The primary goal of treatment is to build up the patient’s Healthy Adult mode, modeled on the therapist, capable of reparenting the Lonely Child and fighting the Self-Aggrandizer and the Detached Self-Soother modes. The goal is increased vulnerability with less overcompensation and less avoidance.
More specifically, the goal of treatment is to help construct a Healthy Adult mode to:
Help the Lonely Child to feel nurtured and understood, and to nurture and empathize with others.
Confront the Self-Aggrandizer so that the patient gives up the excessive need for approval and treats others based on reciprocity, as the Lonely Child takes in more genuine love.
Help the Detached Self-Soother give up maladaptive addictive and avoidant behaviors and replace them with genuine love, self-expression, and experiencing of affect.
The therapist helps the patient establish authentic intimate relationships, first with the therapist and then with appropriate significant others. As the Lonely Child takes in more love and empathy, the patient no longer has to substitute applause or numbness for love and no longer has to act in a demeaning or self-centered manner with others. Both the Self-Aggrandizer and the Detached Self-Soother modes weaken and gradually fade.
The primary focus of treatment, therefore, is the patient’s intimate relationships—both the therapy relationship and the patient’s other significant relationships. As with our treatment of the patient with BPD, the primary strategy is mode work.
We present the elements of the treatment roughly in the order in which we introduce them to the patient.
The therapist strives to keep patients in touch with their emotional suffering because as soon as the suffering is gone, they are likely to leave treatment. The more the therapist keeps patients aware of their inner emptiness, feelings of defectiveness, and loneliness, the more the therapist has leverage for keeping them in treatment. If the patient comes into treatment in a state of emotional distress, this state can serve as leverage to keep the patient motivated to stay in treatment and try to change. The therapist also focuses on the negative consequences of the patient’s narcissism, such as rejection by loved ones or setbacks in one’s career.
Most patients with narcissistic personality disorder do not come to treatment with the goal of working on their underlying feelings of emotional deprivation and defectiveness. Rather, their goal is to get back some source of approval they have lost or to rid themselves of some negative consequence of their self-aggrandizing or self-soothing behaviors. They come for help bolstering their Self-Aggrandizer and Detached Self-Soothing modes. Once it becomes clear that the therapist will not serve the interests of these two modes, some patients become angry and decide to leave treatment. However, if the therapist can keep these patients aware of their emotional suffering and of the inevitable life losses and negative consequences if they do not change, then these can be reasons to stay. The emotional connection to the therapist and fear of reprisal from others are the main motivators for continuing in therapy. If the therapist can keep the patient in the Lonely Child mode and nurture the patient, then the patient is likely to stay in treatment, even though, in the other modes, the patient does not want to stay.
Within the therapy relationship, the therapist tries to create a place in which the patient feels cared about and valued, without having to be perfect or special, and in which the patient cares about and values the therapist, without the therapist having to be perfect or special. The therapist establishes a bond with the Lonely Child. The therapist values the patient for expressing vulnerability and gives the patient “unconditional positive regard” (Rogers, 1951).
Patients with narcissistic personality disorder often do not know that they have trouble experiencing intimacy. They may never have experienced true intimacy. Through the therapy relationship, they begin to realize how difficult it is for them to get emotionally close to other human beings. The therapist reframes the goal of therapy as helping patients to stay in the Lonely Child mode and try to get their basic emotional needs met. In contrast to the parent, who was there for the Self-Aggrandizer, the therapist is there for the Lonely Child. The therapist helps the patient tolerate the pain of being in the Lonely Child mode without switching into one of the other modes. The therapist nurtures the patient in the Lonely Child mode, promoting schema healing. Through “limited reparenting,” the therapist provides a partial antidote to the patient’s Emotional Deprivation and Defectiveness schemas, as well as to the patient’s other schemas.
The therapist confronts the patient’s approval-seeking behavior without devaluing the patient. The therapist always gives the same message: “It’s you I care about, not your performance or appearance.” Similarly, the therapist confronts the patient’s entitled behavior without devaluing the patient. Emphasizing the principle of reciprocity, the therapist sets limits. The therapist gives the message: “I care about you, but I also care about myself and others. We all deserve caring equally.”
When the patient becomes inappropriately angry at the therapist, the therapist empathically confronts the patient. The therapist expresses sympathy and understanding of the patient’s point of view but corrects any of the patient’s distorted ideas that the therapist is selfish, depriving, devaluing, or controlling. If the patient notes a valid criticism, but in a demeaning way, then the therapist asserts the right to be valued nonetheless. The therapist gives the message, “We all deserve caring, even when we are imperfect.” The therapist points out how the devaluing behavior makes the therapist feel and what its impact would be on other people outside therapy. The therapist also helps the patient rise above the incident in order to understand in mode terms, why the patient is engaging in the behavior.
Sooner or later, most patients with narcissistic personality disorder begin to treat their therapists the same way they treat everybody else—in a condescending or challenging manner. The patient begins to devalue the therapist. It is important for the therapist to stand up to the patient when this happens, or else the therapist will lose the patient’s respect.
Confronting these patients is often difficult for therapists, especially because, in our experience, so many therapists have Self-Sacrifice or Subjugation schemas. These schemas tend to make assertiveness in the face of narcissism a formidable task. If these patients resemble one of the therapist’s parents in an important way—for example, if they are demanding, critical, or controlling—then the therapist is at risk of resuming maladaptive childhood coping behaviors rather than doing what is best for the patient. For example, therapists may give in to unreasonable requests or tolerate entitled behavior.
Therapists must be alert to the activation of their own schemas in their treatment of patients with narcissistic personality disorder. The triggering of the therapist’s schemas can lead to counterproductive responses, such as retaliating or competing, that damage rather than help patients. Therapists with Self-Sacrifice or Subjugation schemas generally had a parent who was cold, needy, or controlling, so that the behaviors of patients with narcissistic personality disorder often replicate what that parent did that was hurtful when they were children. These therapists are thus at risk to revert to their childhood coping strategies with these patients, rather than reparenting the patient.
It is important that the therapist stand up to the patient, but through empathic confrontation. The therapist can make statements such as the following:
“I know that you don’t mean to hurt me, but, when you speak to me that way, it feels like you’re trying to hurt me.”
“When you talk to me in that tone of voice, I feel distant from you, even though I know you’re upset and need me to be here for you.”
“When you speak to me in such a demeaning way, it causes me to pull away from you, and makes it harder for me to give you what you need.”
“Even though underneath you want to be close to people, if you speak that way to them, they are not going to want to be close to you.”
