Attachment and Object Relations in Patients With Narcissistic

Personality Disorder: Implications for Therapeutic Process and

Outcome
Diana Diamond
1,2
and Kevin B. Meehan
2,3
1
City University of New York
2
Weill Cornell Medical College
3
Long Island UniversityBrooklyn
This article presents a therapeutic approach for patients with severe personality disorders, transference-
focused psychotherapy (TFP), a manualized evidence-based treatment, which integrates contemporary
object relations theory with attachment theory and research. Case material is presented from a narcis-
sistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena
of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation
between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate
the tactics and techniques of TFP and how they have been rened for treatment of individuals with
NPD. The ways in which conicts around sexuality and love relations were lived out in the transference
is delineated with a focus on the interpretation of devalued and idealized representations of self and
others, both of which are key components of the compensatory grandiose self that defensively protects
the individual from an underlying sense of vulnerability and imperfection.
C
2013 Wiley Periodicals,
Inc. J. Clin. Psychol. 69:11481159, 2013.
Keywords: narcissistic personality disorder; transference focused psychotherapy; sexuality; attachment;
reective capacity
Introduction
A renowned 40-year-old architect, who sought consultation while in the midst of a marital
crisis brought on by his wifes discovery of his engaging in Internet sex, began by saying that he
fully expected that the therapist would not be able to tell him anything he didnt already know
about himself, as was the case in his previous psychotherapy. He was seeking therapy because he
needed someone to be a sounding board while he explored his own feelings about his imperiled
marriage, because his wife was threatening to divorce him if he did not stop his Internet use.
He had been referred by his former cognitive-behavioral therapy (CBT) clinician, with whom he
had terminated treatment abruptly the year prior, after making some gains in curbing his angry
outbursts at work that had been alienating clients and coworkers, his substance abuse, and his
addictive Internet behaviors. He insisted that he wanted only to talk abut his current dilemmas
and that there was no point in talking about the past, refused initially to give a thorough history,
and controlled the content and structure of initial session discussions.
These statements epitomize the presentation of many patients with severe narcissistic pathol-
ogy (that is, those functioning in the borderline range of personality organization) in that they
both crave and devalue attachment, and often nd themselves in a state of paralysis in their re-
lational life as a result. Their often relentless devaluation of therapy, their tendency to provoke,
alienate, or even deskill the therapist, combined with their entitlement and excessive demands
on the therapist, have led some to speculate that these patients are at the limits of treatability and
pose among the most formidable clinical challenges of any patients in the personality disorder
spectrum(Clemence, Perry, &Plakun, 2009; Diamond, Yeomans, &Levy, 2011; Kernberg, 2007).
Please address correspondence to: Diana Diamond, 50 Riverside Drive, Apt. 6A, New York, NY. 10024.
E-mail: ddiamonda@gmail.com
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 69(11), 11481159 (2013)
C
2013 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22042
Attachment and NPD 1149
Indeed their high dropout rate (over 64%in one study, Hilsenroth, 2008), along with the dearth
of case studies and papers on technical approaches to treatment of severe narcissistic pathology,
speaks to both the difculties in engaging and holding these patients in therapy and the need
for development and amplication of treatment strategies and approaches. This is particularly
important because a number of studies have shown a high degree of comorbidity of NPD with
other Axis II disorders, particularly borderline personality disorder (BPD; with rates ranging
from17%(Clarkin et al., 2007) to 37%(Stinson et al., 2008) to 80%(Pfohl, Coryell, Zimmerman,
&Stangl, 1986; see Levy, Reynoso, Wasserman, &Clarkin, 2007 for a review). These high rates of
comorbidity make it likely that patients with other personality disorders will also have signicant
narcissistic pathology that may affect their diagnostic and clinical presentation, the nature and
quality of their mental representations of self and attachment gures, and their treatment course
and outcome (Diamond & Yeomans, 2008; Kernberg, 2007).
In this article, we present a therapeutic approach for such patients, transference-focused
psychotherapy (TFP) based on attachment and object relations theory and research. TFP is
a psychoanalytically oriented treatment for patients with a range of personality disorders at
different levels of severity, including narcissistic personality disorder (NPD; Clarkin, Yeomans,
& Kernberg, 2006). To date, TFP is the only personality disorder treatment that has been
shown in randomized clinical trials to both improve symptomatic functioning and evidence
unique change in security of attachment and reective functioning (Clarkin et al., 2007; Doering
et al., 2010; Levy et al., 2006). Here, we will present a brief overview of the treatment and will
illustrate its major tactics and techniques through case material from an ongoing twice-weekly
TFP treatment of the NPD patient introduced above. We will focus on how his personality and
attachment organization inuence his approach to psychotherapy that required modications
in technique, as well as how the therapy led to substantial changes in his personality and state
of mind with respect to attachment.
