Too Proud To Cry: Clinical Work With Survivors Who Employ Narcissistic Defenses

Rosemary Masters, J.D.,C.S.W.

NCP Clinical Quarterly 6(2): Spring 1996

Trauma survivors, by definition, have suffered experiences too horrible to contemplate. It runs counter to our natural human sympathies, not to mention our professional ideals, to find ourselves irritated, annoyed, contemptuous and/or dismissive of men and women who have endured the unendurable. There is a particular kind of survivor, however, who -- to put it charitably -- can be singularly unlikable. These are the clients who either demand our unremitting attention or scorn our help altogether. Initially they may idealize us, but then, at the slightest disappointment, they drop us. They belittle our interpretations, attack our qualifications and erupt in fury if we do not meet their demands. All too often they defeat our most heroic efforts to engage and assist them. In response, we clinicians often defend against our angry, resentful feelings towards these survivors with defenses of our own. We refer them elsewhere for "more appropriate" help, forget their appointments or try to placate them with one breach of the therapeutic frame after another.

I have found that a helpful approach to understanding and treating these survivors is from a perspective which synthesizes psychoanalytic ideas about narcissism with the contributions of clinicians who have studied post traumatic stress disorder: For the most part, dissociation has been considered the preeminent defense which must be addressed in work with persons suffering from post traumatic stress disorder. I have observed, however, that many survivors protect themselves from traumatic reexperiencing of the feelings associated with traumatic relationships and events through use of the defense mechanisms attributed by Kernberg and Kohut to pathological narcissism. Specifically I have found that survivors may defend against feelings of guilt, humiliation, shame and disillusionment through the defenses of devaluation, contempt and a grandiosity which is accompanied by demands for entitlement and privilege. When these defenses break down, survivors may experience the feelings of panic, desperation and terror characteristic of traumatic flashbacks.

If we are to be successful in our work with these survivors we need to understand the nature of narcissism and narcissistic defenses and the often subtle way such defenses present themselves in the case of trauma survivors. If we are not to drive these clients away, we must be alert for countertransference reactions that indicate that we are having difficulty handling a survivor’s narcissistic adaptations. Finally we need to have specific strategies for forming a therapeutic alliance with the narcissistic trauma survivor and for addressing narcissistic defenses in treatment.

The Concept Of Narcissistic Defenses

Otto Kernberg (1) suggests that some children defend against an intolerable reality (such as overt or covert rejection, abuse or abandonment by the caretakers) through an intrapsychic maneuver by which the child’s actual self representation fuses with the child’s idea of his or her ideal self and with ideal aspects of the caretakers. In their fantasies, these individuals are able to deny dependency on real external others and on imagined others as well. Kernberg describes the state of mind of a narcissistic client in these apt words:

It Is As If They Were Saying,

A number of consequences flow from the child’s adoption of this stance of invulnerable superiority. Authentic relationships in which self and other are seen as mixtures of good and bad become impossible. Because closeness brings with it awareness of need and dependency, an intolerably inferior condition, relationships are often disdained. To the extent intimate relationships are formed, the other must be seen as perfect, the proper match for one's own perfection. Once discovered to be flawed, the other becomes devalued and useless. Narcissistic relationships are thus highly unstable. They may begin with unrealistic idealization of the other but once the other’s "feet of clay" are discovered, the other is quickly discarded with disgust and contempt. Because their internal self image is inflated, narcissistic persons are highly vulnerable to intense shame. Some find it difficult for them to apply themselves consistently to a field of endeavor. Others may be extremely successful, but require constant shoring up of their grandiose self image. If criticized or disappointed, the narcissistic person can experience the set back as a brutal assault, project his or her own rage outward and develop the paranoid belief that others are motivated by the desire to torture and humiliate.

