Transcription
Two prominent counter transference reactions to narcissistic individuals have been identified in surveys of clinicians. And they're so interesting.
One is anger, resentment, you know, wanting to get rid of the patient. And the other one is a sense of defeat, feeling diskilled, feeling they have nothing to offer the patient because the turning away and the dismissing attitude is so pervasive. So the important thing is to tolerate the devaluation and the dismissal and acting like they're directing the treatment. They're the ones in charge. They're the ones who are evaluating the therapist. That often comes up.
I had a patient who every session would say, "Well, you know, well, therapists listen, they empathize, and they interpret." And almost every session he would say, "Well, this was pretty good about listening. Not so great at interpreting." Well, you were very empathic today, but you missed this interpretation. So, that constant evaluation that you encounter from these patients is very off-putting to clinicians. And in fact, I think one of the reasons why treatments with these patients break down is unchecked and unanalyzed counter transference on the part of clinicians in treating these patients, which by the way takes longer in certain cases than it does to treat borderline patients. So, we're looking at treatments that are at least a year, if not a year to five years, I would say.
It's not that you can't make a lot of gains in a year, but what I see after a year or a year and a half is the dismissing attitudes beginning to give way to much more dependent attitudes. Dependent transferences come into play. Patients want to start coming. If they're coming twice a week, they want to come three times a week. There's a tremendous need to be special to the therapist. The therapist becomes extremely important. They begin to talk about things they've hidden from the therapist that they feel deeply ashamed of. So there's a shift from dismissing to more preoccupied attachment in the transference. The transference goes from being a narcissistic transference in which the therapist is discounted or dismissed, devalued relentlessly in the beginning, the whole sometimes for the whole first months of treatment, to the therapist being seen as all-important with themselves as incredibly dependent.
Um, there's often in that phase a lot of fearfulness, fearfulness of dependency because one of the primary narcissistic resistances is fear of dependency. And these patients will do anything to avoid that. And so what you get in the mid phases of treatment, however long the treatment is going to be, is often dependent transferences giving way to what we call depressive transferences. The person's then being able to see the therapist and others and themselves as an amalgam of very good and very bad traits, idealized and devalued at the same time. They're beginning to integrate all of that. They're beginning to recognize the damage that their narcissistic modes of functioning have done both to themselves and to others, the lost opportunities in life, the broken relationships. They're able to mourn losses that they couldn't mourn before.
So in the later phases of treatment as you get depressive functioning coming into play and depressive transferences, there's often tremendous pain and even some depression and even patients can develop transient suicidal feelings. Sometimes that's when clinicians want to rush in to medicate patients. In my experience, that's a time that individuals have to go through in order to really integrate. You see, all these unmorned losses, all these aspects, devalued aspects of self that they have projected onto others and to reach a more integrated state.
So, which is what happens towards the end. Yes, which is what happens towards the end. And as I said, residues of narcissistic functioning do remain, but they become more like mental states that the person can move in and out of at will and that they can reflect on and say, "Oh, in that situation, I just behave like the most grandiose, selfserving, infantile, you know, etc., etc." And they'll tell you that and say that they really felt bad about it. They develop the capacity to reflect on those states when they get into them and to self-correct.