5. Kill the Therapist - 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 5: KILL THE THERAPIST


The therapist often picks up on the eager need for understanding from one of the partners.  The person's enthusiasm and commitment to therapy usually makes it relatively easy for the therapist to establish a strong rapport with him or her.  The therapist may explain in a logical non-judgmental tone the first partner's needs to the other member without being aware of the other member's sensitivities.  By the end of the first session, Ishmael was the eager member who became extremely excited about and well invested in the therapy.  The other member, Nia also seemed receptive, rational, and charming.  What the therapist had presented as the cause of relationship problems and the process and goals of therapy seemed well received.  At the end of the session, the couple and therapist worked out a mutually workable appointment time for the next week's session.  To the therapist's surprise, Ishmael called a couple of days later, and left a message that they are going to try another therapist.  What happened?  The therapist missed the scorpion in the room and thus, had not anticipated the sting.

The therapist had missed telltale signs of something critical to the relationship dynamics.  Although, everyone seemed in tune in the session, the therapist had missed narcissistic tendencies in Nia.  The rapport with the Ishmael- the eager partner was clear.  However upon reflection, the therapist had felt with Nia a little bit of hmmm?  ...that something was not quite right... a bit of unease from a slightly off reaction or not the reaction expected during the session.  As the therapist was enjoying the bi-directional mutual appreciation between self and the eager partner Ishmael, Nia had been sitting still with a somewhat frozen smile… a bit tense.  The therapeutic mistake was not paying due attention to counter-transference.  The therapist had been so delighted with Ishmael's eager response that Nia's ambiguous signals were dismissed. The therapist needs to be aware of his or her susceptibility to wanting to be liked and accepted by others- in this case, clients.  The therapist had been fed significant appreciative excitement by Ishmael, and felt that therapeutic rapport was solid with him.  The therapist assumed that the rapport was solid with both partners.  Nia had spoken positive motivations for therapy and good intentions for her partner.  This sounded good to the therapist.  Unfortunately, for the integrity of therapy, for solidification of therapy, for private practice business, and for Ishmael, the therapist needed to be more attuned to messages from Nia's narcissistic energy.

The therapist may have been misled because he or she did not see grosser presentations of narcissistic personality disorder.  People in general may be more familiar with narcissism that is more extreme.  Characters such as those in "The Devil Wears Prada" (2006)- Miranda Priestly played by Meryl Streep or "Wall Street" (1987)- Gordon Gekko played by Michael Douglas are clearly arrogant, superior, and grandiose.  Nia did not present so grossly.  However, narcissism may have more subtle expressions.  "…(Akhtar, 1989; Cooper & Ronningstam, 1992: Gabbard, 1989, 1994, Wink, 1991) have proposed different variations of a dimensional model that conceptualizes narcissistic personality into two different subtypes: overt and covert.  The first type, which seems to be more consistent with the DSM-IV (1994) classification, refers to narcissistic individuals as oblivious, thick-skinned, egotistical, grandiose, arrogant, craving attention, and disregarding the feelings and reactions of others.  The second type at the other end of the continuum refers to narcissistic individuals as hypervigilant, thin-skinned, dissociative, vulnerable, self-effacing, diverting attention, highly sensitive to the signals from others and easily hurt" (Rivas, 2001, page 27).  Narcissistic individuals are "a dropout risk (always high with these clients)" (Dimaggio et al., 2007, page 46).  

The therapist who works primarily with individuals may be more familiar with narcissistic clients than the couple therapist.  Since the couple therapist is normally drawn and also directed to the couple's dynamics, he or she may be less likely to look for individual psychopathology.  The therapist in individual therapy will have direct experience as the second person in the dyad with a narcissistic, rather than an observer of the dyadic interactions.  For example, "In a single case qualitative study it has been noted that a woman diagnosed as narcissistic… described herself for a short time as being fragile vis-à-vis threatening and critical others. The fragile facet soon disappeared into the background and left room for the struggle for power to become the dominant relational theme. The therapist got involved in this pattern in the third session and embodied the critical and contemptuous character (Semerari et al., 2004), while the patient felt criticized by him. A dominance/submission pattern had thus got established. In the fourth session, this relationship pattern was mutually acknowledged and, thanks to this, a rupture in the alliance was repaired" (Dimaggio et al., 2007, page 46-47).  Whereas in this situation, the therapist experienced narcissism first hand with an individual client and may have been more able to manage the transference and counter-transference, the therapist's intensity and depth of relationship with the narcissistic partner in couple therapy is often more superficial.  The couple's dynamics rather than the individual's dynamics are the focus of the therapist's attention.

