April Quandary: I've recently started working with a client who exhibits some very narcissistic qualities. He's full of himself, has a hard time taking constructive criticism, generally mistreats family and friends, and lacks empathy for others. It's incredibly frustrating! Have you ever worked with someone like this? And how did you break through to them?
1) Building Social Capital
First, let me congratulate you on reaching out! I’ve found one of the benefits of working in this field is the willingness of others to support me when I’m faced with a difficult client or situation. We’ve all been there. Some therapists love working with the clients we find challenging.
In any event, an old sales technique (and believe me, those with narcissistic qualities need to be sold on changing their well-worn behaviors!) is to imagine that every one of us wears a sign that says “What’s in it for me?” I’ve found the only way to bring on board a client who lacks empathy for others is to engage them in the concept of “social capital.” In the therapeutic setting, I define social capital as a type of checking account in which the client does “nice” things or adjusts behaviors in order to preemptively ensure their needs are met later.
For example, my client Georgia refused to make the bed in the morning despite multiple requests to do so from her wife, Savannah. Savannah told her she loved walking into the bedroom to find a freshly made bed. “Why should I pretty it up if I’m just gonna mess it up again later?” Georgia would protest. For her, it just wasn’t important. I asked Georgia to think about changes she’d like to see in Savannah’s behaviors. “Is there something Savannah does regularly you’d like her to stop doing?” I asked. Georgia acknowledged that she disliked that Savannah “always wants me to fold the laundry. I don’t mind washing and drying it, but I hate folding!”
I encouraged Georgia to ask for a trade. I reminded her that these negotiations are not always this transactional (“I’ll do this if you do that”), but that she could consider every time she agreed to make the bed when she preferred not to a way of building social capital for her next “ask.”
Admittedly, shifting someone’s behaviors doesn’t always work the first time around. I validated Georgia’s shift not because she got it “right,” but because she began moving toward a more harmonious relationship which could ultimately benefit her and her partner.
Starlene Kelley, LCSW, CADC
2) The Therapy Room as a Laboratory
This sounds like a tough client. First, I’d want to check my own feelings about working with him. Will I be able to keep my own feelings in check, or will my frustration get in the way of treatment? Should I seek out some supervision, consultation, or do therapy myself to manage my own countertransference? I wouldn’t want any unresolved issues with narcissists in my past to taint my work with him.
If I determine I can work with him instead of referring him out, I’ll want to revisit his presenting problem. Why did he come to therapy? Is his goal related to his narcissistic qualities, or something completely different? Is he seeking treatment for a fear of heights or difficulties with relationships? If his concern isn’t relational, that should be my focus for treatment, not the resolution of a deeply-rooted characterological issue that I see as problematic. I need to take the client’s right to self-determination seriously, and if he wants help for something unrelated to his interpersonal interactions, I should to listen to that. I wouldn’t want to take my car in for an oil change and find them prepping for a paint job.
Having said that, if he came in with a goal of treating something unrelated to relational issues, and his relational issues seem to be getting in the way, I’d be curious about that. I might say something like, “You came seeking treatment for your fear of flying, but you’re late for our sessions and seem to dismiss my suggestions. Does this show up in other areas of your life?” If his ability to engage with me and the therapy is impacted (and it likely will be, with these qualities), then I believe it behooves me to bring this up. I might say, “You’re looking for help, but something is getting in the way of receiving it. Let’s look at that.”
Assuming this is the case, he’ll need to see that working on his relational issues will benefit him in some way. There are likely many times in his life that his relational style has benefited him and resulted in few negative consequences, as far as he’s concerned, so he felt no motivation to change. I would first look for the personal benefits for changing his behavior. A “me first” person will need to see how prosocial behavior and developing empathy benefits him before others. Once he’s more aware of the personal benefits and how that feels, he might be better able to imagine how he comes across to, and impacts, others.
If he buys into the idea that his relational style could use some work, I’d focus on our relationship as a laboratory for this work. If he dismisses a comment of mine, I’d point that out and let him know how that feels. I might say something like, “I gave you my opinion and you quickly changed the topic. That felt like you weren’t listening and could make me less invested in listening to you. Is that what you want? Probably not. What might you do differently?” This kind of real-time relational feedback takes a lot of effort and assertiveness, but he may never have heard how his relational style gives him the opposite of what he wants and needs.