Kohut (pp. 37-65) (2) views narcissism from the perspective of the development of self experience. He suggests that narcissism is a normal developmental stage during which the caretakers help the child consolidate a sense of self by mirroring of the child’s gifts and by providing a strong protective presence with which the child can identify. Failure on the part of the parents to provide these mirroring and idealizing functions (termed selfobject functions) leads to a flawed, fragile sense of self with frantic efforts to maintain self cohesion through the strategies also described by Kernberg.

There is disagreement between Kernberg (p. 309) (1) and Kohut (pp. 249-266) (3) as to how best to help clients with narcissistic issues. Kernberg stresses the importance of confrontation. By confrontation Kernberg means a three step process: the therapist repeatedly draws attention to the client’s use of narcissistic defenses such as contempt, devaluation, and denial; the client is then helped to understand that contempt, devaluation and denial are all ways of avoiding painful feelings; finally the client is encouraged to experience and put the painful feelings into words. In contrast to Kernberg, Kohut believed that empathy alone may be curative. If the client is listened to and feels understood, an empathic stance on the part of the therapist will be internalized and a consolidation of the client’s fragile self will be achieved. As part of that process the therapist must pay keen attention to when the client is disappointed by the therapist and must help the client formulate that disappointment into words. The therapist’s empathic acceptance of how he has failed the client allows the client to internalize that analyst’s selfobject functioning and make it his or her own.

Goldstein (p. 131) (4) suggests that the difference in the approaches can be explained by the fact that Kernberg and Kohut’s theories address somewhat different groups of clients. Kernberg’s clients (most of whom were hospitalized) tended to be more impulse ridden and chaotic than Kohut’s clients, and were hence more likely to flee treatment unless made aware of their defensive strategies.

Despite their differences both Kohut and Kernberg share certain principles of treatment: For both, the central focus of the therapist’s attention is the transference -- how does the client experience the therapist and what does that experience say about the client’s psychic structure, fantasies, interpersonal anxieties and defenses? Both recommend therapeutic neutrality, that is the analyst does not advise, educate or guide the client; rather, the therapist aims at helping the client understand and become aware of his inner experience and psychic structure.

The Problem Of Treating The Narcissistic Trauma Survivor

Recommendations of trauma experts for treatment of PTSD differ significantly from Kohut’s and Kernberg’s psychoanalytical approach to treatment which emphasizes therapeutic neutrality and focus on the transference. Herman (p. 155) (5)recommends that treatment of a trauma survivor unfold in three stages. Initially a climate of safety must be established. By this she means first of all that the client must be given a cognitively based explanation of trauma and its consequences. Simultaneously, the client must be helped to curtail alcohol, drug abuse, sexual acting out and other dysfunctional ways of managing traumatic flashback. An adequate alternative support system must be established through services such as 12 step programs, hot lines and emergency rooms. In the second stage of treatment the client is encouraged to recall and work through traumatic memories. The therapist clearly labels past experiences as abusive and helps the client struggle with the meaning of this new understanding of his or her history. In the final stage of treatment the client is encouraged to make connections with groups which provide a sense of connection and common cause with others. Under Herman’s approach, the therapist is actively protective of the client, often directive about what the client should and should not do and consistently educative by pointing out to the client an alternative cognitive meaning of the client’s traumatic experiences.

Herman’s recommendations for the treatment of PTSD presuppose that the survivor has at least a minimal capacity to form a therapeutic alliance with the therapist. Davies and Frawley (p. 94) (6) point out however, that unlike survivors who undergo trauma as adults, victims of childhood trauma have usually been abused by the persons on whom they depend not only for physical survival but for their very sense of self. They criticize much of the trauma and sex abuse literature for focusing too excessively on the recovery of memories of pathogenic events. Instead, they assert, adequate treatment requires that dissociated aspects of self and other must also become conscious and affectively experienced. In particular they note that the client may experience the therapist in ways wholly at odds with the therapist’s experience of himself or herself. Many treatment failures can be attributed, they suggest to the therapist’s blindly reacting to the client’s negative transference reactions.

