Attachment and Object Relations in Patients With Narcissistic Personality Disorder: Implications for Therapeutic Process and Outcome Diana Diamond1,2 and Kevin B. Meehan2,3 1
City University of New York Weill Cornell Medical College 3 Long Island University–Brooklyn 2
This article presents a therapeutic approach for patients with severe personality disorders, transferencefocused psychotherapy (TFP), a manualized evidence-based treatment, which integrates contemporary object relations theory with attachment theory and research. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate the tactics and techniques of TFP and how they have been refined for treatment of individuals with NPD. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the interpretation of devalued and idealized representations of self and others, both of which are key components of the compensatory grandiose self that defensively protects C 2013 Wiley Periodicals, the individual from an underlying sense of vulnerability and imperfection. Inc. J. Clin. Psychol. 69:1148–1159, 2013. Keywords: narcissistic personality disorder; transference focused psychotherapy; sexuality; attachment; reflective capacity
Introduction A renowned 40-year-old architect, who sought consultation while in the midst of a marital crisis brought on by his wife’s discovery of his engaging in Internet sex, began by saying that he fully expected that the therapist would not be able to tell him anything he didn’t already know about himself, as was the case in his previous psychotherapy. He was seeking therapy because he needed someone to be a sounding board while he explored his own feelings about his imperiled marriage, because his wife was threatening to divorce him if he did not stop his Internet use. He had been referred by his former cognitive-behavioral therapy (CBT) clinician, with whom he had terminated treatment abruptly the year prior, after making some gains in curbing his angry outbursts at work that had been alienating clients and coworkers, his substance abuse, and his addictive Internet behaviors. He insisted that he wanted only to talk abut his current dilemmas and that there was no point in talking about the past, refused initially to give a thorough history, and controlled the content and structure of initial session discussions. These statements epitomize the presentation of many patients with severe narcissistic pathology (that is, those functioning in the borderline range of personality organization) in that they both crave and devalue attachment, and often find themselves in a state of paralysis in their relational life as a result. Their often relentless devaluation of therapy, their tendency to provoke, alienate, or even deskill the therapist, combined with their entitlement and excessive demands on the therapist, have led some to speculate that these patients are at the limits of treatability and pose among the most formidable clinical challenges of any patients in the personality disorder spectrum (Clemence, Perry, & Plakun, 2009; Diamond, Yeomans, & Levy, 2011; Kernberg, 2007). Please address correspondence to: Diana Diamond, 50 Riverside Drive, Apt. 6A, New York, NY. 10024. E-mail:
[email protected] C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 69(11), 1148–1159 (2013) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22042
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Indeed their high dropout rate (over 64% in one study, Hilsenroth, 2008), along with the dearth of case studies and papers on technical approaches to treatment of severe narcissistic pathology, speaks to both the difficulties in engaging and holding these patients in therapy and the need for development and amplification of treatment strategies and approaches. This is particularly important because a number of studies have shown a high degree of comorbidity of NPD with other Axis II disorders, particularly borderline personality disorder (BPD; with rates ranging from 17% (Clarkin et al., 2007) to 37% (Stinson et al., 2008) to 80% (Pfohl, Coryell, Zimmerman, & Stangl, 1986; see Levy, Reynoso, Wasserman, & Clarkin, 2007 for a review). These high rates of comorbidity make it likely that patients with other personality disorders will also have significant narcissistic pathology that may affect their diagnostic and clinical presentation, the nature and quality of their mental representations of self and attachment figures, and their treatment course and outcome (Diamond & Yeomans, 2008; Kernberg, 2007). In this article, we present a therapeutic approach for such patients, transference-focused psychotherapy (TFP) based on attachment and object relations theory and research. TFP is a psychoanalytically oriented treatment for patients with a range of personality disorders at different levels of severity, including narcissistic personality disorder (NPD; Clarkin, Yeomans, & Kernberg, 2006). To date, TFP is the only personality disorder treatment that has been shown in randomized clinical trials to both improve symptomatic functioning and evidence unique change in security of attachment and reflective functioning (Clarkin et al., 2007; Doering et al., 2010; Levy et al., 2006). Here, we will present a brief overview of the treatment and will illustrate its major tactics and techniques through case material from an ongoing twice-weekly TFP treatment of the NPD patient introduced above. We will focus on how his personality and attachment organization influence his approach to psychotherapy that required modifications in technique, as well as how the therapy led to substantial changes in his personality and state of mind with respect to attachment. TFP is a twice weekly, modified psychoanalytic therapy based on contemporary object relations theory. It combines elements of standard psychoanalytic technique (e.g., attention to unconscious processes, a focus on transference, resistance, and