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.