The narcissistic trauma survivor presents particular problems for therapists working from the perspective of a trauma paradigm. In many cases the treatment never really begins, The client’s protective stance of lofty superiority is threatened by the therapeutic relationship and the demands of treatment. Subtly or not so subtly the therapist is held at a distance. The therapist’s insistence on a treatment contract and parameters of safety can be experienced by these clients as coercive or demeaning. Often the treatment has a repetitive or superficial feel. Over time appointments are broken and the treatment gradually trails off into explicit or implicit termination.

Other clients may start off in a seemingly warm related therapeutic alliance. The client complies with the therapist’s helpful suggestions and expresses gratitude for the therapist’s brilliant insights, but at some point things shift. The client becomes disillusioned and after that things are never quite the same. The client may pronounce himself or herself cured or abruptly leave. The therapist is left wondering what happened.

The therapist working with trauma survivors who have narcissistic character pathology is thus presented with a series of treatment conundrums. On the one hand, because a survivor’s reenactment behaviors are often life threatening, treatment cannot go forward without parameters of safety and the secure environment recommended by Herman. On the other hand these clients usually feel insulted and demeaned by suggestions that they are not in control their lives. The client may need help to identify and understand the current consequences of past traumas, but he or she may be intensely resistant to revealing himself to the therapist, since such self revelations imply a degree of dependency and vulnerability that the client cannot tolerate. Finally, the client may genuinely need and benefit from a cognitive understanding of the nature of trauma; however, the therapist’s expertise can be experienced by the client as evidence of the client’s humiliating inferiority. The smarter and more helpful the therapist is, the more envious and uneasy the client becomes.

In sum, the challenge for working with narcissistic survivors is how to weave together the insights of both trauma theory and psychodynamic theory into a coherent and helpful whole. The work is a little like that familiar childhood dare of being asked to pat one’s head and rub one’s stomach at the same time. There is often a sense of confusion and dissonance but it can be done.

Clinical Principles

For myself I find a mix of trauma theories and psychodynamic strategies works, but only within the following overall treatment context:

First, awareness of the impact of the therapist on the client from the first moment of treatment is crucial in work with trauma survivors who use narcissistic defenses. The therapist cannot assume he or she is being experienced as helpful, knowledgeable and concerned. To the client, the therapist may be a condescending know it all, a cold fish, or a sadistic critic.

The second general principle entailed in working with these clients is to be acutely aware of one's own countertransference. Such feelings when induced by the client signal the defensive strategies at work. For example:

The third principle follows from the second. Don’t act on countertransference feelings until you understand what has induced them and considered what they may reveal about the client. Where intense countertransference is concerned, it is often essential to talk out one’s reactions with understanding colleagues, preferably those who don’t expect a therapist to have warm, loving feelings towards a client no matter what the client does.

Fourth, once one's own feelings are defused it is time to sit back and think about what the client is trying to protect against by a particularly confusing or obnoxious bit of behavior. The therapist must mentally assess the cost and benefits to the client of his or her defensive strategy. The therapist should then think of ways of formulating that strategy from the client’s perspective and as soon as possible share that understanding with the client. Just as it is imperative not to act hastily on one's countertransference, it is vital not too wait too long to use the insights gained from induced feelings. With these touchy clients, the therapist is often tempted to "leave well enough alone" and to hope that things will eventually get better by being tolerant and understanding. Unfortunately, unless the client is helped to become aware of how he or she is warding off vulnerability, the client’s envy, resentment and defensive contempt of the therapist will inevitably increase. Treatment will end in stalemate or premature termination.

A fifth principle of work with narcissistic trauma survivors is that the recommendation of a network of safety recommended by Herman cannot be ignored; however, safety requirements must be presented to the client in ways that allow the client to explore what it means to his or her sense of self to accept such requirements. At such times it is crucial for the client to feel understood as to how humiliating or dangerous it feels to abide by the therapist’s treatment requirements.

