched by some pattern or patterns of the other partner's behavior of acceptance, tolerance, compensation, and return (from forgiveness, memory loss, denial, and such).  The characterological issues of the other partner give permission for the couple come together and continue to exist up to the crisis leading to couple therapy.  As such, referring the narcissistic partner to individual therapy to be "readied" for couple therapy absolves the other partner culpability in the relationship's existence and dynamics.  In that sense, the narcissist's anger and resistance to being blamed as the corrupt partner without holding the other partner accountable has validity.  

The therapist needs to be alert his or her counter-transference "not liking" the narcissist and/or judging his or her behavior as the more negative.  The therapist also needs to be aware of complementary counter-transference about the other partner, including "liking" the other partner's "niceness" and/or identifying with his or her being bullied.   Such counter-transference feelings are powerful assessment cues that should be clinically pursued.  The intensity of counter-transference, determining the degree of narcissism and the difficulty of the therapy can be considered versions of essentially the same issues. "An essential element when working with a couple with a narcissistic spouse is to make a determination about the workability of the couple… three characteristics: (i) curtailing acting out, (ii) narcissistic defensiveness and vulnerability, and (iii) complementarity of narcissistic gratification, differentiate couples…"  The individual and couple triggering the therapist, intensity of narcissism, and complications or difficulty can be considered given elements of couple therapy.  At the same time, acting out, narcissistic defensiveness and vulnerability, and complementarity of narcissistic gratification are given elements of a couple with a narcissistic partner.  Links and Stockwell assert the degree of these elements determine "who will and will not benefit from couple therapy" (2002, page 526).  The therapist may consider that working with and through these relationship elements of any severity are intrinsic to therapy rather than indicative of the workability of couple therapy.  The relative severity would be indicative of the difficulty to sustain trust and intimacy within the couple.  Rather than indicative of workability and a theoretical reason to not attempt couple therapy, severity can be considered indicative the difficulty of the therapeutic process and determine therapeutic strategy.

SELF-ESTEEM VS. NARCISSISM
The narcissist presents with confidence that implies high self-esteem.  In fact, he or she, the other partner, and people in general often highly admire his or her apparent self-esteem.  After all, high self-esteem is surely considered much healthier and beneficial than having low self-esteem.  Watson et al (1993) studied the relative benefit of various aspects of narcissism.  "The leadership/authority, superiority/arrogance, and self-absorption/self-admiration dimensions were reconfirmed as largely adaptive in their mental health implications because each correlated directly with self-esteem and inversely with goal instability and peer-group dependence.  A small positive linkage also appeared between self-absorption/self-admiration and mother nurturance scores. Higher superiority scores also were associated with greater self-esteem… a small but reliable positive correlation was observed between self-esteem and exploitativeness/entitlement scores; however, beyond expected linkages with the other narcissism variables, exploitativeness/entitlement scores showed not other significant relationships" (Watson et al., 1993, page 66).  "…adaptive narcissism may operationalized 'positive illusions' about the self that social cognitivists have connected with relative mental health (see, e.g., Hickman, Watson, & Moris, in press; Watson, Sawrie, & Biderman, 1991).  Regarding these illusions, Taylor (1989) suggested, 'Before the exigencies of the world impinge upon the child's self-concept, the child is his or her own hero… Moreover, these grandiose assessments are quite unresponsive to negative feedback' (p.8)" (Watson et al., 1993, page 70).  Grandiose self-assessment may be connected to relative mental health.  Narcissism may not so much the same as high self-esteem but a means to gain self-esteem.  Is such self-esteem stable and qualitatively sound, or is it illusionary- perhaps, indicative of frailty?

