Treating Survivors of Narcissistic Abuse

Although I hadn’t seen her in three years, my client Maya—a woman in her late-40s with two school-aged children—still looked timelessly stylish in jeans and a white cotton top. Her kind, if tentative, smile hadn’t changed, but she looked wan as she settled on my couch and said, “Things aren’t so good.”

She told me she’d become socially withdrawn and had lost interest in the horticulture and gardening that had long been her passion. As she spoke, she dug her nails into her palms. “I’m also very anxious,” she said. When I asked her to describe her distress, it was clear it had reached a clinically significant level of dysphoria.

Maya had been married to her husband, Henry, for 22 years. In our previous work together, we’d spent eight months exploring how often she felt unheard and unappreciated in her marriage. She had a good job as a graphic designer at a nonprofit organization and was a devoted and mindful mother, pouring her infectious energy into her children, but she often felt small and diminished around Henry, a highly valued executive at a rapidly growing tech firm. Before she’d abruptly dropped out of therapy with me the last time, I felt we’d made some progress in strengthening her sense of self as she worked on cultivating deeper friendships and finding pockets of time each day to focus on her own needs.

Now, however, a sense of déjà vu came over me as she described her struggles with Henry. New stories about their relationship weren’t new at all. His patterns of unbridled arrogance, barely disguised contempt, and frequent put-downs of her hadn’t changed.

“Remember how we’d talked about me finding a running group so I could get out of the house a little and get a piece of my old self back?” she asked. “Well, I ended up joining a yoga class, and I really liked it,” she told me. “But Henry would mock it and call it hippie bullshit. I wanted to go on a weekend retreat with a group there, but he was so demeaning of the whole thing, I just stopped asking him to watch the kids so I could go. Then, because I couldn’t take all the snide remarks, I just stopped going altogether.”

Maya started to tear up and added, “I miss it. It felt so different from my life in the house. Do you remember when I told you that it felt like Henry’s schedule trumped everything?”

I nodded.

“When he got home from the office, the kids could be doing their homework and I could be in the middle of taking care of something else, but if he was hungry, we’d need to stop everything and eat. Once I stopped working, this kind of thing just got worse,” Maya continued, her voice stiffening. “Now, when we all sit around the table, he can’t even be bothered to ask about anyone’s day. He’s on his phone the whole time, and if I say anything, he rolls his eyes and tells me I’m being ridiculous.”

She sighed. “I’ve gotten used to it, but my heart breaks to think about what he’s modeling for the kids.”

Before, Maya hadn’t wanted to leave Henry out of concern for her children and a hope that things would improve one day. As I listened, I wondered if that had changed. But almost as if sensing my train of thought, she pivoted her narrative to do something she used to do a lot: point out that there were benefits to their relationship. Henry often spent time skiing with their eldest son. And sometimes, especially when something had gone well at work, he’d come home happy and attentive.

At one point, Maya had convinced Henry to try couples therapy to enhance their connection, but it hadn’t lasted long. That therapist had focused on helping them communicate feelings, but when Maya had attempted to share her concerns about the way he was talking to her or the kids, Henry was dismissive, even contemptuous. Despite this, at one point the therapist had turned to Maya and asked, “What do you see as your contribution to his behavior?”

When Maya recounted this to me, I let her see the discomfort on my face. With clients like her, who’ve endured so much humiliation and gaslighting in their primary relationship, clinicians need to make sure not to implicate them in their partner’s cruelty. Instead, I find being transparently offended about what they’ve endured can be crucial. It’s certainly more validating for them than maintaining a clinical distance.

Three years ago, I’d started pointing out to her the patterns and behaviors that were consistent with a narcissistic relationship, but Henry was aware enough to recognize when he’d pushed his wife too far and would strategically counter his cruelty with the obfuscation of love bombing. This technique—seducing a partner with flagrant demonstrations of affection—is tactical, temporary, and common among narcissists.

After a rough night of fighting, for example, sometimes Henry would leave Maya sweet notes on the fridge before he left for work. Or he’d stop by an expensive bakery on his way home and bring her and the kids their favorite cupcakes. One day, after a previous night’s conflict had ended in his raging at her in front of the kids, he’d taped plane and lift tickets to Aspen to the bakery box.

In what had turned out to be our final session three years ago, I’d reminded her that these patterns had been repeating for a very long time. “What would you do if you knew these patterns wouldn’t change?” I’d asked her.

