Left Eye Blind

Of course, when you are a private practitioner who’s livelihood depends on collecting fees for service it can be annoying, but shouldn’t. If you have a cancelation policy, the patient will have already agreed to pay for non-rescheduled or failed appointments.
Annoyance short-changes the therapy. I always recommend to new therapists to allow themselves to simply sit when a patient is late or fails to attend. I ask them to notice whatever is going through their minds about the patient and the missed appointment. In essence, I suggest free-associating to the failure. Often a surprising thought or insight presents itself that the therapist can use in the next scheduled session. Often, the therapist is able to approach the possibility that their behavior or attitude shaped by counter-transference may be at the root of the missed session and the patient, by failing, is communicating something that they have yet to be able to put into words
In essence, failed appointments are an opportunity for therapist and patient to delve into deeper layers of communication, and thus, change involving both.

I’m not sure this will answer your question as your inquiry was rather broad. I will say this: I have very often while listening to a patient’s awful circumstances in the present or past will leave me with tears in my eyes and often with the tears rolling down my cheeks. This is often accompanied by a temporary inability to talk. I believe that my tears are far more expressive than anything I could say.

My tears have been met with a variety of responses: astonishment that I would feel that strongly; a desire to protect me from the more horrifying instances of abuse; but, mostly, a sincere gratitude that I, too, can feel how horrifying their experience(s) were. Their feeling of thankfulness for affirming through my emotional response that if I can feel it so directly just through the patient’s words and emotions, these patients can then have even more empathy for themselves.

Not having an obvious emotional response to the horrors of evil that so many have endured would be worse than disingenuous. At the end of therapies where I have periodically displayed my deepest feelings, the patients with whom that has happened say that those moments of shared horror, grief, sorrow, wonder, joy, fear, etc. were the most healing for them, and a few have even said they thought those moments may have been healing for me, too.

How perceptive and right they were.

3.7k Views · View Upvoters · Answer requested by Louise Matthias

Mark Maginn
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As a survivor of narcissistic abuse, I sometimes feel destroyed by a negative comment. How do you tell the difference between healthy and unhealthy criticism?
Mark Maginn
Mark Maginn, Psychotherapist, poet, memoirist, blogger, (2012-present)
Answered just now
I’m pleased you reached out here, Trish.

I think being able to tell the difference between healthy and unhealthy criticism difficult under normal circumstances. But for you, now, after a period of abuse, the distinction between the 2 was probably erased for you by the person responsible for harming you.

Though I’m not sure what you mean by “narcissistic abuse,” I can guess, and on that flimsy platform of an informed( I have treated many people with varying degrees of damage to their normal narcissism) guess

Any time any one is abused, their orientation to reality has been damaged and that damage by the perpetrator was inflicted for all manner of horrible motivations but chief among them, & mostly unconscious to the abuser, is the sadistic desire to drive the victim mad. The abuser wants to “fuck” with the victim’s sense and hold on reality. He wants to drive the victim into the veryyyy madness that captured the perpetrator long ago.

This, Trish, is my way of laying the groundwork for writing to you about the possible lingering damage from the abuse. I suspect your abuser was, in part, unconsciously motivated to destroy that part of your healthy narcissism we know as well established self-esteem that allowed you to recognize harmful, deceitful criticism from healthy, and yes, helpful criticism.

That is the damage that comes with possible PTSD resulting from your abuse. It is the aftermath of the abuse that you will, with good help, need to work through. From that work you have regained your confidence and the firm self-regard that will protect you once again from those who wish to harm your self-esteem.

That’s a very timely and pertinent question, Rachel. Mental health services are under attack at the fed, state and local level with many mental health centers shuttered as politicians decide that tax revenue needs to be kicked up to those who need it least.

Working with people with extreme emotional disturbances is difficult: there are huge emotional demands; time demands and pressure from mental health clinics and insurance companies to end the treatment as soon as possible and kick the patient loose.

This coupled with a paucity of training, especially for those of us who know psychodynamically oriented psychotherapy with a well trained therapist and, if needed psychiatric back up for periods when medicine support for the patient is indicated, is a very, very effective treatment.

