Transcription
I already knew how to do sex therapy, or to do sex therapy with people with personality disorders in general. I didn't feel like I really was on safe ground with a treatment of people with narcissistic personality disorders. So it came out of my own difficulty seeing results and seeing results that would make sense to me and also to my patients. And so I became interested in developing something that is more like principles of treatment that could be applied specifically to that population.
Some of the principles are, they may seem very common sensical. I think that a lot of people say, "Why not do this? We're already doing this in our treatment." And in fact, I don't think that there's anything very original about them. They're just principles that seem to work when it comes to treatment of people with narcissistic personality or pathological narcissism. And so some of them would advocate to pay close attention to treatment goals and make those goals very concrete and meaningful, and negotiate goals with a patient until those goals become doable and concrete. Because we know that sometimes patients have goals, but they're unattainable, very vague. And many patients don't want to get engaged in discussion of goals because it's because it feels like it feels like they're signing up for a test and they're afraid of, you know, getting half on that test. So it feels like a performance, which it's not, but it may feel like this.
Another thing that I found that was really helpful is engaging patient's sense of agency, your sense of ownership of their personal history and also their personal choices. And that has a lot of importance because one side of that aspect of treatment is helping people identify their own patterns and identify their own choices, even though some of their choices may be painful and shameful and difficult to to bear. But another side is identifying their capabilities and capacity to move forward and make new choices and make different decisions.
Another aspect is helping people move from the narrative that is related to preserving grandiosity or perpetuating self-criticism and sense of shame to a narrative that is more authentic or genuine. And that's a lengthy process that requires a lot of exploratory interventions on the side of the therapist, expression of curiosity and bearing uncertainty, and also helping patients to get unstuck from a sense of certainty that sometimes they have about themselves and other people.
Those were some of the principles. Other principles really emphasize development of attachment. A lot of the research that we have today about effectiveness of psychotherapy talks about alliance and importance of alliance and change. And we know that with people with narcissistic personality disorder, alliance is usually fragile, and that's documented. And we know that a lot of the treatments are trying to address it. And so that's another reason that when we start treatment, it becomes really important to agree about behaviors that are helpful for treatment, for example, coming on time, attending, participating in a meaningful way, bringing up meaningful experiences, but also behaviors that are not helpful, for example, attending while intoxicated or missing sessions or being late. And that may sound like a very common sense, but those are very important things to spell out sometimes for with patients.
And another aspect of this is understanding that attachment could be fragile for a lot of people with narcissistic pathology. In fact, research shows that a lot of uh people with narcissistic pathology have what we call dismissive attachment. In other words, when they feel distressed, they tend to dismiss others and avoid them and keep things secret and keep the distress secret and then feel very ashamed of disclosing anything that feels uh personal. And that really leaves a stamp on their ability to rely on their therapist an emotional way and feel close to them. And treatment is designed to help people address those issues and look at the tendency to avoid close attachment and withdraw from therapists when they actually need the therapist the most.
So, can you give an example of an exchange where you're on the edge of leading that person into avoidance, or that you notice they're moving into avoidance, so how you bring them back or what you're what you do?
Yeah, like I might be discussing with a patient something that is anxiety provoked. I might be discussing the possibility of them taking on a job, and they're that may be struggling what direction to take. They don't know what career they want to choose. At the same time, they also would like to have a job so they could become financially self-sufficient and independent of their family. Um, it's a painful discussion. And I might be talking about this one session. In the following session, the same patient is coming and giving me a very general description about the gardening practices and how they take care of the vegetables. And while this is meaningful and interesting, but it's really very removed from what we've been talking about a session before.
Many times when things like that happen, I might feel that there is a, as if there is a distance between me and the patient. That maybe because of the tone of their voice, or maybe something just feels uh different in terms of the emotional attunement that I experience in that moment. And looking at this information together, I might wonder to myself if what's happening with the patient is that they're removing themselves from the possibility of discussion of something that is very, very anxiety provoking. And if that happens, I might make a comment about this. And I might notice that we're talking about how to grow vegetables when in the previous sessions we thought about how the patients might grow themselves and and develop their own capacity to become independent and see what they do. And I might bring it up again and see how they think about the possibility that maybe that there is a connection, that today the session feels somewhat light and superficial, and and we're not really getting into things that are more painful. And then if the patient wants to take it up, then we continue talking about this.
Is it your attempt to try to kind of bring them back in?
I see. Yeah. So I point out different examples of avoidance or difficulty engaging with a more effectively charged material that it seems to be happening. We also talked about different don'ts. What we described in this paper, this is the paper with Dr. Elsa Ronningstorm. So some of the don'ts, one of them is talking about emotional reactions of the therapist, also known as countertransference. And those are the reactions that we all have to our patients, and they could range from liking the patients and sometimes actually not liking the patients. However, we all know today that those are very, very important reactions because we learn about more intuitive aspects of the person's functioning, something that means sometimes patients cannot put into words, but is coming through in a more intuitive way through the emotional communication in sessions.
And in treatment of people with narcissistic personality disorder, it's very, very important to pay attention to this because one of the reasons, one of the main reasons actually, that this uh the treatments so stall and don't progress is the therapists do not know how to manage those reactions that could be quite intense. And some of those reactions could be feeling that they're irrelevant, or they feel bored, or they feel angry with the patient, or they feel like they want to teach the patient a lesson. Or sometimes quite the opposite, they feel that the patient is a helpless victim that needs to be recognized and rescued. And those may be some of the reactions. But they are very difficult to bear. They need to be understood and made sense of. Um, and that's one of the principles that we found as really important in guiding treatment.
Your reaction to the patient, understand and make sense out of it, right? It makes sense out of your reaction and also make develop a different way of tolerating it because some of those reactions are really hard to tolerate. Some of the other principles, they are, they seem maybe commonsensical. For example, don't get into a power struggle with patients. Don't try to prove that you're right and they're wrong. For example, we don't want to get into a power struggle with patients, but that's an important reminder for patients with narcissistic personality disorder because of how many practitioners feel tempted to do this.
And another thing that I just wanted to remind in this context is that there is some documentation that life events are really important. Incorporating life events into treatment is really important because people are able to learn from their life experiences, and not every change comes from the psychotherapy alone. It happens outside the room. Some of the changes happen outside the room, and sometimes psychotherapy allows those changes to occur. And we want to be respectful of those changes and pay attention to them.