The therapist points out the patient’s devaluing behavior, showing understanding of why the patient is behaving in this manner, yet still letting the patient know the negative consequences of the behavior in relationships—with the therapist and with other people in the patient’s life.
In the following segment, Dr. Young begins to confront Carl’s Self-Aggrandizing and Detached Self-Soother modes. In the context of a discussion about Carl’s early relationship with his wife Danielle, Dr. Young points out that Carl is behaving in a devaluing way toward him.
DR. YOUNG: What did Danielle look like at that time? Was she beautiful? Was she your ideal?
CARL: She was beautiful. But don’t forget, I was drunk, I was sitting down, she was sitting down (laughs). I always tell the joke that I would never have fallen in love with someone so short, except I was drunk and we were sitting down.
She had the right body type, she had the right hair color.
DR. YOUNG: So she met all these objective criteria.
CARL: (annoyed) They’re not objective criteria. These are the felt, somewhat ineffable criteria that we have, that we don’t know where they come from.
DR. YOUNG: But she seemed to fit all these things that intuitively connect you …
CARL: (Interrupts.) Well, she fit close enough. And she was interested in me, and I was ready. I mean, there’s a confluence of factors here.
DR. YOUNG: (pause) One thing that it feels like as we talk, Carl, is that when I say something that is slightly off base, maybe like one degree off base from what you feel, you pick up on it and sort of fight back as if we were in an argument. Do you know what I mean? Rather than saying, “Yeah, you’re right, that’s right, but it’s not quite it,” you say, “That’s completely off.”
CARL: (annoyed) I don’t see it as one degree off. I wouldn’t say one degree off, but I would say five degrees off—I see it as being different. I’m very picky that way, aren’t I?
The therapist confronts Carl gently, then Carl responds in a challenging manner. The therapist continues to speak empathically while Carl continues to devalue the therapist’s observations. However, this does not deter the therapist, who continues to confront Carl without becoming angry or punitive toward him; instead, the therapist repeatedly points out the consequences of Carl’s behavior in his relationships with the therapist and with other people in his life. The therapist tries to rise above the immediate incident, calmly observe the patient, express empathy, and provide objective feedback and education.
DR. YOUNG: What is the effect on the other person you’re talking to of your doing that, of your making those corrections?
CARL: I don’t know (laughs softly).
DR. YOUNG: What would you guess? You mentioned that you’re a sensitive person …
CARL: (Interrupts.) I’m sensitive normally to how people are reacting. Right now, it seems to bother you. It seems to make you upset, that kind of correction.
DR. YOUNG: Well, I think it would upset other people to be corrected every time they said something. I’m a psychologist, and I understand that, with the kind of issues you have, being perfectionistic and getting everything right on target is very important, so I’m able to say, “Well, from his perspective, the task of getting everything right is crucial and important.”
CARL: (Interrupts.) It only seems to be crucial or important to me in a conversation.
DR. YOUNG: Yes, but what I’m saying is, with somebody who isn’t a psychologist trying to understand your makeup, if you do the same thing, the person is going to experience it, I think, as a kind of criticism, that what they said was not intelligent enough, it wasn’t living up to your expectations for a conversation.
CARL: Or as an unnecessary addendum to a subject that requires no more continuation.
DR. YOUNG: Yes, but I’m not so concerned about that as the part where their feelings are hurt, though.
Carl tries to shift the focus away from the idea of hurting other people: He tries to keep the discussion at an intellectual level and to justify what he is doing as not very serious. However, the therapist does not allow him to get away with this. The therapist keeps gently but firmly reasserting that Carl’s behavior is hurtful to others. In the next segment, Carl begins to demonstrate some insight into his behavior in the session.
CARL: So what you’re pointing out to me, which I think is a useful observation, is that I have a tendency to contextualize all interactions as this kind of game—you could call it a game—where the object is a kind of intellectualization. So it’s a very narrow context for whatever interaction is going on.
DR. YOUNG: What it does is that it has the effect of cutting off feelings. Whatever feelings I’m having about you, or that you might be having about me, sort of get lost in the verbiage. It’s sort of like reading a book that is so much about the words that there’s not enough emotion.
CARL: Perhaps it’s my pattern. Perhaps it’s my pattern to cut off the emotion.
Carl acknowledges the truth of what the therapist is saying—that he intellectualizes and criticizes to avoid his feelings—which is a sign of progress on his part. However, he soon goes back to deriding the therapist. Dr. Young brings up Carl’s current therapist, Leah.
DR. YOUNG: One of the things Leah had mentioned was this “dance of domination”—that’s one of your themes.
CARL: (Laughs mockingly.) I thought it was just something you picked up on. I don’t know if it’s one of my themes. It’s a catchy phrase.
DR. YOUNG: Yes, she mentioned it, but it seems like it might be relevant in this context. It might be that in intellectual conversations, there’s a subtext of two people competing on an intellectual level to see who’s smarter, or to see who is more precise.
CARL: (challenging) Yeah, yeah. And if you’ll notice, that it takes two to tango.
DR. YOUNG: (in disbelief) And you’re saying that I enjoyed it, too?
This kind of jousting back and forth is intrinsic to the treatment of patients with narcissistic personality disorder. The patient keeps debating with or devaluing the therapist, and the therapist keeps responding by pointing out the effects of this behavior, both on the therapist and on other important people in the patient’s life.
As the interview between the therapist and Carl progresses, Carl gradually begins to acknowledge the truth of what the therapist is saying. Even though there is a part of Carl that keeps fighting the therapist—the self-aggrandizing, detached mode that does not want to feel diminished and refuses to give up—there is also a healthy part of him that becomes more receptive to the therapist and more aware of what he is doing. It is the goal of treatment to help Carl elaborate this Healthy Adult mode.
The therapist is appropriately assertive with the patient each time the patient behaves in a devaluing manner. The therapist sets limits for the patient in the same way that a parent does for a child. Just as a good parent does not permit behaviors inside the home that would be unacceptable outside of the home—such as bullying or speaking in a demeaning manner—the therapist does not allow the patient to act toward the therapist in ways that would be unacceptable with people outside of therapy. The therapist sets limits when the patient misbehaves.
Here are some guidelines that therapists can follow when setting limits with patients with narcissistic personality disorder.
1. Therapists empathize with the narcissistic point of view and are tactful in confronting entitlement. The therapist empathizes with why it feels “right” for the patient with narcissistic personality disorder to act selfishly, while at the same time letting the patient know how this behavior affects others. The therapist must strike just the right balance between empathy and confrontation.
