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.