Recommendations for psychotherapeutic management of patients with narcissistic personality disorder are based on clinical experience; however, little attention has been given to the role of couple therapy with these patients. A stable intimate relationship appears to positively affect the course and outcome of narcissistic personality disorder. Based on clinical experience with narcissistic individuals in couple therapy and using a psychoanalytic framework, three characteristics that differentiate couples who will from those who will not benefit from couple therapy are described. These characteristics are the ability of the narcissistic individual to curtail acting out, the narcissistic vulnerability as evidenced by their level of defensiveness, and the couple's complementarity of narcissistic gratification.
Recommendations for psychotherapeutic management of patients suffering from narcissistic personality disorder are primarily based on clinical experience and theoretical formulations. No randomized controlled treatment studies exist with regards to narcissistic personality disorder, and clinical practice guidelines for the disorder are yet to be formulated. Although intensive individual psychotherapy remains the mainstay of recommended treatment, little or no attention has been given to the role of couple therapy for patients with narcissistic personality disorder. In an earlier report, the relevance of couple therapy for borderline personality disorder was discussed. The purposes of this paper are to outline the possible prognostic impact of a stable intimate relationship on the course of narcissistic personality disorder; to propose clinical indications for recommending couple therapy and to outline, using two clinical examples, the possible outcomes of couple therapy.
The course of narcissistic personality disorder has been an area of major controversy. Kernberg suggested that narcissistic individuals get worse with age. He suggested they go through a major mid-life crisis with dramatic vocational shifts and instability in their love relationships. This assertion of deterioration with age was contrary to the work of McGlashan and Heinssen. Their research indicated that as time goes on, these individuals seem to normalize some of their behaviors as social factors impact on them so that much of their destructive interpersonal behavior is extinguished. Perhaps the relentless negative feedback from their socially dystonic behaviors finally leads to maturation. Stone, in his long-term follow-up study, found that negative outcomes in narcissistic individuals were primarily related to the coexistence of antisocial traits. These people did much more poorly than narcissistic individuals without antisocial traits. Finally, Plakun also found that narcissistic individuals were characterized by difficulties in their heterosexual relationships. These subjects over time functioned even more poorly than patients with borderline personality disorder.
The importance of a stable intimate relationship to the course of narcissistic personality disorder was supported by the only existing prospective follow-up study completed by Ronningstam and colleagues. They found that the majority of their subjects, up to 60%, who initially had narcissistic personality disorder, showed significant improvement in their levels of pathological narcissism at three-year follow-up. The other 40% continued to show high levels of pathological narcissism. The authors confirmed that, although grandiosity initially had been an important differentiating characteristic, it did not predict stability of the disorder over time. Subjects who did not show improvement in their levels of narcissistic psychopathology were significantly more narcissistic in their interpersonal relationships and lacked a commitment to anyone. These findings suggested that interpersonal aspects of this disorder may be prognostic and that developmental factors can have a large impact on producing change. Ronningstam and colleagues outlined three events during the course of the narcissistic individual's life that might have had an important impact on effecting change in the narcissistic pathology: corrective achievements, corrective disillusionments, and corrective relationships.
Ronningstam and colleagues found that the narcissistic self-concept could be changed if a very valued achievement is attained and reflected upon. This achievement may be college graduation or professional certification and the resulting establishment of independence. Once this achievement is realized, there is often a more realistic self-evaluation and the diminished need for unrealistic fantasies and exaggeration of achievements. The authors highlight how the subject's grandiosity is reworked with failures, disillusionments, or experiencing limitations of achievement. If these failures or rejections are too harsh, however, serious psychopathology can be activated. In the narcissistic individual, in this circumstance, there is the risk of concurrent major depression, suicidal behavior or significant substance abuse. In our clinical work, personal failure has been an important stimulus for change.
The establishment of a meaningful and durable relationship is also acknowledged by Ronningstam and colleagues as a way of correcting pathological narcissism. The behaviors of self-aggrandizement often are a defensive maneuver, particularly to fend off the existing dependency. With the establishment of a stable, mature relationship, the narcissistic qualities will be less prominent. In our clinical experience, this reflects the maturation that occurs once a relationship is functioning at a more mature level.
