It is important to distinguish the narcissistic personality we are describing from pure entitlement—that is, from cases in which the person has the Entitlement schema in its pure form, without the underlying Emotional Deprivation and Defectiveness schemas.
The Entitlement schema can develop in two ways. In the pure form, the child is simply spoiled. The parents set too few limits and do not require the child to respect the feelings and rights of others. The child fails to learn the principle of reciprocity in relationships. However, the child is neither emotionally deprived nor rejected, so the Entitlement schema is not compensatory.
Alternatively, the Entitlement schema can develop as an overcompensation for feelings of emotional deprivation and defectiveness. Unlike the “spoiled” patients who display pure Entitlement schemas, these are the “fragile” patients. Their sense of entitlement is fragile because underneath they know what it is like to be ignored and devalued. There is always the risk that their compensations could fall down around them, leaving them vulnerable and exposed.
Like the “spoiled” patients, “fragile” patients with narcissistic personality disorder also behave in demanding and superior ways. However, patients with pure Entitlement schemas do not have a Lonely Child mode at the core. Deep inside there is no sad, lost, vulnerable, defective child. At the core of the pure “spoiled” patient is an impulsive, undisciplined child. Although spoiled patients and fragile patients with narcissistic personality disorder might look similar from the outside, their inner worlds are very different.
Actually, most patients with narcissistic personality disorder that we treat show a combination of spoiled and fragile entitlement. Their sense of entitlement is partially learned and partially compensatory—in part they were spoiled and indulged as children, and in part the entitlement is a way of making up for underlying feelings of emotional deprivation and defectiveness. Therefore, most patients need some combination of limit-setting and mode work. However, most patients with narcissistic personality disorder who seek treatment have a significant fragile component; they have come in because one of their overcompensations has collapsed and they are depressed. Most of these patients require the major focus of treatment to be mode work. Limit-setting is part of treatment, but it is not a primary part.
When experts on narcissism write about patients with narcissistic personality disorder, typically they are referring to more fragile, compensated patients rather than to those who have pure Entitlement schemas. We address this chapter to the treatment of fragile patients. There is no point in doing the mode work we describe in this chapter with patients who have pure Entitlement schemas because there are no maladaptive underlying modes to reach. There is just the Entitlement schema, and the therapist’s role is to teach the patient proper limits and reciprocity. (This can be done with a simpler form of mode work: conducting dialogues between the “Spoiled Child” and the “Healthy Adult.”)