interpretation) with a higher level of therapist activity, more attention to the patient’s external life, and a set of mutually agreed upon behavioral parameters designed to limit acting out and promote the unfolding of the patient’s full emotional experience and psychic life in the treatment setting. The major goal of TFP is to address the primitive defensive operations that prevent more realistic, integrated, differentiated representational dyads of self and others. Through the tracking of these self-object dyads and linking affects in the patient’s internal world, and identifying the defensive processes that support them, TFP constitutes an effective treatment for narcissistic disorders. Since TFP emphasizes identifying the totality of the individual’s internal dyadic experience (e.g., grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the different phenotypic presentations and/or fluctuating mental states that may characterize those with severe narcissistic disorders, such as from grandiose to vulnerable, from arrogant/entitled to depressed/depleted (Cain et al., 2011; Kernberg, 2010; PDM Task Force, 2006; Ronningstam, 2011). Based on our clinical experience with and research data on patients with narcissistic personality disorders, we have been refining TFP to treat patients with different levels of severity of narcissistic pathology (Diamond et al., 2011; Diamond et al., 2013). Our clinical formulations have been informed by our research on distinctive internal working models of attachment in patients with severe narcissistic pathology (NPD/BPD) from three international samples of BPD patients in TFP (Diamond et al., 2013). In brief, the majority of NPD/BPD patients were classified with dismissing attachment status, characterized by contemptuous derogation and/or brittle idealization of attachment figures, or by cannot classify status, in which the individual ricochets between different attachment states of mind (usually dismissing devaluation and angry or overwhelmed preoccupation with attachment figures). Thus, we have found that individuals with NPD/BPD may exhibit multiple, unintegrated attachment representations (Cannot Classify), leading to contradictory transferences and resistances that make these patients particularly challenging to treat.
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Relatedly, we have been investigating the interplay between level of personality organization and sexuality, with sexuality becoming increasingly maladaptive as level of personality pathology becomes more severe (Lendvay, Foelsch, Diamond, & Carrasco, 2011). In brief, in a study that included both nonclinical (community) and clinical groups, we found that individuals with higher-level personality pathology, including narcissistic pathology, had significantly less stable love relations, less capacity to combine love and sexuality, and less capacity for sexual pleasure than did individuals without personality pathology. In addition, both high- and low-level personality-disordered patients showed significantly higher levels of infiltration of aggression into sexuality and polymorphous perverse sexuality compared to individuals in the neurotic realm. Interestingly enough, there were also indications that individuals with cluster B personality pathology (borderline, narcissistic, and histrionic and antisocial) did not differ significantly from individuals with neurotic organization in their capacity to use fantasy and in their capacity for some mutuality in love relations (Lendvay et al., 2011). Further findings from the same study on the relationship between attachment status and sexual behavior suggested that secure attachment is related to sexual satisfaction, to the propensity to value and commit to long-term sexual/romantic relationships, along with the capacity to experience pleasure and stability in sexual relationships. On the other hand, insecure attachment is associated with sexual dissatisfaction and the inability to sustain commitments and/or dependency in romantic relationships (Carrassco, 2012). These findings mirror previous research that has also linked attachment styles to the ways individuals experience and engage in love relations and sexuality. Security of attachment has been associated with greater freedom of sexual expression and exploration, along with the propensity to value and commit to long-term sexual/romantic relationships. In contrast, avoidant/dismissing attachment status has been associated with the curtailment of intimacy and the use of sexuality to maintain emotional distance or control over others, with pleasure often linked to domination rather than mutual pleasuring. Preoccupied/ambivalent attachment status has been associated with a subordination of sexual pleasure to the quest for attachment security (see Mikulincer & Shaver, 2007 for a review). These empirical investigations, in addition to our ongoing clinical explorations in treating patients with severe narcissistic pathology with TFP, have led to a more comprehensive understanding of the nature of narcissistic pathology in general, and to the particular difficulties these patients have in the realm of sexuality, attachment, and love relations which often bring them to treatment (Kernberg, 1995, 2007).
Case Illustration We will illustrate some of the typical difficulties in attachment and love relations that characterize patients with severe narcissistic disorders, and how they were addressed in TFP with a narcissistic patient with borderline features. Since the difficulties in the sphere of forming and sustaining attachments also lead to disruptions in the therapeutic relationship, we will focus on the initial phases of TFP, including developing a treatment contract, defining the dominant object relational dyads, and working with role reversal of those dyads as they are alternately enacted and projected in the relationship with the therapist.