These developmental issues underscored by Ronningstam and colleagues have important implications for couple therapy. First, narcissistic pathology often is changeable and a healing intimate relationship may foster this change. Lewis has written about the healing aspects of intimate relationships and has observed the natural healing process of marital relationships in individuals with disorders that are notoriously difficult to treat. We have described the importance of a healing intimate relationship to the course of borderline personality disorder. Second, the narcissistic individual is able to form a stable intimate relationship in certain circumstances. Kohut's concept of the need for a "mirroring relationship" can be useful to understand the narcissist's intimate relationship. Kohut, contrary to other theorists, developed the concept that narcissistic patients could form stable transference relationships if they had their narcissistic and exhibitionistic needs met. With the establishment of a stable transference relationship, individual psychotherapy could proceed. Bird et al. characterized the marital relationship of narcissistic men or the "collapsible men of prominence." These men functioned well if they could recreate their primary primitive dependent attachment to their mothers in their marital relationships. Typically, these women were described as "submissive, mothering" wives who fostered the husbands' functioning as long as the marital relationship was not threatened. These husbands do not develop a sense of autonomy because of their inability to acknowledge the separateness from the other that meets the mirroring needs. However, a mirroring relationship might provide the environment in which a narcissistic individual could achieve some early stability and later growth. The importance of this concept to the determination of the appropriateness of couple therapy will be discussed.
Indications for Couple Therapy
For the most part, individuals with narcissistic personality disorders are uncommon in clinical settings. They make up less than one percent of outpatient samples. These individuals, however, come to attention when their marital or significant relationship runs into difficulties. At the threat of losing their significant other, the narcissistic individual becomes acutely distressed and turns for help. We suggest there are three characteristics, as described in the next section, that can be helpful to judge whether couple therapy is indicated in the care of the narcissistic individual.
Curtailing Acting Out
Glickauf-Hughes and Wells stated that the narcissistic spouse often carries the aggressive rage in a couple, while the masochistic partner carries the sadness. It is crucial to assess the narcissistic individual's ability to handle the rage in a constructive way. Typically, at the time that the couple presents, the narcissistic individual has handled his or her rage by infidelity or other forms of acting out. For one couple, the spouse with narcissistic needs had acted out financially and dealt with his narcissistic injury by making large purchases. He bought a second home while the couple was still paying off the mortgage on their first home. Of course, this created great turmoil in the relationship. His overspending was a partial response to his narcissistic injury and acted out his subsequent rage. The couple had a series of these events, finally leading to financial ruin and the need to declare bankruptcy.
An essential element to assess is whether the narcissistic spouse can deal more openly with his rage and anger. If they are unable to curtail their narcissistic rage, then individual therapy will be needed prior to couple therapy.
Narcissistic Defensiveness and Vulnerability
Narcissistic grandiosity is a defense against deficiencies in self-esteem and the conviction that others do not value them. The couple therapist's role is to assess the level of this defensiveness, the persons' openness to the need for a relationship, and their ability to have the dependency gratified. Typically the assessment of vulnerability can be determined by the patients' openness to interventions and their willingness to accept interpretations. In our experience, individuals who continue to respond with disdain and anger to any kind of interventions will not be able to make progress in couple therapy. Having their spouses listen to interpretations that they see as denigrating and humiliating heightens the defensiveness even more. If they are not able to demonstrate some vulnerability and express some of their fear of separation or loss of the spouse, then individual therapy is indicated as the first step. Sometimes concurrent individual therapy will allow these patients to feel more protected, and will allow them to be more vulnerable.
Complementarity of Narcissistic Gratification
In our experience, couples are more successful if some of the narcissistic needs are met through the relationship. Spouses with narcissistic partners may need and seek some gratification through the achievements of their partner. They accept the value of deferring their needs to the other, but not to the point where they totally devalue their own needs and destroy the critical balance in the relationship. If this complementarity exists, often the couple can progress and the narcissistic spouse will not look for other methods to meet these needs. If this is not available to the narcissistic spouse from the relationship, then that person will continue to seek gratification through multiple affairs or through work. One grandiose man who sought satisfaction through work would spend all week and each weekend at work, totally ignoring the demands and requests from his spouse. Of course, the narcissistic individual felt very uncertain about his success at work and always felt on the brink of total professional failure. If the narcissistic need is demonstrated by continued extramarital affairs, or commitment to everything but the relationship, then the couple therapy is doomed to failure. This is another example where the couple is probably best encouraged to seek individual help before launching into marital therapy.
