Individuals tend not to seek therapy specifically for their narcissistic characteristics, but instead for circumstances and experiences that have been caused at least in part by the characteristics. Narcissistic perspectives and feelings are ego syntonic to the individual. Despite making choices and behaving from cognitive and psychological consistency, in the real world with other people without like-minded perspectives, the results can be problematic. "As the disorder often coexists with other conditions, it is important to assess the extent to which narcissistic traits are impacting (e.g., interacting with, maintaining, escalating, etc.) other diagnoses and adjust treatment accordingly. Employing different assessment techniques and information gathering instruments will help achieve a clearer clinical picture. For example, an individual who does not meet criteria for a narcissistic personality disorder diagnosis may seek treatment for help with depression. While the person may not manifest a sense of grandiosity or lack of empathy, an unfulfilled need for admiration may be escalating the depression. Thus, without a formal diagnosis, narcissistic personality traits are still playing a role clinically and must be addressed as such" (Rivas, 2001, page 30). The therapist often encounters a client who presents initially for depression or anxiety only to discover that the core of the depression or anxiety comes from relationship problems. The client is able to enlist the partner to attempt couple therapy to work on the relationship. In conducting couple therapy, the therapist may find a core issue in the relationship dysfunction may be a partner's alcoholism or drug abuse. Underlying or co-morbid with the substance abuse may be posttraumatic stress disorder (PTSD) for example, from military service trauma or trauma related to sexual abuse in childhood. Concurrent or foundational to all these issues may be a personality disorder. Diagnosis is often fluid and evolves and changes over the course of therapy. Accurate diagnosis is critical to good therapy not just in the initial sessions, but also at every stage of therapy.
The therapist, Lyndee was concerned with her client, Donah who she had diagnosed with borderline personality disorder. She had been seeing Donah and her boyfriend for couple therapy with frequent individual sessions for each of the partners. Donah tended to need individual sessions significantly more often than her boyfriend. Lyndee was considering terminating therapy with Donah and her boyfriend after a series of no shows, late cancellations, bounced checks, and hostility when confronted regarding these issues. Donah and her boyfriend were chaotic in their relationship, communication, and scheduling. Missed therapy appointments, late cancellations, and mix-ups communicating scheduling changes were not isolated, but another aspect of their erratic disconnections. When there were problems with the couple therapy appointments, the partners blamed each other. However, Donah also messed up her individual sessions with Lyndee. She was difficult when asked to take responsibility her appointment problems. These behaviors seemed typical of borderline personality disorder. Lyndee was concerned about Donah's potential vengeful behavior. Donah had told the Lyndee that she had made complaints about two previous therapists to the state licensing board. While the therapist was wary of the borderline tendencies of the client, it was important to consider that was not client was not borderline or just borderline. In other words, Donah may be much worse than the therapist realized. Donah presented borderline behaviors, along with narcissistic issues, and possibly also as having paranoid tendencies. As opposed to a charming narcissistic, Donah might be better characterized then as more of a crude narcissist. She asserted superiority over everyone, and insisted on keeping others, especially her boyfriend in their places. Lyndee observed this in sessions. Donah also tried to keep her, despite Lyndee being the therapist in her place. One can recognize certain public figures in politics, big business, sports, the performing arts: actors, singers (divas), and musicians, and religious and educational leaders who display narcissistic behaviors- more often, the charming narcissist. The therapist may think of the individual with narcissistic personality disorder as usually presenting as sociable, competent, charming, and otherwise "normal" unless threatened with competition.
