Reformulating the contract in order to promote change
Having identified the maladaptive pattern and understanding why Mark gives up, isolate himself, lies, thinks negatively of himself and of others we are now in the position to try and do something different in order to promote change. Overall, a clear and fully agreed upon contract is necessary in order to prevent backsteps or falling again in the position where the therapist pushes for health and the patient derogates her work or thinks nothing will help him. Uhis applies to all patients who suffer from narcissism and above all with Mark: considering his schema, I would have become someone who limits him and does not support him in his choices.
Behavioral experiments ((Lewinsohn, 1974; Levy & Scala, 2015) were the first candidate in order to promote this change, given how much Mark was stuck in his everyday life. This is how the exchange went:
T: “So Mark, we’re seeing what we’re calling an interpersonal pattern driving you, it’s very strong and it’s crushing you and shutting you down.”
M: “Yes…”.
T: “But we discovered your desire to explore is there and is strong. If you want, we could do something to support that part of you that wants to live a richer life. First we would need to figure out something concrete you would like to do, but then don’t out of guilt and the idea of being mean and selfish ”.
M: “This is a part of the job that is on me, correct? But… am I able?
T: “I think you can… but mostly… you really need to live… would you try?
M: “I guess so!(smiling).
T: “I see you smile. Do you like the idea then?”
M: “Yes, at least I’m moving towards something.
T: “Let’s assume that some things will be more challenging than others or that we will discover that some things you really don’t like. Most important you have to be aware that you will face guilty once you act for yourself, we can’t escape that, are you aware of that? I mean you will see yourself as mean and selfish and feel the compulsion to give up. Would you feel like trying?.
The contract is now easier to draw up. Mark agrees to try to incorporate activities into his life like sports or studying languages that he loved as a child, three times a week. This idea improved his mood already in the session, now he is convinced that committed action is necessary and useful.
This moment is important for patients with NPD, like Mark, who have been so stuck in oscillating between harboring grandiose fantasies and existential paralysis. But in order for a contract to be realistic a very important part was telling him, or any other patient with NPD, that experiments come with a cost and therapeutic success depends on facing negative ideas and feelings about themselves and not give them the power to control their action. Thanks to this clarity, Mark is aware that in order to overcome stagnation he will have to expose himself to ideas and feelings that will hurt. Will Mark still think it is worth the price?
M: “Are you telling me that I have to do those things that I never do, that will make me feel bad but that all of this will help me?
T: ”Yes…basically, yes”
M: ”…I don’t know…do you know that it’s not convincing?”
T; “I understand it well. I’m telling you that taking action will make you feel guilty. But I remind you that it will also make you feel free to think about what you want to do and actually do it. You have so many pending wishes waiting to see the light…”
M: “Maybe we’ll find out that I’m a failed artist… or an intellectual ” (smiling).
T: “Why not?.
In practice, on the one hand, Mark knows he has to act, he feels more and more that he wants to do it and he also begins to have clear ideas and this excites him, as can be seen from his answer. On the other hand, however, he is frightened by the idea of feeling bad emotionally, of feeling a sense of guilt. To help him, I remind him of an episode in which a sense of guilt leads him to give up everything. I need this to point out to him that it’s automatic to feel guilty as soon as he does something and that it’s automatic for him to give up but that this doesn’t help him because he gets more and more depressed. I also need it to ask him if he wants to bear the weight of the guilt, even if it’s unpleasant because there’s no alternative.
T: “So Mark, from what you told me yesterday we noticed that it is automatic for you to give up on yourself. Last night Sandra wrote to ask you where you were”.
M:Yes, I really felt that my legs loosing strength and my heart pounding ”.
T: “And how did you see yourself at that moment?
M: “Selfish. As usual. I’m out and she’s locked up at home I felt she was suffering, blaming… I blamed myself actually and so I came back home ”.
T:By now we know this idea: you feel responsible for others since you were a child!
M: “It seems that my mother gave birth to me to help her, Sandra and me? What happened to me? ”.
T: “Look Mark, it’s natural for you to give up on yourself in order not to feel like this but now we’re seeing that you don’t want to do it anymore. Do you feel like working on addressing the blame?.
M: “That is? Does this mean I have to feel more guilty? ”.
T: “Strange as it may seems… yes! If you would seize a change to live freely we have to face that sense of guilt and deprive him of power ”.
I explain to Mark the need to work on the schema to rewrite it. At MIT this phase is crucial because it weakens the pattern and strengthens the healthy parts. I propose to Mark the ”role play technique” and I explain why.
T: “I thought we could do something together here in the session to bring out the pattern and the sense of guilt and try not to succumb. We will do it here together so that you can then acquire strategies to re-propose even alone in your life ”.
M: ”What should we do?”
