Patients with prominent narcissistic psychopathology have long been recognized as posing formidable challenges to clinicians. Their difficulties allowing for a healthy dependency upon and attachment to the therapist, engaging in interpretive work that requires some reflectivity, and tolerating emotional pain in service of growth, pose significant technical challenges.
As a result, clinicians working with narcissistic patients frequently report feeling devalued, deskilled, irrelevant, and under attack.
The treatment process can readily devolve into a vicious downward cycle involving the patient’s retrenchment into a paranoid, hostile stance, generating intense countertransference pressures, compromising the therapist’s observational and analytic functions, and resulting in stalemates, enactments, and the premature termination of treatments.
These observations arise in the context of a discussion of the treatment of a patient called “Grace.” But when you read about Grace you see she’s not really like me in her fragility and emotional dysregulation. I’m a perfectionistic narcissist but not fragile or emotionally dysregulated.
The following paper, published in 2017, contains fascinating transcripts of clinical colloquy between the therapist and Grace. I don’t sound like this in therapy. The authors are colleagues of Dr. Caligor.