Presenting Problem and Client Description Jay, a 40-year-old architect, was referred by a colleague with whom he had been in CBT treatment for 2 years, which had ended precipitously the previous year. He had originally sought CBT therapy because of angry outbursts at work, marital dissatisfaction, sexual dysfunction, and intermittent substance abuse including psychotropic drugs, which compromised his work as an architect. His colleagues had tolerated his erratic behaviors, including angry outbursts with clients and colleagues and episodic binge drinking, because he was extremely talented and his early successes had continued to attract prestigious clients to the firm. Jay has been married for 13 years to an Italian woman, 8 years his junior, who ministered to his needs and bolstered him with her adoration, and into whom he projected his own dreaded object hunger and dependency. He was initially captivated by his wife’s beauty and social prominence
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as the scion of a ruling Italian industrial family when he first met her while studying in Rome on a postdoctoral fellowship. When they moved to the United States, her limited command of English, isolation from her family, and her sense of cultural displacement increased her dependency on him, while he felt suffocated by her emotional demands. She coped by throwing herself into renovating and decorating a series of apartments, where she occasionally entertained his clients, but he often socialized without her and rarely took her with him on his frequent international travel for work. She wanted a child, but Jay refused to consider this since he felt it would curtail his career that required frequent travel. Although he initially saw his wife as the ideal woman–beautiful, subservient, and devoted– after an initially passionate period, he lost his sexual desire for her. About 10 years after they married, he discovered Internet sex, which allowed him to play out erotic fantasies of dominance, submission, and control with no commitment or in-person contact. Jay reported that since adolescence his sexual life was “very vivid, but mostly in fantasy.” Despite his devaluation of his wife, he did report that he feared being alone and became apprehensive whenever she threatened to leave him as a result of his neglect, disparagement, and refusal to have a child. When she discovered his Internet use, she grew increasingly depressed. Although she had a number of past medication and psychotherapy trials, she was not in any treatment when he began therapy. He expressed considerable pessimism about any improvement in her depressed mood, which he attributed solely to her biological make-up rather than any difficulties in the marriage. Jay was raised as the only child of a union between his father, a well-known artist, and his third wife, who was over 20 years his junior. His mother, who was described as a self-involved aspiring artist who had not been successful despite some early attention to her work, was thought to have married his father for his professional connections. As her only child, Jay was the object of her admiration and devotion during childhood, but only if he did her bidding, acting as her companion and accompanying her to social functions. He found her alternately seductive and neglecting, and felt abandoned when she traveled with his father and left in the care of his grandmother. He described his father as a remote and forbidding figure who took only intermittent interest in his son. As a child Jay would often amuse himself by building models, and when he decided to pursue architecture as a career, his father disparaged his choice as being inferior to the fine arts. Jay graduated from a prestigious college and graduate program in architecture, and was awarded a postgraduate fellowship to study in Rome before taking his current position at a major international architectural firm. He developed symptoms of anxiety, depression, and passive suicidal feelings in the midst of a work crisis (a dwindling of his client base, having to accept assignments that he considered mundane and unworthy of his creative gifts) as a result of the economic crisis as well as his own impulsively aggressive behaviors. Further, the deepening crisis in his marriage led him to seek consultation with his former therapist, and he was referred for further treatment.
Case Formulation In the initial evaluation sessions, the patient stated that he was “in a state of paralysis in most areas of his life” and expressed feelings of futility and despair. In short, Jay epitomized the narcissistic patient who often seeks multiple treatments in mid-life when the gap between talent and early aspirations and later reality of lives leads to distress, depression, or acting out. In this case, the former treatment had been only partially successful in that it helped him to reduce but not eliminate his angry outbursts at work and his compulsive engagement in Internet sex, but he terminated prior to resolving conflicts around his marriage. As he put it, “I can’t be sexual and nurtured at the same time.” Further, the underlying narcissistic structure had not been resolved, as evidenced by torturous self-doubt and self-criticism that was obscured by his grandiose sense of superiority, his tendency to find gratification in novel fantasy relationships instead of enduring connections, and his anxiety about dependency when he began to enter into a deeper, more complex realitybased relationship. The drastic split between devalued, desexualized love objects (in this case his wife) and illicit sexually exciting love objects (in this case his Internet partners) is typical of the object relational patterns of patients with severe narcissistic pathology (Kernberg, 1995).
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Although there was no formal assessment of his attachment style, aspects of his presentation including his relentless devaluation of his wife combined with his abject dependency on her, as well as his idealization of women on the Internet with whom he would never be emotionally engaged or intimate, suggested that he vacillated between dismissing and preoccupied attachment strategies, typical of those with comorbid narcissistic and borderline pathology (Diamond et al., 2013).