If the therapist does not express enough empathy, then the patient will feel misunderstood and denigrated and will not listen to what the therapist is saying. If the therapist does not confront the patient enough, then the patient will feel as though the therapist has given implicit permission for the entitled behavior.
2. Therapists neither defend themselves nor attack back when patients devalue them. The therapist does not get lost in the content of the patient’s attacks. The therapist rises above the specific content and does not take it personally, focusing not on the content but on the interpersonal aspects of the discussion. The therapist who argues about the content of what the patient is saying is usually making a mistake. As soon as the therapist becomes defensive or attacks back, then the therapist is playing the patient’s “game,” and the patient is controlling the session. Rather, the therapist stays focused on the process of what is happening—that the patient is devaluing the therapist to avoid his own emotions—and keeps empathically confronting the patient about the consequences of this behavior.
3. Therapists assert their rights nonpunitively. When patients violate the therapist’s rights, the therapist, again using empathic confrontation, points it out. The therapist says something like: “I know that you’re probably not intending to hurt me, and deep down what you’re feeling is misunderstood, but I’m not comfortable with the way you’re speaking to me right now.”
4. Therapists do not let themselves be bullied by patients into doing things they do not want to do. Rather, therapists set clear limits based on what feels comfortable and fair to them, regardless of the pressures the patient brings to bear. For example, therapists do not allow patients to persuade them to constantly reschedule, run over the session time, analyze potential lovers or rivals to help patients manipulate them or win power struggles, or otherwise exceed the boundaries of the therapeutic relationship. In addition, therapists do not try to bully their patients back.
5. Therapists establish that the therapy relationship is mutual, based on reciprocity, not on a master—slave principle. When the patient treats the therapist in an entitled way, the therapist points it out. The therapist says something like: “I know you’re afraid and you need me to help you right now, but I feel like you’re treating me like a servant, and that’s pushing me away” or “You’re treating me disrespectfully, and it’s making it hard for me to be there for you in the way I want to be there, since I know you’re suffering underneath.”
Often the patient will respond, “I’m paying you.” The therapist can respond: “You’re paying for my time, not for the right to treat me disrespectfully.” The therapist communicates that the only acceptable terms for the relationship are those of equals. The fact that the patient is paying the therapist does not entitle the patient to mistreat the therapist, nor does it obligate the therapist to fulfill all of the patient’s demands.
6. Therapists look for evidence of underlying vulnerability and point it out each time it occurs. The therapist looks for the Lonely Child in the patient and draws the patient’s attention to the mode whenever it surfaces. Such signs include expressions of anxiety, sadness, or shame; admissions of weakness; and acknowledgment of unmet needs. The therapist encourages the patient to stay in the Lonely Child mode as much as possible and reparents the patient.
7. Therapists rise above specific incidents and ask the patient to explore the motivation behind entitled, self-aggrandizing, devaluing, or avoidant state-merits. Therapists do not get caught up in the content of arguments. Rather, they address the way the patient is behaving and the effect this behavior has on other people. The therapist realizes that the patient is feeling vulnerable underneath. When patients behave in a devaluing manner, many times they are trying to make the therapist feel the way the therapist made them feel, and the content of the argument reveals more about how the patient felt denigrated than about the patient’s perceptions of the therapist’s flaws.
To avoid sounding accusatory, the therapist asks questions. The therapist says, “Why are you doing this right now? Why are you being condescending? Why are you pushing me away? Why don’t you want to talk about this? Why are you angry with me?”
Often patients with narcissistic personality disorder are very bright and are able to outsmart the therapist and win arguments. However, even when they are winning arguments, they are still wrong if they are treating the therapist in a devaluing or uncaring way. They may not be wrong in the content of the argument, but they are certainly wrong in the process and style. By rising above incidents, the therapist can avoid most arguments.
8. Therapists look for common narcissistic themes and point them out to the patient. Examples of common narcissistic themes are (a) condescending, one-up, competitive behavior; (b) judgmental, critical, and evaluative comments, positive or negative; and (c) status-seeking statements or those that reflect an emphasis on external appearances or performance instead of internal qualities such as love and fulfillment.
Once again, in order to be supportive rather than critical, the therapist can point out the themes in the form of questions. The therapist says: “Why do you think you might be acting in a condescending way right now?” or “Why are you pushing me away?” or “Why do you think it’s so important for you to tell me about your achievements?”
9. Therapists label statements that seem to represent the Self-Aggrandizing or Detached Self-Soother modes. This helps patients learn to recognize their modes when they are in them. When patients are in the Self-Aggrandizing mode or the Detached Self-Soother mode the therapist draws the patient’s attention to the mode, and helps the patient to recognize emotionally the experience of being in the mode.
One of the best ways therapists can show patients with narcissistic personality disorder that it is acceptable to be vulnerable is to be vulnerable themselves. Rather than appearing perfect, therapists acknowledge their vulnerability. Therapists model vulnerability: They acknowledge when their feelings are hurt and admit mistakes readily to the degree that would be appropriate in a close relationship. They are willing to be imperfect. Even if many of these patients view vulnerability as a sign of weakness, it is still important for the therapist to express appropriate vulnerability. We are not suggesting that therapists discuss intimate details of their personal lives; rather, we are suggesting that therapists share with patients the vulnerable feelings that naturally arise in the course of the therapy session. Generally, it is better for therapists to show more vulnerability as the sessions progress rather than toward the beginning of treatment. If therapists show too much vulnerability early on, the patient may misinterpret it to mean that the therapist is too weak to deal with the patient’s difficult behavior. The therapist has to come from a place of strength, having already demonstrated the ability to set limits. Thus what the therapist is trying to convey is really a subtle blend of confidence, strength, and vulnerability.
In the following segment, the therapist expresses vulnerability in order to encourage Carl to do the same. As the segment begins, the therapist is suggesting to Carl that his competitiveness (the “game”) is driven by underlying feelings of inadequacy of which he is largely unaware. That is, Carl is compensating for the feelings of the Lonely Child by flipping into the Self-Aggrandizing mode.
DR. YOUNG: Playing this game, what function does it serve for you? What is the underlying function of playing a game like this with someone?
CARL: (annoyed) I don’t know. It’s just a naturally stimulating way to be.
DR. YOUNG: It feels like there’s a deeper answer to that question.
CARL: Yes, what would be the purpose of playing that game in general? If I can think about a time when that’s the kind of game I would play, that would be the purpose. But if I look at specifically why I would start playing that game with you … (pause). If, in fact, it does detach me from the content of the interaction, then it is a way of me controlling the conversation, and shifting it away from perhaps the emotional content, which might be a little uncomfortable, to a sphere which is more comfortable.