T: “Let’s re-propose you and I a scene among those we know and that have contributed most to making you feel like a bad person. you will be Mark and I for example mom. We repropose here, as if it were a theatre, the same things that happened at the time in order to give it a different meaning. What do you think?”
M: ”Okay, let’s try to be actors come on”.
Mark agrees to work on the scheme and himself chooses the scenes to be rewritten among those with the greatest emotional load. During the role-play session, we stand facing each other and I play the role of Mark’s mother, angrily accusing him of being an ungrateful and selfish son who does not attend to the needs of the family and ask asked Mark to retort. Here’s what happens at a certain point in the performance:
T (while I am the mother, simuling an expression of anger): ”Where would you like to go? To play? And tomorrow you want to go to the Spanish course? But how can you even think about it! Who thinks about Sandra? You really are the worst brother in the world”.
M: (changes expression, voice becomes feeble, lowers shoulders) “So I have to stay at home? but I…but I…I would like to…”
T: ”You don’t have to want anything, of course. You have to stay here. At most, you study at home”.
Mark becomes silent and sad, he sighs and looks at the ground, a sign that something is activating him. for a moment I step out of the role and ask him what he is thinking and feeling and he tells me that he sees himself as really bad and that he feels terribly guilty. At this point I ask him if he wants to go further and when he agrees I ask him to adjust the emotion and I encourage him to stand up, open his shoulders, raise his head and push him to feel strong, close to his right to be free to do what he wants in life. I invite him to breathe and take some time to stand up to the other authoritarian (which is me playing his mother) and then he says:
M: ”Mom, I’m sorry you don’t understand and you’re angry, but it’s important for me to go out and be with my friends and I have the right to do that”.
T: ”Friends?”( I turn around and walk away, as if I don’t want to listen to him anymore).
M: ”And you don’t even understand that learning languages is important for my future. I also think I’m good at it, why not do it?”
The more Mark opposes his mother, the more I accuse him and the therapy room becomes a real emotional gym.
T: (still like the mother) ”Right? To do what you want instead of thinking about us? And what happens to the duty of a son? The duty of a brother?”
M: (who changes expression for a moment and becomes fragile again but I ask him to regulate himself and breathe, to feel strong) ”I understand by now that you don’t understand what is important to me. I understand that I cannot expect this from you. I have to think about myself”
After this sentence Mark bursts into tears and sits down on the chair. we explore what is happening and we notice that he feels sad that his mother does not really understand him but he is also aware that he has to detach himself from her authorization and that he can no longer submit and, above all, he begins to question his nature as a son and selfish brother.
I ask him if he wants to try one last time to talk to me as his mother, he accepts, puts me up in front of me and looking at me he concludes:
M: ”Mom, I hope this is the last time. it’s not right that you talk to me like that and it’s not right that I don’t live freely. I want to do it, I want to build my future. this doesn’t mean abandoning you: I’ll try to stay close to you as much as I can and maybe it won’t be enough for you but I won’t give up on me”.
The session ends with Mark’s surprise that he managed to handle his mother’s accusations and with the agreement to dedicate ourselves to other episodes as well. After three rewriting sessions, always with role plays, of other episodes, (for example the one in which the mother accuses him of Sandra’s suffering during a period in which she was getting worse) Mark believes less in the idea of being a bad person, he can see how an idea that does not correspond to reality and it is said that he is not really responsible for his sister. Moreover, Mark now masters the sense of guilt: he checks its activation and the intensity he feels in his body and, with these weapons in his hand, I ask him if he wants to put them into practice in his daily life too. Basically I ask him if he wants to plan further activities during the week knowing that at the right time he could have taken the blame instead of giving up. Mark tells me that he agrees and, to my surprise, he tells me that one thing he would like to do is tell his aunt the truth: instead of justifying himself or lying, he would also like to try and tell Sandra that, for example, he won’t be back later the work because he has to go out with colleagues or that he would like to stay out for the night on the weekend and take a little trip. I welcome this idea from Mark and support him, encourage him: I’m sure he can do it even if I expect moments in which guilt will be felt.
Moreover, Mark decides to intensify his outings with colleagues and downloads a dating app because he finds it easier to explore the relational and sexual world now that he feels freer to manage his time and, for example, to come home late without having to justify every time. He goes to the gym and thinks he would like to take up some sport, and after a while he opts for tennis. He also takes some Spanish lessons but has realized that evidently he is no longer as passionate about foreign languages as he was as a teenager. This is good because thanks to the experiment he had clearer ideas about his actual preferences than him, so he could decide that he liked tennis, but not learning Spanish. And most importantly, neither goal was pursued by the pursuit of grandeur, he was just exploring whether he enjoyed these activities. He has also discovered that he loves art: he would like to attend painting or theater courses, even if they are in the evening, and he still finds it hard to leave Sandra alone, a sign that his pattern is still partially active. Right now, it makes more sense for him to play tennis early in the morning before going to work.