Essentially, I’d want to assess whether or not this type of work is important for him, and if it is, hold up a mirror to show him how he impacts others, and give him a choice for how to respond. I would also recognize that there’s a low probability that this type of intervention will be effective and adjust my expectations accordingly.
Ryan Howes, PhD
3) Don't Take It Personally
There’s a significant difference between Narcissistic Personality Disorder (NPD) and narcissistic qualities. Narcissism exists on a continuum. We all have narcissistic traits which are healthy in moderation. It’s where someone falls on this continuum that determines the severity of their narcissistic qualities. NPD is pervasive and exists across all domains of life, not just in certain situations with certain people.
A common feature of NPD is an unwillingness to take accountability for harmful behaviors. While people with NPD may have a level of cognitive awareness, they exhibit little remorse. Those with a true NPD have an unwillingness to change their behaviors and are unlikely to voluntarily seek treatment. If they do seek therapy, it is often short lived, and there’s minimal progress.
Sometimes, however, unhealthy behaviors can mimic those of NPD, and it’s important to identify this difference in session. The therapist must assess the client’s awareness, level of empathy, and motivation to change. When the impact of their behavior is gradually and gently brought to their awareness in session, how do they respond? Do they become combative? Defensive? Frustrated? Tearful? Someone with narcissistic features, versus NPD, will be much more likely to acknowledge their unhealthy patterns and their impact on others, and will want to make the changes necessary for themselves and others, even if it’s uncomfortable.
You will not get this response from someone with NPD. Your approach is likely to be met with defensive tactics—anger or gaslighting, for example—and early termination of therapy. What’s most helpful for clinicians is to first assess the client’s level of awareness and accountability for their actions. Second, assess their response to this pattern recognition, including verbal and nonverbal responses. Third, look at the function of their behaviors in session, for example, attempts to manipulate the therapist, alter the treatment narrative, or efforts to make the therapist feel incompetent. When these interactions occur, it’s important to redirect your client back to the present topic rather than engage the content of their distraction efforts. Last, it’s important that you don’t take the lack of progress or early termination personally.
Jaime Zuckerman, PsyD
4) Flexibility, Empathy, and Leverage
Treating narcissistic clients, individually or in couple’s work, can activate a sense of inadequacy, intimidation, and frustration. But peering into their complexities can activate our curiosity.
Effective and sustainable treatment begins with a firm and flexible posture: understanding and regulating our own personal triggers as we come to understand the emotional narrative of narcissism. We need to puzzle-piece together and make sense of maladaptive coping modes and demanding internalized critic modes that line the walls of the narcissist’s survival system.
Treating the narcissistic client involves helping them get their early unmet needs met, including the need for unconditional love and acceptance, empathy, and tolerance for frustration and limits. This comes with the challenge of confronting bullying, critical, and approval-seeking modes.
Empathic attunement enables us to better mitigate the underlying shame and bypass obstacles such as entitlement, detachment, denial, dismissiveness, devaluing, and bully or attack modes by preempting the typical reactions of cynicism and diversion.
Treatment also requires a formidable amount of leverage to sustain a meaningful and long journey through assessment and healing, and to fortify the therapy relationship as a microcosm of the interpersonal world beyond the treatment room. The stakes, or consequences for ending therapy, must be high enough to maintain their commitment to the process.
In doing couples therapy with a narcissistic partner, it’s important to know that intimacy often suffers because of a betrayal trauma experienced by the offended partner. The refurbishing of trust is challenging, but not hopeless, when the leverage is high enough and partners are willing to engage in the treatment process, individually and together.
The heart of schema therapy is a science-informed approach capable of weakening self-defeating coping modes. Adaptive responses replace unhelpful ones as schemas heal. Using proven strategies grounded in emotional engagement and the therapy relationship, therapists are poised to correct early emotional experiences typically linked with high demands for extraordinary performance, confusing messages of over-indulgence alongside inferiority and insecure attachments, devalued emotional experiences, and poor limit setting.
Wendy Behary, MSW, LCSW
Next Month’s Quandary: As a clinician, I often find the start and end of therapy to be a little awkward. Not only do I struggle with first sessions, but last sessions, too! Anyone else? What are some ways you've made your first and last sessions less uncomfortable?
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