TFP is a twice weekly, modied psychoanalytic therapy based on contemporary object re-
lations theory. It combines elements of standard psychoanalytic technique (e.g., attention to
unconscious processes, a focus on transference, resistance, and interpretation) with a higher
level of therapist activity, more attention to the patients external life, and a set of mutually
agreed upon behavioral parameters designed to limit acting out and promote the unfolding of
the patients full emotional experience and psychic life in the treatment setting. The major goal
of TFP is to address the primitive defensive operations that prevent more realistic, integrated,
differentiated representational dyads of self and others. Through the tracking of these self-object
dyads and linking affects in the patients internal world, and identifying the defensive processes
that support them, TFP constitutes an effective treatment for narcissistic disorders. Since TFP
emphasizes identifying the totality of the individuals internal dyadic experience (e.g., grandiose
self, devalued other; vulnerable self, idealized other), it is also effective in addressing the differ-
ent phenotypic presentations and/or uctuating mental states that may characterize those with
severe narcissistic disorders, such as from grandiose to vulnerable, from arrogant/entitled to
depressed/depleted (Cain et al., 2011; Kernberg, 2010; PDM Task Force, 2006; Ronningstam,
2011).
Based on our clinical experience with and research data on patients with narcissistic person-
ality disorders, we have been rening TFP to treat patients with different levels of severity of
narcissistic pathology (Diamond et al., 2011; Diamond et al., 2013). Our clinical formulations
have been informed by our research on distinctive internal working models of attachment in
patients with severe narcissistic pathology (NPD/BPD) from three international samples of
BPD patients in TFP (Diamond et al., 2013). In brief, the majority of NPD/BPD patients were
classied with dismissing attachment status, characterized by contemptuous derogation and/or
brittle idealization of attachment gures, or by cannot classify status, in which the individual
ricochets between different attachment states of mind (usually dismissing devaluation and angry
or overwhelmed preoccupation with attachment gures). Thus, we have found that individu-
als with NPD/BPD may exhibit multiple, unintegrated attachment representations (Cannot
Classify), leading to contradictory transferences and resistances that make these patients par-
ticularly challenging to treat.
1150 Journal of Clinical Psychology: In Session, November 2013
Relatedly, we have been investigating the interplay between level of personality organization
and sexuality, with sexuality becoming increasingly maladaptive as level of personality pathol-
ogy becomes more severe (Lendvay, Foelsch, Diamond, & Carrasco, 2011). In brief, in a study
that included both nonclinical (community) and clinical groups, we found that individuals with
higher-level personality pathology, including narcissistic pathology, had signicantly less stable
love relations, less capacity to combine love and sexuality, and less capacity for sexual plea-
sure than did individuals without personality pathology. In addition, both high- and low-level
personality-disordered patients showed signicantly higher levels of inltration of aggression
into sexuality and polymorphous perverse sexuality compared to individuals in the neurotic
realm. Interestingly enough, there were also indications that individuals with cluster B personal-
ity pathology (borderline, narcissistic, and histrionic and antisocial) did not differ signicantly
from individuals with neurotic organization in their capacity to use fantasy and in their capacity
for some mutuality in love relations (Lendvay et al., 2011).
Further ndings from the same study on the relationship between attachment status and sex-
ual behavior suggested that secure attachment is related to sexual satisfaction, to the propensity
to value and commit to long-term sexual/romantic relationships, along with the capacity to
experience pleasure and stability in sexual relationships. On the other hand, insecure attachment
is associated with sexual dissatisfaction and the inability to sustain commitments and/or de-
pendency in romantic relationships (Carrassco, 2012). These ndings mirror previous research
that has also linked attachment styles to the ways individuals experience and engage in love
relations and sexuality. Security of attachment has been associated with greater freedom of
sexual expression and exploration, along with the propensity to value and commit to long-term
sexual/romantic relationships. In contrast, avoidant/dismissing attachment status has been as-
sociated with the curtailment of intimacy and the use of sexuality to maintain emotional distance
or control over others, with pleasure often linked to domination rather than mutual pleasuring.
Preoccupied/ambivalent attachment status has been associated with a subordination of sexual
pleasure to the quest for attachment security (see Mikulincer & Shaver, 2007 for a review).
These empirical investigations, in addition to our ongoing clinical explorations in treating
patients with severe narcissistic pathology with TFP, have led to a more comprehensive under-
standing of the nature of narcissistic pathology in general, and to the particular difculties these
patients have in the realm of sexuality, attachment, and love relations which often bring them to
treatment (Kernberg, 1995, 2007).