This had been Lyndee's initial experience with Donah. Donah had been fairly charming with Lyndee earlier in therapy. She said she wanted to have a few individual sessions and then bring her boyfriend in for couple therapy. Lyndee brought up potential ethical issues with changing the unit of treatment from individual therapy to couple therapy. Donah reassured her that she really wanted to work on couple's issues but felt that getting to know Lyndee first was important. She would be fine for Lyndee to have some individual sessions with her boyfriend after they started the couple's work. After they began couples sessions, Donah's boyfriend came in for one individual session but had otherwise had not accessed that option. In the beginning individual sessions, Lyndee had been focused on building rapport with Donah as she normally did early in therapy. Lyndee was empathetic and gave feedback on Donah's process as Donah talked about how her boyfriend sometimes disappointed her. She mistook Donah's pleasant responses and flattering commentary about the therapy and her as a "great therapist" as indication of development of their therapeutic bond.
When Donah first did not show up for a scheduled appointment, Lyndee asked for her fee as stipulated in the General Information and Consent form that Donah had been given and had signed. To her surprise, Donah got upset. Donah challenged Lyndee, "You expect me to pay for nothing!? I didn't get a session. So you got an unexpected break. Are you that hard up?" Lyndee reminded her that they had gone over the cancellation policy and the requirement to pay for sessions that were not canceled with 24 hours notice. Lyndee insisted on being paid for the missed session per the agreement, Donah had paid for it but had been sullen for the rest of the session. Although, Lyndee tried to engage her about the issue clinically, Donah refused to talk about it. They scheduled for the next week's session at couple's regular time at 5 pm Tuesday. At exactly 4:59 pm the next Monday, Donah called and left a message on Lyndee's voicemail canceling the appointment. She repeated at the beginning and end of the message that it was 4:59pm and sarcastically emphasized that she "hoped that I made it by the 24 hours deadline as stated by your General Information and Consent form… that I have signed my life to." She also committed to the following week's couple's session at the usual day and time. Lyndee theorized that from this and other behaviors that Lyndee had borderline personality disorder. Lyndee believed that holding her accountable for paying for the missed session had made her the betrayer to Donah. As a result, she believed that she became the target of borderline lashing out. She approached Donah from that diagnosis.
With the individual with borderline personality disorder, his or her entry into therapy often comes from repeated behavior that harms self-esteem, happiness, and relationships. The individual does not enjoy borderline emotions or behaviors. He or she loses valuable relationships that are deeply desired. The individual has tremendous remorse after the fact about over-reactions, emotional outbursts, poor choices, and hurting behaviors. He or she is genuinely sorry for hurting the person who has suffered the borderline lashing. The presence of remorse is a major characteristic of borderline personality disorder that distinguishes it from narcissistic personality disorder. The individual with narcissistic personality disorder does not have genuine remorse for his or her behaviors. In fact, the individual ordinarily feels that his or her behavior is always logical and justified. He or she may have regret that another person is hurt or has problems, but normally lays the blame on the other person. The individual is unable to hold him or herself responsible for any questionable behavior and thus, tends not to have true remorse. The blockage to growth and change in the relationship and also productive therapy with the individual with narcissistic personality disorder is that his or her narcissistic rage is normally subconscious and unavailable for examination and consideration.
Lyndee tried to engage Donah about her anger over having to pay for the session. Donah apologized for her reaction while simultaneously justifying it as coming from being surprised that Lyndee had been unsympathetic to her financial stresses. She also blamed her boyfriend who was in the session. That lead to an argument between them with different memories of what was said and who was supposed to do what. Lyndee could not make sense of it to figure out what was the reality. Donah had remorse to some degree because she was invested in the relationship with Lyndee. However, she also wanted to control the relationship, as she wanted to control all relationships. Moreover, she was very adept at manipulating others by responding to their needs and vulnerabilities. Donah "played" to Lyndee wanting Donah to like her and be bonded to her. In general, Lyndee is similar to many other therapists who want to be liked and appreciated. Donah gave that to her before and after the confrontations. After being blasted a couple of times and getting apologies, Lyndee reaffirmed to herself that Donah fit the pattern of borderline personality disorder.
