Carl is a 37-year-old patient with a diagnosis of narcissistic personality disorder. He first entered therapy with a schema therapist named Leah at the age of 36. We present segments of a consultation Dr. Young conducted with Carl that occurred approximately 1 year into Carl’s therapy with Leah. Leah had requested this consultation with Dr. Young because she felt stuck in her therapy with Carl.
In the first segment, Dr. Young and Leah discuss the patient. (All other segments are from Dr. Young’s session with the patient.) As the segment begins, Leah is describing how Carl presented when he first came to treatment and what it was like to work with him.
LEAH: Carl was very challenging. I did not believe that he would sustain therapy beyond a couple of sessions. I thought he would perhaps “try me out.”
He could push my buttons almost the minute he walked through the door. He would never say my name, he was not one who would respond to nor initiate a greeting of any kind. He’d drop his jacket on the floor and sort of slump into the chair and say things like, “Did you practice those words to impress me this session? You want me to think you’re smart, don’t you?” So he would use very condescending language, and his very esoteric nature came right across, almost deliberately, to try to challenge me.
It felt like a game. It felt like a game from the very beginning.
DR. YOUNG: And what did that make you feel when you could see that he was making it like a game, challenging you, trying to beat you?
LEAH: Angry. I’d feel angry at him, that he was setting me up. My own schemas came up—and the temptation to want to play the game, and to win.
These are some of the typical feelings therapists experience when working with patients with narcissistic personality disorder. However, therapists should not make the mistake of trying to compete with or impress the patient. Such behavior only reinforces the patient’s narcissism and prompts the patient to devalue the therapist over time.
After meeting with Leah, Dr. Young began his consultation with Carl. In the next segment, Carl tells Dr. Young his reasons for entering treatment. He is experiencing serious problems in both his marriage and his work life.
CARL: I’m 37 years old, I’m married, with two children. I grew up in Los Angeles, and I’m currently between careers.
DR. YOUNG: And are you planning to start a second career, or are you just enjoying not having one right now?
CARL: I’m certainly enjoying not having a career, and I may start a second career. This is part of what I’m doing now, trying to figure out what to do.
DR. YOUNG: I see. And what’s your wife’s name?
CARL: Danielle. We’ve been married about 9 years.
DR. YOUNG: Can you tell me what your current goals in therapy are? At this particular point, why do you think you’re in treatment?
CARL: Well, right now I would say that I haven’t yet been able to demonstrate any mastery whatsoever of what, in broad terms, I would call impulse control. In practical terms, I like to stay up all night and sleep during the day, in spite of the fact that I have an idea that this might not be the best way, because it interferes in a lot of ways with my life. And so far I have been completely unable to make any meaningful progress in changing it.
DR. YOUNG: And are there any other goals you want to accomplish in therapy besides mastering this impulse control issue?
CARL: Well, that’s the tangible goal. I think that I still recognize the need to continue working to discover how to be a person, and how to get along with people.
DR. YOUNG: And you feel that’s something that’s difficult for you? In what way is it difficult for you to get along with people?
CARL: Well, I consider myself a little bit different, unusual, or—there was one person who referred to me as a maverick; I don’t know if that’s really accurate. You can call me a maverick, or a nerd, or your typical maladjusted, self-centered kind of intellectual. (Laughs.)
DR. YOUNG: When you think about being different, does it seem like it’s different and better, or different and worse, or different and comparable to other people?
CARL: Well, different and different, but also different and better. But in some contexts, different and worse.
DR. YOUNG: You also mentioned on one of your forms a “paralysis of the will.” Is that still an issue, and what does that mean to you?
CARL: Well, at the time it meant that I was incapable of carrying out even the slightest act that was different from my daily routine, such as make a phone call, schedule an appointment to see a psychotherapist. I determined nearly 2 years ago that I really felt I needed help, and I didn’t make a phone call about it for about 6 months.
DR. YOUNG: Because of the same paralysis.
CARL: Yeah.
DR. YOUNG: Do you have a sense now of what the paralysis was caused by, what it was about?
CARL: Well, I’m really not sure. It seems to be kind of a funk, kind of a state of depression.
It is noteworthy that Carl’s tone of voice and manner of relating to the therapist are somewhat arrogant. He spoke as though he and Dr. Young were on an equal footing, not like a patient coming for help. He was detached in his manner, and his description of his problems was somewhat self-aggrandizing. An arrogant tone and manner are often the first clue that a patient is narcissistic.