However, short term therapies are usually the only ones most insurance carriers will fund.

It’s also problematic that many people on the extreme edges of madness often don’t have the funds necessary to support intensive treatment.

However, there are some of us in private practice willing to see these people at a reduced fee, often based on a sliding scale. This, however, can be difficult especially during stormy periods during the therapy where the patient is truly captured temporarily by the underlying madness and the stress on the therapist can be extreme. It is then that we wonder what on earth are we doing this most challenging work for less than our usual fee.

That however, if the therapist has been well trained and well “therapied” him or herself and has ongoing consultation and or therapy to help the therapist with his or her normal, and not so normal, anger and desire to retaliate. Maintaining boundaries is also difficult as these patients in their desperation will not be able to end the sessions on time as the separation from the therapist is felt as catastrophic.

In short, working with people dwelling in the near suburbs of madness or living inside its city limits all too often, is very demanding, draining, & often draining & exasperating work.

Yet, those of us who do work in the vicinity of Madness, USA find the work exhilarating, often magical, and an offered journey deep into ourselves as we accompany the citizens of Madness on their journey of rage, fear, annihilation, brushes with suicide and through it all, an emerging emotional contact with the therapist who, for the most part has not given up and withdrawn, nor has s/he lashed out in fear, anger or rage.

But, instead, the patient gradually finds a therapist who can contain all those feelings of the patient until those inflamed emotions cool to warm embers and provide a space to be truly alive and connected to someone else. Maybe still damaged and sometimes fragile, but an expatriate of Madness USA.

Narcissism is a broad category that runs from healthy narcissism, pride in one’s work, for example, the abnormal such as paranoia. Paranoia may seem a rather odd manifestation of deranged narcissism but think of it like this: how much narcissism does it take for someone to believe the FBI is following you, yes you and you alone. That is narcissism run amok.

A person who finds it nearly impossible to empathize with others, someone who needs constant admiration, such as our president, someone who becomes enraged or aloof if disappointed in someone, someone who, the narcissist believes, should always pay attention to him/her.

People who suffer from pathological narcissism that have not crossed the frontier into frank madness are often diagnosed with the DSM designation, Narcissistic Character/Personality Disorder. I included “Character” only in so far as this particular disorder was, and still is among many practitioners, thought of as a character disorder. One analytic writer in the last century referred to such patients as having character armor that protected them from a host of thoughts and feelings.

People with this disorder often seek help because things just don’t “feel right,” or a sense of pervasive emptiness or meaninglessness has crept into their lives leaving them vaguely unhappy. They also come for Tx after the breakup of yet another love relationship; or they may be dissatisfied in the progress of their careers.

I have treated many people with varying degrees of disturbance to their narcissistic equilibrium. When they come for therapy with me, and after a period of evaluation including my evaluation of their ability to engage in and profit from therapy, we discuss the diagnosis, prognosis and an estimate (a very loose estimate) of the length and difficulty of their treatment. Once they agree, we begin to look together at what troubles them.

This work is taxing for the therapist as the patient can adopt a haughty, dismissive pose towards me and the treatment itself. Or they may defensively idealize me for often lengthy periods. Some need to do this, and all need to resolve that transference so as to be able to have a firmer vis-a-vie with reality.

This particular transference can be quite tricky and seductive for the therapist. I find being idealized the most difficult transference because being told am the most incisive, intuitive, sensitive therapist the patient has ever seen can induce all manner of disturbances in the therapist; that is, me. I can feel my own grandiosity fed by such idealizing and not want to engage the patient in looking at what is really happening between us.

But fate always steps forward in the guise of me making a terrible mistake: saying something that indicates to the patient that I, god forbid, didn’t understand them, or said something that indicated that I wasn’t the most brilliant person the patient has ever known. This can, and does cause severe disruptions in the therapeutic alliance as the patient rapidly de-idealizes me and begins to degrade me; call into question my intelligence; call into poor light my training; suddenly realize, and they should have known better, that I intentionally duped them.