Course of Treatment Clinical practices: Initial evaluation and contract setting. One of the first steps in setting a viable treatment frame in TFP involves the identification of behaviors that may compromise the patient’s safety or interfere with the patient’s ability to participate in the treatment, or behaviors that thwart the therapist’s ability to function in his or her role as a therapist. Once such behaviors are identified, the patient and therapist together establish mutually agreed-upon parameters for their containment, i.e., the “treatment contract.” Jay was initially dismissive in his attitude toward the therapist, though he insisted that he wanted solutions for his immediate problems, while at the same time he asserted that I, too, would not tell him anything he didn’t already know about himself, and feared getting into a protracted treatment. In the initial consultations, however, I suggested that his presenting conflict around his wife and Internet sex partners might stem from divisions within himself that we needed to explore more fully, and that I would be hesitant to embark on treatment unless he agreed to a treatment contract, which stipulated twice-weekly therapy for at least 1 year, including a commitment to agree to discuss any feelings about ending therapy before acting on them and to report selfdestructive behaviors and feelings, such as abuse of psychotropic medications. As part of the contract, I recommended a consultation with a psychopharmacologist who would monitor his medication use on a regular basis and raised the possibility of a 12-step group if his substance abuse continued. I also anticipated the likelihood that Jay might begin to feel anxious or impatient in the therapy, and that it would be essential to discuss these feelings, rather than act on them by leaving therapy in a repetition of his avoidant behaviors. Initially, Jay was resistant to the idea of a contract that would place any limitations on his behavior. He agreed to these conditions, and stated that he believed I was uniquely suited to treat him because he had looked me up on the Internet and found that I had written a book on attachment and sexuality, and at the same time he dismissed this as a “women’s magazine topic”—a striking mixture of idealization and devaluation. Thus, the treatment contract had already begun to serve its primary purpose–to bring the primary relational dynamics that are being acted out to the forefront in the transference with the therapist. In the context of a discussion in the initial contract setting sessions of why he needed a psychopharmacologist rather than a friend with a MD prescribing his medication, and the ethical guidelines around such practices, the following dialogue emerged: Patient : I still don’t see the need for me to see another psychopharmacologist. And you seem overly conscientious. Everyone I know gets drugs from friends. Therapist : Perhaps a friend prescribing medication may take the sting out of being a patient, and puts you control. For you to comply with my recommendation, that you see a psychopharmacologist, puts me in control. And I think that being in control rather than being controlled is an essential issue for you. Perhaps there’s always a controller and controlee for you–if that’s what is at stake here, I can understand why you would want to be in control of your medication. Patient : Well, I feel like you are not going to tell me anything I don’t already know about myself, so why should I change things until I see if it’s worth doing. Therapist : I can appreciate that, but I think if you didn’t want to try a more intensive therapy you wouldn’t be here. We want to set things up in the beginning to give the therapy a chance. It would be as though you were working with an engineer to build a building that you designed and he is not following sound plans for the foundation. I think you might be concerned about whether that was the best plan.
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Patient : That is a spurious analogy. This is not at all comparable—they are two totally different situations. There is no connection between my work and your work. It’s not even comparable. Therapist : Well fair enough, psychology and architecture are two very different fields, but what strikes me is how upset you seem by that analogy. I’m inviting you to think about this from another perspective and I think that is difficult. I’m struck by how difficult it is to contemplate us working collaboratively to set the framework for this therapy. Patient : I think those guidelines about medication are ridiculous, and they are not for people like me who are well connected and have friends who both really understand me and are knowledgeable about drugs. Therapist : I understand your concerns about embarking on a new therapy, and perhaps you are wondering whether I can understand you and help you with your current dilemmas any more than your former therapists, or your MD friends, and perhaps there is some feeling of futility and fear of putting yourself in the hands of another therapist. Patient : I really don’t want to go into my history again with you—I did that in my previous therapy. Therapist : Yes, I understand that you have told your story to your previous therapists and are less than happy with the results, but there is something about going over your life history with a new person. Perhaps we will come to a somewhat different and maybe deeper understanding of why you are so paralyzed in your life right now, particularly around relationships. Maybe it’s hard to do this with a new person who is not Dr. X. Patient : You have a point there. He did help me to get a better hold of my Internet use. I still don’t really understand why I can’t really commit to my wife or leave her. Therapist : We can explore these issues together and come to a deeper understanding of what is paralyzing you, but in order to do that exploration, I have to know that you are being responsible about your medication and substance use, and Internet use. Otherwise feelings that we should be talking about here will be funneled off in these behaviors. Does that make sense? Patient : Not completely, but okay I’ll give it a try because Dr. X recommended you and I guess you wrote a book about attachment and sexuality. It’s such a women’s magazine topic but maybe you could help me. I’m at the end of my rope here and afraid I’m losing my wife, and I can’t imagine living without her, but I can’t seem to live without the thrill of my Internet partners. Maybe I’m beyond help–I’m not sure what you can do for me. Therapist : It seems like you have a dilemma here—on the one hand thinking I might have some expertise and may be of help, but on the other hand feeling resentful of this and suspicious about whether I can help you. Patient : Well, you are setting all these conditions. Maybe you don’t really want to work with me. Therapist : On the contrary, I’m trying to set up our work so we have the best chance of working together productively. By resisting this framework, it is you who are rejecting what I have to offer. Patient : Okay, I guess I’ll give it a try. The forgoing material from the contract-setting session indicates the challenges of engaging patients with narcissistic pathology in treatment and forging an alliance. Often with patients with severe narcissistic pathology, introducing the contract as a collaborative agreement early in therapy functions as an alliance-building experience in which the idea of a collaborative process in which both patient and therapist have certain roles and responsibilities is introduced. In addition, by creating limits and structure to address destructive, self-destructive behaviors and treatment-threatening behaviors, the contract creates a shared focus for the treatment. The contract functions as a secure base that helps the patient and therapist outline the likely pitfalls they may encounter and sets guidelines that optimize the success and endurance of the therapy– particularly with patients who are prone to early drop out. In so doing, the therapist attempts
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to create an atmosphere of tentative trust and collaboration that functions as a base from which further therapeutic operations can be launched. The forgoing case material illustrates how the dominant relational schemata, involving superior self/inferior other and controlling self/controlled other, are immediately activated in the clinical situation, setting the stage for the first phase of interpretation in TFP.
