In treating patients with narcissistic personality disorder, the therapist’s overarching goal is to help them learn how to get their core emotional needs met, both in therapy and in the outside world. The goal is to help the Lonely Child. Stated in terms of modes, the goal of treatment is to help the patient incorporate the Healthy Adult mode, modeled on the therapist, in order to recognize and nurture the Lonely Child, help the Lonely Child give and receive love, and reassure, and gradually replace, the Detached Self-Soother and the Self-Aggrandizer modes. In order to do this, the therapist must explore what patients do in their intimate relationships to cause their own core needs and their partner’s core needs to go unmet. The patient’s intimate relationships are a thus central focus of treatment.
We describe some characteristics often displayed by patients with narcissistic personality disorder in intimate relationships. Individual patients may have some or all of these characteristics.
Genuine love is so foreign to patients with narcissistic personality disorder that they are unable to absorb it. When someone tries to express empathy or nurture them, they simply cannot take it in. They can take in approval, they can take in admiration, they can take in attention, but they cannot take in love. This inability to absorb love perpetuates their Emotional Deprivation and Defectiveness schemas.
In even the patient’s most intimate relationships with romantic partners and spouses, admiration becomes the substitute for genuine love. This is one of the primary reasons that patients with narcissistic personality disorder are often so unhappy: Their core needs for love are not met, even in their most intimate relationships.
Many of these patients select partners who are themselves emotionally distant and have difficulty giving love. This is schema perpetuation—they are drawn to partners who are like the parent who emotionally deprived them. They feel comfortable not being loved and are willing to tolerate it (usually because they are unaware of what they are missing). Other patients select partners who are warm and giving and proceed to take everything and give nothing back. These patients do not set limits on how much they take; if the partner does not set limits, they will take endlessly, without reciprocating.
Largely because of the deprivation of empathy that they endured as children, many patients are unempathic, especially toward the people who are closest to them. Because they received so little empathy themselves, they do not know how to feel or express empathy for significant others.
Interestingly, when these patients are in the Lonely Child mode, they can often be quite empathic. It is when they are in the other two modes—the Self-Aggrandizer and the Detached Self-Soother—that these patients are most unempathic. It seems that most patients are capable of empathy but that when they are overcompensating for or avoiding their underlying schemas, they lose their capacity for empathy. Thus patients with narcissistic personality disorder often present a mixed picture in regard to empathy. For example, a father with narcissistic personality disorder might watch a movie about an unloved child and become very emotional. The father might even cry. Yet that same father might treat his own child the same way the child in the movie was treated and have little or no empathy. When he watches the child in the movie, the father switches into the Lonely Child mode and can empathize; but when he is with his own child, he switches into the Self-Aggrandizer mode and cannot empathize. What he is able to do in one mode, he is unable to do in another.
Patients with narcissistic personality disorder frequently feel envious of others whom they perceive as one-up in some way. The reason for this envy is that when someone else gets approval, these patients feel as if something has been taken away from them. They feel that there is not enough nurturance, attention, or admiration to go around. If someone else gets some, then they feel as if there is less left for them. They switch into the Lonely Child mode and feel cheated, unloved, deprived, and envious. Either they become depressed or more likely they mobilize and do something to restore their position as the center of attention. That is, they flip into the Self-Aggrandizing mode.
Patients with narcissistic personality disorder often idealize their love objects in the initial stages of the relationship as a compensation for their Defectiveness schemas. They see the love object as perfect because, by gaining the approval of a perfect partner, they feel their own value has been heightened. In this stage, patients are hypersensitive to signs of criticism or rejection from their partner. They will often go overboard and do almost anything to win over the object of their affection.
These patients often select partners who make them look good—who are attractive and whom other people admire. At first they idealize and adore this partner. However, as time goes on, they begin to devalue the partner, spotting every little flaw and imperfection. Patients almost always display this pattern of devaluing their partners over time. There are a number of reasons for this. One reason is schema perpetuation: Every flaw in the partner triggers their own sense of defectiveness. To avoid feeling this defectiveness, they compensate by feeling superior to their partners. Patients devalue their partners in order to boost their own self-esteem. They make themselves feel better by putting the partner below them. They also devalue their partners because they can maintain control over the partners by keeping them in a lower position. Devaluing the partner makes it less likely that the partner will feel worthwhile enough to look for someone better and thus leave the patient. Each time one of the partner’s imperfections is exposed, the patient becomes critical or contemptuous. Some patients become sadistic and humiliate their partners. Eventually they diminish the partners until the partners have little or no value to them. At this point the partners are no longer valuable as a source of approval.
If the partner responds to this treatment by trying harder to please the patient—as often happens—the strategy usually backfires. The more the partner tries to please the patient, the more the patient devalues the partner. The more the partner tries to appease, empathize with, or make excuses for the patient, the more devalued the partner becomes. In general, patients with narcissistic personality disorder only respect people who stand up to them and fight back. The more the partner fights back, the more the patient will value the partner, and the more the patient will value the partner’s approval.
These patients’ Entitlement schema is usually a direct result of having been indulged as a child by one parent. It also serves as an additional source of validation. The patient reasons, “If I’m treated as special by my partner, then I have value. The more special I’m treated, the more value I have.” Patients demand that almost every aspect of the relationship serve to satisfy them. They attempt to exert control over the environment and over the partners’ behavior in order to gratify their own needs and desires (just as a parent often did to them in childhood).
As these patients devalue their partners over time, they begin to distance from their partners and become more involved in solitary self-soothing behaviors. As the partners lose the capacity to serve the aggrandizing function, these patients increasingly isolate themselves from their partners by flipping into the Detached Self-Soother mode. To avoid the pain of the Lonely Child mode, patients turn to solitary addictions, compulsive behaviors, or stimulation-seeking rather than turning to their partners.