The therapist can miss how the individual with narcissistic personality disorder (Nia, for example) becomes annoyed or threatened when the therapist bonds with the engaged and enthusiastic partner (Ishmael).  Validation and support of the other member trigger vigilance that the therapist is not aligning with a partner with narcissistic issues.  Narcissistic vulnerability cannot tolerate any indication of being wrong. The therapist had not thought any sides had been taken.  If the therapist is even handed, the mere implication that there is credence to the partner's feelings, experiences, thoughts, and interpretation can challenge hypersensitive and hyper-vigilant narcissistic omnipotence.  The individual with narcissistic personality disorder wants- more specifically, needs to be idolized and often cannot tolerate even the whiff of criticism.  When the therapist is not charmed by the narcissistic presentation and is egalitarian in holding both members of the couple responsible for the dynamics and dysfunction, the individual can go into a secret narcissistic rage and need to "kill" the therapist.  That is effectively accomplished by killing- terminating therapy.  

At home away from the scrutiny of the therapist, Nia pushed against the therapist- the threat.  Ishmael's protestations and declaration of liking the therapist confirmed Nia's fears of losing control, and made her more adamant against proceeding.  Typical of narcissists, she was able to present a litany of psuedo-logical reasons to seek another therapist.  Alone at home in the dyad with a narcissist, Ishmael was susceptible to having his perceptions, opinions, and feelings turned around and dismissed.  Nia justified stinging the therapist, making her case more compelling with implicit threats to sting Ishmael as well.  Ishmael of course, had to do the dirty work to call and terminate therapy.  Since the couple was not in session, the therapist could not process the dynamics with them.  In some situations, a referring therapist might warn the therapist that one partner had borderline personality disorder.  The therapist might anticipate and prepare therapeutic strategies for borderline sensitivities and issues, but not realize that diagnosis may be more fluid in many personalities.  He or she should have considered that someone thought to have borderline personality disorder, might also have significant elements of histrionic, narcissism, and/or paranoid personalities (as in the example with Donah).  On the other hand, the referral may have been from a partner's therapist with the warning that the other partner sounded like a narcissist.  From the outset, the therapist should then consider adjusting the therapeutic interview and process based on the presence of narcissism.

TARGET OF THERAPEUTIC ENERGY
When the therapist senses a personality disorder, therapeutic energy should be directed (adapted for each type of personality disorder) towards that partner in the couple.  The non-personality disordered partner has been at the mercy so to speak of the personality-disordered partner and is often, desperate and ready to commit to therapy.  Establishing rapport and getting commitment is relatively easy.  It's the personality-disordered partner that needs to be cultivated by the therapist.  Since all personality disorders can be considered developmental disorders- more specifically, attachment disorders, the therapist needs to get that partner to attach to him or her.  These principles can also be applied to individual clients in the first session as well, especially narcissistic individuals.  In many couple's cases that fail to launch past the first session, the therapist had worked on attachment more with the wrong partner!  The therapist had focused on Ishmael instead of Nia.  The therapist had worked more with the non-personality disordered partner.  If both partners have personality disorders, the nature of attachment and ego vulnerability will determine if the therapist needs to focus on immediate rapport work with one or both partners.  Individuals with dependent personality already desperately need the relationship, which gives the therapist more latitude and less urgency to build rapport.  Individuals with histrionic personality disorder want an audience so rapport may never be actually achieved.  As long as the therapist is attentive, the psychic contract is fulfilled for the histrionic.  Individuals with schizoid personality disorder do not care… ever.  It does not matter.  The therapist does not have to worry so much about individuals who have borderline personality disorder in the first session.  They will initially idealize the therapist, "as the best therapist I've ever had!"  The borderline client will "get" the therapist later in therapy when the therapist has inevitably  "betrayed" him or her.  In couples with both individuals with personality disorders, the individuals with narcissistic and paranoid personality disorder, in particular narcissistic personality disorder are the ones who are likely to terminate therapy early.  The therapeutic focus should shift to that person to further continuance of therapy.