DR. YOUNG: Yes, that feels right to me. That feels like what was happening. Do you have a sense of what you might be trying to steer away from that’s uncomfortable? What would it be like to not play that game at all, and to just be completely emotional with each other? You could share your emotional reactions about me, and I could share my emotional reactions about you. I could ask you questions about what you’re feeling at an emotional level, and you would just openly discuss it.
CARL: I think it would be difficult.
At this point, Carl is seeing his motivation accurately—to steer the conversation away from emotional topics that hold the potential to upset him. He chooses detachment and self-aggrandizement to avoid intimacy and the Lonely Child. These avoidant and compensatory modes keep the Lonely Child at bay. Carl has stopped devaluing the therapist. He is shifting into the Lonely Child mode for moments, and then shifting back.
The therapist then begins to address Carl’s Lonely Child mode more directly. The therapist refers to the fact that the interview is being videotaped and asks Carl about his feelings. Carl answers by denying any vulnerable feelings on his part. The therapist responds by expressing his own vulnerability.
DR. YOUNG: How do you feel being here with me, or being here in this situation being taped? Apart from the intellectual analysis of it, what’s your gut-level feeling about being in this situation?
CARL: I think that I’m able to ignore it.
DR. YOUNG: There is no emotional reaction or content?
CARL: (pause) On my part or on your part?
DR. YOUNG: Both parts. I certainly have an emotional reaction. Here I am, doing a videotape that people will be watching …
CARL: (Interrupts.) Well, you’re a lot more salient than I am, because I’m an anonymous patient more or less, and you are the person who is conducting this (chuckles). I won’t be judged by what’s going on here, you will be judged. That’s something that’s in your consciousness. It doesn’t have to be in my consciousness.
DR. YOUNG: Intellectually that makes sense, but somehow, at a gut level, I don’t believe it. I believe that anyone who’s in this situation would have an emotional response underneath.
CARL: (annoyed) Why don’t you talk about how you feel!
DR. YOUNG: Well, I think I did. I was saying: to me, I feel somewhat nervous because, here I am in a situation where I have high expectations for myself, the people watching will have high expectations, and there’s a real chance that I could make a mistake, it could go badly, and it would be embarrassing.
CARL: (Interrupts.) But don’t you see, there’s no chance I could make a mistake. I’m the patient. I can do and say whatever I want. (Laughs triumphantly.)
DR. YOUNG: I’m not saying you’re wrong, but are you sure that’s what you’re feeling underneath, that there’s no other level of anxiety or concern about how other people are viewing you?
CARL: Perhaps that’s hard for you to understand, because you would expect people to be self-conscious.
DR. YOUNG: Yes. Particularly you: You mentioned you had shyness.
CARL: Yes, but it so happens that I’m really not self-conscious.
Carl is in the Self-Aggrandizing mode, subtly putting the therapist down and simultaneously unaware of his own Vulnerable Child mode. The therapist persists, but it is too early for the patient to recognize what he is feeling underneath.
The therapist begins suggesting to the patient that inside of him there is a Lonely Child—a core part of the patient that feels vulnerable, frightened, inadequate, and lost. The therapist reinforces the patient’s vulnerability, while still pointing out the Self-Aggrandizer and Detached Self-Soother modes.
In the following segment, Dr. Young explores Carl’s relationship with his therapist, Leah, to see if Carl can acknowledge any feelings of vulnerability or emotional connection with her. Again, Carl shows the same difficulty acknowledging vulnerability.
DR. YOUNG: How do you feel when you’re in sessions with Leah, as opposed to this sort of situation? What’s your emotional feeling when you’re in session with her? Is it different, or is it the same as in here?
CARL: Well, I think that I try to bring whatever capacities that I’ve learned in my sessions with Leah, to try and be able to apply them here.
DR. YOUNG: No, I meant, when you’re in sessions with Leah, what emotions do you have? What emotions are going on in you when you’re in a session with Leah?
CARL: Well, I try to keep a detached mien, and be conscious of and mindful of the emotions as they arise.
DR. YOUNG: But there’s some sense of not wanting to get lost in emotions, not wanting to get too caught up in them?
CARL: Well, not necessarily. Sometimes I think I like to get caught up in my emotions and discover them and feel them.
DR. YOUNG: But why would you try to maintain a detached mien?
CARL: No, I think that the detached mien is just my natural state. That’s the natural state of Carl.
DR. YOUNG: Detached.
CARL: Yes.
DR. YOUNG: Then we’re back to that other explanation, that you’re detached in order to avoid certain emotional feelings that you don’t want to experience.
CARL: You’re asking now why I learned to become detached. I didn’t start being detached at the age of 37.
DR. YOUNG: When do you think it was that you started developing this separate side of you?
CARL: Perhaps four or earlier, and certainly as a young boy growing up, unquestionably.
Carl acknowledges that he is detached, that detachment is his normal state of being, and that it started very early in his life. Now the therapist has an inroad into his Lonely Child mode. Now the therapist can explore what is underneath his detachment—why at age 4 he started detaching and what he felt prior to detaching that led to the development of this mode.
Dr. Young and Carl call the detached part of Carl, “Detached Carl.” In reality, this mode is a blend of the Self-Aggrandizer and Detached Self-Soother modes.
Once the patient is aware of the modes, the therapist moves onto exploring the origins of the modes in childhood, especially the patient’s Lonely Child mode. We have found that the best way to accomplish this is through the use of imagery. However, first the therapist must nearly always overcome the patient’s opposition to doing imagery.
In the following segment, the therapist explores the origins of Carl’s detached mode. The therapist asks Carl to do an imagery exercise, but Carl first expresses a variety of reservations about proceeding and then resists the imagery process.
DR. YOUNG: Would you be willing to do an imagery exercise to get to what you were like before that? Could I ask you to close your eyes and picture yourself as that 3-year-old child, before you detached—so I could get a feeling for what that emotional part of you was like at that point, before you shut off? Would you be willing to try that, and tell me what you see?
CARL: You could try, but I wouldn’t be too hopeful, about 3-year-olds (laughs).
DR. YOUNG: Well, try to get the youngest age you can picture.
CARL: You know, I think going back is like, there once was a well that over the years the weather and the dirt has filled it in, and if you want to get down to the bottom, you just can’t look down there, you have to dig all this dirt out first, that’s what it feels like to me.