Lyndee misdiagnosed Donah as having borderline personality disorder rather than having narcissistic personality disorder; or possibly has having both borderline and narcissistic personality disorders. The diagnosis labels are conceptualizations and often reflect or imply having reached a threshold of characteristics on a hypothetical spectrum or continuum. How borderline and/or how narcissistic a person may be, or how many characteristics of one or both (or other) characterological disorders or syndromes apply can help shape therapeutic strategies. The therapist can confuse him or herself if failing to maintain a more fluid use of diagnostic suggestions. This may not be uncommon. "The high comorbidity rate among the different personality disorders has been of particular concern to researchers (Clark, 1992; Widiger et al., 1991). Comorbidity in he diagnosis of narcissistic personality disorder has continuously been a source of debate (Geiser & Lieberz, 200; Hart & Hare, 1988; Ronningstam, 1998; Ronningstam & Gunderson, 1988; Siever & Davis, 1991). Morey and Jones (1998) referred to narcissistic personality disorder as '…one of the worst offenders on Axis II with respect to diagnostic overlap' ([.362). They cited research that has found overlap as high as 53.1%, with histrionic personality disorder, and 46.9%, with borderline personality disorder (Morey, 1988). In their review of data from 11 different studies on narcissistic personality disorder, Gunderson, Ronningstam, and Smith (1995) found that individuals who met criteria for narcissistic personality disorder through structured DSM-III (1980) or Diagnostic Statistical Manual for Mental Disorders (3rd ed. Rev: American Psychiatric Association, 1987) assessments consistently met criteria for other Axis II disorders. The overlap for individuals with narcissistic personality disorder and other personality disorders was often in excess of 50%. The overlap between some Axis II disorders was still present when DSM-III-R (1987) criteria were used ranging between 25% and 50%" (Rivas, 2001, page 25). Examination of current DSM-IV or DSM-V criteria for personality disorder overlap would likely replicate the older findings.
Although Donah seemed to acknowledge her negative behavior to Lyndee, there was a subtle subtext to her apologies. She made excuses or justified her negative behavior as compelled by her circumstances. In a more obvious narcissist, the individual is self-righteous and feels entitled to his or her emotional and behavioral reactions. Despite how hurtful, toxic, or the extent of the pattern, the individual experiences it all as ego syntonic. The reaction and behavior makes fundamental sense to the individual or is acceptable because of some exception that may not be perceived or held by others. In contrast, the individual with borderline personality disorder is remorseful about his or her behaviors because it is counter to his or her sense of a positive "good" self. His or her behaviors are disturbing to him or herself because they are ego dystonic. Although, the individual with borderline personality disorder feels justified in lashing out in the midst of intense emotional reactivity, after calming down and contemplating the actions, the individual feels tremendous remorse. The individual with borderline personality disorder is usually eventually able to tolerate the other person subsequent confrontation of the behavior and able to take responsibility for it. The individual with narcissistic personality disorder, on the other hand shirks responsibility.
When Donah talked about her boyfriend, she described him as generally very sweet if a bit simple. He adored her, but would be forgetful. In couple therapy, she often took a condescending tone speaking to him. In an individual session, Donah described how she had scheduled meeting him at an expensive restaurant and stood him up on purpose. "He deserved it for forgetting to call me about his schedule." When Lyndee asked if she thought that was fair, Donah just smiled and said, "My boyfriends don't get away with overlooking me." When Lyndee challenged her about how that behavior could harm the relationship, Donah argued that it was necessary to set the appropriate boundaries and expectations between her and her boyfriend. Questioned about whether she was held to same rules, she asserted that her boyfriend knew that she was "high maintenance." In couples sessions, her boyfriend first asserted that Donah was not fair with him, but also he readily blamed himself for being too passive and not communicating clearly enough. Gradually, Lyndee began to recognize that Donah had convinced him that he was in the wrong. Her narcissistic cognitive distortions had him doubting his own memories, feelings, and thoughts. Narcissistic needs for maintaining omnipotent self-image manifest in verbally and intellectually sparring with others. When Lyndee attempted communications training with them, she observed Donah talking circles around her boyfriend. Donah attempted to do the same with Lyndee, frequently disagreeing with her feedback and interpretations. Over the course of therapy, Donah became less and less deferential with Lyndee. While relatively contrite about being called on her first missed session, over time she became more argumentative with Lyndee. She wanted exceptions allowed for her. In exploring Donah's requests for differential- that is, special treatment, Lyndee began to gather a history and pattern of similar conflicts with friends (former friends), work colleagues including supervisors, and other professionals.