When Maya had cancelled her next two sessions and didn’t return my phone call asking if she’d like to reschedule, I’d sent an email letting her know that my door was always open to her. Now here she was.

I think part of our job is to let clients like Maya know that there will always be safe boundaries and spaces for them in the world, but we must be careful not to overreach when we do this. After all, while we may want nothing more than for them to leave their relationship, all we can do is educate and support them. This can mean helping them manage not only acute issues like anxiety, but also fostering their autonomy and individuation within the relationship, without insisting they get a divorce.

The central pillar of educating clients experiencing narcissistic abuse is to bring a focus to the problem behaviors in their relationship and help them recognize that these patterns are in fact interpersonally unhealthy. Though we might not have met their “Henry,” nor had the opportunity to assess his personality functioning, we can certainly draw some hypothetical inferences. We don’t want to get lost in the thickets of proving that partners like Henry are narcissistic. Rather, the psychoeducation comes in the form of helping our clients discern the unhealthy patterns in their relationship. I often suggest mapping this out experimentally.

I’ll encourage clients to journal about these sequences, and even use a whiteboard or notepad during sessions so they can see visual evidence of the patterns in the relationship over time. This helps bring home the reality that nothing seems to shift the behavior of their invalidating person. They’ll recognize, “Hey, I tried this to get my partner to see me and be more thoughtful and loving, but nothing changed. Then I tried that. Still nothing changed.”

As clients come to terms with the intransigence of their partner’s behaviors, it then becomes essential for them to identify the feelings these behaviors evoke and the ways they’re continually trying to appease their partner to avoid these antagonistic patterns. As they do this, we can help them see more clearly that insults, selfishness, gaslighting, contempt, and devaluation have no place in any relationship. This can be a difficult unbraiding, because these kinds of interpersonal patterns may have been normalized in antagonistic families of origin.

Ultimately, we’re not convincing the client that this person in their life is narcissistic or antagonistic: we’re helping them recognize that they’re experiencing a series of unchanging and harmful behaviors from their partners that are affecting them negatively.

“I left therapy with you because I wanted to hold on to hope,” Maya said to me now. “But last week, Henry was censured at work for an inappropriate relationship with a subordinate. When I confronted him about it, instead of apologizing, he became enraged and blamed me for the betrayal.”

Maya was terrified of divorce, but at least now she was ready to talk about the reality of what she was facing. Still, I knew our work was in a delicate stage. When the curtain gets pulled back and clients can see their relationship more clearly, therapists often think, Finally! Now we can figure it out together! But it’s rarely that simple.

What often follows from these early revelations is a sense of guilt. As happened before, clients like Maya may get lost in the euphoric recall of moments when partners like Henry showered them with love and admiration. They may experience intense shame, grief, and loss. These are common reactions to the dismantling of an intricate structure of justification, years of vacillation between dramatically good and bad feelings, and self-blame that may even predate the primary relationship they’re bringing into therapy.

Narcissus Is Among Us

I’m a Los Angeles-based therapist, author, and professor emerita, who started studying narcissism about 20 years ago. I never sought out this niche. Instead, while doing research on HIV, I noticed some clients treating medical staff poorly. This spearheaded my interest in maladaptive personality styles and exploring how dysregulation and antagonism would show up and affect other behaviors, like medication adherence and risky sexual behavior.

Simultaneously, I was seeing more clients in my practice who were either demonstrating antagonistic patterns or were being harmed by people in their lives who exhibited these patterns. As I dug deeper into narcissistic personality and narcissistic personality disorder (NPD), I realized that my questions about treatment options couldn’t be satisfactorily answered by the existing research. All of this culminated in a program of funded research on personality, health, and behavior that lasted a decade.

At the time, hardly any people were interested in the topic, and our field didn’t talk about it much either. Then the 2016 election took place, and the word narcissism seemed to be on everyone’s lips. The confluence of social media, with its democratization of fame, and the behavior of world and corporate leaders, meant that narcissism was being brandished to explain everything from Instagram attention-seeking to dangerous and charismatic leadership.

For those suffering because of narcissistic people in their lives, the effects of this development have been twofold. There’s been a new level of cultural recognition and validation of their suffering, and a new generation of support groups that have flowered online. But as more narcissistic people are asked to confront their behavior by partners and family members and workplaces, a sticky issue has arisen: we risk oversimplifying a dynamic that’s quite complex and multidetermined.

