Treating NPD in the Therapy Room
Benjamin (1996) asserted that therapy interventions for narcissism could be evaluated in terms of five categories of correct response: whether or not the intervention enhanced collaboration, facilitated learning about patterns, blocked maladaptive patterns, strengthened the will to give up maladaptive patterns, or facilitated new learning. In this article, we take each in turn.
Enhancing collaboration
While therapist empathy is important for any treatment, it is particularly so with NPD. The narcissistic deficit in the self can be corrected if the client can use the therapist as a self-object: that is, as an extension of him/herself. Through consistent empathy, the therapist can provide the affirmation and soothing needed to help the client learn self-regulation. The idea is that the client will eventually internalise this empathic affirmation of self.
“But wait,” you ask, “Isn’t this self-affirmation already ‘over-the-top’ in narcissists anyway?” Yes, good spotting! But the NPD’s self-approval is not balanced by an ability to see and accept defects. The therapist, however, can help this vital process by acknowledging occasional, small lapses in understanding. They shouldn’t be all the time, nor large, and the therapist should not be overly apologetic (which would make the NPD symptoms worse), but tiny reminders of therapist fallibility can help the narcissist to accept his or her own faults.
Facilitating pattern recognition
To break maladaptive patterns, therapist confrontations must be gentle, mixed in with strong support, and appropriately timed. Otherwise, the interventions may enable old patterns or alternatively, risk the narcissist fleeing the therapy, never to return. Here the therapist walks a fine line between offering empathy and colluding with the client to blame others. For instance, a narcissistic student-client might be upset at supposedly poor treatment by a professor. Let’s say the therapist attempts empathy by remarking, “Oh how unforgiving of the professor to have insisted that all of your work be turned in on time!” The student feels affirmed and vindicated, but will continue her maladaptive patterns, because there was nothing in the intervention to help the student understand how she was asking for special treatment.
Let’s say the therapist says, however, “Well, when relationships hit snags, it’s because both parties have created the problem. Do you see how you were demanding special treatment?” Upon hearing this, the average narcissist may be promptly one foot out the door. A more optimal response might be something like, “You have been trying so hard in that biology class and you feel just devastated to learn that deadlines are deadlines no matter what your situation is.” This may be a more accurate summary, a response inviting reflection on the NPD’s sense of entitlement or special treatment, but without blaming the external world or the other party for the NPD’s difficulties. Consistent therapist concentration on careful and supportive reflections of the whole dynamic can help the client to change her patterns.
Blocking maladaptive patterns
Part of healing narcissism is learning to recognise and block patterns which make the person unhappy and create relational problems: patterns such as grandiosity, entitlement, and envy of others. Therapists can do this more effectively when they know what the client experiences were which helped to create the patterns. When narcissistic Duncan angrily tells the therapist that the “Sportsperson of the Year” award in their community went to his friend rather than himself, the therapist can say, “Well, that’s going to put a damper on your dad’s bragging about you at his company.” With such an intervention, the therapist at once picks up on the unhelpful feelings of the moment (the anger and envy), while drawing connection to the originating relationship: the client’s father. Duncan of the moment believes that he should have had the award, and he is unconsciously pressured by the thought that his dad will only be happy if he – Duncan, as the centre of his dad’s universe – receives awards and merit that his father would have loved to receive.
Such an intervention on the part of the therapist gently nudges Duncan’s awareness toward the source of the envy – his father – and helps him to distance himself from some early, unconscious contract which stated that Duncan would carry the heavy burden of achievement for his father. Duncan will be assisted if he can see that his envy is driven by his need to give and receive support from his internalised version of his father. Therapist remarks such as this attempt to enhance the narcissist’s will to separate from old internalisations (i.e., his father’s “voice in his head”), and to shift focus from the angry emotions about the friend to the underlying issues. As a narcissist comes to realise the high price he or she has been paying to carry the noncontingent adoration (from his father in Duncan’s case), he may be able to gradually give up his addiction to it.
There are two caveats here. First, the therapist does need to check that his or her hypotheses regarding the development of the narcissism are on target. So he or she may ask the client, “What do you think your father would say if he were still alive and watching your friend receive the award?” If the client is certain that his father would have merely been happy for the friend, then the hypothesis of parental introjections demanding supreme achievement is not accurate. If, however, the client is sure that his father would say something like, “So how come you aren’t getting that award?”, then the therapist’s hypothesis about the problem root is probably accurate. Second, the matters of style and timing can determine if the narcissistic client will ultimately accept such remarks, or reject them in anger or shame. It is the fine art of pushing the envelope of awareness without scaring off the client.
Another arena for discovering maladaptive patterns to block is that of the alcohol and drug use which often co-occurs with NPD. Some therapists have wondered if that is because alcohol and drugs give a noncontingent feeling of wellbeing and dominance. Many clinicians have compared alcohol to a sometimes nurturant, sometimes withholding, but ultimately destructive parent. The interpersonal dimensions of childhood are recaptured with alcohol and drugs. Obviously, not all people addicted to alcohol or drugs are narcissistic; nevertheless, it is interesting to note that Alcoholics Anonymous – which has a fairly good rate of success – confronts the entitlement pattern that is at the core of narcissism. Members are given much support, but must show active efforts to confront the problem. They repeat, for instance, the organisation’s mantra, “I am an alcoholic. Alcohol controls me. I choose not to let it.” (Benjamin, 1996, p160)
The structure of AA encourages people to give up control, even as they are given the opportunity to control others (through the offering of support) as those others struggle to control alcohol. The blocking of maladaptive patterns thus occurs paradoxically as the NPDs, who have a tendency to want to control and also wish to receive support, are enabled to do so while giving up their sense of entitlement.
