The therapeutic relationship: early ruptures
One reason for the early problems in the therapeutic relationship is
Mark’s poor ability to describe his internal states, a typical feature
of NPD. For example:
M: “Yesterday I was just like this… like this chair, cold
and still. I think things I don’t do, but I don’t know why. And in the
end, I’ve been satisfied for a lifetime… but am I really satisfied? ”
T: “Ok Mark, can you recall a moment in which you felt like this?
Let’s try to understand what you mean when you describe yourself as the
motionless chair… ”
M: “I don’t know… maybe it’s always like this… or when I
returned home the other day… but I wasn’t doing anything at all
particular… ”
T: “It was Wednesday, right? We’re talking about the moment you
entered home after work… what did you think? What did you feel? ”
M: “I wasn’t thinking about anything. I was empty! I told you! ”
Mark cannot describe what he thought and felt, nor understand what he
wants. He focuses more on others than on himself, which is common in
narcissism. He only complains about his difficulty in facing everyday
life. As a result, I experienced bored and confusion and a sense of just
being an audience when he speaks without any emotion. This leads me to
think about something else, sometimes I want the session to end as soon
as possible because I cannot understand what Mark asks from the therapy.
I realized that I had to explore what Mark thinks and feels and
understand what he wants from therapy and the reason to ask for help,
instead of remaining silent, passive and most of all distracted.
T: “So Mark, I understand that you feel that things are not going
well in your life and it has been like this for a long time but we need
to goals and figure out how we want to get there. What do you think? ”
M: “I don’t know what I want, I’m sick and I definitely long for
a different life. Now I don’t know what to tell you doctor! You have to
take care of it, do what you want and hurry up, as time
passes ”.
T: “I understand that you expect therapy to be something magical.
Almost as if I could understand everything and offer you solutions. But
I can’t guess what you think, feel and above all what you want to get
from these sessions. We need to discover it together! ”
M: “What should we do…? I don’t know… ”
T: “We need to understand what you really want from therapy and
figure out how to get there together. What do you think? And, in
general, I need first to all to better understand what you think and
feel in certain situations ”.
M: “A skilled therapist understands everything by intuition and
you ask me instead that we must collect episodes. I can’t get the
sense… Wait, what did you say? We must discover? Do we want to be
explorers of the forest? ”
Mark responds to my attempts to cooperate with sarcasm and humiliation.
I feel belittled and not taken seriously as a psychotherapist.
Furthermore, his attitudes become blatantly arrogant, for example he
laughs at me or talk to me without even looking at my face. At that
point, I realized it was pointless letting him humiliate him. As a first
step I started breathing regularly in order to regulate my sense of hurt
and anger. Then I tried to see things from his perspective, not taking
his offenses personally. I figured out he was spiteful out of some
self-protective mechanisms I had to discover. In MIT we consider that
patients are guided by rigid problematic expectations on how others will
react when we express our wishes, and we name those structure
“maladaptive interpersonal schemas ” (Dimaggio et al., 2015;
2020). Guided by those patterns, patients predict how others will react
to our need to be, for example, cared for, appreciated or supported. In
order to protect themselves from the negative responses they expect,
patients adopt maladaptive coping mechanism (Lazarus & Folkman, 1984).
Very likely arrogance and spite part of Mark’s coping strategies. I
needed to explore if that was the case. Mark is again derogating me in
the middle of one of the first sessions, and I take it as a chance to
explore the underlying reasons.
M: “Where are you going for vacations? ”
T: “I’m going to Greece ”.
M: (sarcastic) “… and you’ll come back tanned, eh? Anyway,
doctor, Greece. It’s so trivial, it’s trendy. You go to Mykonos, like
everyone else, right? I already know! How trivial. ”