Case Illustration
We will illustrate some of the typical difculties in attachment and love relations that charac-
terize patients with severe narcissistic disorders, and how they were addressed in TFP with a
narcissistic patient with borderline features. Since the difculties in the sphere of forming and
sustaining attachments also lead to disruptions in the therapeutic relationship, we will focus
on the initial phases of TFP, including developing a treatment contract, dening the dominant
object relational dyads, and working with role reversal of those dyads as they are alternately
enacted and projected in the relationship with the therapist.
Presenting Problem and Client Description
Jay, a 40-year-old architect, was referred by a colleague with whomhe had been in CBTtreatment
for 2 years, which had ended precipitously the previous year. He had originally sought CBT
therapy because of angry outbursts at work, marital dissatisfaction, sexual dysfunction, and
intermittent substance abuse including psychotropic drugs, which compromised his work as
an architect. His colleagues had tolerated his erratic behaviors, including angry outbursts with
clients and colleagues and episodic binge drinking, because he was extremely talented and his
early successes had continued to attract prestigious clients to the rm.
Jay has been married for 13 years to an Italian woman, 8 years his junior, who ministered to his
needs and bolstered himwith her adoration, and into whomhe projected his own dreaded object
hunger and dependency. He was initially captivated by his wifes beauty and social prominence
Attachment and NPD 1151
as the scion of a ruling Italian industrial family when he rst met her while studying in Rome on a
postdoctoral fellowship. Whenthey movedtothe UnitedStates, her limitedcommandof English,
isolation from her family, and her sense of cultural displacement increased her dependency on
him, while he felt suffocated by her emotional demands. She coped by throwing herself into
renovating and decorating a series of apartments, where she occasionally entertained his clients,
but he often socialized without her and rarely took her with him on his frequent international
travel for work. She wanted a child, but Jay refused to consider this since he felt it would curtail
his career that required frequent travel.
Although he initially saw his wife as the ideal womanbeautiful, subservient, and devoted
after an initially passionate period, he lost his sexual desire for her. About 10 years after they
married, he discovered Internet sex, which allowed himto play out erotic fantasies of dominance,
submission, and control with no commitment or in-person contact. Jay reported that since
adolescence his sexual life was very vivid, but mostly in fantasy. Despite his devaluation of his
wife, he did report that he feared being alone and became apprehensive whenever she threatened
to leave him as a result of his neglect, disparagement, and refusal to have a child. When she
discovered his Internet use, she grew increasingly depressed. Although she had a number of
past medication and psychotherapy trials, she was not in any treatment when he began therapy.
He expressed considerable pessimism about any improvement in her depressed mood, which he
attributed solely to her biological make-up rather than any difculties in the marriage.
Jay was raised as the only child of a union between his father, a well-known artist, and his third
wife, who was over 20 years his junior. His mother, who was described as a self-involved aspiring
artist who had not been successful despite some early attention to her work, was thought to
have married his father for his professional connections. As her only child, Jay was the object
of her admiration and devotion during childhood, but only if he did her bidding, acting as
her companion and accompanying her to social functions. He found her alternately seductive
and neglecting, and felt abandoned when she traveled with his father and left in the care of
his grandmother. He described his father as a remote and forbidding gure who took only
intermittent interest in his son. As a child Jay would often amuse himself by building models,
and when he decided to pursue architecture as a career, his father disparaged his choice as being
inferior to the ne arts.
Jay graduated from a prestigious college and graduate program in architecture, and was
awarded a postgraduate fellowship to study in Rome before taking his current position at a
major international architectural rm. He developed symptoms of anxiety, depression, and
passive suicidal feelings in the midst of a work crisis (a dwindling of his client base, having to
accept assignments that he considered mundane and unworthy of his creative gifts) as a result of
the economic crisis as well as his own impulsively aggressive behaviors. Further, the deepening
crisis in his marriage led him to seek consultation with his former therapist, and he was referred
for further treatment.
Case Formulation
Inthe initial evaluationsessions, the patient statedthat he was ina state of paralysis inmost areas
of his life and expressed feelings of futility and despair. In short, Jay epitomized the narcissistic
patient who often seeks multiple treatments in mid-life when the gap between talent and early
aspirations andlater reality of lives leads todistress, depression, or acting out. Inthis case, the for-
mer treatment had been only partially successful in that it helped himto reduce but not eliminate
his angry outbursts at work and his compulsive engagement in Internet sex, but he terminated
prior to resolving conicts around his marriage. As he put it, I cant be sexual and nurtured at
the same time. Further, the underlying narcissistic structure had not been resolved, as evidenced
by torturous self-doubt and self-criticismthat was obscured by his grandiose sense of superiority,
his tendency to nd gratication in novel fantasy relationships instead of enduring connections,
and his anxiety about dependency when he began to enter into a deeper, more complex reality-
based relationship. The drastic split between devalued, desexualized love objects (in this case his
wife) and illicit sexually exciting love objects (in this case his Internet partners) is typical of the
object relational patterns of patients with severe narcissistic pathology (Kernberg, 1995).