Strengthening the will to give up maladaptive patterns
Benjamin notes that enhancing a client’s will to change is a sensitive area. She believes that often it is sexual fantasies which reinforce the interactional patterns that are the problem, and takes the psychoanalytic position that sexuality has a major role in NPD. The main idea is that the most pleasurable activity of sexual orgasm is, for the narcissist, coupled consistently with fantasies and images which replicate the interpersonal dimensionality of the disorder. That is, a narcissist may be powerfully reinforcing patterns of aggressive control and being adored through images he is conjuring up while having an orgasm.
The appropriate treatment, then, is to reprogram the sexual practices/fantasies in order to achieve behavioural change. Unfortunately, it is not just the narcissist who is hurt by entertaining inappropriate fantasies during sexual intercourse. Narcissists often link with those who have Self-Defeating Personality Disorder. Thus, their fantasies of destroying a sexual partner while that partner adores them form the sadistic part of a sadomasochistic match, while the self-defeater (and sometimes those with Multiple Personality Disorder, also called Dissociative Identity Disorder) forms the masochistic half. The therapist’s job is to try to help both participants in the match change the destructive patterns in the sexual fantasy as well as in social interactions.
The problem with the treatment – substituting healthy fantasies at the moment of orgasm, or even no fantasies if the person’s relationship is in the normal range – is that enacting it reliably ruins the orgasm: for some time! Thus clients lose motivation to make the change, feeling like it isn’t worth it to give up the immediate pleasure of their sexual orgasm for some future possible happiness from better interpersonal relationships.
Facilitating new learning
Once a client understands the patterns of NPD and genuinely decides to stop pursuing maladaptive or unattainable goals, the new learning can come fairly easily. With NPD, the focus must be on empathy. As we noted above, couples or family therapy is an effective context in which to learn this skill. The problem is that couples/family therapy is not easy, undertaken as it is with individuals who are in close contact with the narcissist, have probably been abused by him, and usually are triggered by things he says and does. Moreover, as NPDs often form complementary relationships with people suffering from Self-Defeating Personality Disorder, the therapy runs an ever-present risk of blaming the self-defeating party. The narcissist begins the therapy convinced that his or her troubles are as a result of the flaws in the self-defeater, who is ever-ready to soak up the blame doled out generously by the NPD. Therapists who do not understand this destructive complementarity may be drawn to helping the couple “express feelings” or “communicate more clearly”. If so, they will be missing the boat entirely, and the maladaptive patterns will continue wreaking havoc in the relationship. What is needed is unstinting collaboration against the old patterns, which come to be replaced by an understanding that the relationship must be comprised of two equally entitled selves.
One domain in which this can happen is the area of family finances. Partners wanting to change the NPD/self-defeating pattern can take up therapist suggestions for the re-allocation of goods and resources in the family. This can help to prevent further entitled grabbing by the narcissist and concomitant undue sacrifice on the part of the self-defeater. Financial counselling is often a good idea because once the financial parameters of the family’s income are known by both partners, there can be fair and empathetic plans for managing money. Of course, many funds address the necessary items of expenditure, such as for food, mortgage, utilities, insurances, and so forth. But there can also be separate discretionary funds for personal “self-indulgences”. Rather than believing that the entire household income is carte blanche for the narcissist’s whims of the moment, he or she is now subjected to constraint and limitation on what is allowed to be spent for “fun” or “just because I wanted it”. This meshes well with the narcissist’s need to decrease impulsivity and enhance capacity for self-regulation.
The other way that family or couples therapy can facilitate new learning is through role play. Let’s say a narcissistic woman feels slighted when she visits her husband’s office and is not greeted effusively and affectionately. She may fly into a rage and attack him, believing that he no longer cares for her. In session, he can be asked to explain what was happening for him (perhaps there was a crisis in the organisation which he was trying to resolve, possibly he had just been criticised by a superior, or maybe he was having to multi-task and did not have the bandwidth for an interruption). Once hearing what was happening from his perspective, she can be asked to play the role of her partner, who was the target of her indignation. Here the therapist needs to make sure that, if her words and inflections are used in the role play, they are mirrored with some precision, and as respectfully as possible. To not achieve this is to elicit rage and possible withdrawal from the therapy on the part of the NPD (Benjamin, 1996).
Whether a therapist is working with a narcissist in individual, group, or family/couples therapy, it is difficult “in the heat of the moment” to keep all of the five “balls” of correct therapeutic response in the air, but sustained effort in the context of a deepening therapeutic alliance will make all the difference to the reduction of narcissistic symptoms and the consequent improvement in quality of relationships for the client. Your client may not always be the narcissist, however.
References
Benjamin, L.S. (1996). Interpersonal diagnosis and treatment of personality disorders. New York: The Guilford Press.
This article is an extract of the Mental Health Academy “Treating narcissism in and around your clients” CPD course. This course is geared for working mental health professionals, such as counsellors, psychologists, psychotherapists, social workers, and other health workers, with clients/ patients who either: are showing signs and symptoms of NPD themselves or are being victimised by someone else’s pathological narcissism. Click here for more information.