The therapist and others often assume that the narcissist has high self-esteem and perhaps, an inflated sense of self.  The other partner is normally identified as having lower self-esteem.  People who are aware of the partner's mistreatment at the hands- usually, the mouth of the arrogant narcissistic partner usually perceive him or her as having very low self-esteem.  The assumption is only with the low self-esteem would the partner accept constant demeaning and disrespectful treatment.  If he or she had higher self-esteem, he or she would have given the narcissistic partner the heave ho and found someone who treated him or her better.  Therefore, supporting and building ones and others self-esteem becomes vital to relationships, in particular to raising and educating children.  The narcissistic partner may boast of self-esteem, confidence, and cite numerous career and financial indications of status.  He or she may even lament the low self-esteem of his or her partner while delineating the various criteria the partner has come up short.  His or her rendition of worth and achievement especially relative to the shortcomings of others (in particular, the partner) may be more or less subtle or overt.  Depending on cultural training, social skills, and temperamental traits, self-esteem may come off as highly charming and even humble.  Often, the socially adept narcissist is viewed as a great guy or gal, charismatic, fun, and a leader by almost everyone except the intimate few for whom the veil of propriety is lifted.  Swaggering bravado and occasional bullying behavior is tolerated… even celebrated as an acceptable regrettable characteristic within the package of brilliance and performance craved by others.  Upon closer examination over a longer period of time and in particular, under the stress of confrontation or dispute, the social presentation may become more gross and off-putting.  Possibly illusionary adaptive self-esteem may break down in presentation.  The apparent self-esteem presentation and others perception of them becomes problematic as certain individuals

Often brag
Act smug and superior
Aggressively expect their needs to be satisfied first, and become angered and abusive if not satisfied
Act superior to others based on high skills or desirable qualities in certain areas
Remain ignorant to personal flaws
Unlikely and/or unwilling to change
Often are impulsive
Violate boundaries as applicable to others but not themselves.

A Google search (January 6, 2012) for "Too Much Self-esteem" resulted in 33,200,000 results.  Yet, self-esteem remains considered a desirable trait and goal, especially for children.  The results and discussions may reflect a failure to distinguish or qualify self-esteem as related to but not synonymous to narcissism.  "The psychiatric definition of narcissistic personality includes many destructive forms of selflove — not only vanity but self-importance, self-absorption, self-centeredness, and a patronizing or contemptuous attitude toward others. It is a problem in its own right and a complication in the treatment of many psychiatric disorders. But narcissism is also related to self-esteem, which psychotherapists usually regard as valuable and want to encourage. So it becomes especially important to distinguish narcissism from self-esteem and related traits — self-liking, self-acceptance, and self-confidence" (Harvard Mental Health Letter, 2004, page 1).  Promoting higher self-esteem in clients and especially in couple therapy so that raising one partner's self-esteem is not at the detriment of the other partner's self-esteem is a challenge in therapy.  In a win-lose situation, a partner cannot increase self-esteem without taking down the other partner.  The narcissistic personality experiences win or lose rather than a win-win option in many, most, if not all confrontational, contentious, or competitive situations.  Hypersensitivity causes him or her to see many circumstances otherwise benign to others as confrontational, contentious, or competitive.  Needing to maintain his or her omnipotence is a consequence of deep low self-esteem rather than high self-esteem.  The therapist needs to raise the narcissistic individual's self-esteem contrary to superficial and incomplete and inaccurate assessment of his or her high self-esteem.  "The challenge is to confront grandiose attitudes toward the self at the same time. In treating narcissistic personalities, encouraging the right kind of selflove while promoting realistic attitudes toward oneself and others is a difficult but worthwhile therapeutic challenge" (Harvard Mental Health Letter, 2004, page 4).

The narcissist, the individual with narcissistic personality disorder, or someone with strong narcissistic tendencies or issues become labels that can be used interchangeably.  The degree of narcissistic energy and the frequency and intensity of behaviors become important to ascertain for the therapist in conducting therapy.  "There are a series of advantages to knowing the interpersonal processes typical of narcissistic persons: (a) It makes it possible to foresee, at least in part, how a therapeutic relationship will evolve. For example, if therapists suddenly feel that they have exceptional qualities because the patients they have in front of them are extolling them, they should know that they could soon, on the contrary, be disdained or kept at an emotional distance. (b) It helps therapists to recognize the emotions and thoughts that typically get elicited in them with such clients. This helps them to quickly master any dysfunctional action tendencies; (3) It makes it possible for therapists to help clients become aware of their interpersonal styles and of how these impact the course of any relationship they describe as being unsatisfactory" (DiMaggio et al., 2007page 26).  The therapist awareness and resultant therapeutic strategies or interventions may strongly mirror the relationship interactions and dynamics to be facilitated between the narcissistic partner and the other partner.


ADDRESS:
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Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
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