1152 Journal of Clinical Psychology: In Session, November 2013
Although there was no formal assessment of his attachment style, aspects of his presentation
including his relentless devaluation of his wife combined with his abject dependency on her, as
well as his idealization of women on the Internet with whom he would never be emotionally
engagedor intimate, suggestedthat he vacillatedbetweendismissing andpreoccupiedattachment
strategies, typical of those with comorbid narcissistic and borderline pathology (Diamond et al.,
2013).
Course of Treatment
Clinical practices: Initial evaluation and contract setting. One of the rst steps in
setting a viable treatment frame in TFP involves the identication of behaviors that may com-
promise the patients safety or interfere with the patients ability to participate in the treatment,
or behaviors that thwart the therapists ability to function in his or her role as a therapist. Once
such behaviors are identied, the patient and therapist together establish mutually agreed-upon
parameters for their containment, i.e., the treatment contract. Jay was initially dismissive in
his attitude toward the therapist, though he insisted that he wanted solutions for his immediate
problems, while at the same time he asserted that I, too, would not tell him anything he didnt
already know about himself, and feared getting into a protracted treatment.
In the initial consultations, however, I suggested that his presenting conict around his wife
and Internet sex partners might stem from divisions within himself that we needed to explore
more fully, and that I would be hesitant to embark on treatment unless he agreed to a treatment
contract, which stipulated twice-weekly therapy for at least 1 year, including a commitment to
agree to discuss any feelings about ending therapy before acting on them and to report self-
destructive behaviors and feelings, such as abuse of psychotropic medications. As part of the
contract, I recommended a consultation with a psychopharmacologist who would monitor his
medication use on a regular basis and raised the possibility of a 12-step group if his substance
abuse continued. I alsoanticipatedthe likelihoodthat Jay might begintofeel anxious or impatient
in the therapy, and that it would be essential to discuss these feelings, rather than act on them
by leaving therapy in a repetition of his avoidant behaviors.
Initially, Jay was resistant to the idea of a contract that would place any limitations on his
behavior. He agreed to these conditions, and stated that he believed I was uniquely suited to
treat him because he had looked me up on the Internet and found that I had written a book
on attachment and sexuality, and at the same time he dismissed this as a womens magazine
topica striking mixture of idealization and devaluation. Thus, the treatment contract had
already begun to serve its primary purposeto bring the primary relational dynamics that are
being acted out to the forefront in the transference with the therapist.
In the context of a discussion in the initial contract setting sessions of why he needed a
psychopharmacologist rather than a friend with a MD prescribing his medication, and the
ethical guidelines around such practices, the following dialogue emerged:
Patient : I still dont see the need for me to see another psychopharmacologist. And you
seem overly conscientious. Everyone I know gets drugs from friends.
Therapist : Perhaps a friend prescribing medication may take the sting out of being a patient,
and puts you control. For you to comply with my recommendation, that you see
a psychopharmacologist, puts me in control. And I think that being in control
rather than being controlled is an essential issue for you. Perhaps theres always a
controller and controlee for youif thats what is at stake here, I can understand
why you would want to be in control of your medication.
Patient : Well, I feel like you are not going to tell me anything I dont already know about
myself, so why should I change things until I see if its worth doing.
Therapist : I can appreciate that, but I think if you didnt want to try a more intensive therapy
you wouldnt be here. We want to set things up in the beginning to give the therapy
a chance. It would be as though you were working with an engineer to build a
building that you designed and he is not following sound plans for the foundation.
I think you might be concerned about whether that was the best plan.
Attachment and NPD 1153
Patient : That is a spurious analogy. This is not at all comparablethey are two totally
different situations. There is no connection between my work and your work. Its
not even comparable.
Therapist : Well fair enough, psychology and architecture are two very different elds, but what
strikes me is how upset you seem by that analogy. Im inviting you to think about
this fromanother perspective and I think that is difcult. Imstruck by howdifcult
it is to contemplate us working collaboratively to set the framework for this therapy.
Patient : I think those guidelines about medication are ridiculous, and they are not for people
like me who are well connected and have friends who both really understand me
and are knowledgeable about drugs.
Therapist : I understand your concerns about embarking on a newtherapy, and perhaps you are
wondering whether I can understand you and help you with your current dilemmas
any more than your former therapists, or your MD friends, and perhaps there is
some feeling of futility and fear of putting yourself in the hands of another therapist.
Patient : I really dont want to go into my history again with youI did that in my previous
therapy.
Therapist : Yes, I understand that you have told your story to your previous therapists and
are less than happy with the results, but there is something about going over your
life history with a new person. Perhaps we will come to a somewhat different and
maybe deeper understanding of why you are so paralyzed in your life right now,
particularly around relationships. Maybe its hard to do this with a new person who
is not Dr. X.