DR. YOUNG: Yes, I see what you mean. The image seems hard to get to. But let’s try. (Pause.) Now close your eyes and get an image of Little Carl, as a child, and tell me what you see. Try to keep your eyes closed until we finish the exercise. Another thing is, try to do it in images. Don’t analyze it, or comment on it, try just to tell me what you see, as though it’s a movie going through your head.
CARL: Well, generally speaking, I don’t see images.
DR. YOUNG: So—keeping your eyes closed—as you try to picture Carl as a child, you don’t actually see anything?
CARL: Right. I don’t see an image, a cognizable image.
DR. YOUNG: What do you actually see when you look back there?
CARL: Well, I’ll try to get some kind of impression.
DR. YOUNG: Yes, that would be good.
CARL: I’ll try and just take whatever I get. But it won’t be in the form of an image that I can really see.
DR. YOUNG: Well, the closest you could get to that would be OK.
Carl is still resisting, but at least he is willing to start. Because he said he was having trouble generating an image of himself as a child, Dr. Young suggests that, instead, he get an image of his mother when he was a child. (Offering the patient increasingly easier tasks is one strategy for countering the patient’s resistance to doing imagery.)
DR. YOUNG: How about getting an image of your mother from when you were young, and starting from that. Would that be easier?
CARL: Yes.
DR. YOUNG: What do you feel when you look at the expression on her face in the image? Do you have any reaction to it? What do you feel?
CARL: Well, I feel very sad, because I think I love my mother deeply and dearly, and I just want to be with her and love her.
DR. YOUNG: And does she make that easy?
CARL: (long pause) No.
DR. YOUNG: Can you tell me what she’s like toward you and how she treats you?
CARL: I can’t get an authentic image but, it’s as if she’s just made of stone. She doesn’t move.
DR. YOUNG: Can you tell her right now in the image, as if you were that child, although you couldn’t have said it then, what you needed from her? Just say it out loud to her right now so I can hear.
CARL: (as a child) “Mommy, I just want you to hug me and love me and pay attention to me and be with me always. And never let me go.”
DR. YOUNG: Is it easy for her to touch you, or does she have a hard time showing affection?
CARL: She’s stone. She’s made of stone in this image.
DR. YOUNG: Yes, and therefore, when you look at her, can you imagine that she’s thinking anything? Could you go into her mind?
CARL: (long pause) I just think she has a lot of sadness.
DR. YOUNG: And what is she thinking to herself about you, as you’re saying to her, “I want to be with you, I want to hold you, I want you to love me.”
CARL: I think she can only hear it with just a part of her. I think she’s preoccupied with her sadness.
DR. YOUNG: I see. So she’s self-absorbed with her own mood.
CARL: Yeah.
DR. YOUNG: Now have her answer you when you say that to her.
CARL: She doesn’t really want to talk to me. In fact, I think that she’s angry that I’m intruding on her.
DR. YOUNG: How does that make you feel, that she’s angry at you?
CARL: It makes me feel terrible.
Here we access the Lonely Child for the first time in the imagery. The patient describes a mother made of stone who cannot give of herself emotionally; and he is a child, wanting her love and having no way to get it.
The therapist has been moving toward this moment all along, trying to get Carl to acknowledge and experience his Lonely Child mode. At last, the therapist has bypassed Carl’s detached, self-aggrandizing mode, with whom only a shallow bond is possible. Now the therapist can form a bond with the Lonely Child. The therapist can reparent the Lonely Child and begin the process of schema healing.
The therapist helps patients learn to identify and label their modes and then to create dialogues between them. In the following excerpt, the therapist identifies two modes—”Little Carl” and “Detached Carl.” The former is the Lonely Child, and the latter is a combination of the Detached Self-Soother and the Self-Aggrandizer modes. Beginning with Little Carl, Dr. Young helps Carl connect emotionally to his modes.
DR. YOUNG: I want you to split yourself into two Carls: the Carl that’s the little child who wants his mother’s love, and then this other Carl, who’s got the detached manner.
CARL: OK.
DR. YOUNG: Can you see them both?
CARL: (Nods.) Yes.
DR. YOUNG: Describe them both to me, so I can see how they look different, how they feel different.
CARL: Well, the Carl that wants his mother’s love is very sad. (Pause.) He’s so sad he’s making the detached part sad. (Laughs.)
DR. YOUNG: I see. Is he like, paralyzed sad, like he just wants to stay in bed all the time, that kind of sad, like he can barely move?
CARL: (pause) No. Almost.
DR. YOUNG: Almost.
CARL: But not quite.
Here the therapist links Carl’s depression to the sadness of the Lonely Child.
Once the therapist has helped Carl recognize his Vulnerable Child and Detached-Aggrandizing modes, the therapist moves on to exploring the schemas underlying the modes. The therapist begins asking questions to determine what schemas characterize Carl’s Lonely Child mode. Specifically, he investigates whether Carl has an underlying Defectiveness schema, in addition to the Emotional Deprivation schema he has already portrayed in his image of a mother made of stone.
DR. YOUNG: And does he feel insecure, unloved, rejected, or is he just lonely? What’s making him sad?
CARL: I think he feels insecure about … (pause). Well, mostly rejected, I would say.
DR. YOUNG: Does he have any sense of why his mother doesn’t want to love him the way he wants?
CARL: No, he’s just confused.
DR. YOUNG: Does he think there’s something wrong with him?
CARL: No.
DR. YOUNG: What does he think it is?
CARL: He doesn’t understand.
CARL: No, he just doesn’t understand.
DR. YOUNG: He just misses it so much?
CARL: Yeah, and he has no understanding why.
DR. YOUNG: Is he lonely? Does he feel isolated or lonely?
CARL: He’s lonely for his mother.
Carl indicates that he has an Emotional Deprivation schema, but not a Defectiveness schema. He feels lonely, but not personally deficient.
The therapist educates patients about schema modes. Dr. Young presents the modes to Carl, using Carl’s own modes to illustrate.
DR. YOUNG: Looking at your issues, you seem to have two schema modes. One mode is the lonely, vulnerable child, and that’s the Carl you connected with at three years old with his mother, who feels sad and lonely, because nobody really gives him the love he needs.
Then there’s this second mode, which in your case is an entitled mode combined with a self-soothing mode. And this other mode is designed to hide and compensate for and avoid this more vulnerable little child mode that you don’t want to experience.
CARL: (Speaks in agreement.) Detached Carl is really not interested in getting close, not at all interested in getting close.