Clinical practices: Defining the dominant object relations. A central strategy of TFP is to articulate the internal object relation dyad that is activated in the transference at a given moment. The typical dominant dyad of the narcissistic patient as this case illustrates is often that of the superior, even omnipotent self and inferior, devalued other. The initial identification of this dyad is especially difficult because of the anxiety associated with taking an observing distance from the grandiose, devaluing part to explore other aspects of self (e.g., vulnerability, humiliation, fear of dependency, or envy). In addition, the therapist’s ability to help the patient may be experienced as a humiliation, often leading to negative therapeutic reactions manifested by worsening of symptoms or dropping out of treatment. We have identified several strategies that have helped us to engage in collaborative work with such patients, and to accept our interpretative efforts in particular. Clarifying and simply accepting for the moment the patient’s experience of the therapist (i.e., the object representation) without challenging or interpreting the distortions or projective defenses comprising the view of the therapist help the patient to feel understood and contains the intolerable self-states managed through projective processes. Protracted attention to this side of the dyad, i.e., the patient’s experience of the therapist, is referred to by Steiner as a “therapist-centered” interpretation (1993) and may be important in the initial stages of TFP with narcissistic patients, as it is more tolerable for them to see flaws in the other than it is in the self. Therapist-centered interpretations are designed to bypass, at least at the outset, the patient’s sense of weakness, inadequacy, and confusion, thus hopefully avoiding the provocation of the patient’s shame, humiliation, or rage and allowing for a gentler, more tactful confrontation of the patient’s defensive processes (Caligor, Diamond, Yeomans, & Kernberg, 2007; Steiner, 1993). The initial phase of treatment helped Jay to identify and articulate his experiences in therapy, which took the form of seeing me as flawed, inadequate, or unhelpful, and himself as the expert, thus containing his own sense of inadequacy and vulnerability in a projected state (Steiner, 1993). The dismissing devaluation stemmed from not only his realization that I could not provide magical solutions to his conflicts but also his beginning to experience disavowed aspects of himself in the “here and now” with the therapist. In this case, the action around the treatment frame provided the split-off material that was too difficult to verbalize in session. For example, in the first months of therapy, in a session in which he obsessed about his conflict between his wife and his Internet activities, I observed that the choice seemed to be not between two sexual relationships, but between investing in an actual relationship versus remaining sequestered in his fantasy world where he could control and watch anonymous individuals play out his scenarios of dominance and submission. Jay arrived 15 minutes early for the next session and knocked insistently on my door 5 minutes before his session was scheduled to begin. When I opened the door for him at the appointed time, he presented with rigid body posture and a tortured expression, stating immediately that he was thinking of leaving treatment. Patient : I don’t know why I came this morning. I am feeling very adversarial, and this feeling has grown, not diminished. Therapist : Well, it seemed very important for you to come in and tell me how adversarial you are because you came 15 minutes early. Patient : Well, I did feel that we made some progress last week when you said to me that I am having trouble having a real relationship versus investing in a fantasy world. That was progress on our part, well maybe on your part—but I already knew that. And you misunderstood something crucial in the last session–I was talking about my wife, and you failed to notice that she is not encouraging towards me anymore. When we talked about my mending the relationship with her, it was totally wrong–rather
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than encourage me, she mocks me. And you were disturbingly incorrect when you asked about mending our relationship–how could you not see that she has pushed me away? Of course, I couldn’t really tell you what was going on. This week she even talked about a separation. It sounds like I really disappointed you because I didn’t understand intuitively that you were being pushed away, and that you were having trouble telling me this directly. In addition, I don’t like the way you end the session. Last week, you ended the session just as I was in the midst of talking about this. In fact, you cut me off and I am not one to be cut off. It sounds like you are experiencing me as a woman who will cut off and push you away like your wife, and who will fail to care for you and meet your needs. Yes, my wife has been pulling away. She is away visiting her family and very monosyllabic on the phone with me. She said she doesn’t know if she wants to go on with the marriage. I keep coming back to your comment about my fantasy life and how it sustains me, and how after a while, I withdraw from all relationships. Well, maybe that is happening here as well, because you started out saying we had made some progress, but then backtracked and said it was only I who had made progress, or that you knew this all along about yourself anyway, as though it was not something that had come out of our work together. Well, she [the wife] treats me like I’m a pathetic creature. She is not empathic to me anymore. She ridicules me for my paralysis and inability to stop going on the Internet. Today, I think you were experiencing me that way as well. From the start today, I was someone who couldn’t understand and empathize, who would judge you harshly. How difficult it must be to have a therapist who doesn’t understand your anguish and might judge you. [therapist-centered interpretation] Well . . . I’m very anxious today because I have to do a presentation for a new office complex in China, and I am very worried that they won’t like it and will think I’m incompetent. I wanted to talk about that but then I couldn’t. I guess you were worried about telling me this for fear that I wouldn’t understand how fearful you can be, or that I would judge you as you judge yourself for having these feelings. Yes that’s it. I used to be paralyzed with anxiety in situations like this, and then if the client didn’t like the model, I’d lash out. The CBT treatment helped me to not lash out but I still fear that it will come back–these feelings of incompetence, this paralysis, this rage–and I’ll be humiliated. Maybe that accounts for why you were so insistent on having this session, knocking on my door 5 minutes early, because you needed to talk about these feelings, but then when you saw me, you feared that I would humiliate you as well. It is as though someone always has to humiliate or be humiliated. Today, you fear that someone will be you–it sounds like this fear comes up not just at work but with your colleagues and clients, your wife, and with me as well. Yes, that sums it up. I think I can face the presentation now. [Turns at the door] Thank you.