Patient : You have a point there. He did help me to get a better hold of my Internet use. I
still dont really understand why I cant really commit to my wife or leave her.
Therapist : We can explore these issues together and come to a deeper understanding of what
is paralyzing you, but in order to do that exploration, I have to know that you
are being responsible about your medication and substance use, and Internet use.
Otherwise feelings that we should be talking about here will be funneled off in these
behaviors. Does that make sense?
Patient : Not completely, but okay Ill give it a try because Dr. X recommended you and
I guess you wrote a book about attachment and sexuality. Its such a womens
magazine topic but maybe you could help me. Im at the end of my rope here and
afraid Im losing my wife, and I cant imagine living without her, but I cant seem
to live without the thrill of my Internet partners. Maybe Im beyond helpIm not
sure what you can do for me.
Therapist : It seems like you have a dilemma hereon the one hand thinking I might have
some expertise and may be of help, but on the other hand feeling resentful of this
and suspicious about whether I can help you.
Patient : Well, you are setting all these conditions. Maybe you dont really want to work with
me.
Therapist : On the contrary, Imtrying to set up our work so we have the best chance of working
together productively. By resisting this framework, it is you who are rejecting what
I have to offer.
Patient : Okay, I guess Ill give it a try.
The forgoing material from the contract-setting session indicates the challenges of engaging
patients with narcissistic pathology in treatment and forging an alliance. Often with patients
with severe narcissistic pathology, introducing the contract as a collaborative agreement early
in therapy functions as an alliance-building experience in which the idea of a collaborative
process in which both patient and therapist have certain roles and responsibilities is introduced.
In addition, by creating limits and structure to address destructive, self-destructive behaviors
and treatment-threatening behaviors, the contract creates a shared focus for the treatment. The
contract functions as a secure base that helps the patient and therapist outline the likely pitfalls
they may encounter and sets guidelines that optimize the success and endurance of the therapy
particularly with patients who are prone to early drop out. In so doing, the therapist attempts
1154 Journal of Clinical Psychology: In Session, November 2013
to create an atmosphere of tentative trust and collaboration that functions as a base from
which further therapeutic operations can be launched. The forgoing case material illustrates
how the dominant relational schemata, involving superior self/inferior other and controlling
self/controlled other, are immediately activated in the clinical situation, setting the stage for the
rst phase of interpretation in TFP.
Clinical practices: Dening the dominant object relations. A central strategy of TFP
is to articulate the internal object relation dyad that is activated in the transference at a given
moment. The typical dominant dyad of the narcissistic patient as this case illustrates is often
that of the superior, even omnipotent self and inferior, devalued other. The initial identication
of this dyad is especially difcult because of the anxiety associated with taking an observing
distance from the grandiose, devaluing part to explore other aspects of self (e.g., vulnerability,
humiliation, fear of dependency, or envy). In addition, the therapists ability to help the patient
may be experienced as a humiliation, often leading to negative therapeutic reactions manifested
by worsening of symptoms or dropping out of treatment.
We have identied several strategies that have helped us to engage in collaborative work
with such patients, and to accept our interpretative efforts in particular. Clarifying and simply
accepting for the moment the patients experience of the therapist (i.e., the object representation)
without challenging or interpreting the distortions or projective defenses comprising the view of
the therapist help the patient to feel understood and contains the intolerable self-states managed
through projective processes. Protracted attention to this side of the dyad, i.e., the patients
experience of the therapist, is referred to by Steiner as a therapist-centered interpretation
(1993) and may be important in the initial stages of TFP with narcissistic patients, as it is more
tolerable for themto see aws in the other than it is in the self. Therapist-centered interpretations
are designed to bypass, at least at the outset, the patients sense of weakness, inadequacy,
and confusion, thus hopefully avoiding the provocation of the patients shame, humiliation, or
rage and allowing for a gentler, more tactful confrontation of the patients defensive processes
(Caligor, Diamond, Yeomans, & Kernberg, 2007; Steiner, 1993).
The initial phase of treatment helped Jay to identify and articulate his experiences in therapy,
which took the form of seeing me as awed, inadequate, or unhelpful, and himself as the expert,
thus containing his own sense of inadequacy and vulnerability in a projected state (Steiner,
1993). The dismissing devaluation stemmed from not only his realization that I could not
provide magical solutions to his conicts but also his beginning to experience disavowed aspects
of himself in the here and now with the therapist. In this case, the action around the treatment
frame provided the split-off material that was too difcult to verbalize in session.