Couple Therapy with the Narcissistic Spouse
An essential element when working with a couple with a narcissistic spouse is to make a determination about the workability of the couple. We use two case examples to demonstrate how the following three characteristics: (i) curtailing acting out, (ii) narcissistic defensiveness and vulnerability, and (iii) complementarity of narcissistic gratification, differentiate couples who will and will not benefit from couple therapy. The first case was the more successful and defines the couple that benefits from couple therapy. The couple can work and establish, or reestablish a stable marriage where there is a significant degree of complementarity. Often in this couple, there is a narcissistic individual married to a person with masochistic traits. The masochistic spouse allows his/her own needs to be superseded by those of the narcissistic spouse. The masochistic spouse's need to satisfy his/her own lack of self-esteem by identification with the other person's self-esteem is an essential element of the relationship. These couples, in our experience, can have a workable relationship as long as the complementarity of meeting the narcissistic needs provides each member some satisfaction and some flexibility of roles. The couple therapist can decide that a couple is appropriate for therapy by assessing the three parameters. We find that to stabilize the presenting crisis, the narcissistic individual will need some of his/her gratification from the therapist. We most often work as a cotherapy team allowing one of the therapists to purposely attend to the needs of the narcissistic individual. However, a single therapist can initially in the therapy session provide a small amount of personal attention and this is often sufficient to keep the narcissistic person engaged.
The description of couple work with a narcissistic spouse is well documented by Glickauf-Hughes and Wells. These authors consider the alliance between a masochistic or self-defeating person and a narcissistic individual as the primary focus of couple therapy. They note the masochistic individual often has a deep-seated wish to heal an old narcissistic injury that was the result of interactions with a critical or rejecting parent. This person seeks this relationship to try to finally get the love and approval of a parent substitute. Often, early in the relationship, the masochistic partner shows his/her love and admiration while providing caregiving. The initial idealization and admiration build up his/her own self-esteem, and, of course, meet the narcissistic needs of the narcissistic individual. This pattern can fall apart, however, because a narcissistic person demands that the partner act as a slave to his/her needs. Trouble develops when the narcissist sees the masochist as engulfing, and dependent, and the narcissist may look for other places to gratify his/her need, running away from the fear of being engulfed.
According to Glickauf-Hughes and Wells, to restabilize the relationship the couple has to "grieve" for the unrealistic idealized "prince-and-princess" relationship they had previously. Often, this work requires the therapist go over their history and have them retain the constructive parts but grieve for the destructive parts of their relationship. They can give up aspects that were immature and fostered the "prince-and-princess" relationship while retaining facets that provided for stability and security.
To create sustainable change, Glickauf-Hughes and Wells suggest differentiating the intrapsychic from the interpersonal aspects. In terms of the intrapsychic aspects, the authors discuss the importance of helping the masochistic individuals learn to ask for their dependency needs more directly. They tend to be ashamed of these needs and mistrustful that others can meet these needs. The marital work can be quite successful if the therapist focuses on the masochistic individuals, helping them be more assertive and gain increased self-esteem. This can be done concretely through helping them gain better self-assertion skills and by pursuing various things in their lives that provide more self-esteem. As a result, they will give up some of this need to live vicariously through their partners. The masochistic partners can be given permission to accept some pleasure from the successes of the narcissistic partners. The narcissistic individuals can be helped to give up some of their grandiose goals and to experience and accept some of the unwanted parts of their own dependency needs. Narcissists can also be guided to foster and endorse some of the independence of their masochistic spouses in order to avoid feeling engulfed or smothered. Interpreting the projective identification of the couple dance of pursuer/avoider is an essential aspect of the therapy.
According to Middelberg, the narcissistic spouses deny dependency needs because neediness is equated with losing oneself. Their spouses deny the need for autonomy to avoid abandonment anxiety. Middelberg interprets the projective identification by beginning at the interpersonal level and then moving to the intraspsychic level.
With regard to interpersonal goals, the couple therapist should focus on helping the couple become less enmeshed with each other. They need to develop a better perception of their separateness and become aware that they project aspects of themselves onto each other. They often have been very unaware of their own and their partners' needs, feelings, and behaviors. Again, a large part of the work can be devoted to helping them develop better communication and more directly express their needs and wants.
In addition, the couple has to take more responsibility for experiencing and expressing their anger. Typically the narcissist will be the more overtly aware of anger and rage, but still not able to express it in a constructive way. The masochistic individual may be more passive-aggressive in expressing anger, and needs to develop more appropriate communication skills. As the couple progresses, they will develop a more realistic vision of their relationship and a more realistic vision of the gratifications available from their relationship.
- Links PS, Stockwell M; The role of couple therapy in the treatment of narcissistic personality disorder; American Journal of Psychotherapy; 2002; Vol. 56, Issue 4.
Reflection Exercise #3
The preceding section contained information
about couples narcissistic therapy. Write three case
study examples regarding how you might use the content of this section in your
What are the three events that Ronningstam outlined as potentially effecting change in narcissistic pathology? Record the letter of the correct answer the .