Dr. Young continues exploring Carl’s other schemas. Citing Carl’s questionnaires, he attempts to determine whether Carl has an underlying Mistrust/Abuse schema. He asks Carl if he views other people as trying to mistreat him.
DR. YOUNG: I feel that, with Detached Carl, from the things you said on the inventories, that there’s a more malevolent view of other people, too. It’s not just a view that people won’t give you love, it sounds like there are views of other people that are even more negative: the idea that they’re trying to get you one-down, or expose you, or beat you, meaning “win” over you.
CARL: Well, I think that Detached Carl develops a compensation to have a life and that involves competition.
DR. YOUNG: And that gives him a sense of value and purpose?
CARL: Yes.
DR. YOUNG: The competition is the value.
CARL: Yes. And so this competition, I believe, exists on many planes, not just in the games arena, where it’s obvious, but also in just the interaction, as you were able to witness, that Detached Carl is competing there as well. And this could be even with a stranger, potentially.
DR. YOUNG: And is that just because the game’s afoot, or is that because he actually views people underneath as trying to get him before he gets them?
CARL: (Speaks definitively.) No. He does not view people as trying to get him before he gets them.
DR. YOUNG: It’s not a mistrustful view of other people?
CARL: Not at all.
Carl answers that he does not view other people as abusive. Rather, what motivates him to play the game is the satisfaction of winning. Carl’s main schema seems to be Emotional Deprivation, not Mistrust/Abuse. He plays the game to fill the emptiness of his emotional deprivation, rather than to protect himself from cruelty or humiliation.
DR. YOUNG: It’s just that the game is what gives things a purpose.
CARL: It provides a meaning for life.
DR. YOUNG: Given that there’s not adequate connection.
The therapist helps Carl achieve a thorough intellectual understanding of his modes, including the schemas that underlie them.
The therapist helps Carl access “Detached Carl” and explore the function the mode serves. Detached Carl exists to distract him from his sadness.
CARL: I think I can get in touch with a nine-year-old Detached Carl.
DR. YOUNG: OK. What’s he like?
CARL: Oh, he’s kind of impervious. I think he sees this little boy being very sad, and he recognizes that he used to be sad once. If he thinks about it, he could get sad, too, but he doesn’t want to.
DR. YOUNG: He doesn’t want to think about it?
CARL: Well, he’s not in the habit of thinking about it, no. He’s in the habit of not thinking about it.
DR. YOUNG: What things does he do to distract himself?
CARL: Oh, he likes to read comic books, play chess, and watch TV. (Pause.) I don’t think he needs to do anything special to be detached.
DR. YOUNG: Is he more with people or more isolated, or can he be in either place?
CARL: He can be in either place.
DR. YOUNG: He doesn’t feel any safer, or any less comfortable, one way or the other?
CARL: No, no. He’s impervious.
To protect himself from his sadness about his mother, Carl also turned to stone.
The therapist further helps Carl connect emotionally to Detached Carl. Note that Detached Carl initially tries to distance himself by criticizing the therapist’s question. He engages in schema avoidance, true to his main function. When Dr. Young asks Detached Carl about his feelings, Detached Carl becomes irritated.
DR. YOUNG: Can I talk to Detached Carl for a second?
CARL: Yeah.
DR. YOUNG: Well, here you are, reading comics, playing chess, watching TV. How does that make you feel?
CARL: (pause)
DR. YOUNG: Do you enjoy doing those things?
CARL: (Speaks in an annoyed tone.) Well, I sort of think your question is silly.
DR. YOUNG: OK. Why don’t you come up with a better one? Reword it to make it more reasonable, so it fits the situation better.
CARL: These are just things I like to do. Why wouldn’t I like to do them?
DR. YOUNG: So it sounds like Detached Carl, then, has a slightly argumentative flavor to him?
CARL: (Sounds annoyed.) Oh, he just doesn’t understand. He doesn’t understand what you mean.
DR. YOUNG: But it sounds like there is a little bit of anger in the voice tone—that he’s also feeling something …
CARL: (Interrupts.) Are you asking Detached Carl to have some feelings!
DR. YOUNG: I’m asking if maybe he has some angry feelings, but not the sad feelings.
CARL: (Interrupts.) I think he’s angry if you ask him to focus on himself.
DR. YOUNG: Yeah, that’s what I mean. So he is angry.
CARL: Yeah, he’s angry if you want him to look at what he’s doing or think about what he’s doing.
DR. YOUNG: Yes, exactly. And how do you, as angry, detached Carl, how do you feel toward other people in general? What’s your connection to them, your beliefs about them?
CARL: Hm. (Pause.) Oh, I don’t really, I don’t like them much.
DR. YOUNG: Why?
CARL: (long pause) I don’t know why.
DR. YOUNG: Are they stupid, are they selfish?
CARL: Well, some of them are stupid, but some of them aren’t stupid. They’re not as smart as me, of course.
DR. YOUNG: Do you feel good being smarter than most people?
CARL: (in an emphatic voice) Sure.
DR. YOUNG: Why does that feel good to you right now?
CARL: I have to be the best. I have to be the winner.
DR. YOUNG: And why is it important for you to be the best?
CARL: (in an angry voice) You’re making me angry.
DR. YOUNG: Can you try to explain why you’re angry with me?
CARL: Well, you’re asking me these questions.
DR. YOUNG: And you don’t want to think about these things.
CARL: No.
The therapist helps Carl reach a deeper understanding of Detached Carl. Detached Carl does not like other people very much, does not like to think about his problems, does not like to think about why he does the things he does, and has to be Number One. The therapist helps him understand how Detached Carl feels and operates—an important step toward understanding how Detached Carl negatively affects his life in the long run.
It is noteworthy that Carl describes both the avoidant coping function of Detached Carl and the overcompensating function. As we have said, Detached Carl is both a Detached Self-Soother and a Self-Aggrandizer. One mode serves these two distinct functions: Detached Carl avoids his own negative emotions, and he views himself as superior to other people.
Interestingly, once the therapist identifies Detached Carl and makes him a character in the imagery, Carl’s manner toward the therapist changes. He moves out of his Self-Aggrandizing and Self-Soothing modes. He only cursorily engages in a “dance of domination” with the therapist. He only halfheartedly competes and pushes the therapist away. Having been given a voice as a mode, Detached Carl no longer needs to demonstrate his superiority to the therapist, and he no longer needs to distance from the therapist to the same degree.
Once the patient has identified, labeled, and emotionally connected to the modes, the therapist helps the patient carry on dialogues between them. The therapist teaches the modes to negotiate through schema dialogues. This is a function of the Healthy Adult: to direct negotiations among modes. The aim of the Healthy Adult is to supplant the Self-Aggrandizer and the Detached Self-Soother as protectors of the Lonely Child and to help the Lonely Child get his emotional needs met.