For example, in the rst months of therapy, in a session in which he obsessed about his
conict between his wife and his Internet activities, I observed that the choice seemed to be
not between two sexual relationships, but between investing in an actual relationship versus
remaining sequestered in his fantasy world where he could control and watch anonymous
individuals play out his scenarios of dominance and submission. Jay arrived 15 minutes early for
the next session and knocked insistently on my door 5 minutes before his session was scheduled
to begin. When I opened the door for him at the appointed time, he presented with rigid
body posture and a tortured expression, stating immediately that he was thinking of leaving
treatment.
Patient : I dont knowwhy I came this morning. I amfeeling very adversarial, and this feeling
has grown, not diminished.
Therapist : Well, it seemed very important for you to come in and tell me how adversarial you
are because you came 15 minutes early.
Patient : Well, I did feel that we made some progress last week when you said to me that I am
having trouble having a real relationship versus investing in a fantasy world. That
was progress on our part, well maybe on your partbut I already knew that. And
you misunderstood something crucial in the last sessionI was talking about my
wife, andyoufailedtonotice that she is not encouraging towards me anymore. When
we talked about my mending the relationship with her, it was totally wrongrather
Attachment and NPD 1155
than encourage me, she mocks me. And you were disturbingly incorrect when you
asked about mending our relationshiphow could you not see that she has pushed
me away? Of course, I couldnt really tell you what was going on. This week she
even talked about a separation.
Therapist : It sounds like I really disappointed you because I didnt understand intuitively
that you were being pushed away, and that you were having trouble telling me this
directly.
Patient : In addition, I dont like the way you end the session. Last week, you ended the
session just as I was in the midst of talking about this. In fact, you cut me off and I
am not one to be cut off.
Therapist : It sounds like you are experiencing me as a woman who will cut off and push you
away like your wife, and who will fail to care for you and meet your needs.
Patient : Yes, my wife has been pulling away. She is away visiting her family and very mono-
syllabic on the phone with me. She said she doesnt know if she wants to go on with
the marriage. I keep coming back to your comment about my fantasy life and how
it sustains me, and how after a while, I withdraw from all relationships.
Therapist : Well, maybe that is happening here as well, because you started out saying we had
made some progress, but then backtracked and said it was only I who had made
progress, or that you knew this all along about yourself anyway, as though it was
not something that had come out of our work together.
Patient : Well, she [the wife] treats me like Im a pathetic creature. She is not empathic to
me anymore. She ridicules me for my paralysis and inability to stop going on the
Internet.
Therapist : Today, I think you were experiencing me that way as well. Fromthe start today, I was
someone who couldnt understand and empathize, who would judge you harshly.
How difcult it must be to have a therapist who doesnt understand your anguish
and might judge you. [therapist-centered interpretation]
Patient : Well . . . Im very anxious today because I have to do a presentation for a new ofce
complex in China, and I am very worried that they wont like it and will think Im
incompetent. I wanted to talk about that but then I couldnt.
Therapist : I guess you were worried about telling me this for fear that I wouldnt understand
how fearful you can be, or that I would judge you as you judge yourself for having
these feelings.
Patient : Yes thats it. I used to be paralyzed with anxiety in situations like this, and then if
the client didnt like the model, Id lash out. The CBT treatment helped me to not
lash out but I still fear that it will come backthese feelings of incompetence, this
paralysis, this rageand Ill be humiliated.
Therapist : Maybe that accounts for why you were so insistent on having this session, knocking
on my door 5 minutes early, because you needed to talk about these feelings, but
then when you saw me, you feared that I would humiliate you as well. It is as
though someone always has to humiliate or be humiliated. Today, you fear that
someone will be youit sounds like this fear comes up not just at work but with
your colleagues and clients, your wife, and with me as well.
Patient : Yes, that sums it up. I think I can face the presentation now. [Turns at the door]
Thank you.
As illustrated, my provisional acceptance in the rst part of the session (and in a number of
sessions before and after) of the projection of the devalued aspects of self, without interpreting
that he is nding in me that which he deplores in himself, allowed Jay to begin to reect on
and to talk about his own fear of humiliation. We can speculate that it may be therapeutic for
the patient to see the therapists ability to carry on in the face of imperfections, and the patient
might internalize the therapists less punitive model of coping with aws. Such interpretations
increase the patients tolerance for aspects of self that must otherwise be disowned, and pave the
way for understanding the larger object relational dyad of superior/inferior that was activated
in the transference relationship.