The narcissist's enjoyment and practice of dominating others often works to advance careers, and to dominate another such as the partner without remorse. The individual will also try to dominate the therapist when in therapy, perhaps even more so when compelled to enter therapy. If unable to dominate the other person: colleague, subordinate, partner, adolescent child, or therapist, the individual does not adapt or reflect whether he or she has responsibility. Instead, he or she will intensify tactics to force domination at the risk of destroying the relationship and losing social reciprocity. Maintaining supremacy is more important than maintaining the relationship. When threatened, the individual feels entitled to upset or insult the partner or the therapist, as much as charming the partner or therapist was critical to his or her self-esteem initially. The individual with borderline personality disorder in contrast is highly averse to risk the relationship ending and being alone. Rather than maintaining superiority, he or she feels fundamentally inferior and may fawn over his or her partner. When the narcissist feels threatened, narcissistic rage is triggered and he or she is compelled to try to destroy the challenger as a mortal enemy. Donah's behavior with her boyfriend was problematic. However, her behavior in therapy with Lyndee was more disturbing to Lyndee. Despite clanging clinical instincts in the background, Donah's performance as the attached and regretting person manipulated Lyndee. As Lyndee assumed that it was difficult borderline behavior, she focused the therapy on the deep emotional wounds and attachment needs. Lyndee experienced normal counter-transference successively feeling ambushed, hurt, angered, and then compassionate and forgiving. She was sufficiently theoretically self-aware to identity her response as from dealing with a borderline personality disorder. Lyndee girded herself to deal with a difficult borderline client not realizing that she was dealing with an even more difficult client with combined borderline and narcissistic issues or a version of narcissistic personality disorder.
A major cue of Donah's process came with discussion about her previous conflicts with others. While Donah seemed to regret loss relationships and opportunities because of her acting out, she also seemed to be proud of her prior behavior. Accompanying expressions of regret for loss relationships, she would vilify the antagonists as insensitive and deficient intellectually or morally. The implicit assertion was that they brought her vengeance upon themselves- they deserved what they got. When Lyndee reflected to Donah that she seemed hold a moral justification to her behavior, she stated that she "I'm not someone to be taken lightly." Perhaps, she had been over the top at times, but essentially others got what was deserved. Since individuals with borderline personality disorder often run through several therapists- finding each one lacking sufficient empathy and eventually, betraying them, Lyndee checked about Donah's experiences in therapy. Donah had been in therapy with several therapists over several years. Some of the relationships had lasted multiple years, while others were short-term. This history misled Lyndee somewhat. Individuals with narcissistic personality disorder tend not to bring themselves to therapy so much as they get compelled to when life problems reach undeniable crisis levels. On the other hand, individuals with borderline personality disorders can be habitual and frequent therapy users who experience virtually all intimate relationship loss as crises. Asked how prior therapy and therapists had worked out, Donah gave what appeared to be a classic borderline answer. Initially, saying they had not worked out, eventually she added that one and another had let her down- that is, betrayed her. Then she added, that Lyndee was the "best therapist I have ever had." Recognizing this as a common borderline comment, Lyndee resisted the borderline therapeutic seduction. Pressing her for more specifics that would confirm the borderline process, Lyndee asked about specific experiences with each prior therapist.
