We use a mode-based approach with patients with narcissistic personality disorder. We have observed three primary modes that characterize most of these patients (in addition to the Healthy Adult mode): the Lonely Child; the Self-Aggrandizer; and the Detached Self-Soother. The core schemas of narcissism are Emotional Deprivation and Defectiveness, which are part of the Lonely Child mode. The Entitlement schema is an overcompensation for the other two schemas and is part of the Self-Aggrandizer mode.
Patients with narcissistic personality disorder are usually in the Self-Aggrandizer mode while they are with other people; the Detached Self-Soother is the mode they are usually in when they are alone. The Detached Self-Soother can take many forms, all representing mechanisms of schema avoidance. Patients often engage in a variety of activities to self-stimulate. These activities provide drama and excitement. Another group of patients compulsively engages in solitary activities that are more self-soothing than self-stimulating. These compulsive interests focus their attention away from the pain of their Emotional Deprivation and Defectiveness schemas.
We have found four factors that often characterize the childhood environments of patients with narcissistic personality disorder: (1) loneliness and isolation; (2) insufficient limits; (3) history of being used or manipulated; and (4) conditional approval.
In intimate relationships, patients with narcissistic personality disorder typically display characteristic behaviors. They are generally unable to absorb love and view relationships as sources of approval or validation. They are unempathic, especially toward the people who are closest to them. They frequently feel envious of others whom they perceive as one-up in some way. Patients often idealize their love objects in the initial stages of the relationship; and then, as time goes on, they increasingly devalue the partners. Finally, patients display a pattern of entitlement in their intimate relationships.
To assess 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.
Our treatment of patients with narcissistic personality disorder centers on reparenting the Lonely Child and conducting mode work. The therapist helps the patient build up a Healthy Adult mode, modeled on the therapist, that is capable of reparenting the Lonely Child and regulating the Self-Aggrandizer and the Detached Self-Soother modes. The therapist establishes the current complaints as leverage and begins “limited reparenting” of the Lonely Child. When treating patients with narcissistic personality disorder, it is important for therapists to tactfully confront the patient’s devaluing or challenging style and assert their rights whenever the patient violates them. Rather than appearing perfect, therapists acknowledge their vulnerability.
The therapist introduces the concept of the Lonely Child mode and helps the patient recognize the Self-Aggrandizer and Detached Self-Soother modes. The therapist explores the childhood origins of the modes through imagery. (Usually, the therapist must first overcome considerable resistance on the part of the patient.) The therapist guides the patient through mode work. The Healthy Adult mode conducts negotiations among the modes, in order to: (1) help the Lonely Child to feel nurtured and understood and to nurture and empathize with others; (2) confront the Self-Aggrandizer so that the patient gives up the excessive need for approval and treats others based on principles of respect and reciprocity, as the Lonely Child takes in more genuine love; and (3) 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 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 love.