Behavioral Therapy of Narcissistic Personality Disorder

Introduction

Basic concepts

The model of dual action regulation

Therapeutic interventions
Building of a relationship
Complementarity at the motive level
Non-complementarity at the play level
Never regard the client as deficient
Establishing compliance
Appreciation and acknowledgement
Emphasize resources
Normalize
Leave room for self-portrayal
Absolutely appreciate
Dealing with testing
Therapy phase
Confrontation: Identifying a work assignment
Substantial work

Summary

Literature

Introduction

The narcissistic personality disorder is characterized by a lack of self-confidence and rejection of one's self inwards, alternating with an exaggerated and extremely pronounced self-confidence outwards.

Hence, such a person is always striving for admiration and acknowledgement, while giving little real attention to other people. She/he has an exaggerated sense of importance, hopes to attain and to earn special status. She/he exhibits exploitative attitudes and a lack of empathy. Delusional disorders with concepts of grandness are within the spectrum of possibilities. Moreover, the afflicted shows a striking sensitivity towards criticism, which often is projected globally, stirring feelings of rage, shame, and humiliation.

The term "personality disorder" by itself is hazy and subject to controversy. It is not just a standardized, empirically validated theory that is missing but likewise a sound therapy for the effective treatment.

Furthermore, clients with personality disorders are considered as therapeutically little accessible and difficult on an interaction level.

Prof. Rainer Sachse, psychology professor at the University of Bochum and founder of the "Klärungsorientierte Psychotherapie" (clarification-oriented psychotherapy) and of the dual action regulation model, does not talk about personality disorders anymore, but instead of relationship and interaction disorders.

Herewith the therapist takes on an equally important role, as does the client.

Moreover, he assumes that the forms of relationship, which taken to the extreme lead to the so-called personality disorders, are universal behavior in their milder expression (Sachse, 2006).

For a better understanding of the subject, the present work first discusses the theory of clients with narcissistic personality disorder and subsequently elaborates on the possibilities for intervention. In the light of the model of dual action regulation, central motives, schemata, and strategies of action are pointed out, that are displayed by clients with narcissistic PD. Therapeutic strategies like complementary structuring of relationships, confrontation, schema modifications are being deduced.

Basic concepts

Patients with personality disorders do not draw attention to or work out those relationship and interaction problems, but rather "live" those problems in therapy, ceremoniously elevating the therapist to a complicit participant in the reenactments.

In the course of their socialization, people have learned not to pursue certain goals, desires, and needs anymore, because important people whose judgement they value have reacted negatively to the expression of those desires. In processing these negation and rejection experiences, the affected person develops pathogenic convictions, like "I am not worth it." or "It is for the better not to realize one's goals." or "Humans are unreliable." or "There is no secure relationship."

These problematic behavioral patterns, which for the patient were "life-saving" during early development in an unfavorable or even hostile learning and socialization environment are accompanied by further complications: Due to the ego-syntonic, meaning ego-aligned nature of the interaction and relationship disorder, these patients usually come into treatment for other reasons – often axis-I-disorders. Hence, the narcissistic personality disorder is initially often neglected.

So they exhibit no motivation for change with regard to the problematic interaction behavior, but instead motivation for stabilization: the therapist is supposed to be integrated into the existing system. In his usual way, the patient functionalizes the therapist: he is supposed to console, affirm, take responsibility, etc. If the therapist focuses on the interaction behavior, blockage behavior and resistance is the consequence, which often results in a stalemate with the therapist, provoking helplessness, anger, and frustration.

Thus the therapist can transform from partner in the therapy team to being part of the problem, because he often doesn't realize this functionalization by the patient until the system is already stabilized. Without any strategy to cope with this probing behavior and "being used", the relationship between therapist and patient increasingly deteriorates until ultimately constructive work is not possible anymore.

The model of dual action regulation

The model of dual action regulation by Sachse was derived from the cognitive theory about personality disorder by Beck and Freeman and is associated with the concept of the goal-oriented psychotherapy based on conversation (Beck & Freeman, 1999).