Carl describes several reasons for seeking treatment. The first is his lack of impulse control. This is his Insufficient Self-Control/Self-Discipline schema, and it is part of the Self-Aggrandizer mode. He cannot place limits on his own behavior. The second reason is his difficulty relating to other people. This is a common problem among patients with narcissistic personality disorder—Carl is at least aware of this difficulty, unlike many other patients. The third reason is his “paralysis of the will”—the depression he feels when he is not getting enough stimulation or approval. Note that Carl does not understand this symptom, although he is aware that he is depressed. Later, the interviewer will try to connect his depression to his Lonely Child mode.
In the next segment, Carl discusses the reasons he is having trouble getting along with people. He begins by explaining why he thinks people might find him boring. The segment shows he has some insight into his behavior.
DR. YOUNG: Why do you think people would see you as boring?
CARL: Well, if I had to guess, I would say I’m the kind of person who starts every sentence with the word “I” (laughs).
DR. YOUNG: So you’re boring because you’re self-absorbed? That’s what you’re saying?
CARL: Yes. I think so.
DR. YOUNG: And do you have any sense of why you’re self-absorbed? Why do you think you are so focused on yourself during conversations?
CARL: Oh, well, do you want me to talk to you about my mother? (Laughs sarcastically.)
DR. YOUNG: (Laughs also.) No, I wasn’t thinking so much historically, more just at a gut level. What do you think that it is inside of you that keeps the focus on you, particularly when you now seem to have an awareness that this might turn some people off?
CARL: Well, that’s the point, I don’t really have the awareness. I don’t go into a social interaction with the kind of mindfulness that theoretically one would think that one would be capable of. That’s very hard for me. And it’s not just a self-absorption, I think there’s a kind of shyness or fear.
Carl has the capacity to recognize that he is too self-centered in social situations, but only when he is in the mode he is in at this point in the interview. This is a detached mode. Getting him out of this detached mode is the focus of the interview. When Carl is actually in social situations, his Self-Aggrandizer mode is dominant, and he loses his awareness that he is too self-centered.
Carl shows some awareness of the shyness that is underneath his Self-Aggrandizer mode, which is a good prognostic sign. However, he seems blasé about the fact that he is self-centered—he does not appear to be troubled by it. This is typical of patients with narcissistic personality disorder. Even when they show some insight into their self-centered behavior, they do not seem particularly disturbed by it. In their belle indifference, they are not upset to discover that they have alienated other people or been unfair.
In this next segment, Carl describes his feelings toward his wife. He exhibits the devaluing of the partner that we mentioned earlier as characteristic of patients with narcissistic personality disorder at later stages of relationships.
DR. YOUNG: How about with your wife? How do you feel with her? One of the things you said on here (points to questionnaires) was that one of your wishes would be to “trade in your wife.”
CARL: Yes.
DR. YOUNG: So there must be some negative feelings about the relationship, some disappointment….
CARL: She’s doing a little better now. We’re doing a little better. I’ve more or less moved past that.
DR. YOUNG: What was the disappointment in her? In what ways was she disappointing?
CARL: Well, she was disappointing in her level of integrity, her level of commitment to truth, her level of commitment to self-awareness, and her intellectual capacity.
As one might deduce from the unsympathetic way that criticisms of his wife roll off his tongue here, Carl’s narcissism is not fully healed yet.
In the next segment, Carl describes his wife’s self-absorption. The segment shows that, even though he denigrates her, he still has some insight into her realistic limitations.
DR. YOUNG: How do you treat Danielle?
CARL: Well, sometimes I’ve been in the past very cold, very distant. Sometimes she doesn’t even notice it. In her own way she’s more self-absorbed than I am. She’ll obsess on her problems to the extent that she really blocks out the world, and, if I have trouble getting in touch with my emotions, I would say that she has more trouble getting in touch with her emotions.
DR. YOUNG: What drew you to her in the first place?
CARL: Well, originally I saw this kind of kindred spirit, because I think that we have a lot of things in common in terms of our dysfunctionality
As often happens with patients with narcissistic personality disorder, Carl chose a woman to marry who reinforced his childhood sense of emotional deprivation.