1156 Journal of Clinical Psychology: In Session, November 2013
Clinical Practices: Working with role reversals. The next step of interpretation in TFP
involves identifying and interpreting role reversals in the transference, which entails bringing the
patients attention to his or her alternating views of self in relation to others. While patients with
borderline personality disorder tendtooscillate rapidly betweenviews of self inrelationtoothers,
due to the rigid and defensive nature of the grandiose self, patients with more severe narcissistic
disorders less often shift to a negative viewof the self. However, because the grandiose self sets up
exceedingly high expectations, such individuals are at the risk of a catastrophic shift to extreme
distress if the defensive function of the grandiose self fails. Once the dominant relationship
pattern has been identied between patient (as superior) and therapist (as inferior), enactment
of complementary patterns can be discerned in split-off aspects of what the patient (as inferior)
is saying to or doing with the therapist (as superior). Material from this session 9 months into
treatment will illustrate this bifurcation in the object world, and the ways it was externalized in
the transference:
Patient : Imbothered again by the way you ended our last session, just when we were getting
somewhere. I was eager to come because I appreciate your perspective and your
challenging of me but now thats all I can think about. I know we were out of time,
but its like you think youre the professor and Im the 22-year-old graduate student
in Rome focused on romance every second.
Therapist : It sounds like you felt that you were not important to me because I ended the session
on time. I am struck by your comment about feeling like a 22-year-old romantic
student and me being the professor because on the one hand you have some good
feelings about coming but they are cancelled out by the sense that Im the professor
who has the authority to end the session on time. This sounds like a terrible dilemma
in that you see me as someone who is competent, and might be able to help you,
but I wonder if this doesnt also make you feel some resentment and perhaps envy.
Patient : Yes, I think of you in very different wayssometimes I see you as off the spectrum
brilliant, but really old and haggard, and sometimes as an attractive woman regard-
less of your age with a condence that comes fromthat or somewhere in betweenI
see you as both.
Therapist : This is not unlike the divided way that you experience yourself as assertive, success-
ful, and competent on the one hand and as awed and miserable on the other.
Patient : This is a theme that always comes up for methat of humiliation and not being able
todeal withconicts about vanity. I thinkthis was basically resolvedat work, but not
in love. I keep looking for that ideal woman who is going to cure meparticularly
P [a woman on the Internet who was the main focus of his fantasies]but I found
aws with her too. I guess, what I feel about her parallels to what I feel herethe
hideous duality of being young and beautiful, but awed and unattractive. Thats
why I stopped responding to her e-mails. By the way, my wife is actually seeing a
new therapist and changing her medsI am noticing some changes.
Therapist : It is interesting that you are telling me that your wife is back in treatment, since every
time I raised questions about this you insisted she was beyond help. Yet you have
described her as formerly very attractive and desirable, but now old and repulsive.
This is similar to the bifurcated way that you see me.
Patient : I dont think youve been able to appreciate my attachment to my wife. I dont think
Ive conveyed to you the pull as well as the push of that relationship. The pull is the
comfort and beauty of the household but I live in a halfway housewith therapy,
with my wifenone of them get all of me.
Therapist : The part of you that is always attacking your self-worth attacks them as well,
making it hard to experience and connect with the good partsmaking it hard for
you to appreciate and convey your attachment to your wife. This came up today
as well when you looked forward to coming to session, but then remembered your
negative feelings about my ending the session.
The foregoing clinical material, by necessity quite condensed, provides further illustration of
not only the emergence in the transference of the patients bifurcated internal world but also
Attachment and NPD 1157
the role reversals that occur within the dyads comprising this internal experience. Slowly the
superior and idealized aspects have emerged as a dominant part of the representation of the
therapist, and the underlying vulnerability and helplessness have emerged as a dominant part
of the representation of the self. This highlights the shift from thick-skinned to thin-skinned
narcissistic positions (Rosenfeld, 1964, 1971). Clinical investigation with patients with severe
narcissistic disorders reveals that as those who are more dismissive in their attachment state
of mind (or thick-skinned) start to face what had been their unconscious psychic reality, they
begin to look more preoccupied in their attachment state of mind (or thin-skinned), with an
increasing awareness of feelings of chaos and panic, related to a sense of inner emptiness or
vulnerability. About 10 months into treatment, Jay acknowledged that the real reason that he
hadnt left his marriage was because of a terrifying chasm in himself, which his wife has lled
with her endless devotion. This chasm was associated with terrifying fears of aloneness and
emptiness, which drove both his endless quest for exciting anonymous sexual experiences, and
which also eclipsed his capacity for sustained intimacy.
His being increasingly able to own and articulate the feelings of dependency that had pre-
viously been so strongly defended against marked the subsequent stage of treatment. Most
notably in the transference, he told me that he had fantasies that he was my only patient and
that I thought only of him. Intensive work in the here and now interactions between patient and
therapist is the vehicle for change with such patients, and is often evident in statements such as
the following made by Jay after one year of TFP: Something happened yesterday and I thought
we might make sense of it together, rather than my just exhibiting my psyche to you. Jay talked
about ongoing compulsions to revisit the Internet experiences, but with further exploration,
acknowledged that over time he found his need to dominate and control others both sexually
and emotionally to be disturbing rather than gratifying.