Lyndee was appropriately alarmed when Donah described with calm and charming confidence what had happened when she brought her then boyfriend into therapy with a prior therapist. It was her individual therapy, but the therapist with Donah's prompting thought some conjoint sessions would be helpful to deal with Donah's anxiety and depression from relationship problems. Donah said that she was shocked when the therapist seemed to consider her boyfriend's rendition of their actions and dynamics to be possibly credible. The therapist who Donah felt had been so understanding and compassionate now sided with her boyfriend and criticized Donah's behavior. Donah had walked out of the session leaving her boyfriend and the therapist behind. The boyfriend and the therapist finished the session alone. The next week, Donah had seen the therapist alone. She accused the therapist of betraying her and berated her for aligning with the boyfriend. She went over chapter and verse how the therapist had been wrong. Then she criticized the therapist for continuing the session with her boyfriend. What had they talked about? What secrets of Donah's had the therapist shared with her boyfriend? At the end of the session, the therapist asked for payment for the session and the previous session. Donah was outraged, "I'm not paying you for my boyfriend's session with you!" Donah left without paying for either session. She had "forgotten" her checkbook. Donah never went back to the therapist. Donah never responded when the therapist called and left messages to reschedule and later, to ask for payment for the two sessions.
With a slight smile on her lips, Donah said that she had made a complaint to the state licensing board about the therapist accusing her of unethical practices including her boyfriend in the therapy, breaching confidentiality by talking with her boyfriend, (although, Donah had requested it) and for trying to charge for therapy that was for her boyfriend. She cited quasi-logical and questionable legal rules about confidentiality to justify her actions. Donah smiled expectantly at Lyndee as if she anticipated Lyndee to not only agree with her, but also be impressed. Lyndee tried to point out that the therapist was caught in an unanticipated difficult situation and had responded without necessarily any negative intent. She speculated that the therapist must have been surprised and uncomfortable as things evolved. Donah talked over her as if Lyndee had not said anything, re-emphasizing the injustice of the therapist's behaviors. Donah virtually bragged that after she made the complaint to licensing, the therapist "didn't call me anymore about paying for any sessions!" Lyndee felt dismissed and demeaned, which is more characteristic of therapist counter-transference reacting to a narcissist than with a borderline personality. Donah was demonstrating "a pervasive sense of grandiosity, need for admiration, and a lack of empathy for the feelings of others (DSM-IV, 1994). For example, this could manifest itself behaviorally in the individual who exaggerates a minor achievement (e.g. cleaning the house), expects praise and recognition without doing anything to earn it (e.g., just for being alive), and feels entitled to express their opinion without being burdened by listening to that of others (e.g., 'I don't care what you may have to say about this. Listen to what I have to say.')" (Rivas, 2001, page 24). Donah wanted recognition from her new therapist Lyndee about how well she had manipulated her old therapist! When Lyndee pointed out the ambiguity of legal interpretations and the clinical questions, Donah stated smugly, "Well, I don't think you would understand. I'm not surprised that you therapists would stick up for each other."
Careful reflection on prior therapeutic information and subsequent interactions caused Lyndee more discomfort about her fitness to be work well with Donah. She found herself liking Donah less and less, and losing the compassion that she held previously for her. Lyndee began to get tense when she saw Donah on her daily schedule for individual or couple sessions. She was anxious that Donah would criticize her and she would not be able to respond adequately. Lyndee sought consultation from another therapist. Presenting Donah as having borderline personality disorder, Lyndee got advice from the consultant for working with a borderline client as opposed to a narcissistic client. Lyndee decided to bring her counter-transference overtly into the session. She told Donah what she had observed about Donah blaming others, lashing out, and being self-righteous. In addition, Lyndee told Donah that she noticed how often Donah made demands of and criticized Lyndee as the therapist and the therapy. Donah was unapologetic and dismissed the feedback, asserting, "What am I supposed to do when you're not helping me?" A more characteristic borderline individual might have been alarmed that he or she had upset the therapist. The borderline might have been genuinely apologetic and want to repair the relationship. Instead, Donah's attack threw Lyndee off balance again. Like many therapists, Lyndee wanted to and was used to being liked and respected, or at less treated with deference. When Lyndee asked Donah, "How do you think I feel when you're so critical? What do you think happens with me?" she replied, "What? I'm supposed to take care of your feelings? You're the therapist and you're supposed to know what do." Withholding empathy and being accusatory are responses are typical of narcissism, which Lyndee was beginning to recognize.