If the therapist had recognized the narcissism of Nia immediately, the process of the first session could have changed.  Ishmael would not have been the target of the therapeutic energy.  His investment and commitment to continued therapy was already relatively sound.  He had already "bought in" or did not need much from the therapist to invest in therapy.  In a couple with a narcissistic partner, the narcissist partner is the member who will determine if therapy will happen.  The therapist's energy and the establishment of credibility and a therapeutic contract need to be directed to the individual with narcissistic personality disorder.  This a unique form of connection geared to the narcissist that differs from common therapeutic rapport.  Instead of selling therapy to Nia, the therapist by validating Ishmael had done the opposite.  Nia wanted to hear that she was right and her superiority confirmed.  Instead, the therapist deemed Ishmael's perspective as having validity as well.  Win or lose rather than win-win was her existential reality.  Although, Nia verbalized egalitarian values between herself and Ishmael, secretly she needed to be on top.  When the therapist verbalized the similar equality between the partners, it threatened her grandiosity- a grandiosity that she would not overtly admit.  The theoretical recognition and subsequent conceptualization of narcissism would direct the therapist to strategies to validate the individual's superiority and grandiosity while maintaining therapeutic integrity.  While this is a major clinical challenge that may involve therapeutic art as much as skill and expertise, this changes therapy.  It changes the first session, and creates the possibility of further therapy rather than therapy interruptus.

The therapist often senses a disconnection despite verbal commitments at the end of the session.  In some cases, the therapist pretty much recognize, know what is happening, or realize what had happened right after the session.  The therapist may sense continued disconnection despite other positive feedback and even commitments to continue.  As a result, the therapist was not surprised when the couple canceled.  It is important that the therapist not blame disconnect or failure on clients- that is, their personality disorders.  It was on the therapist to not blame a psychotherapy client for having psychological issues!  The therapist can pick up on a personality disorder or tendencies in the first session (sometimes, in the initial telephone conversation).  He or she then should be better able to manage the individuals with personality disorders in the initial session purposely.  As a result, the therapist can improve clinical outcome and get better connection and commitment.  After this critical first stage of creating the therapeutic commitment, investment, and contract, therapy continues to adapt because of the narcissism in the couple.

Cheri is an executive with an investment banking firm.  She does very well financially and had never been married before.  Jaymes does okay as a salesman.  He says, "I do OK.  Some times, better than others."  He has been married twice.  Cheri complains that Jaymes is moody and can get scary at times.  Jaymes explained to the therapist in great detail how Cheri is projecting her hostilities at her alcoholic abusive father onto him.  His analyses of her "father issues" notably lack compassion.  Jaymes responds to Cheri's complaints about him with a subtle sneer.  He uses non-verbal dismissal rather than giving her an extensive response.  The sneer is a non-verbal communication that says that is all her comments deserve.  Cheri feels the hurt from the sneers, especially as the sting of being marginalized have accumulated over the years.  Jaymes does not relate at all to Cheri's complaints or emotions.  He admits to having have no empathy at all for what he considers to be her neediness.  When asked about what she has done to make the relationship work, Jaymes minimizes how much Cheri has put into the relationship.  Jaymes admits that he was attracted to Cheri because he liked successful women.  Jaymes doesn't like "simple" women.  However, now Jaymes finds Cheri's complaints indicative of her being like the "others."  He doesn't see anything wrong about how he treats her.  She gets what she deserves.

The therapist can tell that Jaymes expects the therapist to respect him and join in his evaluation about Cheri.  "Kohut (1971) and Benjamin (1996) noted that clients' claims to entitlement and admiration may encourage a therapist to join them in mutual applause and criticism of the rest of the world" (Dimaggio et al., 2007, page 35). The therapist should obviously believe his version of the relationship over whatever Cheri has to say.  In the first session, Jaymes questioned the therapist about his or her credentials.  When the therapist asked about what the questions are about, Jaymes responds that he wants to make sure that they are seeing the "best." If the therapist reframed or otherwise directed questions to him in any manner conveying doubt or surprise, Jaymes started to question the credentials more intensely.  His affect became subtly more aggressive and disrespectful.  There is a tinge and sometimes more of anger and impatience.  Implicitly Jaymes seems to want to establish the therapist's inferiority…to assert his superiority.  It becomes obvious that Jaymes wants to  "prove" his superiority.  Whenever he does, he seems more secure… that is, safe.  If the therapist tried to acknowledge Jaymes, he accepted it in a condescending manner.  He worked at keeping the therapist uncomfortable which keeps him in control.  Jaymes works at keeping Cheri uncomfortable.