Although he stated that he feared therapy would not help to change what excited himsexually,
he was able to explore howhis enactment of dominance/submission scenarios were an expression
of both the critical, devaluing part of himself and the self that is the object of those attacks. He
talked about how his relationship with his wife had helped to provide him with a platform from
which to launch his career and began to experience and express gratitude for the beautiful and
gracious home she had created. He recognized that his devaluation of his wife devolved from an
internal scenario involving the scathing critical part of himself with his wife, the willing recipient
of this degraded, devalued aspect of himselfwhat he has termed his judgementalism, stating,
I judge her (wife) and withholdall things you experience with me here. This realization
marked a shift from a dismissing to a preoccupied position, offering the possibility of a more
than intellectualized understanding of the ways in which his chronic devaluation of others,
including the therapist, is an externalization of harsh critical elements of his own internal world.
Thus, in the later stages of TFP, there is often increased recognition of howthe claims of idealized
representations of self and others (the grandiose self) have eclipsed the needs of the real self,
leading to decreased valorization of narcissistic dimensions, and increased capacity for genuine
investment in relationships, both internal and external.
Outcome and Prognosis
With repeated interpretation of how Jays alternate devaluation and idealization of me and
signicant others were actually split-off aspects of his own idealized and hated representations
of self and signicant others, he began to recognize howthese projections protected himfromthe
pain of facing his limitations, truncating his capacity to experience pleasure and gratication in,
as well as gratitude for, what others could realistically offer. He has shown increasing recognition
of how his investment in the sustaining fantasy of nding the ideal woman who would grant him
perfection has curtailed his capacity to value the intimacy and companionship that he nds in his
wife, and to allow himself to re-experience the passion he felt for her for the rst 10 years of their
relationship. Although he continues to be ambivalent about his marriage, he has begun to reect
on and appreciate his wifes contributions to his professional development and well-being, to feel
regret for the relentless rejection and humiliation to which he has subjected her, and to consider
the possibility of having a child with her, recognizing that time for such a decision is not endless.
1158 Journal of Clinical Psychology: In Session, November 2013
In addition, rather than focusing on the prestigious projects that he felt entitled to work on,
he has begun to focus more on developing business for the rm as a whole. Over the course of
the therapy, he has come to understand that his tendency to devalue others was in part a result
of his identication with parental gures who were tantalizing but neglectful (mother) and dis-
tinguished but critical and distant (father)internalized gures that systematically undermined
his own capacity to experience love and happiness, while at the same time fueling his sense of
grandiosity and omnipotence.
Further, as he develops the capacity to reect on himself and his own motivations, it has
become possible to interpret the anxieties and conictsanxieties about abandonment, insignif-
icance and even annihilation (the terrifying chasm)that catalyzed his retreat into grandiosity
and to connect these with early experiences. In sum, through the exploration and integration
of bifurcated self and other representations, the patient developed the capacity to think more
coherently and reectively, with more realistic, complex, and differentiated appraisals of the
thoughts, feelings, intentions, and desires of self and others.
Clinical Practices and Summary
In sum, this patient epitomized many of the difculties with attachment typical of patients with
severe narcissistic pathologythe difculty sustaining sexual interest in his long-term partner,
the split between devalued, desexualized love objects and idealized, anonymous sexually exciting
objects, the terrors of aging and diminution of physical prowess that he projected onto others
including the therapist, and the lack of gratitude for love and ordinary domestic pleasures he
experienced with his wife, along with the projection of blame onto her for all limitations of their
life (Kernberg, 1995, 2007, 2010). The interpretative process in TFP has allowed for systematic
analysis of the grandiose self, leading to a shift froma grandiose, dismissive to a more vulnerable,
preoccupied narcissistic presentation.
This interpretive process leads to the gradual integration of disparate, split-off self and object
representations into a more integrated stable concept of the self and objects, which in turn fosters
reective capacity in that it provides a more integrated, consistent working model of self and
others against which momentary mental states, including those that devolve from the grandiose
self, may be more systematically reected upon and their defensive function understood. The
case calls for ongoing empirical and clinical investigations of the particular difculties in the
sphere of sexuality and love relations that often bring NPD patients to treatment, how such
difculties are related to different internal working models of attachment, and how they change
in the course of treatment.
Selected References and Recommended Readings
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pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis.
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Caligor, E., Diamond, D., Yeomans, F., & Kernberg, O. F. (2009). The Interpretive process in the psycho-
analytic psychotherapy of borderline personality pathology. Journal of the American Psychoanalytic
Association, 57, 271301.
Clarkin, J. F., Kernberg, O. F., & Yeomans, F. (Ed.). (2006). Psychotherapy for borderline personality:
Focusing on object relations. Arlington, VA: American Psychiatric Publishing, Inc.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments
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