After the following interaction, Lyndee should have considered still another diagnostic issue. As Lyndee pointed out that she was a person as well as a therapist and thus, had normal human feelings and reactions to anger and criticism, Donah snorted that, "You're like all the other therapists." Asked to explain what she meant, Donah said, "Therapists always pretend they want to help, but they're in it for the money. They keep on playing along with my feelings and then screw me over. It's only a matter of time before you will too." This exchange caused Lyndee to recall an earlier interaction that rang a small bell of alarm. Something was amiss, but she had not identified what it was. When Donah had told her about making the complaint against the previous therapist, Lyndee had pointed out the ambiguity of legal interpretations and the clinical questions. Donah had been dismissive, as she had increasingly gotten since then, but also stated smugly, "Well, I don't think you would understand. I'm not surprised that you therapists would stick up for each other." Donah's emotional arousal had caused Lyndee to diagnose her as having borderline personality disorder, although she had come to recognize more narcissistic patterns without the calmer or cooler presentation characteristic of classic narcissism. Lumping Lyndee together with "them" as "you therapists" and designating all therapists as being against her suggested that Donah may also have paranoid personality tendencies or issues.
BORDERLINE, NARCISSISTIC, AND PARANOID… OH MY!
As an overwhelmed and scared Dorothy said in "The Wizard of Oz" (LeRoy, 1939) while walking in the forest on the yellow brick road, "Lions, and tigers, and bears! Oh my!" the therapist may realize that he or she is not in therapeutic Kansas anymore. Borderline, narcissistic, and paranoid… Oh my! Therapy is sometimes much more complicated. The individual with narcissistic or paranoid personality disorders share characteristics of entitlement, a sense of superiority, lack of remorse, and believing his or her reactions and behaviors are appropriate. His or her sense of self and emotional and behavioral reactions are ego syntonic. The individual with narcissistic personality disorder, however even when in a narcissistic rage may not show significant arousal. Transitory high emotional arousal is characteristic of borderline personality disorder, while cool logical presentation is characteristic of narcissistic personality disorder. However, intense and frequent emotional arousal that Donah displayed more and more often is characteristic of paranoid personality disorder. In narcissists, harsh, insulting, or hurtful behavior is presented with a veil of reasonableness without overt emotionality. While narcissistic self-righteousness is largely intellectual, while seeming devoid of emotions, paranoid self-righteousness is more fully emotionally aroused. Paranoid arousal however differs from borderline arousal, which comes out of reactivity that is confined to a short time frame. The arousal dissipates relatively quickly as relationship loss is experienced. The individual with borderline personality disorder may function in an otherwise generally positive manner, but can become volatile when triggered. The individual with paranoid personality disorder stays in or is perpetually perched on the edge of arousal, always leery on the lookout for activities of the world conspiracy against him or her. The individual's arousal is based on deep resentments that anticipate eventual insult and violation from anyone and everyone. This was Donah. It is only a matter of time. Borderline reactivity and lashing out has to do with betrayal, abandonment, and rejection threats, while narcissistic annihilation arises out of competitive reaction to image threats. Paranoid animosity and hurtful behavior comes from feeling everyone and anything is a potential threat- including the therapist!
