There are several obstacles to successful treatment of patients with narcissistic personality disorder that we can usually overcome by exercising leverage. Occasionally, the leverage we can bring to bear is not enough. These patients are more likely than most other patients to drop out of treatment, especially in the early sessions. They might drop out for a number of reasons. The Self-Aggrandizer in the patient might be unable to grasp the goal of therapy—to establish a relationship based on caring rather than specialness—especially if the patient has never experienced real caring. The Self-Aggrandizer may not be willing to tolerate the therapist’s frustration of the patient’s narcissistic needs for entitlement or specialness, and there is nothing the therapist can do to keep the patient in treatment short of gratifying the patient’s narcissistic needs, which would be destructive to both the therapist and the patient.
Patients might drop out of treatment to avoid experiencing the pain of the Lonely Child. They may be unwilling to let themselves become vulnerable enough to trust and become attached to the therapist. If they entered treatment during a crisis, they are at a high risk to leave once the crisis is resolved.
The Self-Aggrandizer might reject the therapist as “not good enough” in some way—not rich enough, smart enough, well educated enough, successful enough, famous enough, and so forth. Alternatively, this might happen later in treatment. Having first idealized the therapist, the patient later devalues him or her.
What leverage does the therapist have to keep the patient in treatment? What does the therapist have that the patient wants? As we have noted, one source of leverage is the negative consequences of the patient’s narcissism. The therapist keeps reminding patients that, unless they change, they will continue paying a price for their narcissism in their love and work lives. A second source of leverage is the therapist-patient relationship. If the therapist keeps the patient in the Lonely Child mode and reparents the patient, then the patient’s attachment to the therapist can become a reason for staying in treatment.