For example, the finding that narcissism evolves from and is shaped by trauma or attachment disruptions can lend validation to the idea that narcissism and narcissistic behavior are solely a post-traumatic presentation. Thus, people in relationships with narcissists may feel compelled to offer unidirectional understanding, support, and in the case of their partners, devotion, despite experiencing their own psychological suffering in these relationships. Clients who feel empathy and compassion for their person’s difficult life history, and yet are enduring ongoing abuse, are in the midst of a demanding and sometimes dangerous balancing act. Supporting them through this as therapists can be extraordinarily difficult.

From where I stand, narcissism’s “popularity” is a fraught development. The proliferation of the term, the misunderstandings that are being promulgated, the confusion about how to navigate this territory, and the shaming of survivors in these relationships have created a whole new set of problems.

I’ve made clear that no matter how supportive they try to be, people in relationships with narcissists are rarely going to catalyze meaningful behavioral change in their partners. All therapists, as well-meaning and up for a challenge as they may be, should understand this too.

It can be easy to forget that the diagnosis of NPD has been with us only since 1980. In the intervening years, it’s become clear that despite clinicians’ best efforts, someone diagnosed with NPD will only rarely make lasting and interpersonally meaningful progress in therapy.

Narcissistic people may show up to therapy when something in their life is going wrong. Maybe someone in power has said to them, “We want to keep you in your position, but you need to work on your temper.” Or a spouse says, “Either you go to therapy or it’s over.” Sometimes folks with these personality styles will go into therapy because it’s good PR. Sometimes they’ll go in because it’s part of another clinical issue, such as addiction or even depression.

Just yesterday, I heard from a narcissistic client whose marriage had fallen apart, and he’d called to demand I fit him into my schedule. His entitled expectation that I do so is de rigueur with this population. He wanted a quick fix for his crisis, but any time I approached him about doing deeper, more tectonic work on family of origin issues, emotional regulation, or self-reflection, I was met with a torrent of anger and comments like, “Can you make this better or not? I don’t have time for this.”

Clinicians often feel highly ineffective, frustrated, angry, and at times even triggered when working with narcissistic clients. They need to temper their expectations, as “being effective” might mean only small shifts in their client’s empathy. Or it might mean that the client actually honors the therapeutic frame and practices one skill. If we’re going to work with these clients, we have to be okay with glacial movements and regular setbacks.

We also have to make sure our documentation is precise. This includes front-end issues, like comprehensive consent documents and careful clinical notes, as antagonistic clients can be litigious and reactive. And we should avail ourselves of process tools, including supervision, consultation, and therapy.

Sometimes even all of that won’t assuage the visceral discomfort that these clients can elicit in us. I had one particularly memorable client throw my fee in crumpled up bills on my desk on the way into the office and start our session with “I’m a busy man, whad’ya got for me?”

I’ve dealt with bottomless entitlement and had to set and reset boundaries. Plenty of antagonistic clients have been gallingly racist, sexist, and dismissive. Though I’ve encountered clinicians in my trainings who’ve said, “I enjoy sparring with the antagonistic clients,” many of us who work with narcissists aren’t comfortable with the way we feel about them in our gut. We know that just as they run hot and cold with the people in their work and home lives, they run hot and cold with therapists. There’ll be a few weeks where they’ll tell you, “You’re the best shrink I know. I’ve never known anyone like you. How lucky am I? I’m going to give your name to everyone.”

But then, just when you might start feeling comfortable with the work you’re doing together, you’ll provide an insight that they don’t like, or you won’t tell them what they want to hear, and they may rage at you, storm out, and stop showing up.

They may also text you between sessions and at all hours because of their entitled expectation that they be treated as the exception to every rule. They’ll insist they’re in a state of emergency. Even though I put in writing and re-remind all clients of my holiday closures, one narcissistic client of mine called me on Christmas saying, “This is an emergency! Please call me.” When I broke away from my family and returned the call, he said, “My girlfriend won’t wear the new shoes I bought her.”

Many therapists would say, “I’d just dump the client at that point.” That might be understandable, but if we always choose not to work with these clients, we may never get to observe the patterns that are harming those in relationships with narcissists, and we may never fully appreciate what partners are up against.

Although therapy with narcissistic clients—on the off-chance they do go to therapy—is usually two steps forward, two steps back, it can sometimes serve as an externalized conscience for them. And if we can establish a thera­peutic alliance, set boundaries, and be thicker-skinned in the wake of their tantrums, sessions may serve as a sounding board for how to “be better” in their relationships.