The therapist may need to assess for overlapping and differing characteristics when he or she suspects that the individual may have a personality disorder. Recognition of different disorders enables the therapist to appropriately adjust therapeutic strategy. Lyndee's therapeutic strategies and interventions, and subsequently therapeutic success were compromised from misdiagnosing Donah's complex mixture of personality disorder issues. Donah was a highly problematic client. Lyndee's clinical experience and intuition correctly pointed to a personality disorder of some sort. Her instinct that Donah may be vengeful if Lyndee chose to terminate therapy for clinical and business reasons (ineffective therapy and failure to follow contracted contractual agreements regarding fees and cancellations) was probably also correct. Lyndee could not guarantee that Donah may not try to punish her for termination. However, she could minimize the possibility through correct assessment of Donah's characterological and psychological patterns of behavior, and handle the termination in appropriate therapeutic fashion. And/or best anticipate a probable vengeful act (such as complaint to the licensing agency as Donah claimed that she had previously done) and take necessary and appropriate steps to protect herself.
Hypothetically, the borderline client would be less likely to lash out if he or she can endure the immediacy of pain from betrayal, abandonment, or rejection, or not experience betrayal, abandonment, or rejection in termination. Anticipating that the borderline will feel betrayal, abandonment, or rejection, the therapist can attempt to frame termination clearly in other terms, while acknowledging that those feelings may be triggered. The therapist can develop a termination process and plan where the client can address the feelings rather than act them out. With the narcissistic client, the therapist should avoid igniting his or her narcissistic rage through overtly or inadvertently asserting dominance, superiority, or "winning" in the termination process. Triggering feelings of inferiority, being made wrong, or other negative competitive dynamics is intolerable to the narcissist and cause him or her to need to punish the therapist. This might conceivably mean the therapist letting the narcissist "win" any contentious issue. This may however challenge the therapist's sense of therapeutic integrity. The therapist may be able to terminate with integrity by acknowledging that the dynamics, circumstances, and/or the needs of the client are outside his or her capacity, experience, or skill level. Better left unsaid would be that few if any therapists have the capacity, experience, or skill level to meet the needs of intensely narcissistic individuals.
The individual with paranoid personality is continually accruing experiences and evidence of the ongoing conspiracy against him or her. Theoretically, the therapist's behavior (failures to him or her) is not new or special. They are characteristic of his or her life and circumstances. As such, the therapist as an enemy is also not special. The paranoid personality tends to seethe with resentment, but not necessarily act out until reaching some great threshold of accumulated injury. Chances are that the paranoid personality would not invest enough (trust enough or be vulnerable enough) with the therapist in the first place. And not gain sufficient resentment or injury to cross the threshold and become "postal." Or, if the therapist were unlucky enough to be the one when the threshold is crossed, there would be little that can be done to prevent the punishment. Compared to borderline and narcissism, however the individual with paranoid personality should be relatively easy to recognize. He or she is not nice and pleasing like borderline personality disorders, nor charming with deeply hidden anger like narcissistic personality disorder. The paranoid personality disorder tends to live on the surface- aroused and self-righteous, hypersensitive and reactive. Hypothetically, quick recognition by the therapist should cause the therapist to alter behavior, interactions, or interventions to preclude problematic dynamics that contribute to paranoid feelings, and reduce the likelihood of problematic paranoid-based behaviors directed at the therapist.
Lyndee would have conducted therapy differently if she had diagnosed the significant narcissistic issues and the paranoid tendencies among Donah's increasingly more obvious borderline behaviors. When Donah and her boyfriend broke up, Donah wanted to continue working with Lyndee. Lyndee had major ethical concerns since the unit of treatment had been the couple. However, Donah seduced her into agreeing by telling Lyndee that she did not want to start over with another therapist who did not know her and that she already had a good rapport with Lyndee. She wanted Lyndee to make an exception for her to keep her as an individual client. She used making Lyndee "special" in order to get herself accepted as "special." All these cues to her issues could have been noted and the process and boundaries of therapy managed differently. Therapy may not have needed to come to the point where Lyndee felt a need to terminate. The missed appointments, conflict about payment, and the animosity and acting out were not interferences to therapy as much as they were the core issues to therapy. Donah's behavior was not making therapy difficult. Donah's issues that brought her to therapy manifested in problematic behaviors in all parts of her life. Therapy and her relationship with the therapist were not exceptions. Lyndee had anticipated a collaborative relationship with or deferential relationship from Donah, more typical of "normal neurotic" clients. Instead, she got fluctuations among fawning (borderline), competitive (narcissistic), and distrusting (paranoid) attitudes from Donah. For client work in the future, Lyndee needed to consider why she had waited so long before terminating therapy or letting it degenerate to such a degree. The therapist may consider terminating therapy immediately if there are sufficient indications for both the therapist being unsuited to the work and/or the rigidity and unavailability of the client to the therapeutic process, especially for couple therapy. Quick termination may be clinically, ethically, and legally appropriate if after one session, because it is obvious the potential client is deeply and irrevocably a narcissistic manipulating jerk! That is according to the therapist's counter-transference. The therapist may save him or herself the therapeutic grief.
