There are several methods for assessing narcissism. The therapist can observe the following: (1) the patient’s behavior in therapy sessions; (2) the nature of the patient’s presenting problem and history; (3) the patient’s response to imagery exercises and questions about childhood (including the Young Parenting Inventory); and (4) the patient’s Young Schema Questionnaire.
What are some early signs in therapy that a patient is narcissistic? In the beginning of treatment the most likely signs are behaviors that demonstrate entitlement. The patient cancels sessions at the last minute or comes late (yet expects a full session); asks detailed questions about the therapist’s credentials to determine if he or she is “good enough”; tries to impress the therapist by mentioning achievements or talents; expects the therapist to return phone calls immediately; frequently makes unreasonable scheduling demands; complains about conditions in the therapist’s office; requests special treatment; views the therapist as perfect (only to later devalue the therapist); interrupts the therapist when the therapist is talking or otherwise fails to listen to the therapist; constantly corrects the therapist about minor points; or refuses to adhere to the limits that the therapist has set.
Another early sign that a patient is narcissistic is a propensity to blame others. Rather than taking responsibility these patients tend to blame other people as they discuss their own problems. As treatment progresses, the therapist sometimes becomes one of the targets of the patient’s blame.
A final sign is that the patient appears to lack empathy especially for significant others, including the therapist.
Often the presenting problem and history provide clues that the patient is narcissistic. One common reason that these patients enter treatment is that they are facing a crisis in their personal or professional lives because someone important to them—a lover, spouse, best friend, child, sibling, boss, business partner—is rejecting them or retaliating against them as a result of their own self-centered behavior. (There is a significant risk that, once the crisis resolves, the patient will prematurely leave treatment.)
Sometimes these patients come to treatment because someone is forcing them. Their partners or other family members are threatening to end the relationship unless they seek treatment. Their bosses have demanded that they either seek treatment or leave their jobs. Perhaps the criminal justice system has ordered them into treatment because they have done something illegal, such as driving while intoxicated. They have come to treatment against their will and do not believe their problems are their own fault. They frequently believe that it is other people who should change.
Another reason these patients may seek treatment is a sense of emptiness. Even though they have the outward trappings of success, their lives frequently lack a sense of inner meaning. At the center of their lives, there is a void: the unmet emotional needs of the Lonely Child. Although these patients may seem to have everything, their lives lack both intimate connections to others and true self-expression.
We are the hollow men
We are the stuffed men
Leaning together
Headpiece filled with straw. Alas!
Our dried voices, when
We whisper together
Are quiet and meaningless
As wind in dry grass
Or rats’ feet over broken glass
In our dry cellar.
—T. S. ELIOT, “The Hollow Men”
Some patients with narcissistic personality disorder come to treatment at moments of failure in their personal or professional lives. They have failed in some area of their lives that has served as an overcompensation, and they are now experiencing the underlying feelings of humiliation and despondency. They come for help rebuilding their overcompensations and become irritated whenever the therapist deviates from this function. (This is an important point: We do not believe that therapists should support the patient’s narcissistic compensations. To do so means allying with the patient’s Self-Aggrandizing mode, rather than the Lonely Child or Healthy Adult modes).
Some patients come to treatment because of problems arising from their Detached Self-Soother mode. They are gambling, abusing substances, acting out sexually in ways they later regret, or otherwise engaging in impulsive or compulsive behaviors that are self-destructive.
Finally, dissatisfaction with their marriages is another reason these patients come to therapy. For example, they might come to decide whether to leave a spouse for another person with whom they are having an affair.
Unless they are presenting “perfect” childhood memories, patients with narcissistic personality disorder are generally unable to accurately answer questions that explore deeper themes in their childhoods. They willingly discuss pleasant childhood memories, but they are unaware of painful childhood memories. These patients are usually opposed to doing imagery exercises of childhood involving any painful affect (other than anger). They resist becoming vulnerable and switching into the Lonely Child mode.
Some patients—probably those with a better prognosis—are more willing to acknowledge the existence of the Lonely Child early in therapy. They are more willing to discuss painful childhood memories and to do imagery exercises. And when they generate childhood images, healthier patients can express and experience their feelings of loneliness or shame.
We have found a consistent profile for patients with narcissistic personality disorder on the Young Schema Questionnaire. They typically score high on Entitlement, Unrelenting Standards, and Insufficient Self-Control and low on almost everything else. This profile is a testament to these patients’ powers of overcompensation and avoidance. They are largely unaware of their core Emotional Deprivation and Defectiveness schemas, as well as their other schemas.
Interestingly, these patients are often able to identify many negative aspects of their parents’ treatment of them as children on the Young Parenting Inventory. Even though they are unaware of their schemas, they are frequently able to report on the inventory what their parents did that was damaging to them. Patients with narcissistic personality disorder predictably score high on the Young Compensation Inventory, as they have a large number of compensatory behaviors.