If the therapist challenged Jaymes or otherwise asserts or implies greater competency or expertise, Jaymes treated his words as a personal and vicious attack.  Jaymes goes so far as to try to humiliate the therapist as viciously and cruelly as possible.   He reverted to a mocking and condescending tone.  Despite his insulting behavior, he still expected to be catered to.  He seemed to have therapy amnesia- he forgets prior tantrums towards both Cheri over the relationship and towards the therapist in sessions.  In the first session, Jaymes made demands for a different appointment schedule that fit his requirements even though it would severely inconvenienced the therapist and Cheri. Jaymes was infuriated that anyone had objections.  Because of Jaymes' narcissistic personality disorder or significant narcissistic tendencies, the therapist found Jaymes unlikable and started feeling sorry for Cheri.

SCRUTINY
In therapy alone with the individual with narcissistic personality disorder, the therapist experiences the same counter-transference issues.  The therapist may be initially charmed and impressed by the individual with narcissistic personality disorder.  When the narcissistic behaviors begin to exhibit, the therapist will often become uncomfortable.  Discomfort comes from the individual's insidious domination of the session, denigration of credentials and competence, and from the therapist feeling badly about not liking the individual.  The therapist's sense of self, confidence, emotions, and intellectual process can be severely challenged by the individual with narcissistic personality disorder.  Managing client narcissistic behavior dramatically changes even more when there is a third person in the room.  In therapy alone with the individual with narcissistic personality disorder, the therapist is alone with his or her discomfort and successful or unsuccessful attempts to manage narcissistic behavior.  The therapist also has more latitude to make mistakes and still establish a functional therapeutic relationship.  However, in couple therapy, the non-narcissistic individual-for example, Cheri is carefully observing how the therapist handles Jaymes.  Cheri recognizes the Jaymes' narcissistic behavior with the therapist as very familiar.  While possibly not identifying it as narcissistic behavior, Cheri nevertheless identifies and relates to what the therapist is going through, and acutely observes how the therapist handles the seduction, aspersions, manipulations, and attacks.  She is hopeful that the therapist may be able to withstand the process well enough to intervene in the couple's relationship.  Therapeutic missteps can seriously harm the confidence of other partner in therapy and for relationship growth.  The therapist knows that his or her credibility not just with one, but with both members of the couple is under scrutiny.

Both partners are scrutinizing the therapist for therapeutic competence.  Jaymes, as the narcissistic partner seeks to prove the therapist less competent or exceptionally competent (more on this later).  The non-narcissist partner Cheri is primarily hoping that the therapist is competent in dealing with the other's narcissism.  The therapeutic pressure to perform is significantly more than with an individual narcissist in therapy. And, more may be at stake.  Besides individual functionality, the viability of the couple's relationship and possible family stability and children's well-being may also be at stake. Additional therapeutic complications occur because the therapist as recipient of narcissistic assaults may identify with his or her co-victim, Cheri.  The therapist may find him or herself not just disliking the Jaymes and his narcissistic behavior, but also liking, aligning with, and feeling sympathy for Cheri.  A partner may welcome this affinity but also be wary of the individual's resultant narcissistic rage directed at him or herself as well as the therapist.  Cheri knows that anyone Jaymes feels criticized by will be attacked… too.  In individual therapy, the therapist- especially a humanistic oriented therapist feels free to and often bases the therapeutic rapport on openly liking the client.  If the therapist was seeing Cheri in individual therapy, he or she can freely like Cheri and align with her anxiety and hurt about the partner not in the room.  The therapist would not have to manage Jaymes' reaction since he is a character in Cheri's narrative, but not part of the therapeutic population.