The model of dual action regulation is a generalized model of disorder for personality disorders, which can be specified for every distinct disorder. Hence it is conducive to understanding the functioning of personality disorders and to deducing therapeutic strategies.

The clarification-oriented psychotherapy developed by Sachse is based on the assumption that clients with personality disorders interact with their opposite in ways that aim to fulfill their "interactional basic needs" (motive level), while they use various strategies to disguise it (model of dual action regulation).

The model allows for theory-guided diagnostics and a theory-guided therapy.

It offers therapeutic approaches that allow a constructive therapeutic interaction with clients. It should emphasize that for psychologically comprehensible reasons, these individuals exhibit interactional acting, which is problematic for their partner of interaction (and hence ultimately for themselves). Moreover, it is supposed to point out that the clients for themselves are stuck within their constructs and are incapable of detaching anymore on their own. And it should stress that these constructs by themselves are quite plausible and accepted (ego-syntonic), but that nevertheless the individuals are at least temporarily negatively impacted by it.

Individuals with narcissistic personality disorder exhibit a double concept of self:

On the one hand, they have a negative self-schema containing assumptions like: "I am not o.k.", "I am a failure.", "I cannot live up to expectations.".

At the same time, they also show a positive self-schema making assumptions like: "I am fabulous.", "I am highly capable.", "I can take on any challenge.".

Both schemas exist in parallel: Positive experiences "trigger" the Self-concept+ and produce a positive "state of mind" with a person: He/she activates the positive assumptions, feels tremendous, is motivated to interact, accepts challenges, etc.

However, criticism or failure trigger the SC- and hence elicit a negative "state of mind": The person activates the negative assumptions, feels depressed, avoids challenges, etc.

The individuals now develop interactional solutions based on the discrepancy between the strong relationship motives and the negative schemas:

The first solution consists in building such interactional goals (and then to follow through on them), which present a compensation of the negative schemas; resulting mainly in avoidance goals, with examples for people with NAR being:

"Avoid devaluation and criticism!"

"Be successful in order to gain recognition!"

From a psychological perspective, avoidance goals work differently than goals of rapprochement: Pursuing and reaching goals of rapprochement satisfies central motives and results in a state of contentment (Brunstein, 2005), in a slow dropping of the motive in the hierarchy of motives (Kuhl, 2001) and consequently in a gradual subsiding of the efforts. In contrast, pursuing and reaching avoidance goals leads to the reduction of fear and tension, but not the satiation of central motives and consequently not to a state of contentment: Despite of pursuing avoidance goals, the central motive of recognition is nevertheless ranking high in the hierarchy of motives.

The second solution that people are adopting to resolve the dilemma emerging from extremely strong relationship motives and negative schemes, is the development of manipulative, obscure interaction behavior: Since the individuals believe that others will not accept them as a person, they conclude that others consequently have to be prompted to do so against their own intentions: And this can best be achieved with obscure, manipulative behavior deceiving interaction partners about the actual interactional goals.

One has to acknowledge here that it is basically human nature to manipulate; hence manipulation can only be used as an unbiased psychological concept. Therefore, manipulation by itself is nothing "defamatory". However, people tend to manipulate more the stronger their PD does present itself, and herewith their relationships are ultimately not reciprocated anymore; for this reason they get into interactional difficulties sooner or later. Individuals with NAR develop strategies like:

to outperform, accumulate successes, collect status symbols ("symbolic self-supplementations"), "parade" achievements and successes claiming recognition for them;

demanding "VIP-status" from others;

expect special treatment;

claim privileges for themselves;

define social rules; set standards that regulate how they wish to be treated;

presume that they are entitled to define such rules and to punish rule offenders;

remain autonomous, defining particular territories;

not to commit, only trusting individuals who are not threatening ("not criticizing").

Consequences

In the short term, this strategy is successful: The partner is going to act complementary for some period of time.

In the long term, however, the behavior is bound for failure: the complementary behavior reaches a tipping point and turns into rejection because of neglecting of own goals.

This system stabilizes itself:

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