I find the de-idealizing quite uncomfortable but far easier than being idealized. It takes very patient work on my part to help the patient and me uncover just what my “horrible” mistake was and empathize with the patient’s very deep disappointment and primitive rage at my failure. A failure that usually mirrors the traumatic failures of the patient’s earliest care givers.

These kinds of “enactments” occur rather regularly in the therapy with these exquisitely sensitive and deeply damaged people, who, behind their haughty disdain for me, yearn for genuine, empathic contact. Often the way they treat me is a replication of how they were treated.

At other times the patient may need me to “mirror” them for lengthy periods of time. They need me to accurately see and feel them and convey accurate understanding to them in a manner that slowly repairs the faulty mirroring they received as very young children.

Once again, I will miss something, usually related to my countertransference to their need for me to mirror them, and my mistake will feel horribly wounding and disappointing. Again, we have to patiently, and often painfully reconstruct what happened with me taking responsibility for what I did that was perceived as so wounding.

It is these moments that allow for the healing and growth of not only the patient, but even me, in my advanced age. Both of us share an exquisitely human moment that is ultimately growth producing and precious us both.

I have greatly condensed and simplified what therapy is like for both the therapist and the patient. My apology if my rather prolix “brevity” in this explanation leaves some scratching their heads. If you have questions or comments about what I’ve published here, please feel free to contact me here at Quora. I will try to respond with far fewer paragraphs.

Because, primarily, the person suffering from this disorder is so very sensitive to any signs of rejection. This ravening fear often borders on paranoia and all to often breeches that frontier. In my experience in treatment with those who suffer in this way, the thought or fantasy of rejection is often exquisitely preternatural.

As an experiment in empathy try putting yourself in such shoes and imagine what it must be like, out of your crushing loneliness, to so desperately want a friend, a friend to accept you, sulfurous flaws and all. Yet know that a harrowing flaw your in your personality, a flaw that you consciously or unconsciously know only too well, will command you to behave in a manner that will lead to your dismissal by the very person you so desperately want to accept you.

Yes, rejected once again, and, god forbid, alone again. Alone with a self-hatred and yawning emptiness that, like a cosmic black hole, swallows all in its path. Imagine a self-loathing so barbarously implacable that you cannot see beyond your own hellish abandonment.

Yes. It is the repeated experience of emotional and/or physical abandonment that grinds away in the background of such a stricken person.

It is because of these awful tragedies that I can not brook the prejudicial, and yes, thinly disguised hateful attacks I so often read here on those burdened with the agonizing realities of the mental illnesses of borderline and/or narcissistic personality disorders.

Please, dear readers, silence if not empathy.

How do I know if I subconsciously downplay my problems or if they are real?
Mark Maginn
Mark Maginn, Psychotherapist, poet, memoirist, blogger, (2012-present)
Answered just now
Fascinating question. Not sure, but how about talking over a couple of your problems with a trusted friend and see what feedback you get. If still confused, check in with a licensed psychotherapist and ask for feedback or if present, a diagnosis.

I’m only guessing here, but I suspect that you might not share your problems with others. If you did, you might not be confused about this. If making friends is a possible problem than checking in with your friendly neighborhood psychotherapist might be warranted.

In any event, good luck figuring this out. But really, if your “problems” are not significantly interfering in a major area of your life, such as love relationships, friendships or work, then I wouldn’t be too concerned. If, however, you’re getting feedback from others that you’re missing something, then, again, a trial therapy with a psychotherapist might be in order.

Hold still and feel the sadness; get to know it; don’t push it away; befriend it. This will not only lessen the feeling but will allow the person the time and space to resolve it. By this I mean that the sadness and from where it springs can be safely integrated into the psyche & personality of the person experiencing this most basic of human emotions.

Hold still and feel the sadness; get to know it; don’t push it away; befriend it. This will not only lessen the feeling but will allow the person the time and space to resolve it. By this I mean that the sadness and from where it springs can be safely integrated into the psyche & personality of the person experiencing this most basic of human emotions.