As illustrated, my provisional acceptance in the first part of the session (and in a number of sessions before and after) of the projection of the devalued aspects of self, without interpreting that he is finding in me that which he deplores in himself, allowed Jay to begin to reflect on and to talk about his own fear of humiliation. We can speculate that it may be therapeutic for the patient to see the therapist’s ability to carry on in the face of imperfections, and the patient might internalize the therapist’s less punitive model of coping with flaws. Such interpretations increase the patient’s tolerance for aspects of self that must otherwise be disowned, and pave the way for understanding the larger object relational dyad of superior/inferior that was activated in the transference relationship.
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Clinical Practices: Working with role reversals. The next step of interpretation in TFP involves identifying and interpreting role reversals in the transference, which entails bringing the patient’s attention to his or her alternating views of self in relation to others. While patients with borderline personality disorder tend to oscillate rapidly between views of self in relation to others, due to the rigid and defensive nature of the grandiose self, patients with more severe narcissistic disorders less often shift to a negative view of the self. However, because the grandiose self sets up exceedingly high expectations, such individuals are at the risk of a catastrophic shift to extreme distress if the defensive function of the grandiose self fails. Once the dominant relationship pattern has been identified between patient (as superior) and therapist (as inferior), enactment of complementary patterns can be discerned in split-off aspects of what the patient (as inferior) is saying to or doing with the therapist (as superior). Material from this session 9 months into treatment will illustrate this bifurcation in the object world, and the ways it was externalized in the transference: Patient : I’m bothered again by the way you ended our last session, just when we were getting somewhere. I was eager to come because I appreciate your perspective and your challenging of me but now that’s all I can think about. I know we were out of time, but it’s like you think you’re the professor and I’m the 22-year-old graduate student in Rome focused on romance every second. Therapist : It sounds like you felt that you were not important to me because I ended the session on time. I am struck by your comment about feeling like a 22-year-old romantic student and me being the professor because on the one hand you have some good feelings about coming but they are cancelled out by the sense that I’m the professor who has the authority to end the session on time. This sounds like a terrible dilemma in that you see me as someone who is competent, and might be able to help you, but I wonder if this doesn’t also make you feel some resentment and perhaps envy. Patient : Yes, I think of you in very different ways—sometimes I see you as off the spectrum brilliant, but really old and haggard, and sometimes as an attractive woman regardless of your age with a confidence that comes from that or somewhere in between—I see you as both. Therapist : This is not unlike the divided way that you experience yourself as assertive, successful, and competent on the one hand and as flawed and miserable on the other. Patient : This is a theme that always comes up for me—that of humiliation and not being able to deal with conflicts about vanity. I think this was basically resolved at work, but not in love. I keep looking for that ideal woman who is going to cure me—particularly P [a woman on the Internet who was the main focus of his fantasies]—but I found flaws with her too. I guess, what I feel about her parallels to what I feel here—the hideous duality of being young and beautiful, but flawed and unattractive. That’s why I stopped responding to her e-mails. By the way, my wife is actually seeing a new therapist and changing her meds–I am noticing some changes. Therapist : It is interesting that you are telling me that your wife is back in treatment, since every time I raised questions about this you insisted she was beyond help. Yet you have described her as formerly very attractive and desirable, but now old and repulsive. This is similar to the bifurcated way that you see me. Patient : I don’t think you’ve been able to appreciate my attachment to my wife. I don’t think I’ve conveyed to you the pull as well as the push of that relationship. The pull is the comfort and beauty of the household but I live in a halfway house—with therapy, with my wife—none of them get all of me. Therapist : The part of you that is always attacking your self-worth attacks them as well, making it hard to experience and connect with the good parts—making it hard for you to appreciate and convey your attachment to your wife. This came up today as well when you looked forward to coming to session, but then remembered your negative feelings about my ending the session. The foregoing clinical material, by necessity quite condensed, provides further illustration of not only the emergence in the transference of the patient’s bifurcated internal world but also