Terminating therapy may also be clinically, ethically, and legally appropriate after a reasonable period based on the therapist determination of its effectiveness. Such a decision needs to come from trusting oneself and not holding oneself to be a "nice guy," omnipotently effective therapist, savior, or missionary- that is, denying his or her counter-transference. Many therapists ethically define engaging in therapy or continuing therapy as asserting that therapy has the possibility or probability of being beneficial or effective. The therapist is ethically required to terminate therapy with appropriate referrals and process when he or she determines that it is not beneficial to the client. The therapist must not be intimidated by a client threat to complain to a professional association, the relevant governmental licensing agency, or in civil or criminal court. The therapist must accept that a client may or may not make a formal complaint. The therapist may a try a paradoxical intervention if he or she feels that the client is determined. At that point, there is really nothing to lose. The client will hate the therapist anyway. The client already hates the therapist and everything and everyone else anyway. The therapist should remain aware of the stance required to maintain and keep credibility with an individual with narcissistic tendencies. The individual needs someone, specifically the therapist in this situation to be authoritative and assert expertise. It's not a humanistic egalitarian approach that many therapists ordinarily use. This approach requires greater discussion and the therapist should get both legal and clinical consultation prior to choosing a course of action.
THERAPY CHANGES WITH DIAGNOSIS
The therapist needs to realize that "efficacious treatment of these patients requires differential treatment interventions for each of the disorders: confrontation of maladaptive defences with the borderline individual, mirroring interpretation of narcissistic vulnerability with the narcissistic disorder, and interpretation of the `schizoid dilemma' with schizoid patients. And it is the unique intrapsychic architecture of each of these disorders which informs as to the intervention appropriate to each" (Roberts, 1997, page 234). Differential strategies and treatment is also required in working with couples, that present in great variations of demographics, experiences, and issues. For example as discussed earlier, individuals may differ with regard to social absorption versus social individuation. The degree that two partners may match up along these dimensions can affect the relationship, and thus be a target of therapy. "…what types of activities do these different types of couples engage, and how frequently do they engage in these activities? Do the partners share the same social network, or do they encourage each other to have their own friends? Also, how different are the domestic lives of these different types of couples? Does one type of couple (both partners low in social absorption) prefer to divide up the household tasks and financial decisions, whereas another type of couple (both partners high in social absorption) collaboratively shares these responsibilities? Once we can identify the specific, differential patterns of behavior that individuals who are high versus low on social absorption consistently display in their marriage relationship, we can explore the feasibility of developing effective ways to encourage the expression and enjoyment of these behaviors in low social absorption partners" (Charania and Ickes, 2007, page 206). Couple therapy often takes the strategic approach of identifying along some criteria each partner's style, comfort level, preferences, or tendencies towards particular behavior. The clinical assumption is that the partners are out of sync which causes their problems. Therefore, getting the two partners in sync through communication and negotiation would mitigate or eliminate relationship problems. One or both partners usually agree that they are out of sync and look to the therapist to help them. A personality disorder puts a partner out of sync with just about everyone. Personality disorder issues are a key differential diagnosis that may overshadow or be underlying other differences between partners.