In the following excerpt, the therapist helps Carl conduct a dialogue in imagery between Detached Carl and Little Carl, the Lonely Child. The therapist brings in Danielle, Carl’s wife. Danielle’s self-absorption echoes Carl’s mother, perpetuating the emotional deprivation of his childhood in his adult life. The therapist wants to strengthen the connection between Carl’s Lonely Child and Danielle. The ultimate goal is to get Detached Carl to step aside and allow Little Carl to feel and express his emotions with Danielle.
CARL: I think Little Carl wants his mommy. He wants his mommy, and his mommy has a certain quality—maybe a sad quality, maybe a negative quality—but he wants that quality.
DR. YOUNG: So it can either be her or someone a lot like her.
CARL: I think, yes, Little Carl remembers his mother was sad.
DR. YOUNG: So he wants someone sad and vulnerable like his mother.
CARL: Yes.
DR. YOUNG: And how about Danielle? How does Little Carl—
CARL: (Interrupts.) She’s sad and vulnerable.
DR. YOUNG: Is that what Little Carl wants?
CARL: (Speaks sadly.) Yes.
The therapist helps Little Carl negotiate with Detached Carl.
DR. YOUNG: Then let Little Carl say, “I’d like to try to get closer to Danielle.” What does Detached Carl say back?
CARL: (long pause) I think it’s OK with Detached Carl, it really is.
DR. YOUNG: But there are some problems coming up, aren’t there? It’s not going totally smoothly. So you need to talk about what’s interfering with that—how Detached Carl is interfering.
CARL: Yes, you’re right. There are problems. Detached Carl’s life is being threatened.
DR. YOUNG: Yes, so say that to Little Carl, because you’ve taken on a separate persona now, and you want to survive, too. You’re not just his servant anymore.
CARL: (as Detached Carl, speaking to Little Carl) “Yes, Danielle’s the one. But, you know, I’m not going to give up my life. I have a life, too.”
DR. YOUNG: Tell him about that life, and the good parts of it.
CARL: “You know, I’ve got to play chess. I’ve got to keep the old brain stimulated. You wouldn’t want to get bored, would you? Would you want to get bored, Little Carl, would you?”
DR. YOUNG: And what does he say?
CARL: (as Little Carl in a tentative voice) “Uh, no, no.”
DR. YOUNG: It sounds like Detached Carl’s bullying him a little.
CARL: (Laughs.)
DR. YOUNG: Let Little Carl be a bit stronger. Let him grow up a little bit, maybe, so that he’s still got those feelings, but he’s a bit smarter than that.
CARL: OK. (as Little Carl, more forcefully) “OK, you big bully, listen to me ….”
Detached Carl is much stronger than Little Carl. The therapist allies with Little Carl in order to even things out. He provides the Vulnerable Child with more ammunition against Detached Carl. It is going to be a fair fight, not a trouncing.
With Little Carl thus strengthened, Little Carl and Detached Carl continue to negotiate. Carl plays both sides, with Dr. Young acting as coach.
CARL: (as Detached Carl, speaking to Little Carl) “Yes, yes, OK, you’re right, you’re right. Family’s important, Danielle’s important. But does that mean I have to give up everything? Do I have to give up everything? Can’t I keep something?”
DR. YOUNG: That’s good. Give Little Carl an example, something you would like to keep, without having to keep the whole ball of wax. Negotiate.
CARL: (as Detached Carl) “Can I keep my cookies and my chocolate and pizza? Can I keep playing chess on the computer all night?”
DR. YOUNG: How about playing two hours a night?
CARL: That’s not enough!
DR. YOUNG: Try and negotiate a little bit here. Don’t be quite so hard with him.
CARL: I’m negotiating with Little Carl?
CARL: (as Detached Carl) “Listen, we’ll keep the family, but this is what I need.” (Speaks angrily) “I need you to leave me alone, and I’ll take care of the family.”
DR. YOUNG: And what’s Little Carl say back?
CARL: (as Little Carl, speaking mournfully) “Are you doing it? Are you taking care of the family? I’ll leave you alone if you take care of the family, if you take care of yourself. Are you doing it?”
Note that, at this point, Little Carl is actually a combination of the Lonely Child and Healthy Adult modes. Little Carl has taken over the therapist’s role of empathic confrontation. He confronts Detached Carl with the current state of affairs: Both Little Carl and Danielle feel lonely and neglected.
The therapist helps the Lonely Child connect to significant others in imagery. Dr. Young works to convince Detached Carl to let Little Carl “come out” more with Danielle to give and receive love. This is to Detached Carl’s advantage also, because love is something he wants even more than he wants to play games and to win. (In our model, the Maladaptive Coping modes—in this case, the Detached Self-Soother and Self-Aggrandizer—also want love. These maladaptive modes are not there in order to hurt the patient but rather to protect the patient. When these modes are convinced that the Vulnerable Child is safe, they will allow the Vulnerable Child to surface.)
DR. YOUNG: How about having Detached Carl step aside for a while, and let Little Carl and Danielle connect a bit? Close your eyes and let Little Carl and Danielle connect a little bit, just so I can see what happens when the two of them are there without Detached Carl in the picture. What do you see happening now?
CARL: (pause) Physically what happens?
DR. YOUNG: Yes. What do you see? How are they relating to each other? Look at Little Carl, but make him a little older, so he’s not three.
CARL: Yeah, OK, sure.
DR. YOUNG: What do you see with Little Carl and Danielle? How are they interacting?
CARL: Uh, well, he just crawls into her lap.
CARL: Yeah. She holds him.
DR. YOUNG: How does it feel?
CARL: It feels fine, feels good. He looks into her eyes, he looks into her face ….
DR. YOUNG: He wants this?
CARL: Yes.
Carl can see that he actually wants to get close to Danielle, something he had not recognized before. It is by getting close to Danielle that the Vulnerable Child can get his core emotional needs met. The therapist brings Detached Carl into the image.
DR. YOUNG: Now, put Detached Carl into the image there, and just have him comment on what he’s seeing, from his perspective. What does he feel as he sees that?
CARL: Well, Detached Carl, after all, is pretty enlightened. (Laughs.)
DR. YOUNG: (Laughs.) So what’s he saying as he looks at them?
CARL: (as Detached Carl) “Good, good, good. Good work.”