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the role reversals that occur within the dyads comprising this internal experience. Slowly the superior and idealized aspects have emerged as a dominant part of the representation of the therapist, and the underlying vulnerability and helplessness have emerged as a dominant part of the representation of the self. This highlights the shift from thick-skinned to thin-skinned narcissistic positions (Rosenfeld, 1964, 1971). Clinical investigation with patients with severe narcissistic disorders reveals that as those who are more dismissive in their attachment state of mind (or thick-skinned) start to face what had been their unconscious psychic reality, they begin to look more preoccupied in their attachment state of mind (or thin-skinned), with an increasing awareness of feelings of chaos and panic, related to a sense of inner emptiness or vulnerability. About 10 months into treatment, Jay acknowledged that the real reason that he hadn’t left his marriage was because of a “terrifying chasm” in himself, which his wife has filled with her endless devotion. This “chasm” was associated with terrifying fears of aloneness and emptiness, which drove both his endless quest for exciting anonymous sexual experiences, and which also eclipsed his capacity for sustained intimacy. His being increasingly able to own and articulate the feelings of dependency that had previously been so strongly defended against marked the subsequent stage of treatment. Most notably in the transference, he told me that he had fantasies that he was my only patient and that I thought only of him. Intensive work in the here and now interactions between patient and therapist is the vehicle for change with such patients, and is often evident in statements such as the following made by Jay after one year of TFP: “Something happened yesterday and I thought we might make sense of it together, rather than my just exhibiting my psyche to you.” Jay talked about ongoing compulsions to revisit the Internet experiences, but with further exploration, acknowledged that over time he found his need to dominate and control others both sexually and emotionally to be disturbing rather than gratifying. Although he stated that he feared therapy would not help to change what excited him sexually, he was able to explore how his enactment of dominance/submission scenarios were an expression of both the critical, devaluing part of himself and the self that is the object of those attacks. He talked about how his relationship with his wife had helped to provide him with a platform from which to launch his career and began to experience and express gratitude for the beautiful and gracious home she had created. He recognized that his devaluation of his wife devolved from an internal scenario involving the scathing critical part of himself with his wife, the willing recipient of this degraded, devalued aspect of himself—what he has termed his “judgementalism,” stating, “I judge her (wife) and withhold—all things you experience with me here.” This realization marked a shift from a dismissing to a preoccupied position, offering the possibility of a more than intellectualized understanding of the ways in which his chronic devaluation of others, including the therapist, is an externalization of harsh critical elements of his own internal world. Thus, in the later stages of TFP, there is often increased recognition of how the claims of idealized representations of self and others (the grandiose self) have eclipsed the needs of the real self, leading to decreased valorization of narcissistic dimensions, and increased capacity for genuine investment in relationships, both internal and external.
Outcome and Prognosis With repeated interpretation of how Jay’s alternate devaluation and idealization of me and significant others were actually split-off aspects of his own idealized and hated representations of self and significant others, he began to recognize how these projections protected him from the pain of facing his limitations, truncating his capacity to experience pleasure and gratification in, as well as gratitude for, what others could realistically offer. He has shown increasing recognition of how his investment in the sustaining fantasy of finding the ideal woman who would grant him perfection has curtailed his capacity to value the intimacy and companionship that he finds in his wife, and to allow himself to re-experience the passion he felt for her for the first 10 years of their relationship. Although he continues to be ambivalent about his marriage, he has begun to reflect on and appreciate his wife’s contributions to his professional development and well-being, to feel regret for the relentless rejection and humiliation to which he has subjected her, and to consider the possibility of having a child with her, recognizing that time for such a decision is not endless.
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In addition, rather than focusing on the prestigious projects that he felt entitled to work on, he has begun to focus more on developing business for the firm as a whole. Over the course of the therapy, he has come to understand that his tendency to devalue others was in part a result of his identification with parental figures who were tantalizing but neglectful (mother) and distinguished but critical and distant (father)–internalized figures that systematically undermined his own capacity to experience love and happiness, while at the same time fueling his sense of grandiosity and omnipotence. Further, as he develops the capacity to reflect on himself and his own motivations, it has become possible to interpret the anxieties and conflicts–anxieties about abandonment, insignificance and even annihilation (the terrifying chasm)–that catalyzed his retreat into grandiosity and to connect these with early experiences. In sum, through the exploration and integration of bifurcated self and other representations, the patient developed the capacity to think more coherently and reflectively, with more realistic, complex, and differentiated appraisals of the thoughts, feelings, intentions, and desires of self and others.