Because of all the extra considerations involved in working with narcissistic clients, I remain flabbergasted that during graduate education and supervision, trainees are never explicitly told what that work entails. Sometimes verbal abuse, manipulation, violation of the therapeutic frame, and entitlement may be raised in ethics classes—but even then, the training is focused on the legal and ethical elements of consent and emergency planning.

In my view, too much of the therapy literature on this population focuses on the rare narcissistic client who sees the light, has access to high-quality and long-term psychotherapy, and makes significant behavioral shifts. Suggesting that significant improvement in a narcissistic client is normative runs the risk of generalizing the promise of true change on the basis of a rare event. For the clinician who doesn’t have that experience when working with a narcissistic client, such a bias in the literature can lead them to question their clinical competence.

How Can Therapists Help?

It’s my belief that if the field wants to make a true difference when it comes to narcissism and NPD, we’d do well to devote more of our clinical efforts to the people in relationships with the narcissists, like Maya, who are often most at risk. So how do we best work with a survivor of narcissistic abuse?

That question is key, especially for therapists drawn to doing this work because they’ve lived with a narcissistic parent, sibling, or partner. Without specific training, these practitioners will consistently be faced with the challenge of avoiding overidentification with the client and getting swept up in familiar feelings of helplessness and powerlessness. Clients who’ve experienced narcissistic abuse are already struggling with a loss of autonomy, and therapy becomes the space where they not only develop a sense of self, but practice decision-making and exerting choices and preferences.

Therapists working with clients experiencing narcissistic abuse should become familiar with domestic violence–reporting laws in their jurisdiction as well as emergency procedures, such as restraining orders, but it’s important that they refer their clients to professionals who can help with this, rather than give the guidance themselves.

We must guard against gendered or other biases ourselves. The stereotype of the narcissistic partner is that of a lording, self-obsessed husband in a heterosexual relationship. I’ve worked or consulted on numerous cases in which a narcissistic and antagonistic female or LGBTQ partner was verbally abusive, issuing physical threats, and engaging in financial abuse. Regardless of gender or sexuality, it’s crucial that we give clients clear guidance on how to manage this landscape of narcissism and provide them with referrals that will protect and inform them.

Work with clients experiencing narcissistic abuse very much draws from trauma-informed principles: maintaining safety, fostering autonomy and individuation, and reinforcing their freedom of choice and decision-making. Clear boundaries with these clients are essential—which means not only adhering to issues related to competence, but also honoring the therapeutic frame, not sliding into a role of being a “friend,” maintaining clear guidelines on between-session communication, and avoiding pointed advice. Our work with these clients is to provide a scaffold within which they exert their independence. As they feel more grounded and find their voices, we can slowly start pulling the scaffolding away and reinforce their autonomy.

Some clients may use therapy as a space to get to radical acceptance, but decide not to leave their partners. I’ve had clients who insisted that for custody reasons, they wouldn’t consider leaving the relationship until their youngest child was an adult. In the case of my client Sharon, this will be another 16 years. It’s a constant calibration for her—of managing the grief and regret of tying herself to a narcissistic co-parent to begin with.

Other clients, like Marcus, have come in for months that’ve turned into years. During his decade-long relationship, Marcus has vacillated between hope and despair as he recounts to me evidence of supposed change in his partner, Ryan, only to be devastated when that change—a month of no insults or anger in one case, and a promise never to stray outside the marriage again—isn’t sustained.

These clients will get hurt each time this happens. Still, our role is not to say, “I told you so,” but to let them process their feelings and experience. As we watch this cycle repeat, however, we can offer some gentle nudges, like continuing to teach them about trauma bonding or encouraging them to journal. I did both with Marcus, and I helped him connect to his emotions surrounding Ryan’s repeated relational betrayals: feelings that over time, he’d often dissociate from or “forget.”

It’s not easy to live with a narcissistic partner, nor is it easy to leave one. If a client is ready to leave, we need to be a safe, professional, tandem parachuting partner, who can support them as they jump, or be able to hear the same heartrending stories week after week if they stay.

As Maya and I keep going, I’m going to balance that line of supporting her, educating her, and fostering her independence, recognizing that it could take a while before leaping from such a dizzying place no longer feels so scary to her. And that’ll have to be okay. I’ll be helping her continue her journey of seeing herself clearly, outside the shadow cast by her narcissistic relationship. And even if she never makes the jump, I’m going to ensure she knows I’m her tandem partner, always on her side.

PHOTO © RODNAE PRODUCTIONS