In couple therapy, the therapist senses the narcissist's vigilance for any potential alliance with his or her partner as intolerable alignment against him or her. The therapist may struggle to balance his or her affinity with the "nice" partner.  Trying to be neutral or "fair" can be disingenuous and difficult to hide from the senses of Jaymes.  Narcissism often includes highly acute sensitivity around alignment issues.  The narcissistic partner may accuse the therapist of favoritism, which the therapist may be hard pressed to deny.  Someone like Jaymes intuitively knows he has caught the therapist violating a clinical taboo- favoring one partner over another… losing clinical neutrality.  Once again, the therapist's ability to handle the narcissistic reaction or accusations is carefully scrutinized by Cheri.  The therapist metaphorically dodges the scorpion's sting, and confronts the scorpion for trying to sting.  If the therapist is flummoxed or intimidated Cheri's confidence in the therapist and therapy will suffer precipitously.  If the therapist, on the other hand handles the narcissistic behavior with strength, clarity, integrity, and confidence, the partner feels relief and hope grows that there can be change.  If the therapist is not intimidated and does not placate, he or she thus is able to engage Jaymes from a respectful non-inferior role (not the same as a role of equal status).  Cheri gains a model of a different relationship possibility.  While the therapist should be aware of the non-narcissist's need to gain confidence in therapy, it remains more important to the continuance of therapy to meet the narcissist's needs, especially in the early sessions.  If faced with a choice, it is therapeutically more prudent to risk and temporarily lose the non-narcissist's confidence in therapy.  It can be more readily regained in subsequent sessions.  However, if the therapist loses the narcissist, there will be no later sessions.  The narcissist who dismisses the therapist will also dismiss therapy.  Keeping the narcissist in therapy mitigates the therapist's temporary sacrifice of the non-narcissist's hopes when therapeutic focus shifts toward the narcissist.  The non-narcissist wants to be validated but is unfortunately used to being dismissed and invalidated.  However for a partner such as Cheri, the greater urgency is to find someone and some process that the narcissist will participate in.

Before the session ends, the therapist should bring therapist-narcissist relationship to the table for discussion.  Therapeutic interactions that have integrity- no matter how well presented can ping the narcissistic radar attuned to challenge.  As the therapist has engaged and however slightly challenged Jaymes, there is the potential for a narcissistic injury.  The therapist should ask directly, if a narcissist individual such as Jaymes is mad at the therapist.  The therapist can predict that since he or she disagreed with and challenged Jaymes, that based on dynamics with Cheri that the therapist anticipates the possibility that he will either dismiss the therapist as incompetent (or worse!) and then terminate therapy. Or, be annoyed to angry.  "I'm aware that I may have challenged you or disagreed with you.  Perhaps, annoyed or angered you.  I want to check if that is something you can handle, or if you will need to terminate the therapy by deciding I'm incompetent or something.  I'm asking because this seems to be something you do with Cheri."  The therapist is predicting that Jaymes out of sight of the therapist, as a scorpion will strike Cheri, the therapist, and the therapy with his stinger.  Confronting this probability overtly reveals the "secret" evaluation or testing that has been happening in the session.  This may be a key to building the therapeutic relationship with Jaymes.  As a narcissist although he seeks to intimidate the therapist, Jaymes paradoxically needs the therapist to be strong and competent enough not to be intimidated.  Identifying and exposing Jaymes' potential critique and inclination to dismiss the therapist (and therapy) reveals the therapist's sophistication and fearlessness.  This may be the authoritative parental role that Jaymes is seeking unconsciously.  At the same time this reveals yet respects and accepts Jaymes' process, while avoiding a power struggle between Jaymes and the therapist.  Jaymes is acknowledged as having the need to assess the therapist and as having the power to continue or terminate the therapy, while the therapist asserts his or her knowledge, skills, and most importantly his or her sensitive authoritative role.

"So, besides checking to see how you are tolerating my challenging you, I want you to commit to eight sessions of couple therapy.  No matter what, you will come to the eight sessions.  After eight sessions, then we talk about continuing or not.  This commitment takes away the two of you using coming or not coming to therapy as another weapon in your battles.  You don't need another way to manipulate or threaten each other.  In addition, if you commit to the eight sessions, then I won't have to spend the last ten minutes of every session trying to get you to recommit.  I won't have to convince you, condole you, beg or threaten you.  That has no integrity.  I can be honest with you and run the risk of upsetting you without having to worry about you killing the therapy.  This commitment better insures the integrity of therapy and the integrity of my feedback with you.  From my experience, this gives couple therapy the best chance to work.  How about it?"  In other words, "Put away your stinger!  Commit to not sting!"

The therapist is asserting the authoritative role, including being the expert on what works best while confronting all the overt and implicit threats and assertions of the narcissist.  There is nothing particularly special about eight sessions.  Eight sessions allow for a critical mass of repeated investments and takes away the urgency of any one session to make or break the relationship.  A couple more or less sessions would also work.  Getting a commitment is probably also less critical to the therapy than the therapist asserting the essential superior role as the... therapist!  Getting the narcissist to accept or make the commitment shifts the relational dynamics and offers hope for growth and change.  The therapist role is framed as a non-threatening or less threatening critical and necessary hierarchal role that is less triggering to narcissistic vulnerability.  The therapist starts to become an acceptable or at least tolerable leader, akin to the attentive, nurturing, and boundary setting parental role the narcissist missed and may still be seeking.


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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