A final principle, one stressed by Kohut, is the importance of making the client feel understood about his or her disappointment in the therapist. This does not mean that the therapist agrees with the client (for example, that the therapist is a selfish person for taking a vacation). Rather, disappointments in the therapist need to be undefensively explored in terms of what the client needed and what it means to the client that he or she did not get what was yearned for. It is through this process of formulating disappointment and experiencing grief and rage that the client becomes able to give up the fantasy of protection by an omnipotent caretaker and accept more realistic limitations in self and other.

The following clinical vignette is an example of how to work with a narcissistic client from the foregoing perspective:

A young woman, a survivor of paternal rape, adopted a contemptuous "I couldn’t care less" attitude towards her treatment. She canceled sessions repeatedly and with studied indifference let me know she had far more important things to do than see me. Once I had my irritation under control I pointed out how casual she seemed about her treatment and wondered what it would mean to come more regularly. Together we explored her resistance to regular appointments and identified how as a child she had been praised for being the responsible oldest one who always took care of her numerous younger siblings. She began to articulate how she needed to think of herself as not needing anyone because that way she didn’t need to feel weak or vulnerable. I said to her, "so if you came to see me regularly, it might mean you need me and you’d have to deal with the awful feelings of being weak or needy, something that feels excruciating painful to you. It’s really much safer for you to feel that what we do here doesn’t matter very much and that I’m not very important to you." It was after this empathic intervention that she began to talk about her searing sense of shame that she had decided to come to live with her father (the parents were separated) because she had hoped that he would give her the guidance and protection she had never had as a child. I could then provide her with a cognitive frame for understanding the meaning of the incest: As an inexperienced young teenager she could not possibly have known how to handle her father’s sexual advances. Her father, not she, was responsible.

In Summary:

Many survivors of childhood trauma defend against reexperiencing trauma and associated affects through use of narcissistic defenses. Because of their reliance on devaluation, omnipotent entitlement and idealization, narcissistic survivors present many challenges. They are difficult to engage. If engaged, the therapy is often superficial and short lived. Hypersensitivity to criticism, demands for special treatment and contempt for the therapist can promote countertransferential acting out which can abort the treatment.

Clinical work with narcissistic trauma survivors requires careful attention to one's own countertransference reactions and a carefully thought through formulation of how the client is avoiding real connection and closeness to the therapist. In particular the therapist needs to identify the client’s use of defenses such as devaluation, contempt and denial of need. Once the therapist has begun to formulate how and why the client avoids connection and self exploration, this insight needs to be shared with the client not just once but repeatedly as the client falls back on the use of narcissistic defenses at times of stress and pain.

With these recommendations in mind, treatment of the trauma survivor can still proceed along the lines recommended by Herman. The client can be encouraged to develop a network of safety provided he or she is simultaneously helped to process the fear and shame which the need for this network entails. As the client lets go of narcissistic defenses, authentic work with traumatic memories, their meaning to the client and their associated affects can begin. Such work must run in tandem with continued awareness that the survivor may need to fall back on familiar defenses such as contempt for and avoidance of the therapist. The ultimate goal of treatment is to help the client to make meaning out of the traumatic past in whatever way provides the survivor with a sense of dignity and life purpose.

REFERENCES

1. Kernberg. O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.

2. Kohut, H. (1970). The analysis of the self. New York: International Universities Press.

3. Kohut, H. (1977). The restoration of the self. New York: International Universities Press.

4 .Goldstein, W. (1985). An introduction to borderline conditions. New York: Jason Aronson.

5. Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.

6. Davies, J.M., and Frawley, M.G. (1994). Treating the adult survivor of childhood sexual abuse. New York: Basic Books.

I would like to thank Betta van der Kolk who helped me clairfy my ideas and who served as an able discussant when these ideas were presented at the Tenth Annual Meeting of the International Society for Traumatic Stress Studies, Chicago, 1994.

Rosemary Masters, C.S.W., teaches and supervises in the Family Division of the Institute for Contemporary Psychotherapy in New York City. In her private practice, she specializes in the treatment of eating disorder and PTSD.

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