Clinical Practices and Summary In sum, this patient epitomized many of the difficulties with attachment typical of patients with severe narcissistic pathology–the difficulty sustaining sexual interest in his long-term partner, the split between devalued, desexualized love objects and idealized, anonymous sexually exciting objects, the terrors of aging and diminution of physical prowess that he projected onto others including the therapist, and the lack of gratitude for love and ordinary domestic pleasures he experienced with his wife, along with the projection of blame onto her for all limitations of their life (Kernberg, 1995, 2007, 2010). The interpretative process in TFP has allowed for systematic analysis of the grandiose self, leading to a shift from a grandiose, dismissive to a more vulnerable, preoccupied narcissistic presentation. This interpretive process leads to the gradual integration of disparate, split-off self and object representations into a more integrated stable concept of the self and objects, which in turn fosters reflective capacity in that it provides a more integrated, consistent working model of self and others against which momentary mental states, including those that devolve from the grandiose self, may be more systematically reflected upon and their defensive function understood. The case calls for ongoing empirical and clinical investigations of the particular difficulties in the sphere of sexuality and love relations that often bring NPD patients to treatment, how such difficulties are related to different internal working models of attachment, and how they change in the course of treatment.
Selected References and Recommended Readings Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical Psychology Review, 28, 638–656. Caligor, E., Diamond, D., Yeomans, F., & Kernberg, O. F. (2009). The Interpretive process in the psychoanalytic psychotherapy of borderline personality pathology. Journal of the American Psychoanalytic Association, 57, 271–301. Clarkin, J. F., Kernberg, O. F., & Yeomans, F. (Ed.). (2006). Psychotherapy for borderline personality: Focusing on object relations. Arlington, VA: American Psychiatric Publishing, Inc. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. The American Journal of Psychiatry, 164, 922–928. Clemence, A., Perry, J., & Plakun, E. M. (2009). Narcissistic and borderline personality disorders in a sample of treatment refractory patients. Psychiatric Annals, 39, 175–184. Diamond, D., Levy, K. N., Clarkin, J., Fisher-Kern, M., Cain, N., Doering, . . . Buchheim, A. (2013). Attachment and mentalization in patients with co-morbid narcissistic and borderline personality disorder. Manuscript submitted for publication.
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Diamond, D., & Yeomans F. E. (2008). Psychopathologies narcissiques et psychotherapie focalisee sur le transfert [Narcissism, its disorders and the role of transference-focused psychotherapy]. Sant´e Mentale au Qu´ebec, XXXIII, 115–139. Diamond, D., Yeomans, F. E., & Levy, K. (2011). Psychodynamic psychotherapy for narcissistic personality disorder. In K. Campbell & J. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatment (pp. 423–433). New York: Wiley. ¨ S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., . . . Buchheim, P. (2010). Doering, S., Horz, Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: Randomised controlled trial. British Journal of Psychiatry, 196, 389–395. Hilsenroth, M. J., Holdwick, D. J., Castlebury, F. D., & Blais, M. A. (1998). The effects of DSM-IV cluster B personality disorder symptoms on the termination and continuation of psychotherapy. Psychotherapy, 35, 163–176. doi:10.1037/h0087845 Kernberg, O. F. (1995). Love relations: Normality and pathology. New Haven, CT: Yale University Press. Kernberg, O. F. (2007). The almost untreatable narcissistic patient. Journal of the American Psychoanalytic Association, 55, 503–539. Kernberg, O. F. (2010). Narcissistic personality disorder. In J. F. Clarkin, P. Fonagy, G. O. Gabbard, J. F. Clarkin, P. Fonagy, & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for personality disorders: A clinical handbook (pp. 257–287). Arlington, VA: American Psychiatric Publishing, Inc. Lendvay, J. G., Foelsch, P., Diamond, D., & Carrasco, B. (2011). Sexual fantasy and psychopathology: Clinical and empirical perspectives. Manuscript submitted for publication. Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transferencefocused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040. Levy, K. N., Reynoso, J. S., Wasserman, R. H., & Clarkin, J. F. (2007). Narcissistic personality disorder. In W. T. O’Donohue, K. A. Fowler, & S. O. Lilienfeld (Eds.), Personality disorders: Toward the DSM-V (pp. 233–277). Thousand Oaks, CA: Sage Publications, Inc. Mikulincer, M., & Shaver, P. R. (2007). A behavioral systems perspective on the psychodynamics of attachment and sexuality. In D. Diamond, J. Lichtenberg, & S. Blatt (Eds.), Attachment and sexuality (pp. 51–78). New York, NY: Analytic Press. Ronningstam, E. (2011). Narcissistic personality disorder in DSM V—In support of retaining a significant diagnosis. Journal of Personality Disorders, 25(2), 248–259. Steiner, J. (1993). Psychic retreats. London: Routledge.