DR. YOUNG: (as Detached Carl) “Now I’m going to go back and play chess, or I’ll sit here and watch television for awhile?”
CARL: No. I wish we could do more of this.
The final part of treatment is helping patients generalize from the therapy relationship and imagery exercises in sessions to outside relationships with significant others. The therapist helps the patient select significant others who hold the potential for mutual caring and to emotionally connect to them. The therapist encourages the patient to let the Lonely Child surface in these relationships, to give and receive genuine love.
In the following segment, Dr. Young helps Carl clarify how to generalize from the mode work to life outside therapy.
DR. YOUNG: What do you think is the next step for the “Carls” right now, in terms of making progress in therapy?
CARL: Well, my opinion is that we have to have it so that Little Carl can come out and stay out. I think that we have to focus our attention on and be more mindful of Detached Carl. I think that the dichotomy of Little Carl and Detached Carl is very powerful with respect to my own self-awareness. And to the extent that we have Little Carl there, Detached Carl doesn’t need to be there.
DR. YOUNG: I see, you think Detached Carl actually will recede automatically just by having Little Carl there?
CARL: That’s right.
DR. YOUNG: And consistent with that, you seem different right now talking to me than you seemed at the very beginning. Right now you seem more vulnerable, more emotions are coming through than I felt beforehand, and you’re not debating the little points of the language anymore.
CARL: That’s what Detached Carl has to do.
DR. YOUNG: Yes, exactly, so what you described has already just happened here. You are now less of that Detached Carl than you were earlier. So connecting with Little Carl clearly does change Detached Carl.
CARL: Right. Connecting with Little Carl and connecting to my emotions in general is something I’m not in the habit of doing and not used to doing—but it’s important for me to have the facility of doing. And, as far as Little Carl is concerned, I think that he really has to just come out and stay out.
Once the patient allows the Lonely Child to emerge and connect to others, then the other modes begin to recede. Their functions as protectors of the Vulnerable Child become increasingly obsolete. Of course, these modes will resurface over time, but the more the Lonely Child emerges and connects to others, the less the other modes will exert the pressure to appear.
To help patients generalize changes in therapy to their outside relationships, we often find couples therapy a useful addition, especially in this stage of treatment. In addition, we use cognitive-behavioral homework assignments to help patients work on their relationships with family members, partners, and friends.
Although the case example does not illustrate this part of treatment, early on the therapist introduces cognitive and behavioral strategies. These strategies can help patients with narcissistic personality disorder in both the Assessment and Change Phases. Cognitive-behavioral homework assignments are essential to helping patients overcome the avoidant and overcompensatory coping styles that perpetuate their schemas. If patients maintain their self-aggrandizing and entitled behaviors in their current interpersonal relationships, their underlying Emotional Deprivation and Defectiveness schemas will not fully heal.
By writing down their automatic thoughts when they are upset, patients can learn to identify and correct their cognitive distortions. The following are some cognitive distortions common to patients with narcissistic personality disorder.
1. “Black-or-white” thinking. Using the tools of cognitive therapy, the therapist helps patients learn to correct the “black or white” thinking of the Self-Aggrandizing mode: “Either I am special and the center of attention, or I am worthless and ignored.” The therapist teaches patients to discriminate shades of gray and to respond in more modulated ways to perceived slights. Patients conduct debates between the Self-Aggrandizer and the Healthy Adult or Lonely Child modes.
2. Distortions about being devalued or deprived by others. The therapist teaches patients to correct their distortions about how much other people, especially significant others, are devaluing or depriving them. The therapist provides a “reality check” for patients when they feel affronted and asserts the principle of reciprocity: Patients should not expect from others what they themselves are unwilling to give. The therapist guides patients to seek equality in relationships rather than feeling superior or special.
3. Perfectionism. The therapist teaches patients to challenge their perfectionism by setting more realistic expectations for performance, both for themselves and for others. With the therapy relationship serving as a model, patients learn to become more forgiving of human flaws. The therapist helps patients identify their inner perfectionistic voice as the voice of the Demanding Parent, who was never satisfied.
4. Overemphasizing narcissistic gratification over inner fulfillment. The therapist helps patients examine the advantages and disadvantages of emphasizing success, status, and recognition over genuine love and self-expression. Similarly, the therapist guides patients to examine the advantages and disadvantages of maintaining their entitled thinking and behavior over adopting a stance of empathy and reciprocity. The therapist conducts debates between schemas and the Healthy Adult.
Working with patients, the therapist constructs flash cards that patients use to remain aware of the negative consequences of their narcissism and the positive consequences of practicing “loving kindness” in their lives outside therapy. The therapist helps patients design and conduct behavioral experiments, investigating the consequences of entitled versus loving behavior in their intimate relationships. The therapist acknowledges the patient for behaving in a loving way—for choosing “true love” over temporary narcissistic satisfactions.
The “vertical arrow” technique (Burns, 1980) is useful for helping patients identify the underlying beliefs that drive their endless quest for narcissistic gratification. The therapist helps patients work through “what ifs” such as, “What if you were not perfectly beautiful, brilliant, rich, successful, famous, or high status? What would that mean to you? What would happen? What do you imagine your life would be like?” Working through these “what ifs” with patients is another path to the Lonely Child. When contemplating what life would be like without their narcissistic gifts, patients often get to the loveless place of their Emotional Deprivation and Defectiveness schemas.
Between sessions, patients read flash cards to remind them of what they have learned from doing the cognitive work. The flash cards point them to healthy behaviors that heal, rather than perpetuate, their Emotional Deprivation and Defectiveness schemas.
The therapist combines the cognitive work with behavioral homework assignments. For example, the therapist asks patients to spend time alone for homework, unsoothed and unstimulated, to get to know and understand the Lonely Child. Patients write down or tape-record their thoughts and feelings and then bring them to their next session. The therapist and patient talk about what happened, and the therapist takes the opportunity to reparent the patient.
Patients learn to replace self-destructive impulsive and compulsive behaviors with emotional closeness and authenticity. In social situations, patients carry out experiments in which they resist switching into the Self-Aggrandizing mode. They adopt an observer role for an evening, or focus on listening to others, or refrain from making remarks designed to elicit admiration.
Finally, and perhaps most important, patients with narcissistic personality disorder work on developing their intimate relationships. They carry out homework assignments to nurture others and practice empathy. They reduce the time they devote to impressing others and increase the time they devote to enhancing the emotional quality of their close relationships. They let the Lonely Child come out in suitable intimate encounters to get basic emotional needs met. They observe what happens when they replace addictive, self-soothing behaviors with love and intimacy.